Neurogenic Bladder In Children Research Articles

Pharmacotherapy for Pediatric Neurogenic Bladder.

Neurogenic bladder (NB) is a nonspecific term that may describe conditions ranging from areflectic noncontractile bladder to detrusor overactivity. The most common cause of NB in children is the presence of dysraphic malformations. Urodynamic evaluations make it possible to describe bladder dysfunctions and to plan a therapeutic strategy for each patient. In a child with NB there are two major dangerous functional problems seen in urodynamic investigations: high intravesical pressure in the storage phase and high pressure during urination. The basic goals of urologic treatment for a child with NB are the protection of the urinary tract from complications and improvement of continence. Treatment for a child with NB is usually conservative, and focuses on achieving safe bladder pressures during storage with reliable emptying, via voiding or catheterization. The two most important forms of conservative treatment are clean intermittent catheterization and pharmacological treatment of functional disorders. Some drugs are used in the treatment of functional disorders in children with NB, but none of the drugs are officially approved for small children and babies.

Urodynamic changes after bladder augmentation surgery in paediatric patients with myelomeningocele due to neurogenic bladder

Abstract Background Augmentation cystoplasty is a successful surgical procedure for the management of neurogenic bladder in children in order to improve urodynamic parameters. The aim of this article is to describe urodynamic changes after augmentation cystoplasty in children with myelomeningocele. Materials and methods A descriptive cross-sectional study including children aged 8–16 years with a myelomeningocele operated on for augmentation cystoplasty surgery with sigmoid colon segments due to a neurogenic bladder from the years 2003–2013. A urodynamic study was conducted before and after the surgical procedure. Non-probabilistic sample of consecutive cases. Descriptive statistics with frequencies and percentages, medians, and ranges. Inferential intra-group comparison with the Wilcoxon test and inter-group with Mann–Whitney U . SPSS 20.0 statistical package. Results The study included 50 patients, of whom 25 were male and 25 were female, with a median age of 12 years (range, 6–15 years). Bladder capacity improved from 52.8% to 95.9% ( p p 2 O and 11.0 cmH 2 O, respectively ( p 2 O ( p 2 O ( p Conclusions Augmentation cystoplasty with sigmoid colon significantly improved urodynamic parameters, such as bladder accommodation and filling pressure in children with myelomeningocele-associated neurogenic bladder.

Cambios urodinámicos posteriores a cirugía de ampliación vesical por vejiga neurogénica en pacientes pediátricos con mielomeningocele

BackgroundAugmentation cystoplasty is a successful surgical procedure for the management of neurogenic bladder in children in order to improve urodynamic parameters.The aim of this article is to describe urodynamic changes after augmentation cystoplasty in children with myelomeningocele. Materials and methodsA descriptive cross-sectional study including children aged 8–16 years with a myelomeningocele operated on for augmentation cystoplasty surgery with sigmoid colon segments due to a neurogenic bladder from the years 2003–2013. A urodynamic study was conducted before and after the surgical procedure. Non-probabilistic sample of consecutive cases. Descriptive statistics with frequencies and percentages, medians, and ranges. Inferential intra-group comparison with the Wilcoxon test and inter-group with Mann-Whitney U. SPSS 20.0 statistical package. ResultsThe study included 50 patients, of whom 25 were male and 25 were female, with a median age of 12 years (range, 6–15 years). Bladder capacity improved from 52.8% to 95.9% (p<0.001), uninhibited contractions 1.4–1.8, contraction intensity 47–8.5 (p<0.001), mean pre-surgical and post-surgical filling pressure 40.8cmH2O and 11.0cmH2O, respectively (p<0.001), mean emptying pressure 48.5 vs. 3.6cmH2O (p<0.001), and bladder accommodation 4.6 vs. 41.3cmH2O (p<0.001). ConclusionsAugmentation cystoplasty with sigmoid colon significantly improved urodynamic parameters, such as bladder accommodation and filling pressure in children with myelomeningocele-associated neurogenic bladder.

Textbook of the Neurogenic Bladder. 3rd ed.

