Scandinavian Journal of Surgery 100: 256–263, 2011

Neurogenic bladder in children: basic principles,

new therapeutic trends

J. M. Guys, G. Hery, M. Haddad, C. Borrionne

Pole Medico Chirurgical Pédiatrique, Hôpital d’enfants de la Timone, Marseille, France

ABSTRACT

Diagnosis of neurogenic bladder is straightforward in children with myelomeningocele.

However, recognition is more difficult in patients with occult dysraphism or central ner-
vous system disorders since clinico-anatomical correlations are poor. Careful clinical
examination and urodynamic exploration are mandatory for diagnosis and follow-up.
Even if urinary leak is the first symptom, the main goal of the pediatric surgeon must
be to preserve the upper urinary tract. The ideal protection strategy consists of ensuring
that micturition is voluntary and complete and that the bladder capacity is sufficient with
adequate compliance and sphincter outlet resistances. Balancing these functions requires
a combination of medical and surgical treatment.
A variety of techniques can be used depending on gender and age of the patient and
social environment. In most cases, intermittent bladder catheterization is necessary to
obtain complete evacuation of the bladder. Bladder capacity can be increased by anti-
cholinergic drugs, injection of botulinum toxin into the bladder, and augmentation cys-
toplasty. Augmentation of bladder outlet resistances requires endoscopic injection of
bulking agents, surgical bladder neck reconstruction and urethral lengthening, bladder
neck suspension, and artificial urinary sphincter. In difficult cases, continent cystostomy
with closure of the bladder neck can achieve definitive continence.
At the beginning endoscopic treatment combining anti reflux procedure, injection of
the bladder neck and botulinum toxin can be considered as a “total endoscopic manage-
ment” and should be our first line. Other techniques are under evaluation. Sacral neuro-
modulation has given promising results. Artificial tissue engineering will probably be
used in the next future.
Management of neurogenic bladder is not limited to urological considerations. Ortho-
pedic, digestive, and sexual problems must also be taken into account in order to obtain
an “acceptable quality of life”.
Key words: Urinary incontinence; pediatric neurogenic bladder; spinal dysraphism; bladder sphincter
dyssynergy; total endoscopic management; sacral neuromodulation

Correspondence:
Jean Michel Guys, M.D.
Service de Chirurgie Pédiatrique
Hôpital d’Enfants de la Timone
13 385 Marseille Cedex 5
France
Email: jean-michel.guys@ ap-hm.fr
 Neurogenic bladder, new trends
INTRODUCTION
To ensure adequate treatment of neurogenic bladder
in children, management must be proactive rather
than reactive. Decision-making must take into ac-
count prognostic factors anticipating the consistently
unfavorable natural course of neurogenic bladder.
The purpose of this article is to show the importance
of the circumstances surrounding diagnosis and/or
paraclinical findings in determining the functional
urologic grade of disease as a basis for selecting the­
rapeutic modalities. The last part of this article pres-
ents a quick update of current therapeutic indications
that have advanced in recent years.
Etiologies and diagnostic features
Congenital causes
Myelomeningocele (spina bifida)
For a long time, myelomeningocele, was the main
etiology of neurogenic bladder in children (1,2,3).
With the advent of prenatal diagnosis, the frequency
of this cause has dropped since, in many countries
including France, this in utero finding often leads to
termination of pregnancy. In a recent randomized
trial of prenatal versus postnatal repair of myelom-
eningocele, Adzick et al reported that prenatal repair
reduced the need for shunting and improved motor
outcome at 30 months but was associated with a non
negligible maternal and fetal risks (4).
This finding prompts the question: do the potential
benefits of prenatal coverage of hindbrain herniation,
shunt-dependent hydrocephalus, and leg function
justify the associated risks for mother and child (5)?
Occult spinal dysraphism
This malformation is currently the most common
cause of neurogenic bladder (1). It can be suspected
based on the presence of characteristic lumbosacral
cutaneous stigmata and confirmed by spinal ultra-
sound in the first two months of life. In many cases,
diagnosis is made later upon presentation of mictu-
ritional disturbances and motor or sensory deficits
involving the lower extremities and perineal region.
These manifestations frequently occur around the
time of puberty when growth causes increased trac-
tion on the spinal cord. Dysraphism includes tethered
spinal cord associated or not with imperforate anus,
cloacal malformation, diastematomyelia, and sacral
hypoplasia or agenesis (3).
