Table 2 Surveillance in infants with myelodysplasia (until age 5 years) (IVP intravenous pyelogram, ECHO sonogram, UDS urodynamic study, VCUG voiding cystourethrogram, RNC radionu- clide cystogram) Sphincter activity Recommended tests Frequency Intact-synergic Post-void residual volume IVP or renal ECHO Intact-dyssynergica IVP or renal ECHO 543 Every 4 months Every 12 months Every 12 months Every 12 months Every 12 months Every 12 months Every 4 months Every 12 months Every 12 months Every 12 months Every 6 months Every 12 months Pediatr Nephrol (2008) 23:541–551 herniation of the brainstem and the center for micturition coordination (the pontine mesencephalic center), additional layers of dysfunction are added to those nerve pathways already affected. The over-riding issue at birth is whether or not the child has detrusor external urethral sphincter dyssynergy and whether the infant can empty the bladder completely at low pressure. All newborns with radiologic abnormalities at birth (5–10% with hydronephrosis, reflux) have active obstruction of the bladder outlet that had caused these changes to occur in utero [9]. The presence of elevated detrusor filling pressure, bladder sphincter dyssynergy or high voiding or leaking pressures (above 40 cm H2O) at capacity, which can result in upper urinary tract deteriora- tion in as many as 63% of children [9], warrants early intervention with clean intermittent catheterization (CIC) and anticholinergic drugs [10–13]. Thus, the investigation of these children when newborn includes a renal and bladder ultrasound, a catheterized measurement of urine residual after voiding or leaking, a determination of serum creatinine concentration after 7 days of life and a urodynamic study that incorporates both detrusor pressure measurements and urethral sphincter electromyography. Voiding cystography is undertaken when hydronephrosis is present and/or urodynamic studies indicate bladder outlet obstruction with either increased pressure at capacity or bladder sphincter dyssynergy. The incidence of reflux when there is functional obstruction of the bladder outlet can range as high as 50% [14, 15]. Although some clinicians still preach watchful waiting if the renal ultrasound findings are normal, and do not recommend urodynamic studies in the newborn period, opting instead for instituting CIC and drug therapy only with the first sign of ureteral or renal pelvic dilation [16, 17], most centers within the USA now advocate full investigation of the lower urinary tract and initiate prophylactic treatment if there are signs of outlet obstruc- tion and/or elevated bladder filling or voiding pressure [18– 20]. The incidence of urinary tract deterioration can be greater than 50% [11, 12, 20] when children with the potential for deterioration are followed with expectant and not preemptive therapy. Even though the ‘watchful waiters’ demonstrate that they can reduce the presence of hydro- nephrosis and, possibly reflux, the changes in detrusor dynamics are not as easily reversed, and the need for subsequent aggressive management of the bladder to control incontinence and a poorly compliant bladder is commonplace (Table 2). Therefore, CIC is begun when detrusor sphincter dyssynergy, elevated leak point pressures greater than 40 cm H2O, and/or reflux grade 3 or higher (on a scale of 1 to 5) are present. Instituting CIC and anticholinergic therapy in infancy has revealed many advantages over time [19–21]: the parents and the child UDS UDS VCUG or RNCb Post-void residual volume IVP or renal ECHO UDSc VCUG or RNCb Post-void residual volume Renal ECHO Partial denervation Complete denervation a Patients receiving intermittent catheterization and anticholinergic agents b If detrusor hypertonicity or reflux is already present c Depending on degree of denervation adapt to the routine of CIC much easier than they would have if it were to be begun when the child is older; the bladder often remains very compliant, expanding as the child grows and maintaining appropriate wall thickness as noted on bladder echography; hydronephrosis and ves- icoureteral reflux develop in fewer than 10%; continence is readily achieved in greater than 50% with no additional maneuvers; and the need for augmentation cystoplasty to maintain a reasonable organ for storage is markedly reduced from almost 60% to 16% when compared with that in children followed expectantly [22]. When vesicoureteral reflux is present, CIC effectively lowers the intravesical emptying pressure when the bladder is drained. In addition, anticholinergic medication can be added to lower detrusor filling pressure, increasing compli- ance without fear of causing urinary retention when combined with CIC. The lowered filling and emptying pressures has proven to be very beneficial; in 30–50% of children reflux is resolved within 2–3 years of its discovery and initiation of therapy. The disadvantages are few and include a higher rate of bacteriuria (60–70% versus 30%) but a lower rate of symptomatic urinary tract infection (20% versus 40%) during childhood than in children followed expectantly