The symptoms and conditions resulting from a neurogenic bladder are one of the most commonly encountered clinical scenarios to those involved in managing lower urinary tract dysfunction. However, understanding the neuro-circuit and the various pathologies are considered difficult to learn and absorb. It is probably because the education and training involved are either too minimal or nearly nonexistence during residency. As the title states this is a textbook solely dedicated to the neurogenic bladder. It starts with the basic anatomy and functional pathology of the lower urinary tract and goes on to cover the methods involved in evaluating these patients. The evaluation section starts with patient history and physical examination and reviews methods such as endoscopic, imaging, and electrophysiology exams. What also differentiate this book from others are the separate sections on meningomyelocele and sexual dysfunction. Many chapters with further detailed topic such as pregnancy in spinal cord injury will probably be difficult to find elsewhere. Although this book is mostly focused on adult conditions many discussions can still be applied to children and information specific to neurogenic bladder in children are also covered. This is a truly comprehensive one stop textbook for learning about the various types of neurogenic bladders.

Pharmacokinetics of Intravesical Versus Oral Oxybutynin in Healthy Adults: Results of an Open Label, Randomized, Prospective Clinical Study

We investigated the pharmacokinetics of intravesical oxybutynin and discuss the clinical implications of the results. We performed an open label, randomized, 3-period crossover clinical study in 20 healthy adults. In periods 1 and 2 subjects received a single dose of 10 mg oxybutynin HCl solution intravesically or a 5 mg tablet orally. Period 3 comprised repeat intravesical applications (7 doses) of 10mg oxybutynin HCl. Enantioselective concentrations of oxybutynin and N-desethyloxybutynin were quantified by liquid chromatography-mass spectrometry. Pharmacokinetic parameters were calculated by noncompartmental methods, analyzed by descriptive statistics and compared using the average bioequivalence approach. Systemic exposure to racemic oxybutynin after intravesical administration was significantly greater, yielding 294% (90% CI 211-408) of that after oral intake of immediate release preparations, as measured by the dose normalized area under the plasma concentration time curve. In contrast, systemic exposure to racemic N-desethyloxybutynin reached only 21% (90% CI 15-29). The area under the plasma concentration time curve ratio of N-desethyloxybutynin to oxybutynin was 14-fold decreased for intravesical administration. After intravesical multidose administration, the cumulation of oxybutynin (1.3-fold) and N-desethyloxybutynin (1.6-fold) was weak, absorption was prolonged and apparent elimination half-lives were longer. The study medication was well tolerated with a third of participants reporting anticholinergic adverse effects. Our study provides evidence of significantly higher bioavailability of intravesical vs oral administration of oxybutynin due to circumvention of the intestinal first pass metabolism. Given the high efficacy and decreased rate of adverse effects, intravesical oxybutynin should be considered in patients with neurogenic lower urinary tract dysfunction who do not tolerate oral administration or in whom oral preparations fail to improve detrusor overactivity.

Evolution of the management of acquired neurogenic bladder in children using intradetrusor botulinum toxin type A injections: 5-year experience and perspectives

ObjectiveTo report the clinical and urodynamic results of repeated intradetrusor botulinum toxin type A injections in children with an acquired neurogenic bladder. Patients and methodWe reviewed the data of 8 patients presenting an acquired neurogenic bladder treated between 2005 and 2010. Their mean age was 12.4 years old (range: 5–18). They were all on clean intermittent catheterization. All patients presented detrusor overactivity resistant to oral anticholinergic treatment. They received between 2 and 6 injections at a dose of 12 botulinum toxin units (BU)/kg (maximum 300 BU). Cystometry was performed 4–8 weeks after treatment. ResultsFive patients became completely dry, 2 were only rarely wet, and data are lacking for 1 patient. Febrile urinary tract infections ceased after 1 or 2 injections. The mean maximal detrusor pressure decreased below 40 cmH2O after 1, 2 and 3 injections. The normalized safe capacity rose significantly after 1, 2 and 3 injections. The normalized maximal bladder capacity rose similarly after 1, 2 and 3 injections although not always significantly. ConclusionIntradetrusor botulinum toxin-A injections significantly reduce detrusor pressure and can be repeated with efficacy. They have their place in between anticholinergic treatment and surgery. The procedure could be simplified and the dosage reduced.