Acquired neurogenic bladder
In addition to being less common than in adults, spi-
nal cord injuries in children are intrinsically different
owing to a number of factors including mechanism
of injury. Tumor-related spinal compression is not
uncommon in children. Irreversible changes in blad-
der enervation can occur as complication after pelvic
surgery in patients with urologic malformations rang-
257
ing from ectopic ureter to exstrophy as well as after
treatment for Hirschsprung disease, upper anorectal
malformation, sacral coccygeal teratoma, etc. Tran-
sient or permanent neurogenic bladder can also be
observed in association with myelitis and radicu-
loneuritis. Neonatal cerebral anoxia and central ner-
vous system abnormalities including spastic diplegia
(cerebral palsy) and learning disabilities, severe infec-
tious syndrome (meningitis) can be observed (7).
Diagnostic features
Neurogenic bladder can also be diagnosed in cases
involving a more or less long history of micturitional
disturbances considered as benign and treated medi-
cally and even surgically. In most of the cases, the
possibility of a neurological background is raised
only after repeated therapeutic failure.
Neurogenic bladder may be suspected during di-
agnostic work-up for other symptoms associated or
not with micturitional disturbances, e.g., severe con-
stipation or psychological disorders with encopresia.
In this setting, it should be pointed out that Hinman
syndrome involves bladder dysfunction that closely
mimics organic neurogenic bladder even if no organic
defect can be found (8). The psychological context of
these children is special and abuse can be identified
as a possible cause in numerous cases. Only after
completing an exhaustive work-up, it will be possible
to speak of «non-neurogenic elimination disorders »
that have been indifferently designated under a num-
ber of names including “neurogenic non-neurogenic
bladder”, “occult neurogenic bladder”, “lazy blad-
der”. All of these names clearly reflect the paucity of
our current knowledge in this domain.
Pathophysiology and work up
Natural course
Regardless of etiology of neurogenic bladder, the
natural course almost always involves altered storage
function and vesicosphincteric dyssynergia. Overac-
tivity of the detrusor muscle often due to loss of in-
hibition from the pontine and suprapontine centers
leads to high intravesicular pressure. As a result, the
striated ureteral sphincter exhibits spasticity (1,6).
These changes explain that neurogenic bladder pre-
senting mainly as urinary incontinence actually cor-
responds to an obstructive disorder of the lower tract
due to high-grade vesicosphrincteric dyssynergia.
Strategy
In this setting, the use of the conventional neurologi-
cal categories, i.e., central, peripheral or mixed has
little bearing on therapeutic decision-making. Strat-
egy must simply be aimed at achieving ideal micturi-
tion characterized by voluntary control, low pressure,
and complete voiding. Accordingly, assessment must
focus on the three main bladder functions, i.e., reten-
tion, storage and discharge. Capacity must be suffi-
cient for low-pressure retention and storage with
 So : no sphincterian resistances
S+- : variable sphincter
V- : “big” bladder
258 J. M. Guys, G. Hery, M. Haddad, C. Borrionne
Abbreviations:
R : kidney
V : “normal” bladder (capacity)
V 0 : “small” bladder
S 0 : no sphincterian resistances
S+ – : variable sphincter
V– : “big” bladder
Fig. 1. Urinary incontinence: one symptom, numerous causes.
adequate sphincter resistances and emptying control.
In our view, functional urologic assessment (Wein)
provides the soundest basis for therapeutic planning
(1, 4).
Urinary incontinence can be caused by a variety of
factors (Fig. 1) including:
1. true sphincter-related incontinence (a) with a
“normal” bladder (uncommon).
2. undersize bladder resulting in limited retention
time and need for frequent voiding that is incom-
patible with a normal social life (b).
3. oversize hypotonic bladder that empties by over-
flowing (c).
Any of these bladder conditions can occur in combi-
nation with sphincter-related incontinence that can
range from obstructive hypertonia to a total lack of
resistance. All these disorders lead to the same clini-
cal finding, i.e., leakage. For this reason, a careful
work-up is necessary to determine the exact underly-
ing mechanism.
Work-up
Radiological and urodynamic examination must pro-
vide a precise idea of the morphological and func-
tional condition of the upper tract and of lower tract
function with regard to storage, discharge and syn-
ergy with sphincteric resistance (1).
