Children with monosymptomatic nocturnal enuresis are, in general, physically and emotionally similar to their peers. The difference lies in their inability to awaken during sleep when their bladder is full or contracts. The etiology of this disorder is likely complex, and several factors should be considered.

Family history is significant. If both the parents had enuresis, close to 80% of their offspring will as well. If one parent was affected, 44% of the offspring are affected. If neither parent has a history, only 15% of their children have this problem. ^,

Psychological stress can induce nocturnal enuresis in certain children. Secondary nocturnal enuresis often raises this concern. Common factors include divorce, changing homes, birth of a new sibling, trouble at school, or just starting school.

As children grow, bladder capacity increases significantly each year at a proportion greater than urine volume produced. ^{, ,} Volitional control over bladder and sphincter also may mature at variable rates and may be related to subtle delays in perceptual abilities or fine motor skills.

Studies show that enuretic episodes occur when the bladder is full, and they simulate normal awake voiding. Although nocturnal enuretic patients have more nighttime unstable bladder contractions, these are at low pressure and do not cause leakage.

Night wetting appears to occur in three ways: wetting associated with significant restlessness and visceral and somatic activity (deep respirations), wetting with a quick contraction and minimal movement, and wetting with no central nervous system response (parasomnia).

Parents of children with nocturnal enuresis are generally convinced that these children sleep deeply and are difficult to arouse. However, this is probably not true. Enuretic patients sleep no more deeply than age-matched controls, wet in all stages of sleep, and show no different awakening patterns. Wetting episodes occur as the bladder fills throughout the night. A more recent systematic review showed conflicting findings in the differences in polysomnography between patients with nocturnal enuresis and controls, but sleep questionnaires did show more problems in patients with nocturnal enuresis. These included parasomnias, breathing disorders, and daytime sleepiness.

Antidiuretic hormone (ADH) is released from the pituitary in a circadian rhythm so that levels are higher at night and thus diminish urine output. Some children may undersecrete ADH at night resulting in bed wetting. Although some patients follow this pattern, others do not; the altered circadian patterns appear to normalize with maturation.

The screening evaluation should include a history, physical examination, and urinalysis. If these are normal, then no other testing is needed because organic disease rarely causes monosymptomatic nocturnal enuresis. Any associated anomaly or problem such as urinary tract infection (UTI), sacral anomalies, or complex enuresis patterns warrant radiographic investigation.

The treating physician should recognize enuresis as a symptom and not a disease. Realizing that there may be more than one cause permits the physician to consider more than one treatment option. Specific treatment is generally discouraged before the age of 7 years. Certain measures are sensible in all nocturnal enuretic patients: void just before getting into bed, avoid excessive fluid intake during the evening hours, and avoid caffeine after 3:00 p.m.

Wetting alarms are devices that fit in the underwear of the patients. When moistened, an alarm is sounded. This type of conditioning therapy requires a motivated patient and parents. A variety of products are available with either an audio alarm, a vibrating alarm, or both. In our experience, the best alarm is simply one that is easy to set up and is able to wake the child. The parent may need to help arouse the child, take him or her to the bathroom, and reset the alarm. This may occur multiple times each night, particularly at the onset of therapy. In two studies, wetting alarms were shown to give the best long-term results when compared with other treatments. ^, The length of treatment to achieve dryness varied between 18 nights and 2.5 months. Relapse may occur in 20%–30% of treated children, but retreatment can be successful.

Imipramine, a tricyclic antidepressant, has been used for many years. The exact mechanism of action is unknown. Initial success has been reported in the 50% range. However, a recent review showed only a 20% success with a relapse rate of 96%. Clinical practice reveals that the longer the initial treatment, the more benefit before the effect wanes. It is suggested that the medication be weaned slowly rather than stopped abruptly. Side effects include anxiety, insomnia, dry mouth, nausea, and personality changes. An overdose can cause fatal cardiac arrhythmias. Therefore, medication safety in the home is important. Imipramine may improve response rates to the enuretic alarm.

