Archives of Disease in Childhood, 1983, 58, 310-314

Personal practice

Long term indwelling urethral catheterisation forcongenital neuropathic bladderA M K RICKWOOD, N H PHILP, AND D G THOMAS

Spinal Injuries Unit, Lodge Moor Hospital, and Sub Department ofPaediatric Surgery, Children's HospitalSheffield

SUMMARY Long term urethral catheterisation remains an important and effective method ofachieveing dryness and maintaining renal function in children with congenital neuropathic bladders.Those most likely to require an indwelling catheter are girls who are severely disabled because ofmyelomeningocele. The management of such catheterisation and its consequences, in the light ofour experience with a 100 children treated over a 12 year period, is described.

Until recently permanent urinary diversion wascommonly performed in patients with congenitalneuropathic bladder. There is now ample evidencethat the long term results of such proceduresperformed in children are poor'-3 and this hasprompted a search for alternative forms of manage-ment. More than a decade ago we began to useindwelling urethral catheters, at first as a temporisingmeasure in those unfit for surgery and later as adefinitive treatment. Since then other methods havebecome established-notably, clean intermittentself catheterisation,4 various forms of medication,5and prosthetic urinary sphincters6-but we stillconsider indwelling urethral catheterisation to bethe most appropriate treatment for selected cases.Our experience with this method includes 100

children treated from 1969 to 1981, of whom mostwere girls (90) and cases of myelomeningocele (95).Age at the beginning of catheterisation ranged from15 months to 15 years.

Selection of patients for indwelling catheterisation

Management of the congenital neuropathic bladderhas two objectives, maintenance of renal functionand dryness. Deteriorating renal function is almostalways secondary to bladder outlet obstruction,which must therefore be eliminated or bypassed.Dryness is ideally achieved without recourse to aurinary appliance and in a manner the older childcan practise independently. Appliance freecontinence demands a bladder of adequate functional

capacity, but the definition of 'adequate' is largelydetermined by mobility. For a patient confined to awheelchair, a bladder capacity which ensures drynessfor at least 4 hours is required. Functional capacitymay be reduced by unstable (reflex) detrusorcontractions, reduced detrusor compliance, sphincterweakness, or any combination of these. The first twooften improve with an anticholinergic drug or drugswith a direct inhibitory effect on the detrusor, andclean intermittent self catheterisation is often usedwith such agents. Sphincter weakness is less respon-sive to medication and often the only effectivetreatment for this condition is the prosthetic urinarysphincter. Unfortunately, consideration of cost alonerules out this device for all but a few selectedpatients.Even if functional bladder capacity is adequate, or

can be rendered so with suitable drugs, many spinabifida patients cannot practise clean intermittent selfcatheterisation independently, the main limitingfactors being low intelligence and poor hand-eyecoordination associated with hydrocephalus,7 majorspinal deformities in girls, and good urethralsensation in boys with incomplete cord lesions.For boys with bladder outlet obstruction, who

cannot become appliance free independently, there isusually the alternative of a penile urinal plusendoscopic sphincterotomy. There may be compli-cations with long term catheterisation of the maleurethra, and we reserve it for a few adolescents with apenis too small to be fitted with an appliance andthe occasional child with severe upper renal tract

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deterioration that is unlikely to respond tosphincterotomy.For girls who cannot become independtently

appliance free, the only alternative to urinarydiversion or continued incontinence is an indwellingcatheter.

In summary, catheterisation in girls is indicatedfor the more severely disabled, almost regardless oftheir bladder dysfunction, and for some of the lessdisabled because they lack adequate functionalcapacity due to sphincter weakness. The factorswhich incline us toward indwelling catheterisationare summarised in Table 1 and it will be noted thatin our own experience most of the patients are moreseverely physically or intellectually disabled.

