Pediatr Nephrol (2008) 23:717–725 episodes of acute pyelonephritis and irreversible renal damage. Management of the neurogenic bladder General principles and treatment goals The cornerstone of optimal NBSD management is early identification and characterization (typology) and the institution of proactive therapy. Crucial for long-term prognosis of patients with NBSD is the fact that the management must start before consequences of bladder dysfunction become apparent. From the outset, the goals of management are to prevent or minimize secondary damage to the upper urinary tracts and bladder from the primary neurogenic bladder dysfunction and to achieve safe social continence [14]. Thus, long before continence becomes an issue, starting from the first year of life, management is directed at creating a low-pressure reservoir and ensuring complete and safe bladder emptying. Clean intermittent catheterization (CIC) or self- catheterization (CISC) in combination with anticholiner- gics (oxybutynin) is the standard therapy for children with neurogenic bladder dysfunction with detrusor hyper- activity and/or DSD [11, 15, 16]. This treatment is also feasible and effective in developing countries, where untreated neuropathic bladder is an important cause of preventable chronic renal failure [17, 18]. CIC enables complete bladder emptying and thus avoids bladder residues and consequent risks for infections. In the high- risk bladder with DSD, CIC also allows bladder emptying before the occurrence of otherwise “spontaneous” high- pressure voiding, which is known to be detrimental for kidney function and drainage. Oxybutynin, a bladder smooth-muscle relaxant, is used to improve bladder dynamics through suppression of detrusor hypertonicity and hyperreflexia. By doing so, oxybutynin eliminates (high-pressure) uninhibited detrusor contractions (and thus urinary leakage) and prevents high-pressure bladder storage (due to detrusor hypertonicity or low bladder compliance) and high-pressure emptying (in case of DSD). Early management, including diagnosis and identification of the high-risk bladder At birth, the majority of patients with neurogenic bladder has normal upper urinary tracts. Without proper manage- ment, urinary tract infections and elevated bladder pressures with secondary bladder-wall changes may cause upper urinary tract deterioration within 3 years in up to 58% [5]. One third of children who develop impaired kidney drainage do so within the first year of life [19]. The 719 specific abnormalities vary considerably and are not predicted by the level of the spinal cord defect. Further- more, the dysfunctional pattern may be dynamic, influ- enced by spinal cord surgery, tethering, and denervation. In the initial baseline evaluation, clinical observations must be completed with urinalysis (microscopy and culture), renal/ bladder ultrasound, and cystourethrogram. These allow the experienced clinician to suspect the type of NBSD and to identify the high-risk subgroup. The next consideration is when to perform urodynamic studies. Two different opinions exist in the literature on the use of urodynamic studies in the early evaluation and further follow-up. In one approach, urodynamic assessment has become an integral part of the initial evaluation and subsequent management, as it allows recognition of the different subtypes of NBSD (typology), proactive interven- tions, evaluation and guidance of therapy, and early detection of neurologic deterioration (such as symptomatic tethering of the spinal cord [20]). Advocates justify this approach of routine urodynamics to minimize the deleteri- ous effects of high intravesical pressure by directly measuring it rather than indirectly suspecting it from the development of upper and lower urinary tract changes on serial radiologic imaging. Several studies have shown that early urodynamic evaluation of children with NBSD allows the prediction of which newborns are at risk for upper urinary tract deterioration. Urodynamic risk factors are low bladder compliance, intravesical pressure more than 40 cm H2O, and DSD [2, 3, 6, 21]. The alternative to urodynamic- based management is serial radiologic imaging to detect secondary evidence of high bladder pressure. Critics of newborn and early infancy urodynamics refer to a lack of standards for performance and interpretation, which might lead to unnecessary interventions [22, 23]. Those authors recommend careful history, physical examination, upper urinary tract imaging, and close follow-up during infancy and childhood, reserving urodynamic studies only for patients with evidence of urinary retention on physical examination, new-onset hydronephrosis or febrile urinary tract infection, or for evaluation to achieve continence. Proponents of this approach with selective urodynamics suggest that close monitoring with prompt intervention at first signs of deterioration is effective in protecting the upper urinary tracts (including preservation of nephrons and thus renal function in the long run). A remaining concern, however, could be that in this more expectant approach, high intravesical pressures may have already resulted in irrevers- ible and avoidable damage to the bladder wall, resulting in small-capacity, low-compliance bladders later in life. Although many questions regarding optimal evaluation and management remain unanswered, the consensus on the need of close surveillance, especially in the first years of life, plus the possibility that proactive treatment may be