PubMed1984
Recent advances in the treatment of urinary incontinence of neurological origin in children are discussed. The etiology of the neurological changes is mainly congenital (myelomeningocele, sacral agenesis and hidden dysraphism) other causes such as myelitis, radiculitis or cord injuries being very rarely observed. Two fundamental elements can be evaluated by radiologic and urodynamic investigations of the lower urinary tract: the capacity for compliance of the detrusor muscle and the degree of cervico-urethral resistance. The presence of a cervico-urethral obstruction is no longer an indication for its removal but, on the contrary, a factor that can be retained to assist continence. Intermittent use of self-catheterization enables the obstruction to be used to obtain continence (dryness) and makes the obstruction innocuous, since it enables emptying of the bladder. Of 50 patients (26 girls and 24 boys) treated in this way, 11 were not seen again, but the other 39 are still being followed up after an average of 50 months. This method of bladder emptying maintains the integrity of the upper urinary tract when this was normal previously and improves uretero-pyelo-caliceal distension. Uretero-vesical reimplantation can prevent reflux. Of these 39 children, 23 are continent during the day and 13 among them during the night also. A colocystoplasty was performed in 3 cases to enlarge the bladder capacity. The use of a catheter is well accepted by the girls and young boys but less so by the male adolescents. In the absence of a cervico-urethral obstruction it is impossible to relieve incontinence by re-education, and only three solutions exist: high cutaneous diversion continent cystostomy and artificial sphincter. The high diversion operation should be used as a last resort only. The continent cystostomy uses an appendix isolated on its mesothelium an opening on the abdominal wall and into the bladder in a long anti-reflux tunnel. Catheterization is by a catheter which passes through the newly formed ureter and enables the bladder to be siphoned dry four times daily. This method was used in 25 patients but many complications developed, including febrile attacks with dilatation of the upper urinary tract due to too small a bladder under increased pressure (an enlarging colocystoplasty was required). Eight other children continued to have urine loss through the urethra and required repeated closure of the bladder neck, and one child developed a bladder stone.(ABSTRACT TRUNCATED AT 400 WORDS)