Vesicoureteral Reflux in Children with Cerebral Palsy: Incidence and Association with Detrusor Sphincter Dyssynergy.
While frequency, urgency, incontinence, urinary tract infections (UTIs) and urinary retention are commonly reported urologic manifestations in children with cerebral palsy (CP), there is not much known regarding the incidence of vesicoureteral reflux (VUR) in these children. Likewise, there are few reports regarding the videourodynamic findings in children with CP and more specifically, in those who have associated VUR. In order to better define the incidence of VUR in children with CP and its association, if any, with particular types of neurogenic bladder dysfunction, we reviewed and report on our experience in these children.
The videourodynamic records of all 44 pediatric patients (age range 2.5-18yrs) with CP in our IRB database were reviewed. It included 27 males (mean age 11.9 yrs) and 17 females (mean age 7.4 yrs). The most common reason for referral was urinary incontinence (82%) and UTI (36%); 19 (43%) were self (parent) referred, primarily because of persistent incontinence. Those children found to have VUR were identified and their associated videourodynamic findings analyzed.
Nine of 44 children (20%) (5 boys, 4 girls) had VUR into 15 renal units. Reflux was bilateral in all 4 girls and in 2/5 boys. Grade of reflux was mild to moderate (2-3) in 9 renal units and severe (4-5) in 6 renal units. A history of UTI was reported in 5/9 (56%) including 4/4 girls and 1/5 boys. Neurogenic detrusor overactivity was noted in all 9 children with reflux. Detrusor sphincter dyssynergy was noted in 8/9 (89%) children with VUR. Sphincter dyssynergy was at the level of the external urethral sphincter (DESD) in 2 (25%) and at the internal sphincter (DISD) in 6 (75%). In 4 children, the reflux identified represented recurrent reflux as they had previously been diagnosed with VUR and were treated, 3 with surgical reimplantation and 1 by endoscopic injection; none had urodynamic assessment prior to their anti-reflux procedure.
Overall, 20% of children in our study had VUR, (12.5% if excluding those with prior VUR history). Nearly 90 % of VUR was associated with sphincter dyssynergy and while not unexpected given its association in other conditions of dyssynergic voiding, in our CP patients, most dyssynergy occurred at the internal sphincter. This DISD would likely not be identified without videourodynamics having been performed and should serve as cautionary note that these children are best evaluated with videodynamics, particularly when there is a history of UTI and ideally before any anti-reflux surgery is contemplated or if they are having recurrent febrile UTIs post op and/or surgical failure is suspected. It also opens the possibility of resolution if DISD associated VUR is treated with alpha blocker therapy.