Management of neurogenic bladder dysfunction in children update and recommendations on medical treatment

Abstract

Introduction: Defective closure of the neural tube affects different systems and generates sequelae, such as neurogenic bladder (NB). Myelomeningocele (MMC) represents the most frequent and most severe cause of NB in children. Damage of the renal parenchyma in children with NB acquired in postnatal stages is preventable given adequate evaluation, follow-up and proactive management. The aim of this document is to update issues on medical management of neurogenic bladder in children. Materials and Methods: Five Pediatric Urologists joined a group of experts and reviewed all important issues on "Spina Bifi da, Neurogenic Bladder in Children" and elaborated a draft of the document. All the members of the group focused on the same system of classifi cation of the levels of evidence (GRADE system) in order to assess the literature and the recommendations. During the year 2020 the panel of experts has met virtually to review, discuss and write a consensus document. Results and Discussion: The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies. Clean intermittent catheterization (CIC) should be implemented during the fi rst days of life, and antimuscarinic drugs should be indicated upon results of urodynamic studies. When the patient becomes refractory to fi rst-line therapy, receptor-selective pharmacotherapy is available nowadays, which leads to a reduction in reconstructive procedures, such as augmentation cystoplasty.

Management of neuropathic bladder secondary to spina bifida: Twenty years' experience with a conservative approach

“…Experts have recommended a the use of a detailed protocol with escalation of management from the less to the more invasive treatment. It is possible thus to avoid or delay bladder augmentation by following a strict treatment protocol (16). These studies and recommendations echo our experience, and we consequently postulate that our results in achieving a safe bladder are multifactorial and are a product of marginal gains from utilization of all of the less invasive methods we have described.…”

“…The proportion of these pediatric spina bifida patients who are routinely on CIC varies in the literature from 43-87% (10,14). In recent recommendations from a group of experts, an early start of CIC from day 1 was deemed crucial for maintaining a safe bladder and protecting the upper urinary tract (16). This is the approach that we have been using for 20 years, but we start CIC after performing bladder function assessment in the neonatal unit to confirm that bladder emptying is affected.…”

A nomogram for predicting upper urinary tract damage risk in children with neurogenic bladder

“…With the progression of the disease, children with NB will experience different degrees of UUTD, which is the major factor that compromises the long-term survival rate ( 11 ). Therefore, it is very important to detect UUTD early and take measures to prevent the development of kidney injury.…”

Can concomitant bladder neck incision and primary valve ablation reduce early re-admission rate and secondary intervention?

“…In that instance, PUV ablation alone my not be sufficient to relieve obstruction. Various treatment options have been proposed to target BN obstruction in PUV patients, including alpha blockers (5)(6)(7), bladder neck incision (BNI), BN botulinum toxin injection and clean intermittent catheterization (CIC) (4,8,9). Glassberg and Combs favored alpha blocker therapy to BNI; as the effects of alpha blocker treatment are reversible with treatment discontinuation (4).…”