Desmopressin is an analog of ADH that mimics its urine-concentrating activity without the vasopressor effect. The effect is dose dependent, usually requiring 200–400 μg/day for success.

Complete dryness rates may be highest in patients with a strong family history of success. Efficacy and safety have been demonstrated in a number of studies, but long-term success remains lower than with alarm systems. Desmopressin can occasionally have side effects, including electrolyte changes, nasal irritation, and headaches. Desmopressin is available as a nasal spray. However, this route is not approved for treating nocturnal enuresis due to a higher incidence of hyponatremia. Parents should be warned to avoid overhydration to prevent this side effect.

Oxybutynin is the most common drug used for enuresis. It is effective when day and nighttime wetting occur in the same patient, but has no benefit over placebo when nighttime wetting is the only symptom.

Although many parents consider bed wetting a problem, they often do not consider it significant enough to treat, especially when medications are being considered. For those desiring treatment, an enuretic alarm and desmopressin are considered the first-line therapies in cases of primary nocturnal enuresis. It is often most reasonable to begin with an enuretic alarm, as it has the highest response rate, no side effects, and the lowest relapse rate. Combination therapy with imipramine may be considered when the alarm is not successful. If desmopressin has proved effective in a specific patient, the patient and family may choose to keep it available and use it only on specific nights when dryness is especially desired (e.g., sleepovers, campouts). Some patients do not respond to therapy, and time, reassurance, and a caring approach are all that can be offered.

The patient’s history is of paramount importance in sorting out the various categories of daytime incontinence. ^, The physical examination and evaluation should always assess for an abdominal mass or tenderness, distended bladder, abnormal genitalia, signs of spina bifida occulta, perineal sensation, sacral reflexes, gait, lower extremity reflexes, and urinalysis. Radiographic evaluation, usually voiding cystourethrogram (VCUG) and renal ultrasonography (US), are important in patients with UTI or complex incontinence patterns.

Bladder instability is by far the most common diagnosis in children with persistent daytime wetting. These children are neurologically intact and usually toilet trained, but later develop increasing “accidents” associated with urgency. They describe not knowing that the bladder contraction was coming. They dash to the bathroom or try to “hold it in.” Boys grab and compress the penis, and girls often cross their legs and dance around or squat with the heel compressed over the perineum ( Vincent’s curtsy ). In our experience, children with hyperactivity disorders or a willful disposition appear prone to this pattern.

Urodynamic (UD) studies are typically performed in refractory cases and demonstrate significant unstable (unwanted) contractions during bladder filling, known as detrusor overactivity. This causes leakage before sphincter contraction (or posturing) can control it. Because these unstable contractions or spasms occur frequently during the day, a retentive pattern of using the external sphincter to “hold on” is developed. When these children do get to the bathroom and try to void, the sphincter relaxes poorly or only intermittently, resulting in stop-and-go voiding, difficulty initiating a urinary stream, straining, and poor emptying, all of which are part of the constellation of symptoms known as voiding dysfunction (VD). The elevated pressure during voiding and the poor emptying may result in secondary vesicoureteral reflux (VUR) and UTI. Finally, the overactivity of the urinary sphincter may carry over to the anal sphincter, making stool retention and encopresis commonly associated findings. When VD is present in the setting of bowel symptoms, the child has bladder and bowel dysfunction (BBD).

