1
|
Koch VH, Lopes M, Furusawa E, Vaz K, Barroso U. Multidisciplinary management of people with spina bifida across the lifespan. Pediatr Nephrol 2024; 39:681-697. [PMID: 37501019 DOI: 10.1007/s00467-023-06067-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 07/29/2023]
Abstract
The average worldwide prevalence of neural tube defects (NTDs) is 1.0 per 1000 births. Its development is multifactorial due to genetic and non-genetic factors. Spina bifida (SB) is one of main representatives of NTD. The spinal cord lesion level is the main determinant of the level of paralysis, numbness, and difficulties with bladder/bowel functions. Myelomeningocele prenatal repair reduces hydrocephalus and hindbrain herniation and improves motor function. The severity of hydrocephalus is associated with poorer neurodevelopmental outcomes whether operated on prenatally or after birth. People with SB tend to have a lower IQ and cognitive difficulties. Early diagnosis, proactivity, and lifelong multidisciplinary follow-up are key protective issues. Invasive urological interventions should be considered in selected patients after failure of conservative treatment. Transition to adult care should be well planned as it is challenging. Health literacy is directly associated with success at transition. Sexuality and fertility should be addressed before/during puberty. Overall, the rates of fecal and urinary continence and skin breakdown increase with age, whereas the ability to ambulate declines with age. Bowel and urinary incontinence are independent predictors of lower health-related quality of life (HRQoL) in adults with SB. Bowel incontinence has negative impact on HRQoL regardless of frequency or amount. Long-term caregiver support should be offered at diagnosis. Survival at a mean of 50 years is poor, at 32%, due to central nervous system deaths, cancer, urological disease, and sepsis. Challenges to implementation of recommended practices exist, especially in low and middle-income countries.
Collapse
Affiliation(s)
- Vera H Koch
- Pediatric Nephrology Unit, Department of Pediatrics, University of São Paulo Medical School, Children's Hospital, Hospital das Clinicas, Sau Paulo, Brazil.
| | - MarcosTomasin Lopes
- Pediatric Nephrology Unit, Department of Pediatrics, University of São Paulo Medical School, Children's Hospital, Hospital das Clinicas, Sau Paulo, Brazil
| | - Erika Furusawa
- Pediatric Nephrology Unit, Department of Pediatrics, University of São Paulo Medical School, Children's Hospital, Hospital das Clinicas, Sau Paulo, Brazil
| | - Katharinne Vaz
- Division of Urology, Federal University of Bahia - UFBA, Salvador, BA, Brazil
| | - Ubirajara Barroso
- Division of Urology - Federal University of Bahia, Bahiana School of Medicine, Salvador, BA, Brazil
| |
Collapse
|
2
|
Sari C, Demirbağ BC. Investigation of anxiety levels in caregivers who perform clean intermittent catheterization on their children and affecting factors. Neurourol Urodyn 2024; 43:738-747. [PMID: 38238988 DOI: 10.1002/nau.25388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/20/2023] [Accepted: 12/21/2023] [Indexed: 03/21/2024]
Abstract
PURPOSE The study aimed to determine the anxiety levels of caregivers who performed clean intermittent catheterization (CIC) on their children and the factors affecting them. METHODS This descriptive study was conducted between January 6, and May 29, 2023 with caregivers of 42 patients who were followed up by the pediatric nephrology outpatient clinic of a university for CIC. The study data were collected using the "Participant Information Form" and the "State and Trait Anxiety Scale." RESULTS According to the results, of the children included in the study, 73.8% were female, 64.3% were diagnosed with spina bifida (SB), and 76.2% received CIC applications 4-6 times a day. All the caregivers were mothers, and 76.2% received CIC training from a doctor. However, 78.6% of them found the training insufficient, leading them to rely on self-experimentation when applying CIC to their own children. None of the caregivers received information or training on the CIC application from nurses, and there were no home visits or telephone counseling provided after the hospital discharge. The mean score for the state anxiety scale among the caregivers was 45.90 ± 10.57, while the mean score for the trait anxiety scale was 46.92 ± 8.43. Significantly higher mean trait anxiety scores were observed among caregivers with chronic diseases who did not receive training on the CIC application (p < 0.05). Additionally, caregivers of children who experienced 3-4 urinary tract infections (UTIs) within the last 3 months also had significantly higher mean trait anxiety scores (p < 0.05). The mean trait anxiety level scores of caregivers of children who had 3-4 UTIs in the last 3 months were significantly higher (p < 0.05). CONCLUSIONS It was concluded that caregivers' lack of training on CIC implementation, having chronic disease, and having frequent UTIs in their children were effective on anxiety levels.