Basics of catheterisation

Because most of our patients attend special schoolswhich are now adept at handling catheters, weusually begin treatment in the outpatient departmentor at the school. We admit for a few days thoseattending normal schools so that they and theirparents may become familiar with catheters andtheir problems. Catheter changes are initiallyundertaken by school or district nurses but we laterencourage parents to learn the technique so that thefamily is less dependent on paramedical staff. A fewolder girls change their own catheters.The calibre of the catheter is determined by the

patient's size, but it should never exceed 18 FG evenfor the fully grown. Except in those children with aflaccid bladder and a grossly incompetent bladderneck, balloon size should not exceed 10 ml, and isusually restricted to 5 ml. There are now severaltypes of self retaining balloon catheters available(Table 2) and the choice is governed mainly by cost.Pure silicone and silicone coated catheters arejustified only if they function consistently for at leastfour weeks. We do not believe that the pure siliconecatheters are any better than the cheaper siliconecoated types.

Table 1 Factors predisposing to management byindwelling catheterFemaleNeurological lesion above D12Major spinal deformityIQ below 80Wheelchair boundHip adduction deformitySphincter weakness incontinence

Authors' series (n=100)Wheelchair bound 70Major spinal deformity 44IQ below 80 41Combination of 2 of the above 36Combination 3 of the above 20

Table 2 Principal types ofself-retaining ballooncatheters

Type Price range (£)

Latex rubber .72Silicone coated 2-00-3 -68Pure silicone 5-99-8.25

All 3 types are available from 8-18 FG;with 3-5 ml balloon size.

Catheters must be changed regularly, and not onlywhen they block or give trouble. Latex catheters arechanged at intervals not exceeding two weeks andsilicone or silicone coated catheters at intervals notexceeding six weeks. Although manufacturers statethat they may be left longer, this practice invites theformation of stones and debris in the bladder.

Patients in wheelchairs have the catheter on freedrainage into a leg bag. More active children mayspiggot the catheter for periods of up to 3 hours.

Complications oflong term catheter drainage

Urinary infection. Urinary infection, or ratherbacteriuria, is almost inevitable in patients on longterm catheter drainage,8 9 but there is little evidencethat this is harmful to the kidneys or the bladder.Most episodes are symptomless: 21 of our patientshave had symptomatic bacteriuria but only 10 havehad recurrent episodes. Symptomatic infections aremost common in the first weeks of catheterisationand we give a prophylactic antibiotic for the firstmonth. Urine specimens are taken regularly-monthly for children at special schools-but this isprobably unnecessary as we now tend to treat onlysymptomatic infections.

Haematuria. This is usually an early complicationand can be expected to resolve spontaneously.

Catheter blockage. This is the major problem withlong term catheter drainage, and occurred in halfour patients including 18 who had recurrent episodes.The complication takes two forms. In the first theobstruction is on and in the catheter due to accretionof phosphates, while in the second there is depositionof stones and phosphate debris in the bladder also.The latter has occurred in 6 of our patients, all ofwhom are postpubertal.Why some patients are susceptible to catheter

blockage is unknown, although infection with ureasplitting organisms seems to be a factor. Theoccasional episode is no more than a minor nuisance,but repeated blockage is a major problem calling foractive measures which may include the following,used singly or in combination: (1) A high fluidintake. (2) More frequent catheter changes-if a

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silicone or silicone coated catheter blocks regularlyin less than 4 weeks, a latex type is substituted andchanged every 1 to 2 weeks. (3) Bladder washoutsusing tap water (preboiled), aqueous chlorhexidine,noxytiolin, or Renacidin, the last being theoreticallythe most likely to be effective. The frequency ofwashouts depends on the scale of the problem andthe response obtained, and varies from daily toweekly. (4) Long term administration of a mildurinary antiseptic, such as hexamine hippurate, isoften beneficial. (5) Especially in adolescents,repeated episodes of catheter blockage call forcystoscopy and endoscopic removal of any stones or

debris.

Catheter bypassing and extrusion. Bypassing, whereurine passes around as well as through the catheter, isoften mistaken for blockage and treated inappro-priately. Both bypassing and extrusion ofthe catheterwith the balloon inflated have a common origin,namely, detrusor spasm, which is stimulated by thepresence of the catheter and sometimes exacerbatedby a lower urinary tract infection. These compli-cations are therefore limited to patients with reflexdetrusor activity and can be anticipated when there isa positive anocutaneous reflex.

