**2. Management of bladder storage and voiding symptoms**

Lower urinary tract manifestations are divided into two groups: storage and voiding symptoms. Storage symptoms appear as an alteration in the filling phase of the micturition cycle. These symptoms include: increased voiding frequency, urgency, nocturia, urinary incontinence, and painful bladder syndrome.

Voiding symptoms appear as a difficulty during urination or prior to the onset of it. They include: difficulty to initiate urination, need to strain or effort to initiate and maintain urination, weak or intermittent urinary stream, terminal drip, dysuria and urgency. These symptoms result in incomplete voiding.

The primary goal of treatment is to preserve upper urinary tract function, improve continence, and improve quality of life in these patients. [5]

#### **2.1 Storage management**

In the scenario of the neurogenic patient associated with spinal dysraphism, the main complaint reported by patients is urinary incontinence, accompanied or not by urinary infections. Urinary incontinence can be explained by several pathophysiological mechanisms. Urodynamics is a useful tool that provides objective diagnostic information that allows us to know the specific cause of incontinence.

Treatment includes behavioral measures such as control of fluid intake and personal hygiene. The use of medications should always be combined with conservative measures. The aim of these drugs is to increase bladder capacity and decrease detrusor pressure. Anticholinergics (also named antimuscarinics) are the most commonly used drugs. Its efficacy has been demonstrated in neurogenic patients with urge urinary incontinence associated with an overactive detrusor. Beta 3 agonists are another option that was recently introduced. The efficacy of these drugs appears to be similar to anticholinergics with a non-inferior safety profile. The response to these medications is evaluated with the clinical control of incontinence, as well as an improvement in bladder capacity objectively observed by a decrease in detrusor pressure of less than 40 cmH2O when having a maximum bladder capacity in urodynamics. [5, 6]

#### **2.2 Voiding symptoms**

These patients are at a higher risk of presenting high filling pressures, which generates vesicoureteral reflux, resulting in dilatation of the upper urinary tract and deterioration of renal function. Chronic retention and reflux to the upper tract are conditions that increase the risk of urinary infections. Management focuses on improving and maintaining detrusor pressure below 40 cmH2O and control of urinary incontinence.

The use of clean intermittent catheterization as a mechanism for bladder emptying is considered the treatment of choice in the vast majority of neurogenic patients with evidence of urine retention. This treatment aims to adequately empty the bladder and thereby reduce urinary infections and incontinence. The use of an indwelling transurethral or suprapubic catheter should be avoided due to the demonstrated risks of recurrent urinary tract infections, stone formation, and urethral trauma [6] (**Figure 2**).

**81**

colonization. [10]

classification: [11].

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

**3. Follow-up protocol according to age**

are complex and the decisions may vary. [7]

ergic treatment and intermittent catheterizations. [8]

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

c) Treatment of symptomatic urinary infections.

management may be allowed.

improve bladder-sphincter coordination during urination. [5]

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

In patients where a functional voiding alteration is confirmed with dysfunction of the relaxation of the sphincter in the emptying phase of the micturition cycle, they can benefit from physiotherapy and biofeedback, which consist of training to

The main priority at the moment of birth is the closure of the spinal defect, as neurological complications are the main cause of morbidity and mortality during the first year of life; followed by urological complications. Specialized treatment centers state that the urological management should start immediately with intermittent catheterizations and anticholinergic medications due to the risk of collagen deposition in the bladder wall and consequent increased risk of upper urinary tract damage. In fact, each of the steps toward the management of this congenital disease

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 anticholin-

If no abnormal findings during this first 2-year follow-up are seen, an expectant

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

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

By performing urodynamic tests, the type of functional disturbance of the bladder may be assessed and classified in 4 types according to the Madersbacher

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.

**Figure 2.** *Clean intermittent catheterization technique in male and female.*

In patients where a functional voiding alteration is confirmed with dysfunction of the relaxation of the sphincter in the emptying phase of the micturition cycle, they can benefit from physiotherapy and biofeedback, which consist of training to improve bladder-sphincter coordination during urination. [5]
