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The Treatment of Selected Cases of Urinary Incontinence in Children
Vol, 93, March Printed in U.S.A
THE JOURNAL OF UROLOGY
Copyright © 1965 by The Williams & Wilkins Co.
THE TREATMENT OF SELECTED CASES OF URINARY INCONTINENCE IN CHILDREN BERNARD KAMHI
AND
MARCEL HOROWITZ
From the State University of New York, Downstate Medical Center, the Jewish Chronic Disease Hospital of Brooklyn, and the Jewish Hospital of Brooklyn, Brooklyn, New York
Surgical treatment of urinary incontinence heretofore has been most unsatisfactory. Numerous ingenious surgical procedures have been proposed in the past and while an occasional success has been reported, in the main the results have been found wanting. Recently, an improved method utilizing an acrylic prosthesis for the surgical correction of urinary incontinence in the male patient has been described.I Up to the present time, this method has been limited to adult male patients who are incontinent following surgery of the lower urinary tract. True urinary incontinence in children is infrequent. It is generally associated with lesions of the spinal cord. Iatrogenic urinary incontinence in children occurring as a consequence of surgery of the posterior urethra or bladder neck is occasionally encountered. The social and nursing problems inherent in this condition are formidable. This unfortunate disability creates antisocial tendencies, requires meticulous and exhausting nursing care and prevents some of these children from realizing their full intellectual potential. Their clothing is continuously saturated with foulsmelling urine and social intercourse becomes difficult. This state of affairs in conjunction with the progressive upper urinary tract damage, which the underlying lesion may generate, not infrequently necessitates urinary diversion. The latter involves the creation of an artificial bladder utilizing an isolated ileac loop, bilateral cutaneous ureterostomies or a cutaneous vesicostomy. These are major procedures which are subject to complications and destroy the normal anatomy. Occasionally, a case of urinary incontinence is encountered where the underlying lesion does not cause progressive upper urinary tract damage. Cure of the urinary incontinence without resort to urinary diversion in this situation would be the desired approach. Accepted for publication June 30, 1964. 1 Berry, J. L.: A new procedure for correction of urinary incontinence. J. Urol., 85: 771-775, 1961.
Two cases are reported here in which urinary incontinence in boys was present without progressive upper urinary tract disease. The nursing care requirements were so exacting and the antisocial behavior so acute that the parents of these children sought some form of relief. Rather than subject these children to urinary diversion, surgical cure of the urinary incontinence was undertaken by the relatively simple technique first described by Berry' (fig. 1). CASE REPORTS
Case 1. A 12-year-old NegTo was admitted to the Jewish Chronic Disease Hospital in June 1963 because of persistent urinary incontinence. At the age of 2 months, the child had a repair of a meningomyelocele involving the fifth lumbar and upper sacral segments. Following the procedure the child was incontinent. Rectal continence, however, was almost complete. The boy was hostile with overt antisocial behavior and could not attend school since he was continuously wet. Excretory urography disclosed rapid visualization, normal renal outlines and pelviocalyceal architecture bilaterally. The left ureter was normal. There was minimal dilatation of the right ureter. At cystoscopy, there was slight trabeculation with grnss dilatation of the bladder neck and posterior urethra. The bladder capacity was 150 cc and there was no vesicoureteral reflux. Cystometry disclosed mild hypotonicity, and voiding cystogrnphy confirmed a dilated posterior urethra (fig. 2, A and B). Mild spasticity of the lower extremities was present on physical examination. In view of the excellent status of the urinary tract proximal to the vesical neck, it seemed desirable to allow the patient to keep his bladder intact and to attempt surgical correction distal to the vesical neck. The acrylic prosthesis was inserted surgically according to the technique described by Berry. The postoperative course was uneventful, the perineal wound healed satisfactorily, and by the tenth postoperative day, it was apparent that the child was totally continent in the supine and erect 374
TREATMENT OF URINARY INCONTINENCE IN CHILDREN
Frn. 1. Implantation of Berry prosthesis. Courtesy of Journal of urology (The Williams & Wilkins publishers) and Dr. John L. Berry