General evaluation of neurogenic bladder in children

General evaluation of neurogenic bladder in children

The Effects and Side-Effects of Endoscopic Application of Botulinum Toxin-A In Children with Neurogenic Bladder

Purpose To evaluate the effects and side-effects of endoscopic application of Botulinum-A toxin in the treatment of overactive neurogenic bladder in children. Material and Methods A prospective, non placebo controlled study, conducted with the approval of a Local Ethics Committee. 142 procedures of endoscopic, intradetrusor injections of BTX were performed on 49 girls, and 37 boys, with neurogenic bladder overactivity, aged 1-14 years (mean age 6,4 years). In all of children decreased bladder capacity and detrusor overactivity with urine incontinence were estimated in cystometries despite of oral oxybutynin treatment. In 29 children one injection was performed, in the rest one or more re-injections were performed. Two products were used in weight dependent dosage: Dysport, Ipsen up to 50 U/ kg, Botox, Allergan up to 10 U/ kg body weight. The dose was diluted in 10 ml 0.9% NaCl and injected in 20 sites of bladder dome. We compared pre and post-procedure: volumes of catheterized urine, volumes, pressures from cystometries. Statistical analyses were performed using nonparametric tests: the Wilcoxon signed rank sum test and the U Mann-Whitney test. A p-value of less than 0.05 was considered statistically significant. Results Values of neuro-urologic parameters (catheterized bladder volumes, cystometric bladder capacity, detrusor pressure) improved significantly in 76 to 81% of patients after therapy (p Conclusions Endoscopic administration of Botulinum-A toxin improves functional parameters of neurogenic bladder in children. It represents an alternative to surgical augmentation of bladder and reduction of intravesical pressures.

Natural Fill Urodynamics and Conventional Cystometrogram in Infants With Neurogenic Bladder

We compared findings from natural fill urodynamics and conventional cystometrogram in infants with neurogenic bladder. We retrospectively analyzed data from 19 infants undergoing 24-hour natural fill urodynamics and cystometrogram. The infants concurrently underwent ultrasound. Voided volume, detrusor overactivity, area under the curve (per minute) and baseline detrusor pressure obtained at natural fill urodynamics were compared to cystometric capacity, detrusor overactivity, leak point pressures and bladder compliance obtained at cystometrogram. Voided volumes during natural fill urodynamics were significantly less than cystometric capacity volumes (p <0.001). Natural fill urodynamics revealed more detrusor overactivity than did cystometrogram. Four infants with leak point pressures greater than 40 cm H2O had detrusor overactivity at natural fill urodynamics. Five patients with leak point pressure less than 40 cm H2O had no detrusor overactivity at natural fill urodynamics or cystometrogram. Four of 5 infants with decreased bladder compliance had baseline detrusor pressure greater than 10 cm H2O and detrusor overactivity. Urodynamic parameters obtained at natural fill urodynamics may be associated with cornerstone parameters such as leak point pressure and bladder compliance obtained at cystometrogram.

Evaluation of lower urinary system symptoms and neurogenic bladder in children with cerebral palsy: relationships with the severity of cerebral palsy and mental status

Aim: This study aimed to evaluate lower urinary system symptoms, to determine bladder type in children with cerebral palsy (CP), and to determine the relationship between bladder type, and the severity of CP and mental status of the children. Materials and Methods: The study included 41 children with CP. Subjects were first asked to provide information concerning lower urinary system symptoms. Urodynamic examination was performed in 41 children with CP. The severity of CP was determined according to the Gross Motor Functional Classification System (GMFCS). The Stanford-Binet Intelligence Scale was used to determine intelligence quotients (IQ). After urodynamic examination, subjects were divided into 2 groups based on bladder type: neurogenic detrusor overactivity (NDO) and normal bladder (NB) groups. Results: One or more lower urinary system symptoms were observed in 78% of the subjects. NDO was observed in 30 subjects (73.2%), while NB was observed in 11 (26.8%), based on urodynamic study. While there was an almost statistically significant difference in terms of IQ scores (P = 0.053) between the NDO and NB groups, there was not a statistical difference in terms of GMFCS distribution. Conclusion: The incidences of urinary system symptoms and neurogenic bladder are high in the CP population. Multiple factors, such as the effects on IQ, bladder functions, and mobility caused by cerebral lesions, may cause urinary dysfunction.

