Clinical Course of Pediatric Patients with Neurogenic Bladder in Yemen

1. Introduction

Neurogenic bladder refers to lower urinary tract dysfunction (LUTD) resulting from neurological disorders affecting the central or peripheral nervous system. Lower urinary tract symptoms are common in patients with neurological disease and significantly impair quality of life [1]. The heterogeneous clinical presentation reflects the complexity of neural regulation of the lower urinary tract, with the type and severity of dysfunction largely determined by the level and extent of the neurological lesion. Neurogenic bladder, also termed neurogenic lower urinary tract dysfunction (NLUTD), represents a major medical and social challenge in pediatric populations, arising from conditions such as spina bifida, spinal cord injury, cerebral palsy, and central nervous system infections [2,3].

Loss of supraspinal control commonly results in neurogenic detrusor overactivity (NDO) and detrusor sphincter dyssynergia (DSD), leading to elevated bladder pressures during storage and voiding. Persistent high intravesical pressure is a key factor in the development of vesicoureteral reflux, upper urinary tract dilatation, progressive bladder remodeling, and subsequent renal impairment or failure [3,4]. Spina bifida remains the most frequent cause of pediatric neurogenic bladder worldwide, with an incidence ranging from 0.3 to 4 per 1,000 live births. Renal damage often begins early in life, frequently within the first six months, and remains the most serious long-term complication if appropriate management is not instituted [5].

Advances in early diagnosis and treatment have markedly improved outcomes in children with neurogenic bladder. Conservative management with clean intermittent catheterization and anticholinergic therapy remains the cornerstone of treatment, aiming to convert a high-pressure bladder into a low-pressure, compliant reservoir to preserve renal function [6]. In patients who do not tolerate oral anticholinergics or experience inadequate response, intravesical oxybutynin has been shown to be an effective alternative, while surgical interventions are reserved for refractory cases or established complications [7,8,9,10,11].

Despite these advances, chronic renal failure remains a major complication of inadequately managed pediatric neurogenic bladder, particularly in resource-limited settings. In Yemen, there is a paucity of published data on the clinical course and renal outcomes of affected children, despite a substantial disease burden. Limited access to early diagnosis, specialized multidisciplinary care, and structured follow-up contributes to preventable progression to irreversible renal damage and end-stage renal disease. This study aims to evaluate the clinical course and renal outcomes of pediatric patients with neurogenic bladder in Sana’a city, with particular emphasis on the incidence of renal impairment and chronic renal failure.

2. Materials and Methods

Patients and Methods

Study Design and Setting

This multicenter cross-sectional descriptive study was conducted to evaluate the clinical course and renal outcomes of pediatric patients diagnosed with neurogenic bladder. The study was carried out between January and December 2024 across multiple governmental and private hospitals, pediatric nephrology clinics, urology and neurology outpatient services, rehabilitation centers, and dialysis units in Sana’a city, Yemen. The multicenter design was intended to capture real-world clinical practices and variations in follow-up and management strategies.

Study Population

Children aged 2–15 years with a confirmed diagnosis of neurogenic bladder of congenital or acquired etiology were eligible for inclusion. Patients were identified during routine outpatient follow-up visits or through retrospective review of medical records in dialysis units. Exclusion criteria included age <2 or >15 years, primary congenital anomalies of the urinary tract unrelated to neurogenic bladder, previous lower urinary tract reconstructive surgery, and incomplete medical records that precluded reliable assessment of renal function. These criteria were applied to ensure population homogeneity and comparability with previously published pediatric neurogenic bladder studies.

Data Collection and Clinical Assessment

Data were collected using a standardized, predesigned data collection sheet. Variables included demographic characteristics, underlying neurological diagnosis, duration of neurogenic bladder, bladder management strategies (catheterization methods and pharmacological therapy), history and frequency of urinary tract infections, continence status, and follow-up with pediatric nephrology or urology services. Information was obtained through structured interviews with parents or caregivers and systematic review of medical records.

Renal Function Assessment

Renal function was assessed using serum creatinine measurements and estimated glomerular filtration rate (eGFR). eGFR was calculated using the pediatric height-based Schwartz formula (eGFR = K × height [cm] / serum creatinine), applying K values of 0.7 for males and 0.5 for females. Renal impairment was classified according to established pediatric chronic kidney disease staging guidelines.

Radiological Evaluation

Renal and urinary tract status was evaluated by reviewing available imaging studies, primarily renal and bladder ultrasonography and voiding cystourethrography when available. Imaging parameters included hydronephrosis, hydroureter, vesicoureteral reflux, bladder wall thickening, and kidney size. Ultrasonography was selected as the principal imaging modality due to its safety, availability, and established role in longitudinal monitoring.

