Neurogenic bladder in children

The term "neurogenic (or neurogenic) bladder" includes a number of filling disorders and / or emptying of the bladder, resulting from a violation of the mechanisms of regulation of their nervous system. This is a very common pathology: 10 children out of 100 suffer from it. And even if in most cases the neurogenic bladder does not pose a threat to the life of the child, the quality of his life is substantially decreases: spontaneous urination causes discomfort, causes complexes and difficulties in communicating with peers. In addition, complications can develop which it will be very difficult to eliminate.

Consequently, a neurogenic bladder is not a disease that "goes away" with time; it requires an early comprehensive treatment. About why and how this pathology manifests itself, as well as the principles of its diagnosis and treatment, we'll talk about this in our article. Let's start ...

Basics of anatomy and physiology

The bladder is a hollow organ of a pear-shaped form located in the small basin with a base upward. In fact, it plays the role of a reservoir for urine. Has a wide body and narrow neck. In the body fall into two - the left and right - the ureter, and the cervix passes into the urethra. The smooth muscle wall of the bladder, which ensures its contraction, is called "detrusor", and the muscle pulp, located in the neck, is called the sphincter.

Urine is formed in the kidneys, then it enters the bladder through the ureters, where it accumulates, and when the amount becomes large enough, an act of urination occurs. Let us consider in more detail the phases of accumulation and emptying of the bladder.

Accumulation phase

Detrusor is very elastic and during the accumulation of urine is relaxed - is in a passive state. The sphincter, on the contrary, is firmly compressed - it creates a high urethral resistance, which blocks the exit of urine from the bladder. Urethral resistance, in addition to the sphincter apparatus, is provided by the muscles of the small pelvis, the so-called pelvic diaphragm.

In the muscles of the neck of the bladder are α-adrenoreceptors, which, interacting with the hormone norepinephrine, cause a reduction in the sphincter musculature.

On the surface of the smooth muscles of the bladder are β-adrenoreceptors, with the interaction of norepinephrine with which the detrusor relaxes, providing the accumulation of urine in the bladder.

Emptying phase

When the bladder is full, the person senses this and by strong-willed effort reduces the detrusor, which is accompanied by relaxation of the sphincter and emptying the bladder.

Newborns and children of the first year of life can not control urination: they are carried out involuntarily. This is due to the fact that at an early age the reflex arc closes only at the level of the spinal and midbrain, and cortical and subcortical control of the act of urination is absent. The child grows, the capacity of his bladder increases, gradually gaining control over the sphincter, the urethra The reflex is inhibited by the involvement of cortical and subcortical centers, the frequency of urination decreases. Full cortical control over the act of urination kid gets to 2.5-3 years, but already from one and a half years he feels the filling of the bladder and begins to ask for a pot.

Symptoms of a neurogenic bladder are manifested when control of urination is already formed - usually starting at three years old.

Causes of a neurogenic bladder

This pathology arises as a consequence of the violation of the nervous regulation of urination at one or more levels: peripheral, spinal, cortical. As a result of these disorders, the ratio and the degree of activity of the detrusor and the external sphincter of the bladder change, the patient has some complaints.

The following diseases can cause the development of a neurogenic bladder in children:

• congenital malformations of the central nervous system;
• trauma to the nervous system, including birth trauma;
• malignant and benign neoplasm of the spine;
• spinal hernia;
• cerebral palsy;
• encephalitis;
• neuritis;
• underdevelopment of the sacrum and coccyx;
• dysfunction of the autonomic nervous system;
• weakness of reflex, controlling urination;
• hypothalamic-pituitary insufficiency.

It is proved that female sex hormones - estrogens - increase the sensitivity of smooth muscle receptors of the bladder. That is why the diagnosis of "neurogenic bladder" is exhibited more often than girls, rather than boys.

Classification

In terms of severity, neurogenic bladder dysfunctions are divided into 3 types:

• lungs (a syndrome of frequent daytime urination, stress urinary incontinence, bedwetting);
• of moderate severity (lazy bladder syndrome, hyperreflexive bladder);
• Heavy (syndrome Ochoa and Hinman).

