Management goals for the spina bifida neurogenic bladder: a review from infancy to adulthood

Management of neurogenic bladder dysfunction in children update and recommendations on medical treatment

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.

The Effect of Sacral Neuromodulation in Ambulatory Spina Bifida Patients with Neurogenic Bladder and Bowel Dysfunction

OBJECTIVE

To assess the effect of sacral neuromodulation (SNM) in ambulatory spina bifida patients with neurogenic bladder and bowel dysfunction.

MATERIALS AND METHODS

We retrospectively reviewed the records of 29 ambulatory spina bifida patients with neurogenic bladder and bowel dysfunction who underwent SNM testing from July 2012 to January 2020. Clinical data and video-urodynamic parameters were collected and compared using the t-test and the chi-square test. The potential risk factors were considered by logistic regression analysis. P < .05 was considered significant.

RESULTS

In the test phase, 21 patients (72.4%) achieved successful improvement of at least 1 symptom. The success rate for chronic urinary retention (26.09%) was significantly lower (P <.05) than that for urgency-frequency syndrome (58.82%) and urinary incontinence (56.25%). The mean neurogenic bowel dysfunction score decreased from 13.3±6.29 to 6.9±5.09 (P <.0001). The urodynamic evaluation showed a significant improvement in the mean maximum cystometric capacity, compliance, and maximum detrusor pressure (P <.05). Implantation was performed in 16 cases (55.17%). The analysis of the risk factors showed that chronic urinary retention was a statistically significant variable (P <.05). No complications were reported in the test phase. The average follow-up time was 41.19±33.06 months. Two patients changed to intermittent catheterization, and 2 patients changed to augmentation cystoplasty.

CONCLUSION

SNM is effective for neurogenic bladder and bowel dysfunction in patients with ambulatory spina bifida, especially in those without chronic urinary retention. And SNM can also significantly improve the urodynamic parameters of these patients during the storage period.

Urologic provider experiences in transitioning spina bifida patients from pediatric to adult care

PURPOSE

The lack of precedent in transitioning from pediatric to adult care poses a challenge to providers for patients with spina bifida (SB). The purpose of this study was to summarize perceptions about best practices for the care of adult spina bifida patients.

MATERIALS AND METHODS

A national survey was electronically distributed to 174 urologists who are current members of the Spina Bifida Association Network and AUA Working Group on Urologic Congenitalism. De-identified voluntary responses were assessed for implementation of and barriers to interdisciplinary adult SB clinics, continuity of care, and practices for transitioning from pediatric to adult care.

RESULTS

The response rate was 40% with urologists practicing pediatrics, genitourinary reconstruction, female pelvic medicine and general urology. Patients undergoing transition or who have transitioned were seen in a multidisciplinary clinic (14%), regular adult clinic (34%), combined adult-pediatric multidisciplinary care (20%), or pediatric multidisciplinary clinic (28%). A majority believed transitioning to adult care should occur at 18 (24%) or 21 years (22%). In the absence of acute changes, providers followed adult SB patients annually with upper tract imaging (typically renal ultrasound) and serum creatinine. Acute urologic changes were preferentially managed with urodynamic testing and cystoscopy. Providers identified a need for multidisciplinary care in adult life, with neurosurgery/neurology (87%), social work (84%), and orthopedics (73%).

CONCLUSIONS

Potential solutions to improve the urologic care of this population suggest additional national provider resources, standardized guidelines, multidisciplinary collaboration, access to care, and an advanced-training pathway to improve care of adult patients with spina bifida.

Spina bifida

N/A

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.

Long-Term Complications of the Neurogenic Bladder

It is widely accepted that neurogenic lower urinary tract dysfunction, when left untreated, has a natural history that has a potential for causing deterioration of renal function over time. However, certain patient profiles are at risk for this and other complications. This can be linked to their underlying neurologic disease process. Identifying risk profiles allows the provider to determine what surveillance strategies might be adopted. Risk factors for upper urinary tract deterioration include loss of bladder compliance, repeated bouts of pyelonephritis, and chronic indwelling catheterization. Other long-term complications include nephrolithiasis, refractory urinary incontinence, and malignancy.

