What is a neurogenic bladder?
The bladder has two main functions: To store urine and then to empty urine when it is full. For this process to be successful, the nerves and the muscles of the urinary tract must work together. Nerves carry messages from the bladder to the brain and from the brain to the muscles of the bladder and sphincter (the “hold on” muscle between the bladder and the urethra). These messages tell the bladder muscle to relax or contract. In a neurogenic bladder, the nerves that are supposed to carry these messages to the bladder do not work properly so the bladder is not able to store or empty urine effectively.
In children, a neurogenic bladder may be related to a birth defect, or it may be acquired as the result of a different problem. The following are some of the most common causes of neurogenic bladder:
- Spina bifida
- Tethered spinal cord
- Caudal regression
- Transverse myelitis
- Spinal cord trauma
- Central nervous system tumors
- Pelvic tumors
Symptoms of neurogenic bladder may vary depending upon the cause and other associated conditions. In many cases, neurogenic bladder is associated with the following:
Evaluation and diagnosis
Your child may undergo a variety of tests to help us confirm the diagnosis and learn the extent of the condition. These tests include:
- Renal and bladder ultrasound to evaluate the anatomy of the kidneys and bladder
- Video urodynamic study to evaluate how well your child’s bladder fills, stores urine and empties
- Voiding cystourethrogram to evaluate for Vesicoureteral Reflux (VUR), bladder neck and urethral problems
- MRI of the spine to evaluate for any spinal concerns such as tethered spinal cord
- Blood work to assess kidney function: Basic Metabolic Panel and Cystatin-C
The Division of Urology specializes in the care of children with neurogenic bladder. We provide care for more than 1,000 different patients with this condition, most commonly through our Neurogenic Bladder Program.
Our goals in treating patients with neurogenic bladder are to preserve renal function, achieve social continence and promote positive self-esteem. Our team of physicians, nurses and psychologists will work closely with your family to ensure your individual goals are met.
- Clean intermittent catheterization (CIC): CIC is a clean, but not sterile, procedure taught to parents and families by our trained nursing staff. Routinely emptying the bladder decreases the risk of UTIs, prevents hydronephrosis, protects the bladder and helps achieve continence.
- Overnight catheter drainage: Some children require leaving a catheter in their bladder while they sleep to continuously drain the urine overnight. This can reduce the frequency of UTIs, reduce/decrease kidney dilatation, and improve continence. Overnight drainage in conjunction with daytime clean intermittent catheterization may maintain the bladder’s ability to store urine and avoid surgery.
- Prophylactic antibiotic therapy: If there are concerns of inability to empty the bladder, urinary retention, vesicoureteral reflux (VUR) or other conditions that will put your child at a higher risk of developing a urinary tract infection (UTI), a once-per-day low dose of antibiotics may be recommended.
- Anticholinergic medications: This class of medications (Ditropan, Detrol, Vesicare) helps to relax the smooth muscles of the bladder, improve the ability to store urine at lower pressure, prevent bladder contractions, increase bladder capacity, and contribute to continence.
- Beta3 Agonist Medication: This class of medication (Myrbetriq) helps to relax the smooth muscles of the bladder, improve the ability to store urine at lower pressure, prevent bladder contractions, increase bladder capacity, and contribute to continence. It can be used alone but is often used in combination with an anticholinergic medication.
Surgery may be appropriate for patients who have changes to the kidneys, ureters or bladder on radiology imaging, issues with storing urine in the bladder, recurrent UTIs, or whose incontinence cannot be controlled through medical measures.
- Vesicostomy: This procedure is often done when a child has recurrent urinary tract infections with high fever, inability to empty the bladder completely (urinary retention), or severe dilation of the kidneys and ureters. A vesicostomy is an opening in the lower abdomen into the bladder which allows urine to drain continuously into a diaper. The opening is created by a surgical procedure where a small incision is made through the skin and into the bladder. A small part of the bladder wall is turned inside out and sewn to the abdomen. It appears as a small slit, surrounded by pink tissue. The vesicostomy is a temporary option and can be reversed in the future.
- Bladder augmentation: This procedure is done when a child cannot store urine in their bladder at low pressure, which can cause injury to the bladder and the kidneys. Augmentation of the bladder increases the size of the bladder by using a segment of bowel as a patch. This allows the bladder to store more urine at lower pressure and decreases the risk of injury to the kidneys and bladder.
- Appendicovesicostomy (Mitrofanoff): This procedure is done to allow children and adolescents to pass a catheter through an opening in the abdomen to empty their bladder. The Appendicovesicostomy can give the child age-appropriate independence or allow for a caregiver to assist in emptying the bladder more easily. CHOP’s Division of Urology was the first pediatric urology program in North America to embrace the use of a catheterizable channel constructed with the appendix. In an appendicovesicostomy, a continent stoma (opening) is created on the abdomen to provide easy access to empty the bladder. This segment may be used with the appendix or a portion of the bowel that connects the bladder to the surface of the skin. This procedure is generally combined with additional surgical procedures to increase the capacity of the bladder, decrease the storage pressure and, many times, with procedures that decrease the chances of urinary leakage via the urethra.
- Malone antegrade colonic enema (MACE: Typically, enemas are given from below (retrograde) by inserting the enema device into the anus to deliver fluid that will help the child empty the stool from the colon. A MACE procedure includes the creation of a channel with either the appendix or a portion of the bowel that connects to the surface of the skin, creating a continent stoma (opening). The stoma allows children with neurogenic bowel to deliver the irrigation from above (antegrade) directly into the colon using a catheter passed through the channel, while sitting on the toilet, allowing the colon to empty of stool.
- Cecostomy button: A cecostomy button is a small plastic tube that is placed into the colon through the right side of the abdomen. Like the MACE procedure, it allows children to deliver the irrigation directly into the colon from above (antegrade) using an adapter that connects to the “button” while sitting on the toilet, allowing the colon to empty of stool. This procedure is performed in the OR or by our Interventional Radiology (IR) team. This tube will need to be replaced every 6-12 months by our IR team.
- Mini ACE: A mini ACE is another type of tube that can be placed into the colon through the right side of the abdomen. It allows children to deliver the irrigation from above (antegrade) directly into the colon using an adapter that connects to the tube while sitting on the toilet, allowing the colon to empty of stool. This procedure is performed in the OR or by our Interventional Radiology team. This tube will need to be replaced every 6-12 months by our IR or surgical team.
Reviewed by: Division of Urology