Neurourology and Urodynamics 31:610–614 (2012)

International Children’s Continence Society’s

Recommendations for Initial Diagnostic Evaluation
and Follow-Up in Congenital Neuropathic Bladder
and Bowel Dysfunction in Children
Stuart B. Bauer,1 Paul F. Austin,2 Yazan F. Rawashdeh,3 Tom P. de Jong,4
Israel Franco,5 Charlotte Siggard,6 and Troels Munch Jorgensen7*
1
Children’s Hospital, Boston, Massachusetts
2
Pediatric Urology, St. Louis Childrens Hospital and Washington University, St. Louis, Missouri
3
Pediatric Urology, Aarhus University Hospital, Aarhus, Denmark
4
Pediatric Urology, UMC Utrecht and AMC Amsterdam, The Netherlands
5
Pediatric Urology, New York Medical College, Valhalla, New York
6
Pediatrics, Aarhus University Hospital, Aarhus, Denmark
7
Pediatric Urology, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark

Purpose: The objective of this ICCS standardization document is to report the initial diagnostic evaluation and subse-
quent work-up of children with neuropathic bladder dysfunction. Materials and Methods: Due to a paucity of level I
or level II, ‘‘levels of evidence’’ publications, these recommendations are actually a compilation of best practices because
they seem to be effective and reliable, although not with any control. Results: Throughout the document, the
emphasis is on promoting early, comprehensive evaluation of lower urinary tract function that is thorough but with a
minimum of unnecessary testing. This includes what tests to order, when to order them and what to do with the
results. Some of the recommendations may not be practical in various worldwide locations but the suggested testing
should be considered the ideal approach to completely diagnosing and then promulgating treatments based on the full
knowledge of the condition and its effect on urinary tract function. Once the findings are delineated, those lower
urinary tract patterns of dysfunction that put the kidneys at risk for deterioration, that are barriers to attaining
eventual continence, and that have long-term consequence to the lower urinary track can be obviated by specific
management recommendations. The indications and timing of investigations to achieve these objectives are clearly
defined in each diagnostic category and during follow-up. Recommendations: This document should be used as a
basis for appropriate evaluation and timely surveillance of the various neuro-urologic conditions that affect children.
Neurourol. Urodynam. 31:610–614, 2012. ß 2012 Wiley Periodicals, Inc.

Key words: bladder; bowel; children; evaluation; neuropathic

INTRODUCTION
Neuropathic bladder dysfunction (NBD) in children is an
ever-evolving condition. The expansion of its understanding
and treatment over the last 50 years has been nothing short
of remarkable. In the mid 1950s, there were few insights and
minimal alternatives to being in diapers or wearing an
appliance over an abdominal wall stoma. Starting with the
development of adequate X-ray assessment and reliable
urodynamic investigation (UDS),1 the advent of clean inter-
mittent catheterization (CIC),2 artificial sphincter implanta-
tion,3 continent urinary conduits, a plethora of drug therapies
that modulate lower urinary tract function4 and a multitude
of rehabilitative surgical techniques, we have learned a great
deal about the pathophysiology, pathogenesis, and treatment
of these disorders and the evidenced-based ways to manage
them. With the promise of tissue engineering and stem cell
therapy, new vistas for treatment seem to be on the horizon.
Since the introduction of proactive management of children
with spina bifida,5 there has been a marked reduction in their
progression to end-stage renal disease (ESRD).6 If left untreat-
ed, neonates with detrusor sphincter dyssynergy (DSD) devel-
op upper urinary tract damage in the first year of life, starting
shortly after birth and in some cases even during fetal life.2,5,7
If untreated, death due to renal failure, in the first year of life,
can be as high as 20%. It is essential patients be followed from
early infancy in order to detect early signs of ureteral and
renal dilation that could lead to ESRD.6 How and when these
patients should be followed has generally been left to the
discretion of individual practitioners. A review of the litera-
ture reveals no unanimity on follow-up. We have attempted
to provide a consensus of what appears to be best medical
practice based on our understanding of the pathophysiology
of NBD. We divide follow-up into stages of life since each
stage represents a different challenge for the child and the
practitioner.
Conflicts of interest: none.
Christopher Chapple led the peer-review process as the Associate Editor responsi-
ble for the paper.
The review is produced in normal high ethical standards.
*Correspondence to: Troels Munch Jorgensen, M.D., Faculty of Health, Institute of
Clinical Medicine, Aarhus University, Brendstrupgaardsvej 100, 8200 Aarhus N,
Denmark. E-mail: tmj@dadlnet.dk
Received 3 March 2011; Accepted 5 March 2012
Published online 24 April 2012 in Wiley Online Library
(wileyonlinelibrary.com).
DOI 10.1002/nau.22247

ß 2012 Wiley Periodicals, Inc.

