Neurogenic Vesical Dysfunction in Children1

NEUROGENIC VESICAL DYSFUNCTION IN CHILDREN 1 CLINTON K. SMITH AND LARRY P. ENGEL From Children's Mercy Hospital, Kansas City, Missouri

Few problems have taxed the resourcefulness of the urologist, equal to that of neurogenic vesical dysfunction. The proposition readily resolves itself into two phases, diagnosis and management. While various degrees of borderland dysfunction, as periodical retention, dribbling or intractable enuresis are not without interest, the scope of this presentation is concerned principally with a consideration of the factors involved in cases of frank retention and incontjnence, founded upon a study of 4 cases of retention and 9 cases of incontinence. To come upon the features of diagnostic and therapeutic interest in these cases, a brief discussion of neuro-anatomic physiology is essential. GENERAL NEURO-ANATOMIC CONSIDERATIONS

For practical consideration the bladder receives its nerve supply from two divisions of the autonomic nervous system, and the pudics. The term sympathetic is used to designate that part arising by numerous root filaments from ganglionated structures in the thoracico-lumbar region as descried in detail by Learmonth (10) and Fontaine and Herrman (3). These several filaments coursing downward come together forming a synapsis at about the aortic bifurcation in front of the sacral promontory, known as the presacral nerve or the superior hypogastric plexus. This plexus immediately divides into two bundles or branches known as the right and left hypogastric nerves, which soon give off branches to either ureter and coursing downward and outward for a distance of 2½ to 3 inches terminate in the so-called hypogastric ganglia 1 Read at the twenty-ninth Annual Meeting of the American Urological Association, Toronto, Canada, May 31, 1932.

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situated posterior to the bladder and lateral to the rectum, one on either side. The term parasympathetic is used to designate that part arising from the anterior division of the sacral nerve roots and

FIG.

1.

SCHEMATIC DRAWING ILLUSTRATING THE AUTONOMIC NERVE SUPPLY TO THE BLADDER

A. B. C. D. E.

Presacral or superior hypogastric plexus of the sympathetic system. Hypogastric nerves. Hypogastric ganglion. Parasympathetic nerves. Pudic nerves.

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immediately entering the hypogastric ganglion (fig. 1). A considerable variance of opinion obtains concerning the exact origin of the parasympathetics. According to Learmonth (11) these fibers arise from the second 1 third and fourth sacral nerves; Cordier (1) states that they arise from the first to the fourth inclusive; Latarjet and Rochnet (13) believe they arise from the second to third sacral, while Havelocque (7) states that they arise from the third and fourth sacral roots. THE HYPOGASTRIC GANGLIA

Neither the sympathetics nor the parasympathetics reach the bladder directly, but together, form synapses designated as the hypogastric ganglia, situated as previously described. In addition fibers are received from the second and third sacral ganglia. It is through this ganglionated structure that the sympathetics and parasympathetics reach the bladder. Lee (14), Frankenhauser (5), Robinson (18), Hashimito (6), Jung (8) and Kehrer (9), have all considered this a true sympathetic ganglion. THE PUDICS

These nerves arise from the fourth and fifth sacral roots and are distributed directly to the upper urethra and bladder neck reg10n, PHYSIOLOGICAL CONSIDERATIONS

It is not within the province of this paper to offer a detailed discussion of the complex subject of neurovesical physiology. Since the theme of this contribution is concerned chiefly with the clinical aspects of congenital retention and incontinence, consideration of neurovesical physiology will be limited to a summary of other contributions dealing particularly with neurophysiology. Notwithstanding many valuable and scientific contributions to this fascinating subject much uncertainty remains concerning exact neurovesical physiology. Various highly scientific contributions, by various authors, while clarifying in certain instances, are contradictory and in disagreement in others. Although certain facts have been well established, others equally important are, of necessity, left to hypothetical conjecture.

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Bladder physiology is unique in that it is primarily autonomic, governed by extra-spinal reflex centers, as noted in the automatic bladder of early infancy, which later comes partially under the control of the will with the development of the general nervous system. This point is further evident in later life, when automatic emptying of the bladder is established after cord injuries, occurring at any level of the cord compatible with life. PHYSIOLOGY OF THE COMPONENT PARTS OF THE BLADDER

In analyzing the cause of, and formulating a remedy for, neurogenic retention or incontinence, it is essential to have in mind as definitely as possible, the accepted knowledge of the neurophysiology of the various component parts of the bladder. According to Fontaine and Herrmann (4) the entire sympathetic innervation of the urinary tract and all other viscera is in the form of a vast plexus of nerves, the meshes of which are sometimes wide while at other times the fibers are matted together with small masses of ganglion cells scattered along the entire course of the nerves. For this reason it is difficult to ascribe to any nerve or group of nerves, as an entity, the innervation of any isolated or component part of the bladder. Rose (19) in his cystometric studies has made use of a rather broad generalized classification in which he has designated the sympathetics as the nerves of bladder filling and the parasympathetics as the nerves of bladder emptying. A summary of Learmonth's (11) most excellent contribution to this subject indicates that bladder function is effected chiefly through innervation by the parasympathetics. That through the influence of this innervation, an inherent muscle tonus is maintained within the internal sphincter while relaxation of the detrusor is at the same time effected under the stimulus of intracystic pressure of a constant head of fluid. A further summary indicates that the action of the sympathetics is largely a reinforcement of the function of the parasympathetics in which the predominating feature is a brake like action on the internal sphincter. Further, that in bladder emptying, stimuli from the parasympathetics unlock the sphincteric muscle tonus while at the same time

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effecting a contracture of the detrusor, and that when defective innervatjon this source fails to normally effect this function that the brake like action of the sympathetics assumes control with attendant retention. Justification of his deduction is apparent from observation in 2 cases in which he performed presacral neurectomy (sympathectorny) for the relief of retention due to defective innervation from the parasympathetics, with excellent clinical results. A further justification of these deductions is apparent from clinical observation in one of our own cases in which we performed presacral neurectomy for congenital retention, in excellent bladder emptying was obtained. An interesting observation in this case is that since operation this patient, a boy seven years of age, persistently wets the bed, whereas, previous to operation this had never occurred. Apparently an over-correction his difficulty. In Learmonth's cases, as also in our own case, a transient frequency was noted which soon came to adjustment. Apparently pudics, aside from supplying innervation to the so-called external sphincters, play a very insignificant, if any part, in physiology, as it has been shown repeatedly that no disturbance of this function follows bilateral pudic neurectomy. To summarize neurovesical physiology, we may assume that the component parts of the bladder can be generally classified as the sphincteric segment and the detrusor segment. That in each is antagonistic to the other and that innervation impulses are likewise antagonistic in character although synchronized so that while contraction occurs in one segment, relaxation occurs in the other. That as Rose has pointed out this emptying func·tion is set in motion through stimuli derived when intracystic pressure reaches a certain level, variable in different individuals and with variable degrees of bladder sensitiveness. That the parasympathetics in some manner, not altogether well understood, are capable of on this function alone. That the sympathetics play a part in maintaining a synchronized balance between these antagonistic impulses. Furthermore, it is interesting to infer that the hypogastric ganglion, through which passes the combined vesical innervation,

