Bladder and voiding dusfunction

Introducton
Neurogenic bladder can develop as a result of a lesion at any level in the nervo
system, i.e. cerebral cortex, spinal cord, or peripheral nervous system. Howeve
the commonest cause of neurogenic bladder is spinal cord abnormalites.
Mult- disciplinary approach
Children with spinal dysraphism require care from a multdisciplinary team c
sistng of neurosurgeon, neurologist, orthopedic surgeon, rehabilitaton spec
neonatologist, nephrologists, urologist and other allied medical specialists.
Long-term follow-up is necessary since
renal or bladder functon can still deteriorate afer childhood.
Children with the conditons listed in
table 1 can present with various pate
of detrusor sphincter dysfuncton
within a wide range of severity,
not predicted by the level of the spinal cord defect.

 The commonest cause of neurogenic bladder is lumbosacral myelomeningoco
At birth, the majority of patents with lumbosacral myelomeningocoele have
normal upper urinary tracts, but nearly 60% of them develop upper tract
deterioraton due to infectons, bladder changes and refux by 3 years of age.
Progressive renal damage is due to high detrusor pressures both throughout
flling phase (poor compliance bladder) as well as superimposed detrusor
contractons against a closed sphincter (detrusor sphincter dyssynergia).
Symptoms may range from poor sensation to urinate (void), frank urinary retention (the
inability to void), all the way to florid urinary incontinence and leakage.  Many patients
with neurogenic bladder will frequently have recurrent urinary tract infections and be at
risk for kidney damage based on the severity of their bladder problem.  The bladder acts
as a reservoir for urine and is intended to store urine at a very low pressure.  In some
neurogenic bladder conditions, the "storage pressure" within the bladder is very high
and may cause the urine to "back up" into the kidneys above (much like the pipes in
your house being clogged).  Not every patient will have this serious condition, but
frequent doctor visits and proper diagnostic testing (such as urodynamic testing) are
necessary to diagnose, treat, and hopefully prevent the complications of neurogenic bladder.
Voiding Dysfunction
Many patients who have similar or identical symptoms to those with neurogenic bladder
but who do not have a documented neurologic condition may be classified as having
voiding dysfunction.  Voiding dysfunction simply implies that the process of urination is
abnormal.  Again, this may manifest as urinary incontinence (leakage), difficulty with
initiating urination or difficulty with your stream, or the inability to urinate.
Many medical conditions, although not classified as "neurologic" may have voiding
dysfunction as a consequence.  Diabetes frequently will be associated with voiding
dysfunction and urinary problems.  Many patients who have had recent surgery (such
as pelvic surgery or back surgery) will also suffer from voiding dysfunction and/or
neurogenic bladder surrounding the time of their operation and the post-operative
recovery period.
Aims of management:
 • preserve upper renal tracts and renal functon
 • achieve urinary contnence
 • develop sense of autonomy and beter self esteem
Urodynamic Testing
Patients with neurogenic bladder and voiding dysfunction frequently will require
urodynamic testing.  Urodynamics is a diagnostic "pressure test" of the bladder.  A tiny
catheter is inserted into the bladder as well as a tiny catheter inserted into the rectum.
This measures the pressure within the bladder and the "abdominal cavity."  Fluid is
slowly instilled into the bladder to diagnose the pressure as the bladder fills as well as
the pressure when urinating.  This "bladder pressure" determination can be very helpful
in accurately diagnosing the severity of neurogenic bladder and voiding dysfunction.  In
addition, urodynamics may be used to provide a risk assessment of a patient's potential
for kidney damage and worsening symptoms over the ensuing years.
Urodynamic testing is done as an outpatient, does not require a hospital stay, and is
covered by all major insurance companies as well as Medicare.
It is very helpful to keep a Bladder Diary before obtaining a urodynamic study.  A
bladder diary is a record of patient's urinary habits.  You will be asked to measure the
urine each time you void and record the volume as well as the time and any associated
leakage or problems.
Timing of urodynamic study
Urodynamic study is indicated in all children with neurogenic bladder. However
due to limited availability, urodynamic study should be carried out in children with
neurogenic bladder with the following:
 • recurrent UTI
 • hydronephrosis
 • incontnence despite CIC
 • thickened bladder wall
 • raised serum creatnine
Technique of clean intermitent catheterisaton
Procedure
1. assemble all equipment: catheter, ± lubricant, drainage receptacle, adjustable mirror
2. wash hands with soap and water
3. clean the urethral orifce with clean water.
In boys:
1. lif penis with one hand to straighten out urethra.
2. lubricate the catheter, with local anaesthetc gel (lignocaine) or K-Y jelly.
3. use the other hand to insert the catheter into the urethra. There may be some resistance
    as the catheter tp reaches the bladder neck.
4. contnue to advance the catheter slowly using gentle, frm pressure untl the sphincter relaxes.
In girls:
1. the labia are separated and the catheter inserted through the urethral meatus into the bladder.
For both males and females
1. the catheter is inserted gently untl the urine fows.
2. the urine is collected in a jug or botle or is directed into the lavatory.
3. once the urine has stopped fowing the catheter should be rotated and then, if no urine
    drains, slowly withdrawn.
4. wash hands on completon of catheterizaton
5. catheterise at the prescribed tme with the best available measures
Size of catheters
Small babies: 6F
Children: 8-10F
Adolescence: 12-14F
How Ofen to Catheterise
Infants:    6 tmes a day
children:  4-5 tmes a day, more frequently in patents with a high fuid intake,
                  and in patents with a small capacity bladder.
Reuse of catheters
1. catheters can be re-used for 2 to 4 weeks
2. afer using the catheter, wash in soapy water, rinse well under running tap water,
    hang to air dry and store in clean container.
Note: In infants with myelomeningocoele, management is directed at creatng a low-pressure reservoir
and ensuring complete and safe bladder emptying with clean intermitent catheterizaton. CIC should be
started once the myelomeningocoele is repaired. Startng CIC in early infancy has led to easier acceptance
by parents and children and reduced upper tract deterioraton and improvement in contnence.