Pediatric Neurogenic Bladder

Introduction to Pediatric Neurogenic Bladder A neurogenic bladder is a bladder, urinary tract storage or (and) urinary dysfunction caused by partial or complete damage to the central or peripheral nerves. It can also be referred to as lower urinary tract dysfunction. The main reasons are spinal dysplasia, including spinal meningocele, tethered cord, longitudinal spinal cord, lumbosacral dysplasia and so on. Other causes include trauma, tumors, surgery through the appendix or pelvis, nervous system inflammation, and VATER syndrome. Clinically, it is often possible to focus only on the treatment of neurological diseases or primary diseases, but neglect the effects of neurogenic bladder, especially in the long-term increase of bladder filling period, causing vesicoureteral reflux can harm the renal function of children. Even leading to kidney failure. basic knowledge The proportion of illness: 0.003% Susceptible people: children Mode of infection: non-infectious Complications: hydronephrosis uremia

Pediatric neurogenic bladder etiology

(1) Causes of the disease

Classification method

In urological diseases, the neurogenic bladder is the most classified and the most complicated and conceptually confusing disease. So far, no classification has combined the anatomy, physiology, pathology and symptom characteristics of the neurogenic bladder. Uniformity can not meet the needs of clinical prognosis and treatment. The existing classifications are basically summarized as follows:

(1) Classification of lesions of nerves: The first type is based on the classification of nerve lesions, which is represented by the Bors-Coman classification method, which divides the neurogenic bladder into upper motor neuron types according to the site of spinal cord injury ( Upper sacral type), lower motor neuron type (underarm type) and mixed type.

(2) Classification of changes in bladder function: The second is based on changes in bladder function, such as the Wein classification, which divides the neurogenic bladder into a storage disorder and an emptying disorder according to the function of bladder emptying. The advantage of this method is that Suitable for clinical applications.

(3) Classification by urodynamics: At present, for practical purposes, according to bladder storage and emptying, presence or absence of sensation, resistance of pelvic floor and presence or absence of non-inhibitory detrusor contraction, there are two types: Urine, combined with urinary symptoms and complications, 2 no residual urine, can not urinate, that is, urinary incontinence, the latter accounted for about 1/3 of neurogenic bladder cases, classification according to urodynamics is also getting more and more attention Application, it can comprehensively consider the relationship between the bladder detrusor and urethral sphincter, the bladder and urethra are divided into normal, hyperthyroidism, no reflex, and it is divided into bladder detrusor and urethral sphincter coordination , does not coordinate the two situations.

2. Causes

Common causes of pediatric neurogenic bladder are:

(1) Medullary bulging: Recently, the number of survivors of children suffering from myeloid bulging has increased, and the treatment of neurogenic bladder is more important.

(2) vertebral dysplasia: common partial defect of the atlas, there is a neurogenic bladder in the early stage of the baby, the congenital abnormality of the spinal cord is combined with the movement and sensory disturbance of the limb.

(3) Spinal cord tumor: Although pediatric spinal cord tumor is rare, epithelial metastasis occurs in neuroblastoma, and spinal cord compression occurs. At this time, neurogenic bladder is not uncommon.

(4) vertebral osteomyelitis: although not common, but can occur epidural abscess, compression of the spinal cord, the production of neurogenic bladder, many of the pioneer infection, fever, systemic symptoms and nerve root pain, although the emergence of neurogenic bladder The bones can be normal, but bone destruction occurs soon.

(5) Trauma: Paraplegia caused by rare spine fractures in children, the treatment is the same as that of adults. Extensive pelvic fractures can sometimes be combined with neurogenic bladder. When anorectal malformation or megacolon surgery can damage the bladder nerve, the operation should be as close as possible. Intestinal tubes, such as those designed by Duhamel and Soave, can reduce nerve damage. In addition, removal of neonatal or infant appendix teratoma can also produce a neurogenic bladder.

