Evaluation and Treatment of Incontinence after Bladder Neck Reconstruction in Exstrophy and Epispadias

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.

Current management of bladder exstrophy

“…However, efficiency of voiding perhaps is a more important function of the reconstructed exstrophy bladder and may be suboptimal in a significant number of patients [27]. There are several reports regarding formal urodynamic evaluation in patients with bladder exstrophy [26,28,29]. The report by Diamond et al [29] clearly documented the potential danger of increased outlet resistance that resulted in worsening compliance in some patients after BNR.…”

The role of imipramine therapy in bladder exstrophy after bladder neck reconstruction

“…However, it is well documented that imipramine increases bladder capacity, decreases uninhibited bladder contractions and increases urethral sphincter tone. Cystometric abnormalities in the form of poor compliance and uninhibited contractions (UCs) occur in patients with bladder exstrophy after bladder neck reconstruction (BNR) [8,9]. The aim of the present study was to assess the role of imipramine therapy in reconstructed bladder exstrophy using clinical and urodynamic variables.…”

Cystometric evaluation of reconstructed classical bladder exstrophy

“…There have been few urodynamic studies in children with bladder exstrophy after BNR [4,7–12]. The pioneering studies by Hollowell et al.…”

“…The pioneering studies by Hollowell et al. [7,8] established the significance and role of cystometry in evaluating patients with bladder exstrophy. The abnormal bladder function in these patients is an important factor responsible for failing to achieve continence and preserving upper tract function after reconstruction.…”