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Vesical Neck Obstructions in Children
THE JOURNAL OF UROLOGY
Vol. 70, No. 1, July 1953 Printed in U.S.A.
VESICAL NECK OBSTRUCTIONS IN CHILDREN HAROLD P. McDONALD, WILBORN E. UPCHURCH STURDEVANT
AND
CLINTON E.
In speaking of vesical neck obstructions in children, one usually refers to congenital lesions. The symptoms vary a great deal depending on the severity of the obstruction and whether or not infection is present. There is also a great variation in the resultant damage done to the bladder and upper urinary tract. Due to the wide variation in symptoms, and also because of the failure of many doctors to suspect vesical neck obstruction as a likely cause for unexplained fever, recurrent or persistent pyuria, urgency, frequency, or restricted urinary stream, a large percentage of these little patients suffer irreparable renal damage before relief of the obstruction is undertaken. The purpose of this paper is tb call attention to the prevalence of these bladder neck lesions in children, emphasizing the importance of early recognition and correction so that damage to the upper urinary tract may be prevented or lessened. It, shall be pointed out that a great many children with recurrent pyuria, pyelitis, urgency, frequency, and other urinary symptoms are suffering from vesical neck obstruction. Enuresis as a symptom of bladder neck obstruction is especially emphasized because of the general lack of understanding of this problem by family doctors, pediatricians and even many urologists. As regards enuresis, parents too often are told to wait and probably the child will "outgrow it"; while the little patient is "out-growing" his trouble, his psychological development may be warped while the continued back pressure of the obstruction may cause kidney damage that makes him a renal cripple in later years. Urologists should call attention to these facts at every opportunity, especially before local county and state societies. The practice of giving urinary antiseptics to children with pyuria without proper urological investigation should be condemned vigorously and continually. It should be regarded as equally improper to "treat" pus in the urine as it is to "treat" blood in the urine. In children, this should be even more condemned; because of the delicate nature of the urinary apparatus, delay in diagnosis has so often resulted in damage to bladder and kidneys beyond repair. It is our opinion that bladder neck obstructions are a great deal more common than generally has been believed. This is borne out by the fact that an increasing number of these children are being seen by us and by others. Reports by Howard and Buchtel and by Burns and Harvard (1951) indicate the increasing awareness of the frequent occurrence and importance of vesical neck obstructions in children. Also a report by Peyton in the Journal of Urology (January 1953) of a study of bladder neck obstructions in young adult males, indicates that many of the bladder symptoms of young men in the Army are due to this cause. It appears likely that such obstructions are congenital in origin and might have been corrected in early life had they been suspected and looked for. Read at annual meeting, Southeastern Section, American Urological Association, Boca Raton, Fla., April 3, 1952.
94
VESICAL NECK OBSTRUCTIONS IN CHILDREN
95
Congenital obstructions at the vesical neck may be classified as contractures or valve formations, the former observed more often in girls and the latter more often in boys. Another type of obstruction seen in boys is due to hypertrophy of the verumontanum. AU patients with vesical neck obstructions may be divided into three main groups depending upon the severity of the obstruction, whether mild, moderate or severe. It is important that each child be evaluated as to the grade of obstruction in terms of upper urinary tract damage. Patients with mild obstructions may have little or no residual urine, and there may be little or no dilatation of the ureters or renal pelves. Kidney function may be essentially normal. Pyelograrns may show nothing abnormal. Cysto-urethroscopy with a foroblique telescopic instrument such as the McCarthy miniature cystoscope reveals a small to moderate degree of trabeculation and hyperemic vesical neck masses or other obstructive lesion. Trabeculation in the bladder wall is considered positive proof of vesical neck obstruction. Residual urine need not be present in appreciable amount as it is found only after the bladder begins to decompensate, due to back pressure of voiding against obstruction. Children showing marked bladder trabeculations with residual urine and dilatation of the upper tracts are classified. as having severe obstruction. The management of a patient with such marked or neglected vesical neck obstruction is usually a long term proposition. The child should be observed over a period of many years and multiple operations may be necessary in order for the best end results in terms of adult renal function. In a study of 112 children with bladder symptoms seen by us during the past 10 years, the age variation was from 8 hours to 14 years. There were 45 girls and 67 boys. The symptoms or complaints were: enuresis, 65; frequency, 38; urgency, 36; dysuria, 41; pyuria, straining to void, 21; fever, 16; fever of unexplained origin, 6; pain or soreness over bladder, 12; acute retention, 3; overflow incontinence, L Examination revealed that 57 of these children had a narrow urethral meatus ;. 