 ICCS: Evaluation and Management of Pediatric NBD
Causes:
Spinal dysraphism
Open—Myelodysplasia 85%
Closed—Occult dysraphism 8%
Lipoma
Lipomningocele
Split cord syndrome (Diastematomyelia)
Thickened filum terminale
Anterior meningocele
Sacral agenesis 1%
Associated syndromes 1%
Imperforate anus (40%)
Central nervous system insults
Cerebral palsy 3%
Spinal cord injury 1%
Tumors—Brain (Primary and Metastatic)
Tumors—Spinal cord (Primary and Metastatic)
INITIAL EVALUATION
The first evaluation is based on several factors depending
on: when the child presents and/or is diagnosed, sustains an
injury (in the case of traumatic lesions), develops a neoplastic
condition affecting the central and/or peripheral nervous
system. Neonates diagnosed with an ‘‘open’’ myelomeningo-
cele defect have two factors that need addressing before any
investigation is performed: stability of the child and exigency
for surgical correction. For these children, surgical closure
takes precedent with UDS being performed after the child has
stabilized postoperatively, whereas with closed lesions, inves-
tigation is undertaken before and/or as preparatory to spinal
cord untethering surgery.
For children with an open spinal cord lesion, measurement
of residual urine by ultrasound or catheter after the child
voids or leaks, either spontaneously or with a Valsalva ma-
neuver provides an assessment of the child’s ability to empty.
It provides no information about the intravesical pressure
generated to achieve emptying or the degree of bladder outlet
resistance. If a child cannot empty the bladder spontaneously
then CIC is started until UDS can be safely performed, usually
in the first 2–3 months of life, to measure detrusor filling pres-
sure and the pressure at which the child voids or leaks.5,6,8
Some clinicians feel detrusor leak point pressure (DLLP) is
more accurate than abdominal leak point pressure but main-
taining a rectal probe in neonates in order to get subtracted
detrusor pressure is challenging. High-pressure detrusor over-
active contractions (DO) and/or elevated detrusor filling and/
or voiding pressures, warrant anticholinergic medication to
ensure storage of urine at low pressure while minimizing
voiding at high pressure.5,6,9,10 In addition to UDS, a renal/
bladder ultrasound is needed. If ultrasonography reveals
hydronephrosis, ureteral dilation, a discrepancy in renal size
or contour, or increased bladder wall thickness,11 or UDS
reveal DO or poor compliance, elevated leak point pressure
and DSD, voiding cystourethrography (VCUG) is warranted
looking for vesicoureteral reflux and/or bladder outlet obstruc-
tion. High-grade reflux necessitates CIC and anticholinergic
medication, whereas low-grade reflux, especially when DLLP
is low and compliance is good, may be managed expectantly.
During the first week of life serum creatinine is not useful
because it mimics the mother’s kidney function; if indicated,
it should be obtained after that time.
An occult spinal dysraphism or ‘‘closed’’ lesion is often
detected in the neonatal period because 95% have a cutaneous
mid-line lower spinal lesion or an abnormal gluteal cleft.12
Any suspicion of a closed dysraphic state warrants a spinal
Neurourology and Urodynamics DOI 10.1002/nau
611
ultrasound and MRI in children <3 months of age and an MRI
only in those older.13 The absence of any skin manifestations
delays the diagnosis because most infants have normal lower
extremity function.14,15 With increasing age these lesions may
cause tethering of the spinal cord that affects both the lower
limbs and the lower urinary tract.13,14 Presenting signs in-
clude: failure to toilet train, persistent or new onset urinary
and/or fecal incontinence despite a normal emptying regi-
men, lower extremity weakness, muscle atrophy and/or foot
or gait changes.14–16
UDS consists of residual urine measurement and cystome-
try with DLLP. Because these children tend to be older when
first evaluated and do not have a patulous anus, a rectal
pressure probe is easily maintained in order to determine
subtracted DLLP. Renal/bladder ultrasonography and voiding
cystography are indicated for the same reasons cited for
‘‘open’’ lesions.
When the decision to operate is predicated on urodynamic
findings, it is optimal to obtain needle recording of electro-
myographic activity of the external urethral sphincter (EMG).
Individual motor unit action potentials and reflex activity
when sacral reflexes are stimulated, and synergy versus dys-
synergy when the child voids or leaks are more accurate and
reliable than patch electrodes.17 This baseline information is
important because any change in presence or increase in DO,