Exploration of the upper urinary tract
In the early stages of disease, the upper urinary tract
can be studied by ultrasound since the kidneys are
generally unaffected. This is particularly true in pa-
tients with congenital neurogenic bladder. Functional
exploration (uro-MRI and isotopic examination) be-
comes mandatory if pyelonephritic renal scaring is
suspected.
Bladder exploration
The essential examination for bladder exploration is
cystography coupled with urodynamic investigation.
This combination allows complete morphological,
functional, and dynamic assessment of the lower uri-
nary tract.
Cystography
Cystography is usually performed by retrograde
catherization. Catheter diameter must allow micturi-
tion. Bladder features are key findings for diagnosis
of neurogenic bladder: verticalization of the long axis,
thickening of the wall, diverticulas. Vesico-ureteral
reflux, even if only minor, can be evidence of high
bladder pressure. The bladder neck may open spon-
taneously with opacification of the posterior uretra,
since the external sphincter is often hypertonic (9). In
case of particularly low sphincter resistance, it may
be necessary to perform this examination using an
occlusive catheter at the level of the bladder neck.
Characteristic urodynamic data for diagnosis neu-
rogenic bladder include maximum detrusor pressure,
reflex volume, maximum cystometric capacity, leak
point pressure, and detrusor activity. Detrusor over-
activity is defined as any short-lived pressure rise
> 15 cm H2O over baseline before capacity is reached
(10, 11).
Dynamic electromyography of the striated ureteral
sphincter can be the only way to demonstrate vesico-
sphincterian dyssynergy. However, like study of
evoked somesthesic sensory and motor potentials,
dynamic electromyography is not performed system-
atically in children since these examinations are in-
teresting only if the neurological background is un-
certain (12).
Risk factors and follow-up
The essential goal of workup is to evaluate risk fac-
tors for the upper tract deterioration and to follow-up
the treatment. For this reason, leak point pressure is
one of the main urodynamic prognostic factors. The
estimated critical threshold is at 40 cm H2O. Beyond
this point, upper tract damage appears in 70% of
cases (11). A similar adverse relationship is observed
between bladder overactivity and pressure peaks
again reaching 40 cm H2O on a regular basis. While
there is not always a direct link between high bladder
pressure and appearance of reflux, this finding should
be considered as a high-risk signal of imminent up-
per tract deterioration (13).
In summary, the most detrimental urodynamic 23 fac-
tor is elevated bladder pressure regardless of whether
this occurs throughout the micturition cycle (“blad-
der hypertonia”), transiently (“bladder overactivity”),
or even only in the pre-micturition phase. Early de-
tection and treatment of this condition is mandatory.
In association with elevated pressure, inadequate
 Neurogenic bladder, new trends
emptying whether due to dyssynergy or to sphincter
hypertonicity aggravates the effect of the “high-pres-
sure syndrome”. Chronic retention of urine in the
bladder is the most important clinical prognostic fac-
tor. Urinary incontinence is of limited prognostic
value since it is just a “symptom” of an unbalanced
relationship between the different bladder func-
tions.
Treatment
In all cases, treatment of micturition disturbances as-
sociated with neurogenic bladder must be guided by
the notion of protecting the upper urinary tract (1).
In older children, management of incontinence is nec-
essary to ensure a normal social life. Continence de-
pends on urinary storage, complete voiding, and suf-
ficient sphincter resistances. Ideally the goal should
be to achieve voluntary control of the micturition via
the natural passages. Socially compatible continence
is generally defined as the ability to hold urine for
four hours without leakage. Management of neuro-
genic bladder should therefore focus on:
1. ensuring bladder emptying;
2. improving bladder capacity;
3. increasing sphincter resistances.
Ensuring bladder emptying
Therapeutic modality
The simplest therapeutic modality use expression
voiding methods such as the Crede and Valsalva ma-
neuvers. However Crede voiding is frequently inad-
equate in older children because most have intact
motor function above L1 and any augmentation in
abdominal pressure can lead to a reflexive increase in
urethral sphincter activity, thus producing an increase
in bladder outlet resistance (3).
Intermittent catheterization
Intermittent catheterization performed 4 to 5 times a
day is the easiest-to-use instrumental bladder man-
agement technique (14). Current devices have bene-
fited from numerous technological improvements
(e.g. self-lubricating catheters and built-in drainage
receptacle). By allowing the bladder to be emptied at
low pressure and removing residues that can be
harmful for the upper tract, intermittent catheteriza-
tion is the mainstay of management for neurogenic
bladder. Catheterization allows complete voiding
through the natural passages in a manner that can be
considered as voluntary. There is no age limit for be-
ginning intermittent catheterization that is proposed
to young children by many groups (15).
