**3.1 Management from the moment of birth to the age of two years**

A sonographic evaluation of the upper urinary tract as well as urine cultures are performed every 3 to 4 months. If both tests are normal, we wait until the age of 2 years, the age expected for most children to achieve voluntary control of micturition. In case of abnormal findings during any of the sonographic evaluations or 3 or more positive cultures accompanied with symptomatic infections during a year or less are encountered, it would be necessary to perform urodynamic testing complemented with a cystogram to discard any possibility of upper urinary tract damage due to a hostile bladder. If this is the case, it is time to start the adequate anticholinergic treatment and intermittent catheterizations. [8]

If no abnormal findings during this first 2-year follow-up are seen, an expectant management may be allowed.

### **3.2 Management from the age of two years to 20 years**

Expectant management is modified to active management. Treatment goals are as follows: a) Avoidance of renal damage, b) Preservation of continence and c) Treatment of symptomatic urinary infections.

The first step is the functional evaluation by urodynamics and a structural evaluation with a cystogram. Videourodynamics is the Gold Standard as they are capable of evaluating both parameters. [9] A family member should be trained to perform clean intermittent catheterizations, so when the patient reaches the age of 6 years, this information should be passed onto the child to start self-intermittent catheterizations. We conducted a clinical trial in which we observed that intermittent catheterizations with clean technique using re-sterilized catheters did not increase neither the risk of urinary tract infection, nor bladder bacterial colonization. [10]

By performing urodynamic tests, the type of functional disturbance of the bladder may be assessed and classified in 4 types according to the Madersbacher classification: [11].

Type 1: High bladder pressure. High sphincter pressure.

Type 2: High bladder pressure. Low sphincter pressure.

Type 3: Low bladder pressure. High sphincter pressure.

Type 4: Low bladder pressure. Low sphincter pressure.

The risk of upper urinary tract damage is higher when Madersbacher type 1 and type 3 bladders are encountered. After identification of the bladder type, anticholinergic treatment should be started to normalize increased pressures. Three months after beginning of treatment, follow-up with a new urodynamic test is performed to assess the improvement of urodynamic parameters and clinical status.

The morphology of the bladder and the presence of vesicoureteral reflux (VUR) are assessed with a cystogram. The risk of vesicoureteral reflux in patients with neurogenic bladder is up to 17%. When VUR is observed, it is important to measure the detrusor pressure; if a pressure greater than 40 cmH20 is found, before thinking of any surgical treatment such as ureteral reimplantation, an attempt is made to decrease these pressures with conservative treatment. In case of success, a new evaluation is made to reassess if RUV disappeared (**Figure 3**) [12].

After functional and structural evaluation, proper bladder classification and having started initial treatment, the second stage of management is continued. Follow-up is made with urine cultures every 3 months, renal sonography every 6 months and renography every 1 to 3 years. Regarding the urodynamic test, when the detrusor pressure is greater than 40 cmH2O, the medical treatment is modified and a new urodynamic test is performed 3 months after, this is done until the goal of detrusor pressure of less than 40 cmH2O is achieved [13].

When to perform a new urodynamic test? 1) When there is less than 90% of voluntary micturition control. 2) When a new morphologic or functional disturbance of the kidney is observed. 3) Five years after the last urodynamic study. During this time, the type of neurogenic bladder could be modified due to the morphologic changes of growth and its effect on spinal cord. [14]

#### **3.3 Management from the age of 21 years and over**

When entering this stage, the patient is more aware of the disease and is more organized in its management. The bladder type usually reaches a stable state, and it is uncommon for the neurogenic bladder type to change. If this happens, it is important to evaluate the possibility of having a neurological disturbance that could need primary treatment.

**83**

*Urologic Implications and Management in Spina Bifida DOI: http://dx.doi.org/10.5772/intechopen.94938*

age ranges:

treatment. [16]

no antibiotic treatment.

vulnerable to damage. [18]

< 15 years: 311 (29.5%) 16–29 years: 572 (54.2%) >30 years 172 (16.3%) Total: 1055 (100%)

tion of oxybutynin, from the oral to the intravesical route. [15]

deciding which procedures are the most adequate for them.

