If the child is still having urinary infections, they’re evaluated with a number of tests to see what might have caused the infections. If infection continues, other studies are done to look for anatomic reasons for the repeated infection or the persistent wetting. Then drug therapy is added to the catheterization program in order to achieve continence or prevent infection. In children with normal neurological function, it’s rare that surgical intervention is needed. More likely, additional medication is added to help achieve the level of continence we’d like to see.

Stuart Bauer, MD, Department of Urology

 

Children can leak for a variety of reasons: because their bladders are too small, because their bladders are a good size but too high-pressure, because their bladders are overactive, or any combination of these. I just saw a child with a great bladder, but his outlet resistance was extremely poor, so patient will require a procedure at the bladder neck level to tighten up his outlet resistance.

Sometimes it’s as simple as inefficient catheterization. Often we re-teach families to be sure they’re catheterizing well. Some children, especially when they become more independent, will do it like kids do everything: kind of quick. They pop it in, they drain, get a little impatient, and remove the catheter prior to the bladder being completely empty. If it seems that everything should be okay but isn’t, you have to think, “Maybe they’re not catheterizing well enough, they’re not waiting long enough to empty the bladder fully and that’s why they’re leaking.”

Whenever you’re faced with incontinence, there is a lot of homework to be done to figure out why. But the good news is, for just about everything, there is a solution. We can make you dry. We can achieve urinary continence one way or the other, so that’s reassuring to families. But it all begins with intermittent catheterization.

Carlos Estrada, MD, Myelodysplasia Program, Department of Urology

 

Many of the drugs used to manage the bladder are called anticholinergics, and they’re actually used for the side effect of being able to slow down smooth muscle contractions so the bladders can hold urine for longer periods of time. You might get the bladder to slow down its contractions so it doesn’t leak, but you need to make sure you’re able to empty the bladder, hence the need to catheterize. However, these medicines have a side effect of constipation, and this can set a kid over the edge, to being really uncomfortable and impacted. That affects their ability to empty, to catheterize with ease, and it also can contribute to chronic urinary infections. In cases like this, we have a few things up our sleeve. We stay in communication with our parents and our pediatricians. We will put the kids on routine urine cultures if it’s indicated. Many of our boys and girls are on chronic prophylactic antibiotics. We work hard to communicate with our physician staff about whether patients with positive cultures should be treated, depending on symptomatology. We work with pharmacies in the area, because we have boys and girls on an antibiotic instillation program, where they actually instill antibiotics into the bladder. It keeps the bladder clean and helps decrease symptomatic urinary infection. Treating constipation, urinary infection, and wetting involves a lot of telephone outreach to parents to break everything down and remind them that you can’t put a problem on the shelf because it’s going to set off a bad cycle.

Rosemary Grant, RN, Nurse

 

There are a lot of kids who cath all the time who have issues with leaking, and then you have to figure out how to manage that. What else is going on? Is it a sign of worsening neurological status? Is it related to something else? Is there an infection that’s causing the leaking despite all their good care? Just cathing doesn’t mean you’ll stay dry.

If there’s leaking, we’ll get a urine culture and see if they have a UTI. If there are other symptoms (changes their lower extremity function, changes in bowel habits), we might consider a neurosurgical evaluation, check to see if they’ve had a recent MRI, have they grown, is there potential for tethering of the cord which could be making things worse? And sometimes it’s a compliance problem. In that case, it’s just more education about how important it is to do this, and it will make things better for them.

Rebecca Sherlock, PNP, Clinical Coordinator, Myelodysplasia Program