Bladder Congenital Anomalies

18
Bladder Congenital Anomalies


Katerina Prodromou1 and Pankaj Mishra2


1 Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK


2 Evelina London Children’s Hospital, Guy’s & St. Thomas’ Hospital, NHS Foundation Trust, King’s College Hospital, NHS Foundation Trust, London, UK



Abstract


This chapter will cover the breadth of congenital anatomical and functional abnormalities of the bladder and urinary tract infection (UTI) in children.


Keywords: bladder abnormalities; urinary tract infection (UTI)


18.1 Embryology [1, 2]


The development of the bladder takes place between the fourth and seventh weeks of gestation. The cloaca is the section of the primitive hindgut into which the embryonic ureters and the mesonephric ducts drain. A transient membrane, the cloacal membrane covers the medioventral part of the cloaca. Mesodermal ingrowth between the ectodermal and endodermal layers of the bilaminar cloacal membrane results in formation of the lower abdominal musculature and pelvic bones. Between the fourth and sixth weeks of gestation, the cloaca is compartmentalised by the descending urorectal septum and the ingrowth of the folds of Rathke laterally into the urogenital canal (or primary urogenital sinus) anteriorly and the anorectal canal posteriorly. The primary urogenital sinus then develops into the vesicourethral canal which forms the bladder and the prostatic part of the urethra and the definitive urogenital sinus which forms the urethra, with differences between males and females. During this period, the mesonephric ducts migrate caudally, and their fusion forms the vesical trigone before they join the prostate forming the ejaculatory ducts. The detrusor is the smooth muscle that constitutes the bladder wall, and it is created by the differentiation of the adjacent mesenchyme of the pelvis (i.e. splachnopleural mesoderm) in response to induction with contact with the embryonic urothelium. The dome of the bladder is in continuation with the allantois which progresses into the urachus. Later on, the urachus obliterates and forms the medial umbilical ligament. When the descending urorectal septum reaches the cloacal membrane, their fusion creates the perineal body. The cloacal membrane eventually ruptures, forming the urogenital and anal orifices.


18.2 Exstrophy‐Epispadias Complex


The failure of development of the lower abdominal wall during early foetal development is believed to give rise to a spectrum of abnormalities, which are described as exstrophy‐epispadias complex. Three distinct anomalies comprise this complex: bladder exstrophy, epispadias, and cloaca exstrophy.


Their pathogenesis is believed to depend on the stage of development when the cloacal membrane ruptures. This premature rupture is attributed to the failure of the migration of the mesoderm between the layers of the endoderm and the ectoderm of the cloacal membrane. If the membrane ruptures before the completion of the urorectal septum’s descent, the distal bowel, bladder, and urethra are not compartmentalised giving rise to the anomaly of cloacal exstrophy. Rupture of the membrane later on, after the separation of the urogenital and anal canals is believed to lead to an open bladder and urethral plate, and if it occurs later in development, only the urethra and bladder neck remain open, giving rise to the epispadias anomaly. Various theories have been proposed to explain this embryological anomaly; however, it remains a source of controversy [2, 3].


18.2.1 Bladder Exstrophy


Bladder exstrophy is very rare. Its incidence is 1:50 000 with a male to female ratio of 3:1 [4]. Antenatal diagnosis is difficult with characteristic non‐visualisation of the bladder, accompanied by a low‐set umbilical cord, a short phallus, and an irregular lower abdominal wall (Figures 18.1 and 18.2). Antenatal counselling of the parents is necessary so that they understand the nature and implications of bladder exstrophy, the surgical management, and long‐term outcome [2].

Image described by caption.

Figure 18.1 In exstrophy, the cloacal membrane extends right up to the umbilical cord, and when it dissolves, the bladder is exposed.

Diagram depicting the principal features of exstrophy, with lines marking exposed bladder, ureteric orifices, verumontanum, short flat penis, prolapse of anus, separation of symphysis pubis, etc.

Figure 18.2 Diagram of the principal features of exstrophy.

Image described by caption.

Figure 18.3 (a) and (b) Male bladder exstrophy.


The clinical features of bladder exstrophy is related to its pathogenesis (Figure 18.118.4): [4]



  1. The bladder is open to external environment along with the anterior abdominal wall, and so is the urethral plate with a visible verumontanum in males and a short open urethra running between the open bladder and the vagina in females. The ureters drain directly onto the open bladder plate; the ureteric orifices are laterally placed which can lead to vesicoureteric reflux (VUR). If neglected, the exposed urothelium undergoes intestinal metaplasia.
  2. There is a low‐set umbilicus cranially with associated umbilical hernias, split (diversification) rectus abdominis muscles laterally, and an open pelvic ring caudal to the open bladder plate.
  3. The symphysis pubis diastasis (widening) can vary, reaching a defect of up to 5 cm in newborns with severe forms of exstrophy. This is due to external rotation of the pelvic bones along the sacroiliac joints.
  4. The corpora are separate and attached to the inferior border of the ipsilateral inferior pubic rami. This leads to a shortened, broad, and open penis with deficiency of dorsal foreskin in males, and separate, bifid clitoral bodies and the urethra barely present, short vaginal canals, and can lead to uterine prolapse in females.
  5. The anus is anteriorly placed due to the abnormal development of the anterior abdominal muscles. There might be associated rectal prolapse, compounding faecal incontinence.
  6. In the male, the urethra is represented by a strip of urothelium on the dorsum of a short, broad, up‐turned penis. The testicles are undescended. Inguinal hernias are a common association (80% in boys, 15% in girls).
  7. Superior vesical fissure: Here the exstrophy is restricted to the apex of the bladder. The remainder of the bladder is correctly formed (Figure 18.5).
Image described by caption.

Figure 18.4 Female bladder exstrophy.

Image described by caption and surrounding text.

Figure 18.5 Diagram of the findings in superior vesical fissure.


18.2.1.1 Management


The suspected defects can be seen on prenatal ultrasound, which can help with parental counselling and planning of delivery and further management.


After birth, the bladder plate is covered with cling‐film, the umbilical cord clamp is replaced with a suture tie to avoid trauma to the bladder plate, and the neonate is transferred to appropriate paediatric urology referral centre. Closure is advisable in the first few days of life; however, it can be delayed in cases of premature babies that need a long period of stabilisation and growth.


Preoperative work‐up should include a baseline renal ultrasound and routine blood tests. Other congenital abnormalities are not common with bladder exstrophy. Vitamin K should be administered to the neonate and antibiotic cover is not necessary. As neonates with this condition are usually healthy otherwise, intravenous access is not required preoperatively and the babies can breastfeed [4].


18.2.1.2 Surgery


18.2.1.2.1 Primary Closure of Bladder Plate and Reconstruction of the Lower Abdominal Wall

The primary closure of bladder exstrophy is performed under general anaesthesia and an epidural catheter is preferable because it provides excellent postoperative analgesia.


The primary bladder closure, lower abdominal wall reconstruction, and approximation of the pubic bones are generally achievable without osteotomies in early closure. For delayed closures (which is practiced in several centres across the world) or in cases with wide pubic diastasis, pelvic osteotomies with external fixators are needed. Inguinal hernias are repaired during this procedure when present. Complications after bladder closure include partial or complete wound dehiscence, a tight closure with outflow obstruction, and upper tract dilatation, which in combination with UTIs, may lead to renal damage [4, 5].


18.2.1.2.2 Continence Procedures

In females, the primary closure is rarely adequate to achieve continence, and in the majority of patients with bladder exstrophy, secondary procedures will be necessary for continence and genital reconstruction to achieve continence and cosmesis [6].


