Paediatric case regarding neurogenic bladder and it’s management

1. CASE PRESENTATION
PAEDIATRICS

2. NAME : MS. DHARSHINI
AGE : 11 YEARS
SEX : FEMALE
INFORMANT : MOTHER
EDUCATION OF INFORMANT : 10TH STD
RELIABILITY : GOOD
•

3. HISTORY OF PRESENTING ILLNESS
• A 11 year old 2nd born female child of NCM parents
brought by mother of good reliability who is a K/C/O
operated lipomyelomeningocele/ neurogenic bladder/
bladder outlet obstruction(BOO), came here for further
management. No complaints at present.

4. CASE EXPLAINED
Patient was noticed with a swelling only at birth in lumbosacral region,
said as fat in outside hospital (No treatment). At her 7 years of age she
developed bladder and bowel disturbance,
CT ABDOMEN : Neural tube defect at sacral bone at S1 level measuring
44mm with lipomyelomeningocele, interiorly the cor is extending upto
S2 level.
MRI ABDOMEN: Spinal dysraphism in lumbar spine, tethered cord
with overlying subcutaneous fat thickening with neural placode.
• diagnosed as Neural tube defect - Lipomyelomeningocele, and was
operated at her age of 8 years.

5. • Post surgery she had history of
» decresed food intake(solid foods)
» increased frequency of urination and defection
» vomiting on and off intermittently
» nausea/ abdominal pain for 3 days
Patient was taken to outside hospital,
• USG ABDOMEN done initially revealing chronic cystitis with
bilateral Grade II HUN.
• CT ABDOMEN WITH KUB, done and revealed, Distended urinary
bladder with mucosal irregularities, wall thickening of 5mm,
Bilateral moderate HUN due to reflux. She was started on antibiotics
and was acutely managed.

6. • Paediatric and urology opinion obtained and diagnosed as
Autonomous bladder. Neuro medicine opinion taken and
adviced for Clean intermittent catheterization( Bladder
training). Patient was catheterized for 6 months ( changes
monthly once)
• And reffered to higher centre for definitive management of
Autonomous bladder.
• Presently came to VMCH for the management.

7. • PAST HISTORY : K/C/O Lipomyelomeningocele operated at
her 8 years of age.
H/O Recurrent urinary tract infection
N/K/C/O CHD, Thyroid disorders, seizure disorder.
• ANTENATAL HISTORY : Booked and immunized, folic acid
tablets taken. No H/O GDM, GHTN
• NATAL HISTORY: Term, NVD at private hospital, cried
immediately after birth, Birth weight - 3.25kg, healthy
female child , now 11 years old. Swelling at back noticed at
birth, told as fat and was not operated.
• POSTNATAL HISTORY : No H/o NICU admission.

8. • MENSTRUAL HISTORY : Attained menarche at 9 years of age/
Regular/ 5/30 days cycle, no menstrual irregularities.
• IMMUNIZATION HISTORY: Immunized as per schedule
Last immunization was at 10 years of age.
DEVELOPMENTAL HISTORY: Milestones attained as per age
FAMILY HISTORY: No significant history
15 yrs 11 yrs

9. ANTHROPOMETRY
• HEIGHT - 142cm
• WEIGHT - 49kg
• BMI - 24.3kg/㎡
• WEIGHT FOR AGE - BETWEEN 90TH AND 97TH PERCENTILE
• HEIGHT FOR AGE - BETWEEN 25TH AND 50TH PERCENTILE
• BMI FOR AGE - ABOVE OBESE PERCENTILE( >95TH PERCENTILE)
• NUTRITIONAL ASSESSMENT - OVERWEIGHT
EQUIVALENT

10. • GENERAL EXAMINATION:
O/e patient concious, oriented, afebrile
No pallor, icterus, clubbing, cyanosis, pedal edema,
lymphadenopathy
• VITALS :
• HR - 94/min
• BP - 120/80mmhg
• RR - 22/min
• SPO2 - 98%
• LOCAL EXAMINATION :
Swelling over lumbosacral region
Size of 10*8cm, soft in consistency, no warmth, vertical scar of 11cm
over swelling, fluctuant +

