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Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're highlighting urologic management of spina bifida in pediatric patients. Joining me is Dr. Cynthia Sharadin. She's a pediatric urologist on staff at UF Health Shands Hospital. Dr. Sharadin, it's a pleasure to have you join us. As we get into this topic, and it's important and interesting, can you explain the common urologic issues that are associated with spina bifida in pediatric patients? How does it impact their development and function of the urinary system in these children?

Cynthia Sharadin, MD: Yeah. Well, first of all, thank you for having me. So in addition to some of the other systems that are impacted by spina bifida, the urologic implications are mainly the effect on the bladder kind of at the front of all of our concerns. And because we often manage or monitor the sequelae of this, we also deal with the effects on the bowel urologically. So, the bladder is the main affected organ that is so central for the health of the kidneys. In addition to, there's also potential sexual function effect that can be managed urologically that we generally address when they're older.

Melanie Cole, MS: Well, then what are the goals of urologic management? Is this quality of life? You said that the bladder could affect function of the kidneys. Tell us a little bit about your really ultimate goals in management.

Cynthia Sharadin, MD: Sure. Yeah. There are a few well-established goals as probably little ones that come along the way. But our number one goal is to preserve renal function. A lot of these children several decades ago were struggling or having early complications and, frankly, early dialysis and then complications or even death from that.

So, our number one goal is preserving renal function that can be impacted by how the bladder empties or the pressures of the bladder and cause some secondary what we call upper tract abnormalities or recurring urinary tract infections, mainly febrile infections that can affect that. And then, the other goals are to help with encouraging or finding for the patient and their family's independence as well as continence or control of the bladder and bowels and also to help with urinary tract infection prevention.

Melanie Cole, MS: As we get into this, how do you assess the risk for Kidney damage or other complications you were just speaking of in these patients? And how important is early intervention in managing these urologic situations and outcomes?

Cynthia Sharadin, MD: There are actually several ways that we assess for the risk, as far as the kidney damage or concern and part of renal preserve. There are a few images that we generally turn to that help assist in that workup. Renal scans, the nuclear medicine renal scans are a part of that workup and part of monitoring sometimes of these patients as well. Ultrasound is probably the most common and most frequent. Even though it's technically a snapshot, there's a lot we gain from this, and it's minimally invasive. It doesn't require an IV or other poking or prodding aside from the little, you know, belly scans. And that's kind of our stethoscope in these patients.

Those are the most kind of useful as far as the imaging we order. And then, on top of that, I think truthfully the most important tool that we use to assess very objectively for the risk to the kidney damage is a study called the urodynamics. And that's a pretty fancy study that involves different catheters and probes and a pretty intelligent machine to help with looking at what actual bladder pressures are. It's a dynamic study. I know it's part of the name. But in that, patients need to be awake for it because there's a participation that's involved in understanding their ability to sense or to feel filling and while monitoring the pressures and if they're at safe levels. Early intervention generally serves to protect and preserve the renal function. So, it is really important that we monitor and don't react to say those ultrasounds, for instance, if things look more concerning. That's why we like to kind of have a routine check, especially as they're growing pretty rapidly early in childhood. Occasionally. Early intervention, especially with larger interventions like reconstruction can be a little bit of a double-edged sword. You know, if having undergone earlier, that might provide some improvement early on. But sometimes you know, if they don't grow into it well, so to speak, they will often require maybe more revisions or interventions or have other complications from the reconstructions themselves.

Melanie Cole, MS: Well, then let's talk about some of the key treatment strategies for managing that neurogenic bladder in these patients. What about intermittent catheterization, medicational intervention. At what point do these come into play as treatment strategies?

Cynthia Sharadin, MD: So, the key strategies as far as protection of the kidney, and then usually what comes secondarily with that is then a little bit of that continence part of things. But generally, low bladder pressures and increasing bladder capacity or storage, so more that they can hold. Those are what generally help with that safety and preservation. And then, we generally get a secondary effect of continence. And there are some kids who don't have high pressure issues or concerns for the renal tract, but who maybe their bladder, even though it's low pressure, doesn't hold a lot. And so, we'll intervene on those too for that dependence and kind of socially acceptable dry or drier state.

Yes, we do have a few things that we generally turn to very commonly intermittent catheterization that that introduction has improved greatly the renal function preserve just by helping with emptying at low pressures. So, that ticks that box and emptying more completely, because sometimes these kids don't empty all the way, even if they can empty some.

And the other medications that are often turned to, to help again with lowering pressure or increasing the bladder capacity or storage are anticholinergics, which we see often too in the adult space for different types of overactive bladder symptoms. But anticholinergics or beta adrenergic medications, and those both really help with capacity and lowering the pressures in the bladder. Sometimes, however, they're not enough or they come with some side effects that are not really tolerated well in these children. So, we may have to turn to other, what we call minimally invasive options, like injecting into the bladder directly, different types of medications.