42 had stricture in the urethra; 27 had vesical neck masses or hypertrophy; 17 had vesical neck contracture or bar; 14 had valve-like formations in the deep urethra; and 2 had hypertrophy of the verumontanum. The presence of multiple obstrnctions ,vas noted in many of these patients; hence of those observed with a narrow urethral meatus and/or stricture of the urethra, 57 and 51 respectively, many also had vesical neck obstruction as well. In former years this fact ,ms not well recognized and it is very likely that a great many of these children seen in prior years had unrecognized vesical neck obstruction as well as narrow meatus and urethral stricture. A greater awareness of this possibility of multiple congenital obstructions has shown such to be the case in numerous instances. This occurrence of multiple congenital obstructions has been noted and reported Campbell, Howard and Buchtel, Burns and Harvard and others. ceen at the age of 18 months, had suffered numerous One girl baby with
96
H. P. McDONALD, W. E. UPCHURCH AND C. E. STURDEVANT
bouts of fever all her life and was found to have a narrow urethral meatus, vesical neck masses with contracture of the bladder outlet, bilateral stenosis of the ureterovesical openings and bilateral ureteropelvic obstruction. This little patient has made a remarkable recovery over a period of 3 years following multiple operations, including urethral meatotomy, numerous urethral dilatations, three vesical neck resections and fulgurations and bilateral ureteropelvic plastic operations with nephrostomy and intubation of the ureters. Treatment of children with vesical neck obstructions of mild degree usually consists of fulguration of the vesical neck masses through a miniature cystoscope or a panendoscope using a conical or ball type electrode. The size instrument used depends upon how easily the urethra may be dilated. In most girls a size 24F may be used while most boys must be treated with smaller instruments unless perineal urethrotomy is done. The fulguration is done in two or more stages, at about eight week intervals, one side or one half of the circumference of the vesical neck being destroyed at a time. Meatotomy and urethral dilatations are done as indicated and also bladder dilatations under anesthesia when capacity is found to be subnormal. In small boys or in those with congenitally narrow urethras that do not dilate readily, a button hole perineal urethrotomy, as recommended by Nesbit, may be done for insertion of the instrument into the bladder. Classified as moderate obstructions are those of larger hypertrophic masses or definite contractures at the vesical neck. There may be a small amount of residual bladder urine. Trabeculations are more pronounced than are observed in patients classified as having mild obstructions. A moderate amount of back pressure dilatation and some damage to renal parenchyma may be found. In treatment of this group of patients, transurethral resection with an infant resectoscope is preferred to fulguration, which, because of the larger mass of obstructing tissue present, may be followed by sloughing, and secondary hemorrhage, or prolonged healing time. Care must be exercised in the use of the infant resectoscope due to the possibility of sphincter damage. Treatment of patients with severe obstructions is usually a long term proposition. Classified in this group are children with obstructions of such degree or of such long standing as to produce a great back pressure damage, evidenced by marked trabeculations or cellules in the bladder wall, large dilated ureters and pelves and considerable damage to the renal parenchyma, much of which is permanent. Suprapubic puncture or cystostomy for bladder drainage has been found important in most patients in this group. Failure to recognize this need for suprapubic drainage to bypass the obstruction resulted in death of one of our patients from severe pyelonephritis. The tube should be kept in for such time as is deemed necessary to allow stabilization and maximum recovery from renal damage. In 3 patients in our series, all boys with severe obstruction and a great deal of kidney damage, a suprapubic drainage tube was used for 5, 6, and 8 years respectively. It is conceivable that sufficient bladder and upper urinary tract damage might occur as to make permanent suprapubic drainage necessary.
