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172 Neurogenic Bladder
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neurogenic bladder dysfunction. In addition,
by commencing CIC early it may be possible
to prevent or reduce the requirement for
bladder augmentation as well as helping to
safeguard the kidneys.
2. Monitoring of bladder function with renal
and bladder ultrasound scans (and periodic
urodynamics) with the onset of clean intermittent catheterization being deferred.
ose who advocate this approach argue
that it decreases the burden for the caregivers and carries a lower risk of urinary tract
infection (UTI) because bacteria are not
being introduced into the urinary tract.
However, monitoring and deferred
introduction of CIC are only appropriate for
infants who have safe urodynamic parameters of bladder function. CIC should be
commenced if the initial urodynamic study
demonstrates unfavorable characteristics such
as reduced compliance, signicant detrusor
sphincter dyssynergia, or high-grade VUR.
Indications to abandon the observational
approach in favor of CIC and anticholinergics include; development of hydronephrosis,
worsening parameters of bladder function on
urodynamics or recurrent UTIs.
INVESTIGATIONS
Routine follow-up typically comprises ultrasound scans of the kidneys, ureters and bladder
every 3 months during the rst year of life, then
reducing to 6 monthly intervals until 3 years of
age, with an annual scan thereaer. A baseline
renogram with 99mTc dimercaptosuccinic acid
(DMSA) or 99mTc dimercaptoacetyltriglycine
(MAG3) is performed in the rst 6 months of life
and repeated according to clinical indications.
Renal function is monitored by measurement
of serum creatinine (or cystatin c) on an annual
basis – or more frequently in children with hostile patterns of bladder function or frequent
UTIs. e frequency of video urodynamic studies is determined by such factors as; the results
of initial and subsequent studies, the perceived
level of risk posed by the neurogenic bladder,
the frequent occurrence of UTIs or the onset
of changes in the upper tracts on ultrasound.
Urodynamics should be performed prior to possible reconstructive surgery in children expressing the wish to become socially continent.
VIDEO URODYNAMICS
A urodynamic study will provide information on bladder and sphincteric function. e
study is performed using a dual lumen catheter
inserted into the bladder (for lling and measurement of intravesical pressure) and a balloon
catheter placed in the rectum for the measurement of intra abdominal pressure. e bladder
is lled at a rate of approximately 10% of the
estimated age-adjusted bladder capacity per
minute. is is calculated according to the formula (age in years + 2) × 30 mL. For videourodynamics the bladder is lled with a solution of
radiographic contrast material. During bladder
lling, intravesical pressure (Pves) is recorded.
e contribution made by the detrusor muscle
(Pdet) to intravesical pressure is calculated by
subtracting the intra abdominal pressure (Pabd)
from the intravesical pressure ie (Pves – Pabd).
Sphincteric function can be assessed by electromyography with patch electrodes placed in the
perianal region or by the insertion of needle
electrodes (which is believed to be more accurate). However, there are some dierences in the
use of electromyography. In the UK for example,
X-ray screening (videocystography) is used in
preference to electromyography for the assessment of sphincter function. At dierent stages in
the study uoroscopic imaging is performed to
visualize the bladder and to demonstrate abnormalities such as trabeculation, divertucula,
stones, and/or VUR. Particular attention is paid
to the bladder outlet and sphincter, visualizing whether it is open or closed and observing
the relationship between sphincter activity and
detrusor contractions.
A normal, healthy bladder remains stable
during lling with pressures remaining below
15 cm H
the detrusor muscle contracts aer relaxation
O throughout. At the time of voiding,
2
Video urodynamics 173
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of the external sphincter allowing the bladder to empty to completion. Points of interest
during the lling phase include the maximum
intravesical pressure, the involuntary leakage of
urine (incontinence), and the pressure at which
the leakage occurs. A high detrusor leak point
pressure (DLPP) of >40 cm H2O is regarded as
unsafe. Bladder compliance is calculated as volume over pressure and a gure of <20 mL/cm
H2O denotes reduced compliance (inability of
the bladder to accommodate physiological volumes of urine at safe pressures). If the patient
is capable of voiding, attention is paid to possible detrusor-sphincter dyssynergia (contraction of the detrusor muscle against sphinteric
resistance), voided volume, post-void residual,
ow rate, and characteristics of the ow curve
(bell-shaped, staccato, intermittent, at). It is
important to note, however, that interpretation
of urodynamic ndings is relatively subjective
and is inuenced by a number of factors including inter observer variations, limited reproducibility, technical artifacts and patient anxiety.
