Pelvic Organ Prolapse and Pregnancy in the Female Bladder Exstrophy Patient

Long term outcomes in classic bladder exstrophy - The adult picture

With continued improvements in medical care and surgical reconstruction, more patients with classic bladder exstrophy (CBE) are living into adulthood, than ever before. With improved survival, a greater emphasis on adult issues and improving quality of life (QOL) for these individuals is of increasing importance. This review aims to summarize data on long-term considerations for the adult with exstrophy and to highlight areas of future research and collaboration. Key conclusions are that continence or dryness are achievable alongside the ability to enjoy sexual relationships and a good quality of life.

Exstrophy-Epispadias Complex

Exstrophy-epispadias complex encompasses a spectrum of disorders with lower abdominal midline malformations, including epispadias, bladder exstrophy, and cloacal exstrophy, also known as Omphalocele-Exstrophy-Imperforate Anus-Spinal Anomalies Complex. In this review, the authors discuss the epidemiology, embryologic cause, prenatal findings, phenotypic characteristics, and management strategies of these 3 conditions. The primary focus is to summarize outcomes pertaining to each condition.

Management of Pelvic Organ Prolapse in the Adult Congenital Genitourinary Patient

OBJECTIVES

To assess and present our experience with the management and outcomes of female pelvic organ prolapse in the adult congenital genitourinary patient population.

METHODS

Retrospective review of our adult congenital GU patients with spina bifida with a documented Pelvic Organ Prolapse Quantification exam (POP-Q) from 2006 - 2021 was undertaken. Spina bifida lesion level, bladder management method, prolapse stage and component, and obstetric history were reviewed. Outcomes of treated patients are from most recent follow up.

RESULTS

37 congenital GU patients were identified. 26 (70%) were nulliparous with many showing advanced prolapse, defined as stage 2 or greater. By POP-Q, only 22% were stage 0, indicating no prolapse. 68% had advanced prolapse, with one case of complete procidentia despite no pregnancy history. The dominant prolapse compartment in advanced prolapse patients regardless of parity was apical, or cervical (47%). 16 had symptomatic prolapse, most with vaginal bulge or noticing bulge with catheterization. 6 patients underwent surgery with 2 vaginal hysterectomy and uterosacral suspensions and 1 sacrocolpopexy with mesh. Due to elongated cervix with protrusion, 3 patients underwent cervical shortening as their primary prolapse intervention. 4 of the patients saw a decrease in POP-Q score post-operatively with 2 patients still pending follow-up.

CONCLUSIONS

Congenital GU patients may have more advanced prolapse at younger ages and nulliparity and are frequently apical dominant. A variety of surgical options can provide meaningful improvement in the symptomatic patient.

Bladder exstrophy: We need to improve. A lot

INTRODUCTION

Bladder exstrophy (BE) affects continence and sexual function, impacting on social life and mental health. Long-term data from the patients' point of view are needed to get a real-life perspective on the problem.

STUDY DESIGN

A self-developed questionnaire concerning sexual, psychosexual and psychosocial outcomes was sent to the adult members of the Brazilian Exstrophy Group.

RESULTS

Fifty out of 67 adults from the group (74.5%) responded to the questionnaire. Failure of initial bladder closure attained 62%. Almost ¾ of the patients had augmentation cystoplasty. Bladder lithiasis was common. Esthetic procedures were frequently done. Repetitive UTI (n = 32, 64%) and kidney scars/disease (n = 20, 40%) were frequent. Most (88%) patients either depend on CIC or remain incontinent. Sexual problems predominated in males. Surgery for continence often failed, requiring re-operations, but the prognosis without these procedures was comparatively worse. Continent patients underwent more surgeries (mean 18, 13 and 9 procedures in continent, imperfectly continent and incontinent patients, respectively). Augmented patients more frequently achieved dryness (p = 0.0035). Two-thirds of the women underwent vaginoplasties, but dyspareunia/feeling of "tight" vagina still affected a quarter of them. Four women (15.4%) delivered healthy children. 91.7% of the males reported "normal" erections, but sexual inhibition was common due to feeling of having a small penis (n = 18, 75%). Persistent dorsal curvature and abnormal ejaculation were common (58.3% and 77.1%, respectively). Patients' comments related mainly to mental health issues/need for specialized care, limitations of medicine to cure/treat their disease, unavailability of experts, especially adult specialists, embarrassment over deformities and insufficient information about disease/treatment/prognosis.