Three surgical approaches are currently followed in various part of the world:



  1. Complete primary repair of bladder exstrophy ( CPRE) [716]. Mitchell suggested a complete anatomical reconstruction at the time of the primary closure. The bladder plate is fully mobilised and the bladder neck, urethra, and penis are reconstructed in one setting. This technique is thought to create a bladder outlet resistance early in life, allowing for bladder cycling and growth. The division of the intersymphyseal ligaments allows the appropriate anatomic placement of the bladder neck and posterior urethra deep into the pelvis in its orthotopic position.

    Patients whose bladder does develop will likely undergo fewer procedures than in a staged fashion. Continence has been reported after CPRE to be 76%, defined as dry intervals longer than two hours and spontaneous voiding without catheterizations. However, a significant percentage of patients will likely still require a formal bladder neck procedure to achieve continence. There are concerns with this technique related to a high‐pressure lower urinary system and VUR, urinary tract infections (UTIs), and renal scarring and damage. There is also rare risk of penile injury with loss of glans or penile skin or tissue with penile reconstruction at such a young age, and requirement for multiple procedures despite the name ‘complete repair’. Approximately 36–68% of patients will be left with a hypospadias after CPRE that will require further penile surgery.


  2. Modern Staged Reconstruction of Exstrophy ( MSRE) [1624]. Jeffs and Gearhart advocated MSRE, which has been the standard approach for many centres for many years. It includes an initial primary closure followed by a modified Cantwell‐Ransley epispadias repair in the first 6–12 months of life. The bladder is mobilised (Figure 18.6). The edges of the mobilised bladder and urethra are rolled in to make a new bladder and urethra. The tissues on either side of the bladder neck are mobilised and sewn together. To help closure, an osteotomy is performed through the iliac bone just lateral to the sacroiliac joint. A second operation may be necessary a few years later to achieve continence (Figure 18.7).

    The ongoing incontinence is considered to preserve renal function and at the same time, the bladder may develop with the presence of some outlet resistance. The bladder neck repair (i.e. Young‐Dees‐Leadbetter) for continence is performed between five and nine years of age, when an adequate bladder capacity is achieved, and the patient and family desire continence. Ureteric reimplantation is carried out at this stage through long submucosal tunnels to prevent reflux.


    If the bladder capacity is not good, the patient is left incontinent until the bladder grows and maturity improves or diversion with an augmentation with a catheterisable channel and bladder neck closure when necessary, which is also the procedure of choice in the case of failed bladder neck reconstruction, is used.


    Day and night‐time continence of can reach about 75%, with the patients voiding per urethra without augmentation or intermittent catheterization. Social continence, defined as dry for more than three hours during the day but damp at night, was found in a further 10%. Patients with a mean capacity greater than 100 ml at the time of the bladder neck reconstruction had better outcomes. In males after closure, epispadias, and bladder neck reconstruction, the total complication rate was 41.7%, and in females after bladder closure and bladder neck reconstruction, the total complication rate was 19.5%. In a series of successful bladder growth 19.4% of males and 17% of females had failed bladder neck reconstruction and have undergone or will require an augmentation with a catheterisable stoma and bladder neck closure as indicated. Major complications are reported at 11% (e.g. bladder dehiscence or prolapse, orthopaedic or neurological complications) and minor complications again at 11% (i.e. bladder outflow obstruction [BOO], urethrocutaneous fistula, surgical site infection, UTIs, etc.).


  3. The Kelly procedure (radical soft‐tissue mobilisation) [4, 5, 25, 26]. This surgical technique for continence that was first advocated by J. H. Kelly in the 1980s. Its concept is that continence in bladder exstrophy can be achieved by repairing the disorganised pelvic floor musculature involved in normal continence. An examination under anaesthesia and cystoscopy is carried out at three months after bladder closure to assess the anatomy, capacity, and outlet. The Kelly operation is carried out after the age of nine months. It is performed irrespective of bladder capacity. The bladder is opened in the midline and bilateral ureteric reimplantation (Cohen) is performed. The pelvic floor, penile corpora bodies, and urethra are radically mobilised. The penile corpora along with the periostium are mobilised off from the lower border of the inferior pubic rami with great care to the pudendal nerves and vessels that must be preserved as they run through Alcock canal. Then the penile corpora can be completely mobilised towards the midline, thus increasing their length and protrusion. The urethral plate is dissected from the corpora and glans. A bladder neck repair is performed with excision of two small mucosal triangles lateral to the verumontanum. The tubularisation continues distally, and if the penile length is not compromised, a complete reconstruction of the penis and urethra could be carried out. However, the urethra is usually deemed short, and therefore, brought to a perineal position in males. The perineal muscle is wrapped around the proximal urethra, in an attempt to recreate the sphincter. The corpora are externally rotated to correct the dorsal chordee and joined in the midline. The glans is reconstructed and the shaft skin cover provided. The abdominal wall is closed.

    In girls, the clitoral corpora are similarly mobilised, with the labia minora attached. The pelvic floor is mobilised and the pudendal nerves are again identified and preserved. After the bladder neck repair, the pelvic muscle is wrapped around the urethra and vagina. The clitoral bodies are brought together in the midline.


    The hypospadiac meatus in boys can be repaired in two stages with the use of buccal, labial, or posterior auricular grafts in the future. In girls, no further genital reconstruction is required.


    Although published follow‐up data are limited, good continence outcomes in patients with spontaneous voiding are reported with the Kelly procedure. Continence (complete or partial) is reported in 63.5–70%. In a not as yet published series that was presented at the European Society for Paediatric Urology (ESPU) conference 2015, the Paediatric Urology team of Great Ormond Street Hospital reported 64% spontaneous voiding continence in boys and 79% in girls five years after the Kelly operation in patients who also underwent the primary closure of bladder exstrophy at the same institution. Pelvic floor exercises and biofeedback is applied to the patients when they are old enough to cooperate to enhance the function of the pelvic floor muscles. Complications after this procedure include fistula formation (10%), vulval scarring and dehiscence (5%), recurrent UTIs (59%), urethral stricture (7%), wound dehiscence (11%), and infective bladder calculi (7%). Renal scarring on nuclear medicine scans was 10%, urethral clean intermittent catheterization (CIC) was performed in 3.5%, and bladder augmentation was carried out in 10% of patients in the Great Ormond Street Hospital series. Penile injury and glans loss is extremely rare and erectile dysfunction has not been reported [2529].


    The complexity of bladder exstrophy and its surgery mandates that the management of patients with this condition should be done at exstrophy centres of excellence and by multidisciplinary teams with standardised assessments and management regimens

Image described by caption.

Figure 18.6 Jeffs’ method of closure of exstrophy. First stage – performed in the neonate. (a) The skin incision excises the necrotic umbilicus. (b) The incision is carried round the margin of the bladder. Two flaps are formed inferiorly. The urogenital diaphragm is separated from the symphysis on each side and the corpora cavernosa are mobilised. (c) The skin flap on the left is sewn to the edge of the prostatic urethra. (d) The skin flap on the right is sewn to the prostate. (e) The mobilised bladder and prostate is rolled in (f) and reinforced by the urogenital diaphragm. (g) The incision is closed leaving an epispadiac urethra.

Image described by caption.

