Relationship of bladder dysfunction with upper urinary tract deterioration in cerebral palsy

The assessment and management of voiding dysfunction in adults living with cerebral palsy

PURPOSE

Improvements in life expectancy have resulted in an increasing number of adults with cerebral palsy, of which over a third will have neurogenic lower urinary tract dysfunction (NLUTD). This review explores urinary dysfunction in adults with cerebral palsy.

METHODS

Relevant literature on NLUTD in adults with cerebral palsy was identified using an unrestricted search of PubMed.

RESULTS

Urinary incontinence is the most common complaint, often accompanied by frequency and urgency. Special consideration should be given to women and in those with worse motor or cognitive dysfunction as they have been shown to have more severe urologic symptoms. NLUTD can have significant morbidity and impact quality of life. Hospital admission, urinary tract infections, and hydronephrosis are common urologic complications, with poor urinary function associated with decreased quality of life (QOL). Neurogenic detrusor overactivity is the most common urodynamic abnormality, with elevated detrusor leak point pressure and reduced bladder capacity. Detrusor sphincter dyssynergy is present in some patients and maybe secondary to generalized spasticity or incomplete upper motor neuron injury. Elevated bladder capacity is also present in a portion of patients, and becomes particularly relevant in adults as a result of increased spasticity of the urinary sphincter. Conservative management like functional toileting strategies, medications, and incontinence aids are successful in most patients. Medical management with anticholinergics is well described, and frequently the only intervention required, particularly in children. Intermittent clean catheterization has mixed results with this population, as its efficacy is limited by pelvic spasticity and patient factors. Surgical intervention, while often successful, should be restricted to select patients, as it is associated with significant morbidity in this population.

CONCLUSION

Management of NLUTD in adults with CP involves conservative management, medications, and in rare cases surgical intervention.

Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy

Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.

Zika-Related Microcephaly and Its Repercussions for the Urinary Tract: Clinical, Urodynamic, Scintigraphic and Radiological Aspects

Aims: Describing the urodynamic parameters of children aged 3 to 5 years with microcephaly related to congenital Zika syndrome and verifying the association with clinical, imaging and neurological characteristics. Methods: From October 2018 to March 2020, children with Zika-related microcephaly underwent urological, ultrasonographic and urodynamic evaluation. In selected cases, complementary exams such as urethrocystography and scintigraphy were performed. The children also underwent a complete neurological evaluation. To compare frequency between groups, we used Pearson’s chi-squared test or Fisher’s exact test. Results: This study evaluated 40 children, of whom 85% were 4 years old, and all had abnormalities on the urodynamic study, with low bladder capacity (92.5%) and detrusor overactivity (77.5%) as the most frequent findings. Only three children had ultrasound abnormalities, but no child had cystographic or scintigraphic abnormalities, and the postvoid residual volume was normal in 80% of cases. In spite of a frequency of 67.5% of intestinal constipation, there was no record of febrile urinary tract infection after the first year of life. All children presented severe microcephaly and at least one neurological abnormality in addition to microcephaly. The homogeneity of the children in relation to microcephaly severity and neurological abnormalities limited the study of the association with the urodynamic parameters. Conclusions: Urodynamic abnormalities in children aged 3 to 5 years with Zika-related microcephaly do not seem to characterize a neurogenic bladder with immediate risks for the upper urinary tract. The satisfactory bladder emptying suggests that the voiding pattern is reflex.

Urodynamic study findings and related influential factors in pediatric spastic cerebral palsy

To investigate the urodynamic study (UDS) result in pediatric patients suffering from spastic cerebral palsy (CP). Medical records of patients diagnosed CP having pre-operative UDS results underwent selective dorsal rhizotomy (SDR) from Jan. 2020 to May. 2021 were retrospectively reviewed. Fifty-seven cases diagnosed spastic CP were included in the study (mean age, 6.73 ± 2.84 years), among which, 46 were ambulatory and 11 non-ambulatory. Average gross motor function measure-66 (GMFM-66) score was 62.16 ± 11.39. Reduced bladder capacity was seen in 49.12% of these cases and cases with lower GMFM-66 score possessed a higher incidence rate of having low bladder capacity (p < 0.01). Detrusor overactivity (DO) was shown in 33.33% of the patients. Cases with younger age presented a higher prevalence of DO (p < 0.05). Meanwhile, more non-ambulant patients suffered from DO (p < 0.05). Increased post-voiding residual (PVR) was seen in 21.05% of the cases. Those with higher average threshold in sphincter-associated input spinal nerve roots (rootlets) witnessed a higher rate of having abnormal PVR (p < 0.05). Abnormal UDS results were prevalent in pediatric patients suffering from CP. Motor function, age and threshold of their sphincter-associated spinal nerve roots laid corresponding effect on the abnormal UDS results.