Collapse
Affiliation(s)
- Canan Sari
- Department of Health Care Services, Elderly Care Program, Tonya Vocational School, Trabzon University, Trabzon, Turkey
| | - Birsel C Demirbağ
- Faculty of Health Sciences, Public Health Nursing AB, Karadeniz Technical University, Trabzon, Turkey
| |
Collapse
|
3
|
Bachtel HA, Flores H, Park B, Kim SJ, Koh CJ, Janzen NK. Evaluating the utility of routine urine culture and antibiotic treatment in children with neurogenic bladder undergoing intradetrusor OnabotulinumtoxinA injection. J Pediatr Urol 2023; 19:742.e1-742.e8. [PMID: 37537091 DOI: 10.1016/j.jpurol.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 04/06/2023] [Accepted: 05/11/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION OnabotulinumtoxinA is used as treatment for refractory idiopathic and neurogenic detrusor overactivity in children. Many patients perform intermittent self-catheterization and therefore have higher rates of asymptomatic bacteriuria, which may increase their risk of symptomatic urinary tract infection (UTI) following treatment. Multiple injections are often needed due to the short-term efficacy of onabotulinumtoxinA treatment, which may also increase the risk of UTI. OBJECTIVE We aim to evaluate whether a sterile urinary tract is necessary to decrease the risk of postoperative UTI in pediatric patients treated with onabotulinumtoxinA. STUDY DESIGN A retrospective review of patients undergoing intradetrusor onabotulinumtoxinA injection from 2014 to 2021 was performed. Demographic data, clinical characteristics, antibiotic treatment and culture results were collected. A positive urine culture was defined as ≥ 103 CFU/ml of uropathogenic bacteria. Our primary outcome was symptomatic UTI within 14 days of the procedure. RESULTS 103 patients underwent 158 treatments with onabotulinumtoxinA. The incidence of postoperative UTI was 3.2%. The incidence of symptomatic postoperative UTI in patients with asymptomatic bacteriuria compared to those with sterile urine was not significantly different (3.8% vs 0%, p = 0.57). Obtaining a preoperative urinalysis or urine culture did not affect the incidence of postoperative UTI (p = 0.54). The number needed to treat with antibiotics to prevent one postoperative UTI was 27. The incidence of postoperative UTI was highest in patients with low-risk bladders (p = 0.043). Prior history of multi-drug resistant UTI was a risk factor for postoperative UTI (p = 0.048). DISCUSSION For children undergoing onabotulinumtoxinA injection, there are no evidence-based recommendations regarding antibiotic prophylaxis and the need to screen for and treat asymptomatic bacteruria prior to treatment. Our study addresses this important clinical question, and shows no difference in the rate of postoperative UTI between patients with asymptomatic bacteriuria and those with sterile urine. Patients with a history of multi-drug resistant UTI are at increased risk of symptomatic postoperative UTI and may benefit from preoperative urine testing and treatment. Limitations of our retrospective study include its small sample size in the face of such a low incidence of our primary outcome. CONCLUSIONS The risk of UTI following onabotulinumtoxinA injection in children is low. The presence of sterile urine at the time of surgery does not significantly decrease the risk of postoperative UTI. Routine treatment of asymptomatic bacteriuria prior to surgery results in a large number of patients receiving unnecessary antibiotics. As a result, we recommend against preoperative urine testing for most asymptomatic patients.
Collapse
Affiliation(s)
- Hannah Agard Bachtel
- Division of Pediatric Urology, Texas Children's Hospital and Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.
| | - Hunter Flores
- Division of Pediatric Urology, Texas Children's Hospital and Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.
| | - Bridget Park
- Division of Pediatric Urology, Texas Children's Hospital and Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.
| | - Soo Jeong Kim
- Division of Pediatric Urology, Texas Children's Hospital and Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.
| | - Chester J Koh
- Division of Pediatric Urology, Texas Children's Hospital and Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.
| | - Nicolette K Janzen
- Division of Pediatric Urology, Texas Children's Hospital and Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.
