Which of the following is not true, with respect to myelomeningocele?
A. A low detrusor leak point pressure is associated with a worse outcome for the upper tractsAnswer A
The detrusor leak point pressure is the lowest pressure at which leaking occurs without detrusor contraction or rise in abdominal pressure. Pressures over 40 cm of water are associated with increased risk of upper tract damage.
Poor bladder emptying is most reliably managed with urethral intermittent catheterisation. This can be very daunting for the patient and the parents. However a good clinical nurse specialist can be surprisingly successful in even the most anxious children. Teaching clean intermittent catheterisation to the parents of all infants with myelomeningocele within the first year will avoid the problems of having to teach an older and more reluctant child. The first line treatment of detrusor over-activity is anti-muscarinic medication. Although oxybutynin is probably the most commonly used, tolterodine is also frequently effective.
Botulinum toxin is increasingly being used in the management of neurogenic detrusor overactivity. Treatment is administered under general anaesthesia, and requires repeating. It is best reserved for those who do not tolerate or respond to anti-muscarinics.
Ileocystoplasty is a very effective treatment of unsafe bladder storage. It is a significant undertaking. Those treated this way will have increase urinary mucus, and face increased risk of infection, stones, alkalosis, Vitamin B12 deficiency, bladder rupture and possibly malignancy. Although there is a risk of infection of ventriculoperitoneal shunt, this is not a contraindication to ileocystoplasty.