Figure 18.7 Jeffs’ method for exstrophy. Second stage – performed at about three years. (a) The old incision is reopened. (Not shown here – the ureters are re‐implanted to prevent reflux.) A triangle of mucosa is removed on each side exposing the bladder muscle. (b) A tube is formed to make the prostatic urethra. (c) The denuded triangle of bladder is swung across, first on the right side and then on the left (d), to ‘double breast’ the new prostatic urethra [7].


18.2.2 Epispadias


When the cloacal membrane is less extensive (Figure 18.8), its dissolution leaves a defect in the urethra that may be restricted to the glans or may form a strip along the short curved penis. The urethral meatus opens onto the dorsal penis, either in the glans, penile shaft, or in the penopubic region (Figure 18.9).

Diagrams displaying the top (left) and lateral (right) views of a penis with epispadias.

Figure 18.8 Diagram of the findings in epispadias.

Image described by caption.

Figure 18.9 (a) and (b) Isolated Male epispadias.


Source: Courtesy of Prof Imran Mushtaq.


In males, epispadias is associated with dorsal chordee with incomplete foreskins, dorsally. The leads to an upward curvature and a hooded glans. In females, there is a bifid clitoris and poorly developed labia. There is associated urethral sphincter disruption leading to incontinence. Incidence in males is 1:120 000 and in females 1:400 000.


18.2.2.1 Surgery of Epispadias


Surgical repair of these genital anomalies are usually performed during the first two years of life. The aims of epispadias surgery in boys are to correct the dorsal chordee, to reconstruct the urethra and relocate it ventrally, and to redistribute the skin around the penis to cover the dorsal skin defect at 6–18 months of age. The most commonly used techniques are those described by Ransley, Mitchell, and Kelly.


The Cantwel‐Ransley epispadias repair is widely used. The incision begins in the midline above the urethral opening and is extended dorsally on each side of the urethral plate and ventrally circumferentially the penis is degloved and the urethral plate, the neurovascular bundles and each corporal body are fully mobile except fort their granular part. The urethral plate is tubularised and a MAGPI type plasty (i.e. IPGAM) of its distal end allows ventralisation of the future urethral meatus. The corpora are then rotated and approximated. The skin shaft cover is performed with a transverse flap of ventral skin dissected with its pedicle and transferred to the dorsal side of the penis [3032].


Mitchell’s technique is based on a complete disassembly of the penile structures which allows a tubularisation and ventralisation of the entire urethra, and a more complete release of the corporal rotation. The corpora cavernosa are completely separated from each other with their corresponding hemiglans. The urethral plate is dissected off of the corporeal bodies, tubularised, and transferred ventrally. The corpora entirely separated and independent are rotated to correct the dorsal chordee and sutured together. The glans halves are subsequently brought together [3336].


In the severe forms of epispadias, where the bladder neck is inadequate, and the phallus short and severely curved, the Kelly procedure is more appropriate. At the same time, it offers penile lengthening and protrusion because the postoperative cosmetic appearance of epispadias repairs may often be disappointing with a penis which often looks short and buried.


In girls, the open urethral plate extending from the bladder neck to the medial aspect of both hemi‐clitori anteriorly, and to the anterior vaginal edge posteriorly, is separated from the adjacent structures up into the perineal muscles and subsequently tubularised. The perineal muscles located in front of and between the neo‐urethra and the vaginal orifice are both sutured together. This manoeuvre significantly increases the bladder outlet resistance and aids to social continence in most cases. The Kelly procedure is also used to offer continence and external genital reconstruction simultaneously [37].


18.2.2.2 Continence Surgery


The degree of incontinence is quite variable in children with epispadias and is analogous to the severity of the epispadias. Often, patients who have had epispadias repair require additional procedures to become continent. The injection of biocompatible substance in the bladder neck may offer a less invasive but usually transient solution, with only 30–40% continence rates reported with several years of follow‐up. Although immediate results can be encouraging, continuous deterioration with increased leakage is common. It does not seem that the type of bulking agents used makes a significant difference [38].


Bladder neck reconstruction (i.e. Young‐Dees‐Leadbetter) is usually performed after the age of three or four years, if the bladder capacity is deemed adequate (usually>100 ml). Experience shows that this challenge is rarely achieved in the exstrophy group, although results are better in the epispadias group because the bladder behaviour is probably more normal. This technique often leads to ‘obstructive’ micturitions and retrograde ejaculations related to the deficient sphincter mechanism [39, 40].


The artificial urinary sphincter insertion around the exstrophy‐epispadias complex bladder neck has also been used with poor results. There is a much higher risk of erosion in a reconstructed bladder neck and urethra. The artificial sphincter is therefore not a front‐line solution in the exstrophy‐epispadias complex [41]. For persistent incontinence, bladder neck closure with urinary diversion in the form of a Mitrofanoff channel with or without bladder augmentation (depending on bladder capacity and compliance) is the final continent procedure [40, 4244].


18.2.3 Cloacal Exstrophy


Cloacal exstrophy is the most severe abnormality in the exstrophy spectrum that is compatible with viability. It is extremely rare, occurring in 1 in 200 000–400 000 live births. The male to female ratio has been reported in a large contemporary study to be equal between the sexes, 1:1 [4, 45].


Prenatal diagnosis is possible and based on major criteria (i.e. non‐visualisation of the bladder, a large midline infra‐umbilical anterior wall defect or a cystic anterior wall structure, an omphalocoele and a myelomeningocoele) and minor criteria (i.e. lower extremity anomalies, renal anomalies, ascites, widened pubic arches, narrow thorax, hydrocephalus, and a single umbilical artery) [46].


When a prenatal diagnosis is made, parents should be counselled by an experienced exstrophy surgeon and referred to an exstrophy centre of excellence for delivery whenever possible [47].


Cloacal exstrophy includes findings of exstrophy of the hindgut and bladder complex (Figure 18.10), bifid phallus, wide pubic diastasis, prolapsing terminal ileum and proximal colon, imperforate anus, and an omphalcele (Figure 18.11). When seen coexisting with omphalocele, imperforate anus, and spinal defects it is considered part of the OEIS complex [48]. The lower urinary tract is typically composed of two hemi‐bladders exstrophy on either side of the midline each with its ureteric orifice and rudimentary phallus. Between them, a length of intestine with two openings represents the ileocaecal region a characteristic elephant trunk appearance. The upper opening leads into the ileum and discharges small bowel content; the lower one leads into a loop of large bowel, which ends blindly in front of the sacrum. There maybe one or two appendices. The anus is imperfect, and there is usually spina bifida. Variations, however, are frequent.

Diagrams depicting cloacal exstrophy, with lines marking bowel exstrophy, blind-ending colon, left hemi-bladder, right hemi-bladder, exomphalos, and ileum.

Figure 18.10 Diagram of the findings in cloacal exstrophy.


Source: Courtesy of Mr. J.H. Johnston.

Image described by caption.

Figure 18.11 (a) and (b) Cloacal exstrophy.


Abnormalities from other systems are common and involve the nervous system (spina bifida), skeletal anomalies, gastrointestinal anomalies (e.g. omphalocele, malrotation, bowel duplication, duodenal atresia, duodenal web, Meckel’s diverticulum, and short gut syndrome), upper urinary tract anomalies (e.g. pelvic kidneys, renal agenesis, hydronephrosis, hydroureter, multicystic dysplastic kidney (MCDK), fusion anomalies, ectopic ureter, ureteric duplication, congenital stricture, and megaureter), genital tract anomalies (e.g. uterine duplication, bicornuate uterus, vaginal duplication, vaginal agenesis, and undescended testes) and cardiovascular and pulmonary anomalies (e.g. cyanotic heart disease, aortic duplication, vena caval duplication, bilobed lung and an atretic upper lobe bronchus) [4, 45, 4951].


