Bowel management for paediatric patients with faecal incontinence.

This review assesses the incidence and aetiology of faecal incontinence in childhood. We then systematically address the presentation, clinical assessment, investigation and management of these children. Under management, both medical and surgical approaches and their complications are discussed.

Femoral nerve neuropathy following the psoas hitch procedure.

OBJECTIVE: To present two cases of femoral nerve neuropathy following a psoas hitch procedure performed during Leadbetter-Politano ureteric reimplantation, and emphasize the importance of this rare complication. PATIENTS: Two 2-year-old boys with complex urological histories underwent Leadbetter-Politano ureteric reimplantations with a psoas hitch using non-absorbable sutures independently in Turkey and the UK. Postoperatively both developed a femoral nerve palsy, which required re-exploration and removal of the sutures. In the first case the femoral nerve was not identified, but in the second case re-exploration revealed the femoral nerve stretched by the nearby suture. Both boys made a full recovery from their neuropraxia. CONCLUSION: These two cases illustrate the potential for nerve involvement with the psoas hitch manoeuvre, and the importance of early recognition of this complication. It is recommended that if a psoas hitch procedure is performed great care should be taken to identify the nerves, and if none are seen then the sutures are placed superficially into the belly of the muscle as the nerves may be sited deeper within it.

Is there an association between functional bladder outlet obstruction and Down's syndrome?

OBJECTIVE: The incidence of urinary tract abnormalities in patients with Down's syndrome (DS) is estimated to be 3-7%. Abnormalities included are renal hypoplasia, renal cysts, ureterovesical and ureteropelvic junction obstruction and, more recently, an association between males with DS and the non-neurogenic neurogenic bladder has been reported. Based on clinical experience, the hypothesis is tested that patients with DS have functional bladder outflow obstruction secondary to detrusor sphincter dyssynergia. METHODS: This study comprised three parts: an initial retrospective review of case notes of existing patients, followed by a prospective community-based study of all patients with DS to assess the incidence and types of bladder dysfunction, and a final hospital-based assessment where a problem was identified following return of the questionnaire. RESULTS: The retrospective study identified a high potential for renal injury with three out of seven patients requiring urinary diversion for dilated upper tracts secondary to bladder outflow obstruction. The prospective study identified a high incidence (77%) of bladder dysfunction with 68% having a history of wetting. CONCLUSION: There is a potentially serious problem in children with DS that is not widely appreciated. We recommend that, at the very least, such children have a detailed history of bladder function taken, and where a problem is detected a urinary tract ultrasound scan should be performed.

A case series of nephrogenic adenoma of the urethra and bladder in children: review of this rare diagnosis, its natural history and management, with reference to the literature.

Nephrogenic adenoma (NA) is a rare benign tumour of the urinary tract and is found most commonly in the bladder. Here are presented four cases of paediatric NA, two bladder and two urethral. Their diagnostic and management features in the context of differential diagnosis and natural history are discussed. A 3-year-old girl presented with recurrent urinary tract infections (UTIs) and haematuria. She had undergone a previous hemi-nephro-ureterectomy. An ultrasound scan suggested a large bladder tumour, which was biopsied cystoscopically, and histology confirmed an NA. She then underwent open resection of the tumour. A 4-year-old girl presented with recurrent UTIs and a history of previous bilateral duplex ureterostomies and subsequent trans-uretero-ureterostomy with ureteric re-implantation. A cystoscopy showed a papillary tumour, which was confirmed as NA on histology. An 11-year-old boy presented with haematuria and dysuria and no other relevant history. At urethroscopy a ragged area biopsied in the bulbar urethra showed NA. A 7-year-old boy presented with haematuria and no other relevant history. At urethroscopy an inflamed nodular area was biopsied and nephrogenic adenoma confirmed. In the two bladder cases, but not the urethral cases, a causative factor could be identified. Recurrence was noted in both of the bladder cases. The urethral cases had persistent symptoms suggestive of continuing NA. Treatment consisted of endoscopic and open ablation of the tumours, and endoscopic fulguration of recurrences for the bladder cases, and surveillance for the urethral cases. Only two previous cases of urethral and 25 cases of bladder NA have been reported in children.

