title: Total endoscopic and anal irrigation management approach to noncompliant neuropathic bladder in children: a good alternative.
abstract: OBJECTIVE
  We prospectively evaluated the efficacy and durability of combined intradetrusor botulinum-A toxin and endoscopic treatment for vesicoureteral reflux with anal irrigation as a total endoscopic and anal irrigation management approach. This minimally invasive protocol is used to manage myelomeningocele and noncompliant bladder in children who do not respond to standard conservative therapy and have urine and stool incontinence.
  
  
  METHODS
  Ten females and 3 males with a mean +/- SD age of 5.3 +/- 2.5 years with myelomeningocele and vesicoureteral reflux who did not respond to standard conservative treatment were prospectively included in this study. All had at least 1 year of followup. All patients received a cystoscopic intradetrusor injection of 12 U/kg (maximum 300 U) botulinum-A toxin into an infection-free bladder. Vesicoureteral reflux in a total of 20 refluxing ureters, including bilateral vesicoureteral reflux in 7 patients, showed no resolution on pretreatment voiding cystourethrogram. Thus, we administered a submucosal Deflux injection. Since most patients were still diaper dependent due to stool incontinence, we extended management to include complete bowel rehabilitation with the new Peristeen anal irrigation system to manage stool incontinence.
  
  
  RESULTS
  Mean maximum bladder capacity increased significantly from 75 +/- 35 to 150 +/- 45 ml after 1 month (p <0.02), to 151 +/- 48 after 6 months (p <0.002) and to 136 +/- 32 after 1 year (p <000). Maximum detrusor pressure decreased significantly from 58 +/- 14 to 36 +/- 9 cm H(2)O after 1 month (p <0.001), to 39 +/- 9 after 6 months (p <0.001) and to 38 +/- 6 after 1 year (p = 000). Of 20 refluxing ureters (95%) completely resolved, including 1 after attempt 2, and 1 with grade V vesicoureteral reflux remained unchanged despite 2 attempts. Seven of 8 urinary incontinent patients (87.5%) attained complete dryness between catheterizations and 1 partially improved. Ten of 13 patients achieved stool dryness with anal irrigation 1 to 2 times weekly. Three patients who were stool continent on standard enemas did not require this irrigation system.
  
  
  CONCLUSIONS
  This new total endoscopic and anal irrigation management approach is a comprehensive, minimally invasive, safe, simple, effective way to achieve most goals when treating these patients by protecting the upper tract, maintaining the bladder at safe pressure and providing a satisfactory social life with satisfactory urine and stool continence.
authors.affiliation: College of Medicine, King Saud University, Riyadh, Saudi Arabia. kfouda@ksu.edu.sa
authors.forename: Khalid F
authors.initials: KF
authors.lastname: Neel
mesh_terms: D019274:Botulinum Toxins, Type A / Q000191:economics / Q000627:therapeutic use*; D002675:Child, Preschool; D004724:Endoscopy / Q000191:economics / Q000379:methods*; D005242:Fecal Incontinence / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008591:Meningomyelocele / Q000150:complications*; D009465:Neuromuscular Agents / Q000191:economics / Q000627:therapeutic use*; D011446:Prospective Studies; D007507:Therapeutic Irrigation / Q000191:economics / Q000379:methods; D016896:Treatment Outcome; D001750:Urinary Bladder, Neurogenic / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D014549:Urinary Incontinence / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D014718:Vesico-Ureteral Reflux / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A