The fate of the abnormal bladder in adolescence

The management and reconstruction of the abnormal bladder have made great strides in the last 20 years. Long-term experience comprises patients born more than 20 years ago whose treatment may have been less satisfactory than that available today. The effects of puberty and adolescence on the abnormal bladder and its management in childhood are reviewed.

The current literature on long-term followup is reviewed, and adolescent urology clinic database from 1981 to 1999 is analyzed.

In patients with bladder symptoms but no demonstrable abnormality, such as monosymptomatic enuresis, there is usually improvement with time. In the neuropathic bladder function and opportunities for surgery deteriorate especially after puberty. It is essential that proper management be established in childhood. The bladder of a boy with posterior urethral valves also deteriorates with time but in an unpredictable manner (60% develop high pressure and 40% become hypotonic). Constant followup must be done even in patients who are symptomless. The long-term fate of the exstrophy bladder is particularly hard to determine because techniques of reconstruction have changed so dramatically in the last 20 years. In the short term it would seem that urodynamic abnormalities are seen in about 25% of patients, even in those who are continent. Those who have a working bladder at age 10 years have only a 23% chance of having the same by age 20 years. In patients with renal failure due to lower tract dysfunction the bladder must have low pressure and completely empty (with clean intermittent catheterization if necessary) before a transplant can be considered.

The bladder that is abnormal in childhood undergoes changes at puberty that alter storage and voiding function. When the original abnormality is minor, the change may lead to functional improvement. In the severe anomalies changes are almost invariably for the worse and may precipitate renal failure. Children with significant bladder dysfunction will seldom grow out of it.