| |
Collapse
|
4
|
Nisheljeet S, Azizi AB, Palaniandy K, Ganesan D, Ong TA, Alias A, Rajamanickam R, Atroosh WM, Mohd-Zin SW, Lee-Shamsuddin A, Nivrenjeet S, Lo W, Abdul-Aziz NM. Survey on Untethering of the Spinal Cord and Urological Manifestations among Spina Bifida Patients in Malaysia. CHILDREN 2022; 9:children9071090. [PMID: 35884073 PMCID: PMC9324435 DOI: 10.3390/children9071090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022]
Abstract
The incidence and severity of urinary tract infections (UTIs) due to spina bifida is poorly understood in Malaysia. Tethering of the spinal cord is a pathological fixation of the cord in the vertebral column that can result in neurogenic bladder dysfunction and other neurological problems. It occurs in patients with spina bifida, and the authors of this study sought to investigate the impact of untethering on the urological manifestations of children with a tethered cord, thereby consolidating a previously known understanding that untethering improves bladder and bowel function. Demographic and clinical data were collected via an online questionnaire and convenient sampling techniques were used. A total of 49 individuals affected by spina bifida participated in this study. UTIs were reported based on patients’ observation of cloudy and smelly urine (67%) as well as urine validation (60%). UTI is defined as the combination of symptoms and factoring in urine culture results that eventually affects the UTI diagnosis in spina bifida individuals irrespective of CISC status. Furthermore, 18% of the respondents reported being prescribed antibiotics even though they had no history of UTI. Therefore, indiscriminate prescription of antibiotics by healthcare workers further compounds the severity of future UTIs. Employing CISC (73%) including stringent usage of sterile catheters (71%) did not prevent patients from getting UTI. Overall, 33% of our respondents reported manageable control of UTI (0–35 years of age). All individuals below the age of 5 (100%, n = 14) were seen to have improved urologically after the untethering surgery under the guidance of the Malaysia NTD support group. Improvement was scored and observed using KUB (Kidneys, Ureters and Bladder) ultrasound surveillance before untethering and continued thereafter. Spina bifida individuals may procure healthy bladder and bowel continence for the rest of their lives provided that neurosurgical and urological treatments were sought soon after birth and continues into adulthood.
Collapse
Affiliation(s)
- Singh Nisheljeet
- Invertebrate & Vertebrate Neurobiology Lab, Department of Parasitology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia; (S.N.); (S.W.M.-Z.); (A.L.-S.); (S.N.)
| | - Abu Bakar Azizi
- Department of Surgery, University Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (A.B.A.); (K.P.)
| | - Kamalanathan Palaniandy
- Department of Surgery, University Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (A.B.A.); (K.P.)
| | - Dharmendra Ganesan
- Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia; (D.G.); (T.A.O.)
| | - Teng Aik Ong
- Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia; (D.G.); (T.A.O.)
| | - Azmi Alias
- Department of Neurosurgery, Tunku Abdul Rahman Neuroscience Institute (IKTAR), Hospital Kuala Lumpur, Kuala Lumpur 50586, Malaysia;
- Department of Pediatric Neurosurgery, Women and Children Hospital Kuala Lumpur, Kuala Lumpur 50586, Malaysia
| | | | - Wahib M. Atroosh
- Department of Parasitology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia;
| | - Siti Waheeda Mohd-Zin
- Invertebrate & Vertebrate Neurobiology Lab, Department of Parasitology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia; (S.N.); (S.W.M.-Z.); (A.L.-S.); (S.N.)
| | - Andrea Lee-Shamsuddin
- Invertebrate & Vertebrate Neurobiology Lab, Department of Parasitology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia; (S.N.); (S.W.M.-Z.); (A.L.-S.); (S.N.)
| | - Singh Nivrenjeet
- Invertebrate & Vertebrate Neurobiology Lab, Department of Parasitology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia; (S.N.); (S.W.M.-Z.); (A.L.-S.); (S.N.)
| | - Warren Lo
- Department of Urology, Kuala Lumpur Hospital, Jalan Pahang, Kuala Lumpur 50586, Malaysia
- Correspondence: (W.L.); (N.M.A.-A.)
| | - Noraishah Mydin Abdul-Aziz
- Invertebrate & Vertebrate Neurobiology Lab, Department of Parasitology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia; (S.N.); (S.W.M.-Z.); (A.L.-S.); (S.N.)
- Correspondence: (W.L.); (N.M.A.-A.)
