a Pediatric Urology Division, Arkansas Children’s Hospital, 1 Children’s Way, Slot 840, Little Rock, AR 72202, United States b University of Arkansas for Medical Sciences, 4301 W. Markham St., #540, Little Rock, AR 72205, United States Correspondence to: S. Canon, Tel.: þ1 011 501 364 2632; fax: þ1 011 501 364 3960 SCanon@uams.edu, scanon@sbcglobal.net (S. Canon) Ashera@uams.edu (A. Shera) NPHAN@uams.edu (N.M.H. Phan) LapiczLT@archildrens.org (L. Lapicz) ScheidweilerTW@archil- drens.org (T. Scheidweiler) BatchelorL@archildrens.org (L. Batchelor) CSwearingen@uams.edu (C. Swearingen) Keywords Autonomic dysreﬂexia; Urody- namic study; Pediatrics; Spinal cord injuries; Myelitis Received 26 December 2013 Accepted 17 August 2014 Autonomic dysreﬂexia during urodynamics in children and adolescents with spinal cord injury or severe neurologic disease Stephen Canon a,b , Annashia Shera a,b , Nhan Marc Hieu Phan a,b , Lynne Lapicz a , Tanya Scheidweiler a , Lori Batchelor a , Christopher Swearingen a Summary Introduction Autonomic dysreﬂexia (AD) is a well-established as- sociation of high spinal cord injury (SCI), particularly in those occurring above T6. When a noxious stim- ulus is encountered, the body responds by stimu- lating an increase in blood pressure, which is then countered by vasodilation. In patients with auto- nomic dysreﬂexia, the patient is unable to vaso- dilate below the level of spinal injury due to interruption of the autonomic innervation below the injury. This then leads to persistently elevated blood pressure causing uncoordinated autonomic re- sponses such as headache, ﬂushing, sweating, and even hypertensive crisis. The noxious stimulus most commonly reported is bladder or bowel distention [1]. This potential trigger is especially important since many patients with SCI require catheterization and repeated urodynamic testing, both of which predispose them to bladder distention. In response to an incident during which a patient developed severe hypertension during UDS, institu- tional concern was raised about the potential risk of AD in other patients with SCI  T8 and other severe neurological disease undergoing urodynamic testing, and a protocol was initiated in 2007 for monitoring for AD during UDS. Although no long-term complication was encountered in this incident, the need for improvement in our understanding of the detection and treatment of AD during urodynamic testing was highlighted. However, due to the potential of UDS to trigger AD and possible subsequent severe cardiovas- cular crisis, a protocol was established at our institu- tion. Because of reports documenting episodes of AD for patients with severe, non-SCI neurologic disease and the unknown risk, these patients also were his- torically monitored at our institution as well. Objective Autonomic dysreﬂexia (AD) is an uncoordinated autonomic response seen in patients with spinal cord injury (SCI). AD is often triggered by bladder disten- tion, which may occur during urodynamic studies (UDS), and has potentially life-threatening conse- quences. Our purpose is to determine the prevalence and associated factors of AD in children undergoing UDS with either SCI or other neurological disease. Methods We identiﬁed 13 pediatric patients with SCI at the eighth thoracic vertebrae or above (SCI  T8) or other severe neurological disorder with urodynamic evaluations between 2007 and 2011 at our institu- tion. We retrospectively reviewed these patients for age, gender, bladder volume, bladder compliance, detrusor instability, symptoms of AD, blood pres- sure, and urinary infection. Results There were a total of 13 patients with SCI  T8 (9), transverse myelitis (2), and encephalomyelitis (2). There were a total of 41 urodynamic studies with an average of 3.2 studies per patient. One adolescent with C1/2 injury and a prepubertal child with T2/3 injury developed AD. AD was not observed in non-SCI patients. The patients who developed AD had mul- tiple subsequent episodes with follow up UDS. No statistical associations were found for the variables evaluated. No major complications occurred, and AD was successfully managed conservatively. Conclusions With appropriate monitoring and education, AD is easily recognized and managed conservatively. We found an increased risk of patients developing subsequent AD episodes after an initial episode. Patients who did not have autonomic dysreﬂexia during initial UDS did not experience autonomic dysreﬂexia on subsequent UDS. We did not observe autonomic dysreﬂexia occurring in children with transverse myelitis or encephalomyelitis. Results # of patients 13 # of studies 41 Average studies per patient 3.2 Average age at study 12.4 Number of episodes of AD 1 patient with Thoracic SCI: 7 episodes of AD of 8 UDS 1 patient with Cervical SCI: 2 episodes of AD of 7 UDS + MODEL Please cite this article in press as: Canon S, et al., Autonomic dysreﬂexia during urodynamics in children and adolescents with spinal cord injury or severe neurologic disease, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2014.08.011 http://dx.doi.org/10.1016/j.jpurol.2014.08.011 1477-5131/ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. Journal of Pediatric Urology (2015) xx, 1.e1e1.e4