Neurogenic bladder

Abstract

Primary reasons to diagnose and manage neurogenic bladder: 1. Prevent acquired renal injury. 2. Prevent acquired loss of bladder compliance. Secondary aims: 1. Achieve urinary (and bowel) continence. 2. Improve self-care and/or facilitate management by other caregivers. Summary of evidence for these goals: Renal scar has been diagnosed by DMSA in 25-32 % of patients with spina bifida in retrospective series. No longitudinal data relates UD findings or management of neurogenic bladder to renal scarring. Although UD findings are the cornerstone for therapeutic decision-making, technical aspects of the test (catheter size, filling rates, temperature of infused fluids, seated versus supine positioning, number of cycles) are not standardized, and no study reports inter-and intra-observer agreement in their interpretation for neurogenic bladder. One prospective study showed 20 % of newborns had end filling pressures >40 cm H 2 O, with medical management (CIC plus AC) decreasing pressures to <40 cm H 2 O in all. Of newborns with initial UD end filling pressures <40 cm H 2 O, 10 % had loss of compliance at median age 9 months, with reduction again to <40 cm H 2 O with CIC plusAC. No prospective study reports impact of detrusor leak-point pressure (DLPP) on future bladder compliance. No prospective series reports overall rates of spontaneous voiding, urinary continence with medical management, or evidence of sphincter incompetency leading to surgery in a cohort of consecutive children with spina bifida. Optimal medical management (frequency of CIC, overnight catheter drainage, AC regimens and doses) for detrusor overactivity or decreased compliance before augmentation is not standardized. Many retrospective, and a few prospective, series report outcomes from bladder neck surgery ± augmentation, with dryness in 50-90 %. Generally, LMS, artificial urinary sphincter (AUS), and bladder neck closure more reliably achieve dryness than slings or bladder neck injections. One-third or fewer of patients undergoing bladder outlet surgery without augmentation will manifest decreased compliance on postoperative UD. Most respond to medical therapy. Health-related quality-of-life surveys found no differences reported by patients before versus after surgery for incontinence, but reported improved independence and self-esteem following antegrade continence enema (ACE). ACE procedures can improve self-esteem and independence with bowel care. Few series comparing ACE to retrograde enemas report no additional benefit of ACE to achieve fecal continence. LACE uses less irrigation volume and requires less toilet time than ACE. Complications after ACE occur in 15 % to more than 50 % in published series, most commonly stoma stenosis or leakage. Pain with irrigation is also reported in some series with phosphate, saline, or tap water enemas. Series reporting >5-year follow-up indicate that 10-45 % of patients no longer use the ACE.