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serves a function in maintaining this balance, although concrete evidence of this is not available. Of interest in this connection are those cases in which irritative stimuli from other structures entering the hypogastric ganglion are apparently relayed to the bladder, resulting in retention or impulsive emptying. Every surgeon is familiar with the clinical phenomenon of retention following operations upon the abdominal viscera. There is also the bedwetting boy of twelve to fifteen years of age, who is cured by the passing of a few sounds; apparently an interrupting of an autonomic nerve impulse habit originating in the posterior urethra. A further example of extrinsic nerve impulse habit is apparent in one of our cases; a girl eleven years of age, afflicted with persistent diuresis and enuresis since birth, clinically a functional incontinence, in which a painstaking urological and neurological survey disclosed no abnormalities. Finally an anal fissure was discovered, to which appropriate treatment was applied, followed by a happy recovery of her bladder control. DIAGNOSIS AND ETIOLOGY

Diagnosis resolves itself into two phases: First, as to whether the difficulty is neurogenic or otherwise; second, the character and etiology of the neurologic lesion. The former presents little difficulty as cystoscopy discloses obstructive lesions, as bladder neck contractions or posterior urethral valves, in the small percentage of cases in which these lesions are the etiological factors. In the latter, however, the diagnostic problem is decidedly more complex and involves evaluation of the various elements embraced in the foregoing discussion. CHARACTER OF THE NEUROLOGIC DEFECT

As previously indicated, the basic etiological factor in neurogenic bladder dysfunction is, in most instances, defective innervation from the parasympathetics. Viewed from a congenital standpoint, defective parasympathetic action is usually associated with osseous fusional defects of the lower spine. The coincident development of abnormal fibrosity in or about the meningeal sac,

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producing nerve impingement, undoubtedly accounts for defective impulses reaching the bladder through the parasympathetic pathways. the more exaggerated cases the situation is further complicated by spina bifida, in its various forms. Unfortunately, in rnany of these cases, an early and unskilled operation has diminished the hope of neurosurgical correction of the defect. Obviously, careful roentgen examination of the spine should be first step in diagnostic procedure. Of further diagnostic portance is the characteristic saddle anesthesia of the cutaneous distribution of the lower sacral nerves. In such instances, conceding that we are dealing with diminished function of the parasympathetics, it is not improbable that impingement of the sacral nerves exists, notwithstanding the lack of neuro trophic or roentgen evidence. In this connection it is hoped that experimental which is being done in x-ray visualization of the spinal canal may provide a basis for a better analysis in these cases. CYSTOSCOPY AND CYSTOGRAPHY

A combined cystoscopic and cystographic study is not only desirable, but of the utmost importance. Information from this source discloses: First, whether the difficulty is neurogenic, and second, the current character of the neurologic lesion. To elucidate; cystoscopy ordinarily can be relied upon to rule out bladder neck contractions and posterior urethral in doubtful instances, a cystogram showing the typical funnel-shaped bladder neck noted in neurogenic dysfunction, may a welcome diagnostic adjunct. Further, in cases of incontinence without residual urine, in which cystoscopy verified by cystography discloses marked trabeculation of the bladder walls, it is evident we are dealing with a progressive pathology and that the current incontinence is a sequel. to a previous retention. The fact, as pointed out by Penfield and Cone (16), that when the normal progressive upward migration of the cord, after the third month of fetal life, is prevented by involvement of the sacral nerve roots in a developmental spinal defect, in which, on

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this account, the nerve roots are incorporated in the meningeal sac or are otherwise bound by abnormal fibrous bands, this factor must be considered when symptoms later develop, indicative of defective parasympathetic innervation. In this connection, a review of certain clinical and pathological aspects of the cases reported by Mertz and Smith (15) in comparison with those of our own cases, provides certain features of more than passing interest. In the series of 13 personal cases of Mertz and Smith (15), fusion defects were present in 12; in 1 an infantile paralysis accounted for the difficulty. In 11 cases incontinence was the outstanding symptom, associated with retention in 9 cases; apparently a paradoxical incontinence, an overflow of a retention. In the remaining 2 cases the findings were inconclusive. Apparently in this series of cases the outstanding neuropathology was defective innervation from the parasympathetics allowing the sympathetic impulses to predominate in the production of chronic urinary retention except in 2 doubtful cases. In our own series of 13 cases, there were 11 males and 2 females, ranging in age from two and one-half years to twelve years. In 9 cases there was frank incontinence with no associated retention. In 4 cases there was retention with ability to void small amounts with great difficulty but no enuresis or diuresis. In the 9 cases of incontinence, there were fusional defects of the lower spine in 7, while in 2 no spinous defects could be demonstrated. In the 7 cases showing fusional defects there was well marked trabeculation of the bladder in 5, indicating previous retention. In 6 of the 9 cases of incontinence, there were neurotrophic changes characterized by saddle anesthesia, trophic ulcers, and varying degrees of muscular weakness of the lower legs. In the 4 cases of retention there was a fusional defect in 1 while in the 3 others, no spinous abnormality could be detected. There was well marked trabeculation of the bladder in each case. In none of the cases was there evidence of neurotrophic changes. In 1 case there was a four plus Wassermann reaction. Apparently in most of our cases of incontinence the progressive

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character of nerve degeneration had carried the patient through the over.:.flow incontinence of retention period, as described by Mertz and Smith, to a state of relatively complete breaking down of all neurophysiology, resulting, finally in a frank incontinence. MANAGEMENT

In contemplating the management of these cases, it is convenient to again utilize the classification clinically, as incontinence and retention. Incontinence. In this group the problem must be approached from two angles: First, the correction of the neurological defect; second, correction of the relaxed sphincters by plastic means. Obviously the term correction is used advisedly, as what may be accomplished depends greatly upon the extent to which nerve impulses have been irreparably lost. Keeping in mind the fact that the problem is centered largely in the parasympathetics; that, as is apparent in most of our cases, the lesion is progressive owing to the tendency of the cord to migrate upward while the segment of parasympathetic origin is retarded by fixed fibrous bands, it is apparent that the problem should be first attacked from this angle. N euroresection. According to our present knowledge, the only plan of practical merit is the freeing, by careful dissection of the sacral nerve roots of all pressure or impingement caused by osseous or fibrous elements. Regrettably, in most of our cases operations done in infancy with the objective of covering the meningeal sac only, had so muddled the anatomical picture that neuroresection was extremely difficult and in most instances the operation was unsatisfactory. Plastic operations. As previously mentioned, operative measures on the sacral nerve roots, should be accorded first place; first, with the purpose of limiting the progressive tendency of nerve degeneration, and second, because in some of the cases nerve function is restored by releasing the nerve roots from pressure and impingement. In those cases where no improvement follows neuroresection, some plan of plastic support of the vesical sphincter is advisable as will be shown later in our case reports.