11. SYSTEMIC EXAMINATION:
CVS - S1, S2 heard, no murmur
RS - B/L AE+, no added sounds
P/A - Soft, no tenderness, no organomegaly
CNS:
BULK: No obvious wasting
TONE: Normal in both lower and upeer limbs
POWER: 5/5 in all 4 limbs
REFLEXES : UL LL
» Biceps - ++ ++
» Triceps- ++ ++
» Supinator ++ ++
» Knee jerk +++ +++
» Ankle jerk ++ ++
» BILATERAL PLANTAR - NO RESPONSE
» SENSORY SYSTEM: NORMAL

12. INVESTIGATIONS:
 CBC - TC - 7500 cells/cu.mm
 Hb - 11.8 g/dl
 PLT - 262000/cu.mm
 RFT - urea - 32mg/dl
 creatinine - 0.5mg/dl
 uric acid - 4.5mg/dl
 USG ABDOMEN revealed,
 Bilateral kidneys show normal echoes.
 Bladder is minimally filled and show diffuse wall thickening,
foley’s bulb insitu.
 URINE C/S - No Growth

13. TREATMENT
• ADVICED ABOUT THE STATUS AND CHRONIC CONDITION OF THE
PATIENT TO BOTH THE PATIENT AND ATTENDERS
• Initiated CLEAN INTERMITTENT CATHERIZATION
• PELVIC FLOOR EXERCISE( KEGELS EXERCISE)
• COUNCELLED ON PROPER HANDWASHING AND THE RISK OF
INFECTION OF THIS TREATMENT
• INPUT AND OUTPUT MONITORING DONE REGULARLY.
• PRESENTLY PATIENT PRACTICING FOR SELF CATHETERIZATION.

14. NEUROGENIC BLADDER
• Children with spinal dysraphism, spinal trauma, tumors may develop NEUROGENIC
BLADDER, and they also have a high risk of renal damage besides incontinence.
• They need a very long term follow up.
• Usually bladder innervation seen in spina bifida occulta, sacral agenesis, autonomic
neuropathy, spinal tumors or trauma.
EVALUATION: Firstly, they need a detailed neurological evaluation with attention
iver lower back tone, anal tone, sensations over perineum, heel besides only abdominal or
genital examination.
• USG should be carried out to see kidney size, bladder capacity, wall thickness, post
voidal residue/ MCU for vesicoureteric reflex / DMSA for renal scars, if both these are
normal, these are repeated every 12 to 18 months till 5years of age, as bladder dynamic
change with age.
• Three categories of lower tract dynamics: Bladder sphincter dysenergia
with/without bladder hypertonicity, synergic low pressure incontinent bladder
and a completely denervated bladder.

15. • .
• USG should be carried out to see kidney size, bladder capacity, wall
thickness, post voidal residue/ MCU for vesicoureteric reflex /
DMSA for renal scars, if both these are normal, these are repeated
every 12 to 18 months till 5years of age, as bladder dynamic change
with age.
• Three categories of lower tract dynamics: Bladder sphincter
dysenergia with/without bladder hypertonicity, synergic low
pressure incontinent bladder and a completely denervated
bladder.

16. MANAGEMENT
• Usually a child with spinal dysraphism lkely to have (elimination disorder) affecting evacuation of
both urinary bladder and bowel. If associated with constipation, should be treated early as it worsens
bladder.. with laxatives, a daily enema.
• Firstly, Crede’ maneuver - suprapubic massage, that results in reflux bladder contraction. Incase of
failure, go with CIC ( CLEAN INTERMITTENT CATHETERIZATION). This improves
significantly on long term followup and prevents UTI.
• Children who cannot empty their bladder spontaneously need CIC irrespective of the grade of reflux.
• Anti cholinergic for high pressurwe small volume bladder, Sympathomimmetics for who cannot stay
dry between catheterizations.
• Surgical procedures like, Vesicostomy in infants whose upper UT drainage fails even after CIC and
medications. Sphincterectomy to reduce bladder outlet obstriction. Reimplantation pf urethra in case
of reflux besides safe bladder.
• Pelvic floor exercise : KEGELS EXERCISE. To strengthen pelvic muscles in case of Urinary
incontinance, Fecal incontinance, Pelvic organ prolapse.

17. KEGELS EXERCISE

18. THANKYOU
G.SUBHASHINI
CRRI/ 2018 -19