A “safe” neurogenic bladder is one which does
not pose a threat to the upper tracts and renal
function. However, maintaining a safe pattern of
bladder function is oen dependent on the use of
regular CIC. e type of bladder in which CIC is
most likely to protect the upper tracts and help the
child to achieve continence is one which is capable
of storing physiological volumes of urine at safe
pressure and in which sphincter resistance is sufcient to prevent urinary leakage for periods of
3–4 hours between catheterization (Figure 13.1).
Urodynamic studies oen demonstrate abnormalities of detrusor function, notably detrusor
overactivity. Detrusor overactivity combined
with a sphincter which fails to relax in response to
detrusor contraction (detrusor sphincter dyssynergia) is regarded as an “unsafe” or “hostile” pattern of neurogenic bladder dysfunction. Without
appropriate intervention, over 70% of patients
with detrusor sphincter dyssynergia will experience urinary tract deterioration, including the
development of hydronephrosis, within 3 years.
In such cases, the functional bladder capacity is
reduced and the bladder is typically thick walled
and trabeculated (Figure 13.2). e nding of
detrusor sphincter dyssynergia demands prompt
intervention – initially by the introduction of
CIC. However, this is oen insucient and further measures (notably bladder augmentation)
may be required to safeguard the upper tracts and
enable the child to achieve continence.
Figure 13.1 This is the type of neurogenic bladder which is most amenable to CIC. The blad-
der is capable of storing urine at “safe” pressures and sphincter resistance is adequate to retain
physiological volumes of urine in the bladder for periods of 3–4 hours between catheterizations.
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Figure 13.2 Hostile characteristics. Overactive sphincter and/or detrusor sphincter dyssynergia
causing functional outow obstruction. Detrusor overactivity. Unfavorable urodynamic parameters,
thick walled bladder and upper tract dilatation.
A dierent abnormality of sphincter function is sphincter weakness due to denervation
(typically associated with lower motor neuron
lesions). is is a safe pattern of neurogenic bladder dysfunction because the impaired sphincter
resistance eectively acts as a “safety valve” preventing the bladder from generating sustained
elevated pressures. Functional capacity is
reduced due to low pressure urinary leakage.
Intermittent catheterization is not an eective
means of achieving continence because the bladder is incapable of storing urine without leakage
for a suciently long period between catheterizations (Figure 13.3).
Figure 13.3 Sphincter weakness (typically associated with lower motor neuron lesions). This is a
safe bladder but functional capacity is reduced because of low pressure leakage of urine. CIC does
not achieve continence because the bladder is incapable of storing adequate volumes of urine
between catheterizations.
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Opinion diers on whether children with neurogenic bladder should routinely undergo annual
urodynamic evaluation or whether it should be
performed on a more selective basis in response
to changes in clinical status (e.g. recent onset of
UTIs, new or worsening urinary leakage, new or
worsening upper tract dilation). Proponents of
regular annual urodynamics argue that it is not
sucient to rely on monitoring the upper tracts
because hydronephrosis is not a sensitive indicator of deteriorating lower tract function. ose
who favor a selective approach cite the greater
nancial cost of annual studies and the larger
number of studies which have to be performed in
order to detect those cases of deteriorating bladder function for which intervention might be
required. Regardless of diering policies regarding the frequency of urodynamic studies there
is a strong consensus that all patients with neurogenic bladder should remain under urologic
surveillance to safeguard the upper tracts, ensure
adequate emptying of the bladder, and minimize
the risk of UTI.
TETHERED SPINAL CORD
Children with a tethered spinal cord mostly
have a much better prognosis than those with
meningomyelocele.
TREATMENT AND OUTCOMES
e primary aim is to safeguard renal function
and minimize the risk of UTIs by ensuring that
urine is stored at low pressures and the bladder
empties completely every 3–4 hours. Once this
has been achieved the secondary aim is to try and
provide a socially acceptable degree of urinary
continence if this is a priority for the child and
their family.
Bladder emptying can be achieved by spontaneous voiding in some cases, or more oen
by intermittent catheterization (via the urethra
or a catheterizable channel) or by a cutaneous
vesicostomy or urinary diversion. Reduced functional capacity of the bladder and/or unsafe intravesical pressure can be managed by intravesical
injections of Botox or by bladder augmentation.