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There is very little hope of success in those cases without bladder function sense, or in other words, when complete absence of nerve function obtains. Where a partial sense of bladder filling or emptying is still present, however, very gratifying results may be often expected from these operations. Support of the vesical sphincter may be accomplished by intravesical operation on the bladder neck as advocated by Young (21) or by supplying a ring like resistance about the upper urethra by transplanting the gracilis muscle as described by Deming (2) and later by Player and Cullander (17), as also by one of us (20). Retention. Retention is by far the more serious phase of neurogenic vesical dysfunction owing to the constant hazard of back pressure and sepsis. Sepsis, from retention of urine, is the immediate obstacle to be overcome. The condition is usually one of long-standing and the case is usually first seen in the throes of an acute attack of chills, fever, and prostration. The indwelling urethral catheter is the mainstay in the management of these cases during this stage. It happens, however, in some instances, that retention and sepsis above the bladder require the use of the indwelling ureteral catheter. Here, again the proposition is apparently parasympathetic impairment, wherein normal impulses from the sympathetics have assumed control exerting an abnormal brake like action on the bladder neck sphincters. Operative measures. Where fusional spinous defects are apapparently the primary etiological factor, the problem should be first attacked from this angle, by surgical freeing of the sacral roots. However, fusional defects were present in only 1 of our 4 retention cases. Furthermore, it is of interest to note that where fusion defects are at fault parasympathetic degeneration is apparently progressive. The majority of our cases of incontinence had apparently passed through a stage of relative retention as evidenced by bladder trabeculation and dilatation of the ureters and renal pelves. This unique phenomenon must be accorded due consideration in the treatment and prognosis in these cases.

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BLADDER NECK DILATATION

While small hope may be entertained, of correcting nerve degeneration by means of dilatation of the bladder neck, still, this procedure occasionally is followed by favorable clinical improvement ju the milder degrees of retention. Its usefulness is limited chiefly to those cases where the specific neuropathology is uncertain or in other cases where for one reason or another neurosurgery is not admissable. NEURECTOMY

To Learmonth (12) must be accorded full credit for bringing to our attention this plan for reestablishing the neuro-functional balance of bladder emptying. The section of the sympathetic chain or synapsis, designated as the presacral nerve or superior hypogastric plexus at its location at the promontaryof the sacrum, immediately below the branching of the aorta, releases a brake like tonus effecting the vesicle sphincter, thus allowing the weakened impulses from the parasympathetics to assume a relatively normal function. In our opinion however, this meritorious operation should be deferred (in children) in those cases with spinous fusional defects, until an attempt has been made to restore parasympathetic function by freeing of the sacral nerve roots. Obviously, should parasympathetic degeneration be progressive, presacral neurectomy would hasten an approaching incontinence. In our own case in which no fusional defects were discernible, enuresis, which was not previously noted, has persistently occurred during the seven months since the operation. While the child completely empties his bladder and has perfect control during the day, we are inclined to speculate as to whether we may expect a further tendency towards sphincteric laxness as time goes on. CASE REPORTS WITH ANALYSIS CASES

As a preface to the following reports we wish to say that in each instance obstructive lesions, as posterior urethral valves and bladder neck contractions have been ruled out.

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The case reports are presented in two groups, incontinence and retention. A chronological order is m'.lintained, as nearly as possible, in order that the evolution of our experience with the management of these cases may be apparent and that our present ideas may not appear inconsistent with our management in some of the earlier cases. CASES OF INCONTINENCE

Case 1. A male child, aged twelve years entered Mercy Hospital June 6, 1927. There had been constant dribbling since birth. There was no incontinence of feces. This boy had never been able to walk owing to inability to use his legs below the knees.

FIG. 2. CASE 1 Note absence of sacrum and fusional defect of fifth lumbar vertebra. Note unusual position of the fourth and fifth lumbar vertebra in relation to the ilia.

Examination. A bright intelligent child, well-developed chest, abdomen and thighs. There was apparent atrophy of the gluteal muscles with saddle anesthesia. The lower legs were flexed, the muscles atrophic. The blood and spinal fluid showed a negative Wassermann reaction. The urine was normal. The bladder was empty upon catheterization. X-ray showed an entire absence of the sacrum and a fusional defect of the laminae of the fifth lumbar vertebra. Cystoscopy disclosed fine trabeculations of the bladder walls. The bladder neck was poorly defined. Cystography showed a bladder of 50 cc. capacity with marked serrated marginal outline and slight funnelling of the bladder neck.

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Diagnosis. Defective parasympathetic innervation, producing primarily an over-flow retention, as evidenced by cystoscopy and raphy, which, with further nerve degeneration was converted into a complete incontinence. Operation June 20, 1927. The right gracilis muscle was dissected out from the thigh from its attachment at the inner tuberosity of the tibia, up to its nerve and blood supply and the tendonous end cut near its attachment at the tibial tuberosity. The urethra in the perineum was exposed and the cut end of the gracilis was drawn through a tunnel beneath the skin and fascia of the inner upper thigh into the perineum and looped about the urethra. A retention catheter was left in situ until the fourth day. Upon its removal this for the first time in his memory he was able to stop and start his urinary stream at will. February l, 1928. He was able to control his urine for two to three hour periods without discomfort and remained dry at night if awakened once. The bladder capacity was 80 cc. There was no residual urine. This boy, who resides in a distant state has been heard from at frequent intervals, the last in January, 1932. He has continued to good urinary control. Orthopedic surgery has since enabled him to walk with the aid of hand crutches. Case 2. A female child, aged nine years, entered Mercy Hospital January 10, 1928. Her mother reported that she had never slept in a. dry bed nor passed a day in dry clothes since birth. There was no incontinence of feces. Examination. A well-developed child. The general examination was essentially negative. The blood and spinal fluid 'IN assermann was negative. X-ray of the spine showed no abnormalities. This child was able to stop and start her urinary stream and could retain 30 to 40 cc. of urine in the bladder, although the moment her attention was directed elsewhere, there was incontinence on any exertion. Cystoscopy, cystography and uretero-pyelography disclossed nothing; abnormal. The bladder capacity was 60 cc. Rectal examination disclosed a well marked anal fissure. Judicious anal dilatation with appropriate treatment for fissure was followed immediate urinary control.

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Diagnosis. Empirical as it may seem, we were forced to assume that the dilatation of the rectal sphincter broke up a reflex nervous arc which was productive of bladder dumping. This child, when last heard from two years later was still enjoying good urinary control.

Fm. 3.

CASE

1.

CYSTOGRAM, CASE OF CONSTANT COMPLETE lNCO)[TINENCE, NO RESIDUAL URIKE

Note slight funnelling of the bladder neck. Note serrated marginal outline, showing trabeculation of the bladder walls, indicative of a previous difficulty of emptying bladder.

Case 3. A male child, aged ten years, entered Mercy Hospital March 20, 1928. His mother thinks he had had dysuria since birth. During the past several years there had been constant dribbling both day and night.

FIG.

4.

