Division of Urology, Children's Hospital Los Angeles, Los Angeles, CA, USA.
Department of Pediatric Urology, Children's Medical Center, Dallas, TX, USA.
J Pediatr Urol. 2021 Aug;17(4):522.e1-522.e6. doi: 10.1016/j.jpurol.2021.04.003. Epub 2021 Apr 21.
Patients with transverse myelitis (TM) often present with urinary retention. While many recover their bladder function, some have persistent voiding dysfunction, and both intermediate and long-term outcomes are variable.
In patients who develop urinary retention requiring clean intermittent catheterization (CIC) at onset of TM, we sought to assess factors associated with improved voiding function and the risk of requiring persistent CIC over time.
We reviewed children evaluated at our institution for TM from April 1998 to October 2018. Patients were included if they required CIC at initial presentation of TM. Demographics, initial and follow up neurologic exams were evaluated for their association with a return to baseline volitional voiding after requiring catheterization upon diagnosis of TM, with or without medical therapy.
Among the 78 patients who presented with TM during the study period, 43 patients required CIC, with median follow up of 2.7 years. When evaluating for demographic or sensorimotor features associated with improvement to baseline voiding function in patients who initially required CIC, preserved lower extremity reflexes at presentation was the only significant prognostic factor (p < 0.05). Additionally, having complete lower motor neurologic recovery was associated with volitional voiding (p < 0.05). Among the 43 patients who were initially catheterizing, 27/43 (62%) were volitionally voiding at median follow up of 7 months from initial presentation, while the remaining 16/43 remained on CIC for a median follow up of 3.6 years. The cumulative risk of remaining on CIC was 60%, 47%, and 42% at 1, 5, and 10 year follow up, respectively, though there was not a significant difference in the rate of bladder recovery if patients had preserved reflexes.
In children with TM who initially developed urinary retention, intact reflexes at presentation were associated with urologic recovery. Additionally, complete neurologic recovery was associated with volitional voiding. While 62% were volitionally voiding at most recent follow-up, the cumulative incidence of dependence on CIC within the first year of diagnosis was 60%, with a relatively few patients regaining volitional voiding by 10 years of follow-up.
Among those initially evaluated for urinary retention in the setting of transverse myelitis, intact lower extremity reflexes on physical exam was associated with improved voiding function at most recent follow-up. However, more than half the patients on CIC at initial presentation required CIC at one year of follow-up. Careful, long-term monitoring of voiding status in patients with TM is recommended, even with improvement of neurological status.
患有横贯性脊髓炎（TM）的患者常出现尿潴留。尽管许多患者的膀胱功能会恢复，但仍有一些患者存在持续性排尿功能障碍，且中间和长期的预后结果不一。
我们旨在评估在 TM 发病时出现尿潴留而需要行间歇性清洁导尿（CIC）的患者中，与改善排尿功能相关的因素以及随时间推移需要持续 CIC 的风险。
我们回顾了 1998 年 4 月至 2018 年 10 月在我院接受 TM 评估的儿童患者。如果患者在 TM 初始表现时需要 CIC，则将其纳入研究。我们评估了患者的人口统计学、初始和随访的神经系统检查，以评估其与初始诊断为 TM 后需要行 CIC 以恢复基线自主排尿之间的关联，无论是否接受了药物治疗。
在研究期间出现 TM 的 78 例患者中，43 例患者需要 CIC，中位随访时间为 2.7 年。在评估与初始需要 CIC 的患者的基线排尿功能改善相关的人口统计学或感觉运动特征时，提示初始时下肢反射保留是唯一显著的预后因素（p<0.05）。此外，完全恢复下肢运动神经功能与自主排尿相关（p<0.05）。在最初需要行 CIC 的 43 例患者中，27/43（62%）例患者在初始表现后的中位 7 个月时可以自主排尿，而其余 16/43 例患者需要继续 CIC，中位随访时间为 3.6 年。在 1、5 和 10 年随访时，继续行 CIC 的累积风险分别为 60%、47%和 42%，但如果患者的反射保持完整，膀胱恢复的速度没有显著差异。
在最初出现尿潴留的 TM 患儿中，提示存在初始时反射完整与尿动力学恢复相关。此外，完全恢复神经功能与自主排尿相关。虽然在最近的随访中，62%的患者可以自主排尿，但在诊断后的第一年，对 CIC 的依赖的累积发生率为 60%，并且在 10 年随访时，仅有相对较少的患者恢复自主排尿。
在最初因 TM 而评估尿潴留的患者中，体格检查时下肢反射完整与最近的随访时排尿功能改善相关。然而，初始需要行 CIC 的患者中有一半以上在 1 年随访时仍需要 CIC。建议对 TM 患者进行仔细、长期的排尿状态监测，即使神经状态有所改善也是如此。
