Neuropathic or Neurogenic Bladder

The bladder has two primary functions:

• To store urine
• To empty urine when the bladder is full

In order for these functions to occur, the nerves of the urinary tract communicate between the brain and the muscles of the bladder and the sphincter (this allows urine to stay in the bladder until we are ready to empty the bladder). The nerves send messages to the bladder and sphincter to empty and store urine. If the nerves are damaged or did not develop normally, the bladder may not function properly. This can result in a neurogenic bladder.

In children, a neurogenic bladder can result from a birth defect affecting the nerves or brain or could be an acquired condition as a result of another problem. In children, some of the most common causes include:

• Spina bifida
• Cerebral palsy
• Trauma to the spinal cord or brain
• Tumors of the spinal cord, brain, pelvis
• Tethering of the spinal cord
• Developmental delay

Not all children with a neurogenic bladder will experience the same symptoms and these may also change over time. The most common of these symptoms include:

• Incontinence
• Urinary retention
• Urinary tract infections
• Deterioration of kidney function
• Hydronephrosis
• Vesicoureteral reflux
• Kidney and bladder stones

There are a variety of tests that can be performed to help evaluate the extent to which the bladder is affected by a particular condition. Some are more invasive than others and your provider will review the specifics in more detail.

• Ultrasound of the kidneys and bladder
• Voiding cystourethrogram
• MRI of the spine
• Video urodynamics
• Blood work to assess kidney function

Treatment in patients with neurogenic bladder is individualized and may differ from one patient to another and also one patient’s treatment may change over time. Neurogenic bladder is a dynamic process and requires frequent and long-term care with a urologist.

The goals of urologic management of neurogenic bladder include:

• Preventing kidney damage
• Minimizing the risk of urinary tract infections
• Achieving urinary control, social continence
• Improving independence and overall quality of life

These goals evolve gradually with age. While the primary focus is always centered on preserving renal function, as this population ages, social continence and sexual function also become key elements for overall health and well-being.

Medical management is typically the course of treatment with children with neurogenic bladder. Depending on the age of diagnosis, not all treatments may apply.

• Clean intermittent catheterization (CIC): This is a clean, not sterile, technique to allow patients (are caregivers/parents) to empty his or her bladder appropriately. Parents and patients are taught this technique by skilling nursing staff. This may be started as early as birth, depending on the cause for neurogenic bladder. This will allow the bladder to completely empty, thus decreasing the risk of urinary tract infections, protects the bladder and kidneys from high storage pressures, and achieve continence. Overnight drainage of the bladder with a catheter that stays in while sleeping is also used in some.
• Anticholinergic medications: These medicines help relax the bladder, allowing for the safe storage of urine with low bladder pressures, decreased bladder contractions, and help increase the amount of urine the bladder can safely store. This ultimately helps reduce damage to the kidneys.
• Prophylactic antibiotics: A daily antibiotic may be given to help prevent urinary tract infections, particularly if vesicoureteral reflux exists.

Surgery may be required for the most extensive cases of neurogenic bladder who cannot be controlled with medical treatment alone and to also improve social continence.

• Urinary diversion: A temporary urinary diversion, where a small portion of the bladder is brought to the skin to allow for continuous drainage, may be required if intermittent catheterization is not an option or in adequate drainage to help prevent urinary tract infections. This is temporary and can be reversed in the future when social continence is desired.
• Bladder augmentation: Augmentation of the bladder increases the capacity and decreases the pressure of the bladder by using segments of bowel as a patch. This procedure is usually performed at an older age when social continence is desired and if medical treatment fails to keep the bladder and kidneys safe.
• Appendicovesicostomy (Mitrofanoff): In some, social continence may require narrowing or closure of the bladder neck, necessitating an alternative route to drain urine appropriately. This also allows for independence as patients are able to catheterize through an abdominal stoma more easily than through the urethra. In an appendicovesicostomy, a continent stoma is created to provide easy access to empty the bladder. Usually, the appendix or a piece of small bowel can be used. This procedure is often combined with a bladder augmentation if bladder pressures are unsafe or the capacity is diminished.
• Malone antegrade colonic enema (MACE): Many patients also suffer from a neurogenic bowel, and require daily enemas via the rectum. A A MACE procedure allows children with incontinence of stool to deliver an enema directly into the colon through a small stoma on the skin. This is often performed in combination with other procedures, such as urinary diversion and augmentation.