Management of these complex patients should be carried out in a specialised exstrophy centre. The bowel and bladder plates should be kept covered with a clear cling film wrap as for bladder exstrophy. Often the severity of cloacal exstrophy is enhanced by the nature and severity of the associated anomalies and these in turn may delay the surgical management for several months. Immediate management is intended to medically stabilise the newborns that are usually premature.


A renal and spinal ultrasound (and if needed a spinal magnetic resonance image [MRI]) should be carried out early along with full blood tests and assessment for cardiac anomalies [52]. Optimal feeding to establish growth is necessary. Evaluation should involve a multidisciplinary team to perform an assessment of all the comorbidities and plan the short‐ and long‐term reconstruction. Decisions should only be made after appropriate parental counselling and education. This often will require a chromosomal analysis. As surgical techniques for phallic reconstruction have evolved, a functional and cosmetically acceptable phallus can now almost always be constructed, and it is the general consensus amongst experts that it is important to assign gender that is consistent with karyotype [51].


In patients with spinal conditions, a neurosurgical evaluation and closure should be undertaken as soon as the infant is medically stable. Long‐term follow‐up is important because up to 33% of children can have symptomatic spinal cord tethering [53].


One of the important decisions to make during the initial operative planning is whether to perform a one‐ or two‐stage closure [5456]. A one‐stage repair is preferred, if possible, to minimise the number of neonatal procedures necessary and also allow the bladder to be closed, reducing the risk of trauma and polyp formation, and potentially improve its chances at normal development. During either a one‐ or two‐stage procedure, an omphalocele if present, is excised; the exstrophy plate is dissected from the skin and rectus abdominis muscles laterally; and the bowel is carefully separated from the hemi‐bladders. The hindgut is tubularised and brought out as an end colostomy usually onto the left iliac fossa. The location of the stoma should be such to allow for an effective placement of an appliance. Ileostomies have been widely used in previous years, but they have been associated with malabsortion and nutritional problems. The hemi‐bladders are approximated in the midline to create a single bladder plate, which may then be closed as in primary bladder exstrophy closure. Bilateral osteotomies are performed because usually the closure is delayed and the pubic diastasis is wide. These should allow for a tension‐free closure, but if this is not possible, then the use of a silo to cover the residual abdominal wall defect is advisable. In cases where a two‐staged approach is decided (i.e. in the presence of a large omphalocele defect and respiratory or haemodynamic instability etc.), bladder closure and osteotomy may be delayed until respiratory and gastrointestinal stability are achieved [57, 58].


Preserving as much bowel tissue possible is essential to enhance absorption and avoid complications of short bowel, thus helping the survival rate of these patients [59]. Parenteral nutrition is necessary until enteric feeds are established. Also, any possible distal bowel and appendices should be preserved because they may be used for future reconstruction and stoma formation. When the child is older and if an adequate hindgut exists and there are no neurologic deficits, then a pull through procedure could be performed via the posterior sagittal approach. The majority of these patients however have been reported incontinent of faeces [4, 45].


Patients with cloacal exstrophy are incontinent for urine. Intermittent catheterization is likely to be needed for emptying especially in the presence of spinal defects. Surgery to produce a continent reservoir should be delayed until the child is old enough to participate in self‐care. The choice between a catheterisable urethra and catheterisable stoma should be made according to the adequacy of the urethra and bladder neck, bladder capacity, gender, and orthopaedic status [60, 61].


In males with cloacal exstrophy, reconstruction of the penis is challenging. However, when adequate corporal tissue is present, epispadias repair can be performed at the same time of initial closure or later [62]. Also, when performed by experts, the Kelly procedure offers a great perspective in the cosmetic appearance of the external genitalia of boys [4]. Genital reconstruction in girls is usually done at the time of bladder closure and osteotomy. It is acceptable to leave the vaginas in situ, but further surgery will be needed to bring one of these to the perineum.


18.3 Urachal Anomalies


The progressive obliteration of the urachus is usually complete by the 28th week of gestation. A small remnant proximal to the bladder may be present in 10% of adults [63]. This is called a vesico‐urachal diverticulum and is asymptomatic; very rarely it can be cause of infection or stone formation due to urinary stasis within. After its obliteration, the urachus represents the median umbilical ligament. Should the process of obliteration fail, then urachal anomalies occur (Figure 18.12). These are rarely seen in 1% of paediatric population (1 in 5000–7000 births), and they present as a patent urachus (20%), a urachal sinus (35%) or a urachal cyst (45%), depending on whether there is complete or partial patency of the urachus [64].

Image described by caption.

Figure 18.12 Complications of a persistent urachus. (a) It may cause a urinary fistula if associated with outflow obstruction from urethral valves. (b) There may be a midline cyst which may become infected. (c) Carcinoma arising in the urachus presents in the bladder at the apex and erodes early into the peritoneal cavity.


18.3.1 Patent Urachus


There causes continuous or intermittent drainage of sero‐sanguineous or purulent fluid from the umbilicus. If the umbilicus becomes infected, then there is periumbilical swelling, tenderness, and drainage. It is correlated to a BOO in 14% of cases, and in these cases, it acts as a ‘pop‐off’ mechanism. The diagnosis of a patent urachus can be done with ultrasonography and Micturating cystogram, which is also necessary to exclude BOO (Figure 18.13). A patent urachus needs to be excised. The excision is done through an extraperitoneal approach and the urachus needs to be excised completely, including a part of the bladder dome.

Photo displaying a baby with patent urachus (left), and its corresponding radiograph (right).

Figure 18.13 (a) and (b) Patent urachus.


Source: Courtesy Prof Sandesh Parelkar, K.E.M Hospital, Mumbai.


18.3.2 Urachal Sinus


This represents incomplete closure of the urachus with an ‘opening’ distally towards the umbilicus. Episodic infections of the sinus can lead to purulent drainage from the umbilicus and periumbilical tenderness. Usually it presents as a ‘wet’ umbilicus or a persistent granuloma after multiple cauterisation with silver nitrate. It can be diagnosed with ultrasonography or sinography is possible. In difficult diagnostic cases, a computed tomography (CT) or MRI maybe required. Treatment is again complete excision if the sinus persists for more than two months [65, 66].


18.3.3 Urachal Cyst


This presents as a fluid‐filled structure between the two obliterated ends of the urachus and is usually located in the distal third of the urachus. It is usually an incidental finding, or it can present as a suprapubic mass with fever, pain, and dysuria. In delayed diagnosis, the cyst may rupture towards the peritoneum, causing acute abdomen and peritonitis. The most common organism isolated is Staphylococcus aureus (in >50% of cases) [67]. The diagnosis is again set with ultrasonography, CT, or MRI, and the treatment is surgical excision. For very inflamed cysts, initial incision and drainage (two‐stage approach) is preferable [67, 68].


The surgical excision of urachal anomalies can be done through an open or laparoscopic approach [6870]. Lately robotic‐assisted surgery has also been used [71]. The decision relates to the surgeon’s experience and the degree of inflammation [7275]. The treatment of asymptomatic remnants remains controversial, but it is suggested that the presence of microcalcifications seen in imaging is in favour of excision [67, 75]. These calcifications seem to be related to chronic inflammation, which maybe in turn a predisposing factor for carcinogenesis. Urachal cancer is very rare (0.35–0.7% of bladder cancer) and extremely rare in childhood. Carcinoma of the urachus in the adult presents with haematuria. Cystoscopy shows a cherry‐sized lump at the air bubble, and a much larger mass outside it; biopsy reveals adenocarcinoma. Primary urachal rhabdomyosarcoma has been reported and carries a poor prognosis. It is more common in childhood and especially older than the age of 40 [7679]. Therefore, many surgeons favour preventive removal of urachal remnants when diagnosed.