Finally, bladder neck procedures to increase bladder outlet resistance children can be performed to
treat incontinence caused by sphincter weakness.
is is common feature of closed variants of
spina bida (occult spinal dysraphism). Up to
60% of children have normal urodynamic ndings during early infancy but this gure has
fallen to 20% by 3 years of age. ese ndings
have been cited as evidence that this is a progressive neurologic lesion for which early surgical intervention to untether the spinal cord
is indicated in order to improve urodynamic
outcomes. However, this does not obviate the
requirement for continuous monitoring and
follow-up because there is a 25% incidence of
retethering aer surgery. Some care is required
when interpreting and the published data on
pre and postoperative urodynamic studies in
children undergoing surgery for tethered cord.
Whereas neurosurgical intervention for tethered cord in infants is widely performed by
pediatric neurosurgeons in the United States a
more conservative, selective policy is generally
favored by British Pediatric Neurosurgeons.
CATHETERIZATION
Clean intermittent catheterization (CIC) is
usually initially performed via the urethra but
for some young patients this may not be feasible
or acceptable in the longer term. is may be
because of body habitus, inability to catheterize
the urethra or the preference of the child and/
or family. In these circumstances it becomes
necessary to create an alternative route for catheterization, namely a continent catheterizable
channel.
e introduction of the Mitrofano appendicovesicostomy was a signicant advance in
the management of neurogenic bladder dysfunction (Figure 13.4). It usually provides
patients with a much greater degree of personal independence and has been shown to be
durable with a high long-term success rate. e
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Figure 13.4 Appendicovesicostomy (Mitrofanoff
procedure). The appendix is disconnected from
the caecum and mobilized on its blood supply. The tip is excised to create a tube which is
implanted into the bladder using a submucosal
(anti reux) tunnel. The other end of the appendix is brought out as a discreet stoma on the
skin of the abdominal wall (or umbilicus).
commonest complication is stenosis of the cutaneous stoma – with a reported incidence varying
between 15% and 40% over a 5-year period. is
is usually amenable to simple revision, although
more than one revision may be required. e
Mitrofano procedure is particularly benecial
for young females – especially those conned to
a wheelchair.
If the appendix is not available because it
has been removed, is unusable, or reserved for
another channel (such as appendicocecostomy)
the main alternative is a channel created from the
wall of the ileum or colon – eponymously named
as Monti or Yang-Monti channel (Figure 13.5).
However the appendix is the preferred source of
a continent catheterizable channel because it provides the most reliable access for the passage of
catheters and has a lower complication rate compared with the alternatives.
Intermittent catheterization is a clean rather
than sterile procedure and some bacteria are
inevitably introduced into the bladder with the
passage of the catheter. Approximately 70% of
Figure 13.5 Monti tube fashioned from ileum.
This is the most satisfactory alternative to the
appendix for creating a continent catheterizable
channel.
patients on CIC have asymptomatic bacteriuria
but fewer than a third of these experience symptomatic UTIs. e risk of UTIs can be lowered by
increasing the frequency of CIC to minimize the
opportunity for bacteria to multiply within static
bladder urine. Where possible, the use of antibiotics should be kept to a minimum to reduce the
risk of bacterial resistance.
CIC is typically performed at 3–4 hourly intervals throughout the day. Night time management is oen more problematic because children
and parents may (understandably) be reluctant to
have perform CIC late at night or the early hours
of the morning. is is of particular relevance in
those neurogenic bladders which exhibit “hostile”
characteristics since this may lead to sustained
high-pressure storage of urine and consequent deleterious eects on both the kidneys and bladder.
As in children with posterior urethral valves, overnight drainage with an indwelling catheter has been
shown to be benecial in protecting bladder and
renal function and reducing the frequency of UTIs.
INCREASING BLADDER
CAPACITY AND REDUCING
INTRAVESICAL PRESSURE
e options for achieving this include: pharmacological agents, intravesical injections, and surgical reconstruction.
