An urgency about bladder dysfunction in cerebral palsy

Continence is a fundamental issue for all individuals, but has historically been glossed over for many people with motor disorders, especially if they also have some element of intellectual disability. Murphy et al. provide information on incontinence and management from a large population of children and adults with cerebral palsy (CP). In a retrospective sample, the authors demonstrate urodynamic evidence of neurogenic bladder in over one-fifth of patients with bilateral CP. This population of 35 patients received further medical treatment and management with about 80% of the individuals attaining continence or major improvement. Most of the remaining individuals responded positively to indwelling catheters or intermittent catheterization. There is much to be learned from this paper. Although it is not entirely clear how many, if any, of the patients had normal urodynamic studies, over 20% of those with diplegia or quadriplegia had symptomatic neurogenic bladder confirmed by cystometry. Bladder dysfunction occurred throughout the sample without regard to age, sex, education status, or gross motor function, although individuals with unilateral CP were spared. Others have reported high rates of neurogenic bladder in populations with CP; this paper reinforces that knowledge by demonstrating prevalence in bilateral CP within a clinical sample, but also draws a new distinction between unilateral and bilateral CP. Clinical practice in this paper included evaluation for neurogenic bladder for patients with incontinence or other urinary symptoms as long as they could communicate basic yes ⁄no responses verbally or by activating simple switches. Thus, the sample undoubtedly included a fair number of patients who had some degree of intellectual disability as well as motor disability, including a larger group of patients to evaluate than would be expected in many practices. Due to the inclusion of patients who are less able to express themselves fully, it is all the more fascinating to note the high attainment of continence with fairly simple treatment. Most patients responded to medication and a smaller group did well with environmental and behavioral interventions. Four of the 35 patients with symptomatic neurogenic bladder required catheters to be continent and only two individuals did not achieve a positive outcome. While the authors do not report how many patients declined screening or how many achieved continence versus just ‘major improvement’ (which could include up to two episodes of minor wetting each day), their findings should invoke greater commitment amongst all of us to evaluate and treat neurogenic bladder in our patients. Readers will be wise to embrace the challenge set forth with this paper. Namely, given the high prevalence of neurogenic bladder in individuals with CP who have incontinence, and given the high response to medical therapy and other interventions, greater attention should be devoted to understanding bladder function and treating dysfunction. When neurogenic bladder is identified in patients, straightforward pharmaceutical management is indicated. Moreover, use of behavior techniques, eneuresis alarms, and adaptations of the physical environment can also promote continence. These issues may be particularly applicable to school-age populations with CP, but should be considered for all individuals with bilateral CP across the spectrum of age and motor ability. Continence appears achievable for the majority of children with CP who are able to communicate basic needs. Murphy et al. suggest that with urodynamic studies to guide management and attention to the patient and family’s situation, outcomes can be improved without significant risk or expense. We should work to ensure that all children and adults with CP have that opportunity.