VESICAL NECK OBSTRUCTIONS IN CHILDREN
97
FIG. 1. A, endoscopic photograph of vesical neck obstruction in 9 year old boy. B, photograph of vesical trabeculations in same boy. C, photograph of resected pieces removed through McCarthy infant resectoscope.
FIG. 2. Types of vesical neck obstructions encountered in children. A, papillomatous appearance seen often in enuretic girls. B, inflammatory masses also seen in enuretics. C, masses with more obstruction seen in both girls and boys.
FIG. 3. Hydronephrosis in children with vesical neck obstruction. A, minimal hydronephrosis and hydro-ureter. B, moderate hydronephrosis and hydro-ureter. C, marked dilatation of upper urinary passages with irreparable damage to kidneys.
After stabilization by drainage and control of infection, proper measures for the complete removal of the obstruction at the bladder neck are undertaken. Other corrective procedures are also done according to indication. Transurethral resection of the obstructing bar or bladder neck contracture is preferred by us and also by Campbell and by Howard and by Buchtel. Burns
98
H. P. McDONALD, W. E. UPCHURCH AND C. E. STURDEVANT
and Harvard have recommended a modified retropubic approach. The relative merits of these two approaches to the problem will not be discussed here. Whether by transurethral resection or by open operation, the important thing is complete removal of the vesical neck obstruction and correction of whatever other abnormalities may be found. A patient illustrating severe obstruction with a great deal of renal damage was seen at the age of 22 months. The bladder was greatly distended and there was overflow incontinence. Suprapubic cystostomy was done and 30 ounces of uninfected urine was obtained. The suprapubic tube was worn for a period of 6
FIG. 4. A, cystogram showing vesical neck obstructing masses with reflux up dilated ureters and renal pelves. B, same patient 4 years after two vesical neck resections and suprapubic drainage.
years during which time urethral meatotomy, urethral dilatations and two transurethral resections of the bar and contracted vesical neck were done. Growth and development were normal, renal function improved phenomenally, and the dilated ureters and pelves contracted considerably. Some dilatation and impairment of the upper urinary tract remain and, quite likely, may be permanent. However, the boy now 11 years old, voids a fine stream, completely empties his bladder, has clear, uninfected urine and vows he is going to study medicine and some day help us practice urology. (See figures 1, 2, 3, 4.) SUMMARY
Congenital obstructions at the vesical neck are much more common than generally has been believed. A great many children who have enuresis, frequency, urgency, nocturia, pyuria, or recurrent fever of unexplained origin, or other symptoms referable to the urinary tract have, as the basic cause, obstruction at the vesical neck. Careful history and examination will often reveal the presence of such a lesion hitherto unsuspected.
VESICAL NECK OBSTRUCTIONS IN CHILDREN
99
Recognition of and correction of less severe and milder obstructing lesions are important in stopping enuresis and in preventing psychological maI-adjustments often seen in children ,vho have enuresis, urgency, and frequency. The less severe obstructions also may be the beginning of obstructive lesions at the bladder neck seen in young adult malec:1 which have recently been recognized and ""'""'"'""'·" multiple obstructions and some bladder neck obstructions of mild or less severe degree may be overlooked unless suspected and a careful evaluation made. recognition and correction of severe obstructive lesions are of prime importance in order that progressive renal damage may be prevented or stopped. In children with such severe obstructions and considerable back pressure renal damage, suprapubic drainage is an important stabilizing measure to corrective surgery. 57
N.W.,
Ga..
REFERENCES E. AND HAlWARD, B.: J.AJVI.A., 146: 419, 1951. CAMI'BELL, .M. · Clinical Pediatric Urology. Philadelphia: W. B. Saunders Co., 1951. HOWARD, T. L. AND B GCH'I'EL, H.: J.A.M.A., 146; 1202, 1951. NESBIT, Jt JVL: South. Surg., 7: 501, 1938. PBrroN, A. B.: J. UroL, 69: 109, 1953. BURNS,
Vol. 70, No. 1, July 1953 Printed in U.S.A.