Pharmacological treatment
Pharmacological treatment in order to facilitate blad-
der emptying is not widely used in patients with neu-
rogenic bladder. Alpha-adrenergic blockers and
259
smooth muscle relaxants may be useful in some cases
involving hypertonia but indications are limited due
to adverse effects (cardiac) and poor clinical efficacy.
Neurotomy and sphrincterotomy
Neurotomy and sphincterotomy have been used to
permanently suppress peripheral resistance. How-
ever, this definitive solution has been largely aban-
doned due to severe side effects (impotence) and too
definitive incontinence.
Improving bladder capacity
Pharmacological treatment
Anticholinergic agents are most commonly used
medication to improve bladder capacity. Oxybutinin
chloride is currently the most active agent. Detrus-
itol® (tolteridine) seems to be best tolerated. Ceris®
(trospium chloride) is used in adult patients and ap-
pears to have fewer side effects but has not been ap-
proved for children. In theory more than in practice,
diazepam is thought to have a relaxant effect on the
detrusor muscle and tonic effect on the sphincter. Im-
pramine is hazardous at effective doses. Betamimetics
(Isoprenaline) also have a relaxant activity on the de-
trusor muscle but their use is greatly limited by un-
desirable systemic effects.
Botulinum toxin
Botulinum toxin has been proposed for management
of neurological detrusor hyperactivity. The first de-
scription of this technique was published in 2000 by
Schurch et al (16) who administered botulinum toxin
(Botox®, Allergan®) by endoscopic injection and ob-
served a significant increase in maximal bladder ca-
pacity and a decrease in maximal detrusor pressure
and number of incontinence episodes. Since 2002,
prospective studies have confirmed the efficacy of
botulinum toxin in children with a neurogenic detru-
sor overactivity (17–20) with continence rates ranging
from 60 to 83%.
In our center, patients undergoing intermittent
catheterization for urinary incontinence associated
with poorly compliant and overactive bladder that
fails to respond to anticholinergic agents are included
in a ongoing prospective trial after informed consent.
The treatment protocol calls for injection of 12 U/kg
of Botox (maximum 300U) into the detrusor and 2 to
3 cc of polydimethylsolixane into the bladder neck.
Response is evaluated on the basis of urinary diary
data and urodynamic testing at 2 and 6 months after
the 1st injection and 4 months after subsequent injec-
tions. Ten patients (7 boys and 3 girls) with a mean
age of 9.36 years (range, 5.6–16) have been included.
All but two presented spina bifida. The number of
injections was 1 in 3 patients, 2 in 5, and 3 in 2. From
a clinical standpoint, 8 patients reported a decrease
in leak episodes and 2 reported no response. No pa-
tient achieved continence even after 3 injections.
Clinical effects were observed at a mean interval of
3.13 ± 3.98 days after injection and lasted for a mean
260 J. M. Guys, G. Hery, M. Haddad, C. Borrionne
duration of 2.87 ± 1.27 months. Follow-up at 2 and 6
months showed increased bladder compliance
(p < 0.01). A positive effect (not statistically signifi-
cant) was also observed on maximal bladder capacity
and maximal detrusor pressure. The same results
were noted after repeated injections.
Bladder autoaugmentation
If performed early, auto-augmentation that consists
of anteroposterior section of the detrusor muscle fi-
bers can be sufficient to increase bladder capacity.
Some evidence indicates that instrumental bladder
dilation using an intravesicular balloon is necessary
to ensureat least short term success of this procedure
(21).
Bladder enlargement
Bladder enlargement can be performed using various
materials including segments from the colon, ileum,
stomach, or dilated ureter. The ileum is the most com-
monly used tissue reported in the literature (22). En-
largement is always achieved using the detubularized
patch technique to avoid residual hyperactivity due
to intrinsic intestinal peristalsis. Results after removal
of the digestive mucosa are controversial but some
investigators have reported excellent clinical out-
comes (23). As a prerequisite for bladder enlargement,
it is mandatory for the patient to be able to perform
effective emptying of the new bladder (1, 3). In par-
ticular, the patient must accept and understand the
need for intermittent catheterization and his/her abil-
ity to use the device must be tested before undertak-
ing bladder enlargement. Disadvantages include mu-
cus production, recurrent urinary infection, electro-
lyte imbalance, stone formation and the risk for the
late occurrence of cancer in the augmented segment
(25). In the future, it is likely that tissue culture will
provide a new source of material for bladder enlarge-
ment (26).