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Pharmacological Agents
Oxybutynin is currently the only anticholinergic drug approved by the American Food and
Drug Administration (FDA) for the treatment of
neurogenic bladder in children. Anticholinergics
act by suppressing overactivity of the detrusor
muscle but have the disadvantage of causing
anticholinergic side eects such as dry mouth,
constipation, ushing, and impaired concentration. Alternative agents for the treatment of
detrusor overactivity include other anticholinergics and Mirabegron – a beta-3 adrenergic
agonist. Although none of the currently available
alternatives to oxybutynin are approved for use
in children by the FDA, clinicians may decide to
prescribe them on an “o-label” basis for young
patients those who are unable to tolerate rst-line
agents such as oxybutynin. Alpha-adrenergic
blockers (such as doxazosin and tamsulosin)
which act on receptors at the bladder neck
smooth muscle can be used for the management
of functional outow obstruction in children
with both non-neurogenic and neurogenic
voiding dysfunction. Studies in small series
of patients have been reported to demonstrate
improved ow rates and reduced post void residual volumes in those capable of voiding spontaneously. However, there are conicting data and
the published studies are of varying quality. e
side eects of alpha-adrenergic blockers include
orthostatic hypotension, reex tachycardia, syncope, dizziness, and palpitations.
INTRAVESICAL BOTOX
INJECTIONS
Botulinum A toxin is a neurotoxin produced by
Clostridium botulinum. When injected into the
detrusor muscle, it inhibits the release of acetylcholine from the presynaptic neuron at the
neuromuscular junction. Intravesical Botox is
used for the treatment of detrusor overactivity to
improve bladder compliance and increase functional capacity. Injections into the bladder wall
muscle are performed at multiple sites via a cystoscope. e standard dosage is 10 international
units (IU) per kg up to 300 IU in adults. Although
it is not approved by the FDA, numerous studies
have shown intravesical Botox injection to be a
safe and eective treatment of neurogenic bladder in both children and adults. e duration of
eect is approximately 6–12 months. In one study
in children with spina bida 73% of patients were
enabled to become dry between intermittent catheterizations for 4 months aer intravesical Botox
injection and 88% experienced symptomatic
improvement. Intravesical Botox injections can
administered repeatedly without giving rise to
tolerance (loss of eectiveness) or causing brosis in the bladder wall. e principal side eect is
impaired bladder emptying and patients should
therefore be prepared for the possibility that they
may need to perform CIC – if they are not already
doing so. UTI is another potential complication
but systemic side eects are rare.
BLADDER AUGMENTATION
(ENTEROCYSTOPLASTY)
is is a reliable means of increasing bladder
capacity, improving bladder compliance, and
reducing intravesical pressure. e urodynamic
prole of children being considered for augmentation is characterized by reduced functional
bladder capacity, elevated absolute detrusor lling pressures (P
sor leak point pressures (>35 cm H2O), and poor
compliance (<10 mL/cm H2O). In addition, there
are oen upper tract changes such as hydronephrosis, hydroureteronephrosis, or secondary
VUR. Bladder augmentation is most frequently
indicated in children with thoracic and lumbar
meningomyelocele and less commonly in those
sacral spina bida and lipomeningocele. It is
rarely required in cases of tethered spinal cord.
e technique consists of opening the bladder and incorporating a vascularized segment of
intestine (ileum or sigmoid colon) into the bladder wall. It is usually performed as an open surgical procedure but a minimally invasive approach
has also been reported. e simplest (and probably most widely performed) technique is the
“Clam” ileocystoplasty (Figure 13.6).
>40 cm H2O), elevated detru-
det
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Figure 13.6 Clam ileocystoplasty. (a) Bladder opened and incised down to the trigone creating a
“clam” conguration. (b) Segment of ileum isolated on its mesentery, opened (detubularized) and
sutured to the bladder. (c) Intraoperative photograph.
By adopting Enhanced Recovery aer Surgery
protocols developed in adult patients undergoing
radical cystectomy it has been possible to reduce
the duration of hospital stay for children undergoing bladder augmentation in the authors’ institution from 8 to 5.4 days. In addition the average
number of complications per patient has been
reduced from 2.1 to 1.3 (p = 0.035).
Augmentation cystoplasty is associated with a
signicant incidence of long-term complications,
with approximately one-third of patients requiring some further surgery within 13 years of the
original operation (Table 13.2). Introducing
intestine into the urinary tract carries a risk of
hyperchloremic hypokalemic metabolic acidosis
and possible implications for growth. Vitamin
B
deciency is an additional risk following aug-
12
mentation with distal ileum. Asymptomatic bacteriuria is almost universal as a result of bacterial
colonization of the reconstructed bladder and
the presence of mucus in the urine. Symptomatic
infections also occur in up to a third of patients.