Non-surgical management of urinary incontinence in children

Urinary incontinence and neurogenic bladder are common in children, and can be difficult to treat. This themed issue includes contributions by experts in the management of these disorders. Dr. John Kryger discusses the nonsurgical management of neurogenic bladder in children with spina bifida. Drs. Lori Dyer and Israel Franco summarize the literature and their experience with the use of botulinum toxin in neurogenic and non-neurogenic incontinence in children. Dr. Paul Austin summarizes the use of alpha-adrenergic blockers. These drugs are primarily used to treat bladder outlet obstruction due to prostatic hyperplasia, but show great promise in the treatment of dysfunctional voiding in children.

Effects of electrotherapy in treatment of neurogenic bladder in children with occult spinal dysraphism

Neurogenic bladder can develop as a result of various degrees of neurogenic lesion in spina bifida. The degree of bladder dysfunction depends on the level and type of spina bifida. Due to results upon complete diagnostic protocols, treatment options are applied. Comparison of therapy results of patients with occult spinal dysraphism with neurogenic bladder that underwent medicamentous therapy and medicamentous with electrotherapy treatment. We had 49 patients with neurogenic bladder that were treated at the University Children's Hospital in Belgrade in the period 2003-2008. The first group of children received medicamentous therapy and the second group received medicamentous therapy with transcutaneous electric nerve stimulation. In both groups we evaluated 4 symptoms: daily enuresis, enuresis nocturna, urgency and frequency and 4 urodynamic parameters: lower bladder capacity, unstable contractions and residual urine and detrusor sphincter dyssynergia. Follow-up urodynamic evaluation was done after 3, 6 and 12 months respectively. Our findings pointed out a high statistical significance of improvement in all evaluated urodynamic parameters of neurogenic bladder (predominantly in bladder capacity) in the group of children with combined therapy as well in resolution of symptoms (predominantly enuresis nocturna, urgency and frequency). Combined therapy is more efficient in treatment of children with neurogenic bladder. Electrotherapy is non-invasive, easily applicable and has had a significant place in treatment of children with dysfunctional voiding.

Myelomeningocele: neglected aspects

The commonest cause of neurogenic bladder in children is myelomeningocele. Survival of children is much improved in the Western world, but by 35 years old, about 50% will have died. In adults, the commonest causes of death are lung and heart diseases. All physical aspects deteriorate with age, especially in those with thoracic lesions. Those who walk in childhood have a 20–50% chance of becoming wheelchair dependent as adults. Immobility, poor respiratory reserve, obesity, latex allergy and worsening kyphoscoliosis contribute to the increased risks of surgery. It is essential that safe and manageable urine drainage is established in childhood: the bladder never improves with time, and surgical reconstruction becomes progressively more difficult. Independence in adult life will only be possible with intense preparation in childhood. Children must be allowed to join in with family chores and events. Education, both academic and practical, must be encouraged. Skills such as driving, shopping and birth control must be taught. However, even with the best support, less than 40% will have gainful employment. Children who are continent and have lesions below L2 are likely to have normal sexual function. Sexual activity in adolescents, especially in those with hydrocephalus, is limited (but not absent). However, by adult life, about two thirds will have established a regular partnership. All females and those males who are naturally potent are likely to be fertile. There is a high risk of neural tube defects in their offspring unless the female partner takes prophylactic folic acid for 3 months before pregnancy and for first trimester.

Nonsurgical Management of the Neurogenic Bladder in Children

The neurogenic bladder can have many serious consequences. However, with proper understanding of the disease spectrum, and with proper awareness of the surveillance and management tools, adverse outcomes can be minimized. The incidence of renal failure is uncommon. With proper medical therapy, one can achieve continence and minimize the risk of symptomatic urinary tract infections. There are a number of nonsurgical strategies described that can help in the management of the neurogenic bladder.

