Surgical aspects of pediatric urinary incontinence

Abstract

This thesis tries to bridge between functional and structural non-neuro- genic incontinence and to give insight in the surgical options. Children with anatomically based bladder neck and urethral insufficiency often present with the same symptoms as children with genuine non-neurogenic functional incontinence. Bladder neck insufficiency causes urine to leak into the proximal urethra and urine in the proximal urethra is one of the triggers of the micturition reflex with detrusor contraction and sphinc- teric relaxation as a result. Children with an insufficient bladder neck are constantly counteracting this micturition reflex by pelvic floor contraction and can present with typical symptoms of true dysfunctional voiding. Constant awareness of these facts is mandatory for all the members of the team. The urologist should be very meticulous in the endoscopic and ultrasound judgement of the anatomy of the bladder, the bladder neck and the urethra. Video-urodynamic studies must be interpreted with the assumption that derailment of the Wolffian duct can be a cause of the incontinence. The urotherapist must know that some children cannot be cured by biofeedback treatment and eventually will need an operation to get rid of the urinary incontinence. The physical therapist is the only per- son that can specifically teach the child to use the puborectalis muscle instead of all the muscles around. This is an underestimated task because many physical therapists do not realise that this result can only be obtained by invasive treatment with rectal examination and biofeedback training by anal balloon expulsion. Meanwhile, the physical therapist must be aware of the rare neurogenic anomalies that sometimes can be over- looked by urodynamic studies. The psychologists and all the members of the team should realise the psychological impact of incontinence, some- times combined with malformations of the external genitalia, on the behaviour of a child. Any child with a handicap copes with the disability by eleminating the concerning part of the body from the self-image. The resulting ignoring behaviour of the child that should be interpreted as a natural defence mechanism to cope with the disability is commonly mis- interpreted as a behavioural disorder by parents and therapists. Finally one must realise that also children with structural anatomically based inconti- nence as in bladder extrophy and epispadias as well as children with ambiguous genitalia often need to be treated by the team of urotherapists and physical therapists to accomodate the function of the restored anato- my to the daily life situation.. Moreover, in many cases these children need specific guidance for gender identity and psychosexual development by a team that is specialised in dealing with ambiguous genitalia in childhood. The chapters in this thesis describe functional incontinence and many aspects of structural incontinence in childhood. The main objective in the treatment of the different patient groups has been to minimise morbidity and health care consumption in patient groups that historically present with chronic lower urinary tract problems. Our approach to ectopic urete- roceles, in our opinion, reduces the morbidity as much as possible. More research in this field by other groups will be neccessary to prove this fact. The Otis-urethrotomy victims, when untreated, are bound to life-long uri- nary incontinence with many frustrating events by failing therapies. Our approach for girls with ambiguous genitalia has been able to reduce the work-load of the urotherapists in this group of patients to zero, in con- trast to their work load in the relatively large group of patients that has been treated by historic schedules resulting in non-neurogenic bladder/sphincter dysfunction and/or urinary tract infections in the majority of the patients. The treatment of female epispadias as presented in this thesis appears to reduce the morbidity and the number of surgical procedures for the patients. Further an extensive overview of the treatment of extrophia vesicae (open bladder) and of epispadias is presented.