CASE 2. CYSTOGRAM, CASE OF INTRACTABLE DIURESIS AND ENURESIS. NORMAL BLADDER OUTLINE. No EvrnENCE OF PREVIOUS EMPTYING DIFFICULTY. No SPINous FusIONAL DEFECTS

Good control followed care of anal fissure

FIG.

5. CASE

3

Note fusional defect of fifth lumbar vertebra and sacrum. second and third lumbar vertebra, a recent development.

689

Note fused first,

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Examination. A bright but very much undernourished child. There was saddle anesthesia and atrophy of the lower leg muscles on account

FIG. 6.

CASE

3.

CYSTOGRAM, CASE OF PERSISTENT INCONTINENCE AND ENURESIS. No REsrnuAL URINE

Note funnelling of bladder neck. Note marked irregular marginal bladder outline. Marked trabeculation, indicative of previous difficulty bladder emptying.

of which he was wearing braces. but no fecal incontinence.

There was a very lax anal sphincter

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X-ray showed a fusional defect involving the last lumbar vertebra and the entire sacrum. There was no bulging at the site of the sacral de-

FIG. 7. CASE 4. CASE OF INTRACTABLE DIURESIS AND ENURESIS. No RESIDUAL URINE. SPrNous FusroNAL DEFECTS. NoRMAL CYRTO·· GRAPHIC BLADDER OUTLINE EXCEPT SLIGHT FUNNELLING OF THE BLADDER NECK

Condition greatly improved

bladder neck dilatations, Kollman dilator

feet. Bycatheter the bladderwas empty. There was constant dribbling --a complete incontinence. The urine contained numerous pus cells. THE JOURNAL OF CROLOGY, VOL, XXYIII, NO.

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Cystoscopy disclosed a markedly trabeculated bladder with a poorly defined bladder neck. Cystography showed a markedly serrated bladder outline with moderate degree of funnelling of the bladder neck, capacity 145 cc. The blood and spinal fluid Wassermann was four plus. Diagnosis. Neurogenic incontinence, a sequel to a previous retention, due to parasympathetic degeneration, probably a combination of congenital syphilis and involvement of the sacral nerve roots in the spinal defect. This child was vigorously treated for syphilis during the ensuing two years with general improvement but no change in his incontinence. Operation October 9, 1930. A gracilis transplant was done. Following operation this boy was able to control his urine during the day for periods of from one to two hours. His ability to retain his urine was still further improved by persistent coaching in starting and stopping his urinary stream together with dilatation of the bladder with water. He was able to reenter school and made good progress in his studies. His condition remained practically stationary during the ensuing year. Notwithstanding vigorous anti-syphilitic treatment his general condition began to decline during the latter months of 1931. He then lost almost all use of his legs. His incontinence recurred with incontinence of feces. X-ray showed the upper three lumbar vertebra involved in a fused bony mass, which was diagnosed as luetic spondylitis. Since that time there has been practically no change in his condition.

Comment. Undoubtedly a case of parasympathetic degeneration owing to osseous spinal fusional defect in which congenital syphilis played a contributory part. Case 4- A male child, aged nine, entered Mercy Hospital October 14, 1929. There had been diuresis and enuresis since birth. He complained of pain in the bladder region on exercise. He had had most of the contagious diseases, including scarlet fever. Examination. The general examination was essentially negative, excepting a general undernourished condition. X-ray of the spine was normal. The blood and spinal fluid Wassermann was negative. The urine was normal. Cystoscopy disclosed a slightly trabeculated bladder with poorly defined bladder neck.

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Cystography showed a normal bladder outline except slight funnelling of the bladder neck. The bladder capacity was 80 cc. This boy was able to control his bladder action at will, but when the bladder became distended he lost control on exertion. Diagnosis. Defective innervation of the parasympathetics, cause undetermined. Treatment. The bladder neck was dilated to 24 F by a Kollman dilator at intervals of four to six weeks. October 10, 1930. This child had shown a steady improvement. He then controlled his urine very well during the day and had only occasional enuresis.

FIG. 8. CASE 5

Note fusional defect of fifth lumbar vertebra and sacrum. sacrum.

Note deformity of

Case 5. A male child, aged seven years, entered Mercy Hospital, May 10, 1929. The history indicated that he had been troubled with difficulty, straining and dribbling since birth. During the past two to three years there was constant dribbling of urine without discomfort while on his feet, and persistent enuresis. He had very little sense of bladder control. He had had measles and whooping cough. Examination. An intelligent and fairly well-developed child. There was saddle anesthesia but no apparent defect in the muscular development of his leg muscles. There was a bulging tumor over the sacral region and a trophic ulcer over the buttocks, a spina bifida of the meningomyelocele type. X-ray examination of the spine showed a fusional defect of the laminae

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of the fifth lumbar vertebra and of the entire sacrum. There was a bulging mass over the sacral region. The sacrum was deformed, showing almost no formation to the left of the canal. The blood and spinal

FIG, 9.

CASE

5.

CYSTOGRAM, CASE OF CONSTANT COMPLETE INCONTINENCE, NO RESIDUAL URINE

Note marked funnelling of bladder neck. Note unique bladder outline with marked marginal irregularity. Deep trabeculation indicative of previous emptying difficulty.

fluid Wassermann was negative. The bladder was empty by catheter. The urine contained pus and colon bacilli. Cystoscopy disclosed a markedly trabeculated bladder with poorly defined bladder neck. The bladder mucosa appeared fairly normaL

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As the pyuria was not compatible with the degree of cystitis, bilateral catheterization of the ureters was done. About 20 cc. of retained urine containing pus and colon bacilli was drained from each kidney. Bilateral ureteropyelograms disclosed marked dilatation of each ureter and renal pelvis. The pus and bacteria cleared with repeated ureteral catheterization lavage. Cystography showed a pear-shaped bladder outline with serrated marginal contour and funnelling of the bladder neck. Diagnosis. Neurogenic incontinence, a sequel to neurogenic retention as evidenced by cystoscopy and cystography. Probably incident to parasympathetic nerve degeneration in association with involvement of the scaral nerve roots in the fibrous formation of the meningomyelocele spina bifida. Operation June 5, 1929. The distal end of the right gracilis was transplanted into the perineum and looped about the urethra. A retention catheter was left in situ for ten days following operation. Upon removal of the catheter, the boy was able to retain his urine for one-half to one hour periods. He could stop and start his urinary stream at will. Coaching in starting and stopping his urine was carried out by the nurses several times daily during the ensuing six weeks. He left the hospital September 10, able to control his urine from one to two hour periods. His enuresis persisted. February 20, 1931. This child had continued to show improvement. He was then able to void 100 cc. of clear urine. During play however, he would lose control and wet his clothes. Operation August 14, 1931. This child again was admitted to Mercy Hospital and a resection of the meningeal sac of the spina bifida was done. Numerous fibrous bands were found crossing the walls of the sac, producing impingement of the sacral nerves, which, were also found to be incorporated in the walls of the sac. These were carefully freed and the wound closed in the usual manner. Following this operation there was a considerable improvement in his ability to retain his urine for longer periods. Comment. It is of particular interest to speculate on the probable evolution of the neuro-pathology. Apparently a primary bladder retention in which parasympathetic degeneration allowed the sympathetic innervation to assume control of the bladder emptying with attendant retention. It is further speculative interest that the same condition obtained at the uretero-vesical