Outcome Measures

The primary outcome was the presence of renal impairment or chronic renal failure. Secondary outcomes included radiological evidence of upper urinary tract deterioration and the relationship between regular multidisciplinary follow-up and renal status.

Ethical Considerations

The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the local institutional ethics committee/health authority (approval code: to be provided upon acceptance). Written informed consent was obtained from parents or legal guardians prior to enrollment. Patient confidentiality was maintained through anonymization of all collected data.

Data Availability

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. No publicly accessible repository accession number is currently assigned.

Use of Generative Artificial Intelligence

Generative artificial intelligence tools were not used in study design, data collection, data analysis, or interpretation. Any language refinement was limited to minor grammar and clarity editing and does not require formal disclosure under journal policy.

Statistical Analysis

Data were coded, entered, and analyzed using the Statistical Package for the Social Sciences (SPSS), latest version. Descriptive statistics were used to summarize demographic, clinical, laboratory, and radiological variables.

3. Results

During the study period, 54 pediatric patients diagnosed with neurogenic bladder were included. The cohort comprised 29 (53.7%) females and 25 (46.3%) males. A majority of patients (59.3%, n=32) resided in rural areas, while 40.7% (n=22) were from urban settings.

The primary etiology of neurogenic bladder was myelomeningocele (MMC), identified in 31 patients (57.4%). Other causes included spina bifida occulta (9.3%, n=5), transverse myelitis (7.4%, n=4), hydrocephalus with meningocele (5.5%, n=3), Down syndrome (3.7%, n=2), and spinal cord injury (1.8%, n=1). In 8 patients (14.8%), no definitive underlying cause was identified (Table 1).

Treatment initiation and follow-up patterns revealed that 35 patients (65%) commenced management and regular follow-up at diagnosis, while 19 (35%) had irregular follow-up. Functional status and disease awareness are summarized in Table 2. The majority of patients (85.2%, n=46) were handicapped. While 63% (n=34) were aware of their diagnosis and its cause, 37% (n=20) lacked this knowledge. Half of the patients (n=27) were capable of self-care, with the other half requiring assistance. Parental care was reported for 23 patients (42.6%).

Neurological and lower urinary tract manifestations are detailed in Table 3. Neurological deficits were present in 77.8% (n=42) of patients, with paraplegia/paresis or lower limb muscle wasting observed in 66.7% (n=36). Sensory level deficiency or loss of sensation was noted in 48.1% (n=26). All patients (100%) reported lower urinary tract symptoms (LUTS), with urgency and frequency being most common (77.8%, n=42). Nocturnal enuresis was reported by 44.4% (n=24).

Difficulty in micturition was reported by all patients. Daily difficulty was noted in 30 patients (55.6%), weekly difficulty in 10 patients (18.6%), monthly intermittent difficulty in 11 patients (20.35%), and rare episodes in 3 patients. Initial management strategies are Foley’s catheterization in 21 patients (38.9%), suprapubic catheterization in 10 patients (18.6%), clean intermittent catheterization (CIC) in 7 patients (13%), and medical treatment alone in 16 patients (29.6%) (Table 4)

For overall management of voiding disorders, indwelling Foley catheters (40.7%, n=22), suprapubic catheters (24.1%, n=13), clean intermittent catheterization (CIC; 16.7%, n=9), and vesicostomy (18.5%, n=10) were utilized (Figure 4). All patients had urinary incontinence, predominantly overflow (44.4%, n=24) and urge (40.7%, n=22) types. (Table 4)

All patients had a history of recurrent urinary tract infection (UTI) and pyelonephritis, with most experiencing 1-3 episodes per year (Table 5). Empirical antibiotic treatment was universal, while prophylactic antibiotics were used in 12.2% (n=5) of patients with vesicoureteral reflux (VUR).

Renal impairment was universal, with 90% (n=49) diagnosed with chronic kidney disease (CKD). Symptoms were present for >3 years in 64.8% (n=35) of patients. Three patients (5.6%) required regular dialysis (Table 6).

Imaging findings confirmed hydronephrosis in all patients. Vesicoureteral reflux (VUR) was present in 92.6% (n=50) of patients, predominantly bilateral (86%, n=43). Small kidney size was noted in 46.6% (n=24) of cases (Table 7).

Descriptive Statistics

The mean age of the study population was 8.60 ± 3.18 years. The mean age at onset of LUTS, UTI, and VUR was 3.39 ± 1.68 years. The mean duration since diagnosis of chronic kidney disease was 2.92 ± 1.26 years. The mean serum creatinine level was 2.19 ± 0.89 mg/dL, and the mean calculated creatinine clearance was 36.94 ± 22.59 mL/min/1.73 m² (Table 8).