It is wrong to try to overcome these problems byincreasing the balloon size since this only increasesthe detrusor spasm. Correct management consists ofminimising balloon size (usually to 5 ml) and longterm administration of a detrusor antispasmodic, ofwhich propantheline is the best available. Moreeffective is oxybutynin, which will probably becomeavailable in the UK shortly.

Urethral complications. These we have seen in boysonly, two developing erosion of the ventral anteriorurethra to give a hypospadias-like deformity andone an anterior urethral diverticulum. Urethralcomplications can occur in girls if drainage problemsare treated by ever increasing the calibre of thecatheter-a policy which leads to a wide, patulous,and unmanageable urethra. Certainly it is proper toreview regularly the calibre of the catheter as thechild grows, but, we emphasise that this should never

exceed 18 FG.

Results of long term catheterisation

At the present time 71 of our patients use an in-dwelling catheter. Fifty three experience virtually no

problems, 13 have occasional complications, while 5have frequent difficulties but prefer a catheter toother forms of treatment. Eleven patients hadsatisfactory catheter drainage for a year or more,but later changed to other management either

electively or as a result of complications; 6 of theseare now established on clean intermittent selfcatheterisation. In 18 cases catheterisation wasabandoned in less than a year because of variouscomplications of which blockage was the mostcommon. Most of these early failures occurred someyears ago and with our present knowledge it isprobable they would now be handled more success-fully with a catheter.

Bladder function. There is a belief that long termcatheterisation may result in irreversible loss ofbladder capacity. Our experience has been that ifuseful function exists before catheterisation it isretained and that long term catheterisation does notpreclude clean intermittent self catheterisation laterif this is feasible.

4-

3-

Lfl

0X

eefore catheter After catheterdrainage drainage

IVU appearances - Grade O Normal upper tractGrade 1 Ureteric distensibility onlyGrade 2 Ureteric +pelv icaliceal dilotation -

Grade 3 Ureteric + pelvicaliceal dilcatation-modeZrlieGrade 4 Ureteric + pelvicaliceal dilatation-

severe

Grade 5 Non -funct ion

Fig. 1 Effects ofcatheterisation on intravenousurogram (IVU) appearances ofindividual renal units inpatients with unilateral or bilater-al upper renal tractcomplications (23 patients, 38 renal units).

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Upper renal tracts. Of our patients managed with acatheter for a year or more, 56 were treated purelyfor incontinence and had normal upper renal tracts.Only 3 have subsequently shown any deteriorationof the intravenous urogram (IVU) appearances afterperiods of catheter drainage which range from 1 to13 years.

Progress of 23 patients who had establishedhydronephrosis (38 renal units) before catheterisationis shown in Fig. 1. Follow up in these cases rangedfrom 1 to 10 years and averaged 4.1 years.Included in this group are 12 patients (14 renal units)with grade II or III vesicoureteric reflux and theyhave fared as well as those without reflux eventhough cystography has shown that reflux mayremain unchanged after several years of catheterisa-tion (Fig. 2). So far in only one patient has the im-provement not been maintained: this girl presented inrenal failure, improved considerably for 6 yearsafter catheterisation, and then suddenly died fromrenal failure.

Three patients were catheterised after urinaryundiversion. In two of these the intravenous urogram

appearances have deteriorated, but this is thought tobe entirely due to the surgical procedure.

In terms of preservation of renal function ourresults with indwelling catheters compare favourablywith those of urinary diversion and appear to be atleast as good as those obtained by any other methodof dealing with bladder outlet obstruction. This,despite the many episodes of bacteriuria, supportsthe contention that the prime cause of renaldeterioration in patients with congenital neuropathicbladder is outlet obstruction rather than urinaryinfection. Because of the satisfactory results, wemonitor the upper renal tracts in these patients lessfrequently than previously when it was our practiceto repeat intravenous urograms at one to two yearintervals. As with other units, we are turning toultrasound and isotope renography to monitorupper tract anatomy and function, and now reckonto do this at three to five year intervals unless there issome specific indication for more frequent study.