Multi-Organ Dysfunction in Cerebral Palsy

Cerebral Palsy (CP) describes a heterogenous group of non-progressive disorders of posture or movement, causing activity limitation, due to a lesion in the developing brain. CP is an umbrella term for a heterogenous condition and is, therefore, descriptive rather than a diagnosis. Each case requires detailed consideration of etiology. Our understanding of the underlying cause of CP has developed significantly, with areas such as inflammation, epigenetics and genetic susceptibility to subsequent insults providing new insights. Alongside this, there has been increasing recognition of the multi-organ dysfunction (MOD) associated with CP, in particular in children with higher levels of motor impairment. Therefore, CP should not be seen as an unchanging disorder caused by a solitary insult but rather, as a condition which evolves over time. Assessment of multi-organ function may help to prevent complications in later childhood or adulthood. It may also contribute to an improved understanding of the etiology and thus may have an implication in prevention, interventional methods and therapies. MOD in CP has not yet been quantified and a scoring system may prove useful in allowing advanced clinical planning and follow-up of children with CP. Additionally, several biomarkers hold promise in assisting with long-term monitoring. Clinicians should be aware of the multi-system complications that are associated with CP and which may present significant diagnostic challenges given that many children with CP communicate non-verbally. A step-wise, logical, multi-system approach is required to ensure that the best care is provided to these children. This review summarizes multi-organ dysfunction in children with CP whilst highlighting emerging research and gaps in our knowledge. We identify some potential organ-specific biomarkers which may prove useful in developing guidelines for follow-up and management of these children throughout their lifespan.

Acute urinary retention in pediatric cerebral palsy: Is there an optimal management strategy?

INTRODUCTION AND OBJECTIVE

Cerebral palsy (CP) patients commonly have lower urinary tract dysfunction. Urinary retention (UR), which has been associated with dysfunctional voiding in CP can correlate to chronic upper tract dysfunction. We sought to provide insight into the pediatric presentation of acute UR in patients with CP and subsequent outcomes in this at-risk population.

STUDY DESIGN

All children with perinatally acquired CP presenting to a regional health network were identified from 2009 to 2019. Retrospective analysis of a hospitalized subset concurrently diagnosed with a first episode of acute UR was performed. Factors associated with new-onset UR are described, as well as management. Using follow-up data, we also assessed the risk for recurrent UR and/or abnormal renal imaging after an initial UR presentation.

RESULTS

3404 CP patients were analyzed with only 33 fulfilling inclusion criteria. Median age was 10(IQR 7.5-16; range 1-22) years, 87.9% were GMFCS-V. 39.4% had a reported history of decreased urinary frequency. At presentation, median maximal time without void prior to catheterization was 13 h, and catheterized volume was a median 120% expected capacity-for-age. 84.8% of presentations were associated with a known transient/reversible etiology. 51.5% were post-anesthesia at median 3.5 days, 33.3% had associated constipation, 30.3% had received exacerbating medications. 11/33 were taught clean intermittent catheterization (CIC) after the initial presentation (all pro re nata [PRN] except one). At a median follow-up of 37 months: 50% of those without a CIC PRN no void plan had a repeat episode, at a median of 10.8 months later. Of the patients who had follow-up renal imaging at a median 22.0 months after presentation, 45% had abnormalities: 7 with debris or suspected stones and 2 with collecting system dilation. No factors associated with the initial UR presentation were found to be significantly predictive of recurrence or abnormal follow-up imaging.

DISCUSSION

Patients with CP presenting with acute UR are often those with the most severe limitations and have a history of decreased urinary frequency. They usually have transient or reversible factors associated with UR presentation, however UR recurrence and abnormal imaging in this population subset is common.

CONCLUSIONS

Pediatric patients with CP who present with acute UR usually present in the context of recent anesthesia and in the setting of exacerbating factors. They are at risk for recurrence and may be best managed with caretaker education of CIC PRN no void to address recurrent episodes. Providers should consider surveillance of these patients for the development of abnormal renal imaging.