4. Discussion

Neurogenic bladder dysfunction in children is known to predispose patients to progressive upper urinary tract deterioration if not managed appropriately from an early stage. Although the upper urinary tract is typically normal at birth, sustained high intravesical pressures, poor bladder compliance, detrusor overactivity, and detrusor–sphincter dyssynergia may result in renal damage and eventual chronic kidney disease. Early diagnosis and timely intervention are therefore essential to preserve renal function and prevent long-term complications [12].

In the present study, myelomeningocele was the leading etiology of neurogenic bladder, accounting for 57.4% of cases. This finding is consistent with international and regional studies reporting spinal dysraphism, particularly MMC, as the most common cause of pediatric neurogenic bladder. Olandoski et al. reported MMC in 71.4% of Brazilian children with neurogenic bladder, while Cass et al. documented MMC in 78.2% of a large cohort of 413 patients. The lower proportion observed in our study may reflect differences in referral patterns, diagnostic availability, or regional epidemiology [13,14].

The female predominance observed in this cohort (53.7%) is comparable to findings reported by Olandoski et al., who noted a female proportion of 56.9%. In contrast, Kari reported a male predominance in a Saudi cohort. The mean age of patients in our study (8.6 years) was higher than that reported by Olandoski et al. (4.2 years) and Kari (6.2 years), suggesting delayed presentation and referral in our setting, which may have contributed to the advanced disease manifestations observed [13,15].

Recurrent urinary tract infections were universal in our patients and frequently severe, with most children experiencing multiple episodes annually. Similar findings were reported by Ghoniem et al., who documented UTI in 70.5% of patients with MMC, and by Kari et al., who reported a mean of 4.5 UTIs per year. The higher frequency and severity of UTIs in our cohort likely reflect delayed initiation of bladder management strategies and limited access to culture-guided antibiotic therapy [16,17].

Neurological deficits were common in this study, with two-thirds of patients exhibiting paraplegia or paraparesis, findings comparable to those reported by Kari et al., where nearly all patients were paraplegic. The high prevalence of neurological impairment underscores the strong association between the severity of neurological injury and bladder dysfunction, as well as the increased risk of renal deterioration in these patients [17].

Imaging findings in our cohort demonstrated a high prevalence of hydronephrosis and vesicoureteral reflux, with bilateral VUR present in the majority of patients. Similar imaging patterns were described by Kari, who reported bilateral hydronephrosis and VUR in all studied children. In contrast, Dik et al. and Lewis et al. reported lower rates of renal scarring in populations where early bladder management and CIC were more widely implemented. The markedly higher burden of upper tract damage in our study likely reflects delayed diagnosis and suboptimal early intervention [15,18,19].

Chronic kidney disease was identified in 90% of patients in this study, with a small proportion requiring renal replacement therapy. This rate is considerably higher than that reported in other regional studies, where earlier referral and structured follow-up reduced progression to end-stage renal disease. Kari reported that one-third of children required dialysis, while the majority of our patients remained on conservative management despite advanced CKD. These findings suggest differences in disease trajectory, access to dialysis services, and timing of intervention [15].

Delayed initiation of clean intermittent catheterization and anticholinergic therapy appears to be a major contributing factor to the poor renal outcomes observed. Previous studies have demonstrated that early CIC initiation significantly reduces the risk of VUR, recurrent UTIs, and renal scarring. However, cultural, psychosocial, and educational barriers, as highlighted by Dik et al. and Kari, often limit acceptance of CIC, particularly in resource-limited and conservative settings. The findings of the present study further emphasize the need for early, aggressive bladder management and improved parental education to protect renal function in children with neurogenic bladder [15,18].

Despite its multicentric design, the relatively small sample size may limit generalizability. The observational nature of the study and reliance on clinical records may have introduced information bias, particularly regarding prior infections, treatment adherence, and timing of interventions. Variability in management and follow-up across centers also limited assessment of long-term outcomes.

5. Conclusions

Pediatric neurogenic bladder in Yemen is associated with a high burden of renal morbidity, largely related to delayed diagnosis, inadequate early bladder management, and inconsistent follow-up. In this study, most patients presented with advanced lower urinary tract dysfunction, recurrent urinary tract infections, vesicoureteral reflux, and established renal impairment, with myelomeningocele as the predominant etiology. These findings underscore the importance of early identification, prompt initiation of clean intermittent catheterization and anticholinergic therapy, and sustained multidisciplinary follow-up to preserve renal function. Improving caregiver awareness and access to specialized pediatric urology and nephrology services is essential to reduce preventable progression to chronic kidney disease in this vulnerable population.