(6) Infection: Occasionally, measles encephalitis or poliomyelitis with neurogenic bladder. Transverse myelitis is a viral infection. A transient neurogenic bladder can occur. The prognosis is good, but short-term bladder drainage is required.

(7) Recessive neurogenic bladder: There are no other neurological symptoms other than bladder symptoms.

(two) pathogenesis

1. Detrusor hyperreflexia combined with urethral sphincter dyssynergia

The common features of these types of lesions are: there is a manifestation of detrusor hyperreflexia, there may be detrusor contraction during urination, but the urethral sphincter [inside and/or outside] can not coordinate the relaxation, or even strengthen the contraction, see In patients with supraspinal neuropathy, there are three cases:

(1) Detrusor hyperreflexia combined with extra-urethral sphincter dyssynergia.

(2) Detrusor hyperreflexia combined with urethral sphincter dyssynergia.

(3) Detrusor hyperreflexia combined with extra-urethral and internal sphincter dyssynergia.

2. Detrusor no reflection combined with urethral sphincter achalasia

The common features of this type of lesion are: there is no reflection of the detrusor, no detrusor contraction during urination, urethral sphincter [inside and/or outside] can not coordinate relaxation, or even strengthen contraction, and detrusor Different from hyperreflexia, because there is no detrusor contraction during urination, it is not called a synergistic disorder, but is called achalasia. In patients with medullary or medullary efferent neuropathy, there are three cases:

(1) Detrusor no reflection combined with urethral sphincter achalasia.

(2) Detrusor no reflection combined with urethral sphincter achalasia.

(3) Detrusor no reflection combined with urethral and internal sphincter achalasia.

3. Extra-urethral sphincter denervation

This is one of the detrusor no reflections.

Pediatric neurogenic bladder prevention

Long-term follow-up of children with this disease, especially the use of the stomach, intestinal enlargement of bladder capacity, must follow up the urinary tract infection, upper urinary tract damage and electrolyte balance and check the application of the stomach, intestinal expansion of the bladder with or without malignant transformation.

Pediatric neurogenic bladder complications Complications hydronephrosis uremia

Due to the weakness or inability of the detrusor contraction, the detrusor and external sphincter or bladder neck synergy and the urethral resistance are relatively high, so that the bladder is incompletely emptied, and urinary retention occurs. At this time, the intravesical pressure rises, often with the bladder. Ureteral reflux, rare reflux in the neonatal period, more than 50% of vesicoureteral reflux by the age of 10, leading to ureteral hydrops, hydronephrosis and urinary tract infection, eventually leading to renal insufficiency and chronic uremia. The importance of neurogenic bladder is threefold:

1. Affect the life of the patient, due to chronic urinary retention, infection, can cause severe renal insufficiency.

2. The neurogenic bladder loses control of the urine, thus affecting the social activities of the child.

3. Male patients with neurogenic bladder often have sexual dysfunction in adulthood. The penis cannot be erected and ejaculated, nor is it fertile.

Pediatric neurogenic bladder symptoms Common symptoms Increased bladder residual urine gait abnormalities Urinary incontinence Anal relaxation Anuria

The cause of neurogenic bladder in children is mainly congenital, so most of them can be found early in life, and those who have acquired such as trauma can also conclude from the medical history that the neurogenic bladder has a large amount of residual urine, combined with urinary symptoms. And complications and no residual urine, urinary incontinence, the former is more, because the bladder motor and sensory nerves have obstacles, so when the bladder is filled, there is no urine, and because of internal and external sphincter synergy and bladder wall Rules and weak autonomic contraction, it is manifested as a large number of involuntary urination, urinary and a large amount of residual urine, up to 200 ~ 300ml, physical examination in addition to lower abdominal bladder expansion, may have anal relaxation, lower extremity dyskinesia or perineal sensation Disappearance, also known as saddle-shaped paralysis, congenital spinal dysplasia such as spinal meningocele and spinal canal dysplasia often lead to abnormal urination (defecation) after birth, spinal skin lesions, lower extremities, foot deformities and gait abnormalities In the case of neonatal or infants, the latter two cases are often seen; in older children, usually in the stage of controlled bowel movements and walking Often found by parents, such as combined with upper urinary tract damage and infection, may have renal dysfunction, these children are common anemia and high blood pressure, but not often with stones, pediatric neurogenic bladder is mostly found early in life, although Urodynamic examination is very important, but often because the child can not cooperate or under anesthesia, so that a complete and true evaluation is not available, so detailed medical history and physical examination, complete laboratory and imaging examinations are often required. And some necessary special checks to make up for the above deficiencies, medical history and physical examination can provide a generalization of the situation of the child, but also has the following effects:

1. Identify medical history that may be related to bowel function, such as history of enuresis, type of urination in children, etc.

2. Position the damage to the nervous system to confirm and explain the results of the urodynamic test.

3. Understand the prognosis of the child and provide a reference for the treatment plan.

4. Physical examination: physical examination of the spine, especially the appendix, can be used to understand whether the child has vertebral dysplasia such as spina bifida; nervous system examination such as saddle area feels diminished or disappeared, anal sphincter reflex and bulbar muscle reflex hyperthyroidism, Decreased or disappeared, etc., all contribute to the evaluation of the extent and location of neurological damage in children.

Pediatric neurogenic bladder examination

The most common complication of neurogenic bladder is urinary tract infection, but the symptoms are atypical. For example, vesicoureteral regurgitation may accelerate kidney damage; in neonates or infants, water and electrolyte disorders may occur, and acid-base balance may be imbalanced. Kidney failure, etc., threaten the lives of children, therefore, urine and urine culture, urea nitrogen and creatinine, and blood sodium, potassium, chlorine and carbon dioxide binding, etc., to understand the upper urinary tract of children with neurogenic bladder The extent of damage and general condition are important.

1. Imaging examination

X-ray spine examination can detect spinal deformity (such as vertebral deformity) and spina bifida. Urinary bladder urethrography can find a typical "Christmas tree"-like bladder. It can understand the shape and volume of the bladder during filling, and whether there is a vesic ureter. The degree of reflux and reflux; observation of the opening of the urethra and bladder neck during urination, has a certain diagnostic significance for the presence of detrusor and sphincter discomfort, and can exclude congenital lower urinary tract obstruction such as posterior urethral valve Sexual diseases and radionuclide imaging can accurately assess the degree of renal dysfunction in children. Because of its non-invasive nature, B-ultrasound is used to understand the upper urinary tract and long-term follow-up of children.

2. Urodynamic examination

Including bladder pressure measurement, external sphincter electromyography, urethral pressure measurement and urine flow rate measurement, etc., there are routine urodynamic examination, imaging urodynamics and dynamic urodynamics in the examination method, in addition to urine flow rate measurement In addition, as an unnatural irritative examination of bladder and urinary tract function, urodynamic examination has certain limitations, but some of its objective findings, such as the presence of non-inhibitory contraction of the bladder, the sphincter has denervated myoelectricity Chart performance and other conditions can still provide important diagnostic data for the clinic, and it has certain guiding significance for the classification and treatment of neurogenic bladder. For the urodynamic examination of children, the lower urinary tract innervation should also be considered. The degree of development to prevent a one-sided conclusion, therefore, the comprehensive evaluation of urodynamic results and medical history, physical examination and imaging findings can make an individualized comprehensive diagnosis of children with neurogenic bladder. Provide reasonable guidance for treatment.

Diagnosis and diagnosis of neurogenic bladder in children

diagnosis

Diagnosis can be based on the cause, symptoms and related tests.

Differential diagnosis

1. It is often found in patients with common urinary tract infections that the cause of infection is easy to control and will not recur.

2. Identification with urinary reflux can be identified by imaging and urodynamics, but urinary reflux can also be a complication of this disease.

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