Learning Motivational Interviewing: A Pathway to Caring and Mindful Patient Encounters

We designed our project to explore the experience of learning motivational interviewing (MI). The project impetus came from a desire to improve our skill in communicating with patients. We created a curriculum led by an MI specialist that provided didactic sessions, discussions and individual feedback. In evaluating our audio-taped MI encounters, we approached beginner proficiency. Also, we recognized the need for formal MI education and practice to fully develop the interventionist skills needed for clinical work and our next research project about preparing patients for transition to adult health care. Lastly, we realized that MI strategies reflect aspects of caring theory and mindfulness, important components of patient-centered care.

A snapshot of the adult spina bifida patient - high incidence of urologic procedures

Introduction

To describe the urologic outcomes of contemporary adult spina bifida patients managed in a multidisciplinary clinic.

Material and methods

A retrospective chart review of patients seen in our adult spina bifida clinic from January 2004 to November 2011 was performed to identify urologic management, urologic surgeries, and co-morbidities.

Results

225 patients were identified (57.8% female, 42.2% male). Current median age was 30 years (IQR 27, 36) with a median age at first visit of 25 years (IQR 22, 30). The majority (70.7%) utilized clean intermittent catheterization, and 111 patients (49.3%) were prescribed anticholinergic medications. 65.8% had urodynamics performed at least once, and 56% obtained appropriate upper tract imaging at least every other year while under our care. 101 patients (44.9%) underwent at least one urologic surgical procedure during their lifetime, with a total of 191 procedures being performed, of which stone procedures (n = 51, 26.7%) were the most common. Other common procedures included continence procedures (n = 35, 18.3%) and augmentation cystoplasty (n = 29, 15.2%). Only 3.6% had a documented diagnosis of chronic kidney disease and 0.9% with end-stage renal disease.

Conclusions

Most adult spina bifida patient continue on anticholinergic medications and clean intermittent catheterization. A large percentage of patients required urologic procedures in adulthood. Patients should be encouraged to utilize conservative and effective bladder management strategies to reduce their risk of renal compromise.

Transition to adult care for patients with spina bifida

More individuals with spina bifida are living into adulthood, and unique challenges arise as they age. These patients have multiple organ system involvement in addition to physical impairments, disabilities, cognitive involvement, and psychosocial challenges. There is a growing need for transitional care for adults with spina bifida. This article explores the 5 key elements for a transition program to adult care: preparation, flexible timing, care coordination, transitional clinic visits, and health care providers who are interested in taking care of adults with disabilities.

Inpatient and emergency room visits for adolescents and young adults with spina bifida living in South Carolina

OBJECTIVE

To compare emergency room (ER) and inpatient hospital (IP) use rates for persons with spina bifida (SB) to peers without SB, when transition from pediatric to adult health care is likely to occur; and to analyze those ER and IP rates by age, race, socioeconomic status, gender, and type of residential area.

DESIGN

A retrospective cohort study.

SETTING

Secondary data analysis in South Carolina.

PARTICIPANTS

We studied individuals who were between 15 and 24 years old and enrolled in the State Health Plan (SHP) or state Medicaid during the 2000-2010 study period.

METHODS

Individuals with SB were identified using ICD-9 billing codes (741.0, 741.9) in SHP, Medicaid, and hospital uniform billing (UB) data. ER and IP encounters were identified using UB data. Multivariable Generalized Estimating Equation (GEE) Poisson models were estimated to compare rates of ER and IP use among the SB group to the comparison group.

MAIN OUTCOME MEASURES

Total ER rate and IP rate, in addition to cause-specific rates for ambulatory care sensitive conditions (ACSC) and other condition categories.

RESULTS

We found higher rates of ER and IP use in persons with SB compared to the control group. Among individuals with SB, young adults (those 20-24 years old) had higher rates of ER use due to all ACSC (P = .023), other ACSC (P = .04), and urinary tract infections (UTI; P = .002) compared to adolescents (those 15-19 years old).

CONCLUSIONS

Young adulthood is associated with increased ER use overall, as well as in specific condition categories (most notably UTI) in individuals 15-24 years old with SB. This association may be indicative of changing healthcare access as people with SB move from adolescent to adult health care, and/or physiologic changes during the age range studied.