Effective treatment rests on managing all aspects of this condition simultaneously. Constipation is treated with fiber or laxatives, and mineral oil after initial bowel clean-out. Recurring UTIs are managed with prophylactic antibiotics. Bladder instability is treated with timed voiding at frequent intervals (an alarm watch or phone application for the child is helpful). Use of pharmacologic therapy has been described for lower urinary tract dysfunction and can be used as an adjunct to behavioral therapy and biofeedback. The type of medication employed is typically based on the clinical picture. Anticholinergics are a mainstay for the typical overactive bladder in a child with incontinence and urgency with complete emptying. Oxybutynin is the only Food and Drug Administration (FDA)-approved anticholinergic for use in children, but tolterodine has been well studied, as have other anticholinergics. ^, More recently, another class of drugs targeting the detrusor muscle have been approved for use in adult patients with overactive bladder symptoms. These medications are agonists of the beta-3 (β3) receptor, which is a β-adrenergic receptor that is mainly expressed in the bladder. The main drug in this class is mirabegron, which has been FDA approved in adults for both neurogenic and nonneurogenic overactive bladder. In children, FDA approval has only been given for neurogenic detrusor overactivity, but studies have shown both safety and efficacy in pediatric patients with nonneurogenic overactive bladder. ^, Mirabegron has been shown to have comparable efficacy to anticholinergics in pediatric patients with OAB symptoms. ^, It has also shown some promise in combination with anticholinergics for refractory patients. Alpha-blocker therapy such as tamsulosin has been described in neurologically intact patients with incomplete emptying and a lag time in external sphincter relaxation. ^,

Biofeedback has gained popularity for treatment of the VD. Electrodes placed on the perineum near the genitourinary diaphragm can be attached to monitors, an audio signal, or a computer display so children can learn to relax their external sphincter voluntarily, resulting in better voiding coordination. The process typically requires four to eight weekly visits, with follow-up as needed.

Initial success with any treatment is often followed by later relapse. If initial treatment is unsuccessful, it may be successful if retried later. Patients older than 8 years who fail treatment should be considered for UD testing. Secondary VUR usually resolves (80%) as bladder function improves. Failure of behavioral and medical therapy is rare, with 2% in one large recent series failing nonoperative management. Further management typically involves either cystoscopic injection of botulinum toxin (Botox) or a form of neuromodulation. Patients who are likely candidates for these treatments should be evaluated with imaging and UD studies prior to further intervention. Injection of Botox has been FDA approved for nonneuropathic overactive bladder in adults, while it remains off-label in neurologically intact children with lower urinary tract dysfunction. Despite this, cystoscopic Botox injection of the detrusor in children with an overactive bladder or detrusor overactivity, and injection of Botox into the sphincter complex in patients with incomplete emptying and dysfunctional voiding, have been recently shown to be effective.

Neuromodulation has been used mainly in adults who have a refractory overactive bladder; however, there has been recent use in children. Transcutaneous electrical nerve stimulation (TENS) has been popular because of its noninvasive nature, though it requires numerous sessions. The TENS unit is thought to inhibit bladder activity via the pudendal–pelvic nerve reflex. Initial studies show promise with improvements ranging from 73% to 100% in small series ^, and improvement in UD parameters.

Surgically implanted sacral neuromodulators have also recently been shown to be successful in patients with refractory bladder and bowel dysfunction. While this therapy is off-label in children, it has shown durable improvement in quality of life and validated symptom scores. While it is promising, the rate of complications is high, with one study reporting 27% of patients in their series requiring reoperation due to a complication. Of those patients who do have success, there are a number of patients who have a complete cure and in whom the device can then be explanted (usually after at least 2 years of treatment).

A separate, and much less common, group of children present with acute onset of urinary frequency. They appear healthy, are normal on examination, and have a normal urinalysis and culture. They do not have true urgency or any wetting, but feel that they must urinate frequently, sometimes every 5–10 minutes. They void a very small amount each time. Most sleep through the night and void a large amount on awakening. The pattern may come and go over weeks or months.

The cause is unclear but is related to emotional stress in many cases. Careful assessment is crucial, and reassurance to parent and child is paramount. Sometimes, setting an alarm to progressively lengthen voiding intervals with a reward for success is helpful. This condition is benign and self-limited, although it may persist intermittently for months. Anticholinergics have no benefit, and further evaluation is not needed.