Bowel management

There is little point in keeping patients dry with

Fig. 2 Left: Girl aged3years, thoracolunibar myelomeningocele. IVUshowing bilateral hydronephrosis, rightgrade 3,left grade 4, associated with bilateralgrade III vesicoureteric reflux. Right: Same patient; IVUafter 6 years ofcatherisation showing resolution ofthe hydronephrosis. A cystogram has shown the reflux to be unchanged.

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catheters if they remain dirty with their bowels.What little has been written on this topic is somewhatopaque. Our policy is simple and generally effective.If the anocutaneous reflex is positive, a bisacodylsuppository or rectal solution is administered,usually on alternate days. This should give a goodbowel action within 30 minutes, and no more untilthe next administration. If the reflex is negative andthe motor neurological level is above D12 a manualevacuation is performed, usually daily. If the motorlevel is below D12 the patient has to strain to defecatedaily, but may also need to do a manual evacuationif this manoeuvre does not completely empty therectum. Bran, senna, etc may be helpful in somecases but are secondary to the basic scheme oftreatment.

Envoi

Use of indwelling urethral catheters has receivedremarkably little attention in published reports'01'and there undoubtedly remains a general distaste forthis method of management which stems partly fromthe practical problems it engenders and partly froman exaggerated view of the importance of bacteriuriain these patients. It is hoped that this article will helpanswer these objections.

Certainly the proportion of our patients requiringcatheterisation has declined with the advent of moremodern methods of treatment and will decline stillfurther as a result of a selective policy of treatingmyelomeningocele. Nevertheless, it is an effectivemethod of achieving dryness and maintaining renalfunction, and for the more severely disabled girlsit is likely to remain the most realistic form ofmanagement.

References

1 Middleton A W, Jr, Hendren W H. Ileal conduits inchildren at the Massachusetts General Hospital from1955 to 1970. J Urol 1976; 115: 591-5.

2 Elder D D, Moisey C U, Rees R W M. A long-termfollow-up of the colonic conduit operation in children.BrJ Urol 1979; 51: 462-5.

3 Rickwood A M K. Urinary diversion in children. In:Ashken M H, ed. Urinary diversion. Berlin: Springer,1982: 22-58.

4 Eckstein H B, Molyneux A. Intermittent catheterisationof the bladder for urinary incontinence. Z Kinderchir1982; 37: 143-4.Barrett D M, Furlow W L. Management of severe urinaryincontinence in patients with myelodysplasia by implan-tation of AS 791/792 urinary sphincter device. J Urol1982; 128: 484-6.

6 Rickwood A M K, Thomas D G, Philp N H, Spicer R D.A system of management of the congenital neuropathicbladder based upon combined urodynamic and radio-logical assessment. BrJ Urol 1982; 54: 507-11.Lonton A P. Location of the myelomeningocele and itsrelationship to subsequent physical and intellectualabilities in children with myelomeningocele associatedwith hydrocephalus. Z Kinderchir 1977; 22: 51-7.

8 Kass E H. Bacteriuria and the diagnosis of infections inthe urinary tract. Arch Intern Med 1957; 100: 709-14.McCleod J W, Mason J M, Neill R W K. Survey of thedifferent urinary infections which develop in the paraplegicand their relative significance. Paraplegia 1965; 3: 124-43.

10 Forrest D M, Tabara Z. The indwelling catheter-areappraisal. Z Kinderchir 1980; 31: 397-402.Minns R A, Oag J C, Duffy S W, Brown J K, Stark G,McClement E. Indwelling urinary catheters in childhoodspinal palsy. Z Kinderchir 1980; 31: 387-97.

Correspondence to A M K Rickwood FRCS,Spinal Injuries Unit, Lodge Moor Hospital, SheffieldS10 4LH.

Received 10 January 1983

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