Irene Kalil (IFF/Fiocruz)
A group of researchers from the National Institute of Women, Children and Adolescents Health Fernandes Figueira (IFF/Fiocruz), led by the physician Lucia Monteiro from the Pediatric Urodynamics Outpatient Unit, published an article in the international journal Plos One with new results confirming changes that interfere with the normal bladder functioning in infants born of women infected with the zika virus during pregnancy. This is the first global report about urologic sequelae associated with the condition of babies with Congenital Zika Syndrome. Until the publication, urinary infection was not a suspected cause of fever and hospitalization in these patients.
Team responsible for assisting urologic patients with Congenital Zika Syndrome at IFF (Photo: Ascom / IFF)
Patients with microcephaly and confirmed diagnosis of Congenital Zika Syndrome monitored in IFF/Fiocruz from June 2016 to May 2017 were include in the initial phase of the study. Of the 22 patients referred for urological evaluation, all had a dysfunction known as neurogenic bladder, which can generate urinary infection, urinary incontinence and even kidney damage if not treated properly. Currently, among patients with microcephaly of IFF Congenital Zika Syndrome Institutional Cohort, 67 had their urinary system evaluated, and of these, only two had a near-normal urodynamic evaluation, although they did not completely empty bladder during urination.
The finding was based on brain magnetic resonance imaging in infants diagnosed with Congenital Zika Syndrome and microcephaly from compromised brain areas that would also be responsible for controlling urination. During the initial urodynamic evaluation, patients showed very high intravesical pressures, which may impede the proper functioning of kidneys, as well as incomplete bladder emptying with urine retention, facilitating the appearance of urinary infections.
The good news brought by the research is that the early treatment of babies with neurogenic bladder has shown effective results, including the possibility of normalizing this organ’s functioning. Urological evaluation enables diagnostic and treatment of high-risk changes to the urinary system. According to the study coordinator, it is very important to investigate the problem as soon as possible. “Treatment response tends to be better when it is done preventively, preferably even in the first year of the child's life,” warns Lucia Monteiro.
In addition to being globally innovative, such results allow us to advance the knowledge of neurogenic bladder and improve the quality of life of children affected by the disease. With the publication, the group of researchers intends to raise health professionals awareness on the urological evaluation inclusion in the care protocol for patients with microcephaly, thus promoting the early diagnosis of the disease and preventing renal failure.
Neurogenic bladder is an alteration of the organ functioning caused by neurological dysfunction that interferes in the mechanisms of filling and/or emptying of urine which causes risks for the patient. In general, these alterations are progressive and may result in injury to the urinary system caused by an infectious (urinary infection) or mechanical (increased pressure within the system and urinary retention) process. However, this is a silent disease, especially in infants. The most frequent symptoms - fever and urinary incontinence - can easily go unnoticed by parents, since other causes of fever and the use of disposable diapers are common in this age group.
The gold standard for neurogenic bladder diagnosis is urodynamic evaluation. It evaluates bladder functioning and the urination process that allow to evidence risk situations. An early diagnosis and treatment can reduce the patient’s chance to develop renal failure by up to three times.
However, the physician Lucia Monteiro points out the few Brazilian public services experienced in diagnosing and treating neurogenic bladder. Another challenge pointed out by the study coordinator is the fact that some examinations part of the protocol, as renal scintigraphy, are not widely available in the Unified Health System (SUS). In this sense, IFF has been working on the training and expanding the number of professionals qualified to take the exam in the regions that most need this service. “As a National Institute we are responsible for raising managers of the Department of Health awareness on the creation of partnerships and referral systems that prioritize patients at greater risk,” concludes the researcher.
Care at the IFF
The IFF/Fiocruz Urodynamics Outpatient Unit is the only public service offering continuous urodynamic evaluation for babies for more than 25 years in Rio de Janeiro. Also, since 2015, the Institute became reference in care for children exposed to zika during the gestation period. Referred children with diagnosis of Congenital Zika Syndrome are accompanied by a group of specialists in the institutional cohorts and those who also have microcephaly are served at the Pediatric Urodynamics Outpatient Unit of the Institute, in order to evaluate the possibility of developing neurogenic bladder as sequelae.
The initial evaluation protocol is published and includes uroculture, renal and urinary tract ultrasound and urodynamic evaluation. If the result is positive, the patient's family is instructed to begin treatment immediately, with visits every two months to monitor the patient's progress and a reassessment every six months.
The article of IFF researchers published in Plos One can be accessed here.