Pediatric Voiding Dysfunction and Neurogenic Bladder
Core concepts
Understand normal bladder development and the spectrum of lower urinary tract dysfunction: overactive bladder, dysfunctional voiding, underactive bladder, and the non-neurogenic neurogenic bladder (Hinman syndrome). Know the clinical clues: daytime incontinence, urgency, frequency, infrequent voiding, and stool retention. Constipation is a major contributor and must be treated. Uroflow with EMG and post-void residual help classify dysfunction. Neurogenic bladder causes include myelomeningocele, spinal cord tethering, sacral agenesis, and cerebral palsy. Understand clean intermittent catheterization, anticholinergics, and the goals of protecting the upper tracts by maintaining low bladder storage pressures. Recognize the value of urodynamics in identifying detrusor overactivity, poor compliance, and detrusor leak point pressure. Bladder outlet obstruction and vesicoureteral reflux may complicate neurogenic bladder.
Traps
- Treating incontinence pharmacologically before addressing constipation and voiding habits.
- Missing tethered cord in a child with new neurologic findings and worsening bladder function.
- Assuming all neurogenic bladders need augmentation; many are managed with CIC and anticholinergics.
- Overlooking detrusor leak point pressure as a risk factor for upper tract deterioration.
Worked example
A 7-year-old with daytime wetting, urgency, and constipation improves with bowel management, timed voiding, and bladder retraining; urodynamics are reserved for refractory cases or suspected neurogenic etiology.
Rule of thumb
Always treat the bowel before the bladder, and always image the spine when bladder dysfunction is new or progressive.