On the other end of the voiding spectrum are those children who void only once or twice daily, and may not urinate until afternoon after waking in the morning. These children have developed urinary retentive behavior without any bladder instability and have dilated, high-capacity, low-pressure bladders. Some show an aversion to bathrooms or exhibit excessive neatness, whereas many others appear reasonably adjusted. They may be somewhat prone to UTIs and stress incontinence.

It is important to exclude a neurologic cause and a structural obstruction to emptying. US can demonstrate good emptying if performed before and after voiding. A timed voiding regimen is usually required to get these children to urinate regularly if problems are occurring. This pattern tends to improve with age. Treatment with biofeedback and neuromodulation have also been described in management of refractory cases. ^,

Patients who present with total incontinence and constant dribbling have a higher probability of urinary tract anomaly or pathology and require radiographic and possibly UD evaluation.

A small number of children demonstrate persistent incontinence, repeated febrile UTI, VUR, high bladder storage pressures, and very poor emptying. This appears to be a deeply ingrained, “learned” disorder of severe voluntary detrusor sphincter dyssynergia (DSD). In these patients, the urinary tract has the appearance of a patient with a neurogenic bladder. There is hydronephrosis, a trabeculated bladder, reflux, and sometimes progressive loss of renal function ( Fig. 54.1 ).

(A) This cystogram shows the typical findings in a patient with Hinman syndrome: Trabeculated bladder and severe reflux. (B) This voiding study in the same patient demonstrates dilation of the posterior urethra (asterisk) as a result of chronic contraction of the external sphincter during voiding.

Aggressive therapy with prophylactic antibiotics, anticholinergics, alpha-blockers, UD biofeedback training, timed voiding, or clean intermittent catheterization (CIC) may be required. ^, Some recalcitrant cases may require bladder diversion or augmentation to avoid renal failure. As with many “functional” disorders, the severity of Hinman syndrome tends to wane with maturation, but progressive deterioration may not permit the surgeon to wait.

Periodic reassessment of the anatomy and function of the urinary tract in patients with a neurogenic bladder is important because the clinical and UD picture may change with growth and spinal cord tethering. Initiation of a bladder management program is generally undertaken when there is worsening bladder function: VUR, hydronephrosis, or infection. It may also be initiated if findings on UD studies are worrisome. If the urinary tract is stable, such management may be delayed until social continence is desired.

The cornerstone of treatment programs for neurogenic bladder is CIC. Popularized in the early 1970s, CIC has revolutionized the treatment for these children. The purpose of CIC is to provide periodic low-pressure emptying of the bladder, which can prevent or improve deterioration of the upper tracts. ^, In younger children, this task is performed by the caretaker. As children become older and more responsible, they can assume this task.

CIC is associated with a high incidence of bacteriuria, varying greatly in different series. ^, Bacteriuria is eventually found in at least 60% of patients on CIC within 1 year, often with one or two symptomatic episodes per year. In patients with no VUR and with normal intravesical pressure, asymptomatic bacteriuria appears to have little clinical significance. However, in patients with high storage pressures and/or VUR, the likelihood for upper-tract infection increases significantly. As indicated previously, CIC has been shown to increase the risk of infection among infants with myelomeningocele and initiating antibiotic prophylaxis in these infants should be considered.

Pharmacologic therapy for neurogenic bladder coupled with CIC is aimed at decreasing the pressures in the hypertonic, noncompliant bladder or increasing bladder outlet resistance to aid in obtaining continence. Anticholinergic drugs, such as oxybutynin or tolterodine, can be used to lower bladder storage pressures by blocking hypertonic detrusor activity. Imipramine may also be useful alone or in combination with the anticholinergic agents because it can both relax the detrusor and tighten the outlet. Inadequate vesical outlet resistance may also respond to α-adrenergic medications, such as pseudoephedrine. In some cases, the combination of anticholinergics, α-agonists, and CIC is required to achieve adequate continence. Side effects of anticholinergics, including constipation and dry mouth, can sometimes limit their use. Extended-release formulations are reported to cause fewer side effects than immediate-release anticholinergics. The side-effect profile of one anticholinergic over another may vary from patient to patient, and changing to a different anticholinergic may be worthwhile if the side effects become problematic. Instillation of oxybutynin directly into the bladder can lessen the side effects and still maintain a therapeutic response. Also, the oxybutynin cutaneous patch may offer improved treatment for these patients.

