This is the first study to investigate the characteristics of Japanese pediatric patients with neurogenic bladder, the status of laboratory test implementation, and clinical practice patterns of treatments. Congenital neurogenic bladder caused by spinal cord-related diseases such as spina bifida causes not only lower urinary tract dysfunction but also progressive upper urinary tract deterioration [1]. Early diagnosis, urinary tract evaluation, and early intervention are important for better prognosis of these patients and their quality of life. Based on the urinary tract evaluation using primarily ultrasonography and urodynamics, early prophylactic intermittent catheterization and anticholinergic medications should be initiated based on individual disease conditions [2, 3]. In this study, we investigated the background and complications of pediatric patients with neurogenic bladder, as well as when the diagnosis, urologic examination, and treatment were performed in real clinical practice.

This was a retrospective claims database analysis of the JMDC database, which constitutes receipts and medical information of inpatients and outpatients from multiple health insurance societies in Japan since 2005. A total of 1,065 patients (≤17 years) identified as having neurogenic bladder due to neurological disorders, such as Spina bifida or spinal cord injury, were included. Demographic and clinical characteristics of the patients, including comorbidities, medical procedures, and examinations were investigated during the 12-month follow-up period. A multivariate analysis evaluating the potential risk factors for the development of urinary tract infection during the 12-month follow-up period was performed. The diagnosis of spina bifida, patient demographics (sex and age at the index month), presence of comorbidities at baseline, and use of CIC and/or OAB drugs at the index month, etc. were used as independent variables.

Gastrointestinal symptoms such as constipation (40.1%), gastroenteritis, and colitis (35.5%) were common complications in pediatric patients with neurogenic bladder, indicating the importance of defecation care in addition to urination care. Urodynamic study was performed in only 3.0% of all cases compared with renal/urinary tract ultrasonography in 38.3%. Drugs, mostly anticholinergics, were used in 18.3% of all cases and 35.0% of those with occult Spina bifida. Clean intermittent catheterization (CIC) was performed in 9.3% of all cases and more often in patients with an open Spina bifida (28.0%). Lower urinary tract infection (UTI) developed in 18.1% of all cases and 29.2% of Spina bifida cases. In open Spina bifida, the rate was high at 54.1%, and ≥4 recurrences were also high at 19.1%. Upper UTI occurred in 3.3% of all cases and 7.6% of open Spina bifida cases. The renal failure rate was 1.8% of all cases. Urinary incontinence was present in 8.0% of all cases and 15.9% of Spina bifida cases (15.9%). Incontinence was more common in patients with occult Spina bifida (24.9%). Multivariate analysis evaluating risk factors for urinary tract infection showed significantly higher ORs with point estimates of ≥2 for CIC (7.75), presence of spina bifida (2.69), and constipation (2.09).

In clinical practice, studies on lower urinary tract dysfunction are not often performed, as recommended by the guidelines [2, 3]. Our data on the complications of neurogenic bladder suggest that management (monitoring and treatment) of neurogenic bladder may be inadequate in routine clinical practice.

Without adequate evaluation, there is an increased risk of not appropriately identifying disease status, and timely and appropriate treatment may not be provided. Thus, conducting periodic examinations, as recommended by the guidelines, and selecting the appropriate treatment for each patient, such as behavioral therapy, CIC, and medication are necessary.

Manack A, Motsko S.P, Haag-Molkenteller C, Dmochowski R.R, Goehring E.L. Jr, Nguyen-Khoa B.A, Jones J.K. Epidemiology and healthcare utilization of neurogenic bladder patients in a US claims database. Neurourol Urodyn. 2011; 30: 395–401.
The Japanese Continence Society. Clinical Guidelines for Lower Urinary Tract Dysfunction in Patients with Spina Bifida. https://www.urol.or.jp/lib/files/other/guideline/31_lower-urinary_dysfunction_2017.pdf
Stein R, Bogaert G, Dogan H.S, Hoen L, Kocvara R, Nijman R.J.M, Quadackers J.S.L.T, Rawashdeh Y.F, Silay M.S, Tekgul S, Radmayr C. EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part I diagnostics and conservative treatment. Neurourol Urodyn. 2020; 39: 45–57.