The results of conservative management of neurogenic vesical dysfunction in children.

Ninety-three cases of neurogenic vesical dysfunction were treated between 1957 and 1974, including 68 children with spina bifida, 10 with occult neurogenic bladders, 7 with sacral agenesis, 2 with spinal dysraphism, and 6 with miscellaneous disorders. No attempt at classification into types of neurogenic bladder was made. Three children in the series died, two from renal causes and one from neurosurgical complications. Treatment consisted of antireflux surgery, methods to lower bladder outlet resistance, operations to relieve obstruction or stasis, or urinary diversion as a last resort. Ureteral reimplantation was performed in 25 children. Reflux was cured in 29 of the 34 ureters reimplanted. Bilateral ureteral reimplantation is recommended because of the subsequent development of vesicoureteral reflux on the opposite side in more than half of the cases of unilateral ureteral reimplantation. Bladder outlet resistance must be lowered in most cases at the time of ureteral reimplantation. This was accomplished in these cases and the group of children as a whole by means of Y-V plasty of the bladder neck, transurethral bladder neck resection, urethral dilation, or pharmacological therapy with phenoxybenzamine (an alpha-symphathetic blocking agent). Urinary calculi were removed in six children in order to preserve renal function. Fifteen children underwent urinary diversion becuase of upper tract deterioration, and in eight children this was performed primarily for urinary incontinence. With conservative treatment, it was possible to preserve renal function as determined by intravenous urography in nearly two-thirds of the cases. Urinary incontinence was difficult to manage in most cases. Manipulations of the bladder neck were only occasionally helpful. Results with the Caldwell stimulator were disappointing. Pharmacological therapy was moderately successful. Phenoxybenzamine was the most useful drug. Imipramine was occasionally of benefit. It is concluded that the upper urinary tracts may be preserved in many cases by means of conservative therapy. Urinary diversion has been avoided in most cases because of its disappointing results. We believe that the trend will be towards increasingly conservative therapy of these children for some years to come.