**4. Urinary tract infections, when to treat?**

Mexico, where we presently have 1055 patients enrolled with the following

By this age, intermittent catheterizations are usually mastered by the patient and clinical signs that could be suspicious of active infection are well identified. Other topics, such as sexuality and reproduction are approached. Reproduction methods are informed and instructed; recommendations are given to women who wish to reproduce, such as folic acid intake and modifications on the route of administra-

On November 23rd of 1993, we founded the Spina Bifida Association in Moterrey,

A total of 472 (44.7%) patients assist with relative frequency (At least 3 consultations per year). Our experience has been forged working with the everyday management of our patients during 26 years, assessing their progression and

Patients with neurogenic bladder due to spinal dysraphism have several factors that potentially increase the risk of urinary tract infections, such as, vesico-ureteral reflux (any grade), hypertonic bladder and foreign bodies inside the bladder. Schlager et al. observed that 70% of patients that perform intermittent bladder catheterizations present asymptomatic bacteriuria 24 weeks after the beginning of

In patients with neurogenic bladder, including those secondary to myelomeningocele, urinary tract infections should be considered differently from those without any neurofunctional disease. The presence of bacteriuria within this group of patients is very common and unnecessary antibiotic treatment could be given if there is no acknowledgment of these facts. This could lead to future complications

In patients performing intermittent bladder catheterizations, urine culture results with more than 10,000 CFU/ml are considered a clinical infection only when one or more of the following clinical features are present: foul smell, cloudy urine, fever of 38°C or more and abdominal or flank pain. [17] Positive urine culture without other clinical features is considered as bacterial colonization and requires

When deciding which antibiotic to prescribe, it is important to consider which antibiotics show the highest resistance within a community, which option would be delivered at adequate concentrations to the urinary bladder, this depending on the kidney's capacity to eliminate the active drug, and which would be more suitable to eliminate infection. It is important to ponder these considerations before antibiotic administration, as damage to the renal parenchyma may develop in a kidney already

Among the behavioral methods that help us in the prevention of urinary tract infections we include: Adequate liquid intake, maintenance of low postvoid urine

Intermittent bladder catheterization is a risk factor that predisposes to infection. There is no significant difference in the prevention of urinary tract infections when comparing the sterile technique with the clean technique, as well as with the use

that develop due to antibiotic resistance and antibiotic side effects.

and short time periods between intermittent catheterizations.

#### **Figure 3.**

*Diagnostic and therapeutic algorithm in neurogenic bladder with vesico-ureteral reflux.*

*Urologic Implications and Management in Spina Bifida DOI: http://dx.doi.org/10.5772/intechopen.94938*

By this age, intermittent catheterizations are usually mastered by the patient and clinical signs that could be suspicious of active infection are well identified. Other topics, such as sexuality and reproduction are approached. Reproduction methods are informed and instructed; recommendations are given to women who wish to reproduce, such as folic acid intake and modifications on the route of administration of oxybutynin, from the oral to the intravesical route. [15]

On November 23rd of 1993, we founded the Spina Bifida Association in Moterrey, Mexico, where we presently have 1055 patients enrolled with the following age ranges:

< 15 years: 311 (29.5%) 16–29 years: 572 (54.2%) >30 years 172 (16.3%) Total: 1055 (100%)

A total of 472 (44.7%) patients assist with relative frequency (At least 3 consultations per year). Our experience has been forged working with the everyday management of our patients during 26 years, assessing their progression and deciding which procedures are the most adequate for them.

### **4. Urinary tract infections, when to treat?**

Patients with neurogenic bladder due to spinal dysraphism have several factors that potentially increase the risk of urinary tract infections, such as, vesico-ureteral reflux (any grade), hypertonic bladder and foreign bodies inside the bladder. Schlager et al. observed that 70% of patients that perform intermittent bladder catheterizations present asymptomatic bacteriuria 24 weeks after the beginning of treatment. [16]

In patients with neurogenic bladder, including those secondary to myelomeningocele, urinary tract infections should be considered differently from those without any neurofunctional disease. The presence of bacteriuria within this group of patients is very common and unnecessary antibiotic treatment could be given if there is no acknowledgment of these facts. This could lead to future complications that develop due to antibiotic resistance and antibiotic side effects.

In patients performing intermittent bladder catheterizations, urine culture results with more than 10,000 CFU/ml are considered a clinical infection only when one or more of the following clinical features are present: foul smell, cloudy urine, fever of 38°C or more and abdominal or flank pain. [17] Positive urine culture without other clinical features is considered as bacterial colonization and requires no antibiotic treatment.

When deciding which antibiotic to prescribe, it is important to consider which antibiotics show the highest resistance within a community, which option would be delivered at adequate concentrations to the urinary bladder, this depending on the kidney's capacity to eliminate the active drug, and which would be more suitable to eliminate infection. It is important to ponder these considerations before antibiotic administration, as damage to the renal parenchyma may develop in a kidney already vulnerable to damage. [18]

Among the behavioral methods that help us in the prevention of urinary tract infections we include: Adequate liquid intake, maintenance of low postvoid urine and short time periods between intermittent catheterizations.

Intermittent bladder catheterization is a risk factor that predisposes to infection. There is no significant difference in the prevention of urinary tract infections when comparing the sterile technique with the clean technique, as well as with the use

of a sterile catheter compared to a reused clean catheter; furthermore, the risk of colonization is the same between both techniques. [19]