Urological profile of children with microcephaly and congenital zika syndrome

INTRODUCTION

An outbreak of Zika virus disease, a self-limiting arbovirus infection involving skin rash and fever, occurred in Brazil in 2015 and was followed by an increase in newborns with microcephaly and brain malformations. Although two recent studies reported neurogenic bladder in children with microcephaly and congenital Zika syndrome (CZS), urologic evaluation is not yet routine.

OBJECTIVE

To investigate the urological profile of children with microcephaly and CZS.

STUDY DESIGN

A descriptive, cross-sectional study conducted with children with microcephaly undergoing clinical, laboratory, urodynamic and ultrasonographic evaluation at a center for childhood urinary disorders in Salvador, Bahia, Brazil.

RESULTS

Thirty-three children were evaluated. Mean age was 40.3 ± 3.2 months (range 35-47 months). Twenty-one (63.6%) were female. None urinated voluntarily. Urine stream was continuous in 22 (66.7%) and intermittent in 3 (9.1%), with no information in 8 cases (24.2%). Abdominal straining during voiding was absent in 27 (81.8%) and present in 3 (9.1%), with no information in 3 cases (9.1%). Upper urinary tract dilatation was not detected in any of the 27 ultrasounds performed. Twenty-two urine cultures were performed, with no cases of bacterial growth. Renal function was normal in all cases (mean creatinine 0.41 ± 0.1 mg/dl, range 0.29-0.79 mg/dl and urea 20 ± 7 mg/dl, 6-36 mg/dl). Mean maximum bladder capacity was lower than expected for age: 46.4 ± 25.6 mL range 15-110 mL versus 135.2 ± 6.6 mL, 125.5-153 mL, respectively (p < 0.0001). Sixteen patients (59.2%) had immature and reflex bladder, 3 (11.1%) had neurogenic bladder with small bladder compliance, 5 (18.5%) had neurogenic bladder and detrusor overactivity and 1 (3.7%) had normal bladder capacity and compliance, but urinated with abdominal straining and a significant residue. Urodynamic evaluation was normal in only two children (7.4%).

DISCUSSION

Most children evaluated had immature and reflex bladder, with no repercussions on the upper urinary tract. Literature on urological complications in children with microcephaly is sparse; however, the present results differ from cases of neurogenic bladder in children with neural tube closure defects. Microcephaly in CZS involves a neurological and urodynamic pattern very similar to that found in children with cerebral palsy. Study limitations include the absence of a control group and neurological data with which to correlate these findings.

CONCLUSION

Neurogenic bladder in children with CZS-associated microcephaly was much less common than recently reported. Most patients had no kidney abnormalities, but small bladder capacity and reflex bladder, with non-significant post-void residual urine.

Routine Screening and Treatment of Urinary Tract Infection May Be Justified in Children and Adolescents with Cerebral Palsy: A Systematic Review

Context: Children and adolescents with cerebral palsy may present with lower urinary tract dysfunction which increases their risk for urinary tract infection (UTI). Whereas few studies reported low prevalence rates of UTI in these patients, several studies documented high prevalence rates. Thus, it appears there is no unanimity about the burden of UTI in affected children and adolescents to justify routine screening and treatment of the infection. This systematic review aims to determine the risk and pooled prevalence rate of UTI in children and adolescents with cerebral palsy. Evidence Acquisition: Using appropriate descriptors, we searched the PubMed and Google Scholar databases. Eligible papers were primary studies published in English language: reporting an association between cerebral palsy and UTI or UTI prevalence in children and adolescents with cerebral palsy and healthy comparators, with a clear definition of UTI and cerebral palsy. We assessed the quality of included studies with the Newcastle-Ottawa Scale (NOS) and resolved inter-rater discrepancies by consensus. We independently retrieved relevant data from these studies using a preconceived data-extraction form. We analyzed the aggregate data on UTI prevalence in these pediatric patients, using the log odds ratio (OR) at 95% confidence interval as the summary estimate. Results: Of the seven included studies, only two (28.6%) were case-control studies, while five (71.4%) were cross-sectional studies. There was no uniform definition of UTI in these studies. Prevalence rates varied widely from as low as 2.2% to as high as 56.7%. The mean UTI prevalence rate estimated for six of the included studies was 31.8%. The log OR at 95% CI computed for the case-control studies was 10.9 (95% CI: 9.0, 12.9). Conclusions: The prevalence and risk of UTI in children and adolescents with cerebral palsy are significantly high. Routine screening and treatment for UTI may be justified in these pediatric patients. We however recommend more prospective case-control studies to strengthen the current evidence of the high UTI burden in these patients.