Depending on the nature of the change in the vesicle reflex, one distinguishes:

• hyporeflexive urinary bladder (this disorder occurs when the neurological disorders in the sacral region are localized, the essence of the disorder is in that the filling phase is extended, and the emptying phase does not occur; The bladder stretches to large sizes, the urine in it is delayed, the bladder can collect up to 1.5 l of urine; often the urine in the bladder becomes infected, or it rises to the kidneys in the ureters, provoking the development of the inflammatory process in them);
• hyperreflex urinary bladder (occurs when the pathological process is localized in the central nervous system, urine does not accumulate in the urinary a bubble, and, getting into it, immediately stands out - the urge to urinate occurs frequently, and the portions of the urine released in this case are very small);
• areplectory urinary bladder (conscious urination is impossible, urine accumulates in the bladder to the maximum possible age, after which there is spontaneous urination).

Symptoms

Clinical manifestations of the neurogenic bladder in children are all kinds of disorders of urination, the severity of which depends on the severity of the disease, against which they arose.

Manifestations of the hyperactive (hyperreflex) urinary bladder are as follows:

• frequent (8 times a day or more) urination;
• imperative (sudden, urgent) urge to urinate, forcing the child to run urgently to the toilet;
• small volume of excreted urine;
• night and / or daytime urinary incontinence;
• the accumulation of sufficient volume of urine in the bladder with this form is impossible.

The signs of the hypotonic (hyporeflective) urinary bladder are:

• extremely rare (1-3 times a day) urination;
• large (up to one and a half liters) volume of excreted urine;
• languid urination;
• a feeling of incomplete emptying of the bladder (on examination it is found that up to 400 ml of residual urine remains after it is emptied).

Syndrome of daytime frequent urination. Manifestations of it are:

• sudden urge to urinate every 15-20 minutes;
• act of emptying the bladder painless;
• symptoms last from two days to two months and regress themselves.

Lazy bladder is characterized by a combination of rare urination with urinary incontinence, urinary tract infections, and constipation.

Stress incontinence is typical for teenage girls. With this form of disorder during exercise, they note spontaneous excretion of small portions of urine.

Urinary incontinence with laughter is also common among girls of the puberty period. During intense laughter, involuntary urination from small portions to complete emptying of the bladder is noted.

In the postural neurogenic bladder, involuntary urination occurs in the daytime after the body moves to a vertical position from the horizontal position. Urination at night is not disturbed.

Night enuresis. It occurs more often in boys. Characterized by spontaneous urination during sleep.

For Hinman's syndrome are characteristic:

• urinary incontinence day and night;
• recurrent urinary tract infections;
• chronic constipation;
• spontaneous defecation;
• absence of neurologic pathology and abnormalities of the urinary tract at any level;
• in mental status - lack of individuality.

Ochoa Syndrome:

• characterized by hereditary predisposition;
• develops more often in boys aged 3 months - 16 years;
• manifested by day and / or night spontaneous urination, chronic constipation, urinary tract infections;
• the probability of development of complications is high - symptomatic arterial hypertension and chronic kidney disease.

Violation of the innervation of the bladder, at whatever level it is, leads to significant violations of it nutrition, which explains the frequent interstitial cystitis developing against the background of a neurogenic bladder. The outcome of this cystitis is the replacement of inflamed connective tissue (or sclerosing) and wrinkling of the bladder. Also, complications of the disorder described by us are chronic pyelonephritis, hydronephrosis, nephrosclerosis and chronic kidney disease.

Diagnosis of a neurogenic bladder

A child with suspected disability is subject to a comprehensive examination.

Based on the complaints of the child and / or parents, the history of the disease and life, the objective diagnosis, the doctor will suspect the disease. Confirm it, he can on the basis of the results of laboratory and instrumental research methods. Patients with suspected neurogenic bladder may be assigned the following diagnostic methods:

• general blood analysis;
• blood chemistry;
• general urine analysis;
• urine test for the presence of bacteria;
• a study of urine in Zimnitskii;
• urinalysis by Nechiporenko;
• Ultrasonography of kidney and bladder with determination of residual urine volume;
• Mictional and conventional urethrocystography;
• urography (review and excretory);
• ascending pyelography;
• overview radiography of the abdominal cavity;
• magnetic resonance and computed tomography;
• cysto- and ureteroscopy;
• kidney scintigraphy;
• urofluometry;
• retrograde cystometry;
• sphincterometry;
• urethral profilometry;
• electromyography;
• consultations of neurologist, psychologist, urologist, nephrologist.

