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Postpubertal urodynamic and upper urinary tract changes in children with conservatively treated myelomeningocele
Fayez Almodhen1, Jean Paul Capolicchio, Roman Jednak
1Division of Pediatric Urology, Montreal Children's Hospital and McGill University Health Center, Montreal, Quebec, Canada.
Insights
Children with myelomeningocele who received conservative treatment showed significant increases in bladder capacity and detrusor pressures post-puberty. Many achieved urinary continence, with no significant upper urinary tract deterioration observed.
Area of Science:
- Pediatric Urology
- Neurogenic Bladder Management
- Spinal Cord Injury Research
Background:
- Myelomeningocele often leads to neurogenic bladder dysfunction, impacting continence and upper urinary tract health.
- Conservative management strategies are crucial for optimizing outcomes in these patients.
- Pubertal development significantly influences bladder function and continence in children with myelomeningocele.
Purpose of the Study:
- To evaluate urodynamic and upper urinary tract changes in children with myelomeningocele undergoing conservative management through puberty.
- To assess the impact of puberty on urinary continence and bladder parameters in this cohort.
- To identify factors associated with achieving continence post-puberty.
Main Methods:
- Retrospective review of 37 patients (17 males, 20 females) with myelomeningocele treated conservatively through puberty.
- Regular clinical evaluations, urodynamic studies, and upper urinary tract imaging (radiological) were performed every 6-12 months.
- Comparison of prepubertal and postpubertal continence status, urodynamic parameters, and upper urinary tract changes.
Main Results:
- 45% of patients with pre-pubertal incontinence achieved continence post-puberty.
- Significant increases observed in total cystometric bladder capacity (277 to 487 ml), maximum detrusor pressure (45 to 54 cm H2O), and detrusor leak point pressure (49 to 59 cm H2O) post-puberty.
- Upper urinary tract changes (hydronephrosis, vesicoureteral reflux) remained largely stable, with no significant deterioration.
Conclusions:
- Puberty leads to significant increases in bladder capacity and pressures in myelomeningocele patients on conservative management.
- Spontaneous achievement of continence is possible at puberty, particularly with adequate bladder capacity.
- Conservative management appears safe for the upper urinary tract through puberty in this population.
Purpose:
We examined the urodynamic and upper urinary tract changes in children with myelomeningocele treated conservatively through puberty at our institution between 1980 and 2006.
Materials And Methods:
A total of 40 patients were exclusively treated conservatively with or without anticholinergics and/or clean intermittent catheterization through puberty at our institution. The records of 37 patients (17 males and 20 females) were available for review and constituted the subject matter for our study. The neurological lesion was sacral in 4 patients, lumbosacral in 5, thoracic in 12 and lumbar in 16. Clinical evaluations, radiological imaging studies of the upper urinary tract and urodynamic studies were repeated every 6 to 12 months. Data were collected and comparisons were made with respect to prepubertal (age 10 years) and postpubertal (15) continence status, urodynamic parameters and upper urinary tract changes. Children spontaneously achieving urinary continence postpubertally were examined in a similar fashion as a separate subgroup. Continence was defined as a dry interval of 4 hours or more.
Results:
Of the 26 patients with urinary incontinence before puberty 12 (2 males and 10 females, 45%, p <0.003) achieved continence following puberty. Hydronephrosis remained stable in 4 patients, improved in 3 and was new onset in 3 (p >0.05). Vesicoureteral reflux persisted in 1 patient, resolved in 4 and was new onset in 1 (p >0.05). Total cystometric bladder capacity, maximum detrusor pressure and detrusor leak point pressure all increased significantly after puberty, from 277 +/- 82 to 487 +/- 140 ml, 45 +/- 17 to 54 +/- 20 cm H(2)O and 49 +/- 16 to 59 +/- 21 cm H2O, respectively. In patients achieving urinary continence following puberty total cystometric bladder capacity increased significantly from 284 +/- 58 to 473 +/- 93 ml (p <0.005). Maximum detrusor pressure and detrusor leak point pressure showed insignificant changes after puberty, increasing from 45 +/- 11 to 47 +/- 16 cm H2O and from 46 +/- 11 to 55 +/- 21 cm H2O, respectively.
Conclusions:
This study demonstrates that total cystometric bladder capacity, maximum detrusor pressure and detrusor leak point pressure increase significantly in patients with myelomeningocele following puberty. The increase in bladder capacity could be attributed to increasing bladder outlet resistance resulting from prostate gland enlargement in males and estrogenization in females. A significant number of patients spontaneously achieve continence at puberty, and continence becomes more likely when increased total cystometric bladder capacity is not associated with an increase in maximum detrusor pressure. Finally, no significant postpubertal upper urinary tract deterioration was observed in our series.
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