Electrical stimulation
Electrical stimulation has been used in adults for
more than 25 years.
Transuretral electrical bladder stimulation
Kaplan was the main proponent of the technique of
transurethral electrical bladder stimulation in chil-
dren and reported a series of 372 patients with a mean
age of 5.5 years and mean follow-up 6.6 years. In
76.9% of these patients, the increase in bladder capac-
ity was 20% or greater (27). Despite these results, few
groups have adopted this technique.
Stimulation of the posterior tibial nerve
Some investigators have reported statistically sig-
nificant symptomatic improvement after percutane-
ous tibial nerve stimulation in adult patients with
overactive bladder. Twelve weekly procedures
achieved some short term success results for 12
months (28). This technique is considered as safe and
effective (29).
Few series describing percutaneous tibial nerve
stimulation in children have been published, but ex-
isting data suggest that improvement in continence
was significantly greater for patients with non-neu-
rogenic than neurogenic disease (30).
Parasacral transcutaneous electrical nerve stimulation
The effectiveness of parasacral transcutaneous electri-
cal nerve stimulation for treatment of overactive
bladder in children was recently evaluated in a pro-
spective trial in which 25 girls and 12 boys were ran-
domized into a test and sham group. Thirteen of the
16 patients who underwent parasacral transcutane-
ous electrical nerve stimulation were cured. Again
none of these patients presented neurogenic bladder
(31).
Direct stimulation of the S3 and S4 nerve roots
Direct stimulation of the S3 and S4 nerve roots i.e.,
sacral neuromodulation (SNM: “Interstim therapy”)
is performed not only to reinforce the sphincter tone
by stimulating contraction of all the muscles of the
perineal floor but also to improve bladder compliance
by reactivating certain efferent and afferent nerves
(32). The efficacy of this treatment in children was
assessed in a multicenter, open label, randomized,
crossover study including children older than 5 years
in France. The positive response rate was more than
75% overall, 81% for urinary incontinence and (78%)
for bowel incontinence. Crossover analysis indicated
that SNM is more effective than conservative treat-
ment for both types of incontinence (p = 0.001) (33).
Various radiculotomy procedures
Various selective radiculotomy procedures (S2 or S3)
have been used in adults. The goal of these proce-
dures is to suppress detrusor contraction and increase
bladder capacity. Continuous intraoperative monitor-
ing of the bladder pressure is necessary to ensure
precise selection of the targeted nerve roots. No in-
formation is available about the long-term outcome
of these procedures.
Increasing sphincter resistances
Pharmacodynamic treatment
Cholinergic and alpha-stimulating agents exhibit
weak action and have undesirable side effects.
Surgery of the bladder neck
Surgery of the bladder neck such as anterior wedge
reinforcement type Young Dees, bladder neck sus-
pension (rectus facial sling) (Goebbel-Stœckel) or
simple urethropexy (Marshall-Marchetti) are well
known and have been used for years (34). In a recent
51-case Spanish study using the rectus fascial sling
technique, good continence was achieved in 88% of
patients with a mean follow-up of 4.16 years (35).
Bladder neck reconstruction using the Kropp and
Pippi Salle techniques appeared to be promising. The
short-term success rate was 61% in girls but few long-
term data have been reported (36).
 Neurogenic bladder, new trends
Combined techniques, e.g. fascial wrap and ure-
thral lengthening, appear to give the best results (37).
In one 19-case series using this approach, complete
continence was achieved in 15 patients with a mean
± SD follow-up of 35.5 ± 29.1 months (38).
Artificial urinary sphincter
The only model now used is the totally implantable
Scott device (AS800). In children, the cuff is placed at
the level of the bladder neck. Short- and middle-term
results are often good (80% continence) but technical
problems require a mean number of 3 re-operations
per patient (39). One review in the literature showed
that long-term results of artificial urinary sphincter
placement were better and more reproducible in
terms of continence, preservation of voluntary void-
ing including CIC (Clean Intermittent Catheteriza-
tion) and avoidance of bladder augmentation (34).
Placement of an artificial sphincter does not rule out
intermittent catheterization (39).