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outlet resulting in wide dilatation of the ureters and renal pelves. Further, that as parasympathetic degeneration progressed, complete sphincteric muscular tonus was last. The favorable results following the gracilis transplant can be attributed to the supplying of muscular resistance jn bladder emptying, thus restoring, in a degree, the lost balance of bladder control. The resection of the meningeal sac of the spina bifida undoubtedly relieved the sacral nerve roots of impingement with attendant release of inhibition of neuro motor impulses. Case 6. A male child, aged six, entered Mercy Hospital April 19, 1930. There had been incontinence of urine and feces since birth. This child had never been able to walk or stand, owing to weakness of the lower leg muscles and to incoordination of movement of the thighs. Examination. A well nourished child of sluggish mentality. There was a longitudinal scar over the sacral region from an operation performed soon after birth for the closure of a spina bifida of the meningomyelocele type. There was no bulging at the site of operation. There was saddle anesthesia with trophic ulceration over the buttocks. He was unable to move the thighs with any coordination. The lower leg muscles were atrophic with talipes varus of both feet. X-ray of the spine and pelvis showed a partial fusional defect involving the laminae of the first, second and third lumbar vertebrae; a complete absence of fusion of the laminae of the fourth and fifth lumbar vertebrae. The sacrum was rudimentary with no indication of fusion of the laminae. There was an absence of the descending rami of the ischium. There was no formation of the acetabulum. The blood and spinal fluid Wassermann was negative. The bladder by catheter was empty. The urine was normal. Cystoscopy revealed a bladder normal in appearance with fairly well defined bladder neck. There was no trabeculation of the muscular structures. Cystography showed a bladder outline of smooth margin, the upper fundus inclined to the right. There was no funnelling of the bladder neck. There was regurgitation of the cystographic media into either ureter. Diagnosis. Congenital neurogenic incontinence of urine and feces owing to defective innervation of the autonomic nerves incident to involvement of the nerve roots with osseous spinal fusional defect.

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Fm. 10. CASE 6 Note fusional defect involving last cervical, all the lumbar and sacral vertebra,. Note rudimentary sacrum.

Fm. 11.

CAsE 6. CYSTOGRAM, CASE OF PERSISTENT AND CONSTANT INCONTINENCE SINCE BIRTH. No RESIDUAL URINE. NORMAL CYSTOGRAPHIC OuTLrnE

Note incontinent return of media into urethra. tying difficulty.

No evidence of previous emp-

69.8

CLINTON K. SMITH AND LARRY P. ENGEL

Operation May 20, 1930. The distal end of the right gracilis muscle was transplanted into the perineum and looped about the urethra. Convalescence was uneventful. After this operation the boy was able to pass small amounts of urine with coaching by the nurses by bearing down abdominal pressure. He continued to dribble urine however, and had no sense of bladder capacity, nor could he sense the passing of urine. Operation November 20, 1931. An attempt was made to isolate and free the sacral nerve roots but was unsatisfactory owing to the dense fibrous covering of the sacral canal. There was no improvement after this operation. Operation January 25, 1932. The bladder was opened and a bar-like dam was constructed at the bladder neck by drawing the outer margins of the trigone upward and forward to the sides of the bladder neck. The net results of this operation were that 30 to 40 cc. of urine was retained in the bladder which could be expelled by abdominal pressure. A dribbling over-flow occurred however, unless this emptying was done at frequent intervals. There was no sense of bladder capacity nor of bladder emptying.

Interest attaches to this case, first, in connection with operation for the freeing of sacral nerve roots from fibrous involvement with the meningeal sac, in which emphasis should be placed upon the necessity of this operation being carefully performed in early life by a competent neurological surgeon. Second, that plastic reinforcement of the bladder neck by gracilis transplant or intravesical tightening of the bladder outlet are useless in the absence to bladder functional sense. Comment.

Case 7. A male child, aged four, entered Mercy Hospital October 20, 1929. There had been incontinence of urine and feces since birth. He had been operated upon elsewhere in December, 1928, for meningomyelocele type of spina bifida, when an attempt was made to isolate and free the sacral nerves from the meningeal sac. This operation was not followed by any improvement in his sphincteric control nor in the use of his lower legs. Examination. A well nourished child of rather sluggish mentality. There was saddle anesthesia with several trophic ulcerations over the buttocks. There was a well markedlongitudinal scar over the sacrum. The lower legs were atrophic with talipes varus of both feet.

) Fm. 12.

FIG.

CArn

FusIONAL DEFECT, ENTIRE SACRUM OPEN POSTERIORLY

13.

CASE 7. CYSTOGRAM, CASE OF CONSTANT INCONTINENCE SINCE BIRTH. SMOOTH BLADDER OUTLINE, NO EVIDENCE OF EARLIER OBSTRUCTION

Note marked funnelling of the bladder neck. sense. Bladder empty by catheter. 699

Constant dribbling, no voiding

700

CLINTON K. SMl'l'H AND LARRY P. ENGEL

X-ray of the spine showed a fusional defect involving the laminae of the entire sacrum. There was no bulging at the site of the operation previously mentioned. The blood and spinal fluid Wassermann was negative. The bladder by catheter was empty. The urine was normal. Cystoscopy disclosed a bladder normal in appearance with poorly defined bladder neck. Cystography, capacity 170 cc., showed a smooth marginal outline of the bladder, the upper fundus inclined to the right side, with funnelling of the bladder neck. There was regurgitation of the cystographic media into the left ureter which was considerably dilated. Diagnosis. Congenital neurogenic incontinence of urine and feces due to defective parasympathetic innervation. Cystography indicated that this condition had persisted since birth. Operation March 3, 1930. The distal end of the right gracilis muscle was transplanted into the perineum and looped about the urethra. Convalescence was uneventful. Following this operation the child was able to void small amounts of urine when instructed by nurses, in bearing down and tensing the abdomen. However, he was never able to sense his bladder capacity even when filled by water pressure, nor was he able to sense the passing of water or urine. His dribbling continued. Comment. Interest attaches to this experience, in that it was evident that without some degree of bladder filling or emptying sense that gracilis transplant is useless as evidence in this case in contrast with the encouraging results obtained in our three other cases, wherein, a sense of bladder capacity was present. Case 8. A female child, aged five, entered Mercy Hospital August 29, 1931. This child complained of loss of bladder control while at play and persistent enuresis. She had had frequency and dribbling since birth. She was able to control about 60 to 90 cc. of urine when this was given her undivided attention, but otherwise seemed not to sense the bladder emptying impulse. She had had none of the infectious diseases except measles. Examination. A child well nourished but of rather sluggish mentality. The x-ray of the spine showed a fusional defect involving the laminae of the entire sacrum. There was a slight bulging mass over the sacral region. There was no saddle anesthesia, nor weakness of the leg muscles. Catheterization after voiding showed no residual urine. The urine contained a considerable amount of pus cells. The blood and spinal fluid Wassermann was negative.

