Improved bladder function after prophylactic treatment of the high risk neurogenic bladder in newborns with myelomeningocele

Purpose: High pressure dyssynergic voiding may result in irreversible damag e to the urinary tract. Prophylactic therapy in the form of clean intermitt ent catheterization and anticholinergic medication may significantly decrea se the incidence of upper urinary tract deterioration. Whether prophylactic therapy in the high risk bladder may also lead to improved long-term bladd er dynamics prompted us to study the effect of early versus late treatment of bladder hypertonicity and detrusor-sphincter dyssynergia on the ultimate need for bladder augmentation. Materials and Methods: We retrospectively reviewed urological outcomes in p atients with myelodysplasia who were at risk for urological deterioration w ithin year 1 of life based on bladder sphincter dyssynergia and/or high fil ling or voiding pressure. We recorded the dates when high risk voiding dyna mics were initially observed, and when intermittent catheterization and ant icholinergic therapy were initiated. Patients in whom treatment began at th e time a high risk profile was noted (prophylactic group seen between 1985 and 1990) were compared to controls with the same high risk voiding paramet ers who did not receive early therapy (observation group seen between 1978 and 1984 with therapy instituted 1 year or longer after high risk was noted ). The number of augmentations performed in each group was indexed to the t otal number of years of followup in the 2 populations, respectively. Patien ts with less than 2 years of followup were excluded from further analysis. Results: Of the 45 patients at risk clean intermittent catheterization and anticholinergic medication were immediately initiated in 18, while 27 were treated expectantly. Patients in the observation group were followed an ave rage of 4.1 years (range 1.1 to 14) before clean intermittent catheterizati on and anticholinergic medication were started. Of the 27 children treated expectantly 11 (41%) required augmentation, whereas only 3 of the 18 (17%) treated prophylactically required enterocystoplasty. When the number of aug mentations was indexed to total years of followup in each of the 2 groups ( 296 versus 156 years) patients in the expectant group were nearly twice as likely to require augmentation. Conclusions: Identification and early proactive treatment of the high press ure, dyssynergic lower urinary tract significantly decreases the need for b ladder augmentation as children with neurogenic bladder secondary to myelom eningocele mature.