The prevalence of stress urinary incontinence in patients with cystic fibrosis: an under-recognized problem.

OBJECTIVE: To identify the prevalence of stress urinary and fecal incontinence in patients with cystic fibrosis (CF) and investigate any correlation between CF severity and the incidence and degree of incontinence. PATIENTS AND METHODS: An initial postal questionnaire was used to identify patients with an incontinence problem, followed by a detailed interview-administered questionnaire assessing the type of incontinence and the impact of the incontinence on patients and the management of their CF. The correlation between CF severity and the incidence and severity of incontinence was also analysed. All patients aged 5-18 years attending the CF service at The Respiratory and Urology departments of a University Teaching Hospital were invited to participate. There was no therapeutic intervention. RESULTS: Stress urinary incontinence was present in 31% of girls and 2.2% of boys, with fecal incontinence in four girls. The youngest patient with incontinence was 9 years old. Of the patients, 78% found their incontinence a problem and 44% had hidden the problem from parents and carers. There was no correlation between incontinence and the severity of CF as measured by the forced expiratory volume in 1s. CONCLUSIONS: Urinary incontinence is common in girls with CF and in many cases it is a hidden problem. These patients need to be identified so they can receive appropriate management, instead of suffering in silence.

Severe perineal pain after enterocystoplasty in bladder exstrophy.

OBJECTIVE: To describe a previously unreported complication (severe perineal pain) after bladder reconstruction and enterocystoplasty in patients with bladder exstrophy. PATIENTS AND METHODS: The notes were reviewed retrospectively for four patients (two boys and two girls) with classical bladder exstrophy who had severe penile or perineal pain after bladder reconstruction. They were all continent and using intermittent catheterization. A range of conservative management failed and all patients subsequently required excision of their native bladders between 1997 and 2000. RESULTS: All four patients had perineal or penile pain which began 4 months to 8 years after bladder augmentation. Investigations included plain abdominal X-ray, renal and bladder ultrasonography, computerized tomography of the pelvis, video-urodynamics and cysto-urethroscopy. When therapeutic interventions such as more frequent bladder washouts, analgesic and anticholinergic drugs, and cystolithotomy (two patients) were unsuccessful in alleviating the symptoms, all had their native bladder excised. Histological examination of the excised tissue showed neither normal urothelium nor enteric mucosa at the margins of the excision; two patients already had squamous metaplasia within what represented the bladder, and in the others squamous epithelium was present amongst the enteric mucosa. All four children were pain-free with a follow-up of 2-6 years. CONCLUSION: All four patients developed severe referred bladder pain that was probably secondary to the abnormal retained bladder remnants. Cystectomy cured the pain and may also have removed a potential site of future malignant tumour.

Continent catheterizable conduits: which stoma, which conduit and which reservoir?

OBJECTIVE: To assess the outcome of the various methods used in creating continent catheterizable conduits. PATIENTS AND METHODS: The case notes were reviewed from 89 patients who underwent the formation of 112 continent catheterizable conduits. RESULTS: Sixty-five conduits were Mitrofanoff and 47 were antegrade colonic enema (ACE); 21 patients had both. At a mean follow-up of 34 months, 95 (85%) conduits were still in use. There was no difference in complications between the Mitrofanoff and ACE conduits; 109 (97%) conduits were continent and stomal stenosis occurred 35 (31%). There was no significant difference relating to the conduit used, the reservoir, the stoma type or the stoma site. Only 39% of patients required no revisional surgery. CONCLUSION: Although urinary and fecal continence can be achieved in most patients there is a high burden of complications and revisional surgery. All patients should be counselled accordingly.