sphincter muscle denervation, change in sacral reflexes or
DSD on subsequent studies are signs of tethering that warrant
neurosurgical intervention.18–20
Sacral agenesis is often missed in the newborn period
because the child appears normal with no lower extremity
motor and sensory dysfunction. Except for the pathognomonic
sign of flattened buttocks and a shortened gluteal cleft or ma-
ternal insulin dependent diabetes (1%), nothing is suspected.
Fortunately, the lesion is stable from birth as tethering is
unlikely.
If the condition is not detected in the newborn period it
often comes to light after the child seeks help with toilet
training or has UTI and the radiologic work-up (AP or lateral
film of the pelvis) reveals absent lower sacral vertebrae. UDS
determine the specific type of bladder and urethral function
present because the level of the bony defect is not predictive
of any specific type of dysfunction.21
About 20% have normal lower urinary tract function. Of the
others, an almost equal number have DO with high voiding
pressure secondary to DSD, or an areflexic detrusor with a low
leak point pressure from severe or complete denervation of
the external urethral sphincter. The former group will often
develop hydronephrosis and reflux, whereas the latter tends
to have normal kidneys due to low LPP. A renal ultrasound
should suffice in the latter cohort, whereas a renal echo and
VCUG are needed when DO and DSD are detected in the for-
mer. The exigency of tests depends on age, presentation, and
type of symptoms that lead to the diagnosis.
When a child has an imperforate anus, the timing of investi-
gational studies is critical. Renal and spinal ultrasound in the
newborn period are needed due to the likelihood of unilateral
renal agenesis and an intraspinal abnormality, respectively. A
VCUG in boys denotes the presence and location of the
recto-urethral fistula and any distortion of the posterior
urethra following surgical repair of the defect. The incidence
of NBD approaches 40% but varies from 10% to 50%,
depending on the height (above or below the levator ani
muscle) of the rectal lesion (positive correlation)22 and how
thorough the investigation.23 If a suspected neuropathic
bladder is confirmed with UDS then spinal MRI is indicated.24
UDS determining the presence of DO, the degree of
612 Bauer et al.
denervation in the external urethral and rectal sphincters FOLLOW-UP OF CONGENITAL NEUROPATHIC BLADDER
and DSD in the first few months of life after an initial DYSFUNCTION IN CHILDREN
colostomy or definitive pull-through surgery is performed,
serve as a baseline as noted for patients with an occult Newborn to Toddler
dysraphism.25,26
Open spinal cord lesion. Once UDS has been performed a
Persistent urinary and bowel incontinence suggest
decision can be made as to whether the child is a candidate
unrecognized NBD from an occult spinal dyraphism. Some
for continuing CIC or allowed to void freely. If the bladder is
infants with normal lower urinary and bowel function in the
overactive then anticholinergics should be started and CIC
first year of life suffer from tethering of the spinal cord with
continued. It is advisable to repeat UDS (cystometry) 2–3
increasing age. This leads to permanent damage if not
months later to confirm that therapy is adequately reducing
detected early. Thus, baseline and surveillance UDS help
bladder pressures and abolishing DO. In this condition repeat
determine the current or changing neurologic lesion that
renal/bladder sonography should be performed, especially if
warrants MRI imaging and possibly spinal cord untethering, if
hydronephrosis and/or reflux was present initially. Repeat
an operable lesion is found. It is extremely rare for these
VCUG or RNC is not necessary if initial studies did not reveal
children to exhibit lower extremity neurologic impairment or
reflux. Indications for repeating a VCUG or RNC include a
a cutaneous manifestation of this associated condition.
change in upper urinary tract dilation, poor renal growth, loss
Spinal cord injury demands UDS (cystometry and sphincter
of parenchyma, or symptomatic pyelonephritis. It is under-
EMG) at a minimum of approximately 6 weeks but preferably
stood most children who progress to ESRD will have associat-
3 months after the injury because in the very early stages af-
ed reflux nephropathy.6 If the child with NBD begins with
ter the insult, the neurologic picture can change dramatically.
reflux and then develops a high-pressure bladder the likeli-
The child should be started on CIC as soon as feasible after the
hood of continued damage to the kidney(s) is greater and sub-