Injection of bulking agents
Injection of bulking agents at the level of the bladder
neck increase passive resistance to urinary flow. The
current popularity of injection (for the authors) is
based on the materials used and the minimal inva-
siveness of the technique that can be carried out en-
doscopically. The most common materials now in use
are Macroplastic® and Deflux®. Used alone or in com-
bination with other techniques, these materials have
a 30% success rate (40,41).
Urinary diversion and continent cystotomy
Urinary diversion and continent cystotomy is ulti-
mate procedure for reinforcement of resistance since
the bladder neck is divided. This technique has un-
dergone many technical improvements according to
the Mitrofanoff principle to allow creation of a cath-
eterizable urinary stoma by anti-reflux reimplanta-
tion of the appendix or of a tubularized bowel seg-
ment (Monti) or a ureter. This procedure was initially
used in patients in whom self-catheterization of the
urethra was difficult due to obesity, poor eye–hand
coordination or caretaker issues surrounding genital
organ privacy. In a recent review of their continent
stomas, Pippi Salle et al reported surgical revision in
39% of patients, including stomal revision in 18%,
redo in 8%, bulking agent injection in 8% and pro-
lapse correction in 4%. No statistically significant dif-
ferences in complication rates were noted between
appendix and tubularized bowel or different stoma
locations (42).
External urinary diversion
External urinary diversion, once considered as an ef-
fective method to protect the upper tract, is now used
only in special cases involving infants and young
children that develop high intravesicular pressure
syndrome (> 40 cm H2O during filling phase). The
adverse effects of high pressure requires temporary
261
but rapid decompression. The only other indications
for external urinary diversion are in extreme situa-
tions and usually for social reasons (1, 3).
Therapeutic indications
A succinct description of therapeutic strategies is dif-
ficult because incontinence can be compounded by a
host of other problems associated with the underly-
ing disease: digestive, sexual and orthopedic disor-
ders.
Emptying of the bladder and protection of the upper
urinary tract
The first step is to ensure adequate bladder emptying
and to protect the upper urinary tract. In baby, the
Crede or Vasalva method or, in case of reflux in small
children, intermittent catheterization can be pro-
posed. In cases strictly limited to vesicosphincteric
dyssynergy, biofeedback training can be tried in the
older patient. Surgical treatment of reflux more likely
involves a Cohen crossed trigonal ureteral reimplan-
tation more than the Leadbetter technique. Bilateral
treatment of the reflux is performed in all cases. Sub-
ureteral injections (Teflon, collagen, or silicone gel)
must be used as an alternative to surgery in young
children or as a bridge therapy if a bladder surgery
is planned at a later time.
Improving bladder capacity
The second phase consists of improving bladder ca-
pacity once complete bladder emptying has been en-
abled. If pharmacological treatment using anticholin-
ergic agents fails, botulinum toxin followed in case of
failure by bladder enlargement is mandatory. In our
opinion, the preferred method is sigmoid plasty. We
only use the stomach in association with the bowel in
case of low-grade kidney insufficiency to alleviate
ionic reabsorption problems.
Necessary sphincter resistance
If only a slight increase of the sphincter resistances is
needed, our approach consists of injecting silicone gel
in the bladder neck. If reinforcement is required dur-
ing a bladder procedure (anti-reflux or cystoplasty),
we prefer the Young-Dees or Pippi Salles procedure
in boys in association with suspension of the bladder
neck in girls. Once again endoscopic injection can
enhance results in terms of residual continence. In
our hands, the artificial sphincter remains an excel-
lent tool especially in boys and more as the first line.
Continent cystostomy is proposed to patients in
whom micturition by natural passages is not easy,
e.g., patients who are in wheelchairs or obese. De-
finitive closure of the bladder neck is performed only
if bladder catheterization through the Mitrofanoff ca-
nal is fully functional.
Optimizing the patient´s wellbeing
Decision-making at each step of treatment must take
into account the cooperation of the patient, his au-
262 J. M. Guys, G. Hery, M. Haddad, C. Borrionne
tonomy and the family situation. The adolescent pe-
riod is even more difficult to manage and requires a
global approach to digestive, sexual and orthopedic
problems. Close cooperation between the different
specialties is necessary to optimize the quality of the
patient’s social life.
Conclusion
Management of neurogenic bladder in children is
wrought with endless servitude for the patient and
challenge without real victory for the paediatric sur-
geon. However, technology and techniques have im-
proved and it is now possible to give a hopeful mes-
sage to these patients and their families.
