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Evaluation and treatment of incontinence after bladder neck reconstruction in exstrophy and epispadias
J G Hollowell1, P D Hill, P G Duffy
1Department of Paediatric Urology, St Peter's Hospitals, London.
Insights
Children with bladder exstrophy/epispadias often have lower urinary tract dysfunction. Urodynamic studies are essential for assessing bladder and urethral function to guide treatment for incontinence.
Area of Science:
- Pediatric Urology
- Urology
- Developmental Biology
Background:
- Bladder exstrophy/epispadias complex (BEEC) is a congenital condition affecting the urinary tract.
- Urinary incontinence is a common complication in children with BEEC, often requiring surgical intervention.
- Previous bladder neck operations may not fully restore continence, necessitating further evaluation of lower urinary tract function.
Purpose of the Study:
- To comprehensively assess lower urinary tract function in children with BEEC and prior bladder neck surgery.
- To investigate the interplay between bladder and bladder neck/urethral properties in achieving continence.
- To identify urodynamic parameters predictive of incontinence in this specific patient group.
Main Methods:
- Cystometrography (CMG) and urethral pressure profile (UPP) studies were performed on 25 children with BEEC.
- Evaluation included detrusor function during filling and voiding phases.
- Analysis focused on involuntary detrusor contractions, end-fill pressures, voiding initiation, and leak pressures.
Main Results:
- Abnormal detrusor function was prevalent, with involuntary contractions in 12 children and high end-fill pressures in 8.
- Only 6 of 21 children could initiate a detrusor contraction for voiding.
- Incontinent children often exhibited measurable leak pressures (> or = 15 cm H2O in 12 of 18).
- Even continent children showed lower urinary tract functional abnormalities.
- UPP maximum pressure did not correlate with leak pressure, questioning its utility in this population.
Conclusions:
- Lower urinary tract dysfunction is common in children with BEEC post-bladder neck surgery.
- Urodynamic assessment is crucial for understanding individual functional deficits.
- Detailed urodynamic studies are necessary to guide management and objectively evaluate treatment efficacy.
Abstract:
Twenty-five children with exstrophy/epispadias who had had at least one bladder neck operation (but no augmentation) for incontinence underwent cystometrography (CMG) and urethral pressure profile (UPP) studies. The purpose of this study was to examine all components of lower urinary tract function and to determine how the properties of the bladder and the properties of the bladder neck/urethra interacted to achieve continence or to result in incontinence in the individual child. Examination of detrusor function during filling revealed involuntary contractions in 12 children and an end-fill pressure > 10 cm H2O in 8. Of the 21 children in whom voiding could be evaluated only 6 could initiate a detrusor contraction. In the 18 incontinent children leak pressure could be measured and was > or = 15 cm H2O in 12. Five of the 7 continent children also demonstrated at least one abnormality in lower tract function. The maximum pressure of the UPP did not agree with the leak pressure and may not be a valid measure of the closing pressure of the bladder neck/urethra in this patient population. Detailed urodynamic investigation is necessary in these children to guide the next step of management and to evaluate objectively each form of treatment.