VESICAL NECK OBSTRUCTIONS IN CHILDREN HAROLD P. McDONALD, WILBORN E. UPCHURCH STURDEVANT
AND
CLINTON E.
In speaking of vesical neck obstructions in children, one usually refers to congenital lesions. The symptoms vary a great deal depending on the severity of the obstruction and whether or not infection is present. There is also a great variation in the resultant damage done to the bladder and upper urinary tract. Due to the wide variation in symptoms, and also because of the failure of many doctors to suspect vesical neck obstruction as a likely cause for unexplained fever, recurrent or persistent pyuria, urgency, frequency, or restricted urinary stream, a large percentage of these little patients suffer irreparable renal damage before relief of the obstruction is undertaken. The purpose of this paper is tb call attention to the prevalence of these bladder neck lesions in children, emphasizing the importance of early recognition and correction so that damage to the upper urinary tract may be prevented or lessened. It, shall be pointed out that a great many children with recurrent pyuria, pyelitis, urgency, frequency, and other urinary symptoms are suffering from vesical neck obstruction. Enuresis as a symptom of bladder neck obstruction is especially emphasized because of the general lack of understanding of this problem by family doctors, pediatricians and even many urologists. As regards enuresis, parents too often are told to wait and probably the child will "outgrow it"; while the little patient is "out-growing" his trouble, his psychological development may be warped while the continued back pressure of the obstruction may cause kidney damage that makes him a renal cripple in later years. Urologists should call attention to these facts at every opportunity, especially before local county and state societies. The practice of giving urinary antiseptics to children with pyuria without proper urological investigation should be condemned vigorously and continually. It should be regarded as equally improper to "treat" pus in the urine as it is to "treat" blood in the urine. In children, this should be even more condemned; because of the delicate nature of the urinary apparatus, delay in diagnosis has so often resulted in damage to bladder and kidneys beyond repair. It is our opinion that bladder neck obstructions are a great deal more common than generally has been believed. This is borne out by the fact that an increasing number of these children are being seen by us and by others. Reports by Howard and Buchtel and by Burns and Harvard (1951) indicate the increasing awareness of the frequent occurrence and importance of vesical neck obstructions in children. Also a report by Peyton in the Journal of Urology (January 1953) of a study of bladder neck obstructions in young adult males, indicates that many of the bladder symptoms of young men in the Army are due to this cause. It appears likely that such obstructions are congenital in origin and might have been corrected in early life had they been suspected and looked for. Read at annual meeting, Southeastern Section, American Urological Association, Boca Raton, Fla., April 3, 1952.
94
VESICAL NECK OBSTRUCTIONS IN CHILDREN
95
Congenital obstructions at the vesical neck may be classified as contractures or valve formations, the former observed more often in girls and the latter more often in boys. Another type of obstruction seen in boys is due to hypertrophy of the verumontanum. AU patients with vesical neck obstructions may be divided into three main groups depending upon the severity of the obstruction, whether mild, moderate or severe. It is important that each child be evaluated as to the grade of obstruction in terms of upper urinary tract damage. Patients with mild obstructions may have little or no residual urine, and there may be little or no dilatation of the ureters or renal pelves. Kidney function may be essentially normal. Pyelograrns may show nothing abnormal. Cysto-urethroscopy with a foroblique telescopic instrument such as the McCarthy miniature cystoscope reveals a small to moderate degree of trabeculation and hyperemic vesical neck masses or other obstructive lesion. Trabeculation in the bladder wall is considered positive proof of vesical neck obstruction. Residual urine need not be present in appreciable amount as it is found only after the bladder begins to decompensate, due to back pressure of voiding against obstruction. Children showing marked bladder trabeculations with residual urine and dilatation of the upper tracts are classified. as having severe obstruction. The management of a patient with such marked or neglected vesical neck obstruction is usually a long term proposition. The child should be observed over a period of many years and multiple operations may be necessary in order for the best end results in terms of adult renal function. In a study of 112 children with bladder symptoms seen by us during the past 10 years, the age variation was from 8 hours to 14 years. There were 45 girls and 67 boys. The symptoms or complaints were: enuresis, 65; frequency, 38; urgency, 36; dysuria, 41; pyuria, straining to void, 21; fever, 16; fever of unexplained origin, 6; pain or soreness over bladder, 12; acute retention, 3; overflow incontinence, L Examination revealed that 57 of these children had a narrow urethral meatus ;. 