Urological consequences of incomplete cord lesions in patients with myelomeningocele.

OBJECTIVES

To determine the urological consequences of incomplete cord lesions in patients with myelomeningocele and a neuropathic bladder.

PATIENTS AND METHODS

From a total of 407 patients with myelomeningocele and a neuropathic bladder, 31 (8%) were identified as having a combination of sacral sensory or motor sparing and positive conus reflexes. Their case-notes were reviewed with reference to spinal neurology, patterns of micturition, including the degree of spontaneous continence, findings on imaging and urodynamic studies, and forms and outcomes of any treatment given.

RESULTS

The anatomical distribution of the lesions was thoracic (two), thoracolumbar (three), lumbar (six), lumbosacral (four) and sacral (11). The mean age at presentation was 9.5 years (range 3.5-19.5) and the mean follow-up 4.5 years (range 0.5-10.5). At presentation, 14 patients had urinary incontinent episodes both day and night, 10 by day only, seven by night only, and the upper urinary tracts were dilated in eight (26%). Nineteen were ambulant unaided and 10 with aid of crutches or calipers, whilst two were wheelchair-bound. Only one patient had faecal incontinence. A urodynamic examination in 18 patients showed competent sphincteric mechanism and detrusor hyper-reflexia in all, and detrusor sphincter dyssynergia in 11. The methods of treatment included oxybutynin and/or clean intermittent catheterization alone or in combination. Thirty patients are currently reliably dry by day and 26 also by night. Five patients have undergone surgical treatment for vesico-ureteric reflux, three a Mitrofanoff procedure and two augmentation cystoplasty.

CONCLUSION

Although patients with congenital incomplete cord lesions and positive conus reflexes may gain some measure or urinary continence spontaneously, they are at serious risk of developing upper urinary tract complications. The treatment of urinary continence is simple and effective because there is a competent sphincter mechanism. These patients require life-long supervision even if they require no treatment for urinary incontinence.