Lynn Wu

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Neurogenic bladder can affect a lot of different, um, um, disease states, and so we always think of spina bifida as probably the most common cause in our PES populations, but, um, truth be told, you can see neurogenic bladder, you know, in children with any spinal cord abnorm. Abnormality, a spinal cord injury, certainly after trauma, um, with which you guys are very familiar and then other, um, congenital anomalies like, uh, cloacal and bladder atrophy or even in the anal rectal malformations or children with the, the veal. Kind of complex, uh, where there's a known spinal cord problem, um, those children often have a high incidence of neurogenic bladder as well.

quote · Neurogenic Bladder

If, if it's, the pressure is so high that it's actually forcing urine back up into the kidneys, this becomes a very, you know, visibly dangerous situation. And then And combining that with recurrent UTIs is also, or urinary tract infections, is, is equally deleterious because now you've got backup of a high pressure situation. So you've got, you're hammering the kidneys with high pressure, and you are potentially showering the kidneys with bacteria, which now have an escalator to the kidneys, if you will, through this reflux mechanism.

quote · Neurogenic Bladder

Reflux in the urology literature, it can happen for a couple of reasons. Some kids can just, kids with non-neuropathic bladders can have reflux, and we feel that that happens for a, uh, uh, a reason about the, the bladder and ureterral anatomy. But in kids with a neurogenic bladder or abnormal functioning bladders, reflux can be what we call. Secondary. So, the pressures within the bladder are so abnormally high that it overwhelms the valve mechanism where the ureter meets the bladder, and then you get back up.

quote · Spina Bifida

Oxybutynin or Ditropan, and this is a safe, well-accepted, uh, medication that, um. Helps to sort of relax the bladder or, or increase the compliance of the bladder. For non-neuropathic patients, we use it to treat overactive bladder, so that, that feeling of needing to go all the time. And so we found that in this population, the anticholinergic medication in combination with intermittent catheterization is sort of our, our key combo therapy for how you manage a hostile bladder.

quote · Spina Bifida

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Lynn's statements about Neurogenic Bladder 53 statements

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Neurogenic Bladder

Quotation Neurogenic bladder can affect a lot of different, um, um, disease states, and so we always think of spina bifida as probably the most common cause in our PES populations, but, um, truth be told, you can see neurogenic bladder, you know, in children with any spinal cord abnorm. Abnormality, a spinal cord injury, certainly after trauma, um, with which you guys are very familiar and then other, um, congenital anomalies like, uh, cloacal and bladder atrophy or even in the anal rectal malformations or children with the, the veal. Kind of complex, uh, where there's a known spinal cord problem, um, those children often have a high incidence of neurogenic bladder as well. Open

Statement Neurogenic bladder in pediatric populations is most commonly associated with spina bifida (myelomeningocele, lipomyelomeningocele, meningocele), but also occurs with spinal cord injury, cloacal exstrophy, anorectal malformations, and VACTERL association. Open

Statement Baseline evaluation of a newborn with myelomeningocele includes renal-bladder ultrasound and VCUG to assess for two kidneys, hydronephrosis, bladder shape, trabeculations, reflux, and bladder neck/urethral contour. Open

Statement The majority of children with spina bifida will have normal imaging studies at birth, making baseline documentation important. Open

Statement Urodynamics should be performed within the first month or couple of months of life to measure bladder pressure and compliance; a normal bladder maintains low pressure as it fills. Open

Quotation A normal bladder should be a low pressure kind of situation as it fills, the compliance should be good, meaning that the change in the pressure as the volume changes should be very, very little, and that's the hallmark of a normal bladder. Open

Statement A hostile bladder is defined by high pressure, instability (contracting during filling), or poor compliance; high bladder pressure is the most dangerous feature for renal function. Open

Statement Detrusor-sphincter dyssynergia (DSD) is a discoordination between bladder contraction and sphincter relaxation, resulting in high-pressure voiding; it can occur in any neurogenic bladder, including after spinal cord trauma. Open

Quotation DSD means that there's a discoordination between the bladder and the sphincter, and you don't think about it in normal life, but those are regulated, um, between very complex pathways between the brain and the spinal cord, and then the, the nerves that go to the bladder. And so for a normal person, when you go to void, your sphincter knows to relax and open so that. There's no resistance to that at all. Open

Statement Clean intermittent catheterization (CIC) is the mainstay of neurogenic bladder management; it empties the bladder completely, reduces pressure, and bypasses sphincter dysfunction. Open

Quotation The idea behind CIC or, or IC, uh. Um, and catheterization is that on a scheduled basis, you're going in, or the patients, you know, as they learn to do it, or their parents are doing it, to empty that bladder. And that will, A, make the bladder empty completely. It will help with the overall pressure situation because now you've taken a filled bladder that may be under pressure and taken that out. Open