42 had stricture in the urethra; 27 had vesical neck masses or hypertrophy; 17 had vesical neck contracture or bar; 14 had valve-like formations in the deep urethra; and 2 had hypertrophy of the verumontanum. The presence of multiple obstrnctions ,vas noted in many of these patients; hence of those observed with a narrow urethral meatus and/or stricture of the urethra, 57 and 51 respectively, many also had vesical neck obstruction as well. In former years this fact ,ms not well recognized and it is very likely that a great many of these children seen in prior years had unrecognized vesical neck obstruction as well as narrow meatus and urethral stricture. A greater awareness of this possibility of multiple congenital obstructions has shown such to be the case in numerous instances. This occurrence of multiple congenital obstructions has been noted and reported Campbell, Howard and Buchtel, Burns and Harvard and others. ceen at the age of 18 months, had suffered numerous One girl baby with
96
H. P. McDONALD, W. E. UPCHURCH AND C. E. STURDEVANT
bouts of fever all her life and was found to have a narrow urethral meatus, vesical neck masses with contracture of the bladder outlet, bilateral stenosis of the ureterovesical openings and bilateral ureteropelvic obstruction. This little patient has made a remarkable recovery over a period of 3 years following multiple operations, including urethral meatotomy, numerous urethral dilatations, three vesical neck resections and fulgurations and bilateral ureteropelvic plastic operations with nephrostomy and intubation of the ureters. Treatment of children with vesical neck obstructions of mild degree usually consists of fulguration of the vesical neck masses through a miniature cystoscope or a panendoscope using a conical or ball type electrode. The size instrument used depends upon how easily the urethra may be dilated. In most girls a size 24F may be used while most boys must be treated with smaller instruments unless perineal urethrotomy is done. The fulguration is done in two or more stages, at about eight week intervals, one side or one half of the circumference of the vesical neck being destroyed at a time. Meatotomy and urethral dilatations are done as indicated and also bladder dilatations under anesthesia when capacity is found to be subnormal. In small boys or in those with congenitally narrow urethras that do not dilate readily, a button hole perineal urethrotomy, as recommended by Nesbit, may be done for insertion of the instrument into the bladder. Classified as moderate obstructions are those of larger hypertrophic masses or definite contractures at the vesical neck. There may be a small amount of residual bladder urine. Trabeculations are more pronounced than are observed in patients classified as having mild obstructions. A moderate amount of back pressure dilatation and some damage to renal parenchyma may be found. In treatment of this group of patients, transurethral resection with an infant resectoscope is preferred to fulguration, which, because of the larger mass of obstructing tissue present, may be followed by sloughing, and secondary hemorrhage, or prolonged healing time. Care must be exercised in the use of the infant resectoscope due to the possibility of sphincter damage. Treatment of patients with severe obstructions is usually a long term proposition. Classified in this group are children with obstructions of such degree or of such long standing as to produce a great back pressure damage, evidenced by marked trabeculations or cellules in the bladder wall, large dilated ureters and pelves and considerable damage to the renal parenchyma, much of which is permanent. Suprapubic puncture or cystostomy for bladder drainage has been found important in most patients in this group. Failure to recognize this need for suprapubic drainage to bypass the obstruction resulted in death of one of our patients from severe pyelonephritis. The tube should be kept in for such time as is deemed necessary to allow stabilization and maximum recovery from renal damage. In 3 patients in our series, all boys with severe obstruction and a great deal of kidney damage, a suprapubic drainage tube was used for 5, 6, and 8 years respectively. It is conceivable that sufficient bladder and upper urinary tract damage might occur as to make permanent suprapubic drainage necessary.
