Gaining Continence in a Child with Spina Bifida
By Kimberly Jarczyk, MSN, CPNP, ARNP
Worldwide, approximately one out of every 1,000 children will be born with Spina Bifida. Spina Bifida is the incomplete formation of the spine that can reslut in damage to the spinal cord. Spina Bifida affects many body systems since the spinal cord governs many bodily functions. The bowel and the bladder are frequently impacted because the nerves that control the lower bowel and the bladder reside at the lowest portion of the spinal cord and these are almost always involved. The specific nerve fibers which are damaged will determine the degree to which normal bowel and bladder function is disrupted. In most instances of Spina Bifida there is abnormal function of the bladder (neurogenic bladder) and bowel function (neurogenic bowel), resulting in incontinence of urine and stool. Achieving continence is an important part of normal growth and development as well as helping to establish early self-esteem. Toilet training in the child with Spina Bifida should be attempted at the same age as children without spinal cord problems. A main goal of therapy should be to help the child gain continence with as little disruption in lifestyle as possible, in a manner that allows the child to independently manage his/her self-care as early as possible.
Neurogenic Bladder
Careful monitoring and management of neurogenic bladder throughout one's lifespan is essential to preserve healthy kidney function and gain and maintain continence. Bladder function in children with Spina Bifida can change over time, therfore, tests are performed at regular intervals to identify potential problems, monitor bladder dysfunction, and guide therapy. The two main tests are kidney/bladder ultrasound an urodynamics. Kidney and bladder ultrasounds are important to assess the general health of the urinary system. Urodynamics measures bladder pressures and function as well as urinary sphincter function, and is very helpful in guiding proper therapy.
Some individuals with Spina Bifida have poorly compliant (less elastic) bladders that often hold urine under higher than normal pressure. Untreated, this poses and increased risk for kidney damage due to high bladder pressures, and can elevate the chance for recurring urinary tract infection if there is incomplete emptying of the bladder. Intermittent catheterization (IC) is used to empty the bladder. IC at timed intervals helps to keep bladder pressures low, may prevent incontinence, and can lessen the occurrence of significant urinary tract infection. IC is performed by carefully placing a small latex free catheter into the urethra (the tube that carries urine from the bladder to the outside of the body) and immediately removing the cateter once the bladder is empty. Because the urethra is generally numb in children with Spina Bifida, this does not usually cause discomfort. Medications that help the bladder relax may be of benefit.
Many individuals with Spina Bifida have bladders that leak. Gaining and maintaining continence generally requires:
- Use of medication that help the bladder relax, which are given either by mouth or placed directly in the bladder
- Intermittent catheterization
- Possibly surgery to increase the size of the bladder (augmentation), improve the sphincter or help bladder outlet resistance.
If the bladder is augmented, or increased in size for greater capasity, it will need to be washed out and emptied via regular intermittent catheterization. At the time of augmentation, a channel connecting the bladder to the skin can be created to make the process of catheterization easier and promote self-care. This technique is known as the Mitrofanoff procedure.
Neurogentic Bowel
There are two major types of neurogenic bowel, Reflexic and Areflexic. A test called an Anal-rectal manometry can be used to determine the degree to which the rectal sphincter (thick muscle fibers in the rectum just above the anus) has been affected and can help direct therapy; however, achieving continence for stool in the child with neurogenic bowel is a process of trial and error.
Children with high spinal cord involvement often have a rectal sphincter that is closed and can hold stool in although there is no sensation of stool in the rectum and they cannot consciously relax the sphincter to empty the rectum. Daily rectal stimulation may be sufficient to help these children achieve continence.
Areflexic SphincterChildren with low spinal cord involvement often have a rectal sphincter that does not close and cannot hold stool in. They have no sensation when there is stool in the rectum. Whatever moves through the bowel into the rectum leaks out. Keeping the stool formed and soft is important since maintaining continence is not possible in the presence of diarrhea.
Steps to achieve continence for stool are as follows:
- A combination of regulating the consistency of the bowel motion by balancing fiber intake and stool softening agents and having the child sit on the commode after meals may be effective.
- Rectal stimulation using a lubricated gloved finger to stimulate the wall of the rectum, or suppository therapy may be effective.
- Enema therapy using a special enema administration device may be effective. A cone enema or continence catheter act as a plug to keep the enema solution in the rectum long enough to work. Studies have shown these maintain continence in 68% to 73% of individuals who use them.
- An antegrade continence enema (A.C.E.) requires a surgery to create a tube or insert a small button that connects the cecum (the beginning of the large intestine) to the abdominal wall. Enema solution is put through this stoma or button every day to every third day. The enema solution flushes out the entire colon. Studies have shown this maintains continence in 95 to 97% of the individuals who use it.
The most frequent barrier to achieving continence in children with Spina Bifida is constipation. Constipation increases susceptibility to urinary tract infection, and can cause worsening urinary and fecal incontinence, which increases the likelihood of chronic skin irritation and even breakdown. Gaining continence is highly unlikely if the colon is full of stool. The bowel must be cleaned out before starting a bowel or bladder training program. Recurring incontinence for urine or stool in the child with Spina Bifida may indicate ongoing spinal cord problems and requires timely evaluation.
What lies ahead?
A nerve rerouting procedure to restore nerve stimulation to the bowel and bladder is currently being studied.
An excellent comprehensive resource for management of neurogenic bowel and neurogenic bladder in the child with Spina Bifida is available through the Spina Bifida Association. It can be reached toll-free at (800) 621-3141 or online at www.spinabifidaassociation.org