| |
Collapse
|
5
|
Elagami H, Abbas TO, Evans K, Murphy F. Management of neuropathic bladder secondary to spina bifida: Twenty years' experience with a conservative approach. Front Pediatr 2022; 10:913078. [PMID: 35967567 PMCID: PMC9372397 DOI: 10.3389/fped.2022.913078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/12/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Treatment of neuropathic bladder secondary to spina bifida is an ongoing challenge. Although different management strategies and protocols are available in the literature, reliance on expert opinion remains fundamental. A conservative approach can be utilized, but patients must be closely monitored throughout the management process. The objective of this study was to review the management and outcomes of neuropathic bladder in spina bifida by appraising long-term bladder and renal function in patients treated at a medical center utilizing a conservative management style. METHODS This is a single-center retrospective review of urology care for all spina bifida patients 5-19 years of age with a neuropathic bladder who attended follow-ups between April 2000 and April 2020. Only patients with more than 5 years of follow-up were included. Renal functions, continence and results of invasive video urodynamics (IUD) and any surgical interventions were recorded. RESULTS Seventy-one patients (mean age = 10.5 years) were identified after exclusions. Bladder compliance between first and last IUDs increased significantly (p = 0.0056). Anticholinergic treatment was started at the first outpatient appointment. Intravesical botulinum toxin injection was the second line treatment in ten patients. 94% of patients had an end fill pressure below 40 cm H2O in their last IUD. 82% were socially continent (dry or occasional damp patches) with or without catheterisations at the age of 11.5 years. One patient in the cohort had bladder augmentation. CONCLUSION The optimal management of neuropathic bladder secondary to spina bifida remains controversial. Bladder and renal functional outcomes can be improved with close monitoring and less invasive management.
Collapse
Affiliation(s)
| | - Tariq O Abbas
- Weill Cornell Medicine - Qatar, Ar-Rayyan, Qatar.,Sidra Medicine, Doha, Qatar
| | | | | |
Collapse
|
6
|
Forster CS, Kowalewski NN, Atienza M, Reines K, Ross S. Defining Urinary Tract Infections in Children With Spina Bifida: A Systematic Review. Hosp Pediatr 2021; 11:1280-1287. [PMID: 34697071 DOI: 10.1542/hpeds.2021-005934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
CONTEXT Children with spina bifida are at high risk for urinary tract infections (UTI). However, there is no standardized definition of UTI in this population, leading to variability in both clinical management and research. This was highlighted in the 2013 systematic review on the same topic. OBJECTIVE Evaluate the frequency with which researchers are defining UTI in their studies of children with spina bifida and to determine what parameters are used. DATA SOURCES We searched Medline and Scopus databases for articles that included pediatric patients with spina bifida and used UTI as an outcome. STUDY SELECTION Exclusion criteria included publication before October 1, 2012, non-English language, and nonprimary research articles. DATA EXTRACTION Two independent reviewers each extracted data. RESULTS A total of 39 studies were included; 74% of these analyzed included an explicit definition of UTI. The most commonly used definition included a combination of symptoms and culture results (34.5%), whereas 31% used a combination of symptoms, culture results, and urinalysis data. Only 3.4% of articles used a urine culture alone to define UTI. CONCLUSIONS More articles that focus on children with spina bifida included a definition of UTI. However, significant variability persists in the definition of UTI in this patient population.
Collapse
Affiliation(s)
- Catherine S Forster
- Children's National Hospital, Washington, District of Columbia .,The George Washington School of Medicine and Health Sciences, The George Washington University, Washington, DC
| | | | - Matthew Atienza
- The George Washington School of Medicine and Health Sciences, The George Washington University, Washington, DC
| | - Katy Reines
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Sherry Ross
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
7
|
Hobbs KT, Krischak M, Tejwani R, Purves JT, Wiener JS, Routh JC. The Importance of Early Diagnosis and Management of Pediatric Neurogenic Bladder Dysfunction. Res Rep Urol 2021; 13:647-657. [PMID: 34513742 PMCID: PMC8421253 DOI: 10.2147/rru.s259307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/17/2021] [Indexed: 11/23/2022] Open
Abstract
Neurogenic bladder dysfunction is a major source of urologic morbidity in children, especially in those with spina bifida (SB). Complications from progression of bladder dysfunction can include urinary tract infections (UTIs), urinary incontinence, upper tract deterioration, and renal dysfunction or failure. In these children, there has been a recent trend toward proactive rather than expectant management of neurogenic bladder. However, there is a lack of consensus on how to best achieve the three main goals of neurogenic bladder management: 1) preserving kidney function, 2) achieving continence (if desired by the family/individual), and 3) achieving social and functional urologic independence (if appropriate). Hence, our objective was to perform a narrative literature review to evaluate the approaches to diagnosis and management of pediatric neurogenic bladder dysfunction, with special focus on children with SB. The approach strategies vary across a spectrum, with a proactive strategy on one end of the spectrum and an expectant strategy at the other end. The proactive management strategy is characterized by early and frequent labs, imaging, and urodynamic (UDS) evaluation, with early initiation of clean intermittent catheterization (CIC) and proceeding with pharmacotherapy, or surgery if indicated. The expectant management strategy prioritizes surveillance labs and imaging prior to proceeding with invasive assessments and interventions such as UDS or pharmacotherapy. Both treatment strategies are currently utilized and data have historically been inconclusive in demonstrating efficacy of one regimen over the other. We performed a narrative literature evaluating proactive and expectant treatment strategies as they relate to diagnostics and management of Spina Bifida. From the available literature and our practice, a proactive strategy favors greater benefit in preventative management and may decrease risk of renal dysfunction compared with expectant management.