And then, another common medication that we have to use is antibiotics. You know, prophylactic antibiotics helps in those kids who were still trying to figure out what their regimen is as far as the bladder management concern and emptying, all of that. And those kids who are at, a higher risk for urinary tract infection. We put them on antibiotic prophylaxis to help decrease the bothersome symptoms, but mainly to help decrease infections that are causing fevers. Those generally are what over time constantly will affect and impact that renal health.

Melanie Cole, MS: How do you decide then when surgical intervention might be necessary?

Cynthia Sharadin, MD: Yeah. So when they fail medical therapy, essentially generally, if we're intervening, it's because of something in the clinical history they're sharing with us, or something that we're seeing on the ultrasound imaging, or the renal scans, or the urodynamics. So generally, after we put them on a medication, we follow up whatever study sort of, inspired us to go down that route to see if there's actual objective improvement. And if there's not, and there's still need for more capacity or decreasing pressures, then we consider those larger interventions.

As I mentioned a little bit earlier, there are some what we call endoscopic injections that we can do, so no big cuts or incisions, that can be actually pretty effective. But if they can't tolerate that either, then we move on to bigger reconstructive surgeries or including channels that help with providing independence or bladder augments, which is basically patching some bowel on to increase that capacity if they don't seem to be responding to the medications or injectable medications.

Melanie Cole, MS: Dr. Sharadin, as you're telling us all of this and one important factor is as these children grow, certainly their urologic needs change, how do you monitor that urologic health as they grow into adolescence and adulthood and transition into adult care? Because we talk a lot about spina bifida children transitioning to adult care. Tell us in the urologic perspective, what's involved in that?

Cynthia Sharadin, MD: Yeah. Everybody does it a little bit differently. But generally, the follow up is either every six months or every 12 months depending on what the earlier studies have shown kind of in those early first four years of life. The most common followup, kind of the basics or bread and butter, generally involves the ultrasound. And it also involves the renal function labs, mainly the creatinine and cystatin C that are really helpful because sometimes imaging doesn't reflect the function itself. And so, those two are the basic parts of our monitoring on top of symptom checks to see how happy are they with what's going on.

The Spina Bifida Association, kind of a bigger national consortium that helps provide both for providers as well as for families a kind of central location of information. They have a really great kind of outline and guideline on what things to maybe be addressing at certain ages. And that's generally around where I fall unless I meet a patient later. But some of the things that we start talking about early on, especially if they're already catheterizing or requiring medications, those are generally going to be lifelong medications, unless they eventually want to undergo reconstruction. You know, generally, we start talking about transition early around 13 years of age is when we mention in the next couple of years, we might have you visit or to meet an Adult Urology provider, you know, so they can start getting to know you. You're still going to follow up with us, we're still the manager of your care. And so, that they can expect and prepare for that around age 15 or 16 as it's getting closer. We still plan for that and some of our patients who are maybe kind of turning down a road where they might need intervention so that in case they do need something more, we'll still follow them probably a little bit longer past that age mark, which is very different depending on your facility, anywhere from 18 to 22, or even a little bit later. But that way, you can start to smooth out the care of what has happened with them and what they need to know moving forward.

Melanie Cole, MS: Dr. Sharadin, this has been such an interesting conversation. I'd like you to summarize for us with key takeaways for other providers and the importance of the role of a multidisciplinary team in managing urologic issues in patients with spina bifida, certainly pediatric patients. How do you collaborate with all of these other specialties and give us the key takeaways, what you think is most important for other providers to hear.

Cynthia Sharadin, MD: Yeah. So, spina bifida is a very varietal presentation, meaning that it affects every patient a little bit differently and a little bit more or less intensely. There are multiple organ systems that are usually affected, urology being probably the most common. And even if it doesn't seem necessary, it's one of those silent things that we have to make sure we're at least on board early on to say if it's safe or not. From the multidisciplinary standpoint, these patients go on to, generally, require assistance or help from the orthopedic team, the physical therapists, neurosurgery, nutrition, wound care from different, you know, mobility limitations, even nephrology, behavior therapy, and psych support. Those can be really helpful to provide care to our patients and institutions that have a true multidisciplinary team with all of those involved. It helps to provide kind of a one-stop shop care for the patient and to allow for faster facilitated discussions on some of the management options for maybe acute issues that are coming up that may involve one or more specialists.

I think the takeaway is that If you meet a patient who has the diagnosis of spina bifida, maybe mild, maybe they've been doing great, and they're new to you at say like 12 years of age and, nope, they haven't seen, you know, an orthopedic surgeon or a urologist or a neurosurgeon in several years, and they seem to be doing fine, there are some things that subtly happen under the surface, especially with the bowel and bladder stuff, that it's always reasonable to start with getting an ultrasound and looping Urology back in, even if to just make sure they are still safe and important things to look out for as they go into adulthood.

Melanie Cole, MS: Thank you so much, Dr. Sharadin. That was a very enlightening conversation and very educational. Thank you so much. And that concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other health care topics at UF Health Shands Hospital, you can always visit innovation.ufhealth.org. And to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. I'm Melanie Cole. Thanks so much for joining us today.