Mirabegron is a beta-3 adrenoreceptor agonist that has been shown to have similar efficacy to standard anticholinergic therapy with an improved side effect profile. It received FDA approval in 2021 for use in neurogenic detrusor overactivity in children. A recent retrospective study in children with neurogenic bladder showed improvements in compliance, bladder capacity, and end fill pressures.

Finally, cystoscopic injection of botulinum toxin type A received FDA approval in 2021 for neurogenic detrusor overactivity in children over 5 years of age. Its use in pediatric patients with myelomeningocele has been rising in the United States, while bladder augmentation rates have remained relatively stable. The effects of Botox injection are temporary, but repeat injections result in a durable and often progressive improvement in UD parameters along with sustained symptomatic improvement. However, injections must be repeated approximately every 4–6 months for a continued effect, necessitating periodic exposure to general anesthesia in most pediatric patients along with the associated costs of the operating room. Botox has also been shown to be ineffective in patients with fibrotic, noncompliant bladders.

UD assessment can be elaborate in certain situations but is usually a simple measurement of the pressure–volume relationship of the bladder during filling. It is performed using a double-lumen catheter in the bladder and involves simultaneous assessment of external sphincter function with a perineal electrode. It can also be performed with contrast material and monitored fluoroscopically to add information. Evaluation of bladder compliance, hyperreflexic contractions, leak-point pressure, stress leak-point pressure, and sphincter dyssynergia can be extremely helpful in choosing among treatment options. Fig. 54.2 demonstrates the effect of anticholinergics in shifting the pressure–volume curve to the right and thus permitting the bladder to store more urine at any given pressure. Fig. 54.3 shows the effect of α-adrenergic agonists on raising the leak-point pressure and thus improving continence.

Bladder filling pressure–volume curve in a patient with a neurogenic bladder. Note the shift of the curve to the right (A to B) when anticholinergics relax the detrusor, allowing lower pressure at any given volume.

Bladder filling pressure–volume curve demonstrating a higher leak-point pressure (from A to B), sometimes achieved with α-adrenergic agents such as pseudoephedrine and imipramine. The effect is to decrease incontinence at lower pressures.

It is crucial to understand that when bladder pressures remain >35–40 cmH ₂ O, ureteral peristalsis does not effectively empty the upper tracts, and hydronephrosis and renal insufficiency eventually result. Thus, coupling UD data with a particular patient’s estimated (or measured) hourly output permits the clinician to decide what CIC interval would keep bladder pressures in a safe range. Medications can then be adjusted to extend CIC intervals, achieve dryness, and avoid the development or progression of hydronephrosis.

While the objective measurement of bladder pressure is felt to be critical in identifying patients at risk for upper-tract deterioration, it must be recognized that interpretation of UD studies is subjective and can be difficult, particularly in the pediatric population. ^, Differences in interpretation may be significant enough to alter patient management. Pattern recognition may be as important as obtaining objective pressure measurements.

In children with high bladder storage pressures and deterioration of the upper tracts that cannot be managed by CIC and pharmacologic therapy, temporary diversion with cutaneous vesicostomy may be necessary. ^, Protection of the upper urinary tracts from high bladder pressures is thus accomplished until such time that other treatments can be effective. We reserve this treatment for infants who have serious deterioration of the upper tract and those who, for social, medical, or anatomic reasons, cannot be managed with the other aforementioned forms of medical treatment.

Although most patients with neurogenic bladder can be managed adequately without surgery, those with VUR, a poorly compliant bladder that is not responsive to medical therapy, or refractory incontinence may benefit from an operative approach.