Endoscopic management is the first option nowa-
days: we can treat vesico renal reflux, improve blad-
der compliance (botulinum toxin), and increase
sphincterian resistances (neck injection) at the same
operation. Instead of definitive surgery, electrical
neuro stimulation (and particularly sacral nerve stim-
ulation) became a valuable option.
In 2011, therapy of urinary incontinence in neuro-
genic bladder can be considered as successful in more
than 90% of our patients.
REFERENCES
01. Guys JM, Aubert D: La vessie neurologique de l’enfant. Eds
Sauramps Medical (Montpellier) 1998: 280 p
02. Genitori L, Caulheiro S, Lena G, et al: Spina bifida, myelo­
meningocele. Encycl Med Chir (Paris) Pediatrie 1993;4096 D
10
03. Stuart B: Neurogenic bladder: etiology and assessment. Bauer
Pediatr Nephrol 2008;23:541–551
04. Adzick NS, Thom EA, Spong CY, et al: A randomized trial of
prenatal versus postnatal repair of myelomeningocele. N Engl
J Med 2011;364:993–1004
05. Mayer S, Weisser M, Till H, et al: Congenital myelomeningo-
cele – do we have to change our management? Cerebrospinal
Fluid Res 2010;7:17. Published online 2010 October 14;7:17
06. Guys JM, Simeoni-Alias J, Fakhro A, et al: Use of polydimeth-
ylsiloxane for endoscopic treatment of neurogenic urinary
incontinence in children. J Urol 1999;162:2133–2135
07. Kuban KC, Leviton: A cerebral palsy. N Engl J Med 1994;330:
188–195
08. Guys JM, Fakhro A, Louis Borrione C, et al: Endoscopic treat-
ment of urinary incontinence: long term evaluation of the re-
sults. J Urol 2001;165:389–392
09. Mitrofanoff P: Cystostomie continente trans-appendiculaire
dans le traitement des vessies neurologiques. Chir Pediatr
1980;21:297–302
10. Bauer SB, Labib KB, Dieppa RA, et al: Urodynamic evaluation
in a boy with myelodysplasia and incontinence. Urology 1977;
10:354–362
11. Wan J, Mc Guire EJ, Bloom DA, et al: Stress leak point pressure:
a diagnostic tool for incontinent children. J Urol 1993;150:
700–702
12. Torre M, Planche D, Louis Borrione C, et al: Value of electro-
physiological assessment after surgical treatment of spinal
dysraphism. J Urol 2002:168:1759–1763
13. Torre M, Guida E, Bisio G, et al: Risk factors for renal function
impairment in a series of 502 patients born with spinal dysra-
phisms. J Pediatr Urol 2011;7:39–43
14. Wyndaile JJ, Maes D: Clean intermittent self catheterization: a
12 years follow up. J Urol 1990;143:906–915
15. Edelstein RA, Bauer SB, Kelly MD, et al: The long-term uro-
logic response of neonates with myelodysplasia treated proac-
tively with intermittent catheterization and anticholinergic
therapy. J Urol 1995;154:1500–1504
16. Schurch B, Stohrer M, Kramer G, et al: Botulinum-A toxin for
treating detrusor hyperreflexia in spinal cord injured patients:
a new alternative to anticholinergic drugs? Preliminary results.
J Urol 2000;164:692–697
17. Riccabona M, Koen M, Schindler M, et al: Botulinum-A toxin
injection into the detrusor : a safe alternative in the treatment
of children with myelomeningocele with detrusor hyper­
reflexia. J Urol 2004;171:845–848
18. Altaweel W, Jednack R, Bilodeau C, Corcos J: Repeated intrade-
trusor botulinum toxin type A in children with neurogenic
bladder due to myelomeningocele. J Urol 2006;175:1102–1105
19. Hoebeke P, De Caestecker K, Vande, Walle J, et al: The effect
of botulinum-A toxin in incontinent children. J Urol 2006:176;
328–330
20. Do Ngog Thanh C, Audry G, Forin V: Botulinum toxin type A
for neurogenic detrusor overactivity due to spinal cord lesions
in children: a retrospective study of seven cases. J Pediatr Urol
2009; Dec 5 (6):430–436
21. Alova I, Margaryan M, Verkarre V, et al: Outcome of conti-
nence procedures after failed endoscopic treatment with dex-
tranomerbases implants (Deflux®). J Pediatr Urol 2011 Jan 28
(Epub ahead of print)
22. Guys JM, Faure F, Kreitmann B, et al: L’entérocystoplastie dans
les vessies neurologiques : peut-on améliorer les résultats?
