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The management of paediatric neurogenic bladder: an approach in a resource-poor setting
Patrick Opoku Manu Maison1, John Lazarus1
1a Division of Urology , Red Cross War Memorial Hospital, University of Cape Town , Cape Town , South Africa.
Insights
Early management of paediatric neurogenic bladder is crucial for preserving renal function and achieving social continence in children, especially in resource-poor settings. This involves monitoring from birth and utilizing cost-effective treatments like clean intermittent catheterisation.
Area of Science:
- Pediatric Urology
- Neurology
- Public Health in Resource-Poor Settings
Background:
- Paediatric neurogenic bladder, often linked to neural tube defects like myelomeningocele, can lead to severe renal failure and urinary incontinence if untreated.
- Early detection and management from birth are vital for preserving renal function and achieving social continence in affected children.
- Resource-poor settings often face challenges with late presentation and urological complications due to limited awareness of neurological impacts on the urinary tract.
Purpose of the Study:
- To outline appropriate management options for paediatric neurogenic bladder in resource-poor settings.
- To emphasize the importance of early intervention for preserving renal function and achieving social continence.
- To highlight cost-effective treatment strategies suitable for limited-resource environments.
Main Methods:
- Comprehensive assessment including neurological examination, urinalysis, serial ultrasounds, and urodynamics (including simple eyeball urodynamics in resource-limited contexts).
- Primary treatment involves clean intermittent catheterisation (CIC), a cost-effective and efficient method.
- Pharmacological and surgical adjuncts like antimuscarinic drugs (oxybutynin), Botox injections, and bladder augmentation are considered for refractory cases.
Main Results:
- Delayed presentation is common in low- and middle-income countries, often resulting in urological complications.
- Physical and neurological examinations, including assessment of sacral reflexes, are essential for diagnosis.
- Urodynamic assessment is key for diagnosis and prognosis, with adaptable methods available for resource-poor settings.
Conclusions:
- Early and consistent bladder management is essential for children with neurogenic bladder in resource-poor settings.
- The primary goals of management are to preserve renal function and achieve social continence.
- Cost-effective strategies, particularly clean intermittent catheterisation, are highly effective and suitable for these environments.
Background:
If untreated, paediatric neurogenic bladder can cause renal failure and urinary incontinence. It is usually caused by neural tube defects such as myelomeningocele. Children with a neurogenic bladder should be monitored from birth and management should aim to preserve renal function and achieve social continence. This article outlines the management options appropriate for these children in resource-poor settings.
Assessment:
In most low- and middle-income countries, a general lack of awareness of the neurological effects on the urinary tract results in late presentation, usually with urological complications even when spina bifida is diagnosed early. Physical examination must include neurological examination for spinal deformities and intact sacral reflexes. About 90% of children with occult spinal dysraphisms will have cutaneous sacral lesions. The work-up includes urinalysis, serial ultrasound of the urinary tracts and urodynamics. Urodynamic assessment is essential for the diagnosis and prognosis of the paediatric neurogenic bladder. In poorly resourced settings, simple eyeball urodynamics can be performed in the absence of a conventional urodynamic set-up.
Treatment:
Clean intermittent catheterisation (CIC), the mainstay of treatment, is most suitable for resource-poor settings because it is effective and inexpensive. Antimuscarinic drugs such as oxybutynin complement CIC by reducing detrusor overactivity. Intravesical injection of Botox and bladder augmentation surgery is required by a small subset of patients who fail to respond to combined CIC and oxybutynin therapy.
Conclusion:
Children with neurogenic bladder in resource-poor settings should have early bladder management to preserve renal function and provide social continence.
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