NEUROGENIC VESICAL DYSFUNCTION IN CHILDREN

701

Cystoscopy disclosed a mild general cystitis; the bladder walls showed fine trabeculation.

Fra. 14.

FIG.

15.

CASE

8.

CASE

8.

FusroNAL SPINAL DEFECT, ENTIRE SACRUM OPEN PosTERIORLt

CYSTOGRAM, CASE OF RELATIVE lNCON1'INENCE, UNCONTROLLABLE DIURESIS AND ENURESIS

Note slight funnelling of bladder neck and markedly serrated marginal outline; evidence of earlier emptying difficulty.

Cystography, 150 cc. capacity, showed a bladder outline irregular, with finely serrated margin and slight funnelling of the bladder neck.

702

CLINTON K. SMITH AND LARRY P. ENGEL

Diagnosis. Neurogenic incomplete incontinence due to defective parasympathetic innervation incident to defective fusion of the sacral laminae probably a sequel to a previous retention as indicated by cystography. Operation September 11, 1931. A neuro-scaral exposure was done which showed that the x-ray analysis of the fusional defect was correct. A fatty pad was removed from the sacral canal which was the only thing discernible, which might have produced pressure on the sacral nerves. There was no evidence of adhesions about the nerves. A retention catheter was maintained in situ putting the bladder at rest for a five-day period. Convalescence was uneventful. During the ensuing three months there was a decided improvement in bladder control during the day but no change in the enuresis. February 6, 1932. The child was again admitted to the hospital. Her mother stated that recently she had again began to loose control of the urine during the day. Operation February 10, 1932. The bladder was opened and a plastic tightening of the vesical outlet was done by drawing the outer margins of the trigone forward to the bladder neck, forming a bar-like dam at the vesical outlet. The net result of this procedure was a 30 cc. urine retention with no appreciable improvement in control.

Comment. Although it is evident that defective innervation is at fault in this case as cystoscopic and cystographic evidence indicates, the fact that good control was maintained after the first operation during her hospital supervision and soon lost on her return home, suggest very strongly not only a defective bladder innervation but a psychological defect as well. Case 9. A male child, aged six, was first examined at Mercy Hospital January 20, 1932 on account of constant dribbling of urine, which had persisted during the preceding several years. Prior to that time there had been painful urination since birth. Examination. A poorly nourished child. There was saddle anesthesia and talipes varus. By catheter the bladder contained only 10 cc. of urine. X-ray showed a fusional defect of the lower spine, involving the fourth and fifth lumbar vertebrae and the entire sacrum. There was a definite bulging over the sacral region.

FIG.

16.

CASE

9.

SPINUOS FUSION AL DEFECT INYOLYING THE FOURTH AND FIFTH LUMBAR VERTEBRA AND THE SACRUM

Note fifth lumbar and entire sacrum open posteriorly.

FIG.

17.

CASE 9. CYSTOGRAM. CASE OF INCONTINENCE. HISTORY OF EARLIER DIFFICULT AND PAINFUL V ornrNG. CoNs·rANT DRIBBLING. BLADDER EMPTY BY CATHETER

Note elongated bladder outline with funnelling of the bladder neck and irregular marginal contour. 703

704

CLINTON K. SMITH AND LARRY P. ENGEL

Cystoscopy under gas anesthesia disclosed a markedly trabeculated bladder with poorly defined bladder neck. Cystography showed an elongated bladder outline with serrated margin and marked funnell type neck. Capacity 150 cc. Diagnosis. Defective parasympathetic innervation due to fusional defect of the lower spine. A primary retention as evidenced by the early clinical history and the trabeculated bladder, passing on to an incontinence with further nerve degeneration. As this child died of pneumonia four days following anesthesia, no opportunity was offered for correction of his urinary derangement. CASES OF RETENTION

Case 10. A male child, aged thirteen, entered Mercy Hospital January 24, 1928. He complained of frequent and painful urination of several years duration, with more or less bladder disturbance since birth. He had measles and whooping cough about six years previously. Examination. This child was extremely ill with chills and high temperature. He was dribbling small amounts of urine at frequent intervals with much distress. The bladder was distended to the level of the umbilicus. Slow catheter decompression was done. The urine was loaded with pus and colon bacilli. The x-ray of the spine disclosed no fusional spinous defects. The blood Wassermann was four plus. There was saddle anesthesia but no muscular weakness of the lower extremities. Cystoscopy disclosed a markedly trabeculated bladder with poorly defined neck. Cystography disclosed a bladder outline with deeply serrated marginal outline with regurgitation into both ureters and funnelling of the bladder neck. Diagnosis. Neurogenic retention, due to parasympathetic degeneration, probably leutic in origin of congenital type. A retention catheter was maintained in situ together with general supportive measures. His condition became progressively worse and death occurred February 28 due to sepsis and uremia. Autopsy was unobtainable. Case 11. A male child, aged eleven years, entered Mercy Hospital January 21, 1928. He had a complete retention of urine of twenty

NEUROGENIC VESICAL DYSFUNCTION IN CHILDREN

705

hours' duration, with pain in the lower abdominal quadrant. He had difficult and painful urination for several years with intermittent attacks of retention. There was no enuresis. He had had none of the infectious diseases except measles. Examination. A well-developed boy. His bladder was distended almost to the umbilicus. A catheter was passed without difficulty and 600 cc. of cloudy urine was evacuated. The urine contained pus and colon bacilli. X-ray of the spine disclosed no fusional defects. There was no saddle anesthesia nor muscular 'Yeakness of the leg muscles. The blood and spinal fluid Wassermann was negative. Cystoscopy disclosed a generally inflamed bladder, there was marked trabeculation of the walJ~ _of the fundus with several deep cellules resembling small diverticula.' ,The bladder neck was well defined but to all appearance not of the contia,cfed{type. Cystography. The bladder shadow showed irregularity in the marginal outline in the upper half. There were several small cellules or diverticula. There was no funnelling of the bladder neck. There was regurgitation of the cystographic media into each ureter. The ureters abnormally dilated. Diagnosis. In the absence of any obstructive element, either of bladder neck or in the urethra, it seemed logical to conclude that we were dealing with a neurogenic retention. The fact that regurgitation into each ureter occurred, indicated to our minds that we were not dealing with over-activity of the sympathetics to dominate the situation, but with an under activity of the parasympathetics. A retention catheter was left in situ during the ensuing five days. This period was entirely uneventful. The catheter was removed on the fifth day and the bladder neck dilated to 24F. by Kollman dilator. The patient voided fairly well but daily catheterization persistently disclosed 75 to 100 cc. of residual urine. He left the hospital on February 22, 1928, feeling well and voiding with comfort. During the ensuing period the bladder neck has been dilated to 24 F. at three- to four-month intervals. His general condition has continued good but the bladder still retains 100 cc. of urine.

