 injury and 1/3 with lumbar injury were emptying the bladder using intermittent catheterization/anticholinergic drugs at this follow up; video fluoroscopy during UDS showed the bladder wall to be smooth in 43%, mildly trabeculated in 50% of participants, and markedly trabeculated in 7%. Five patients had a change from a smooth bladder wall to mild trabeculation (four cervical injuries and one thoracic injury). Four patients had a change from a trabeculated bladder wall to a smooth wall (three cervical injuries and one thoracic injury) at six months follow-up after institution of intracranial pressure and anticholinergic therapy. One patient had a grade 2/5 vesicoureteral reflux, which resolved on intermittent catheterization/anticholinergics. The authors noted that neurogenic management treatment failure was related to non-compliance with catheterization or pharmacologic regimen.
Unlike the studies discussed previously, Vogel and colleagues (2002b) work assessed the consequences of pediatric SCI/D-related neurogenic bladder by interviewing 216 adults with pediatric-onset SCI using a structured questionnaire. Mean number of UTI’s/year was reported to be 3.9 and occurred in 74% of individuals; those experiencing more UTIs had lower International Standards for Neurological Classification of Spinal Cord Injury motor scores and were less likely to have AIS D grade injury. In addition, a history of severe UTIs and urinary stones were associated with lower motor scores, higher injury level, and Functional Independence Measure scores. Those who reported having orchitis and epididymitis tended to be older, injured for a longer period of time, and reported having had severe UTIs. Bladder incontinence was reported by 25% of participants, more common in those using external catheters; UTIs were more common in individuals managing bladder with all types of catheters. Severe UTIs, orchitis, and epididymitis were not associated with any specific type of bladder program, but stones were more common in individuals using indwelling catheters.
Generao et al. (2004) performed a retrospective review of 42 pediatric patients who had been living with SCD-related paralysis for a minimum of 1 year. Assessed outcomes were bladder management, continence, medication, UTI occurrence, upper urinary tract health (US), and video-UDS in the context of safe bladder capacity (defined as pressure-specific volume of 40 cm water or less. 40/42 children were managing the bladder using intermittent catheterization and 37 were taking anticholinergic medications. Upper tract exploration showed no vesicoureteral reflux, hydronephrosis, or renal parenchymal scarring. Bladder capacity was less than expected in 80% of cervical injuries (but increasing with time); it was less than expected in 58% of thoracic injuries (and only 76% were found to progress as expected with time) and was less than expected in 50% of lumbar injuries. Early bladder management with intermittent catheterization and anticholinergic drug usage was considered to prevent hydronephrosis, scarring, reflux, and bladder trabeculation, improve continence and decrease rates of infection. In addition, thoracic injuries were found to have the most variable bladder pattern.
Patki et al. (2006) conducted a retrospective review of urological follow-up in 10 adults with pediatric-onset SC The group was divided into Neurogenic Detrusor Overactivity with or without Detrusor Sphincter Dyssynergia and a-contractile detrusor with or without low bladder compliance, based on initial UDS studies. It was found that patients with Neurogenic Detrusor Overactivity and Detrusor Sphincter Dyssynergia were at higher risk of developing complications. In addition, those who opt for reflex voiding and SPC were more likely to experience multiple problems requiring hospitalizations and interventions. The authors also noted that over time, most participants required changes to optimize urological management.