Prevalence and antimicrobial sensitivity pattern of urinary tract infection among children with cerebral palsy, Moshi, Tanzania

Background

Urinary tract infection (UTI) in children with cerebral palsy (CP) is a challenging yet common clinical condition. Children with CP bare the greatest risk of contracting UTI because of their difficulties in neuromotor control which lead to delay of bladder control, causing incomplete bladder emptying and urine retention.

Method

This was an analytical cross-sectional study that was conducted from September 2016 to March 2017 at Comprehensive Community Based Rehabilitation in Tanzania – Moshi and Kilimanjaro Christian Medical Centre Neurological Pediatrics Outpatient Clinic. All children who met the inclusion criteria were studied. Urine samples were collected at one point by catheterization, and urine dipstick and urine culture were done. Data were analyzed using SPSS version 20.

Results

A total of 99 children were enrolled in the study. The median age was 4 years (3–8 years); 53.5% were aged between 2 and 4 years. More than half were male. UTI was detected in 13.1% (n=13) of the children. Five causative agents of UTI were isolated, namely Escherichia coli, Proteus mirabilis, Klebsiella pneumonia, Staphylococcus aureus, and Enterococcus faecalis. The two most common organisms, E. coli and P. mirabilis, both had low sensitivity to ampicillin and co-trimoxazole while they were sensitive to ciprofloxacin and ceftriaxone.

Conclusion

UTI is a common finding among children with CP. E. coli and P. mirabilis are the commonest causative agents and are sensitive to ciprofloxacin and ceftriaxone but have low sensitivity to ampicillin and co-trimoxazole.

Fever in Children: Pearls and Pitfalls

Fever in children is a common concern for parents and one of the most frequent presenting complaints in emergency department visits, often involving non-pediatric emergency physicians. Although the incidence of serious infections has decreased after the introduction of conjugate vaccines, fever remains a major cause of laboratory investigation and hospital admissions. Furthermore, antipyretics are the most common medications administered to children. We review the epidemiology and measurement of fever, the meaning of fever and associated clinical signs in children of different ages and under special conditions, including fever in children with cognitive impairment, recurrent fevers, and fever of unknown origin. While the majority of febrile children have mild, self-resolving viral illness, a minority may be at risk of life-threatening infections. Clinical assessment differs markedly from adult patients. Hands-off evaluation is paramount for a correct evaluation of breathing, circulation and level of interaction. Laboratory markers and clinical prediction rules provide limited help in identifying children at risk for serious infections; however, clinical examination, prudent utilization of laboratory tests, and post-discharge guidance ("safety netting") remain the cornerstone of safe management of febrile children.

Risk Factors for Daytime or Combined Incontinence in Children with Cerebral Palsy

PURPOSE

We identify risk factors for daytime or combined urinary incontinence in children with cerebral palsy.

MATERIALS AND METHODS

A cross-sectional case-control study was conducted including children with cerebral palsy with or without daytime or combined urinary incontinence from the CP-Reference Center at Ghent University Hospital and 2 associated special education schools. Factors were subdivided in 3 clusters of demographic and general medical data, cerebral palsy classification, and bladder and bowel dysfunction. Data were obtained using uroflowmetry with electromyography testing, a nonvalidated questionnaire and bladder diaries. Univariate and multivariate analyses were performed for variables and clusters, respectively. A final associative logistic model including all clusters was developed.

RESULTS

The study included 34 incontinent children and 45 continent children. Daytime or combined urinary incontinence was associated with intellectual disability (OR 7.69), swallowing problems (OR 15.11), use of external aids (OR 27.50) and use of laxatives (OR 13.31). Daytime or combined urinary incontinence was positively associated with dyskinesia (OR 5.67) or combined spasticity and dystonia (OR 4.78), bilateral involvement (OR 4.25), Gross Motor Function Classification System level IV (OR 10.63) and V (OR 34.00), and severe impairment in manual (OR 24.27) or communication skills (OR 14.38). Lower maximum voided volume (OR 0.97) and oral fluid intake (OR 0.96) influenced daytime or combined urinary incontinence negatively. Pathological uroflow curves were not significantly associated with incontinence. The final model defined functional impairment, intellectual disability and oral fluid intake as predictive factors for daytime or combined urinary incontinence.

CONCLUSIONS

Risk analysis revealed functional impairment, intellectual disability and fluid intake as important factors influencing continence in a child with cerebral palsy.