positions. He could stop and start his urinary stream with facility. on marked exertion V>'aS there any escape of urine and this was minimal. He was able to perform the routine tasks of the day and engage in light play with total urinary continence. An ad,kd dividend has been the change in the patient's psychological attitude from one of marked to marked frienclliliness and gratitude. Postoperative evaluation at 3 and 6 months disclosed of this gratifying result. Urogra]lhy and voiding (fig. 2, C and D) disclosed no deterioration of his upper urinary tract and no residual urine. The posterior urethra may be seen to be cJr,,atecl and its diameter more nearly normal. \Vire sutures arc seen holding the prosthesis in
Case 2. A JO-year-old :\ egro was admitted the Jewish Hospital of Brooklyn for evahmtion uf a urinary tract problem of many duration. At the age of 3 months, because of anll. symptoms of urinary tract infection, it was dis covered that the child hacl bilateral sis. The etiology of the upper tract dilatation wa·, not noted in the past records. A lcf1 and a right nephrostomy ,n!re age of 18 months ancl 3 years sequently, at the age of 5, be had resection of his vcsical neck. On thi., admission, his blood urea. 6 mg. per cent. Excretory urography sbowed prompt visualization with bilatend sis. Retrograde cystography showed a large bladder without vesicourcteral reflux. The
376
KAMHI AND HOROWITZ
Fm. 2. A, preoperative urogram; right ureter is minimally dilated. Pelviocalyccal architecture is normal as is left ureter and bladder. B, preoperative voiding cystourethrogram. Posterior urethra is dilated. There is no uretcrovesical reflux. C, postoperative urogram, 6 months postoperatively; no deterioration of urinary tract is noted; right ureter appears less dilated. D, postoperative voiding cystourethrog;ram. Posterior urethra appears to be shorter and narrower. Wire sutures holding the Berry prosthesis in place are seen.
TRK\Tl\IE-:-,[T OF URINARY L'.\fCONTINI<~XCE IK CHILDREN
377
Fru. :3. A, preoperntivc urogram, IO-minute urogram reveals bilnJcral cali0ctr1sis. Lakr films disclosed bilateral hydronephrosis. R, preopc,rative voiding cystourcthrogram. Widely dilated poskrior urethra, is seen. C', postoperative vojding; eystourethrogram. Foreshorknecl posterior urethra of small dianwkr and wire sutures am scc,11. D, post-voiding cystogram. ::\i"o residual urine is present. bladder capacity was 360 c·c. Cystornetry was
within normal limits. C\stoscopic examination showed irregularity ancl dilatation of the posterior urethra. Voiding cystography ccnfirmed the presence of a dilated pos1erim urethrn (fig. 3, .1
and B). The patient. was almost totally incontinent of urine and was forced to 1Year and night. An acrylic prosthesis was imertecl the technique of Derry ancl the
378
KAMHI AND HOROWITZ
course was uneventful. At the 6-weeks and 2-months followup evaluation, the child was considerably improved. Whereas he previously required diapers, he could now get along without them and showed minimal wetting of his underclothes. While this patient did not obtain quite the degree of continence as the previous patient, the result was still gratifying. A review of figure 3, C and D indicates that the previously dilated posterior urethra is somewhat narrower and more nearly approaches the normal. One can see the wire sutures holding the prosthesis in place. A post-voiding film showed no residual urine. DISCUSSION
Certain requisites must be fulfilled before the Berry prosthesis can be inserted with any degree of safety. The presence of considerable low-pressure reflux may be a contraindication to the insertion of the Berry prosthesis. If the patient's detrusor is not adequate to develop a degree of intravesical pressure sufficient to overcome the I
r
I
'
resistance created by the Berry prosthesis, then the patient will probably not be able to empty the bladder effectively. An interesting observation is that relative to the adult perineum, the Berry prosthesis used appeared to be oversized for the perineum of a 10 to 12-year-old child. However, the smaller size did fit quite adequately and it has occurred to the operator that perhaps some of the failures in the utilization of this prosthesis in adults may be due to the fact that it is comparatively too small for the adult perineum. SUMMARY
Two cases of urinary incontinence markedly alleviated by the utilization of a Berry acrylic prosthesis are presented. In one case, the etiological factor was a meningomyelocele with paralysis of the external sphincter. The second case of urinary incontinence was due to surgical damage to the external sphincter. In both cases, a most satisfactory diminution of the patient's urinary incontinence was effected.