18.4 Bladder Diverticula


The incidence of bladder diverticula is 1.7%. They represent a herniation of the bladder mucosa through the detrusor [80]. They can be congenital or acquired. Congenital diverticula are usually solitary and usually located near the ureteric orifice [81]. Acquired diverticula are usually multiple, and they are secondary to BOO, recurrent infections, or can be iatrogenic. The most common causes are urethral valves, urethral strictures, neuropathic bladders, detrusor‐sphincter dys‐synergy, or can occur after anti‐reflux surgery. Bladder diverticula are also associated with Ehlers‐Danlos syndrome [82].


Diverticula can present with UTIs, VUR (8–13%), ureteric obstruction (5%), or BOO. The presentation depends on their site and size. The cases of the ureteric orifice situated within the diverticulum are associated with VUR, and in 15–33% of cases, there is some degree of renal dysplasia. Diverticula are also related to voiding dysfunction, but there is always a dilemma of cause versus effect correlation. Urinary stasis within the diverticulum may cause the formation of stones or epithelial dysplasia [81, 83].


The diagnosis is set with ultrasonography, Micturating cystogram and cystoscopy (Figure 18.14). Treatment is mandatory when diverticula are symptomatic, and it includes open or laparoscopic or vesicoscopic excision of the diverticulum with ureteric reimplantation where indicated. BOO must always be excluded and treated prior to any surgery for the diverticulum [8083].

Image described by caption and surrounding text.

Figure 18.14 (a) and (b) Bladder diverticulum before and after bladder emptying.


18.4.1 Bladder ‘Ears’


Innocent protrusions of the bladder are normal in male infants and common in women. In the adult male, they commonly accompany an inguinal hernia into the inguinal canal.


18.4.2 Megacystis


This is a very rare abnormality that can present antenatally, postnatally on ultrasound, or with UTIs. It is associated with high‐grade VUR. It can also be related to other conditions such as posterior urethral valves, Ehlers‐Danlos syndrome, and urethral diverticula. It can also be a manifestation of megacystis‐microcolon‐intestinal hypoperistalsis syndrome (MMIHS), which is characterised by neonatal abdominal distension due to bowel dilatation, severely dilated bladder, and severely dilated ureters. The causes of this rare syndrome are not known. Myogenic, neurogenic, or hormonal factors may be involved. It presents more commonly with functional neonatal intestinal obstruction and urinary retention [84]. There is clear preponderance of females, 70.6 vs. 29.4% in 227 MMIHS cases [85]. The survival rate is about 20% with the oldest survivor being 24 years old. Outcomes seem to be improving with the introduction of long‐term total parenteral nutrition (TPN) and multi‐organ transplantations.


Bladder duplication is extremely rare. It can be partial or complete, with the duplication being in the sagittal or coronal plane. In complete duplication, there are two hemi‐bladders usually in a sagittal plane, with the corresponding ipsilateral ureter draining within each hemi‐bladder and in continuation with a duplicated urethra. Associated anomalies include a duplicated penis, duplicated vagina and uterus, vertebral anomalies (usually lumbar), and hindgut anomalies. Often rectovesical, vesicovaginal, or vesicourethral fistulae are present. Diagnosis can be made with ultrasound, micturating cystourethrogram (MCUG), and cystoscopy, and treatment is necessary if there are symptoms such as urinary incontinence, UTIs, or upper tract obstruction [80, 86, 87].


Bladder septations are fibromuscular or mucosal septations that divide the bladder into equal or unequal compartments. They are diagnosed when they are symptomatic because of complications such as upper tract drainage impairment. They are diagnosed with MCUG and ultrasound.


Bladder agenesis is extremely rare and incompatible with life. Twenty‐three cases have been reported in live births, and all were female infants. In the absence of the bladder, the ureters are seen draining into the urethra, vagina, Gartner’s duct in girls, or the rectum. The urachus may stay patent. They are associated with hydroureteronephrosis, renal dysplasia or agenesis, agenesis of the prostate, seminal vessels, epididymis, penis, or vagina, and spinal, orthopaedic or hindgut anomalies. Diagnosis is made with ultrasound, MCUG, and MRI. In infants that survive, diversion is essential as initial management, and later in life, a neo‐bladder can be constructed [8890].


18.5 Disorders of Development of the Sacrum


18.5.1 Sacral Agenesis


These are exceedingly rare and represent a variation on the theme of failure of development of the neural canal. The child is born with an absence of most of the sacrum, and a lesion of the cauda equina leading to a neuropathic bladder. The diagnosis is obvious from a plain radiograph of the pelvis, but it is all too easy to miss the absence of the sacrum.


18.5.2 Presacral Dermoid


A congenital neural canal defect leads to the formation of a dermoid cyst between the sacrum and the rectum. Clinically, they may present with bizarre symptoms, few of which are serious unless the cyst becomes infected. On rectal examination, a large mass is found. Surgical intervention is only required if the cyst is causing obstruction or is associated with a cauda equina lesion and carries a high risk of producing a neuropathic bladder even if not already present.


18.6 UTI in Children [91, 92]


UTI is one of the most common causes of referral to paediatric urology unit. As such, standard guidelines have been developed to aid management [9193]. Epidemiology and pathophysiology [9193]:


UTIs in the first 3 months of life occurs in 4% of boys and 2% of girls; in the first 10 years the incidence changes to 1% in boys and 3% in girls; and changing to 0.5% in boys and 5% in girls during school years. Uncircumcised boys have a higher incident of UTIs.


Though majority of UTIs are successfully treated with no long‐term consequences, a minority will develop renal scarring, especially infants. This can lead to hypertension, proteinuria, renal impairment, or even renal failure in adult life.


Most common organism is Escherichia coli and is responsible for >90% of UTIs; however enterococcus, Pseudomonas, Klebsiella, and Proteus spp. and Staphylococcus epidermidis can all be causative agents.


The infection of the urinary tract is most commonly due to ascending infection and any condition predisposing for this increases the risk of infection.


Risk factors for UTIs:



  • previous UTI.
  • premature birth (due to immature immune system), poor growth, or malnutrition.
  • congenital anomalies (e.g. pelvic‐ureteric or vesicoureteric obstruction, ureterocele, VUR, posterior urethral valves, enlarged bladder, or spinal anomalies).
  • functional anomalies (voiding dysfunction and chronic constipation).

18.6.1 Classification


UTIs can be divided based on site:



  • Lower urinary tract (LUT) or cystitis: dysuria, frequency, urgency, malodorous urine, enuresis, haematuria, or lower abdomen or suprapubic pain.
  • Upper urinary tract (UUT) or pyelonephritis: fever, chills, or flank, back, or lower chest pains. Symptoms of LUT may also be present.

Classified according to severity:


Typical UTI: could be asymptomatic or symptomatic;



  • Simple UTI: low‐grade pyrexia with mild dehydration; generally, well.
  • Severe UTI: high‐grade pyrexia (>39 °C), vomiting, moderate to severe dehydration; unwell.

Atypical UTI: seriously ill, non‐E. coli infection, poor urinary flow, deranged renal function, abdominal or bladder mass, septicaemia, and failure to respond to treatment within 48 hours.