Collapse
Affiliation(s)
- K Tyler Hobbs
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Rohit Tejwani
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - J Todd Purves
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - John S Wiener
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
8
|
Incidence of Urinary Tract Infections in Newborns with Spina Bifida-Is Antibiotic Prophylaxis Necessary? J Urol 2021; 206:126-132. [PMID: 33683941 PMCID: PMC8268042 DOI: 10.1097/ju.0000000000001690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Urinary tract infections commonly occur in patients with spina bifida and pose a risk of renal scarring. Routine antibiotic prophylaxis has been utilized in newborns with spina bifida to prevent urinary tract infections. We hypothesized that prophylaxis can safely be withheld in newborns with spina bifida until clinical assessment allows for risk stratification. MATERIALS AND METHODS Newborns with myelomeningocele at 9 institutions were prospectively enrolled in the UMPIRE study and managed by a standardized protocol with a strict definition of urinary tract infection. Patient data were collected regarding details of reported urinary tract infection, baseline renal ultrasound findings, vesicoureteral reflux, use of clean intermittent catheterization and circumcision status in boys. Risk ratios and corresponding 95% confidence intervals were calculated using log-binomial models. RESULTS From February 2015 through August 2019 data were available on 299 newborns (50.5% male). During the first 4 months of life, 48 newborns (16.1%) were treated for urinary tract infection with 23 (7.7%) having positive cultures; however, only 12 (4.0%) met the strict definition of urinary tract infection. Infants with grade 3-4 hydronephrosis had an increased risk of urinary tract infection compared to infants with no hydronephrosis (RR=10.1; 95% CI=2.8, 36.3). Infants on clean intermittent catheterization also had an increased risk of urinary tract infection (RR=3.3; 95% CI=1.0, 10.5). CONCLUSIONS The incidence of a culture positive, symptomatic urinary tract infection among newborns with spina bifida in the first 4 months of life was low. Patients with high grades of hydronephrosis or those on clean intermittent catheterization had a significantly greater incidence of urinary tract infection. Our findings suggest that routine antibiotic prophylaxis may not be necessary for most newborns with spina bifida.
Collapse
|
9
|
Sager C, Barroso U, Bastos JM, Retamal G, Ormaechea E. Management of neurogenic bladder dysfunction in children update and recommendations on medical treatment. Int Braz J Urol 2021; 48:31-51. [PMID: 33861059 PMCID: PMC8691255 DOI: 10.1590/s1677-5538.ibju.2020.0989] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/07/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Defective closure of the neural tube affects different systems and generates sequelae, such as neurogenic bladder (NB). Myelomeningocele (MMC) represents the most frequent and most severe cause of NB in children. Damage of the renal parenchyma in children with NB acquired in postnatal stages is preventable given adequate evaluation, follow-up and proactive management. The aim of this document is to update issues on medical management of neurogenic bladder in children. MATERIALS AND METHODS Five Pediatric Urologists joined a group of experts and reviewed all important issues on "Spina Bifida, Neurogenic Bladder in Children" and elaborated a draft of the document. All the members of the group focused on the same system of classification of the levels of evidence (GRADE system) in order to assess the literature and the recommendations. During the year 2020 the panel of experts has met virtually to review, discuss and write a consensus document. RESULTS AND DISCUSSION The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies. Clean intermittent catheterization (CIC) should be implemented during the first days of life, and antimuscarinic drugs should be indicated upon results of urodynamic studies. When the patient becomes refractory to first-line therapy, receptor-selective pharmacotherapy is available nowadays, which leads to a reduction in reconstructive procedures, such as augmentation cystoplasty.
