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Neurogenic Bladder & Voiding Dysfunction

Also see Urinary Incontinence

Voiding dysfunction is a general term that comprises abnormal voiding in childhood without underlying neurologic causes. Voiding dysfunction can take many forms such as wetting, poor bladder emptying, high bladder capacity, or high bladder pressures. 

Daytime and/or nighttime wetting is common in children and may occur with and without infections. Nighttime wetting (nocturnal enuresis) is defined as involuntary bedwetting while asleep by a child older than 5, two or more times a month. Nighttime wetting occurs in up to 20 percent of children at 5 years old. About 15 percent of this group gain control each year, leaving one to two percent of adolescents with this problem.

Secondary enuresis starts after the child was apparently toilet trained, dry during the night for at least six months, and comprises 25 percent of the nighttime wetting group. Daytime wetting occurs in another 15 percent of children with nighttime wetting. Daytime wetters have uncontrolled daytime wetting accidents that are often embarrassing, especially if the child is in school or daycare.  

The HAWK Center for voiding dysfunction attends to the special needs of children with wetting issues and other forms of abnormal urination. Voiding dysfunction causes a great deal of anxiety for patients and parents. These children are often excluded from social events such as sleepovers and summer camps.

At Georgia Pediatric Urology, two highly-trained and experienced nurse practitioners specialize in the evaluation and treatment of children with voiding dysfunction. After taking a patient’s thorough history, physical causes for voiding dysfunction are ruled out such as phimosis, meatal stenosis, constipation or spinal abnormalities. Diagnostic tools include ultrasound, videourodynamic studies, and urine tests. Behavioral (e.g., timed voiding, double voiding), dietary (e.g., minimizing intake of fluids, sodas, caffeine), and pharmacologic management as well as the use of bed-wetting alarms are discussed. Biofeedback teaches children in a video game-like setting to relax the pelvic floor and urinary sphincter in order to facilitate complete bladder emptying.

What causes neurogenic bladder?

In children a neurogenic bladder may be secondary to a birth defect or it may be an acquired condtion. The following are some of the most common causes of neurogenic bladder:

  • Spina bifida
    A defect that occurs during early fetal development. The defect consists of incomplete bony closure of the spinal cord through which the spinal cord may or may not protrude.
  • Spinal cord trauma 
  • Central nervous system or spinal cord tumors

A neurogenic bladder is caused by an abnormal innervation of the bladder secondary to congenital spinal cord abnormalities, spinal cord injury or injury to nerves during pelvic surgery. The most common cause of a neurogenic bladder in childhood is spina bifida. Appropriate bladder innervation is paramount for normal bladder and bladder outlet (sphincter) function and allows normal storage and emptying of urine.

Abnormal storage and emptying of urine leads to urinary incontinence, urinary tract infections, and occasionally—but most importantly—deteriorating kidney function. Early kidney ultrasound and a videourodynamic study at 3 months of age are necessary to assess the need for clean intermittent catheterization and pharmacologic therapy.

The Children’s Spina Bifida Clinic offers patients the convenience of a multi-specialty clinic. This clinic is attended by urologists, neurosurgeons, neuropsychologists, orthopaedic surgeons, physiatrists, physical therapists, occupational therapists, social workers, orthotic specialists and nutritionists. Assessment and preservation of renal function is of highest priority and depends significantly on the dynamics of bladder and bladder outlet. Bladder management is an effort to achieve social continence by having or producing a bladder capable of holding urine and able to be emptied at intervals by catheterization.Initially this consists of catheterization with or without medications, which relax bladder contractility and with or without antibiotic prophylaxis. This typically begins between ages 3 to 5 years. When these conservative—or non-surgical—treatments fails and/or kidney function deteriorates a bladder augmentation with catheterizable channel (Mitrofanoff) and possible bladder neck sling become necessary. In some cases of severe constipation a catheterizable channel to the colon for Malone’s antegrade colonic enemas (MACE) is created in the same setting.  

Videourodynamic studies assess the anatomy as well as function of the bladder and bladder outlet with X-rays and pressure measurements of the bladder and abdomen. Placement of two small catheters into the bladder and rectum are facilitated with the use of local anesthetic gel. A DVD player is available and children are encouraged to bring their favorite movie, toy or blanket. Children who require catheter placement by cystoscopy or sedation undergo videourodynamic studies at Children’s.