Statement Some urologists advocate universal early CIC from birth in all spina bifida patients to familiarize families, promote child acceptance, and potentially influence favorable bladder development. Open

Quotation There are some people that feel all kids from birth with the diagnosis of spina bifida and neurogenic bladder should be initiated on CIC as soon as possible. Parents should be introduced to the concept, um, and that. Can do many things. One, it can familiarize the family with what otherwise seems like a fairly complicated or daunting task. Um, it allows the child to accept it sooner. Open

Quotation There's some data now coming out that suggests if you do it early, you may actually be able to influence how that bladder develops, and you may actually improve the overall bladder dynamics as that child grows. So, it can be potentially protective, um, in, in a proactive way to start catheterization early. Open

Statement The traditional approach initiates CIC only in patients with worrisome urodynamic features or hostile bladders, to avoid unnecessary intervention and potential infection risk. Open

Statement Absolute indications for CIC include bladder pressure >40 cm H₂O, hydronephrosis, reflux, small bladder capacity, or detrusor-sphincter dyssynergia on urodynamics. Open

Quotation Most of us would agree that if the, the pressures on neurodynamics are very high, and historically we use, uh, 40 centimeters of water as our cut-off point for, for pressure. Uh, that's a worrisome situation, so those patients should be initiated on CIC if there's already evidence that there's hydronephrosis or, um, uh, a small capacity bladder, um, or evidence of reflux because of the pressure, those are reasons to do it. Open

Quotation I think this is like any major congenital anomaly. It can be extremely overwhelming for for parents who have a newborn, um, and then they're being told that there are all of these things that they have to be, you know, worrying about as that. Child grows. Open

Quotation For, for urology, what our priorities are. And that would be making sure that we're safeguarding the, the renal function or the kidney function as a secondary part, um, as the child grows, then we'll have that discussion about social continence. Open

Statement Renal ultrasound should be repeated every 3–6 months in the first several years of life to monitor for hydronephrosis as the child and kidneys grow rapidly. Open

Quotation Oxybutynin or Ditropan, and this is a safe, well-accepted, uh, medication that, um. Helps to sort of relax the bladder or, or increase the compliance of the bladder. For non-neuropathic patients, we use it to treat overactive bladder, so that, that feeling of needing to go all the time. And so we found that in this population, the anticholinergic medication in combination with intermittent catheterization is sort of our, our key combo therapy for how you manage a hostile bladder. Open

Statement Oxybutynin (Ditropan), an anticholinergic medication, relaxes the bladder and increases compliance; it is used in combination with CIC to manage hostile bladders. Open

Statement Urodynamics are generally repeated every 6–12 months; intervals are shortened if the bladder is hostile or parental compliance is uncertain. Open

Quotation Reflux in the urology literature, it can happen for a couple of reasons. Some kids can just, kids with non-neuropathic bladders can have reflux, and we feel that that happens for a, uh, uh, a reason about the, the bladder and ureterral anatomy. But in kids with a neurogenic bladder or abnormal functioning bladders, reflux can be what we call. Secondary. So, the pressures within the bladder are so abnormally high that it overwhelms the valve mechanism where the ureter meets the bladder, and then you get back up. Open

Statement Secondary reflux in neurogenic bladder occurs when high bladder pressure overwhelms the ureterovesical valve mechanism, forcing urine back into the kidneys. Open

Statement High-grade reflux combined with recurrent UTIs is a dangerous situation: high pressure damages the kidneys and bacteria ascend via reflux, causing pyelonephritis and scarring. Open

Quotation If, if it's, the pressure is so high that it's actually forcing urine back up into the kidneys, this becomes a very, you know, visibly dangerous situation. And then And combining that with recurrent UTIs is also, or urinary tract infections, is, is equally deleterious because now you've got backup of a high pressure situation. So you've got, you're hammering the kidneys with high pressure, and you are potentially showering the kidneys with bacteria, which now have an escalator to the kidneys, if you will, through this reflux mechanism. Open

Statement Cutaneous vesicostomy—opening the bladder dome to the skin as an incontinent stoma—decompresses the bladder, eliminates high pressure, and resolves reflux; it is the easiest and quickest intervention in infants with hostile bladders. Open

Quotation One of the gold standard ways that we in neurology will get around this is a, is a, uh, cutaneous diversion. So we will do a cutaneous vesicostomy, um, and we can talk more about that later, but that's, uh, a, a fairly straightforward procedure where we will open the bladder. At the dome and sew it to the skin in the form of a an incontinent stoma. Open