Treatment of VUR in the neurogenic bladder is much the same as that for the normal bladder. It is imperative that the bladder is adequately treated for poor compliance and hyperreflexia (CIC and anticholinergics) before and after the operation to diminish the risk of recurrence.

In some cases, bladder augmentation may be required. Bladder augmentation is designed to create a reservoir with good compliance and adequate capacity to store urine until it can be emptied by CIC at socially appropriate intervals. Detubularized segments of large or small bowel employed as a patch on the widely opened bladder (enterocystoplasty) are current popular techniques for augmentation ( Fig. 54.4 ). Another approach is gastrocystoplasty, which was used in the 1990s, but has since fallen out of favor. ^, Its advantages over enterocystoplasty include a decrease in mucus formation, a possible decrease in infection, and maintenance of electrolyte balance in patients with renal insufficiency. Unfortunately, the hematuria–dysuria syndrome may affect up to one-third of patients, which limits its applicability. This problem and other complications of enterocystoplasty—metabolic derangements secondary to the absorption of urine by the gastrointestinal (GI) tract, excessive mucus production, stone formation, and a debatably increased risk of bladder cancer —have led to a search for other approaches.

Bladder enlargement by enterocystoplasty (sigmoid) and bladder neck reconstruction. Enterocystoplasty enlarges the bladder nicely but has significant potential complications, including occasional perforation, which may present as acute abdominal pain.

Bladder autoaugmentation or detrusorectomy is an alternative augmenting technique that may prove useful in selected patients ( Figs. 54.5 and 54.6 ). This approach involves removal of the detrusor muscle over the superior portion of the bladder, leaving the underlying bladder mucosa intact. This creates a large compliant surface, essentially a large diverticulum, which decreases bladder pressures and increases bladder capacity at the time of filling. The advantage of this technique is that the bladder epithelium is preserved and not replaced with GI epithelium as in bowel augmentation, thus eliminating the problems associated with the secretory and absorptive functions of bowel mucosa. Long-term follow-up data on large numbers of children are lacking and smaller series demonstrated mixed results. Nonetheless, this technique remains a viable alternative for use in bladders with a reasonable capacity and primarily poor compliance. The concept has been extended to create “composite” bladders by placing demucosalized bowel or stomach patches over the urothelial bulge created in autoaugmentation. ^,

(A) Radiographic and (B) ultrasonographic images of a patient with spina bifida showing a small, poorly compliant bladder and worsening hydronephrosis.

(A) Radiographic and (B) ultrasonographic images in the patient shown in Fig. 54.5 after bladder autoaugmentation, demonstrating improved bladder capacity and better compliance, which resulted in continence and diminished hydronephrosis.

Augmentation with ureter has also been shown to be successful, but its application is limited to patients with significant reflux to a large, dilated ureter, where the kidney or polar moiety has poor function. As the urothelial lining of the ureter is similar to that of the bladder, there are similar advantages of using ureteral augmentation (rather than bowel) as there are with autoaugmentation. In contemporary practice, however, patients with neurogenic bladders typically have close surveillance to prevent massive reflux and ureteral dilation, so this treatment modality only has limited application.

The concept of urothelial preservation during augmentation is carried forward by current innovative approaches to replace the bladder wall with biodegradable scaffolds, typically seeded with urothelial and detrusor smooth muscle cells. While the concept is promising, a recent multiinstitutional phase II prospective study using autologous cell seeded scaffolds for augmentation did not show improvement in capacity or compliance and had a high rate of adverse events.

Persistent incontinence, despite adequate treatment of the bladder to lower pressures and increase compliance, may require bladder outlet repair to increase resistance. The Young–Dees technique, which lengthens the urethra by infolding and tubularizing the trigone of the bladder, still has some advocates. Kropp’s procedure uses a tubularized anterior bladder strip reimplanted in the submucosa of the trigone to gain continence by a flap valve mechanism. Continence is commonly achieved, but catheterization is sometimes difficult. Pippi Salle’s procedure creates a similar (but easier to catheterize) flap valve by onlaying an anterior bladder wall flap onto a posterior incised strip up the middle of the trigone. Owing to the lack of a pop-off mechanism in both these procedures, if the bladder becomes overfilled, there is an increased potential for bladder rupture or for upper-tract deterioration if high bladder pressure develops.