Efficacy, tolerability, and safety of oxybutynin chloride in pediatric neurogenic bladder with spinal dysraphism: a retrospective, multicenter, observational study

Purpose

Anticholinergics are a key element in treating neurogenic detrusor overactivity, but only limited data are available in the pediatric population, thus limiting the application to children even for oxybutynin chloride (OC), a prototype drug. This retrospective study was designed to provide data regarding the efficacy, tolerability, and safety of OC in the pediatric population (0-15 years old) with spinal dysraphism (SD).

Materials and Methods

Records relevant to OC use for neurogenic bladder were gathered and scrutinized from four specialized clinics for pediatric urology. The primary efficacy outcomes were maximal cystometric capacity (MCC) and end filling pressure (EFP). Data on tolerability, compliance, and adverse events (AEs) were also analyzed.

Results

Of the 121 patient records analyzed, 41 patients (34%) received OC at less than 5 years of age. The range of prescribed doses varied from 3 to 24 mg/d. The median treatment duration was 19 months (range, 0.3-111 months). Significant improvement of both primary efficacy outcomes was noted following OC treatment. MCC increased about 8% even after adjustment for age-related increases in MCC. Likewise, mean EFP was reduced from 33 to 21 cm H₂O. More than 80% of patients showed compliance above 70%, and approximately 50% of patients used OC for more than 1 year. No serious AEs were reported; constipation and facial flushing consisted of the major AEs.

Conclusions

OC is safe and efficacious in treating pediatric neurogenic bladder associated with SD. The drug is also tolerable and the safety profile suggests that adjustment of dosage for age may not be strictly observed.

Characteristics and survival of patients with end stage renal disease and spina bifida in the United States renal data system

PURPOSE

We describe the characteristics, treatments and survival of patients with spina bifida in whom end stage renal disease developed from 2004 through 2008 in the United States Renal Data System.

MATERIALS AND METHODS

We used ICD-9-CM code 741.* to identify individuals with spina bifida using hospital inpatient data from 1977 to 2010, and physician and facility claims from 2004 to 2008. We constructed a 5:1 comparison group of patients with end stage renal disease without spina bifida matched by age at first end stage renal disease service, gender and race/ethnicity. We assessed the risk of mortality and of renal transplantation while on dialysis using multivariate cause specific proportional hazards survival analysis. We also compared survival after the first renal transplant from the first end stage renal disease service to August 2011.

RESULTS

We identified 439 patients with end stage renal disease and spina bifida in whom end stage renal disease developed at an average younger age than in patients without spina bifida (41 vs 62 years, p <0.001) and in whom urological issues were the most common primary cause of end stage renal disease. Compared to patients with end stage renal disease without spina bifida those who had spina bifida showed a similar mortality hazard on dialysis and after transplantation. However, patients with end stage renal disease without spina bifida were more likely to undergo renal transplantation than patients with spina bifida (HR 1.51, 95% CI 1.13-2.03). Hospitalizations related to urinary tract infections were positively associated with the risk of death on dialysis in patients with end stage renal disease and spina bifida (HR 1.42, 95% CI 1.33-1.53).

CONCLUSIONS

Spina bifida was not associated with increased mortality in patients with end stage renal disease on dialysis or after renal transplantation. Proper urological and bladder management is imperative in patients with spina bifida, particularly in adults.

Drug development for pediatric neurogenic bladder dysfunction: dosing, endpoints, and study design

Pediatric drug development is challenging when a product is studied for a pediatric disease that has a different underlying etiology and pathophysiology compared to the adult disease. Neurogenic bladder dysfunction (NBD) is such a therapeutic area with multiple unsuccessful development programs. The objective of this study was to critically evaluate clinical trial design elements that may have contributed to unsuccessful drug development programs for pediatric NBD. Trial design elements of drugs tested for pediatric NBD were identified from trials submitted to the U.S. Food and Drug Administration. Data were extracted from publically available FDA reviews and labeling and included trial design, primary endpoints, enrollment eligibilities, and pharmacokinetic data. A total of four products were identified. Although all four programs potentially provided clinically useful information, only one drug (oxybutynin) demonstrated efficacy in children with NBD. The lack of demonstrable efficacy for the remainder of the products illustrates that future trials should give careful attention to testing a range of doses, using objectively measured, clinically meaningful endpoints, and selecting clinical trial designs that are both interpretable and feasible. Compiling the drug development experience with pediatric NBD will facilitate an improved approach for future drug development for this, and perhaps other, therapeutic areas.

