PRIMARY CARE TREATMENT OF CHILDREN MANAGED WITH CLEAN INTERMITTENT CATHETERIZATION

Routine urinalysis (UA) and UC are not recommended during well-child check-ups if the child looks well and is asymptomatic. If bacteriuria is detected in the urine, it is important to determine whether it represents a clinical infection or colonization of the bladder. Only clinical UTIs with symptoms of fever, abdominal/back pain, painful urination/catheterization, new or worsening incontinence or urinary symptoms, or hematuria should be treated (122). Prophylaxis in the absence of VUR is not routinely recommended.

ANTIBIOTIC PROPHYLAXIS AND BACTERIURIA TREATMENT

A number of studies were done on antibiotic prophylaxis and bacteriuria treatment with individuals with neurogenic bladders. Kass found that if there is no VUR, bacteriuria is innocuous; in his study, 17 hydronephrotic kidneys showed significant radiographic improvement since starting CIC (125). Ottolini found that asymptomatic bacteriuria requires no antibiotic therapy in the absence of VUR (126). Van Hala found that there is no correlation among the number of UTIs, the type of catheter used, and the use of prophylactic antibiotics (127). Johnson and colleagues found that nitrofurantoin is an effective prophylactic agent during a 3-month period for bacteriuria (128). Schlager and colleagues found that asymptomatic bacteriuria persists for weeks in children with neurogenic bladders with normal upper UTs managed with CIC (129). The asymptomatic bacteriuria is different from the symptomatic bacteriuria. Jayawardena and colleagues found that patients with a spinal cord injury (SCI) frequently have asymptomatic bacteriuria without data to support treatment and that routine UCs should not be done at annual evaluations (130).

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

NEONATAL VERSUS CHILDHOOD TREATMENT

Early proper management is imperative for the preservation of renal function (131). A urologist should be involved from the newborn period as 20% are born with renal anomalies and kidney damage was found to be approximately 1 in 4 without proper management of the neurogenic bladder (115).

Treatment of neurogenic bladder dysfunction due to myelomeningocele in neonates is recommended. A study of 98 individuals (46 started CIC in the first year of life, 52 began CIC after 4 years of life) reviewed the charts of those using CIC who were believed to be at risk for renal deterioration. The mean follow-up of this study was 4.9 years, and the average age of the patient at the last follow-up was 11.9 years. The study found that neonatal treatment enabled UDY to identify those infants at risk for upper tract deterioration, which was prevented by the initiation of oxybutynin and CIC. There was a similar improvement in UTI rate, hydronephrosis, and reflux. The percentage of patients with worsening hydronephrosis and persistent high intravesical pressures who needed bladder augmentation was 11% in the earlier treatment group versus 27% in the later treatment group (P < .05) (132).

FURTHER SURGICAL MANAGEMENT FOR REFLUX AND SMALL NEUROGENIC BLADDERS

Lowering the bladder pressure below 40 cm HzO is the goal. Ureteral reimplantation may be necessary for reflux; however, most people with neurogenic bladders have reflux from a high-pressure bladder and not from a ureterovesical junction that is dysfunctional. Medical management with CIC and anticholinergic medication frequently causes reflux to resolve, and surgical correction is rarely necessary. Bladder augmentation may be considered for a small or high-pressure bladder refractory to medical treatment. Bladder augmentation may increase the risk of bladder cancer, rupture, and stone, and mucus may be excessive in the urine, obstructing CIC (133). For cancer surveillance in those with augmented bladders, cystostomy was recommended annually starting 10 years following the bladder augmentation (118). Newer recommendations may be different and a urologist should be involved to determine adequate surveillance. Augmentation should be explored only after pharmacologic management has failed and the system continues to be a high-pressure system, thus putting the kidneys at risk. The complication rate for bladder augmentation in one study was approximately 1 in 3 (134).

In conclusion, those individuals with a normal neurologic exam with sacral-level spina bifida likely have a neurogenic bladder and need appropriate management. This point is demonstrated in a study of bladder dysfunction and neurologic disability at presentation in closed spina bifida. There were 51 individuals in the study, with a mean age of presentation of 3.3 years. Of these patients, 25 had UT disturbance, 12 had neurologic problems, 33 had a normal neurologic exam, 21 had a normal renal ultrasound (RUS), and 31 had abnormal videourodynamics, despite a normal neurologic exam and RUS (135). The majority of individuals with spina bifida have a neurogenic bowel and bladder; even if there are no motor signs of weakness, infants found to have perineal sensation are likely to be continent as well as have decreased renal complications and improved survival long term (136). The management of neurogenic bladder starts in the NICU in the perinatal period by the urologist, physiatrist, nursing, and family.

SOCIAL ASPECTS

The bladder focus may put considerable strain on the family (137). Children and adolescents with neuropathic bladders using intermittent catheterization have worries about peers discovering catheters used to empty their bladder and regarding leakage of urine. Urinary incontinence does affect self-esteem, and it is important to aim medical management at continence for psychological (138) as well as physical well-being. Urinary continence is an important developmental milestone in individuals with and without spina bifida (138). As mentioned in the previous edition of this book, urinary continence, although important, should not occur at the expense of the kidneys.

 
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