THE JOURNAL OF UROLOGY
Copyright © 1965 by The Williams & Wilkins Co.
THE TREATMENT OF SELECTED CASES OF URINARY INCONTINENCE IN CHILDREN BERNARD KAMHI
AND
MARCEL HOROWITZ
From the State University of New York, Downstate Medical Center, the Jewish Chronic Disease Hospital of Brooklyn, and the Jewish Hospital of Brooklyn, Brooklyn, New York
Surgical treatment of urinary incontinence heretofore has been most unsatisfactory. Numerous ingenious surgical procedures have been proposed in the past and while an occasional success has been reported, in the main the results have been found wanting. Recently, an improved method utilizing an acrylic prosthesis for the surgical correction of urinary incontinence in the male patient has been described.I Up to the present time, this method has been limited to adult male patients who are incontinent following surgery of the lower urinary tract. True urinary incontinence in children is infrequent. It is generally associated with lesions of the spinal cord. Iatrogenic urinary incontinence in children occurring as a consequence of surgery of the posterior urethra or bladder neck is occasionally encountered. The social and nursing problems inherent in this condition are formidable. This unfortunate disability creates antisocial tendencies, requires meticulous and exhausting nursing care and prevents some of these children from realizing their full intellectual potential. Their clothing is continuously saturated with foulsmelling urine and social intercourse becomes difficult. This state of affairs in conjunction with the progressive upper urinary tract damage, which the underlying lesion may generate, not infrequently necessitates urinary diversion. The latter involves the creation of an artificial bladder utilizing an isolated ileac loop, bilateral cutaneous ureterostomies or a cutaneous vesicostomy. These are major procedures which are subject to complications and destroy the normal anatomy. Occasionally, a case of urinary incontinence is encountered where the underlying lesion does not cause progressive upper urinary tract damage. Cure of the urinary incontinence without resort to urinary diversion in this situation would be the desired approach. Accepted for publication June 30, 1964. 1 Berry, J. L.: A new procedure for correction of urinary incontinence. J. Urol., 85: 771-775, 1961.
Two cases are reported here in which urinary incontinence in boys was present without progressive upper urinary tract disease. The nursing care requirements were so exacting and the antisocial behavior so acute that the parents of these children sought some form of relief. Rather than subject these children to urinary diversion, surgical cure of the urinary incontinence was undertaken by the relatively simple technique first described by Berry' (fig. 1). CASE REPORTS
Case 1. A 12-year-old NegTo was admitted to the Jewish Chronic Disease Hospital in June 1963 because of persistent urinary incontinence. At the age of 2 months, the child had a repair of a meningomyelocele involving the fifth lumbar and upper sacral segments. Following the procedure the child was incontinent. Rectal continence, however, was almost complete. The boy was hostile with overt antisocial behavior and could not attend school since he was continuously wet. Excretory urography disclosed rapid visualization, normal renal outlines and pelviocalyceal architecture bilaterally. The left ureter was normal. There was minimal dilatation of the right ureter. At cystoscopy, there was slight trabeculation with grnss dilatation of the bladder neck and posterior urethra. The bladder capacity was 150 cc and there was no vesicoureteral reflux. Cystometry disclosed mild hypotonicity, and voiding cystogrnphy confirmed a dilated posterior urethra (fig. 2, A and B). Mild spasticity of the lower extremities was present on physical examination. In view of the excellent status of the urinary tract proximal to the vesical neck, it seemed desirable to allow the patient to keep his bladder intact and to attempt surgical correction distal to the vesical neck. The acrylic prosthesis was inserted surgically according to the technique described by Berry. The postoperative course was uneventful, the perineal wound healed satisfactorily, and by the tenth postoperative day, it was apparent that the child was totally continent in the supine and erect 374
TREATMENT OF URINARY INCONTINENCE IN CHILDREN
Frn. 1. Implantation of Berry prosthesis. Courtesy of Journal of urology (The Williams & Wilkins publishers) and Dr. John L. Berry