Finally, Tanaka et al. (2006) retrospectively examined the long-term urological outcomes in 22 children affected by transverse myelitis, as well as the correlation between bladder dysfunction and lower limbs spasticity and ambulatory status in addition to neurologic level of injury. Lower limb spasticity was documented in 14/22 (61%) and, while none of the children were ambulatory immediately post-onset of neurologic deficit, 9/22 (41%) became ambulatory during the follow-up period. At follow-up, 86% of children reported persistent bladder dysfunction. Bladder management was done by intermittent catheterization in 73% and 64% was using anticholinergic medications. Three were still incontinent despite adequate bladder management and 1 had the incontinence resolved by undergoing intra-detrusor onabotulinumtoxin type A injections. 6/22 were able to void volitionally, 2 of them having incomplete cervical injuries and maintaining continence (one using anticholinergic medication) and 4 of them having incomplete lumbar injuries, with only 2/4 maintaining continence. All patients with complete injury remained on intermittent catheterization. UDS were completed in 17 at follow-up, an average of 2.2 years after disease onset; detrusor over-activity was present in 10 patients (59%), Detrusor Sphincter Dyssynergia in 7 (41%), low compliance in 8 (47%) and detrusor leak point pressure greater than 40 cm water in 2 (12%). Upper tract was evaluated in 19/22 individuals using renal ultrasound and cystography for vesicoureteral reflux; 26% had upper tract changes (hydronephrosis in 3, reflux in 1, and hydronephrosis and reflux in 1). Chronic renal insufficiency developed in only 1 individual that did not have adequate urologic care for the initial 2.7 years post-injury, developed hydronephrosis and vesicoureteral reflux despite having a complete thoracic injury with no lower limb spasticity; the bladder was found to have low compliance and, despite treatment with intermittent catheterization and anticholinergics, patient needed to undergo augmentation cystoplasty and bilateral ureteral reimplantation to address the complications. 6 individuals that subsequently underwent upper tract and UDS evaluation started intermittent catheterization in the first 9 months post-injury, and another 10 in the first 2.3 years post-injury and were considered early intermittent catheterization users; none of the early catheterization users developed low bladder compliance of upper pathologic tract changes, as opposed to 7 of 10 patients in the delayed catheterization group exhibiting low bladder compliance and 4 of 10 having upper tract changes at follow up.
Major shortcomings of the literature pertaining to management and consequences of neurogenic upper and lower urinary tract dysfunction in children with SCI/D-related paralysis is the retrospective, observational case studies reporting type. That is because high-quality evidence regarding management and follow-up does not exist in the literature (Averbeck & Madersbacher, 2015). There is no standardization of intervention or even follow-up. The approach is not scientifically rigorous but clinically driven and there are no controls. Sometimes, even the definition of terms is variable (e.g., bladder compliance).
With that said, given the fact that pediatric SCI/D is extremely rare, learning from robust case series is the first step toward building knowledge. The reviewed papers consistently point to the lack of predictive value of neurological injury category on bladder function and management. To that point, it does appear that thoracic injuries are less likely to be predictable when it comes to the type and subsequent management of neurologic bladder dysfunction. The ideal urological treatment needs to be individualized and tailored to suit a specific patient’s medical and social needs and both needs are changing as the child grows. Changes in bladder management required at later stage in injury and variation of renal deterioration with different bladder managements make a strong case for regular and long-term follow-up of the pediatric SCI population. Ongoing long-term comprehensive assessment utilizing imaging (renal ultrasound and scan, computed tomography scan, cystometrogram, cystoscopy) and functional (video-urodynamics, creatinine clearance, glomerular filtration rate, cystatin C, radio-isotope studies etc.) tools to assess both upper and lower tracts is strongly recommended for management guidance in the ever-growing and evolving genitourinary system. Preservation of renal function is the most important objective of any long-term treatment plan in children with SCI/D-related neurogenic bladder dysfunction. Early assessment of the bladder function in this population and ongoing treatment compliance monitoring appears to play a major role in preventing long-term medical complications. Asymptomatic bacteriuria and recurrent infections are frequent, especially in the instrumented bladder and prophylactic antibiotic usage is not well supported. There is a great need for developing prospective, controlled studies looking at effect of specific interventions on renal function preservation and prevention of bladder pathologic changes.
Personalized, long-term neuro-urologic care is necessary for individuals with pediatric-onset neurologic upper and lower urinary tract dysfunction.New."
The quarterback's light-tipping "scandal" really resonated with me. When I go into a restaurant where the wait staff brings food to me, I generally tip 20 percent, that is, more than what's socially expected. But when I have to go to the food, that is, when I'm not actually being served, most times I don't tip anything. I think that's a fairly good system. I really do. Even so, I've often wondered if that stubbornness wouldn't one day get me in trouble. Every time I sign my name on a take-out receipt, I worry. Is somebody going to say that columnist guy is a stingy, no-tipping jerk?
I'm not wealthy, so maybe I'm not the best comparison. At the same time, I empathize with the Saints' signal caller. It seems sometimes you can't go into any business establishment without seeing a tip jar