How Do You Categorize Bladder Dysfunction?

Patient Presentation
A 9-month-old female came to the emergency room with with runny nose and fever to 101° F
for 2 days. She was found to have a left otitis media and was treated with amoxicillin.
She did well with resolution of the fever and improvement of the rhinorrhea, but then had a fever to 103° F on day 4. Her parents brought her back to the emergency room. The laboratory evaluation found a white blood cell count of 10.3 x 1000/mm2 with bands of 8%, and a urinalysis that was leukocyte esterase positive with 45 white blood cells/high powered field.
She was admitted to the floor for presumed pyelonephritis and possible bacteremia.
The past medical history showed a normal prenatal history and birth. She had no prior urinary tract infections.
The family history was negative for kidney or otologic disease.
The review of systems was negative, and she was drinking and urinating well.
The pertinent physical exam showed a tired-appearing infant with growth parameters in the 25-50%, whose temperature was 38.2° C, pulse of 118, respiratory rate of 42 and blood pressure of 95/60.
HEENT revealed a mild amount of serous fluid in the left ear with normal mobility and slightly splayed light reflex and mild rhinorrhea. Lungs, heart and abdomen were normal. She had normal genitalia.
The laboratory evaluation included blood and urine cultures which were negative presumably because she had received the amoxicillin. The C-reactive protein was 3.8 mg/dl, BUN was 10, and creatinine was 0.4 mg/dL.
The radiologic evaluation included an ultrasound of the kidneys during hospitalization which showed right hydronephrosis.
The patient’s clinical course showed she was clinically improving over two days and became afebrile. She was discharged on treatment doses of trimethoprim-sulfamethoxazole and then prophylactic doses.
Two weeks later, she had a voiding cystourethrogram which showed vesiculoureteral reflux and significant chronic changes to the bladder similar to a neurogenic bladder.
The diagnosis of right hydronephrosis with chronic bladder changes was made. The patient was referred to urology for further evaluation and magnetic resonance imaging study of the spine was also ordered. She is continuing her trimethoprim-sulfamethoxazole while she awaits further evaluation.


Figure 50 – Sagittal ultrasound image of the right kidney shows a mild to moderate amount of hydronephrosis.


Figure 51 – Supine spot film of the abdomen taken during a voiding cystourethrogram demonstrates right grade 2 vesicoureteral reflux. Note the bumpy, trabeculated contour of the bladder, signifying the presence of a neurogenic bladder. The right ureter was felt to insert into one of these bladder trabeculations / diverticuli.

Discussion
Normal micturition is a complex process divided into two phases: filling (and storage) and voiding. During normal micturition, the urethra and bladder neck gradually open, the detrusor muscle of the bladder contracts and the urine flows.
This is coordinated in the pontine micturition center and through nerves in T10-L2 and S2-S4.

Therefore any abnormalities of the brainstem, and much of the spinal cord may cause bladder dysfunction. An incoordination of the normal micturition process also causes bladder dysfunction.
Micturition is a normal developmental process which usually concludes in school-age children.

Learning Point
The differential diagnosis of bladder dysfunction is first categorized on the presence or absence of identifiable neurological or anatomical abnormalities.
If no abnormalities are identifiable, then the bladder dysfunction is further categorized based upon which phase of micturition process is abnormal.

  • Normal developmental process
    • Nocturnal enuresis
    • Diurnal enuresis
  • Neurogenic bladder dysfunction
    Definition: neurological, musculoskeletal and/or anatomical abnormalities are identifiable
    Patients are at risk for incontinence, urinary tract infections, vesicoureteral reflux and constipation

    Causes of neurogenic bladder include:

    • Meningomyelocoele
    • Tethered cord
    • Sacral anomalies
    • Spinal cord or brainstem infection, trauma or tumor
    • Muscular dystrophy

  • Non-neurogenic bladder dysfunction or functional incontinence
    Definition: neurological, musculoskeletal and/or anatomical abnormalities are not identifiable but due to functional deficits.
    • Defects during the micturition filling phase
      • Urge syndrome and urge incontinence

        • Clinically: Frequent urgent need to void with voluntary contraction of the pelvic floor muscles
        • Physiologically: Detrusor overactivity during filling phase causes urgent need to void with voluntary contraction of the pelvic floor muscles to counter the voiding
        • Voiding phase is normal
    • Defects during the micturition voiding phase
      • Dysfunctional voiding
        • Clinically: incontinence, urinary tract infections and constipation are common presentations
        • Physiologically: poor coordination or dysfunction of the contraction of the bladder and relation of the pelvic floor muscles. This could be caused by an overactive bladder or learned condition
      • Staccato voiding
        • Clinically: has prolonged urination times and may have residual urine
        • Physiologically: intermittent bursts of pelvic floor activity during voiding
      • Fractionated voiding
        • Clinically/Physiologically: incomplete and infrequent voiding, ie. voiding in different fractions, bladder volumes are large and usually has residual urine
      • Lazy bladder syndrome
        • Clinically: infrequent voiding and urinary tract infections, possibly overflow incontinence
        • Physiologically: increased bladder capacity with no detrusor contraction during voiding. Voiding is accomplished by abdominal pressure.

Questions for Further Discussion
1. What are the treatment options for neurogenic bladder?
2. What are the treatment options for non-neurogenic bladder?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Urinary Incontinence and Bladder Diseases.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Nijman RJ. Neurogenic and non-neurogenic bladder dysfunction. Curr Opin Urol. 2001 Nov;11(6):577-83.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:538-539.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement

    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    August 20, 2007