Neurogenic Lower Urinary Tract Dysfunction - Beyond the Abstract
Historically, renal failure and recurrent pyelonephritis were not infrequent outcomes, so incontinent urinary diversion was frequently employed. The development of urodynamic assessment of NLUTD, effective medications, the concept of clean intermittent catheterization (CIC), and surgical procedures to mitigate deleterious consequences and to create continence have brought us to today’s nuanced approach to affected children.
In “Neurogenic Lower Urinary Tract Dysfunction” recently published in Urologic Clinics of North America, four contemporary management guidelines are discussed. These include protocols or consensus statements from the Spina Bifida Association (USA), European Society of Pediatric Urology, International Children’s Continence Society, and the British Association of Pediatric Urologists published 2012-2022. All are relatively proactive in managing NLUTD and use urodynamic evaluation to identify those bladders that are at greater risk to cause renal insult. The working hypothesis embraced is that early identification and treatment of hostile bladders can result in better continence and renal preservation rates over time. Conversely, others are more reactive in only evaluating and initiating therapy if there is sonographic evidence of upper tract damage, recurrent urinary tract infections (UTI), or desire for urinary continence. The US Centers for Disease Control and Prevention’s UMPIRE (Urologic Management to Preserve Initial Renal Function) is a prospective attempt to determine if the proactive approach improves long term outcomes.
Urodynamic assessment is the basis for much of the management of pediatric NLUTD; however, standardization and agreement on the technique and interpretation of such studies remain elusive. Infants and children come in different sizes and are not always cooperative, creating significant variability among studies. Multiple manuscripts have shown that the supposed experts have difficulty reaching agreement when reading pediatric urodynamic tracings which further complicates protocol development and adherence. When bladder hostility is encountered, the guidelines nicely lay out stepwise approaches using medications, botulinum toxin, and surgery in addition to CIC. Interventions to attain continence are myriad but must be individualized to each patient and their family as they can convert a safe lower urinary tract into a hostile one. Furthermore, surgical procedures must stand the test of time as most of these children will thrive for many decades.
The goal of management of children with NLUTD is to help them live long and healthy lives by minimizing renal damage and UTI while gaining continence if desired. In the transition to adulthood, it is important to focus on the attainment of independence in bladder management. In addition, bowel management and sexual health should be addressed. The advances of the past half-century have made survival to adulthood the norm for children with NLUTD, but we must continue to strive to help them achieve a better quality of life.
Written by: John Wiener, MD, Professor of Surgery and Pediatrics, Duke University Hospital, Durham, NC
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