Newborns with neurogenic bladders remain at low risk without medical management
Medical management of newborns with neurogenic bladders and detrusor leak point pressure (DLPP) <40 ml/cmH2O may be delayed for up to 3 years, with majority of the patients remaining at low risk, according to a study. Interval urodynamic and renal ultrasound monitoring can be performed to identify the minority who develop higher DLPP.
While medical management of neurogenic bladders aims at avoiding upper tract deterioration and preserve bladder compliance, it is unclear how anticholinergics (AC) and clean intermittent catheterization (CIC) may benefit patients presumed at low risk for renal damage, researchers said.
With the aim of assessing renal and bladder outcomes in low-risk neurogenic bladder patients who had not received medical management, researchers observed 57 newborn patients in diapers until approximately 3 years, when CIC/AC were offered for social continence. Low risk was defined as DLPP <40 ml/cmH2O on initial urodynamic study.
All patients had renal ultrasound, dimercaptosuccinic-acid scan (DMSA), and fluoroscopic urodynamics at baseline, 1 and 3 years. Acquired renal damage was defined as the presence of new cortical defect(s) with/without function loss on DMSA.
Of the newborns, 84 percent were identified as low risk. Baseline imaging indicated upper-tract abnormalities in 33 percent, while baseline DMSAs were abnormal in 6 percent. During 3 years of follow-up, hydronephrosis resolved in 75 percent and vesicoureteral reflux in 63 percent without intervention, while progression occurred in 13 percent.
Urodynamic change to high-risk patients was reported in 20 percent of patients, and 7 percent of these acquired scars on DMSA after conversion to high risk and febrile urinary tract infections. No significant changes in bladder compliance were observed from baseline in patients who remained low risk.
The current data indicate that most newborns with neurogenic bladders and DLPP <40 ml/cmH2O observed to age 3 years without medical management remain at low risk, with new renal damage and decreased bladder compliance occurring only in patients who convert to high risk.
In the majority of cases with initial DLPP <40 ml/cmH2O, medical management can be delayed until 3 years, researchers said, adding that interval urodynamics and renal ultrasound monitoring can be used to detect the minority who develop higher DLPP.
Neurogenic bladder dysfunction in children involves a broad range of conditions, from those associated with specific anatomic abnormalities to those that may occur perinatally or from accidents or sports or motor vehicle related injuries. Despite the aetiology, the guiding principles for management are similar—to insure and maintain an adequate sized, normally compliant, reservoir that evacuates urine completely, at a relatively low pressure. [Pediatr Nephrol 2008;23:541–551]