Chir Pediatr 1986;27:124–127
23. González R, Ludwikowski B, Horst M: Determinants of suc-
cess and failure of seromuscular colocystoplasty lined with
urothelium. J Urol 2009;182:1781–1784
24. Lima SV, Araujo LA, Vilar Fde O, Lima RS, Lima RF: Nonsecre-
tory intestinocystoplasty: a 15-year prospective study of 183
patients. J Urol 2008;179:1113–1116
25. Metcalfe PD, Rink RC: Bladder augmentation: complications
in the pediatric population. Curr Urol Rep 2007;8:152–156
26. Atala A: Tissue engineering of human bladder. Br Med Bull
2011;97:81–104
27. Hagerty JA, Richards I, Kaplan WE: Intravesical electrotherapy
for neurogenic bladder dysfunction: a 22-year experience.
J Urol 2007;178:1680–1683
28. MacDiarmid SA, Peters KM, Shobeiri SA, Wooldridge LS, et
al: Long-term durability of percutaneous tibial nerve stimula-
tion for the treatment of overactive bladder. J Urol 2010;183:
234–240
29. Peters KM, Macdiarmid SA, Wooldridge LS, et al: Randomized
trial of percutaneous tibial nerve stimulation versus extended-
release tolterodine: results from the overactive bladder innova-
tive therapy trial. J Urol 2009;182:1055–1061
30. Capitanucci ML, Camanni D, Demelas F, et al: Long-term ef-
ficacy of percutaneous tibial nerve stimulation for different
types of lower urinary tract dysfunction in children. J Urol
2009;182:2056–2061
31. Lordêlo P, Teles A, Veiga ML, et al: Transcutaneous electrical
nerve stimulation in children with overactive bladder: a ran-
domized clinical trial. J Urol 2010;184:683–689
32. Guys JM, Haddad M, Planche D, et al: J. Sacral neuromodula-
tion for neurogenic bladder dysfunction in children. J Urol
2004;172:1673–1676
33. Haddad M, Besson R, Aubert D, et al: Sacral neuromodulation
in children with urinary and fecal incontinence: a multicenter,
open label, randomized, crossover study. J Urol 2010;184:696–
701
34. Kryger JV, Gonzalez R, Spencer Barthold J: Surgical manage-
ment of urinary incontinence in children with neurogenic
sphincteric incompetence. J Urol 2000;163:256–263
35. Castellan M, Gosalbez R, Labbie A, et al: Bladder neck sling
for treatment of neurogenic incontinence in children with aug-
mentation cystoplasty: long-term follow-up. J Urol 2005;173:
2128–2131
36. Hayes MC, Bulusu A, Terry T, Mouriquand PD, Malone PS:
The Pippi Salle urethral lengthening procedure; experience
and outcome from three United Kingdom centers. BJU Int
1999;84:701–705
37. Snodgrass W, Barber T: Comparison of bladder outlet proce-
dures without augmentation in children with neurogenic in-
continence. J Urol 2010;184:1775–1780
38. Churchill BM, Bergman J, Kristo B, Gore JL: Improved conti-
nence in patients with neurogenic sphincteric incompetence
with combination tubularized posterior urethroplasty and fas-
cial wrap: the lengthening, narrowing and tightening proce-
dure. J Urol 2010;184:1763–1767
 Neurogenic bladder, new trends 263

39. Simeoni J, Guys JM, Mollard P, et al: Artificial urinary sphinc-
ter implantation for neurogenic bladder : a multi-institutional
study in 107 children. Br J Urol 1996;78:287–293
40. Guys JM, Breaud J, Hery G, et al: Endoscopic injection with
polydimethylsiloxane for the treatment of pediatric urinary
incontinence in the neurogenic bladder: long-term results.
J Urol 2006;175:1106–1110
41. Lottman HB, Margaryan M, Bernuy M, et al: Long-term effects
of dextranomer endoscopic injections for treatment of urinary
incontinence: an update of a prospective study of 31 patients.
J Urol 2006;175:1485–1489
42. Leslie B, Lorenzo AJ, Moore K, et al: Long-term follow-up and
time to event outcome Analysis of continent catheterizable
channels. J Urol 2011;185(6):2298–2302

Received: July 30, 2011