VESICAL NECK OBSTRUCTIONS IN CHILDREN
97
FIG. 1. A, endoscopic photograph of vesical neck obstruction in 9 year old boy. B, photograph of vesical trabeculations in same boy. C, photograph of resected pieces removed through McCarthy infant resectoscope.
FIG. 2. Types of vesical neck obstructions encountered in children. A, papillomatous appearance seen often in enuretic girls. B, inflammatory masses also seen in enuretics. C, masses with more obstruction seen in both girls and boys.
FIG. 3. Hydronephrosis in children with vesical neck obstruction. A, minimal hydronephrosis and hydro-ureter. B, moderate hydronephrosis and hydro-ureter. C, marked dilatation of upper urinary passages with irreparable damage to kidneys.
After stabilization by drainage and control of infection, proper measures for the complete removal of the obstruction at the bladder neck are undertaken. Other corrective procedures are also done according to indication. Transurethral resection of the obstructing bar or bladder neck contracture is preferred by us and also by Campbell and by Howard and by Buchtel. Burns
98
H. P. McDONALD, W. E. UPCHURCH AND C. E. STURDEVANT
and Harvard have recommended a modified retropubic approach. The relative merits of these two approaches to the problem will not be discussed here. Whether by transurethral resection or by open operation, the important thing is complete removal of the vesical neck obstruction and correction of whatever other abnormalities may be found. A patient illustrating severe obstruction with a great deal of renal damage was seen at the age of 22 months. The bladder was greatly distended and there was overflow incontinence. Suprapubic cystostomy was done and 30 ounces of uninfected urine was obtained. The suprapubic tube was worn for a period of 6
FIG. 4. A, cystogram showing vesical neck obstructing masses with reflux up dilated ureters and renal pelves. B, same patient 4 years after two vesical neck resections and suprapubic drainage.
years during which time urethral meatotomy, urethral dilatations and two transurethral resections of the bar and contracted vesical neck were done. Growth and development were normal, renal function improved phenomenally, and the dilated ureters and pelves contracted considerably. Some dilatation and impairment of the upper urinary tract remain and, quite likely, may be permanent. However, the boy now 11 years old, voids a fine stream, completely empties his bladder, has clear, uninfected urine and vows he is going to study medicine and some day help us practice urology. (See figures 1, 2, 3, 4.) SUMMARY
Congenital obstructions at the vesical neck are much more common than generally has been believed. A great many children who have enuresis, frequency, urgency, nocturia, pyuria, or recurrent fever of unexplained origin, or other symptoms referable to the urinary tract have, as the basic cause, obstruction at the vesical neck. Careful history and examination will often reveal the presence of such a lesion hitherto unsuspected.
VESICAL NECK OBSTRUCTIONS IN CHILDREN
99
Recognition of and correction of less severe and milder obstructing lesions are important in stopping enuresis and in preventing psychological maI-adjustments often seen in children ,vho have enuresis, urgency, and frequency. The less severe obstructions also may be the beginning of obstructive lesions at the bladder neck seen in young adult malec:1 which have recently been recognized and ""'""'"'""'·" multiple obstructions and some bladder neck obstructions of mild or less severe degree may be overlooked unless suspected and a careful evaluation made. recognition and correction of severe obstructive lesions are of prime importance in order that progressive renal damage may be prevented or stopped. In children with such severe obstructions and considerable back pressure renal damage, suprapubic drainage is an important stabilizing measure to corrective surgery. 57
N.W.,
Ga..
REFERENCES E. AND HAlWARD, B.: J.AJVI.A., 146: 419, 1951. CAMI'BELL, .M. · Clinical Pediatric Urology. Philadelphia: W. B. Saunders Co., 1951. HOWARD, T. L. AND B GCH'I'EL, H.: J.A.M.A., 146; 1202, 1951. NESBIT, Jt JVL: South. Surg., 7: 501, 1938. PBrroN, A. B.: J. UroL, 69: 109, 1953. BURNS,