Other complications may include bladder stone
formation (10–20%) (Figure 13.7) and spontaneous bladder perforation (5%). is is serious
and potentially lethal complication if it is not
diagnosed promptly. A high index of suspicion
is required because the initial presentation of
bladder perforation may consist of no more than
Table 13.2 Complications of bladder
augmentation
Mucus production
Catheter blockage
Urinary tract infection
Bladder stones
Metabolic changes
Hyperchloremic metabolic acidosis
Electrolyte disturbances
Spontaneous perforation
Metaplasia, malignancy
Bowel problems
Diarrhea
Vitamin B
Hematuria-dysuria syndrome (gastrocystoplasty)
deciency
12
vague abdominal pain. A computed tomography
(CT) cystogram is the most accurate diagnostic
investigation. Adhesive intestinal obstruction
occurs in approximately 5% of patients within
15 years of bladder augmentation.
e high rates of late malignancy in patients following ureterosigmoidostomy and the ndings of
studies demonstrating bacterial-derived carcinogens in the urine following enterocystoplasty raised
initial concerns that the use of bowel for bladder
reconstruction would carry a signicant long-term
Figure 13.7 Ultrasound scan demonstrating
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3.5 cm bladder stone in an augmented bladder.
cancer risk. However, it has now become clear that
these concerns were largely unfounded. Long-term
studies have found that the risk of bladder cancer in
patients with spina bida who had undergone bladder augmentation is not signicantly higher than
in age matched spina bida patients whose bladders
had not been augmented. e overall long-term
incidence of bladder cancer has been reported to lie
between 1% and 4%, with no signicant dierences
between augmented and non-augmented patients
in terms of age at diagnosis or survival rates.
Although cystoscopic surveillance and biopsy
commencing 10 years aer augmentation was
previously advocated this has been discontinued
in most centers because it not been shown to be
helpful or cost eective.
Experimental Research
Bladder outlet procedures 179
for bladder augmentation in spina bida patients
found that it did not result in any improvement
in bladder compliance or capacity. In addition
there was a relatively high rate of serious adverse
events – including bladder rupture. On the basis of
this study, the authors concluded that the technique
could not be recommended for clinical use.
VESICOURETERAL REFLUX
Up to 20% of infants with neurogenic bladder
have VUR. Because this VUR is oen secondary
to the unfavorable urodynamic features of the
neuropathic bladder it will resolve in approximately 50% of cases once bladder dynamics have
been improved by CIC and anticholinergic medication. If the VUR persists despite these measures and the child is suering recurrent UTIs
it is reasonable to consider correcting the reux
by ureteral reimplantation. However, this is most
unlikely to succeed unless it is also accompanied by other measures to address the underlying bladder dysfunction. Endoscopic correction
by sub-ureteric injection of bulking agents has
a lower success rate in neuropathic bladders –
although success rates of 60% to 70% have been
claimed by some authors. Ureteral reimplantation can combined with bladder augmentation
but is technically more dicult than in a normal bladder. However, ureteral reimplantation is
oen unnecessary because secondary VUR has
a high tendency to resolve once the unfavorable
characteristics of the neurogenic bladder have
been corrected by bladder augmentation.
Because the complications of augmentation are
largely attributable to the use of intestine, a number of research programs have tried to address
this problem by devising experimental techniques
to augment the bladder with materials derived
from tissue engineered autologous urothelium or
acellular matrices (serving as scaolds for regenerative cellular inltration). Clinical experience
of this approach is very limited. Following an
initial report in a small series of meningomyelocele patients, a subsequent Phase II study of the
use of autologous seeded biodegradable scaolds
BLADDER OUTLET PROCEDURES
Although a number of dierent surgical procedures are available for increasing bladder outlet
and sphincteric resistance, no single technique
has proved suciently reliable to have gained
widescale acceptance. When considering any
of these procedures it is essential to ensure that
the patient has the physical ability and motivation to perform intermittent catheterization.
Preoperative evaluation includes imaging of the
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upper tracts and video urodynamics. If possible,
bladder compliance and detrusor activity should
be assessed with the bladder outlet occluded to
try and predict how the bladder will behave following surgery. Unless there is good evidence that
the bladder will function as a safe low pressure
reservoir, strong consideration should be given
to performing bladder augmentation at the same
time as the surgery to increase outlet resistance.
e surgical procedures can considered in
three broad categories (Figure 13.8):
●
Operations designed to increase xed outow
resistance by narrowing the bladder outlet
and/or increasing the length of the urethra
e.g. Kropp, Pippi Salle procedures.