initial clinical picture stabilizes. Spontaneous voiding may
sequent development of ESRD accelerated.
commence very soon thereafter but even though the child
In the child with DO and either an open or closed bladder
empties his (her) bladder it is imperative to know at what
neck an ultrasound every 6 months in the first 2 years of life
pressure this occurs.
is indicated. UDS should be repeated yearly, or sooner if any
If detrusor filling and voiding pressures are normal and the
changes occur involving the upper urinary tract or lower ex-
child empties the bladder with synergy then CIC may be safe-
tremities. The rationale for such close follow-up in the first
ly stopped.27 If the filling and voiding pressures are elevated
few years of life is that these children are at risk for develop-
due to DSD then CIC should be continued and anticholinergic
ing tethering of the spinal cord during periods of rapid
agents added to achieve normal detrusor compliance and safe
growth.33,34 The enhanced skeletal growth as they double and
voiding pressures.28 If CIC is discontinued then periodic
triple their weight in the first 1–3 years of life can lead to ten-
assessment of residual urine volume is necessary to ensure
sion and ischemic changes in the spinal cord if it is fixed in
stability. Renal/bladder ultrasound is performed as a baseline.
scar tissue. An MRI scan of the spine is performed if clinically
VCUG is undertaken when hydronephrosis or subtle signs of
indicated at this time.35
vesicoureteral reflux are seen on ultrasonography and/or UTI
Renal scarring rates of 10% or more have been noted on ul-
is present.
trasound while with DMSA scanning the rate of scarring
Some central nervous system derangements may lead
varies between 15% and 31%.36 In a study by Shiroyanagi
to lower urinary tract dysfunction, which may require
et al., no renal scars were noted in children with NBD who did
neuro-urologic evaluation. Spastic diplegia or the spectrum
not have reflux. DMSA scanning looking for renal scarring is
of cerebral palsy can be associated with urinary incontinence
not imperative if the initial VCUG reveals no reflux and the
(5–10%). In some instances the diagnosis is obvious, with
kidneys are growing. It would be wise to consider a baseline
spasticity and motor delays evident early in development,
DMSA study if reflux is noted at the primary examination, for
whereas others may only exhibit poor school performance or
later comparison.
difficulty with fine motor coordination over time.
Urgency incontinence may be due to an inability to notify
caregivers and/or reach the bathroom quickly enough to pre- Toddler to Adolescent
vent leakage from an overactive and/or smaller than expected Once in the toddler stage, rapid periods of growth are
capacity bladder,29 or it is the consequence of UTI.30 If UTI is reduced so the likelihood of significant progression of
present then renal ultrasonography and uroflowmetry with a tethering is less.37 During this time a yearly or biannual
post-void residual urine measurement should be obtained. A ultrasound is recommended to follow the child, looking at
UDS (cystometrogram and sphincter EMG) is essential when residual urine or changes in the degree of hydronephrosis or
ultrasound demonstrates a thick-walled bladder with or with- bladder wall thickening. If any one of these is noted, UDS
out hydroureteronephrosis or substantial residual urine, be- should be reconsidered. Throughout this period any changes
cause affected children tend to exhibit DO but rarely (<10%) in ambulation or lower extremity function warrants repeat
DSD.31 If UDS reveals DSD then VCUG (males) or radionuclide UDS, looking for a change in lower urinary tract dynamics,
cystography (RNC; females) is needed to diagnose reflux and/ which might indicate spinal cord tethering. If numerous
or other pathology. Following treatment sequential urody- febrile UTIs have occurred DMSA scanning should also be
namic testing is indicated if incontinence and/or hydroneph- performed.
rosis persists or recurs. It has recently been shown urinary
incontinence can be improved with just adequate fluid
Adolescent to Adult
intake.32
Tumors (either primary or metastatic) of the central During this period patients will exhibit the usual adolescent
nervous system in children are rare and the symptom growth spurt. It is during this transformation that tethering
complexes they produce quite varied; the workup should be can occur, so careful monitoring of signs is mandatory. Ultra-
individualized and tailored to the specific location of the sonography should be performed yearly looking for changes
disease. in kidney dilation and/or bladder wall thickening. The need to