[Preliminary study: Lower urinary tract dysfunction and anorectal disorders in children with cerebral palsy]

GOAL

Describe lower urinary tract dysfunction and anorectal disorders to children with cerebral palsy (CP), indicating their impact on quality of life.

MATERIALS

This was a prospective single-center study. A data collection was: type of PC, Gross Motor Function-Classification System (GMF-CS), mainstream education or not, Functional Independence Measure in children (MIF-kid), standardized vesicosphincteric symptoms and quality of life questionnaires (specific issue of impact sphincter dysfunction and generic scale Kidscreen-52).

RESULTS

Between January and March 2013, 19 children aged 5-17 years were included, including 16 into mainstream schooling. Of the 19, 16 had bladder and sphincter disorders: 14 urinary incontinence, 3 nycturies, 6 dysuria, 12 urgenturies, no urinary infection. Of the 14 urinary incontinence, 13 were in school. Of the 16 children enrolled, 5 were daytime fecal incontinence and 2 nocturnal fecal incontinence. Functional scores (GMF-CS and MIF-kid) children urinary incontinence were lower than those of children urinary continents (P=0.04 and 0.0007). Ten children had an impact of these disorders on quality of life. All were enrolled, eight (80%) in the mainstream.

CONCLUSION

The bladder and sphincter disorders were common in children with CP. They led to an impact on quality of life in more than half of the children studied, mostly educated in mainstream schools.

Best practice in the assessment of bladder function in infants

The purpose of this article is to review normal developmental bladder physiology in infants and bladder dysfunction in conditions such as neurogenic bladder, posterior urethral valves and high grade vesicoureteric reflux. We contrast the classical concept that bladder function in nontoilet-trained children is thought to be 'reflexive' or 'uninhibited', with the results of more recent research showing that infants most commonly have a stable detrusor. The infant bladder is physiologically distinct from the state seen in older children or adults. The voiding pattern of the infant is characterized by an interrupted voiding stream due to lack of proper urinary sphincter relaxation during voiding. This is called physiologic detrusor sphincter dyscoordination and is different from the pathologic 'detrusor sphincter dyssynergy' seen in patients with neurogenic bladder. Urodynamic abnormalities in neonates born with spina bifida are common and depend on the level and severity of the spinal cord malformation. Upper neuron lesions most commonly lead to an overactive bladder with or without detrusor sphincter dyssynergy while a lower neuron lesion is associated with an acontractile detrusor with possible denervation of the external urinary sphincter. In infants with neurogenic bladder, the role of 'early prophylactic treatment (clean intermittent catheterization and anticholinergics)' versus initial 'watchful waiting and treatment as needed' is still controversial and needs more research. Many urodynamic-based interventions have been suggested in patients with posterior urethral valves and are currently under scrutiny, but their impact on the long-term outcome of the upper and lower urinary tract is still unknown. Cumulative data suggest that there is no benefit to early intervention regarding bladder function in infants with high-grade vesicoureteric reflux.

Prevalence and Predictors of Urinary Tract Infections among Children with Cerebral Palsy in Makurdi, Nigeria

Background. Children with cerebral palsy (CP) are prone to urinary tract infection (UTI). Methods/Objectives. The prevalence and the predictors of UTI among children with CP were compared to age- and sex-matched children without CP at Federal Medical Centre, Makurdi, Nigeria, from December 2011 to May 2013. Results. The age range was between 2 and 15 years with a mean age of 8.63 ± 3.83 years including 30 males and 22 females. UTI was confirmed in 20 (38.5%) CP children compared to 2 children (3.8%) without CP (P value 0.000). Among CP children, Escherichia coli was the commonest organism isolated in 9 (9/20, 45.0%), Streptococcus faecalis in 4 (20.0%), and Staphylococcus aureus in 3 (15%), while both Proteus spp. and Klebsiella spp. were isolated in 2 children (10.0%) each. Escherichia coli was also found in the 2 children without CP. All the organisms were resistant to cotrimoxazole, nalidixic acid, nitrofurantoin, and amoxiclav, while they were 100% sensitive to ceftriaxone and the quinolones. In a univariate regression analysis, only moderate to severe gross motor dysfunction predicted the risk of UTI (OR = 54.81, 95% CI, 2.27-1324.00, P value 0.014). Conclusion. Efforts should be put in place to aid mobility among CP children in order to reduce the risk of UTI.