One of the more popular forms of increasing urethral resistance in a neurogenic bladder is by a bladder neck fascial sling. This procedure has many advocates and involves securing a rectus fascial strip (or other material) around the bladder neck and suspending it from the anterior rectus fascia or pubis. This elevates and compresses the urethra to increase outlet resistance. More recent series combined a bladder neck reconstruction with a sling to improve continence rates. ^, Finally, bladder neck closure may be required to achieve continence in some patients.

Robotic-assisted techniques have been increasingly used in lower urinary tract reconstruction. A literature review in 2020 highlighted the safety and efficacy of robotic assisted bladder neck procedures. Continence rates for bladder neck procedures ranged from 60% to 100% and similar rates were found in procedures performed with robotic assistance. Although operative times were typically longer, the authors noted decreased blood loss, improved cosmesis, and potentially decreased intraabdominal adhesion formation.

The artificial urinary sphincter (AUS) is a fluid-filled pressurized cuff around the urethra or bladder neck, which can be deflated by a pump-reservoir device that permits the urethra to open and the bladder to drain ( Fig. 54.7 ). The AUS can also be used in higher-pressure bladders in conjunction with bladder augmentation. The main disadvantage is that it is a mechanical device that can erode into the urethra and malfunction over time. Revision rates approach 30%, with erosion occurring in 20%. Erosion at the bladder neck is less common if there has been no prior bladder neck procedure and if the activation is delayed for 6 weeks. Children with neurogenic bladder dysfunction can continue to perform CIC with an AUS in place. In pediatric patients, however, life expectancy is ever-increasing, and the sphincter will eventually need revision or replacement. For this reason, we prefer to use autologous tissue techniques whenever possible.

Typical artificial urinary sphincter. The scrotal pump moves fluid from the cuff to the reservoir to permit bladder emptying.

The periurethral injection of dextranomer/hyaluronic acid copolymer (Deflux), Teflon, or polydimethylsiloxane represents a simple, safe technique for enhancing urethral resistance in selected patients with poor intrinsic sphincter tone. It appears to be most applicable in patients requiring only a minimal increase in stress leak-point pressure. Long-term success is unlikely, and the usefulness of this approach in children is unclear. ^,

With all procedures to enhance resistance at the bladder outlet, it is crucial that the storage pressures of the bladder be considered simultaneously. When the bladder outlet is tightened but the bladder is unable to store increasing volumes at low pressure, hydronephrosis or VUR results. When the surgeon is considering bladder-outlet reconstruction, it may be necessary to occlude the bladder neck with a urinary catheter balloon during preoperative UD assessment to determine the bladder capacity and storage pressures to assess whether augmentation is also needed.

One beneficial adjunct in patients unable to self-catheterize their urethra (e.g., owing to spinal deformity, discomfort, or false passage) is the creation of a continent catheterizable stoma. This can be performed using the appendix or another small tubularized structure implanted into the bladder and anastomosed to the skin (Mitrofanoff principle). ^, The implanted conduit can be hidden at the base of the umbilicus ( Fig. 54.8 ) and CIC carried out using it. Alternatively, the appendix may be left in continuity with the cecum and brought to the skin as a catheterizable channel for irrigation/enemas for the neurogenic colon. In this circumstance, a small segment of ileum can be fashioned as a catheterizable Monti–Yang stoma for bladder access. This concept has been a great adjunct to simplify catheterization for wheelchair-bound patients. A robotic-assisted approach to creating an appendicovesicostomy has gained popularity and demonstrates comparable success rates with a decreased length of hospital stay.

Umbilical positioning of an appendicovesicostomy permits easy access for clean intermittent catheterization.

Stay updated, free articles. Join our Telegram channel

Join