This is the first study to investigate the status of the management of neurogenic bladder including monitoring, treatments, and complications in Japanese pediatric patients with neurogenic bladder. Spina bifida is complicated by several related diseases, such as neurogenic bladder and gastrointestinal symptoms, and requires multidisciplinary collaboration [1]. Based on medical conditions that change with age, the medical specialists involved, examinations, treatments, and instructions should be changed. Long-term periodic management is important for better prognosis and higher quality of life (QOL) [2, 3]. However, the follow-up status in real-world clinical practice remains unclear. We investigated what and when examinations and what kinds of treatments were performed during the first 2 years, as well as the incidence of related medical complications.

This was a retrospective analysis of the JMDC database, a database of receipts and medical information from multiple health insurance societies in Japan since 2005. A total of 883 patients (≤17 years) with neurogenic bladder due to neurological disorders, such as Spina bifida or spinal cord injury, were included. The demographic and clinical characteristics of the patients and their management status were investigated during the 24-month follow-up period. A multivariate analysis evaluating the potential risk factors for the development of urinary tract infection during the 24-month follow-up period was performed. The diagnosis of spina bifida, patient demographics (sex and age at the index month), presence of comorbidities at baseline, and use of CIC and/or OAB drugs at the index month, etc. were used as independent variables.

According to Japanese guidelines, renal/urinary tract ultrasonography should be performed every 6 months during childhood. However, it was performed only in 52.7% in the first year and in 38.3% in the second year of Spina bifida cases. A urodynamic study was performed in 21.3% in the first year and 9.5% in the second year of Spina bifida cases. Drugs, mostly anticholinergics, were used in 21.5% of all patients and in 40.9% of patients with occult Spina bifida. Clean intermittent catheterization (CIC) was performed in 10.8% of all patients and in 31.5% with open Spina bifida. Lower urinary tract infections (UTI) occurred in 23.3% of all patients, with an increase of 18.1% in the first year. It was more common in patients with Spina bifida (35.4%), especially in open Spina bifida (63.0%). While upper UTI also occurred in 4.0% of all patients, it was more common in the open Spina bifida group (8.7%). Renal failure occurred in 2.4% of all patients. Urinary incontinence was present in 9.7% and 19.3% of all patients and those with Spina bifida (19.3%), respectively. Compared with the first year, the percentage of medical complications increased slightly in the second year. Multivariate analysis evaluating risk factors for urinary tract infection showed significantly higher ORs with point estimates of ≥2 for CIC (5.70), presence of spina bifida (2.86), and constipation (2.07).

A urodynamic study was not adequately performed, which indicates that the guideline recommendations were not followed [2, 3], and there is a risk of inadequate identification of the disease status at treatment initiation and of changes in the disease status with growth. Patients with use of CIC, spina bifida and constipation were suggested to have a higher risk of developing urinary tract infection, suggesting the need for careful follow-up.

Follow-up, including long-term and periodic examinations as the child grows, is important for better prognosis and better QOL in pediatric neurogenic bladder patients. Prevention of complications such as UTI and kidney damage through periodic examination is important. More guideline-compliant and diligent patient management is necessary.

Manack A, Motsko S.P, Haag-Molkenteller C, Dmochowski R.R, Goehring E.L. Jr, Nguyen-Khoa B.A, Jones J.K. Epidemiology and healthcare utilization of neurogenic bladder patients in a US claims database. Neurourol Urodyn. 2011; 30: 395–401.
The Japanese Continence Society. Clinical Guidelines for Lower Urinary Tract Dysfunction in Patients with Spina Bifida. https://www.urol.or.jp/lib/files/other/guideline/31_lower-urinary_dysfunction_2017.pdf
Stein R, Bogaert G, Dogan H.S, Hoen L, Kocvara R, Nijman R.J.M, Quadackers J.S.L.T, Rawashdeh Y.F, Silay M.S, Tekgul S, Radmayr C. EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part I diagnostics and conservative treatment. Neurourol Urodyn. 2020; 39: 45–57.

Continence 7S1 (2023) 100782
DOI: 10.1016/j.cont.2023.100782