Classification according to episode:


A single infection is treated successfully and does not recur. However, it can be a sign an underlying condition.


Recurrent UTIs could be due to bacterial persistence, unresolved infection (due to noncompliance with treatment, subtherapeutic antimicrobial level, malabsorption, or resistant organism), or reinfections and must be one of the following:



  • one episode of cystitis with one episode of pyelonephritis.
  • ≥2 episodes of pyelonephritis.
  • ≥3 episodes of cystitis.

The clinical presentation of the UTI in children varies and is summarised in Table 18.1 [91].


Table 18.1 Presenting symptoms and signs in infants and children with UTI [91].


Source: From NICE guideline.























Age group Symptoms and signs
Most common > Least common
Infants younger than 3 months Fever
Vomiting
Lethargy
Irritability
Poor feeding
Failure to thrive
Abdominal pain
Jaundice
Haematuria
Offensive urine
Infants and children, 3 months or older Preverbal Fever Abdominal pain
Loin tenderness
Vomiting
Poor feeding
Lethargy
Irritability
Haematuria
Offensive urine
Failure to thrive
Verbal Frequency
Dysuria
Dysfunctional voiding
Changes to continence
Abdominal pain
Loin tenderness
Fever
Malaise
Vomiting
Haematuria
Offensive urine
Cloudy urine

18.6.2 History and Examination


The history is focused on enquiring about symptoms to distinguish between primary or recurrent infection. Also looking for risk factors for UTIs. The child should be examined from head to toe, looking for palpable masses, lymph nodes, tenderness, phimosis, labial adhesions, and stigmata of spina bifida or sacral agenesis.


18.6.3 Investigations


Infants and children presenting with unexplained fever of 38 °C or higher with or without the symptoms and signs suggestive of UTI should have a urine sample send for culture irrespective of the urine dip and microscopy result.


18.6.3.1 Urine Collection and Interpretation [91]


Urinary dipstick testing is only a screening test for UTI. It has poor sensitivity and specificity, especially in children younger than three years of age.


A urine culture is the gold standard for diagnosis of UTI; however, it is only as good as the collection method. It is important to take into consideration the sample collection method while interpreting the culture reports (Tables 18.2 and 18.3).


Table 18.2 The interpretation of urine dip test for children three years or older [91].

















Dipstick testing for leukocyte esterase and nitrite is diagnostically as useful as microscopy and culture and can safely be used.
If both leukocyte esterase and nitrite are positive The child should be regarded as having UTI and antibiotic treatment should be started. If a child has a high or intermediate risk of serious illness or a past history of previous UTI, a urine sample should be sent for culture.
If leukocyte esterase is negative and nitrite is positive Antibiotic treatment should be started if the urine test was carried out on a fresh sample of urine. A urine sample should be sent for culture. Subsequent management will depend upon the result of urine culture.
If leukocyte esterase is positive and nitrite is negative A urine sample should be sent for microscopy and culture. Antibiotic treatment for UTI should not be started unless there is good clinical evidence of UTI (e.g. obvious urinary symptoms). Leukocyte esterase may be indicative of an infection outside the urinary tract which may need to be managed differently.
If both leukocyte esterase and nitrite are negative The child should not be regarded as having UTI. Antibiotic treatment for UTI should not be started, and a urine sample should not be sent for culture. Other causes of illness should be explored.

UTI, urinary tract infection.


Table 18.3 Guidance on the interpretation of microscopy results [91].


Source: From NICE guideline.
























Microscopy results Pyuria positive Pyuria negative
Bacteriuria positive The infant or child should be regarded as having UTI The infant or child should be regarded as having UTI
Bacteriuria negative Antibiotic treatment should be started if clinically UTI The infant or child should be regarded as not having UTI
Urine from Suprapubic puncture Urine from catheterisation Urine from midstream void
Any number of cfu ml−1 (at least 10 identical colonies) ≥103–105 cfu ml−1 ≥104 cfu ml−1 with symptoms
≥105 cfu ml−1 without symptoms

cfu, colony‐forming unit; UTI, urinary tract infection.


A clean catch urine sample is the recommended method for urine collection.


If a clean catch urine sample cannot be obtained, other noninvasive methods such as urine collection bags should be used. When it is not possible or practical to collect urine by noninvasive methods, catheter samples or suprapubic aspiration (SPA) under ultrasound guidance should be used.


In an infant or child with a high risk of serious illness, it is highly preferable that a urine sample is obtained; however, treatment should not be delayed if a urine sample is unobtainable.


If urine is to be cultured and it cannot be cultured within four hours of collection, the sample should be refrigerated or preserved with boric acid immediately.


18.6.3.2 Clinical Differentiation between Acute Pyelonephritis (Upper Urinary Tract Infection) and Cystitis (Lower Urinary Tract Infection) [91]


Infants and children who have bacteriuria and fever of 38 °C or higher should be considered to have acute pyelonephritis or upper UTI. Infants and children presenting with fever lower than 38 °C with loin pain or tenderness and bacteriuria should also be considered to have acute pyelonephritis or upper UTI. All other infants and children who have bacteriuria but no systemic symptoms or signs should be considered to have cystitis or lower UTI.


18.6.4 Radiological Investigation (Table 18.4)


Table 18.4 Recommended investigations and timing [91].


Source: From NICE guideline.











































































Test Responds well to treatment within 48 hours Atypical UTI Recurrent UTIa
Imaging schedule for infants younger than 6 months
Ultrasound during the acute infection No Yesa Yes
Ultrasound within 6 weeks Yesb No No
DMSA 4–6 months following the acute infection No Yes Yes
MCUG No Yes Yes
Imaging schedule for infants and children 6 months or older but younger than 3 years.
Ultrasound during the acute infection No Yesb No
Ultrasound within 6 weeks No No Yes
DMSA 4–6 months following the acute infection No Yes Yes
MCUG No Noc Noc
Imaging schedule for children 3 years or older.
Ultrasound during the acute infection No Yesd,e No
Ultrasound within 6 weeks No No Yesd
DMSA 4–6 months following the acute infection No No Yes
MCUG No No No

a In an infant or child with a non‐Escherichia coli‐UTI, responding well to antibiotics and with no other features of atypical infection, the ultrasound can be requested on a nonurgent basis to take place within six weeks.


b If abnormal consider MCUG.


c While MCUG should not be performed routinely it should be considered if the following features are present:



  • dilatation on ultrasound
  • poor urine flow
  • non‐E. coli‐infection
  • family history of vesicoureteral reflux (VUR).

d Ultrasound in toilet‐trained children should be performed with a full bladder with an estimate of bladder volume before and after micturition.


e In a child with a non‐E. coli‐UTI, responding well to antibiotics and with no other features of atypical infection; the ultrasound can be requested on a nonurgent basis to take place within six weeks.


MCUG, micturating cystourethrogram; UTI, urinary tract infection.


18.6.4.1 Ultrasonography


In presence of UTI acute ultrasound (within 24 hours) is indicated in all of the following situations (to rule out obstruction specifically):



  1. Sick child needing hospital admission and or parenteral antibiotics.
  2. Deranged renal function test.
  3. Not responding to suitable oral antibiotics within 48 hours.

If the child has responded well to oral antibiotics, then a planned ultrasound should be arranged. Ultrasound can identify anatomical anomalies such as hydronephrosis, renal duplication, or renal scars and urinary stones.


