Neurogenic bladder and urinary incontinence in children Overview of neurogenic bladder The dysfunction of urine storage and voiding in the bladder and lower urinary tract caused by damage to the central or peripheral nerves that control urination is called neurogenic bladder dysfunction, also known as neurogenic bladder. Neurogenic bladder severely affects the social life of patients, and in some patients this can eventually lead to renal failure and death. The basic function of the bladder is to store and pass urine, and the bladder relies on the detrusor and sphincter muscles (equivalent to a switch) to perform both functions under normal neurological control. During normal urination, the detrusor muscle contracts and the sphincter muscle opens to expel urine to the outside of the body. In pathological states, damage to the nerves that innervate the bladder’s forceps can cause bladder paralysis in the form of either no contraction or contracture, with the former primarily causing loss of power to urinate and the latter causing the bladder to hold only a small amount of urine. Damage to the nerves that innervate the sphincter can cause the sphincter to be either non-contractile and continuously open, which prevents the bladder from storing urine, or spastic and closed, which prevents urine from being expelled. Because the nerves innervating the bladder forceps and sphincter are relatively separate, and there is complete and incomplete damage to the nerves, the types of neurogenic bladder are complex and varied, and their treatment varies or even diverges. Overall, there is still a lot of uncharted territory regarding the mechanisms of bladder innervation, physiological functions and pathological states of the disorder. For example, the mechanism of voiding initiation, the innervation of the various parts of the bladder and their functional synergy, etc., and a more scientific classification of neurogenic bladder was established only recently. Currently, the knowledge of neurogenic bladder is still very unpopular and its treatment is still difficult in this country as well as worldwide. Normal development of bladder control in the pediatric population The bladder is autonomic at birth, i.e., there is no voluntary conscious voiding, and the bladder is completely filled to a certain level with spontaneous contractions of the detrusor muscle to empty the bladder. Within one year after birth, bladder sensation begins to develop, which is reflected in the child’s obvious discomfort when holding urine, and a comfortable state after emptying. The number of urinations per day gradually decreases from 20 times per day at birth to about 10 times per day, and this urination condition is maintained until about 2 years of age. Toddlers between the ages of 2 and 4 years old begin to develop true bladder control, with the first signs of bladder control occurring around 18 months of age, namely the ability to control and hold urine for an appropriately long period of time. Because urinary control requires not only neurological maturity, but also a certain level of understanding to work with their parents to train them in toileting. A child has good urinary control if he or she can feel a full bladder or an empty bladder, or if he or she can hold urine for a longer period of time if needed. The final step in the development of urinary control is the ability to initiate the urination reflex on his or her own at any time if needed. By about 4 years of age, most children have basic urinary control in addition to the ability to initiate urination on their own. In general, the developmental sequence of voiding control is: first nocturnal stool control, then daytime stool control, then daytime urinary control, and finally nighttime urinary control. Urinary training should be completed for preschool (4 to 6 years of age) children. Occasional daytime incontinence is not uncommon at this time, but is mostly due to the child’s poor decisive ability, as the child is often unable to determine whether the bladder is holding urine to its limit, and eventually develops urge incontinence due to overfilling of the bladder inducing uninhibited contraction of the detrusor muscle. As children become more mature mentally and physically, the ability to control urine will also become more refined. School-aged children should have good urinary control and be able to follow the school routine. If incontinence continues to occur repeatedly, the child should be seen for further investigation. Neurogenic bladder in children Children with urinary incontinence often first consult a primary care general practitioner or pediatrician, but the causes of pediatric incontinence are complex and involve many departments, such as neurology, urology, and orthopedics, making it difficult for primary care physicians and pediatricians to properly manage them. Nocturnal enuresis in children is mostly associated with poor voiding training, and most children can be treated well with behavioral training and appropriate adjunctive medication. However, in the presence of significant daytime enuresis or incontinence, one should be alert to the possible presence of organic disease causing neurogenic bladder. Common causes of pediatric urinary incontinence include neurogenic bladder, urinary tract infections, psychological stimulation, enuresis, and urinary tract malformations. Common diseases causing neurogenic incontinence can be divided into congenital and acquired. The main congenital diseases are spina bifida and spinal cord embolism syndrome, etc.; acquired diseases mainly include spinal cord injury, spinal cord tumor, post-pelvic surgery, and myelitis, etc. Neurogenic bladder caused by spina bifida, spinal cord embolism syndrome, and spinal cord tumor is a condition that requires joint management by neurosurgery and urology. Spinal cord embolism surgery is completed by neurosurgery, and then urology follows the patient after surgery to prevent neurogenic bladder from impairing renal function. Purpose and Principles of Urologic Management Neurosurgical procedures can address to some extent the factors that cause ongoing damage to the spinal cord from spina bifida, but they do not necessarily restore pre-existing neurological dysplasia or damage. As the child grows, spinal cord embolism caused by adhesions of the spinal cord ends and nerve roots to surrounding tissues is the primary cause of neurogenic bladder in spina bifida. In infancy, urinary incontinence due to neurological damage is often difficult to take seriously unless significant neurological disease is present. A significant proportion of children with vesicourethral dysfunction result in elevated intravesical pressure, chronic hypertensive bladder, and vesicoureteral reflux, recurrent urinary tract infections, dilatation of the upper urinary tract, and even renal failure. Therefore, children with spina bifida should be strictly followed up regardless of the presence or absence of urological symptoms and whether or not the parents of the child can recognize urinary incontinence as a problem, so that possible vesicoureteral dysfunction can be detected in a timely manner and treated as early as possible to preserve bladder storage function and renal function. Parents should be made to understand that the symptoms of urinary incontinence in children with spina bifida are only one manifestation of a complex urinary disease, and that in fact there are more serious renal, bladder, and urethral dysfunctions behind the incontinence that may be life-threatening if not treated promptly. In conclusion, the two main objectives of urological management of spina bifida are to protect renal function as much as possible and to control urination and improve quality of life as much as possible. It is also important to avoid urinary diversion as much as possible to provide a reliable guarantee for the child’s future life and work.