Treatment with modified intravesical oxybutynin chloride for neurogenic bladder in children

Objective We have previously reported that intravesical oxybutynin chloride with hydroxypropylcellulose (modified intravesical oxybutynin) is an effective therapeutic agent for patients with detrusor overactivity. In this study, we report on the efficacy, safety and side effects of modified intravesical oxybutynin administration in children with neurogenic bladder. Patients Modified intravesical oxybutynin (1.25 mg/5 mL, twice a day) was administered to four children (three males and one female) with neurogenic bladder (detrusor overactivity and/or low compliance bladder), who were previously unresponsive to or experienced intolerable side effects from oral medications. A cystometrogram was obtained before, 1 week after, and 1 year after the first intravesical instillation of modified oxybutynin. We also carefully observed anticholinergic side effects, occurrence of urinary tract infection and degree of incontinence during this treatment. Results After 1 week, both cystometric bladder capacity and compliance were improved in all patients, and detrusor overactivity was undetectable in three of four patients. At 1 year, there was further improvement in bladder compliance in three patients, and detrusor overactivity was not observed in two patients. Significant improvement in the degree of incontinence was achieved. No systemic anticholinergic side effects were observed in any of the patients. One patient with vesicoureteral reflux discontinued the therapy after 2 months due to upper urinary tract infections. Conclusion Modified intravesical oxybutynin is an effective and relatively safe therapeutic option for children with neurogenic bladders.

Does Surgical Release of Secondary Spinal Cord Tethering Improve the Prognosis of Neurogenic Bladder in Children With Myelomeningocele?

The diagnostic criteria for secondary tethering of the spinal cord in children with prior closure of an open spinal defect are not well defined. Urological, neurological or orthopedic deterioration during followup remains the only strong indicator for the diagnosis of this condition. However, the outcome of untethering surgery cannot always be predicted. The aim of this study was to determine neurourological outcome after secondary untethering surgery in children with myelomeningocele. Of 401 children with myelomeningocele followed at our multidisciplinary spina bifida clinic between 1996 and 2005, 56 (14%) were diagnosed with secondary tethering of the spinal cord (median age at diagnosis 4.1 years). The diagnosis was based on urological and neuro-orthopedic deterioration in 58% and 42% of children, respectively. Preoperative urological findings were compared with 6-month postoperative findings. Febrile urinary tract infection, upper tract dilatation and vesicoureteral reflux were preoperatively documented in 48.2%, 19% and 30% of the 56 children, respectively. At 6 months postoperatively urine cultures were sterile in 34% of patients and upper tract dilatation completely resolved in 45%. For all grades of vesicoureteral reflux complete resolution occurred in 47% of patients. Urodynamic parameters in terms of cystometric bladder capacity and detrusor leak point pressure substantially improved 6 months after untethering surgery (125 vs 170 ml and 69.1 vs 47.5 cm H2O, respectively, p < 0.05). Assessment of urodynamic findings in 19 children at 1 year failed to demonstrate a significant change in these parameters. A subgroup analysis according to patient age at untethering surgery revealed urodynamic improvement was more significant in children who were diagnosed and treated before age 7 years. Secondary tethering of the spinal cord is a major risk factor for urological and neurological deterioration in children with myelomeningocele. Close urological surveillance remains the most valuable tool in the early diagnosis. Our study shows that secondary untethering surgery may significantly improve urological outcome.

Las Disfunciones Miccionales en la Infancia

Voiding micturing dysfunction is a disease of the bladder that compromises the emptying or filling function, with a neurogenic, miogenic or unknown etiology. The diagnostic and therapeutical approach have been actualized in the last years. Neurogenic bladder is defined as a voiding disfunction as consequence of neuropathic or miogenic disorders. Neurogenic non neurogenic bladder is defined as a voiding disfunction without organic etiology. Raqui-medular dysraphias, caudal pole malformations, tumors, infections or traumatism of nervous central system are the main etiologies of neurogenic bladder in children. Early and correct management of dysfunction micturing avoid renal and urinary tract damage, and deletereous consequences as chronic renal failure. Functional voiding dysfunctions are evidenced by symptoms like urge-incontinence, enuresis, soiling, urinary tract infections, recurrent vulvovaginitis etc. To present the current knowledge in diagnostic and therapeutics methods as urodynamics, drugs, and pelvic floor kinetics (bio feedback) in neurogenic and non neurogenic dysfunction voiding bladder is the aim of this presentation.