Quotation It essentially prevents the bladder from filling and so it takes care of that pressure situation. And if you take care of the pressure situation and the bladder's not filling, then no more reflux. Open

Statement Vesicostomy is generally a temporary measure; diapering becomes messier as the child grows, and closure requires a plan for ongoing bladder management. Open

Quotation Continence in this situation comes at a price. So, anything. That we're going to do to try to help that patient gain continence could adversely affect how their bladder, um, works. And you can take a situation that was previously non-hostile and create a hostile situation based on something that you're surgically doing for that patient. Open

Statement Urinary continence in neurogenic bladder patients comes at a price: surgical interventions to achieve continence can adversely affect bladder function and create a hostile bladder where none existed before. Open

Statement Incontinence in neurogenic bladder is multifactorial: bladder overactivity, sphincter dysfunction (always open or never open), insufficient bladder capacity, or a combination. Open

Quotation Our surgical reconstruction can consist of, and any combination of. Physically enlarging the bladder and that's done through an augmentation and the and augmentation is typically done with um bowel. So a segment of bowel enter your pediatric surgeon. Open

Quotation We can't create a sphincter, but we can do something that hopefully will increase the resistance to the outflow of the bladder. So that's tightening up the bladder for, for just to keep it simple. Open

Quotation If you do something to increase the size of the bladder, and you do something to tighten up the bladder, you need to give that patient a reliable way to empty. Open

Statement Bladder augmentation cystoplasty uses a segment of detubularized ileum or colon (typically 20–30 cm) anastomosed to the opened bladder to increase capacity and reduce pressure. Open

Statement Bladder neck procedures to increase outlet resistance include rectus fascial sling, artificial urinary sphincter, urethral lengthening, or complete bladder neck closure. Open

Statement A continent catheterizable channel (Mitrofanoff appendicovesicostomy or Yang-Monty ileal tube) provides a reliable route for bladder emptying when the native urethra is not suitable after reconstruction. Open

Quotation I think the goal is to try to get the patient to be as independent-minded and independent in their care as much as possible. And, and that's not always feasible, and, and sometimes you have to also look at the maturity of the patient, but in this, in this current, um, Day and age, our myelo patients are living a lot longer. Open

Statement Surgical reconstruction must be individualized based on the patient's mobility, hand function, cognitive status, family support, and potential for independence. Open

Quotation The parents may be very excited to sign up for any and all of the procedures you're describing, but who's going to manage that? When the parent's not there. And so, I think that that opens up a whole another discussion that can be had, you know, in, in a separate, in a separate podcast, if anyone's interested about what happens to these patients later. Open

Statement Ethical considerations arise when parents are aging and the patient may require nursing home care; the feasibility of lifelong catheterization by caregivers must inform surgical decision-making. Open

Quotation You can, can, you can. Can you can always, but should you? And for that particular patient, is that the best thing for them? Open

Quotation More recently, uh, urologists are offering Botox injections done cystoscopically. Um, and the Botox, um, is a method by which we can sort of paralyze the diffuser muscle and help potentially with some of that overactivity or high-pressure situation. And This is being viewed favorably because it obviously may help delay, um, the need for a major reconstruction. Open

Statement Cystoscopic Botox injection into the detrusor muscle paralyzes the bladder, reducing overactivity and pressure; it is minimally invasive but not permanent and requires repeat injections. Open

Statement Botox may delay or obviate the need for major reconstruction and help manage bladder dynamics safely, but may not fully resolve incontinence. Open

Statement Transition to adult urology care is poorly developed at many hospitals; barriers include patient loss to follow-up, mistrust of new providers, and adult urologists' discomfort with complex congenital reconstructive history. Open

Quotation It is definitely uncharted territory as you're getting into, um, adulthood. And again, we, we discussed the challenges of gaining independence, um, and, um, having less reliance on their, their parents or their guardians, um, and taking charge of a complicated health history. Open

Statement Structured transitional clinics starting in adolescence, with gradual handoff to adult providers and emphasis on patient independence, are needed but remain an unmet need. Open

Quotation I am embarrassed to admit that this isn't well, well fleshed out, um, at many, at many hospitals. I think that that's the next priority, um, to, to get a good transition. A transitional plan for these patients. Open

Quotation There's the challenge of our adult providers not necessarily being comfortable managing, um, these patients with complex congenital anomalies. And I think that our pediatric surgery colleagues can probably sympathize because, um, many of these patients do have. You know, a long list of surgeries and, and, and, and complications that, um, make it, uh, fairly daunting for a, you know, a, a general adult provider to want to take on. Open

Lynn's statements about Spina Bifida 53 statements

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