18.6.4.2 Nuclear Medical Scans


Nuclear medicine scans should be done for split renal function and renal scarring four to six months following the acute infection in following situations:



  1. Recurrent infections.
  2. Deranged renal function test.
  3. Ultrasound showing dilated ureter and or kidney.

Static scan: Dimercaptosuccinic acid (DMSA) labelled with metastable technetium‐99 (Tc‐99 m) bind to the basement membrane of the proximal renal tubules, with a half‐life of nearly six hours and has a radiation dose of 1 millisieverts (mSv). These scans help determine the split function of the kidneys as well as duplex kidneys, in addition to the accurate diagnosis of cortical scarring. The scan is avoided during an infection because the infection interferes with the uptake of the radiotracer by the renal tubules.


18.6.4.3 Cystourethrography


MCUG (with antibiotic cover) is indicated in children up to one year of age in following situations (i.e. MCUG is difficult to perform after the age of one year because of practicality and in such situation MAG‐3 with indirect radionuclide cystography [IRC] can be useful in selected situations):



  1. Bilateral hydronephrosis or hydronephrosis in solitary kidney.
  2. Unilateral or bilateral hydroureter.
  3. Known spinal dysraphism.
  4. Children with voiding difficulties.
  5. Other known uropathies on case‐to‐case basis.

MCUG is the most commonly used scan to investigate the urinary tract especially in UTIs, with nearly 25% revealing VUR. Dynamic scans are used to assess obstructive uropathy, such as pelviureteric junction (PUJ), as well as split function and with indirect cystogram for VUR. Mercapto‐acetyltriglycine (MAG‐3) labelled with Tc‐99 m, is the radiotracer use, it is excreted by the renal tubules (90%) and the glomeruli (10%), its radiation dose is 0.4 mSv.


18.6.4.4 Urodynamics


Urodynamic evaluation is indicated in patients with voiding dysfunction, incontinence, residual urine, and increased bladder wall thickness.


18.6.5 Management


The main goals of investigating and treating UTIs is to eliminate symptoms and eradicate the causative organism in the acute episode, prevention of renal scarring, recurrent UTIs, and correction of associated urological anomalies or abnormalities.


Management if UTIs is aimed at treating the acute scenario, then diagnosing the cause followed by treating of the underlying cause if present.


18.6.5.1 Acute Management [9193]


Finding a UTI in a sick child does not exclude another site of serious infection (e.g. meningitis). Remember that 2% of young children will have asymptomatic bacteriuria, and this may not be the cause of this acute presentation.


Infants and children with a high risk of serious illness and younger than three months with a possible UTI should be referred immediately to the care of a paediatric specialist for treatment with parenteral antibiotics.


For infants and children three months or older with acute pyelonephritis or upper UTI:



  • Consider referral to a paediatric specialist.
  • Treat with oral antibiotics for 7–10 days.
  • If oral antibiotics cannot be used, treat with an intravenous (IV) antibiotic agent such as cefotaxime or ceftriaxone for 2–4 days followed by oral antibiotics for a total duration of 10 days.
  • Fluid resuscitation: 20 ml kg−1 bolus of fluid, followed by 4 ml kg−1 h−1 as maintenance.

For infants and children three months or older with cystitis or lower UTI:



  • Treat with oral antibiotics for three days. The choice of antibiotics should be directed by locally developed multidisciplinary guidance. Trimethoprim, nitrofurantoin, cephalosporin, or amoxicillin may be suitable.
  • The parents or carers should be advised to bring the infant or child for reassessment if the infant or child is still unwell after 24–48 hours.

If an infant or child is receiving prophylactic medication and develops an infection, treatment should be with a different antibiotic, not a higher dose of the same antibiotic and should be tailored as per clinical response and sensitivity report.


18.6.5.2 Prevention of Recurrence


Dysfunctional elimination syndromes and constipation should be addressed in infants and children who have had a UTI. Children who have had a UTI should have ready access to clean toilets when required and should not be expected to delay voiding, and should maintain adequate amount of fluids.


18.6.5.3 Antibiotic Prophylaxis


Antibiotic prophylaxis should not be routinely recommended in infants and children following first‐time UTI. However, it may be considered in infants and children with recurrent UTIs. In addition to those with increased risk of UTIs, such as VUR, trimethoprim 2 mg kg−1 is the usual prophylaxis.


Asymptomatic bacteriuria in infants and children should not be treated with prophylactic antibiotics.


Cranberry juice or tablets and probiotics might help in preventing recurrent infections.


18.6.6 Follow‐Up [91]


Infants and children who have recurrent UTI or abnormal imaging results should be assessed by a paediatric specialist.


Assessment of infants and children with renal parenchymal defects should include height, weight, blood pressure, and routine testing for proteinuria.


Infants and children with a minor, unilateral renal parenchymal defect do not need long‐term follow‐up unless they have recurrent UTI, family history, or lifestyle risk factors for hypertension.


Infants and children who have bilateral renal abnormalities, impaired kidney function, raised blood pressure, or proteinuria should receive monitoring and appropriate management by a paediatric nephrologist to slow the progression of chronic kidney disease.


Infants and children who are asymptomatic following an episode of UTI should not routinely have their urine retested for infection.


Asymptomatic bacteriuria is not an indication for follow‐up.


18.6.7 Information and Advice for Children, Young People, and Parents or Caregivers


Healthcare professionals should ensure that when a child or young person has been identified as having a suspected UTI, they and their parents or caregivers as appropriate are given information about the need for treatment, the importance of completing any course of treatment, and advice about prevention and possible long‐term management [91].


Healthcare professionals should ensure that children, young people, and their parents or caregivers, as appropriate, are aware of the possibility of a UTI recurring and understand the need for vigilance and to seek prompt treatment from a healthcare professional for any suspected reinfection.


Healthcare professionals should offer children, young people, and their parents or caregivers appropriate advice and information on:



  • prompt recognition of symptoms.
  • urine collection, storage and testing.
  • appropriate treatment options.
  • prevention.
  • the nature of and reason for any urinary tract investigation.
  • prognosis.
  • reasons and arrangements for long‐term management if required.

18.6.7.1 Lower Urinary Tract Symptoms in Children


18.6.7.1.1 Definitions

Daytime LUT conditions encompasses symptoms including urgency, urge incontinence, poor flow, hesitancy, frequency, and UTIs. All children with incontinence are also included in this new terminology; however, night‐time incontinence is known as ‘enuresis’.


Bowel disturbances can be seen in more than 50% of children with bladder disturbances; therefore, concomitant bladder and bowel disturbances is known as bladder bowel dysfunction (BBD).


18.6.7.1.2 Normal Physiology

In neonates, the trigger to void is from the sacral spinal cord and is a reflex when the bladder is full. As the infant develops, the voiding reflex when the bladder is full is supressed, the bladder capacity increases, and the voiding frequency decreases. Eventually the child learns to control voiding and understands bladder sensation to void.


18.6.7.1.3 Urinary Incontinence in Children

More than 95% of cases of incontinence are functional and tend to resolve spontaneously or with conservative treatment. Organic causes such as ectopic ureter, epispadias, posterior urethral valves, or spina bifida need to be closely monitored to ensure protection of the renal function.


