Pediatr Nephrol (2008) 23:717–725 723 Fig. 2 Suppression of detrusor hyperactivity with resolution of reflux by nonsurgical management. Illustrative patient with high-risk neurogenic bladder sphincter dysfunction (NBSD) (type B), urody- namically showing early unsafe filling pressures (A) with high-grade reflux (a) and urosepsis before treatment. Under clean intermittent catheterization (CIC) plus oxybutynin, the unsafe high-pressure bladder was converted into a safe low-pressure reservoir with good capacity and disappearance of the reflux at control cystography 3 months later (b). Severe systemic side effects, making continuation of oral oxybutynin impossible, disappeared after switching to intravesical oxybutynin. Further urodynamic evaluations (B: after first intravesical administration; C: after 4 months) documented adequate suppression of detrusor hyperactivity (modified from [40]). Long-term (currently 13 years) continuation of CIC and intravesical oxybutynin has resulted in a safe and adequate capacity bladder with social continence for the patient Conclusions Medical management with CIC and anticholinergics is effective in preserving renal function and providing safe urinary continence in more than 90% of patients with a neurogenic bladder. Early diagnosis and treatment institu- tion, long before continence becomes an issue at toddler age, can prevent both renal damage and secondary bladder- wall changes, thereby improving long-term outcomes. Compared with oral oxybutynin, intravesical oxybutynin has more potent and longer-acting detrusor suppressive effects with good tolerance and should be used prior to considering surgical therapies. Therapeutic goals should no longer be restricted to prevention of secondary damage to both upper and lower urinary tracts. Instead, our goal should be to achieve normal renal and bladder growth at safe bladder pressure, with appliance-free continence. Study questions (Answers appear following the reference list) Directions: Each of the numbered questions is followed by several possible answers. Select the one lettered answer that is NOT CORRECT in each case. 1. 2. 3. Medical management of NBSD will be similar, irre- spective of : a. Underlying cause b. Patient age c. Pattern of bladder dysfunction Depending on the pattern of bladder dysfunction, safe urinary continence can be achieved by: a. CIC + anticholinergics + bladder-neck surgery b. Bladder-neck surgery alone c. CIC alone Urodynamic risk factors for upper urinary tract deteri- oration are: a. DSD b. High bladder compliance c. Intravesical pressure >40 cm H2O 4. In a patient where CIC was started and in which catheterized volumes are always far below the expected bladder capacity for age: a. There is no indication for CIC, and CIC can be stopped b. Anticholinergic treatment may need to be added to CIC c. Bladder-outlet resistance may be very insufficient