Incidence of normal micturition in myelomeningocele patients.

Abstract

Among 108 consecutive patients with myelomeningocele aged 5-12 years initiaily treated by a selective policy, seven (6-5%) achieved spontaneous urinary continence, five with normal micturition and two with urgency. AlU had positive conus reflexes and incomplete cord lesions which, with one exception, comprised motor as weli as sensory sacral sparing.Neuropathic bladder, with urinary incontinence and the risk of renal complications, is a major problem for patients with myelomeningocele and especially for those with smaller lesions whose handicaps otherwise tend to be slight. Reports Among the 11 patients reviewed clinically, four had gross urinary and faecal incontinence. Five had an entirely normal pattern of micturition by day although one had primary nocturnal enuresis. Two children were fully continent but had marked urgency of micturition.Neurological examination ofthe seven children with spontaneous daytime urinary continence showed a primary neurological level (that to which motor and sensory functions were entirely normal) ranging from L3 to S2. All had positive conus reflexes and an incomplete cord lesion which, except for one girl with urgent micturition, comprised motor as well as sensory sparing in the second to fourth sacral segments. None had suffered symptomatic urinary infections; recent ultrasound examinations or intravenous urography had shown normal upper renal tracts. Bowel habit was normal in all cases.The incidence of spontaneous urinary continence in relation to the anatomical level of the cord lesion was thoracolumbar 0/8, lumbar 3/44 (7%), lumbosacral 3/39 (8%), and sacral 1/16 (6%). DiscussionThe incidence ofspontaneous urinary continence in the present series, 6-5%, is far less than that previously claimed of children treated by nonselective' 2 or selective3 policies and lesser still when considering those with entirely normal daytime micturition.Normal urinary control would be expected only of patients with positive conus reflexes and incomplete cord lesions with both motor and sensory sacral sparing, as were the findings in the present series. Incomplete cord lesions are quite common with sacral and lumbosacral myelomeningoceles but unusual with lumbar and exceptional with thoracolumbar lesions. As a rule there is only sensory sacral sparing and when this is accompanied by positive conus reflexes a precarious form of urinary control may be achieved but one which is undoubtedly abnormal.5 Urgent micturition is associated with detrusor hyperreflexia and detrusorsphincter dyssynergia; residual urine is common and upper renal tract complications may develop. A few patients with a combination of detrusor areflexia and moderate urethral resistance manage to stay more or less dry by regular voiding by abdominal straining or compression. Possibly previous reports included as having normal urinary control some patients precariously continent by these abnormal means, others where the casenotes were inaccurate 640 on 12 May 2018 by guest. Protected by copyright.

Outcome of Augmentation Cystoplasty and Bladder Substitution in a Pediatric Age Group

“…Accordingly, only 1 out of 21 patients suff ered a decrease of renal function postoperatively in the reported series. The rate of spontaneous urinary continence in children with meningomyelocele is described to be as low as 6 -22 % [16,17] . Social urinary continence can be accomplished by CIC and anticholinergics in 75 -80 % of patients with neurogenic bladder dysfunction [18] .…”

Urinary diversion in children and adolescents with neurogenic bladder: the Mainz experience

“…Reimer et al found that only 6% of the patients with myelomenigocele achieved spontaneous urinary continence [11]. However, Ottolini et al reported that 72% of the children using CISC and pharmacotherapy were dry during the day [12], but in a series from Houston, 47/76 patients with improvement of bladder compliance by pharmacotherapy and CISC remained wet between catheterizations [5].…”

Urological consequences of incomplete cord lesions in patients with myelomeningocele

“…Some 30% of patients with myelomeningocele have positive conus reflexes, regardless of the level of the lesion [ 2], although results indicate that in only a small proportion of cases is this associated with sacral sensory sparing, and in a smaller fraction still with motor sparing [ 1]. Occasional examples of incomplete cord lesions are encountered in patients with negative conus reflexes.…”

“…It is well recognized that whilst the great majority of patients with myelomeningocele have a neuropathic bladder, a small proportion (6% by the most recent estimate [ 1]) are free of this complaint, all having an incomplete cord lesion and almost all with motor as well as sensory sparing. So far undescribed is a subcategory of patients with a neuropathic bladder and an incomplete cord lesion who as a result can gain some measure of urinary continence spontaneously, but who are still at risk of secondary upper urinary tract complications; such patients form the basis of this report.…”