Spina bifida 4 – bladder and bowel management

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This series is covering all you need to know about spina bifida. In the previous posts we looked at issues around diagnosis and antenatal counselling. In this post, we look at the bladder and bowel problems associated with spina bifida.

25% of patients with spina bifida will have renal damage. In the first few years of life, this can be progressive and therefore patients should have 6-monthly renal ultrasounds. They should also have annual urology reviews (BP, urinalysis, UECs).

Patients should only have symptomatic UTIs treated. A DMSA should be carried out if there are concerns about real scarring.

When are urodynamics tests appropriate?

These should be carried out where there is:

  • Unexpected incontinence
  • Increase in leakage between catheters
  • Upper renal tract changes on ultrasound
  • New musculoskeletal symptoms

The key to healthy urinary system is regular complete bladder emptying.

Patients usually require medication such as oxybutynin to relax the detrusor muscle and faciliate the storage of urine between catheterisations. Continence pads of varying size and absorbencies will be required. Adolescent males sometimes use a penile appliance.

Teaching  clean self-intermittent catheterisation depends on cognitive ability and the level of disability. With clean intermittent catheterisation – use the largest catheter possible at least 4-6 times a day.

What are the principles of bowel management?

Spina bifida is a life-long condition. The ‘toilet timing’ program should commence at around two years of age. Children should have a regular, consistent toileting routine.

Avoid constipation – suitable diet, adequate fluids, and regular exercise.

Regular evacuation – usually daily after breakfast or after dinner at night. May need assistance by using a suppository or enema.

What are the best bowel treatments?

Stimulant laxatives should be avoided for long-term bowel problems. The usual preference is lubricants or stool softeners (or bulking agents) if diet alone is not adequate. Macrogel osmotic laxatives are ideal to prevent and treat constipation.

Young people need to be taught to know their own body, be observant, and to anticipate higher risk times for accidents.

Non-surgical management includes: suppositories; small disposable enemas; retrograde bowel washouts; and anal plugs.

When conservative methods fail, a normal saline retrograde bowel washout using a Willis home bowel washout kit, Peristeen anal irrigation, or Cardiomed system may help.

Surgical management includes: MACE – Malone antegrade continence enemas (percutaneous caecostomy using a gastrostom button, Chait button, or appendix).

Rarely a colostomy is required.

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Lydia Garside is a general paediatrician based at Sydney Children’s Hospital

Author: Lydia Garside

Lydia Garside is a general paediatrician based at Sydney Children’s Hospital