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BACKGROUND: Over the past two decades, there has been increased awareness of the value of early urodynamic assessment and proactive management of neurogenic bladder dysfunction in children with spina bifida (SB). We sought to determine if children are now being referred for urodynamic (UDS) evaluation at an earlier age than in the past by reviewing both our own practice of when to obtain initial UDS as well as those of physicians in the region who utilize our urodynamic services. We also wished to determine if age at initial assessment had any effect on clinical findings.
METHODS: With IRB approval, we reviewed the records of all pediatric SB patients whose initial urodynamic assessment of record was performed by us during two time periods - 1990-1993 and 2005-2011. The age of the patients at their first UDS assessment was noted and compared between both time periods and between those patients under our direct care and those referred by other physicians solely for UDS evaluation. Determination that this was the child’s first UDS evaluation was by medical record review and confirmed by parent attestation.
RESULTS: Between1990-1993, 72 children (35F, 37M) were studied urodynamically for the first time. Their mean age was 7.4 years (range 15 months-21 years) including 2 (2.8%) who had already undergone bladder augmentation. Since all of the children during that time period were from our institution’s SB clinic, we viewed them as non-referred patients. Between 2005-2011, we performed initial urodynamic evaluations on 83 children (39F, 44M) including 36 patients under our direct care and 47 under the care of other physicians. Amongst our group during the most recent time period, the mean age was 7.1 months (range 1-24 months) including 20 (56%) studied within the first 6 months of life. None had prior urologic surgery; only 4 (11%) had mild hydronephrosis and none had renal insufficiency. In the referred group, the mean age was 7.8 years (range 1 month-18 years); 8 (17%) had prior augmentation surgery, 18 (38%) had hydronephrosis and/or VUR grade 3 or higher, 5 (11%) had renal insufficiency.
CONCLUSIONS: Although we have dramatically changed our own practice over the past 2 decades regarding obtaining urodynamic assessment as early as possible in children with SB, no similar decrease in age at initial UDS evaluation was noted in patients referred by outside physicians. It is not clear the reasons underlying why some patients are not evaluated urodynamically earlier in life. What is clear is that there is a significant clinical price to be paid for failing to do so, and underscores the need to educate all clinicians caring for SB patients on this subject as well as the importance of developing standard of care guidelines.