Elsevier

European Urology Focus

Volume 6, Issue 5, 15 September 2020, Pages 838-867
European Urology Focus

Review – Neuro-urology
Pediatric Neurogenic Bladder and Bowel Dysfunction: Will My Child Ever Be out of Diapers?

https://doi.org/10.1016/j.euf.2020.01.003Get rights and content

Abstract

Context

Managing patient and parent expectations regarding urinary and fecal continence is important with congenital conditions that produce neurogenic bladder and bowel dysfunction. Physicians need to be aware of common treatment algorithms and expected outcomes to best counsel these families.

Objective

To systematically evaluate evidence regarding the utilization and success of various modalities in achieving continence, as well as related outcomes, in children with neurogenic bladder and bowel dysfunction.

Evidence acquisition

We performed a systematic review of the literature in PubMed/Medline in August 2019. A total of 114 publications were included in the analysis, including 49 for bladder management and 65 for bowel management.

Evidence synthesis

Children with neurogenic bladder conditions achieved urinary continence 50% of the time, including 44% of children treated with nonsurgical methods and 64% with surgical interventions. Patients with neurogenic bowel problems achieved fecal continence 75% of the time, including 78% of patients treated with nonsurgical methods and 73% with surgical treatment. Surgical complications and need for revisions were high in both categories.

Conclusions

Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Surgical intervention can be successful in patients refractory to nonsurgical management, but the high complication and revision rates support their use as second-line therapy. This is consistent with guidelines issued by the International Children’s Continence Society.

Patient summary

Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence, and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Most children can be managed without surgery. Patients who do not achieve continence with nonsurgical methods frequently have success with operative procedures, but complications and requirements for additional procedures must be expected.

Introduction

Congenital spinal dysraphism accounts for the vast majority of cases of neurogenic bladder and bowel dysfunction in the pediatric population [1]. Rarer etiologies include urologic or anorectal malformations (eg, bladder exstrophy and imperforate anus), as well as acquired injuries from spinal cord/brain trauma or central nervous system tumors. Disruption of sensory and/or motor input to the bladder, urinary sphincter muscles, rectum, and anal sphincter results in urinary and gastrointestinal dysfunction.

Management of neurogenic bladder is critical to the prevention of life-threatening renal failure. The introduction of modern multimodal treatments including both nonsurgical and surgical techniques has resulted in increased life expectancy of patients with spina bifida (SB) [2]. With patients living longer, there is increasing focus on urinary continence. As better quality of life (QoL) research instruments have become available, it is apparent that patients enjoy better lives with successful management of urinary incontinence [3]. Although bowel dysfunction rarely leads to life-threatening complications, constipation and soiling have similar significant consequences on patient well-being. Therefore, it is incumbent on treating physicians to address both urinary and fecal continence, as well as associated issues, such as urinary tract infections (UTIs) and constipation, to maximize patients’ QoL.

Section snippets

Search strategy

A systematic PubMed/Medline search was conducted in August 2019 using Medical Subject Headings (MeSH) terms “neurogenic bladder” and “neurogenic bowel.” Using Boolen techniques, we utilized the following additional MeSH terms: “neurogenic bladder AND sling, suburethral”; “neurogenic bladder AND artificial urinary sphincter”; “neurogenic bladder AND agents, anticholinergic”; “neurogenic bladder AND oxybutynin”; “neurogenic bowel AND fecal incontinence”; “neurogenic bowel AND enema”; “neurogenic

Management of neurogenic bladder

The flow diagram of the neurogenic bladder literature search and results is shown in Figure 1. A total of 49 studies were included in the review: 24 studies for nonsurgical management (Table 1) [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28] and 27 studies for surgical management (Table 2) [7], [19], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46],

Conclusions

Approximately half of children born with neurogenic bladder and bowel dysfunction can achieve continence with nonsurgical therapy. The majority of children who cannot attain continence with these measures are able to do so successfully after surgical intervention, but this comes with a high cost of postoperative complications and need for additional procedures. Therefore, agencies such as the International Children’s Continence Society promote a stepwise approach. The entire literature

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