Definitions and types of incontinence in children [94]



  • Urgency with or with urgency incontinence: etrusor overactivity gives rise to an overactive bladder.
  • Stress incontinence: usually seen in neuropathic children and in those with cystic fibrosis.
  • Underactive or hypotonic bladder: either secondary to spinal anomalies, poor voiding habits of ‘holding it in’ (voiding postponement), or as part as urological congenital anomalies such as posterior urethral valves.
  • Extraordinary daytime urinary frequency: self‐limiting, the child voids small amounts and frequently.
  • Voiding postponement: usually behavioural or psychological disturbances whereby the children habitually postpone micturition, leaving voiding too late, which leads to incontinence. Seen mainly in girls, and they tend to use holding manoeuvres to postpone voiding, such as leg crossing and squatting (i.e. Vincent’s curtsy). Over time, the bladder may become hypreflexive and sensation decreased. This may lead to overflow or stress incontinence and leave the child prone to recurrent UTIs due to high postvoid residual volumes.
  • Laughing or giggling incontinence: affects girls, whereby incontinence occurs when laughing or giggling, probably due to a week pelvic floor. Resolves with age.
  • Vaginal reflux: urine refluxes into the vagina and leaks out at a later time. Labial adhesion could be the culprit, which can be divided.
  • Dysfunctional voiding: the external urethral sphincter contracts during voiding either intermittently or continuous. This results in residual urine, which can lead to recurrent UTIs.

History and Examination

The history should focus to rule out underlying pathology and establish toilet habits. History should include voiding habits, family history, bowel habits or problems, and social, behavioural, and psychological history.


Incontinence from birth is classified as primary incontinence, whereas if incontinence has developed after a period of being continent for at least six months, it is secondary. Primary incontinence is more likely due to an organic cause, while secondary incontinence more likely to be due to functional causes. Continuous incontinence might be caused by an ectopic ureter. Incontinence shortly after voiding may indicate vaginal reflux. Voiding habits may indicate holding it until the last minute (i.e. voiding postponement).


In addition to the general examination of the whole patient, a focused external genitalia examination for congenital anomalies, such as bifid clitoris, epispadias, meatal stenosis, phimosis (increased risk of infections), as well as a neurological examination should be carried out, looking for pigmented or hairy lesions over the midline indicating spinal anomalies. Sacral agenesis typically presents with a flattening of the buttocks.


Investigations

Similarly, to adults: should include



  • Urine dip sticks to rule out infection.
  • Frequency volume charts, bladder voiding diaries to establish voiding timing and habits, as well as the expected bladder capacity: for <2 years of age is 7.5 ml kg−1, while that of >2 years of age is 30 ml X (age +2).
  • Uroflowmetry: bell‐shaped curve is the normal flow pattern.
  • Ultrasound: for postvoid residuals and PUJ obstruction.
  • MCUG for VUR
  • Videourodynamics: for neuropathic bladders or those that do not respond to treatment or where the diagnosis is not clear.
  • Spinal MRI for neurological causes.

Management

Conservative Management


Conservative therapy can be successful in up to 80% of children. Child and parent education is as important as all other measures. Behavioural and psychological therapies might be needed. Many children respond to conservative approaches, including bladder retraining, timed voiding, appropriate voiding posture (for vaginal reflux), avoiding holding manoeuvres and avoidance of bladder irritants such as any caffeinated drinks, blackcurrant, or medication. Lifestyle modification, regular fluid intake, and preventing constipation with diet modification or laxatives are also key points.


Specific Management


These are focused on treating the underlying cause, including physiotherapy for supervised pelvic floor exercises, biofeedback, alarm therapy, medication, and neurostimulation.


If for overactive bladder syndrome, conservative measure fail, antispasmodics, anticholinergics, or beta agonists are indicated. Neuromodulation, Botox injection, and ileocystoplasty procedures are other modalities used in a stepwise manner.


For laughing or giggling incontinence, anticholinergics, imipramine (a tricyclic antidepressant with anticholinergic and antispasmodic properties), and methylphenidate are recommended.


For underactive bladder, intermittent self or parental catheterisation (ISC) is used.


For dysfunctional voiding, antispasmodics, anticholinergics, ISC, and counselling are recommended.


18.6.7.2 Nocturnal Enuresis [94]


Nocturnal enuresis (NE) is intermittent incontinence during sleeping and is divided into:



  • mono‐symptomatic nocturnal enuresis (MNE): NE without any other lower urinary tract symptom (LUTS) and without a history of bladder dysfunction.
  • Non‐Mono‐Symptomatic NE (NMNE): has associated voiding dysfunction.

NE is classified into either:



  • Primary NE: incontinence since birth, never been dry for more than a six‐month period.
  • Secondary NE: incontinent emerging after a period of dryness for at least six months.

18.6.7.2.1 Prevalence

More common in girls, NE affects 15% of five year olds and 10% of seven year olds with nearly 15% spontaneous resolution per year, and 0.7% continue to adulthood.


18.6.7.2.2 Pathophysiology

NE is a results of three processes:



  • Altered antidiuretic hormone (ADH) section: the normal circadian reduction in urine output during sleep is diminished in nearly 60% of these children because of decreased ADH levels at night causing increased urine production.
  • Altered sleep or arousal mechanism: impairment of the natural arousal from sleep response to a full bladder.
  • Reduced nocturnal functional bladder capacity with or without overactive bladder (OAB) symptoms.

Risk factors that worsen NE:



  • Family history, any siblings, or other family members have or had NE.
  • Psychological and behavioural factors: vicious circle as NE can be caused be psychological factors; however, NE can be a stressful condition causing a huge psychological burden on the child leading to low self‐esteem.
  • UTIs.
  • Constipation.

History and examination are similar to that of incontinence aimed at establishing an underlying pathophysiology.


18.6.7.2.3 Investigations

Diagnostic evaluation is largely from the history and examination, especially for monosymptomatic NE.



  • Voiding diaries to assess nocturnal polyuria and estimated functional bladder capacity. Diaper weighing in the morning to estimate night‐time volumes.
  • Urinalysis to exclude infection, diabetes, or renal disease.

18.6.7.2.4 Management

Conservative

Treatment is usually commenced after five years of age because of a high chance of spontaneous resolution in those younger than five.


Behavioural or supportive measures:



  • Reassurance, positive reinforcement, and counselling of children and parents is vital to understand the problem, and its management course aides a more rapid positive response.
  • Motivational techniques and reward systems can improve child’s confidence and self‐esteem.
  • Bladder training: regular daytime toileting, emptying the bladder before bed, avoiding bladder stimulants, and reduced fluid intake in the hours before sleep. Avoid constipation through modifying diet or laxatives.
  • Conditioning therapy: first‐line treatment modality, especially beneficial for arousal disorder. An enuritic alarm connected to the child’s underwear, triggered with the first few drops of urine, wakes the child up. This is affective in 60–80% of cases.

Medical Therapy


  • Desmopressin: given just before bedtime with no further drinking; producing an antidiuretic response. Success rates of 70% can be seen: with nearly 30% achieving full response and 40% having partial response. The recommended forms are either tablets (200–400 ug) or sublingual (120–240 ug).
  • Anticholinergics or antispasmodics can help with small bladder capacity.
  • Imipramine might help in resistant cases; however, response rates are 50%, with caution of overdose, which can cause cardiotoxicity or death.

A full response is considered with 14 consecutive dry nights or a 90% improvement in the number of wet pads.


Patients with nocturnal polyuria and normal bladder function have a good response to desmopressin.


Patients with functionally reduced bladder capacity benefit from a combination of enuresis alarm, bladder training, and anticholinergics with or without desmopressin.

Aug 6, 2020 | Posted by in UROLOGY | Comments Off on Bladder Congenital Anomalies

Full access? Get Clinical Tree

Get Clinical Tree app for offline access