Comment. A presacral neurectomy has been advised for this patient but owing to his continued good general condition, consent has not been obtainable.

706

CLINTON K. SMITH AND LARRY P. ENGEL

Case 12. A male child, aged four, entered Mercy Hospital April 19, 1929. He complained of difficult and painful urination with dribbling. There was no enuresis. His mother thought his symptoms had been more or less constant since about one year of age. There was also pain-

Fm. 18.

CASE

10.

CYsTOGRAM, CAsE oF CHRONIC RETENTION WITH OVER-FLOW INCONTINENCE. BLADDER MARKEDLY DISTENDED

Note marked irregularity of marginal contour and funnelling of the bladder neck.

ful defecation. This child was the offspring of deaf and dumb parents. He had had none of the infectious diseases. Examination. A poorly nourished child, very ill with high temperature. The bladder distended almost to the level of the umbilicus. A

N~;lJHU(mNlC VJ~SJCAL DYSFUNCTWN lN CHIU>H~N

retention catheter was inserted and :mo cc. of urine withdrawn. The urine contained pus and colon bacilli. X-ray of the spine disclosed a fusional defect of the laminae of the entire sacrum. The coccyx was absent. There was slight bulging over

Cn,1·0GRAM, C.\SI<} OP CHRONIC DtF~·rcuLT AND l' Al Nl<'ll I, VoIJHNG, WITH lNT]lHMI'I''l'1'JN'r ACU'l'l•] A'I"I'ACKS (ll<' li.ETIDN'l'!ON. Bl,AllllER ]VlARKKDLY DJSTENDKD

F1u. HJ. G\t\ls LL

Note irregular marginal contour w.ith sevend small diverticu!n.

Lhc sacral region. Them ,vas no saddle anesthesia nor weakness of (,he leg muscles. The blood and spinal fluid \Vassermann was negative. Cystoscopy dh,closed slight trabeculation of the bladder with poorly defined bladder neck. THJ!.: J(}l.;H,.NAL OF UHOJ.A)GY, VOL,

:-:..snn,

NO.

ti

Fm. 20. CAKl•J 12. SACRAL Fu:,;rnNAL DEFEC'r Note entire 8Uerum open posteriorly with deformity and ubBence of the coccyx

FIG. 21.

CASE 12. CYSTOGRAM, CASE OF URINATION WITH DRIBBLING OVER-FLOW.

CHRONIC DIFFICULT AND PAINFUL BLADDER MARKEDLY DISTENDED

Note irregular marginal contour with slight funnelling of the bladder neck

708

NEUROGENIC VESICAL DYSFUNCTION IN CHILDREN

Cystography disclosed a bladder outline with slight marginal irregularity of the upper portion. There was slight funnelling of the bladder neck D1:agnosis. retention owing to defective parasympathetic innervation, due to involvcmnnt of sacral nerve root:;; in :;;pina bificb fornrntion.

FIG.

22.

CAHE

13.

CYSTOGRAM, CASE OF CHRONIC RETENTION Wl"I'H DRIBBLING OVER-FLOW

Note marked serration of the marginal contour with slight funnelling of the bladder neck.

A retention catheter was maintained in situ. This child rapidly improved during the following two weeks. A meatatomy was done, a Kollman dilator inserted and the bladder neck dilated to 20 F. Treatment was continued daily catheterization and bladder lavage. The dilatations were carried out at weekly intervals. Neuro-sacral resection was adviRcd hut declined hiR parents.

710

CLINTON K. SMITH AND LARRY P. ENGEL

June 10, 1929. The general condition had greatly improved and the child voided quite freely with almost no distress. Residual urine was 60 cc. He was dismissed from the hospital. During the ensuing year he was treated by bladder neck dilatatiorn, at monthly intervals. His condition remained fairly Ratisfactory . .January 10, 19:32. This child has continued to make normal gain in weight and voids without difficulty. There is 75 cc. of clear residual urine.

Comnient. The improved bladder action in this case following dilatation of the bladder neck can probably be attributed to stimulation of the intrinsic nerve supply of the bladder neck and trigone. Neuro-surgery has been advised in this case hut owing to the apparent good clinical condition, is as yet declined. Case 13. A male child, aged five, entered Wesley Hospital May 5, 1930, very ill with chills, fever and passing small amounts of urine with difficulty and much distress. His mother thought his trouble began about three to four months prior to that time. He had never been troubled with enuresis. He had never had any of the infectious diseases of childhood, although his general health had always been delicate. Examination. This child was extremely ill. The bladder contained 300 cc. of foul residual urine. X-ray of the spine was normal. There was no saddle anesthesia, no laxness of the anal sphincter nor any motor or trophic changes in the lower extremities. His blood and spinal Wassermann was negative. Cystoscopy. The bladder was markedly inflamed, markedly trabeculated with poorly defined bladder neck. Cystography showed a typical neurogenic bladder with funnelled neck and serrated, irregular outline. Diagnosis. Neurogenic bladder retention, probably due to parasmpathetic degeneration, although no direct neurological evidence could be discovered. A retention catheter was left in situ and general supportive measures instituted, together with local bladder therapy. His condition continued critical with chills and high temperature. May 10, 1930. A ureteral retention catheter was introduced to each kidney, releasing about 10 cc. of retained, foul urine from each renal pelvis. A slow but steady improvement began. The ureteral catheters were removed on the fifth day and the indwelling urethral catheter replaced. Slow but steady improvement continued. His mother was

J\iEUR.OGENIC VIDSICAL DYS1''UNCTION IN CHILDREN

711

instructed in the use of the mcthral catheter to he twed twice daily with antiReptic irrigations. June 10, 19:30. The child was sent home with instructions to conlim1e tlw hl:1.dder i.rriga.tions, once daily. He was Lhen able to void sni:iJI

Fm. 23.

CAsE 13 CYSTOGRAM, CASE 13; FouR MoNTHS FOLLOWING l'RESACRAL NE,JREC'I'OMY No DIFFICULTY IN VornING. No RESIDUAL UmNE

Note lesser degree of irregularity in marginfll contour and 1vell defined bladder neck.

amounts of urine which had considerably cleared and his general condition had very much improved. This regime was carried out with continued improvement during the ensuing year. July rn:rl. This chi.kl entered JVforcy Hospital. His

712

CLINTON K. SMITH AND LARRY P. ENGEL

vitality had greatly improved. He was well nourished, and his urine was normal except for a few pus cells. Operation September 1, 1931. A presacral neurectomy, as described by Learmonth, was done and a retention catheter left in situ. On the fifth post-operative day the catheter was removed and this patient voided freely. (At operation the bladder contained 300 cc. of retained urine.) Convalescence was uneventful. At no time after removal of the catheter was there to exceed 25 cc. of residual urine. January 5, 1932. Reexamination showed a continued normal gain in weight. Residual urine was 15 cc. The urine was normal. A cystogram showed a very appreciable change in the irregular marginal outline of the bladder shadow. There was no funnelling of the bladder neck.

