Two important functions of urinary bladder are

• Storage of urine
 
• Evacuation of urine at the socially acceptable proper time

The co-ordinated neurological control of bladder functions are under control of sympathetic, parasympathetic motor and sensory nerves and three separate centers in spinal cord (segments L1-S4), brain stem and central nervous system. During maturation the bladder and bowel control is achieved by sequential achievements as follows:

• Initially involuntary voiding till 6 months
 
• Subconscious inhibition by 2-3 yeas of voluntary voiding
  
  
  • Nocturnal bowel control
    
    
  • Daytime bowel control
    
    
  • Daytime bladder control
    
    
  • Nocturnal bladder control

By three years of age, almost all children achieve daytime bladder control and by seven years less than 10% remain enuretic at night.


When to suspect neurogenic bladder?

In all children with myelodysplasia, obstructive uropathy, VUR, recurrent UTI.

Abnormal neurogenic control of bladder results in daytime and/or nighttime enuresis or incontinence or voiding dysfunction.

The causes of voiding dysfunctions are

• Neurogenic causes: Meningomyelocele, lipomeningocele, spina bifida, sacral agenesis, diastematomyelia, tethering of spinal cord, Arnold Chiari malformation, trauma to spinal cord and rarely tumors of spinal cord.
  
  Many of these conditions are associated with abnormal findings on neurological examination of lower extremities, abnormalities of feet, tuft of hair, nevus or dimple in the region of lower back and bowel dysfunction.
 
• Non-neurogenic causes: Neuropathic or non-neurogenic / neurogenic bladder or Hinman's syndrome, monosymptomatic nocturnal enuresis, psychologic disturbances.
  
  UTI, obstructive uropathy, vesicoureteral reflux, polyuric syndromes can easily be detected by good history, physical examination, urine culture and radiologic studies.

Evaluation of a child suspected of neurogenic bladder

• Detailed history of voiding habits including wetting the bed and clothes, dribbling, urgency, hesitancy, posture adopted to stop voiding like crossing the legs, pressing the perineum with heel etc. (Hinman's)
  
  Frequency of voiding, fluid intake and constipation or bowel incontinent, recurrent urinary tract infections, onset of enuresis, F/H enuresis.
 
• Physical examination: Examination of spine and skull, foot deformities (club foot).
  
  
  • Abdominal examination for renal lumps (hydronephrosis), distended firm bladder, genital abnormalities
    
    
  • Neurological examination for spastic paraplegia or flaccid paraplegia, sensations in perineal area, anal sphincter, posture and gait.