Why do children with neurological impairment need to catheterize?
Basically, 30 or 40 years ago, kids with spina bifida had no bladder management. They were just allowed to void on their own or their urine was diverted because their bladders were so bad. Generally those kids were in renal failure by the time they were 18 or 20 years of age. In the early 1970’s, this guy Lapides in Detroit proposed the technique to very simply empty the bladder intermittently with a catheter. If the bladder is managed with catheterization and medications, it significantly reduces the risk of kidney damage in the long term.
When the bladder is not emptied, it contracts against a sphincter that’s discoordinated, and that contraction against a closed sphincter produces very high pressures in the bladder. Those high pressures are transmitted to the kidneys, and over time that increased pressure will destroy the kidneys. If you empty the bladder by bypassing that closed sphincter, then it removes this discoordination and high pressure voiding. In addition, because kids with spina bifida are chronically in retention, they chronically overdistend their bladders. That also leads to pathological remodeling and high pressures. But if you empty the bladder intermittently, then it doesn’t pathologically overdistend. It’s all about minimizing pathological bladder remodeling, and keeping the bladder soft and supple, accepting urine at low pressures.
Carlos Estrada, MD, Myelodysplasia Program, Department of Urology
How long do children with neurological impairment need to catheterize?
The families know from the get-go that this is likely to be a lifelong treatment, and I think the children are told that very early, as soon as they can grasp that concept. For the ones who are started on it early, it’s generally a little easier, because it’s just what they do: “Oh, okay, time to cath!” It becomes just second nature to them. For the children who are started a bit later, it may be a little tougher to get started. That takes a little more convincing and certainly more teaching and more visits to usher them along. But we provide all the teaching that’s needed to do catheterization, with videos for kids, a backpack, a lot of other stuff to help kids understand why they need to do this and how they do it.
I think it’s sort of implicit in how they’re cared for that they’re going to have to do catheterization for the long term. Once in a blue moon a child will ask, “Am I going to do this forever?” and the answer is very straightforward.
Carlos Estrada, MD, Myelodysplasia Program, Department of Urology
How are bladder and bowel problems related?
It’s part and parcel of the disease: they have a neurogenic bladder, they have a neurogenic bowel. Basically, the aberrant nerves supplying to the bladder are the same as the nerves supplying to the colon. So what they get is a poorly functioning bladder and a poorly functioning colon. They’re just completely backed up with stool and have chronic constipation, which can lead to fecal accidents, fecal soiling. Many are incontinent of urine and stool, which is very socially tough for these kids. Managing the bowels is a big social thing for them. Urinary accidents you can hide for awhile until they get kind of stinky; stool you cannot and so that’s a big deal for them.
We do aggressive bowel programs to keep these kids as regular as possible. If that doesn’t work out, we have also a surgical solution for them: the same kind of channel that we create for their bladder, we create for their colon. The appendix is brought up to the skin, the stoma is made continent so it doesn’t leak stool, and then they catheterize their appendix through their belly and give themselves an enema antegrade. So instead of having to do an enema via the rectum, which is tough and it’s a pain, you just literally put a catheter in, inject a bunch of saline or other agents we could use – half hour to 45 minutes, they sit on the toilet and everything just sort of flushes through. So there are solutions for constipation as well, and again that’s something we drive home to the families, that there’s a solution to this thing. We’re not going to leave you like this, we can fix this. There are a number of escalating things we do, but we will make them continent.
Carlos Estrada, MD, Myelodysplasia Program, Department of Urology