Urologic care of the neurogenic bladder in children.

Initial care of newborns with spina bifida centers on preventing bladder and upper tract damage from detrusor leak point pressure of greater than 40 cm H(2)O. The authors recommend using urodynamic-based management to select patients with elevated pressures for anticholinergic therapy and intermittent catheterization (CIC), using diapers and observation with biannual renal sonography for the remainder. At the age of toilet training, children who have urodynamic evidence of uninhibited contractions or rising pressure during filling are started on anticholinergics and CIC, or have their dosage increased until pressures less than 40 cm H(2)O and areflexia are achieved. Sphincter incompetency is diagnosed in incontinent children with pressures less than 40 cm H(2)O and areflexia or stress incontinence. Augmentation is indicated in patients with hydronephrosis or reflux and end-filling pressures or DLPP less than 40 cm H(2)O despite medical management to the point of patient tolerance. A minority of patients, not yet well-defined, will also need augmentation after bladder outlet surgery for similar postoperative indications.