Treatment

Goals

■ Preservation of renal function

■ Age -appropriate social continence

■ No significant urinary tract infections

■ Normalized lifestyle

Treatment of Storage Dysfunctions

Detrusor hyperreflexia is decreased with these anti­cholinergic medications: propantheline bromide or oxybutynin chloride.

Treatment of Emptying Dysfunctions

The typical day-to-day management of the neurogenic bladder is clean intermittent catheterization every four hours while awake to keep bladder volumes within normal limits for age. In 1972, Lapides was the first to state that the sterile single-use catheter is unnecessary in the management of persons with neurogenic blad­ders because it does not reduce bacteriuria (86). This continues to be substantiated in the pediatric popu­lation (89). If this intervention is unsuccessful, vari­ous pharmacological and urologic surgical procedures may be explored. Crede's manuver should be used with extreme caution. Valsalva or Crede's maneuvers to empty the neurogenic bladder that has detrusor sphincter dyssynergia will likely raise the intravesicu- lar pressure to greater than 40 cm H20, thus putting the kidneys at risk. Bethanechol is rarely used to treat weak expulsive force of the detrusor. Hyperactive inter­nal sphincter mechanism may be treated with alpha- adrenergic blockers. Hyperactive external urethral sphincter may be treated with baclofen, neuromus­cular reeducation of the pelvic floor, Botox injections (87), or surgery.

Botox A injections to the external sphincter have shown promise for decreasing the resistance of the external urinary sphincter (87). The Mitrofanoff pro­cedure, first introduced in this country in the 1980s, uses the appendix to create a catheterizable conduit, typically between the bladder and the umbilicus. A flutter valve can help prevent external leakage; how­ever, leakage may be problematic in a small percent­age (88). A Mitrofanoff procedure may be useful in females who may have more difficulty cauteriz­ing than males. A vesicostomy may be a temporiz­ing measure for older children and adults. The ileal conduit was the first urinary diversion procedure, but follow-up studies showed a disappointingly high rate of renal deterioration, calculosis, hydronephro­sis, and the need for reversal of the procedure (74). Artificial sphincters have been found to be helpful in some, but can have infection, erosion, and mechani­cal problems.

Primary Care Treatment of Children Managed With Clean Intermittent Catheterization

Routine urinalysis (UA) and urine culture (UC) are not recommended during well-child check-ups if the child looks well. If bacteriuria is detected in the urine, it is important to determine whether it represents a clinical infection or colonization of the bladder. Only clinical UTIs should be treated (89). Prophylaxis in the absence of VUR is not routinely recommended.

Antibiotic Prophylaxis and Bacteriuria Treatment

A number of studies were done on antibiotic prophy­laxis and bacteriuria treatment with individuals with neurogenic bladders. Kass found that if there is no VUR, bacteriuria is innocuous; in his study, 17 hydroneph- rotic kidneys showed significant radiographic improve­ment since starting clean intermittent catheterization (CIC) (90). Ottolini found that asymptomatic bacteri- uria requires no antibiotic therapy in the absence of VUR (91). Van Hala found that there is no correlation between number of UTIs, the type of catheter used, or the use of prophylactic antibiotics (92).

(Note: It may be appropriate for a pediatric patient without a neurogenic bladder and with frequent UTIs secondary to dysfunctional voiding to receive prophy­lactic antibiotics for a time. Patients with VUR and with or without a neurogenic bladder routinely receive prophylactic antibiotics.)

Neonatal vs Childhood Treatment

Early proper management is imperative for the pres­ervation of renal function (96). Kidney damage was found to be approximately 1 in 4 without proper man­agement of the neurogenic bladder (97). On urody­namic testing, subtracted detrusor leak point pressure (p vesical-p abdominal) greater than 40 cm H2O, with a bladder capacity less than 33% of expected, was associated with renal damage (97).

Treatment of neurogenic bladder dysfunction due to myelomeningocele in neonates is recommended. A study of 98 individuals (46 started CIC in first year of life, 52 began CIC after four years of life) reviewed the charts of those using CIC who were believed to be at risk for renal deterioration. The mean follow-up of this study was 4.9 years, and the average age of the patient at the last follow-up was 11.9 years. The study found that neonatal treatment enabled UDY to identify those infants at risk for upper tract deterioration, which was prevented by the start of Ditropan (oxybutynin chlo­ride) and CIC. There was a similar improvement in UTI rate, hydronephrosis, and reflux.

If the bowels are void of constipation, accidents of stool and urine are less likely. With severe constipa­tion seen on an abdominal film, or with palpable stool still in the abdomen, the previous procedure should be followed along with an enema. Anatomic bowel obstruction should be ruled out by abdominal x-ray in severe constipation before a colonic cleansing enema is performed. A surgical procedure may be necessary, such as a catheterizable appendicocecostomy through the abdominal wall to flush the large intestine from the proximal end with an enema (105).

Anorectal manometry and biofeedback in the pres­ence of intact or partial rectal sensation anocutane- ous reflex offer encouraging results. Rectal sensation is considered normal when a rectal balloon inflated with 10 mL of water or less is perceived. The external sphincter activity can be recorded with surface elec­trodes. Repeated sessions of inflating and deflating the balloon comprises the biofeedback training (74). This can be done during a urodynamic procedure.