CASE PRESENTATION NEUROGENIC BLADDER- Dr. Subhashini

Paediatric case regarding neurogenic bladder and it’s management

1. CASE PRESENTATION PAEDIATRICS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

17. KEGELS EXERCISE

18. THANKYOU G.SUBHASHINI CRRI/ 2018 -19 CRRI/ 2018 -19