positions. He could stop and start his urinary stream with facility. on marked exertion V>'aS there any escape of urine and this was minimal. He was able to perform the routine tasks of the day and engage in light play with total urinary continence. An ad,kd dividend has been the change in the patient's psychological attitude from one of marked to marked frienclliliness and gratitude. Postoperative evaluation at 3 and 6 months disclosed of this gratifying result. Urogra]lhy and voiding (fig. 2, C and D) disclosed no deterioration of his upper urinary tract and no residual urine. The posterior urethra may be seen to be cJr,,atecl and its diameter more nearly normal. \Vire sutures arc seen holding the prosthesis in
Case 2. A JO-year-old :\ egro was admitted the Jewish Hospital of Brooklyn for evahmtion uf a urinary tract problem of many duration. At the age of 3 months, because of anll. symptoms of urinary tract infection, it was dis covered that the child hacl bilateral sis. The etiology of the upper tract dilatation wa·, not noted in the past records. A lcf1 and a right nephrostomy ,n!re age of 18 months ancl 3 years sequently, at the age of 5, be had resection of his vcsical neck. On thi., admission, his blood urea. 6 mg. per cent. Excretory urography sbowed prompt visualization with bilatend sis. Retrograde cystography showed a large bladder without vesicourcteral reflux. The
376
KAMHI AND HOROWITZ
Fm. 2. A, preoperative urogram; right ureter is minimally dilated. Pelviocalyccal architecture is normal as is left ureter and bladder. B, preoperative voiding cystourethrogram. Posterior urethra is dilated. There is no uretcrovesical reflux. C, postoperative urogram, 6 months postoperatively; no deterioration of urinary tract is noted; right ureter appears less dilated. D, postoperative voiding cystourethrog;ram. Posterior urethra appears to be shorter and narrower. Wire sutures holding the Berry prosthesis in place are seen.
TRK\Tl\IE-:-,[T OF URINARY L'.\fCONTINI<~XCE IK CHILDREN
377
Fru. :3. A, preoperntivc urogram, IO-minute urogram reveals bilnJcral cali0ctr1sis. Lakr films disclosed bilateral hydronephrosis. R, preopc,rative voiding cystourcthrogram. Widely dilated poskrior urethra, is seen. C', postoperative vojding; eystourethrogram. Foreshorknecl posterior urethra of small dianwkr and wire sutures am scc,11. D, post-voiding cystogram. ::\i"o residual urine is present. bladder capacity was 360 c·c. Cystornetry was
within normal limits. C\stoscopic examination showed irregularity ancl dilatation of the posterior urethra. Voiding cystography ccnfirmed the presence of a dilated pos1erim urethrn (fig. 3, .1
and B). The patient. was almost totally incontinent of urine and was forced to 1Year and night. An acrylic prosthesis was imertecl the technique of Derry ancl the
378
KAMHI AND HOROWITZ
course was uneventful. At the 6-weeks and 2-months followup evaluation, the child was considerably improved. Whereas he previously required diapers, he could now get along without them and showed minimal wetting of his underclothes. While this patient did not obtain quite the degree of continence as the previous patient, the result was still gratifying. A review of figure 3, C and D indicates that the previously dilated posterior urethra is somewhat narrower and more nearly approaches the normal. One can see the wire sutures holding the prosthesis in place. A post-voiding film showed no residual urine. DISCUSSION
Certain requisites must be fulfilled before the Berry prosthesis can be inserted with any degree of safety. The presence of considerable low-pressure reflux may be a contraindication to the insertion of the Berry prosthesis. If the patient's detrusor is not adequate to develop a degree of intravesical pressure sufficient to overcome the I
r
I
'
resistance created by the Berry prosthesis, then the patient will probably not be able to empty the bladder effectively. An interesting observation is that relative to the adult perineum, the Berry prosthesis used appeared to be oversized for the perineum of a 10 to 12-year-old child. However, the smaller size did fit quite adequately and it has occurred to the operator that perhaps some of the failures in the utilization of this prosthesis in adults may be due to the fact that it is comparatively too small for the adult perineum. SUMMARY
Two cases of urinary incontinence markedly alleviated by the utilization of a Berry acrylic prosthesis are presented. In one case, the etiological factor was a meningomyelocele with paralysis of the external sphincter. The second case of urinary incontinence was due to surgical damage to the external sphincter. In both cases, a most satisfactory diminution of the patient's urinary incontinence was effected.