Percutaneous nephrolithotomy in adult patients with spina bifida, severe spinal deformity and large renal stones

AIMS

To present our experience in patients with spina bifida with severe spinal abnormality undergoing percutaneous nephrolithotomy (PCNL) for large stone burden.

PATIENTS AND METHODS

A retrospective review identified five spina bifida patients with abnormal spinal curvature who had a PCNL for large kidney stones. The mean age was 28 years. In two patients, stones were on the concave side of the scoliotic spine further limiting percutaneous access. Mean stone burden was 940 mm2. All patients were paraplegic, three patients had symptomatic stone disease. We performed initial percutaneous renal access in radiology department and staged nephrolithotomy in operating room. Tract dilatation was accomplished using Amplatz dilators and a 24 Ch or 26 Ch nephroscope was used. Fragmentation and stone removal were accomplished in all patients using pneumatic and or ultrasound lithotripter and a retrieval grasper.

RESULTS

No anaesthetic complications were recorded. One patient required multiple percutaneous tracts, four had single tract to access stones. Three patients were stone free after PCNL. One required second PCNL through the same tract and another patient had multiple adjunctive ESWL. All five patients were stone clear after the final procedure. Two patients required blood transfusion. No patient had major complication or admission to intensive care unit.

CONCLUSIONS

Percutaneous nephrolithotomy in patients with spina bifida is challenging but safe. Detailed pre-operative anaesthetic assessment and precise uroradiological evaluation of renal anatomy is essential. Second-look PCNL and additional ESWL/URS treatment may be required to completely clear stones.

Management of lower urinary tract dysfunction in patients with neurological disorders

The proper performance of the lower urinary tract is dependent on an intact neural innervation of the individual structures involved. Therefore, any congenital neurological anomalies, diseases, or lesions of the central, peripheral, or autonomic nervous systems can result in lower urinary tract symptoms. Lower urinary tract dysfunction (LUTD) secondary to neurological disorders can significantly reduce quality of life (QoL) and may also give rise to serious complications and psychological and social sequelae. The goals of management of LUTD in patients with neurological disorders are to prevent serious complications and to improve the patient's QoL. Understanding the physiology and pathophysiology of micturition is critical to selecting appropriate treatment options. This article provides an overview of the clinical characteristics, diagnosis, and management of LUTD in patients with certain central and peripheral neuropathies and common lesions.

Pyonephrosis and urosepsis in a 41-year old patient with spina bifida: Case report of a preventable death

Background

Urological complications are the major cause of ill health in patients with spina bifida. Urinary sepsis accounted for the majority of admissions in patients with spina bifida. As the patient grows older, changes occur in the adult bladder, leading to increases in storage pressure and consequent risk of deterioration of renal function, which may occur insidiously.

Case presentation

A 34-year-old male spinal bifida patient had been managing neuropathic bladder by penile sheath. Intravenous urography revealed normal kidneys. This patient was advised intermittent catheterisations. But self-catheterisation was not possible because of long, overhanging prepuce and marked spinal curvature. This patient developed repeated urine infections. Five years later, ultrasound examination of urinary tract revealed hydronephrotic right kidney with echogenic debris within the collecting system. There was no evidence of dilatation of the ureter near the vesicoureteric junction. The left kidney appeared normal. There was no evidence of calculus disease seen in either kidney. Indwelling urethral catheter drainage was established.

Two years later, MAG-3 renogram revealed normal uptake and excretion by left kidney. The right kidney showed little functioning tissue. Following a routine change of urethral catheter this patient became unwell. Ultrasound examination revealed hydronephrotic right kidney containing thick hyper-echoic internal septations and debris in the right renal pelvis suspicious of pyonephrosis. Under both ultrasound and fluoroscopic guidance, an 8 French pig tail catheter was inserted into the right renal collecting system. 150 ml of turbid urine was aspirated immediately. This patient developed large left pleural effusion, collapse/consolidation of the left lower lobe, a large fluid collection in the abdomen extending into the pelvis and expired twenty days later because of sepsis and respiratory failure.

Conclusion

Although penile sheath drainage may be convenient for a spina bifida patient and the carers, hydronephrosis can occur insidiously. With recurrent urine infections, hydronephrotic kidney can become pyonephrosis, which is life-threatening. Therefore, every effort should be made to carry out intermittent catheterisations along with antimuscarinic drug therapy.