Collapse
Affiliation(s)
- Cristian Sager
- Service of Urology, National Hospital of Pediatrics Prof. Dr. P. J. Garrahan, Buenos Aires, Argentina
| | - Ubirajara Barroso
- Departamento de Urologia, Universidade Federal da Bahia - UFBA, Salvador, BA, Brasil.,Escola Bahiana de Medicina (BAHIANA), Salvador, BA, Brasil
| | - José Murillo Bastos
- Universidade Federal de Juiz de Fora - UFJF, Juiz de Fora, MG, Brasil.,Hospital e Maternidade Therezinha de Jesus da Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (HMTJ-SUPREMA), Juiz de Fora, MG, Brasil
| | | | | |
Collapse
|
10
|
Önal B, Kırlı EA, Selçuk B, Buğdaycı D, Can G, Çetinel B. Risk factors predicting upper urinary tract deterioration in children with spinal cord injury. Neurourol Urodyn 2020; 40:435-442. [PMID: 33205858 DOI: 10.1002/nau.24580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/04/2020] [Accepted: 11/04/2020] [Indexed: 11/08/2022]
Abstract
AIM The aim of this study is to determine the risk factors predicting upper urinary tract (UUT) deterioration in children with spinal cord injury (SCI). METHODS The medical records of 108 children with SCI who were referred to our unit between 1996 and 2018 were retrospectively reviewed. The data included general patient demographics, SCI characteristics, bladder management methods, presence of urinary tract infection, radiological evaluation of the UUT and lower urinary tract (LUT), and videourodynamic findings. The receiver operating characteristic (ROC) curve analysis was performed to determine the cutoff values of the maximum detrusor pressure during filling and the bladder volume ratio (BVR) for predicting UUT deterioration. Multivariate analyses were used to determine the risk factors predicting UUT deterioration. RESULTS Complete data were available for 76 children. The median patient age was 15 years (2-17). The leading causes of SCI were motor vehicle accidents (44%) and fall (33%). UUT deterioration was identified in 33 patients (43%). Iatrogenic SCI etiology, abnormal radiological LUT findings, and detrusor pressures greater than 70 cmH2 O were found to be independent risk factors for UUT deterioration using regression analysis. In addition, ROC analysis revealed that a BVR less than 0.7 was the cutoff value for UUT deterioration in children with SCI. CONCLUSION Abnormal radiological LUT findings, iatrogenic SCI etiology, detrusor pressure greater than 70 cmH2 O, and a BVR less than 0.7 were independent risk factors for UUT deterioration in children with SCI.
Collapse
Affiliation(s)
- Bülent Önal
- Department of Urology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Elif A Kırlı
- Department of Urology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Berin Selçuk
- Department of Urology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Derya Buğdaycı
- Department of Physical Medicine and Rehabilitation, Istanbul Physical Medicine and Rehabilitation Training and Research Hospital, Istanbul, Turkey
| | - Günay Can
- Department of Public Health, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Bülent Çetinel
- Department of Urology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| |
Collapse
|
11
|
Cicek N, Yildiz N, Alpay H. Intravesical hyaluronic acid treatment in recurrent urinary tract infections in children with spina bifida and neurogenic bladder. J Pediatr Urol 2020; 16:366.e1-366.e5. [PMID: 32197933 DOI: 10.1016/j.jpurol.2020.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/16/2020] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Damage to the glycosaminoglycan layer of the urothelium, which is composed of hyaluronic acid (HA), may increase the possibility of bacterial adherence and infections. Patients with neurogenic bladder (NB) who perform clean intermittent catheterization (CIC) 4-6 times a day are also under great risk for recurrent urinary tract infections (RUTIs). OBJECTIVE The aim of this study was to assess the efficacy and safety of intravesical HA in reducing the frequency of RUTIs in patients with spina bifida (SB) and NB, who perform CIC. MATERIALS AND METHODS Ten patients (nine girls, one boy) with SB and NB affected by RUTIs received intravesical instillation of HA. Ten patients (seven girls, three boys) with SB and NB who did not accept the intravesical HA therapy were included in the control group. All patients developed symptomatic RUTIs, which occurred at least three times in the previous 12 months. The study group was treated with intravesical 40 mg HA (Hyacyst®) weekly for four weeks, then monthly for the consequent three months. Recurrence of UTIs before and after the treatment was analyzed. RESULTS The mean age of the study group and the controls were 11.1 ± 4.8 (3.2-18.6) and 9.3 ± 5.4 (2.1-16.2) years, respectively. The mean UTIs per patient-month in the study group and the controls were 0.34 ± 0.05 and 0.35 ± 0.06, respectively. The mean follow-up time after the treatment was 16.6 ± 6.9 months in the study group and 16 ± 6.1 months in the controls. The mean UTIs per patient-month significantly decreased in the study group after the treatment (p < 0.001) but showed no significant difference in the control group (p = 0.174). When study and control groups were compared, the mean UTIs per patient-month showed no significant difference before treatment (p = 0.77) but significantly decreased in the study group after the treatment (p < 0.001). DISCUSSION To the best of the authors' knowledge, this study is the first one evaluating the efficacy of intravesical HA in the treatment of RUTIs in children with SB and NB. However, this study has several limitations, such as the small sample size and short follow-up time. CONCLUSION The findings of the present study indicate that intravesical HA is an effective and safe treatment that reduces RUTIs in patients with SB and NB, who perform CIC.
