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  1. #1

    Bladder Management - Pediatric

    My 3.5 year old son has an overactive bladder and leaks in between caths (cath 4x a day). He has a grade 3 reflux into left kidney, though they said this is okay (ultrasound shows kidneys are fine). He can hold up to 120ml, which they think is normal-ish for his age and size, but he will leak in between. If I cath him now, without medication he can hold it dry for about 1 to 1.5 hours.

    It has been suggested we start him on a 10mg dose of Oxybutynin and to inject it into the bladder with 15ml of saline solution once a day - through his cath.

    I am worried about the cognitive side-effects since he is so little, but I do not know of other medications that I should explore. It is unfortunate that there is so little research into the effects on the pediatric pop. but I realize there is some discussion and studies in the older pop.

    I know there is another that they mentioned that I dismissed because it has issues with BP from what they said. We arn't 100% sure but he may have AD episodes and I do not want to risk it right now.

    Botox is an option in the future - currently they would have to put him under (general) and there is research this can also cause cognitive issues so it is not something I want repeated every 4-6 months.

    Any suggestions of other things I should look at?

  2. #2
    Sanctura (Trospium Chloride) is the anticholenergic with the least cognitive side effects, and there are reports that Myrbetriq (mirabegron) also has less cognitive side effects than the traditional anticholenergics. IInstillation of oxybutinin solution into the bladder is a well known procedure in adults on intermittent cath, and significantly reduces the systemic effects of oxybutinin such as dry mouth, constipation, and cognitive side effects. am not very familiar with pediatric uses of these drugs, so will ask CKF (another SCI-Nurse who has a peds background) to weigh in on this too.

    4X daily caths is infrequent for an adult doing this as bladder management, and would most often be doing 6X daily. I am concerned that your provider is not concerned about ureteral reflux of any degree, as this significantly increases the risk of long term kidney damage and also of transmission of bacteria from a colonized bladder to the kidneys for more serious kidney infections. Has he had urodynamics? If so, what was his PdetMax (maximum detrusor pressure)? If over 40 CmH20, this must be corrected.

    (KLD)
    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

  3. #3
    Thank you!

    In regards to the urodynamics, I will ask what the number was.

    for the reflux, they basically said since the ultrasound shows kidneys are fine, that it’s fine.

    i had asked if the kidney reflux is something that is reversible. Meaning, if he has a degree 2 reflux, can it only get worse? What is the usual management of this? I did note that during urodynamics, almost every time he contracted and urinated, it also went up towards kidney.

    On a side note, how accurate are urodynamics? His bladder contracted and voided a lot more often, at lower amounts during the study, than what I have observed at home.

    Quote Originally Posted by SCI-Nurse View Post
    Sanctura (Trospium Chloride) is the anticholenergic with the least cognitive side effects, and there are reports that Myrbetriq (mirabegron) also has less cognitive side effects than the traditional anticholenergics. IInstillation of oxybutinin solution into the bladder is a well known procedure in adults on intermittent cath, and significantly reduces the systemic effects of oxybutinin such as dry mouth, constipation, and cognitive side effects. am not very familiar with pediatric uses of these drugs, so will ask CKF (another SCI-Nurse who has a peds background) to weigh in on this too.

    4X daily caths is infrequent for an adult doing this as bladder management, and would most often be doing 6X daily. I am concerned that your provider is not concerned about ureteral reflux of any degree, as this significantly increases the risk of long term kidney damage and also of transmission of bacteria from a colonized bladder to the kidneys for more serious kidney infections. Has he had urodynamics? If so, what was his PdetMax (maximum detrusor pressure)? If over 40 CmH20, this must be corrected.

    (KLD)

  4. #4
    Quote Originally Posted by MomNoah View Post

    for the reflux, they basically said since the ultrasound shows kidneys are fine, that it’s fine.

    i had asked if the kidney reflux is something that is reversible. Meaning, if he has a degree 2 reflux, can it only get worse? What is the usual management of this? I did note that during urodynamics, almost every time he contracted and urinated, it also went up towards kidney.

    On a side note, how accurate are urodynamics? His bladder contracted and voided a lot more often, at lower amounts during the study, than what I have observed at home.
    Urodynamics is much more accurate than what you see in day to day care; often showing hidden problems such as dangerously high pressures that cannot be detected otherwise.

    While reflux may not have damaged the kidney structurally yet, it almost certainly will harm it functionally in the long run. I would get a second opinion from a urologist who is an expert in neurologic urology. I believe you previously took your son to Shriner's SCI Center...is it possible to have him evaluated there again?

    (KLD)
    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

  5. #5
    I am trying to get the urodynamics study and I am actually sharing it with Shriners in Chicago to get a second opinion. We currently only do antibiotics into the bladder to prevent UTIs. They said the only concern with the reflux is the bacteria, and since we are doing the antibiotics this should not be an issue.

    Can you explain what can be done to minimize the kidney reflux? Currently he is not on any medication and they are suggesting the Oxybutinin to lessen the spasms/contractions, and they said this will resolve the issue basically. Is this correct?

    Quote Originally Posted by SCI-Nurse View Post
    Urodynamics is much more accurate than what you see in day to day care; often showing hidden problems such as dangerously high pressures that cannot be detected otherwise.

    While reflux may not have damaged the kidney structurally yet, it almost certainly will harm it functionally in the long run. I would get a second opinion from a urologist who is an expert in neurologic urology. I believe you previously took your son to Shriner's SCI Center...is it possible to have him evaluated there again?

    (KLD)

  6. #6
    To minimize the kidney reflux, he should be cathing more frequently, probably 6 times a day. I know that this asking a lot, but I would like to see the baldder not epty reflexically. You really want to minimize the amount of reflex voiding he is doing. The bladder contracting is what causes the reflux.

    I know that you are worried about the cognitive issues from the medications, but the kidney issues are also concerning. I would agree with the medications that were recommended above. I would certainly rcomend instilling the meds over taking them orally for the reasons that are stated above. And I would start with the smallest dose possible, and increase it if need be over time. That will give you an idea of whether or not there is any cognitive changes from them.

    I would definitely recommend Shriner's in Chicago - they are very skilled at managing the issues that go with pediatric spinal cord dysfunction.

    ckf
    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

  7. #7
    I have bladder botox injections done every 5-6 months. I have 250-300 units injected. I have been doing it for 5-6 years. I will have maybe 1-2 accidents a YEAR. It makes a huge difference. I do not have a cognitive issues, at least yet. You need to decide if the risk is worth it, it drastically improves quality of life. I usually do it under general, but last month I did it awake and was fine.

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