Pediatr Nephrol (2008) 23:541–551 DOI 10.1007/s00467-008-0764-7 EDUCATIONAL FEATURE Neurogenic bladder: etiology and assessment Stuart B. Bauer Received: 21 September 2007 / Revised: 23 December 2007 / Accepted: 31 December 2007 / Published online: 13 February 2008 # IPNA 2008 Abstract A review of the various causes of neurologic impairment to the lower urinary tract in children was the aim of this presentation. The emphasis was on diagnosis, pathophysiology, and treatment that strive to maintain as normal a function as possible in order to achieve eventual urinary continence and health of the upper urinary tract. The latest principles based on the most up to date evidence are promulgated but with an eye towards historical prospective. The reader should gain an adequate under- standing of various disorders that comprise this condition and feel comfortable with proposing options for manage- ment when faced with the responsibility of caring for an affected child. Keywords Pediatric neurogenic bladder . Myelodysplasia . Diagnosis and evaluation Introduction Neurogenic bladder dysfunction in children is an ever- evolving condition. The expansion of its understanding and treatment over the past 50 years has been just remarkable. In the mid 1950s there were few insights and minimal alternatives to the child’s being in diapers or wearing an S. B. Bauer Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA S. B. Bauer (*) Department of Urology, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA e-mail: stuart.bauer@childrens.harvard.edu appliance over an abdominal wall stoma. Starting with the development of adequate X-ray assessment and reliable urodynamic investigation, the advent of clean intermittent catheterization, artificial sphincter implantation, continent urinary conduits and a plethora of drug therapies that modulate lower urinary tract function, we have learned a great deal about the pathophysiology, pathogenesis and treatment of this disorder and the evidence specific ways to manage it. With the promise of tissue engineering and stem cell therapy, new vistas for treatment seem to be on the horizon. The most common cause of neurogenic bladder dys- function in children is neurospinal dysraphism, primarily an open back lesion, but an occult or closed dysraphic state is being diagnosed with more frequency as neonatal spinal ultrasound and magnetic resonance imaging (MRI) are used with increasing regularity to visualize any lower midline spinal cutaneous or gluteal cleft malformation. It was thought that folic acid deficiency was a cause of this disease and that its replacement in women of childbearing age would practically eliminate the condition, but this has not happened. There has been a definite decrease in its incidence; however, in parts of the USA its prevalence has not diminished at all [1–4]. Other causes of neurogenic dysfunction involving the spine include sacral agenesis, tethered spinal cord associ- ated with imperforate anus, cloacal malformations, and spinal cord injuries from sporting injuries and motor vehicle accidents. Central nervous system abnormalities include spastic diplegia (cerebral palsy) and learning disabilities, i.e. attention deficit hyperactivity disorder (ADHD) or attention deficit disorder (ADD). Terminology used throughout this manuscript will conform to the standardization document recently published in the Journal of Urology [5].