DISCUSSION

Most BE patients are well-integrated into society, but feelings of sadness and low self-esteem are common. Most welcome procedures to become dry, despite self-catheterization. The results of bladder neck reconstruction are far from perfect, despite multiple attempts and bladder augmentation was often necessary. Volitional voiding is uncommon. Sexual problems are worse for males, and sexual avoidance is common. Sexual function and self-image are inter-related. It seems reasonable to offer selective esthetic procedures to improve social/sexual interaction. Obstetric complications are common, especially UTI, need for ureteral and/or conduit stenting, abnormal fetal positioning, uterine prolapse, technical problems during surgical deliveries and prematurity.

CONCLUSION

Continence/dryness in BE was mostly eventually achieved, usually depending on multiple interventions, bladder augmentation and self-catheterization. Despite multiple surgeries many adults remain incontinent. Sexual problems and avoidance are the rule in males, due to the feelings of penile inadequacy. Pregnant females deserve expert obstetric care.

Pelvic floor anatomical variations in children with exstrophy-epispadias complex using MRI

OBJECTIVE

To quantitatively measure the anatomical variations of the pelvic floor in children with exstrophy-epispadias complex (EEC) using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Six cases of classic bladder exstrophy (CBE), 5 cases of penile epispadias (PE) and 11 cases of penopubic epispadias (PPE) were included. Another 8 cases with the testicular tumor were taken as the controls. A series of measurements obtained from the pelvic floor MRI were analyzed, and the measurements with significant differences were obtained by ANOVA.

RESULTS

The pelvic floor of the CBE was significantly different from that of controls in measurements including wider pubic diastasis (p<0.001), greater posterior anal distance (p=0.019), greater posterior bladder neck distance (p=0.004), larger iliac wing angle (p<0.001), diminutive ischial angle (p<0.001), bigger puborectalis angle (p<0.001), larger ileococcygeous angle (p=0.002) and shortened anterior corporal length (p<0.001). For the PE, the posterior bladder neck distance (p=0.038) was greater than that of controls. In the PPE, the posterior bladder neck distance (p=0.001) and puborectalis angle (p=0.026) was greater than that of controls, respectively.

CONCLUSIONS

CBE shows severe anatomical variations of the pelvic floor. The bladder neck moves more anteriorly both in PE and PPE than the control. The enlarged puborectalis angle resulting from wider pubic diastasis and more anterior position of the anorectal canal is also noticed in PPE.

Outcomes of pregnancy and delivery in women with continent lower urinary tract reconstruction: systematic review of the literature

INTRODUCTION AND HYPOTHESIS

The aim of this systematic review of the literature was to pool all the existing data regarding pregnancy and delivery in women with neurogenic bladder or bladder exstrophy who had undergone previous lower urinary tract reconstruction (LUTR).

METHODS

We conducted a systematic review of the literature from PubMed/MedLine, ClinicalTrials.gov and the Google Scholar database, from 1972 to July 2020. Fifty articles were included, of which 25 contained data that could be pooled (229 women representing 292 pregnancies).

RESULTS

Ninety-eight women had bladder exstrophy (43%), 58 had spinal dysraphism (25%), 14 had spinal cord injury (6%), and 59 presented other pathological conditions. Of these, 138 have had an augmentation cystoplasty (61%), 42 (18%) had a continent cutaneous urinary diversion, and 31 had an artificial urinary sphincter (14%). During their pregnancy, 97 women (33%) experienced at least one febrile urinary tract infection. Thirty-one women (11%) required ureteral stenting or nephrostomy placement for upper urinary tract dilatation. Forty-six pregnancies ended with premature delivery (16%). Delivery mode was by C-section for 108 patients (62%) and vaginal delivery for 104 (36%). Twenty complications were reported during delivery (mainly urological), of which 19 occurred during C-section. Nine women experienced postpartum urinary incontinence (4%); in 5 of then this was due to urinary fistulae secondary to complicated C-section.