Follow-up of Long-term Treatment with Clean Intermittent Catheterization for Neurogenic Bladder in Children

To assess the results of long-term clean intermittent catheterization (CIC) treatment for neurogenic bladder in children born with myelomeningocele, and to compare the long-term results between the early treatment group (< 1 year old) and late treatment group (> 3 years old). Thirty-six paediatric patients with myelomeningocele who were treated in the first year of life (Group 1) and 31 cases who were treated after the age of 3 years (Group 2) were followed regularly for at least 11 years. All medical records were reviewed and long-term results of treatment, including increases in blood urea nitrogen (BUN) and serum creatinine, development of hydronephrosis, recurrent upper urinary tract infection, and the number of augmentation cystoplasties needed, were noted. Kaplan-Meier methods were used to analyse time-to-event data. Mean age at start of treatment was 6.88 months (range, 3-1 months) in Group 1 and 44.97 months (range, 37-60 months) in Group 2. Increases in BUN and serum creatinine were found in 12 cases (33.3%) in Group 1 and 19 cases (61.3%) in Group 2. Patients in Group 2 showed earlier renal deterioration and worse renal function at the last follow-up. Hydronephrosis was found in 10 cases (27.8%) in Group 1 and 18 cases (58.1%) in Group 2. Patients in Group 2 also had earlier and more severe hydronephrosis. Augmentation cystoplasty was needed in five cases (13.9%) in Group 1 and 10 cases (32.3%) in Group 2. The results of surgery were better in Group 1 than in Group 2, and surgery was needed earlier in Group 2 compared with Group 1. There was no significant difference regarding upper urinary tract infection between the two groups. For most patients and with close long-term follow-up, early treatment of neurogenic bladder using CIC in children born with myelomeningocele yields better results than late treatment. In our experience, treatment is recommended as soon as possible, especially during the first year of life.

Botulinum-A Toxin in the Treatment of Neurogenic Bladder in Children

Botulinum-A Toxin in the Treatment of Neurogenic Bladder in Children

A SHORT-TERM, MULTICENTER, RANDOMIZED DOUBLE-BLIND DOSE TITRATION STUDY OF THE EFFICACY AND ANTICHOLINERGIC SIDE EFFECTS OF TRANSDERMAL COMPARED TO IMMEDIATE RELEASE ORAL OXYBUTYNIN TREATMENT OF PATIENTS WITH URGE URINARY INCONTINENCE

We compared the short-term efficacy, safety and tolerability of transdermal versus oral oxybutynin in adults with urge urinary incontinence. Volunteers with detrusor instability currently responding to oral immediate release oxybutynin were enrolled in our study. Those patients presenting with recurrence of incontinent symptoms after a 2-week washout underwent confirmatory cystometrogram with subsequent randomization to transdermal or oral treatment. Matching active and placebo medications included matrix patches applied twice weekly and capsules taken 2 or 3 times daily. Dose titration was based on anticholinergic symptoms. Outcome measures included comparison of baseline to 6 week changes in incontinence episodes on a 3 day urinary diary, a visual analog scale for efficacy and anticholinergic symptoms reported on a questionnaire. Safety monitoring included adverse events and skin tolerability of the transdermal system. A total of 76 patients were enrolled and 74 completed at least 4 weeks of treatment. Mean age in the transdermal and oral groups was 64 and 63 years, and 87% and 97% were female, respectively. Daily incontinent episodes decreased in the transdermal and oral groups (7.3 to 2.4 [66%] and 7.4 to 2.6 [72%], respectively, p = 0.39). The visual analog scale reduction in urinary leakage improved from washout in both groups (p <0.0001) with no difference between them (p = 0.9). Dry mouth occurred in significantly fewer patients in the transdermal (38%) compared with those in the oral group (94%, p <0.001). Of the patients in the transdermal group 67% noticed a reduction in dry mouth severity compared with previous oral treatment, and 90% had none or mild skin erythema. Transdermal delivery of oxybutynin resulted in comparable efficacy and a significantly improved anticholinergic side effect profile compared with oral administration in adults with urge urinary incontinence.