Collapse
Affiliation(s)
- Neslihan Cicek
- Department of Pediatric Nephrology, Marmara University School of Medicine, Istanbul, Turkey.
| | - Nurdan Yildiz
- Department of Pediatric Nephrology, Marmara University School of Medicine, Istanbul, Turkey
| | - Harika Alpay
- Department of Pediatric Nephrology, Marmara University School of Medicine, Istanbul, Turkey
| |
Collapse
|
12
|
Early Vs. Expectant Management of Spina Bifida Patients-Are We All Talking About a Risk Stratified Approach? Curr Urol Rep 2019; 20:76. [PMID: 31734847 DOI: 10.1007/s11934-019-0943-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Advancements in the care of patients affected by myelomeningocele have flourished in recent years especially with respect to renal preservation and continence. Involvement of urologists both prenatally and early in life has driven many developments in preventative care and early intervention. As of yet, however, the ideal management algorithm that offers these patients the least invasive diagnostic testing and interventions while still preserving renal and bladder function remains ill defined. RECENT FINDINGS In a shift from prior years where the use of surgical intervention and intermittent catheterization were more liberally employed, some providers have more recently advocated for monitoring patients in a more conservative manner with a variety of diagnostic tests until radiographic or clinical changes are discovered. The criteria used to define the need for catheterization and the timing to initiate CIC or more invasive interventions is disparate across pediatric urology and there is published data to support several approaches. This review presents some of these criteria for use of CIC and some newer evidence to support different approaches along with supporting the trend toward individualized medicine and use of risk stratification in developing clinical treatment algorithms.
Collapse
|
13
|
Carter B, Whittaker K, Sanders C. Evaluating a telehealth intervention for urinalysis monitoring in children with neurogenic bladder. J Child Health Care 2019; 23:45-62. [PMID: 29804471 PMCID: PMC7324124 DOI: 10.1177/1367493518777294] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Telehealth as a community-monitoring project within children's urology care is an innovative development. There is limited evidence of the inclusion of staff and parents in the early-stage development and later adoption of telehealth initiatives within routine urological nursing care or families' management of their child's bladder. The aim was to explore the experiences of key stakeholders (parents, clinicians, and technical experts) of the proof of concept telehealth intervention in terms of remote community-based urinalysis monitoring by parents of their child's urine. A concurrent mixed-methods research design used soft systems methodology tools to inform data collection and analysis following interviews, observation, and e-surveys with stakeholders. Findings showed that the parents adopted aspects of the telehealth intervention (urinalysis) but were less engaged with the voiding diary and weighing. The parents gained confidence in decision-making and identified that the intervention reduced delays in their child receiving appropriate treatment, decreased the time burden, and improved engagement with general practitioners. Managing the additional workload was a challenge for the clinical team. Parental empowerment and self-efficacy were clear outcomes from the intervention. Parents exercised their confidence and control and were selective about which aspects of the intervention they perceived as having credibility and which they valued.
Collapse
Affiliation(s)
- Bernie Carter
- Faculty of Health and Social Care, Edge Hill University, Ormskirk, UK,Bernie Carter, Faculty of Health and Social Care, Edge Hill University, St Helens Road, Ormskirk L39 4QP, UK.
| | - Karen Whittaker
- Faculty of Health and Wellbeing, University of Central Lancashire, Lancashire, UK
| | - Caroline Sanders
- School of Nursing, University of Northern British Columbia, British Columbia, Canada
| |
Collapse
|
14
|
Elzeneini W, Waly R, Marshall D, Bailie A. Early start of clean intermittent catheterization versus expectant management in children with spina bifida. J Pediatr Surg 2019; 54:322-325. [PMID: 30558962 DOI: 10.1016/j.jpedsurg.2018.10.096] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 10/30/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE We instituted early clean intermittent catheterization (CIC) in 1997 for all newborn infants with spina bifida (SB). We compared this group to a historical group managed expectantly to see if early catheterization was associated with a reduction in renal scar rate as determined by DMSA scanning. METHODS Data were studied retrospectively on all infants with SB over a recent 13-year period who were treated with early universal CIC in a regional pediatric urology department. These were compared to our previously published outcomes in a historical group (1985-1994) that was managed expectantly [Brown et al. Chronic pyelonephritis in association with neuropathic bladder. Eur J Pediatr Surg 1999;9 Suppl 1:29-30.] RESULTS: 114 infants were born with SB from 1997 to 2010, of which 13 were excluded from this analysis. Mean follow-up was 11.4 years. In the historical cohort there were 126 infants born from 1985 to 1994, with 26 exclusions; follow-up then ranged from 4 to 13 years. DMSA scan showed renal scarring in 19/101 (18.8%) of the recent cohort versus 39/100 (39%) of the previous group (P = 0.002). Renal scarring at a later age also appeared to be a feature of the recent group, with first detection occuring by 4 years in only 9/19 (47%) in the latest cohort compared to 28/39 (72%) in the historical cohort. CONCLUSION Based on these renal protective data, we recommend indwelling and then intermittent catheterization from birth in all patients with SB. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective, cohort comparison study.