CONCLUSIONS

Pregnancy and vaginal delivery are possible for women with LUTR who have no obstetric or medical contraindications, except for some particular cases of bladder exstrophy. However, these high-risk pregnancies and deliveries should be managed by a specialist multidisciplinary team.

Pregnancy in Pateints With Exstrophy-Epispadias Complex: Are Higher Rates of Complications and Spontaneous Abortion Inevitable?

OBJECTIVE

To report on the characteristics of pregnancy in female patients with EEC (exstrophy-epispadias complex), determining in particular whether they are at higher risk of spontaneous abortion or complications.

MATERIALS AND METHOD

Fifty patients diagnosed with EEC and treated in a reference center for this pathology were reviewed. Those with an incomplete medical history were excluded, leaving a total of 37 women with a median follow-up of 26 years (1-48 years). The outcome measurements were successful pregnancies, miscarriages, urological, gynecological and obstetric complications, impaired renal function, newborn characteristics, and postpartum urogynecological complications. Descriptive statistics was used.

RESULTS

Eight patients achieved 17 pregnancies (88.2% spontaneous). Of these pregnancies, 10 (58.8%) were successful, while 7 (41.2%) terminated in miscarriages. Urinary tract infection (UTI) was the most frequent complication (41.6%) and intestinal occlusion was the most severe. A total of 62.5% of the patients presented genital prolapses after pregnancies. A total of 85.7% of patients were dry during the follow-up after their pregnancies. No newborn presented EEC or any other type of malformation. Our study has the limitation of being a retrospective review of a very heterogeneous and small group of patients.

CONCLUSION

EEC patients can achieve spontaneous pregnancies but have an increased risk of miscarriage. For this reason, monitoring and control by a specialized and integrated multidisciplinary team is required to minimize complications.

Management of the Transitional Urology Patient: the Role of the Adult Reconstructive Urologist

PURPOSE OF REVIEW

Patients with congenital urologic conditions present unique challenges as adults. Herein, we review the literature relevant to the adult reconstructive urologist confronted with complex surgical concerns affecting their patients with a history of hypospadias, spina bifida, and other syndromes affecting the genitourinary tract.

RECENT FINDINGS

Urethral stricture disease related to hypospadias is complex, but successful urethroplasty and penile curvature correction can be achieved with an anatomically minded approach. Multiple urinary diversion techniques can be considered in a patient-centered approach to bladder management in the adult spina bifida patient, but complications are common and revision surgeries are frequently required. Strong evidence is lacking for most surgical techniques in this population, but experiences reported by pediatric and adult urologists with genitourinary reconstruction training can help foster consensus in decision-making. Urologists trained in genitourinary reconstruction may be uniquely positioned to care for the transitional urology patient as they enter adolescence and adulthood.

A 27-year-old patient with congenital bladder exstrophy and recurrent pelvic organ prolapse: a case report

Bladder exstrophy (BE) is a rare congenital malformation estimated to occur in up to 1/250,000 female live births. The evidence supporting the incidence, uterine preservation and its overall fertility rate in patients with pelvic organ prolapse (POP) and BE is not precisely determined. We report a case of BE and POP in a 27-year-old nulliparous Caucasian. Due to the patient’s strong fertility desire, considering her extensive surgical history background, our approach was to correct POP via the Manchester-Fothergill procedure. After 36 months, the patient was still asymptomatic with no evidence for prolapse recurrence. This case demonstrates diagnostic challenges and surgical dilemmas in treatment strategy for patients with BE and co-existent POP. Furthermore, routine long-term surveillance is necessary in terms of renal function, urinary continence, malignancy and possible obstetric issues.