Neurogenic bladder in children: basic principles, new therapeutic trends

Diagnosis of neurogenic bladder is straightforward in children with myelomeningocele. However, recognition is more difficult in patients with occult dysraphism or central nervous system disorders since clinico-anatomical correlations are poor. Careful clinical examination and urodynamic exploration are mandatory for diagnosis and follow-up. Even if urinary leak is the first symptom, the main goal of the pediatric surgeon must be to preserve the upper urinary tract. The ideal protection strategy consists of ensuring that micturition is voluntary and complete and that the bladder capacity is sufficient with adequate compliance and sphincter outlet resistances. Balancing these functions requires a combination of medical and surgical treatment. A variety of techniques can be used depending on gender and age of the patient and social environment. In most cases, intermittent bladder catheterization is necessary to obtain complete evacuation of the bladder. Bladder capacity can be increased by anticholinergic drugs, injection of botulinum toxin into the bladder, and augmentation cystoplasty. Augmentation of bladder outlet resistances requires endoscopic injection of bulking agents, surgical bladder neck reconstruction and urethral lengthening, bladder neck suspension, and artificial urinary sphincter. In difficult cases, continent cystostomy with closure of the bladder neck can achieve definitive continence. At the beginning endoscopic treatment combining anti reflux procedure, injection of the bladder neck and botulinum toxin can be considered as a "total endoscopic management" and should be our first line. Other techniques are under evaluation. Sacral neuro-modulation has given promising results. Artificial tissue engineering will probably be used in the next future. Management of neurogenic bladder is not limited to urological considerations. Orthopedic, digestive, and sexual problems must also be taken into account in order to obtain an "acceptable quality of life".