Collapse
Affiliation(s)
- Wael Elzeneini
- Department of Paediatric Urology, Royal Belfast Hospital for Sick Children, Northern Ireland
| | - Ramy Waly
- Department of Paediatric Urology, Royal Belfast Hospital for Sick Children, Northern Ireland
| | - David Marshall
- Department of Paediatric Urology, Royal Belfast Hospital for Sick Children, Northern Ireland.
| | - Alan Bailie
- Department of Paediatric Urology, Royal Belfast Hospital for Sick Children, Northern Ireland
| |
Collapse
|
15
|
Timberlake MD, Kern AJ, Adams R, Walker C, Schlomer BJ, Jacobs MA. Expectant use of CIC in newborns with spinal dysraphism: Report of clinical outcomes. J Pediatr Rehabil Med 2017; 10:319-325. [PMID: 29125524 DOI: 10.3233/prm-170464] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Report urologic outcomes among newborns with spinal dysraphism managed within an expectant clean intermittent catheterization (CIC) program. METHODS Newborns were followed clinically and with serial ultrasound (US). Urodynamics (UD) and dimercaptosuccinic acid (DMSA) renal scan were obtained at 3-6 months, 1 year, 3 years, then as needed. Patients with initial evaluation after 6 months were excluded. RESULTS Median follow-up was 3.2 years. 11/102 began catheterization for continence (median 4.0 years) and 47/102 did not start CIC. Of these, 2/58 developed a DMSA abnormality. 44/102 began CIC early, often for elevated storage pressures and febrile urinary tract infection (UTI). Of these, 20/44 developed a DMSA abnormality including 9 who had abnormality detected prior to starting CIC. Being on CIC or starting immediately upon recognition of new hydronephrosis, reflux, elevated filling pressures, or febrile UTI was associated with lower chance of DMSA abnormalities (4/17, 24%) compared to delaying CIC (16/27, 60%) (p= 0.03). CONCLUSIONS CIC can be deferred until continence in select infants with a low risk of significant DMSA abnormality. However, immediate initiation of CIC upon recognition of risk factors is recommended as this was associated with fewer DMSA abnormalities than delaying CIC. Recommendations for expectantly-managed patients include close follow-up, serial US and UD, and prompt initiation of CIC upon recognition of new hydronephrosis, reflux, elevated storage pressures, or febrile UTIs.
Collapse
Affiliation(s)
- Matthew D Timberlake
- Division of Pediatric Urology, University of Texas Southwestern/Childrens' Medical Center, Dallas, TX, USA
| | - Adam J Kern
- Division of Pediatric Urology, University of Texas Southwestern/Childrens' Medical Center, Dallas, TX, USA
| | - Richard Adams
- Department of Pediatrics, University of Texas Southwestern/Texas Scottish Rite Hospital for Children, Dallas, TX, USA
| | - Candice Walker
- Department of Pediatrics, University of Texas Southwestern/Texas Scottish Rite Hospital for Children, Dallas, TX, USA
| | - Bruce J Schlomer
- Division of Pediatric Urology, University of Texas Southwestern/Childrens' Medical Center, Dallas, TX, USA
| | - Micah A Jacobs
- Division of Pediatric Urology, University of Texas Southwestern/Childrens' Medical Center, Dallas, TX, USA
| |
Collapse
|
16
|
Metcalfe PD. Neuropathic bladders: Investigation and treatment through their lifetime. Can Urol Assoc J 2017; 11:S81-S86. [PMID: 28265327 DOI: 10.5489/cuaj.4276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The child with a neuropathic bladder requires lifelong dedicated care. Just as each patient presents with unique physiology, each phase of their life presents varying challenges. The primary concern for our patients is their renal health, but continence and independence also play significant roles. Most patients can be managed conservatively, but a myriad of surgical options are also available, reinforcing our emphasis on individualized care. Appropriate pre-surgical planning is required to ensure the right patient receives the best operation for his/her wants and needs. Furthermore, the numerous potential complications must be understood and long-term followup and surveillance is required. This review outlines the basic pathophysiology, investigations, and treatments, with a focus on the changing needs throughout their lives.
Collapse
Affiliation(s)
- Peter D Metcalfe
- University of Alberta, Stollery Children's Hospital, Edmonton, AB, Canada
| |
Collapse
|