Management of the neurogenic (referring to an abnormally functioning bladder due to compromised nerve supply) bladder secondary to myelomeningocele should be started when a child normally obtains bladder control; however, a baseline urological evaluation should be attained within the first month of life and at regular six-month to yearly intervals thereafter.
A regular bladder routine initially performed by the patient’s parents (at about 3 years of age) consists of intermittent clean catheterization performed three to four times per day based on the patient's residual urine volume (that amount of urine left in the bladder after the patient voids without the assistance of a catheter) and the bladder's capacity to hold urine. As soon as the patient is cognitively and physically able to perform self-catheterization, instruction should be started with the goal of independent catheterization. Yearly urological follow-up examination is imperative in patients with spina bifida to monitor bladder pressure (an indicator of whether the bladder is being stretched by overfilling due to excessive intervals between catheterization) as well as bladder capacity, sphincter function (how well the muscle controlling the outlet of the bladder is functioning) and monitoring for bladder or renal stones. Pharmacological agents are prescribed as indicated for high-pressure bladder and bladder or sphincter spasticity. Urinary incontinence in a patient on a regular bladder routine is most often due to a urinary tract infection but may also be due to bladder/sphincter dyssynergia.
Control of bowel function in a patient with myelomeningocele is individualized and must be done on a consistent basis. As in starting a bladder routine, a regular bowel routine should be started at about the age of normal bowel continence (at approximately age 3 years). Prior to the age of beginning a routine, parents should be instructed to modify the child's diet, ensure adequate fluid intake and use a laxative as required to prevent constipation and overdistention of the bowels. Bowel management in the child over 3 years of age should be attempted on a daily or every-other-day schedule. It is best to take advantage of the rectocolic reflex that occurs after eating in the morning or evening as the time of rectal evacuation. An initial combination of a stool softener, irritant cathartic (e.g., Dulcolax) or peristaltic agent (e.g., Senokot) and suppositories may be tried to establish a regular routine. Modification of the diet as well as the addition of Metamucil may be indicated. The end goal is to attain a regular routine without the use of a laxative. Typically, digital stimulation of the rectal outlet is the mechanism used to stimulate evacuation once the routine is established. It must be kept in mind that there cannot be a rigidly prescribed bowel routine that is applicable to all patients—each patient must be tried on a series of medications until a successful bowel routine can be attained.