●
Operations designed to enhance outow
resistance by compressing or angulating the
bladder neck and/or urethra, e.g. articial
urinary sphincter, colposuspension, or sling.
●
Closure of the bladder neck.
Closure of the bladder neck is the most eective
means of achieving continence but is usually kept
in reserve as a second line approach.
ere is considerable variation between dierent published studies in the reported continence
rates following the dierent procedures. Published
continence rates typically average around 60% to
70% but the published results are dicult to compare because of dierences in the denition of
what constitutes “continence” adopted in dierent
studies and the varying duration of follow-up.
Injection of bulking agents into the bladder
neck and sphincter region has also been reported
as a method of increasing xed outow resistance.
Figure 13.8 Some of the procedures available for increasing sphincter/outow resistance. (a) Urethral
lengthening (e.g. detrusor tube) to increase static outow resistance. (b) External compression by an
articial urinary sphincter cuff implanted around the urethra. The pump is implanted in the scrotum
and the pressure regulating balloon is implanted in a plane between the peritoneum and abdominal
wall musculature. (Reproduced by permission from American Medical Systems). (c) Sling procedure.
Slings created from autologous or allograft tissue are preferable to synthetic materials.
Neurogenic bowel 181
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e continence rates are generally inferior to
those achieved by open surgical techniques but a
success rate of 25% with one or two injections has
been reported.
Complications of the various dierent procedures include outow obstruction (“hypercontinence”), tissue erosion, infection, and
malfunction of articial sphincter devices. A further complication is the relatively high incidence
of bladder stones – particularly in patients who
have also undergone enterocystoplasty.
Closure of the bladder neck is generally seen as
a reliable last resort when other techniques have
failed. Nevertheless, some pediatric urologists
favor bladder neck closure sooner rather than
later. e principal drawback of bladder neck closure is that the bladder becomes an enclosed system, with emptying being entirely dependent on
a catheterizable channel or indwelling suprapubic
catheter or drainage device.
Cutaneous urinary diversion (ileal conduit)
was once the mainstay of management of neurogenic bladder but is now rarely used because
of the availability of better alternatives. Specic
complications include stomal stenosis, long-term
upper tract changes and the adverse impact on
body image and quality of life imposed by the
stoma and urine collection bag.
TRANSITION TO PUBERTY
IN ADULTHOOD
Unfortunately, there is a tendency for myelomeningocele patients to become less compliant with regular CIC and other aspects of their care when they
progress into adolescence and adulthood. In the
United States over 50% of adult spina bida patients
whose neurogenic bladders were previously managed by intermittent catheterization will cease to
perform CIC, contrary to medical advice. Factors
implicated in poor compliance with treatment and
follow-up include obesity, immobility, developmental delay and alcohol and drug dependence.
ose patients who comply with measures to
manage their neuropathic bladder appropriately
and who remain u nder urologic surveil lance have a
very low long-term risk of severe renal impairment
(2%). Indeed, they more likely to die from infection, shunt complications, and pulmonary embolism than renal failure. However, the risks of renal
impairment and urological complications are
signicantly higher in adult spina bida patients
who do not comply with recommended treatment
or are lost to urologic surveillance.
Spina bida patients require multispecialty
healthcare throughout their lives and it is important that they receive the help they need to make
a successful transition from the care of pediatric
specialists to the care of adult specialists in the
relevant disciplines.
SEXUALITY AND
REPRODUCTIVE HEALTH
e early onset of menarche is more common in
female myelomeningocele patients than the general population (12% and 0.6% respectively) and
they are less likely to use contraception when they
become sexually active.
Pregnancy creates specic problems – particularly in women who have previously undergone reconstructive procedures such as bladder
augmentation or the creation of catheterizable
channels. Obstetric care should be provided by
multidisciplinary team including obstetriciangynecologist, urologist and other clinicians.
Elective caesarian section is oen more appropriate than vaginal delivery.
Males may experience erectile dysfunction (ED)
of varying severity and 80% of men with spina
bida have been demonstrated to have improved
erectile function with the use of sildenal.
One-quarter to one-third of adolescents and
young adults with meningomyelocele between 14
and 23 years of age report having had sexual encounters but only half of meningomyelocele patients state
that they are satised with their sexual lives.
NEUROGENIC BOWEL
e majority of children with neurogenic bladder
also suer from neurogenic bowel dysfunction.
is is unsurprising since the lower urinary tract
ALGRAWANY
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