Neurourology and Urodynamics DOI 10.1002/nau

 ICCS: Evaluation and Management of Pediatric NBD
do CIC more frequently, new onset wetting, or recurrent UTI
are indicators of potential changes in lower urinary tract
function. In such situations, UDS is warranted in the former
two conditions as well as an RNC in the latter third condition.
Once the growth velocity has diminished in adolescence
follow-up ultrasounds can be performed at 2 years intervals.
It is important for the practitioner to consider that adoles-
cent hormonal changes may impact the lower urinary tract. It
has been shown bladder outlet resistance may increase in
teenagers, the result of prostatic enlargement in boys38 and
estrogenization in girls. While 45% with incontinence become
continent after going through puberty, this does not result in
upper urinary tract deterioration.
Adulthood
In general patients who have completed their growth are
not likely to develop any further changes in the spinal cord
that would precipitate tethering. With this knowledge the
frequency of follow-up with a renal/bladder ultrasound can
be prolonged to once every 3 years. As long as no changes in
bladder dynamics occur (i.e., need to increase CIC frequency to
stay dry, increased UTIs) repeat UDS are not required. It is im-
perative these young adults be followed closely to insure they
are maintaining good CIC routines and are periodically being
checked for unrecognized UTI or stone formation.
Caudal regression syndrome in sacral agenesis or imperforate
anus. In the patient with caudal regression syndrome, it is
well known that the incidence of renal anomalies is greater
that that seen in spina bifida patients.39 Thus, renal agenesis
is associated with caudal regression. The renal reserve is
markedly diminished in these patients. If any damage occurs
to the solitary kidney it will have profound effects on renal
function and long-term survival, especially if the child has DO
or DSD.
EVALUATION OF NEUROPATHIC BOWEL DYSFUNCTION
Disorders involving spinal cord function often affect
colorectal motility40 ano-rectal sensation, and anal sphincter
function. Cardinal symptoms consist of chronic constipation
and fecal incontinence. The severity and type of bowel dys-
function correlate partly with the level of spinal cord injury.41
Bowel dysfunction has a major impact on social activities and
quality of life, which becomes more acute as the child grows
older. Neuropathic bowel dysfunction is commonly seen in
children with myelomeningocele and sacral agenesis. It also
results from an organic or anatomical lesion, for example,
malformation, surgery, trauma, or a neuromuscular disorder.
Assessment and treatment of children with these issues
follow similar pathways.
Infants
Breastfed children suffering from a neuropathic bowel often
have problems with constant fecal leakage and diaper derma-
titis. Once diagnosed, parents should be told about the risk of
constipation. As more solid foods are introduced, constipation
develops, often followed by diarrhea leading to poor appetite
and failure to thrive if left untreated.
School Children and Adolescents
At this age fecal incontinence is a major problem due to
either constipation and/or insufficient sphincter tone. Bowel
control is very important for social integration and quality of
Neurourology and Urodynamics DOI 10.1002/nau
613
life.41 Some children suffer from abdominal pain, decreased
appetite, and poor weight gain from constipation.
EVALUATION
History
A comprehensive history is necessary including frequency
of bowel movements, consistency of feces (hard, soft, watery),
current use of laxatives, and frequency of fecal incontinence.
Other important information includes the child’s ability to
feel the urge to defecate, to sit on the toilet, to cooperate and
to determine the child’s response to prior treatments, for ex-
ample, digital rectal stimulation, enemas, and suppositories. A
validated assessment of a child’s defecation habits can be
gleaned from a 2-week bowel diary. Although not mandatory
it is an excellent supplement to history taking.
Physical Examination
A thorough physical examination is recommended includ-
ing inspection of the anus, digital rectal examination, and
palpation of the abdomen. It is important to denote anal
fissures, anal prolapse, irritation of the skin, a patulous anus,
as well as the presence of an ano-cutaneous reflex, a large fe-
ces mass in the rectum, anal sphincter tone, ability to contract
the sphincter when asked, abdominal masses and a potential
fecoloma. Radiologically determined colorectal transit time is
often prolonged in children with neuropathic bowel. Anorec-
tal manometry should be performed when a neuropathic
bowel is suspected, measuring anal resting pressure, anal
squeeze pressure, rectal capacity, and anorectal sensibility.
In some instances, deteriorations of the child’s bowel or uro-
logical function may be the first indication of a tethered
spinal cord. If suspected, an MRI of the spine is needed for
confirmation.
In conclusion, the many facets of NBD warrant a variety of
approaches based on principals outlined above. The timing
and extent of these investigational tools are meant to provide
for efficient and effective measurements of the state of the
urinary tract in order to insure normal function on a long-
term basis.
ACKNOWLEDGMENTS
Professor Chung Kwong Young, Hong Kong, and Professor
Antoine E. Khoury, Toronto, has followed the work with the
review article closely and revised the manuscript critically.
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