Comment. A feature of interest was soon after leaving the hospital, enuresis, which had never previously occurred, began and has persisted until the present writing. It is interesting to speculate on the specific neuropathology, in the absence of a history of infectious disease, spinous fusional defects, or trophic or muscular abnormalities. Undoubtedly defective parasympathetic innervation, although there was no specific evidence aside from the fact that the clinical picture and the vesical pathology stimulated closely that of the cases wherein parasympathetic degeneration was never in doubt. Interest further attaches to this case, in that it is evident that after severing the sympathetic nerve control, that parasympathetic innervation was capable of carrying on normal function. Prognosis. It is of further interest to speculate on the ultimate prognosis. The child continues in good health. It is hardly to be expected that retention will recur, but the enuresis suggests an over-correction of the difficulty and the specter of progressive parasympathetic degeneration with the development of incontinence lurks in the background. SUMMARY

1. N euromotor vesical function is briefly discussed and the conclusion drawn that the normal motor function of the bladder

NJt;UROUENIC VESJUAL DYSFUNC'l'lON IN CHILDREN is maintained by balanced innervation from two separate divisiom: by the autonomic system, the sympathetics and the panrnympathetics; the parasympathetics are capable of carrying on bladder function independently and that the action of the sympathetics is a brake-like action on the sphincteric outlet, speaking, a retarding balance against the action of the parasympathetics. 2. The diagnostic proposition, in considering the problem of retention or incontinence, resolves itself into several phases. First, whether retention is due to anatomical obstructions, or defective innervation, which must be determined by cystoscopy cystography. Second, whether incontinence is an over-flow retention or an out and out absence of sphincteric control. Third, ,vhich division or part of the autonomic nerve supply is affected. Personal experience, and a digest of current literature indicateR in most instances responsibility for either incontinence or retention can be placed upon faulty innervation from the parasympathetics, which in most instances, is associated with osseous fusional defects of the lower spine, in which the nerve roots have become invol"ved in associated fibrous tissue formation during the development of the individual. In cases of retention, in this situation, degeneration of the parasympathetics apparently leaves the brake-like innervation from the sympathetics in control of sphincters_ In cases of incontinence, which in our series comprised cases of primary incontinence and other cases, -which, the earlier stages were undoubtedly cases of retention, we must conclude inherent muscle tonus of the sphincters, \\hich is dependent on parasympathetic innervation was absent from the first in the more aggravated cases, and had been completely lost during the degenerative process, wherein, a primary retention had passed over an incontinence. :-L JVIanagernent is regarded as essentially surgical C'oncction of nerve impingenient involved in osseous spinal defects should receive primary consideration. In cases of incontinence, reinforcement of sphincteric control should be attempted by muscle transplant into the perineum encircling the urethrn or by plastic tightening of the vesical sphincteric outlet. Where sense of

714

C:LINTON K. SMI'l'H AND LARRY P. ENGEL

bladder filling or emptying remains, fair to good results may be expected. On the contrary, where no such sense remains this plan is useless. In cases of retention, resection of the sympathetic chain releases the brake-like action on the sphincter and good emptying power may be expected. It remains, however, to be anticipated, that the condition may come to a later incontinence, should parasympathetic degeneration be progressive. 505 Professional Building, Kansas City, M·issmtri REFERENCES (1) CmWlEl\ 1 l'.: Sur l'iunervtdion de l'utcnrn. Compt. rend. soc. de biol., Hl21, lxxxiv, 898. (2) DEMING, C. L.: Transplantation of the gracilis muscle for incontinence of urine. four. Amer. Med. Assoc., March, 1926, lxxxvi, 822. (3) FoN'rAINE, RENE, AND HERRMAN, Lours: Surgery of the pelvic sympathetie nerve. Surg. Gyneeol. Obstet., February, 1932, 133. (4) FONTAINE, RENE, AND HERRMAN, J,ourc; S.: Surgery of the pelvic sympathetic nerve. Surg. Gyne<'ol. and Obstet., February, 19::l2, 136. (5) FRANK~JNI-IAEUSER, F.: Die Nerven der Gabaermutter und ihre Endigungen in den gbtten Nluskelfasern. Ein Beitrag flir Amitomie und Gynaekologie. Jena; Fr. Mauke, 1867. (6) HAtiHIMITO, S.: Zur Kenntnis der ganglion der \Yciblichen Genitalien. Beitr. z. Geburtsh u. Gynaek., 1904, viii, :33. (7) HAVELOCQUE, A.: Anatomic des nefs cranins et rachidiens ct du systeme µ;rand sympathetiquc. Paris Doin, HJ27. (8) JuNG, P.: Untersuchungen ucber die innervi1tion der weiblidrnn Genitalurganc. :VIonatschr. f. Geburtsh u. Gynaek., 1905, xxi, 1. (9) KEHRER, E.: Experirnentelle untersuchungen neber nervoese Reflexe von verschicdenen Orgmrnn nnd pcripheren Xerven ttuf den Uterus. Arch. f. Gynack., 1910, xc, 169. (10) LEARMONTH, JAMES R.: A contribution to the neurophysiology of the blttdder m man. Brain, 1931, !iv, part 2, 147. (11) LEARMONTH, JAMES R.: A contribution to the neurophysiology of the bladder in man. Brnin, 19;:n, !iv, part 2, 169. (12) LEARMONTH, .JAMJcS R.: The vttlue of neurosurgery in certain vesical conditions. ,Tour. Arner. Med. Assoc., February, 1932, xcviii:8, 633. (13) LATAU.rE'l', A., AND RocHET, P.: De ]'interest chirurgicttl du ganglion hypogastric et des nerfs de !'uterus. Lyon chir., 1922, xix, 56:3. (14) LEE, ROBERT: Memoirs on the Ganglia and Nerves of the Uterus. 4th edition, London, J. and A. Churchill, 1849. (15) MERTZ, HENRY AND SMITH, LESTER A.: Posterior spinal fusion 'defects and nerve dysfunction of the urinary tract. Jour. Urol., 1930, xxiv, no. 1, 41.

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(16) PENFIELD, WILDER AND CoNE, WILLIAM: Spina bifida and cranuim bifidum. Jour. Amer. Med. Assoc., 1932, xcviii, no. 6, 455. (17) PLAYER, LIONEL P., AND CALLANDER, C. LALIMORE: A method for the cure of urinary incontinence in the male. Jour. Amer, Med. Assoc., March, 1927, lxxxviii, 13. (18) ROBINSON, R: The cervical ganglion of the uterus. Med. Rec., 1894, xl, vi, 403. (19) RosE, D. K., AND DEAKIN, Romrns: A cystometric study of the pharmacology of the bladder, Surg., GynecoL and Obstet., February, 1928, 22L (20) SMITH, CLINTON K.: Control of congenital urinary incontinence in the male. Kansas City Southwest Clinical Society Bulletin, July, 1928, (21) YouNG, HuGH H., AND DAVIS, DAVID M.: Practice of Urology, ii, 407.

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