In addition, it is necessary to track the number and volume of urination per day, registering their time. It should be borne in mind that the drinking and temperature regime with this study should be comfortable.

If a suspected organ pathology of the central nervous system is suspected, the patient may be assigned:

• electroencephalography;
• echoencephalography;
• radiography of the skull;
• radiography of the spine;
• CT or MRI of the brain or spinal cord.

Treatment

Methods of treatment of a neurogenic bladder are divided into:

• non-pharmacological;
• medicamentous;
• surgical.

Let us consider each of these directions in more detail.

Non-drug therapies

This type of therapy is characterized by a minimum of side effects and the possibility of combining it with other methods of treatment.

The main directions of non-drug treatment are:

• protective regime with full night sleep and extra daytime (for 60-120 minutes), lack of active games before bed and elimination of factors that hurt the child's psyche;
• walks in the open air;
• compliance with patients with a previously established mode of urination; gradual increase in the interval between them;
• regular use of the Kegel exercise complex (to strengthen the pelvic muscles);
• physiotherapy (laser exposure, hyperbaric oxygenation, drug electrophoresis, diadynamic therapy, amplipulse therapy, heat treatment, ultrasound, electrostimulation of the bladder);
• psychotherapy.

Medication

Depending on the type of neurogenic urination disorder, combinations of the following drugs can be used to correct it:

• anticholinergic agents (atropine, oxybutynin, ubretid, detrusitol, propiverin);
• cholinomimetics (acetylidine, distigmine bromide, galantamine);
• inhibitors of prostaglandin synthesis (indomethacin, flurbiprofen);
• tricyclic antidepressants (melipramine);
• nootropics (picamilon, pantogam);
• amino acids (glycine, glutamic acid);
• calcium antagonists (nifedipine);
• phytopreparations (preparations of the root of the peony, valerian, motherwort);
• desmopressin;
• vitamins of group B, PP, A, E in the form of tablets or injections;
• adaptogens (extract of ginseng, eleutherococcus, magnolia vine);
• correctors of immunity (levamisole).

The above drugs, as a rule, prescribe courses for 1-1.5 months after 1-1.5 months. If the patient is shown taking a large number of drugs, their simultaneous reception is undesirable - they should be assigned consistently.

To reduce the tone of the wall of the bladder, it is possible to inject botulinum toxin, capsaicin, and resincratoxin into its wall.

In the case of a large volume of residual urine with a hypotonic urinary bladder, the patient is occasionally catheterized.

As agents for the treatment of urinary tract infection, broad-spectrum antibiotics (eg cephalosporin groups) are used. uroseptics (furagin, nalidixic acid), complex preparations of plant origin (kanefron, trinefron). To prevent recurrence of infection, after the abatement of acute symptoms, supportive therapy is prescribed with the same drugs in small doses for 30-45 days.

Surgery

This direction of therapy of the neurogenic bladder is used in cases where conservative methods are ineffective, or with the existing organic causes that caused micturition disorders.

As a rule, surgical interventions are performed using endoscopic techniques and are performed in the following volume:

• implantation of collagen in the ureter's mouth;
• transurethral resection of the neck of the bladder;
• Operation on the ganglia involved in the regulation of the act of urination.

In addition, an operation to increase the volume of the bladder can be performed.

Prognosis and prevention

The prognosis is favorable provided timely diagnosis and adequate treatment of urinary disorders.

A measure of primary prevention of a neurogenic bladder is the prevention of the development of diseases against which urinary disorders develop. To prevent the development of complications, it is necessary to start complex treatment of the neurogenic bladder in children in a timely manner.

Children with this diagnosis should be on a dispensary record with the control of urine tests every 3 months and against a background accompanying diseases, the control of a mode of an emiction, carrying out of US of urinary ways 1 time a year.

N. A. Ermakova, a urologist, talks about what a neurogenic bladder is: