Sexual function in boys born with exstrophy, myelomeningocele, and micropenis

Recurrent giant neobladder calculus extrusion after bladder exstrophy repair

Introduction

Patients with bladder exstrophy subjected to reconstructive surgeries are at risk of developing urinary calculus.

Case presentation

We report the case of a 29-year-old male patient with bladder exstrophy who presented with a recurrent episode of extrusion of calculus through the neobladder and anterior abdominal wall. Calculus removal and reconstructive repair of the neobladder and abdominal wall were performed in 2010. Nine years following the procedure, the patient returned with new large neobladder calculus extrusion.

Conclusion

Recurrence of large calculus should be seen as the new paradigm for the importance of close follow-up in bladder exstrophy patients.

Male infertility and genitourinary birth defects: there is more than meets the eye

Male factor infertility is a significant problem present in up to 50% of infertile couples. The relationship between male infertility and systemic disease is of significant interest, and emerging evidence suggests a relationship between male infertility and male genitourinary (GU) birth defects (cryptorchidism, hypospadias, ambiguous genitalia, and congenital anomalies of the kidney and urinary tract). Many of these birth defects are treated in isolation by busy urologists without acknowledgment that these may be related to more global syndromic conditions. Conversely, geneticists and nonurologists who treat variable systemic phenotypes may overlook GU defects, which are indeed related conditions. Many of these defects are attributed to copy number variants dosage-sensitive genes due to chromosome microdeletions or microduplications. These variants are responsible for disease phenotypes seen in the general population. The copy number variants described in this review are syndromic in some cases and responsible for both GU birth defects as well as other systemic phenotypes. This review highlights the emerging evidence between these birth defects, male infertility, and other systemic conditions.

Long-term Follow-up of Exstrophy-epispadias Complex from a Lower-middle Income Country: A Case Report and Review of the Literature

Bladder exstrophy-epispadias complex (EEC) is a rare congenital defect where the abdominal muscles and bones fail to close in the mid-pelvis. It is crucial to understand the health-related quality of life (QOL) of exstrophy patients who have undergone multiple correctional surgeries. We herein discuss a case of bladder EEC that was repaired through a series of procedures at a resource-limited hospital in Karachi, Pakistan. A 21-year-old male, who was born with EEC, underwent bladder augmentation, Mitrofanoff procedure, bladder neck reconstruction, ureter implantation and a right nephrectomy in a single one-stage procedure during late childhood for urinary incontinence. However, this required a further revision because the urinary incontinence persisted, with difficulty in catheterizing the Mitrofanoff channel. On follow-up after 10 years, our patient currently describes normal QOL with near-normal sexual function. Validated questionnaires for QOL, erectile dysfunction, incontinence and prostatic function were used to assess the patient's post-operative status in these domains. Through our report, we conclude that such patients can have a normal QOL by means of a holistic multidisciplinary management, which includes timely surgical corrections along with an additional focus on the psycho-social and sexual aspects of this condition.

Fertility and sexuality issues in congenital lifelong urology patients: male aspects

PURPOSE

To review existing literature about fertility and sexuality of boys born with complex congenital genitourinary anomalies.

METHODS

A Pubmed review was performed in December 2018 to identify the most relevant original manuscripts regarding male complex congenital conditions affecting the urogenital system in male patients including spina bifida (SB), bladder exstrophy-epispadias complex (BEEC) and hypospadias. A comprehensive review was drafted exploring sexual dysfunction from a medical, psychosexual, surgical and reproductive point of view during transition from childhood (or adolescence) to adulthood.

RESULTS

About 75% of men with SB have erectile dysfunction (ED) (Gamé et al. in Urology 67(3):566-570, 2006; Diamond et al. in 58(4):434-435, 1986). Most SB patients have impaired sexual development mainly due to diminished self-esteem, dependence on caregivers and lack of privacy (Blum et al. in Pediatrics 88(2):280-285, 1991). Men with BEEC have fewer intimate relationships than women because of the greater difficulties with issues regarding their genitalia and sexual activities (Deans et al. in Am J Obstet Gynecol 206(6):496.e1-496.e6, 2012). However, a good quality of life is achievable with the effective use of coping strategies (Deng et al. in Transl Androl Urol 7:941, 2018; Rikken et al. in BMC Womens Health 18(1):163, 2018; Friedler et al. in Reprod Biomed Online 32(1):54-61, 2016). Chordee occurs in 25% of all hypospadias patients. More severe hypospadias is related to a greater risk for complications. The long-term sexual quality of life (QoL) in men who underwent hypospadias surgery is influenced by a lot of factors. Therefore, an interactive and dynamic biopsychosocial model of sexual QoL was proposed.

CONCLUSIONS

The care of patients with congenital urologic conditions becomes a challenge especially in the period of 'transition'. The goal of follow-up is a holistic management viewed from a medical, psychosexual, surgical end reproductive point. All patients should be asked for specific urinary, fecal or sexual concerns.

Neurological dysfunction of the bladder from myelomeningocele

Myelomeningocele (MMC) affects approximately 2000 infants in the US yearly and causes long-term damage to the genitourinary system. There is a wide spectrum of effects on the bladder and urethral sphincter that do not correlate with the level of the spinal cord defect. The bladder changes can provide a safe storage pressure, often at the expense of continence, or can create a hostile environment leading to increased pressure on the kidneys and eventually to chronic kidney disease. The ultimate goals in management are to maintain a safe system that prevents renal deterioration, while providing social continence and independence in the long term. This review intends to provide an overview of the effects of MMC on the genitourinary system, regardless of intervention, in order to understand the pathophysiology of the disease.

Male Sexuality, Fertility, and Urinary Continence in Bladder Exstrophy-Epispadias Complex

BACKGROUND

The bladder exstrophy-epispadias complex is a rare congenital malformation associated with severe dysfunction of the genital and urinary tracts and requiring a staged surgical reconstruction.

AIM

The primary aims of this study were to report the sexuality, infertility, and urinary incontinence outcomes in a cohort of men born with bladder exstrophy-epispadias complex. The secondary aim was to highlight some predictive factors of infertility in this population.

METHODS

We conducted a descriptive, cross-sectional study of men diagnosed with classic presentations of bladder exstrophy or epispadias.

OUTCOMES

Patients were asked to complete 4 validated questionnaires: the International Index of Erectile Function (IIEF)-5, the Erection Hardness Score (EHS), the Self-Esteem and Relationship, and the International Consultation Incontinence modular Questionnaire-Short Form. Fertility potential was assessed with semen analysis and a non-validated questionnaire.

RESULTS

38 Patients 18-64 years old (M [mean] = 32.2) completed the questionnaires. The average IIEF-5 score was 18.1/25 (ranging from 3-25; SE = 7.62), with results indicating that 55% of the sample had normal erectile function. Results also showed higher scores for patients with normal spermatozoa concentration (M = 22.75, SE = 1.89, P = .08) than for those with oligospermia (M = 17.30, SE = 8.53, P = .08). Results on the IIEF-5 also indicated higher scores for patients who conceived children without assisted reproductive technologies (ART) (M = 22.83, SE = 2.317, P = .02) than for patients without children (M = 15.76, SE = 8.342, P = .02). The average EHS was 3.43/4 (ranging from 1-4, SE = 0.9). EHS was higher for patients who had reconstruction than for patients who had cystectomy (M = 3.88, SE = 1.07 and 2.78, SE = 1.09, P = .02). The average total Self-Esteem and Relationship score was 67.04/100 (ranging from 10.71-96.43, SE = 22.11). The average total International Consultation Incontinence modular Questionnaire-Short Form score was 4.97/21 (ranging from 0-18, SE = 5.44), higher score indicating more urinary incontinence. Among the patients surveyed, 31.6% were parents at the time of study and 50% of them benefited from ART. With regards to the 14 semen analyses performed, only 7.1% produced normal results and 44.7% indicated that ejaculation was weak and dribbling.

CLINICAL TRANSLATION

Erectile function appears to be decreased and psychological aspects of sexuality indicate low self-esteem about sexual relationship. Although ethical problems could not allow prospective spermograms, our cohort is large enough to provide significant data.

CONCLUSIONS

Early sperm storage for future ART, sexual medicine management, and complementary genital reconstruction in adulthood constitute potential treatment options for this population. Reynaud N, Courtois F, Mouriquand P, et al. Male Sexuality, Fertility, and Urinary Continence in Bladder Exstrophy-Epispadias Complex. J Sex Med 2017;15:314-323.

Penile Prosthesis Implantation in an Exstrophy-Epispadias Complex Patient: A Case Report

Penile prosthesis implantation (PPI) is a definitive treatment option for patients with medically refractory erectile dysfunction (ED). It is a safe, reliable operation with high patient satisfaction and few complications. We report a novel case of an adult patient with exstrophy-epispadias complex who underwent PPI for ED and discuss the surgical challenges presented by the unique anatomic constraints of this condition.

Sotimehin AE, Burnett AL. Penile Prosthesis Implantation in an Exstrophy-Epispadias Complex Patient: A Case Report. Sex Med 2019;7:540–542.

Contemporary issues relating to transitional care in bladder exstrophy

N/A

Psychosexual development management of bladder exstrophy epispadias in complex patients

INTRODUCTION

Bladder-exstrophy-epispadias complex (BEEC) represents a spectrum of urogenital step-wise malformations: epispadias, complete exstrophy, and cloacal exstrophy. Psychosexual development in adolescent patients with BEEC may become especially problematic. At present, there are few contributions in the literature investigating the validity of psychosexual treatment in order to tackle this particularly emotional and personal development phase.

OBJECTIVE

The study aimed at verifying the efficacy of an intervention methodology for psychosexual support of a group of adolescents with BEEC. The main goal of the intervention program was to educate the adolescents and re-frame how they see themselves or feel about themselves, especially in relation to BEEC. In particular it was predicted that the program could: (1) improve the perception of pleasure concerning the body, particularly regarding the genital area, giving proper and specific information on pleasure, masturbation and medical history of BEEC; and (2) elicit a more relational-affective perspective on sexuality.

STUDY DESIGN

13 adolescent patients took part in the 1-year program. The effects of the intervention program were verified through a test-retest methodology using Sexuality Evaluation Schedule Assessment Monitoring (SESAMO).

RESULTS

The results showed that participants changed their attitude in several psychosexual areas, more specifically: psycho-environmental situations, body experience, areas of pleasure, medical and sexual history, and motivation and conflict areas (Summary Table).

DISCUSSION

This study demonstrated, for the first time, that a targeted program may significantly improve the psycho-sexual condition of adolescents with BEEC. In particular, this research showed that adolescents need to be able to discuss and tackle topics of a psychological and sexual nature, as well as receive understandable answers that can be put into practice in their everyday lives. The study had several methodological limitations, especially owing to the limited number of participants, the absence of a follow-up period of a few months after the intervention, and the overall exploratory nature of the program.

CONCLUSION

This intervention methodology may be considered a first attempt at improving the self-esteem of adolescents with BEEC, by contrasting forms of psychological difficulties in order to improve the quality of life of these young people.

Continent Anal Urinary Diversion in Classic Bladder Exstrophy: 45-Year Experience

OBJECTIVE

To evaluate the long-term outcomes in patients with classic bladder exstrophy and continent anal urinary diversion (CAD) for continence, upper urinary tract status, secondary malignancies, and sexual function.

PATIENTS AND METHODS

The medical records of 82 exstrophy patients having undergone CAD in our department between 1970 and 2015 were reviewed. Patients were invited for follow-up examinations and asked to complete validated questionnaires relating to sexual function.

RESULTS

Thirty-two of 57 eligible patients with a median follow-up of 23.9 years were included in the study. Ninety-seven percent of patients were fully continent during daytime. Upper urinary tract and renal function remained stable in 75% and 87%, respectively. Five patients developed secondary malignancies originating from the rectal reservoir. Forty-one percent received prophylactic alkaline substitution. Sexual function as measured by the Female Sexual Function Index and the International Index on Erectile Function was negatively affected in all domains in both genders. Eighty-six percent of patients had a stable relationship and 35% were married. Five women conceived a total of 6 healthy children. Paternity rate was 40%.

CONCLUSION

CAD constitutes an effective treatment option with acceptable long-term outcomes in exstrophy patients in whom all attempts at restoring the lower urinary tract have failed. Long-term follow-up of the upper urinary tract, assessment of acid-base balance, and endoscopy of the rectosigmoid reservoir are paramount for the safety of this type of management. Evaluation of sexual dysfunction should be an active part of follow-up.

Long-term functional outcomes after bladder exstrophy repair: A single, low-volume centre experience

INTRODUCTION

In this study, we present our experience managing bladder exstrophy (BE) in a low-volume centre over 24 years.

METHODS

Charts of patients with BE between 1990 and 2014 were retrospectively reviewed. Patients with BE closure and ≥5 years followup were included. BE closure was carried out in the first two days of life using either complete primary repair (CPRE) or modern-staged repair (MSRE). Daytime urinary continence (UC) was evaluated by the age of five years. Patients were considered continent if completely dry for ≥3 hours using no or one pad/day. Incontinent patients with bladder capacity (BC) ≥100 ml underwent bladder neck reconstruction (BNR) and bilateral ureteric reimplantation (BUR), while patients with BC <100ml underwent simultaneous augmentation cystoplasty (ACP).

RESULTS

Sixteen (16) patients met our inclusion criteria with a mean followup time of 18±5 years. Ten (10) underwent CPRE, while six underwent MSRE. Four surgeons were involved in patients' management. Two surgeons had previous experience in BE surgery while working in other institutions. Complications included dehiscence in five patients, vesicocutanous fistula in three and breakthrough UTI in eight. Continence was achieved in 15/16 patients: two after BE closure only, seven with BNR, and six who required ACP and BNR.

CONCLUSIONS

Despite the small number of patients and the reterospective nature of the study, some observations are noteworthy. Although continence rate post-primary BE closure was initially low, it rose to 93.8% after auxiliary continence procedures. This might be at the cost of urethral voiding, which was achieved in 60% of patients. Our small cohort did not show clear advantage of CPRE vs. MSRE. Our outcomes may not be different from high-volume centres due to the fact that two exstrophy-experienced surgeons performed most primary or subsequent surgeries. For this reason, we recommend assigning designated centres for BE repair for both new and repeat cases.

Sexual Function, Social Integration and Paternity of Males with Classic Bladder Exstrophy following Urinary Diversion

PURPOSE

We evaluated patients with classic bladder exstrophy and a history of urinary diversion for sexual function, social integration and paternity.

MATERIALS AND METHODS

We reviewed the medical records of males older than 18 years with exstrophy who had undergone urinary diversion at our department between 1969 and 2014. Patients were invited for structured followup examinations and were asked to complete questionnaires relating to sexual function, social integration and paternity.

RESULTS

Of 79 eligible patients 39 (49%) with a mean followup of 23.8 years (range 2 to 45) were included in the study. Of the patients 41% had undergone primary urinary diversion and 59% had undergone secondary urinary diversion after failed reconstruction of the exstrophic bladder. Sexual function as measured by the International Index of Erectile Function was negatively affected in all domains, with mild to moderate dysfunction in 90% of patients. Of the patients 73% had a stable relationship and 32% were married. A high level of education had been achieved by 77% of patients. Sperm quality was poor (oligoasthenoteratozoospermia) in 71% of patients. Among the patients 11 had fathered a total of 16 healthy children.

CONCLUSIONS

Despite multiple reconstructive procedures of the genitourinary tract, including removal of the exstrophic bladder and subsequent urinary diversion, sexuality and paternity in this subset of patients was comparable to reported series of men in whom the bladder had been preserved. Evaluation of sexual function and fertility should be part of long-term followup, and treatment should be offered if indicated. Currently staged concepts of exstrophy repair should be applied to improve the cosmetic and functional outcomes of the genitourinary tract in patients with exstrophy.

Exstrophy-Epispadias Complex in a Newborn: Case Report and Review of the Literature

Aim The aim of this report is to present a brief review of the current literature on the management of EEC. Case Report A term male neonate presented at birth with classic bladder exstrophy, a variant of the exstrophy-epispadias complex (EEC). The defect was covered with sterile silicon gauzes and waterproof dressing; at 72 hours of life, primary closure without osteotomy of bladder, pelvis, and abdominal wall was successfully performed. Discussion EEC incidence is approximately 2.15 per 1,00,000 live births; several urological, musculocutaneous, spinal, orthopedic, gastrointestinal, and gynecological anomalies may be associated to EEC. Initial medical management includes use of occlusive dressings to prevent air contact and dehydration of the open bladder template. Umbilical catheters should not be positioned. Surgical repair stages include initial closure of the bladder and abdominal wall with or without osteotomy, followed by epispadias repair at 6 to 12 months, and bladder neck repair around 5 years of life. Those who fail to attain continence eventually undergo bladder augmentation and placement of a catheterizable conduit. Conclusion Modern-staged repair of EEC guarantees socially acceptable urinary continence in up to 80% of cases; sexual function can be an issue in the long term, but overall quality of life can be good.

The effect of spinal cord level on sexual function in the spina bifida population

INTRODUCTION

Sexual dysfunction and infertility are prevalent in the spina bifida (SB) population; however, the mechanism of how they affect a person with spina bifida is poorly understood. Additionally, the management of children with spina bifida becomes more difficult as they exit from pediatric institutes.

OBJECTIVE

The present study sought to evaluate sexual health (using validated questionnaires) and fertility in adults with spina bifida and to correlate spinal cord level and ambulatory status with degree of sexual function.

STUDY DESIGN

After institutional board review approval, 199 adult patients with SB, aged 18 and older and who were followed in one pediatric institution, were identified. Patients who were non-English speaking, cognitively and/or developmentally delayed, or unable to be contacted were excluded. Surveys regarding demographics, sexual health and infertility were mailed to the patients and administered in the clinic with the option to opt-out of the survey. Survey questions regarding sexual health were constructed using validated questionnaires: Female Sexual Function Index (FSFI) for females, and International Index of Erectile Function (IIEF) and Sexual Health Inventory for Men (SHIM) for males. Sexual dysfunction scores were correlated to the patients' spinal level and ambulatory status.

RESULTS

Of the 121 eligible patients, 45 replied, with a response rate of 39%. For females, using a cut-off value of 26.5 for FSFI scoring, 25 out of 28 (89%) had sexual dysfunction. No association was seen between spinal level or ambulatory status and overall FSFI, satisfaction, or desire scores. For males, 10 out of 17 (59%) had severe erectile dysfunction (ED), and one out of 17 (6%) had no ED. No association was seen between ambulatory status and sexual function scores for the males. However, SHIM, satisfaction, and ED scores were higher in males with lower spinal lesions. People with spina bifida of both genders tended to have more severe dysfunction compared to those with sexual dysfunction of other etiologies, except with similar sexual desire scores. Regarding questions on fertility, no participant attempted to have children; thus, there was no infertility reported.

DISCUSSION

Few studies have been conducted on sexual health and fertility in adults with SB. Three studies have utilized validated questionnaires and found varying degrees of sexual dysfunction in this subset of patients; however, only one study found sexual activity to be more likely in patients with more caudal levels of neurologic impairment. The present study also showed that SHIM, satisfaction, and ED scores were higher in males with lower spinal lesions. Limitations to this study primarily included the small sample size and low survey response rate.

CONCLUSION

Limited information is known about adults with SB, and sexual function and fertility. While expressing sexual desire, adults with SB appear to experience high rates of sexual dysfunction. Fertility rates were inadequately assessed; this was possibly due to the high rate of sexual dysfunction. Sexual health in the SB population is an important component of the myriad of urologic care issues for these people. Due to the disparity in their care after reaching adulthood, it is prudent to follow these patients and understand their pathophysiology as they continue to mature through life.

Sexual Health Outcomes in Adults with Complete Male Epispadias

PURPOSE

Complete male epispadias is a rare congenital anomaly characterized by failed closure of the entire penopubic dorsal urethra. Epispadias repair is typically performed during infancy, and resultant genitourinary abnormalities can have a marked impact on adult life. We assess long-term post-reconstruction sexual health and fertility outcomes in adults with complete male epispadias.

MATERIALS AND METHODS

A total of 132 patients 18 years or older with complete male epispadias who had undergone reconstruction were identified from a prospectively maintained, institutionally approved database. Patients who could be contacted were asked to complete a telephone survey regarding sexual function. Reconstructive history and clinical details were obtained by chart/database review.

RESULTS

Of 132 patients with complete male epispadias 74 met inclusion criteria and 15 (20%) completed the questionnaire. Seven patients (47%) reported currently being in a relationship. Although 12 patients (80%) reported overall satisfactory sexual intercourse, 11 (73%) admitted to 1 or more problems with sexual function, including abnormal ejaculation (53%), diminished sensation (20%) and difficulty maintaining an erection (20%). When questioned regarding the importance of fertility on a scale of 0 to 5 using a Likert-type item the response of 10 patients (67%) was 4 points or greater. Five patients (33%) reported having impregnated a sexual partner. Although 4 patients (27%) had suspicion of fertility problems, only 2 (13%) reported having abnormal semen analyses.

CONCLUSIONS

This is one of few studies examining post-reconstruction sexual health and function in adults with complete male epispadias. Although small, our study demonstrates that patients are able to engage in relationships, participate in sexual intercourse and impregnate their partners. These results highlight sexual concerns and outcomes that may be of use when counselling patients with complete male epispadias and their families.

Adult care of children from pediatric urology: part 2

PURPOSE

We describe the outcomes of undescended testes and sex development disorders in adolescence and young adulthood. We reviewed the requirements for the long-term care of children born with these and other major congenital anomalies of the genitourinary system.

MATERIALS AND METHODS

The current English language literature was retrieved with a PubMed® search for articles on these subjects. Only articles covering outcomes at ages past puberty were included in analysis. The material was supplemented from the database of the clinic for adults with sex development disorders at University College London Hospitals.

RESULTS

An undescended testis has impaired spermatogenesis. In men in whom a unilateral undescended testis was corrected before puberty the incidence of paternity is normal at around 90% of those who attempt it. The equivalent rate for those with bilateral undescended testes is about 65%. If surgery for bilateral undescended testes is delayed until after puberty, fertility is unlikely. The risk of testicular neoplasms is overestimated and the relative risk is between 2.5 and 8. Children born with a sex development disorder receive multidisciplinary treatment throughout childhood and require the same care as adults. Males who are under virilized likely have a micropenis (greater than 2 SD below the mean stretched length) but they may have normal sexual function. Fertility depends on the underlying condition. Virilized females, who most commonly have congenital adrenal hyperplasia, currently present to adult clinics with an inadequate vagina after infantile surgery. Reconstruction is required to allow intercourse.

CONCLUSIONS

The care of adults born with abnormalities of the genitalia is complex. Early management may define upbringing in childhood but requirements for sexuality and fertility in adult life are different. Multidisciplinary care is essential and a case can be made to establish a subspecialty of urology to coordinate it.

Combined bladder exstrophy and epispadias repair

A 2-year-old male child of exstrophy-epispadias complex presented to us. He had not received any treatment at the time of presentation. It was decided to perform a combined bladder exstrophy and epispadias repair under general anaesthesia. There was a wide diastasis of symphysis pubis, it was decided to perform a bilateral anterior innominate and vertical iliac osteotomy. The bladder was closed in two layers. The urethroplasty and penile reconstruction was done by modified Cantwell-Ransley repair. At the completion of procedure to prevent distraction of pubis, the baby was strapped using elastoplast bandage. The child had a very good cosmetic outcome, good pubic and rectus muscle approximation. On clamping the suprapubic catheter, the patient started passing urine per urethrally and there was a small penopubic fistula. Thereafter the suprapubic catheter was removed. The urine culture was sterile and the patient was discharged on prophylactic antibiotics. The patient is due for follow-up.

Resultant hypospadias after epispadias repair in bladder exstrophy patients: a difficult surgical task with high complication rate

BACKGROUND/PURPOSE

The aim of this study was to analyze the complication rate in male bladder exstrophy (BE) patients undergoing flap or graft urethroplasty for the repair of resultant hypospadias after epispadias repair.

METHODS

We retrospectively reviewed the charts of 22 male BE patients who underwent 24 urethroplasties for resultant hypospadias between 2000 and 2009. Median patient age was 4.2 (range, 1.5-26.5) years, and median follow-up was 7.5 (range, 0.8-10.3) years. Meatal location after epispadias repair was midshaft in 6 cases and proximal shaft in 15. Complications were compared in relation to meatal position, type of urethroplasty (no graft vs graft), use of second-layer coverage of the urethroplasty, and use of suprapubic diversion.

RESULTS

Overall, complications developed in 12 (50%) patients, including 10 urethrocutaneous fistulas and 2 urethroplasty dehiscence. Univariate analysis failed to show any differences between complicated and uncomplicated cases in all the variables. Only the 3 cases undergoing a 2-stage repair had fully successful outcomes.

CONCLUSIONS

Urethroplasty in patients with BE has a high complication rate. Quality of local tissue and presence of scarring are possibly the 2 major determinants of a poor outcome. A staged repair seems the safest, although this commits the patient to 2 procedures.

Sexual function and fertility issues in cases of exstrophy epispadias complex

In patients with EEC, the issues such as sexuality, sexual function and fertility gain more importance once theses patients advance from puberty to adulthood. The aim of this review is to critically examine the available evidence on these issues. A systemic literature search was performed in Medline over the last 25 years using the key words: Exstrophy, sexual function and pregnancy. Search results were limited to studies of patients with exstrophy published in English literature. A total of 1500 publications were found and subsequently screened by title and when appropriate by abstracts. Of these, 40 publications pertinent to the subject were included for the analysis. The publications were supplemented by an additional 15 publications obtained from their bibliographies. The studies were rated according to the guidelines published by the US department of health and human services. Heterosexuality is usually expressed in both the sexes and most of them have adequate sexual function. Urinary diversion in some series seems to result in better ejaculatory hence fertility outcome in male patients. Recent series have shown equally good results with primary reconstruction. Most of the female patients have normal fertility while male patients have significantly low fertility. Most of the male and female patients with EEC have adequate sexual function. Most of the female patients have normal fertility while most of the male patients have significantly low fertility.

Exstrophy in the adolescent and young adult population

The bladder exstrophy-epispadias-cloacal exstrophy complex is a spectrum of genitourinary malformations requiring multiple major reconstructive operations on each affected child. The need for surgical correction in this condition often continues through adolescence and into adulthood. Experience in caring for individuals with exstrophy-epispadias has taught us a great deal about the long-term functional, psychological, and social outcomes involved. Children undergoing repeated hospital admissions and extensive multiple operations have the potential for long-term adjustment problems with incontinence, ambulatory difficulties, psychological disturbance, sexual dysfunction, and issues surrounding self-esteem and social integration. By examining relevant published works from the world literature over the last 20 years, in this article we address with each of these areas and offers some insight into the ongoing issues.

Short and long-term quality of life after reconstruction of bladder exstrophy in infancy: preliminary results of the QUALEX (QUAlity of Life of bladder EXstrophy) study

PURPOSE

The aim of the study was to assess quality of life (QOL) of patients born with bladder exstrophy (BE) and reconstructed during early childhood in 7 French university hospitals (QUALEX study: QUAlity of Life of bladder EXstrophy).

METHODS

Patients from 6 to 42 years old answered self-administered Short-Form 36 (SF-36), VSP-A (Vécu et Santé Perçue de l'Adolescent), VSP-AE (Vécu et Santé Perçue de l'Enfant), AUQUIE (AUto-QUestionnaire Imagé de l'Enfant), and general questionnaires about functional and socioeconomic data. Dimension scores were compared between adults and adolescents using SF-36 and adolescents and children using VSP-AE. Scores were also compared to the general French population.

RESULTS

Among the 134 eligible patients, 36 adults, 18 adolescents, and 17 children answered the questionnaire. There was no difference between responders and nonresponders in reconstruction criteria. Continence was achieved in 77% of adults, 65% of adolescents, and 12% of children. Adolescent QOL was globally superior to adults and children. Adult QOL was globally lower than the general population except on the physical dimension. Children's QOL was also globally lower than the general population except for relations with family and school work. Adolescents' scores on SF-36 were superior to the general population but lower on half of the dimensions with VSP-AE.

CONCLUSION

Patients presenting with reconstructed BE have impaired QOL, and functional results seem to be the most likely predictive factor of health-related QOL score.

The genetic and phenotypic basis of infertility in men with pediatric urologic disorders

Male factor is a major component of infertility for many couples. The presence of congenital genitourinary anomalies in male partners can cause male infertility. We reviewed the state-of-the-art treatment and outcomes for male infertility caused by pediatric urologic disorders. Disorders were classified by whether they led to infertility through pre-testis, testicular, or post-testis effects. Despite the complexity of pediatric urologic disorders that can affect fertility, natural paternity and paternity through assisted reproductive technology are common. Given the significant recent advances in infertility treatments, paternity with many currently untreatable pediatric disorders is likely in the future.

Long-term follow-up of male patients after reconstruction of the bladder-exstrophy-epispadias complex: psychosocial status, continence, renal and genital function

OBJECTIVE

There is a paucity of knowledge about long-term outcome issues in the bladder-exstrophy-epispadias complex (BEEC). Adult male BEEC patients were investigated in respect of bladder and renal function, fertility, genital function and psychosocial facts.

PATIENTS AND METHODS

In a cross-sectional study, 17 adult male BEEC patients (mean age 23.4 years) from a single centre were evaluated with a questionnaire, renal and bladder ultrasound, blood tests, hormonal profile and semen analysis.

RESULTS

Phenotypically one patient had complete epispadias and 16 had classical bladder exstrophy. Five patients underwent a one-stage functional reconstruction as a primary and 12 as a redo procedure. After a mean follow-up of 19.4 years, 15 bladders were preserved with 12 voiding per urethram and 3 performing intermittent catheterization; 2 were secondarily diverted. Significant residual urine was present in 10; kidneys were normal in 14 patients. Sixteen patients proved ejaculations, 3 had normospermia, 7 oligoasthenospermia and 6 azospermia. In patients with only one single bladder neck procedure normospermia was statistically significant.

CONCLUSION

After functional BEEC reconstruction, long-term bladder function is preserved with mostly normal renal function. The number of bladder neck attempts has a significant influence on andrologic outcome. Detailed analysis may detect multifactorial pathogenesis from the impaired sperm quality in the BEEC.

Phalloplasty: a valuable treatment for males with penile insufficiency

OBJECTIVES

To apply a phalloplasty technique used in female-to-male transsexual surgery in male patients with penile insufficiency.

METHODS

Seven male patients (aged 15 to 42 years) were treated with phalloplasty (6 with radial forearm free flap and one with anterolateral thigh flap) between March 2004 and April 2006 (follow-up, 9 to 34 months). All patients suffered psychologically from their condition, with low self-esteem and sexual and relational dysfunction. They were evaluated by a sexologist-psychiatrist before and after surgery. Erectile implant surgery is offered approximately 1 year after the phallic reconstruction.

RESULTS

There were no complications concerning the flap. Two complications were reported in the early postoperative period. Two patients developed urinary complications (stricture and/or fistula). Patient satisfaction after surgery was high in 6 cases and moderate in 1 case. Psychological evaluation confirms this, especially on the self-esteem level. Four patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed.

CONCLUSIONS

This success has convinced us that phalloplasty is a valuable treatment for penile insufficiency. It has good results in terms of patient self-esteem and sexual well-being. This technique opens new horizons for the treatment of penile agenesis, micropenis, crippled penis, shrivelled penis, some disorders of sexual development, traumatic amputations, and cloacal exstrophy.

The psychosocial impact of bladder exstrophy in adolescence

PURPOSE

To examine the experiences of young people living with bladder exstrophy.

METHODS

Qualitative interviews with 16 adolescents aged 16-21 years, exploring the psychological and social impact of bladder exstrophy.

RESULTS

Participants described difficulties, solutions, and practical assistance needed to manage living with bladder exstrophy. Participants identified practical difficulties, their identities, and relationships as the three main areas of importance. They discussed challenges associated with disclosing the nature of their condition, being bullied, and sexual relationships. Despite the difficulties and challenges described, young people repeatedly expressed a determination to live their lives as normally as their peers did.

CONCLUSION

Many examples of difficulties experienced in the past and the present are described. Young people report a range of creative coping strategies used to respond to the demands of living with a chronic health condition.

Urologischer Erkrankungen bei Patienten mit Meningomyelozele

Since the 1980s the management of children and adolescents with meningomyelocele has undergone major changes. The introduction of pharmacotherapy with antimuscarinic agents, clean intermittent catheterization (CIC) and antibacterial prophylaxis has revolutionized the management of children with neurogenic bladder. The co-operation between neonatologists, neurosurgeons, paediatric neurologists, paediatricians, paediatric urologists, paediatric nephrologists, paediatric orthopaedists and paediatric surgeons is necessary to achieve an optimized therapy in each individual patient. In this interdisciplinary consensus paper we provide definitions and classifications as well as a timetable for the appropriate investigations. The conservative and surgical options are explained in detail. A short review is given concerning orthopaedic management, incidence of latex allergy, options for bowel management, diagnosis and treatment of urinary tract infections, problems with sexuality and fertility as well as the long-term compliance of these patients and their relatives.

[Vesicosphincteric and sexual disorders associated with spina bifida and myelomeningocele]

Neurogenic bladder secondary to spina bifida can have a very variable clinical presentation, but all forms share a common feature: a high risk of deterioration of the patient's quality of life and their life expectancy due to damage to the upper urinary tract. In this article, the authors present the epidemiological characteristics of this disease, its main clinical and urodynamic signs and discuss the prognosis of the disease, with particular emphasis on the value of close surveillance of these high-risk patients.

Bladder exstrophy and male fertility: pregnancies after ICSI with ejaculated or epididymal sperm

OBJECTIVE

To define the additional value of intracytoplasmatic sperm injection (ICSI).

DESIGN

Descriptive clinical study.

SETTING

Male patients with bladder exstrophy in an academic setting.

PATIENT(S)

Three male patients in a stable relationship, desirous to have their own children. They were born with bladder exstrophy and had undergone surgical reconstruction.

INTERVENTION(S)

The ICSI procedure.

MAIN OUTCOME MEASURE(S)

Number of pregnancies.

RESULT(S)

Each of the three men presented a different way of producing sperm. The first male patient had no ejaculation, and sperm cells were retrieved by percutaneous sperm aspiration (PESA). The second could ejaculate with the production of sperm cells, and the third had no ejaculation but collected prostatic fluid by catheterization of a cutaneous fistula; this fluid contained sperm cells. Their partners all had undergone a successful ICSI procedure.

CONCLUSION(S)

Nowadays, men with bladder exstrophy reach adult age and therefore express the desire to parent their own children. Careful attention to genital reconstruction has to be given to enhance the possibility to antegrade production of sperm. In cases when this is not possible, PESA/testicular sperm extraction in combination with ICSI offer an added opportunity for these couples.

Evaluation of sexual function in young men with spina bifida and myelomeningocele using the International Index of Erectile Function

OBJECTIVES

To assess sexual function in young men with spina bifida and myelomeningocele.

METHODS

Between November 2003 and February 2004, a cross-sectional study was performed in 55 men older than 18 years of age who had been regularly followed up for myelomeningocele since childhood, between 1961 and 1985, in the Pediatric Internal Surgery Department. The International Index of Erectile Function (IIEF) questionnaire was mailed to each man.

RESULTS

The response rate was 72.7%. Of the 40 men who replied, 16 (40%) had had sexual intercourse at least once during the previous month. These were the older men (age 31.9 +/- 5.7 years versus 27.7 +/- 5.5 years, P = 0.027). The IIEF scores for the whole group were erectile function 11.61 +/- 9.44, orgasmic function 3.53 +/- 3.86, sexual desire 6.94 +/- 2.4, intercourse satisfaction 3.7 +/- 4.81, and overall satisfaction 4.7 +/- 3.34. According to the classification of Cappelleri, of the 16 men who had had sexual intercourse during the previous month, 4 had no erectile dysfunction, 3 had mild, 4 mild to moderate, and 5 severe dysfunction. Erectile function was statistically related to the ability to maintain erections (mean IIEF score 4 and 5 for men with no erectile dysfunction versus a mean IIEF score of 4 and 5 for men with erectile dysfunction: 4.75 +/- 0.5 versus 2.00 +/- 1.32, P = 0.011 for IIEF score of 4 and 4.50 +/- 1.5 versus 3 +/- 2, P = 0.040 for IIEF score of 5).

CONCLUSIONS

Young adult men with spina bifida and myelomeningocele begin sexual activity late. Moreover, 75% have erectile dysfunction that is related to difficulty in maintaining erections.

Surgery Insight: advantages and pitfalls of surgical techniques for the correction of bladder exstrophy

Staged reconstruction repair of bladder exstrophy results in hydronephrosis or renal scarring in 15-25% of patients. A cosmetically acceptable and functional phallus can be achieved in 85% of patients, 20-30% of whom will require more than one operation for penile reconstruction. Episodes of penile glans loss or corporal loss are rarely reported with this technique. Widely disparate results relating to complete urinary continence and volitional voiding have been published, with urinary continence reported to occur in 7-85% of patients. The need for bladder augmentation to obtain urinary continence also varies, with reports that somewhere between 10% and 90% of patients require an augmentation procedure to gain urinary continence. Complete primary repair of bladder exstrophy using the penile disassembly technique results in hydronephrosis or renal scarring in 0-30% of patients, and hypospadias, as a consequence of this repair, will occur in 30-70% of patients. Loss of the glans and corpora appear more frequently with penile disassembly than in staged reconstruction of bladder exstrophy, however, the exact incidence of this complication is unknown. Reported complete urinary continence and volitional voiding rates are also varied following penile disassembly, ranging from 25-65%. A modified bladder-neck reconstruction to gain urinary continence is reportedly required in 15-90% of patients, with 5-10% requiring both bladder augmentation and bladder-neck reconstruction. Experience with complete primary repair of bladder exstrophy, using the penile disassembly approach, seems promising but is not a panacea. To outline the risks and benefits regarding the various surgical techniques for bladder exstrophy, we would recommend the establishment of a national registry for patients with this disorder.

Gender-associated differences in the psychosocial and developmental outcome in patients affected with the bladder exstrophy-epispadias complex

OBJECTIVE

To identify problems in the long-term psychosocial and developmental outcome specific to patients with the bladder exstrophy-epispadias complex (BEEC), using a self-developed semi-structured questionnaire, as there are various techniques of reconstruction to repair BEEC but to date neither patients nor surgeons have a clear answer about which type gives the most acceptable long-term results.

PATIENTS AND METHODS

Increasingly many patients with BEEC reach adulthood and wish to have sexual relationships and families. To date, no studies have used disease-specific psychological instruments to measure the psychosocial status of patients with BEEC. Thus we contacted 208 patients with BEEC, and 122 were enrolled, covering the complete spectrum of the BEEC. The data assessed included the surgical reconstruction, subjective assessment of continence, developmental milestones, school performance and career, overall satisfaction in life, disease-specific fears and partnership experiences in patients aged >18 years. We compared affected females and males to assess gender-associated differences in quality of life.

RESULTS

Affected females had more close friendships, fewer disadvantages in relation to healthy female peers and more partnerships than the males. Family planning seemed to be less of a problem in affected females. There were no gender differences in the adjustments within school and professional career, which was very good in general.

CONCLUSION

Future studies are needed to assess the disease-specific anxieties, considering gender-specific differences.

Sex Education, Relationships, and Sexuality in Young Adults With Spina Bifida

OBJECTIVES

To assess the adequacy of sex education and to determine the incidence of various difficulties encountered in relationships and sexual contact by young adults who have spina bifida (SB) with and without hydrocephalus (HC) in the Netherlands.

DESIGN

Cross-sectional.

SETTING

Community.

PARTICIPANTS

Patients with SB occulta or aperta (N=157; 41% male; mean age, 20.8 y; age range, 16-25 y). Interventions Not applicable.

MAIN OUTCOME MEASURES

Structured interview on sex education, relationships, sexual activities, and sexual functioning.

RESULTS

Although sex education had been provided to almost all patients, fewer than a quarter received information specific to people with SB. Of all patients, 25% had a partner, 70% desired sexual contact, 47% had had sexual contact, and 22% had had sexual intercourse during the last year. Only 52% were satisfied with their present sex life. Incontinence and lack of self-confidence were important obstacles. Compared with patients without HC (HC-), patients with HC (HC+) less often had a partner, were sexually less active, and more often had problems with sexual functioning. Predictors of not having sexual contact were having HC and being male.

CONCLUSIONS

Relationships and sexuality are important for young adults with SB. HC+ patients are less active and perceive more problems than HC- patients. Counseling in relationships and sexuality should be part of the regular care for this group.

Effect of penile size on nocturnal erections: evaluation with NPTR testing with men having micropenis

There has been conflicting opinions in the literature regarding sexual function in hypogonadal men with micropenis. In this study we aimed to evaluate erectile function in hypogonadal men with micropenis by nocturnal penile tumescence and rigidity testing (NPTR) and compared the results with young potent normal penile sized men. A total of 15 men (ages 17-30 y) defined having a micropenis with a stretched penile length of less than 9.3 cm were constituted the study group. Mean stretched penile length was 6.8+/-1.6 cm (range 3.6-7.8 cm). Karyotype analysis showed 46XY in all cases. Control group included 22 potent and normal penile sized men (23-29 y). All subjects completed three sessions of consecutive nights using the RigiScan Plus device. Comparison of the results of NPTR of control group with study group revealed that number and duration of erectile episodes (P < 0.001), duration of tip rigidity > 60% (P < 0.01), TAU tip and TAU base (P = 0.001), and RAU base (P = 0.01) were found to be significantly lower in men with micropenis. In conclusion, our study showed that men with micropenis are associated with decreased nocturnal erectile activity.

Pathophysiology of Erectile Dysfunction

INTRODUCTION

Multiple regulatory systems are involved in normal erectile function. Disruption of psychological, neurological, hormonal, vascular, and cavernosal factors, individually, or in combination, can induced erectile dysfunction (ED). The contribution of neurogenic, vascular, and cavernosal factors was thoroughly reviewed by our committee, while psychological and hormonal factors contributing to ED were evaluated by other committees.

AIM

To provide state of the art knowledge on the physiology of ED.

METHODS

An international consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five different continents developed in a process over a 2-year period. Concerning the pathophysiology of ED committee, there were seven experts from five different countries.

MAIN OUTCOME MEASURE

Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.

RESULTS

The epidemiology and classification of neurogenic ED was reviewed. The evidence for the association between vascular ED and atherosclerosis/hypercholesterolemia, hypertension and diabetes was evaluated. In addition, the pathophysiological mechanisms implicated in vascular ED were defined, including: arterial remodeling, increased vasoconstriction, impaired neurogenic vasodilatation, and impaired endothelium-dependent vasodilatation. The possible mechanisms underlying the association between chronic renal failure and ED were also evaluated as well as the evidence supporting the association of ED with various classes of medications.

CONCLUSIONS

A better understanding of how diseases interfere with the physiological mechanisms that regulate penile erection has been achieved over the last few years, which helps establish a strategy for the prevention and treatment of ED.

The exstrophy-epispadias complex: is aesthetic appearance important?

OBJECTIVE

To show the relevance of cosmetic appearance in the adequate treatment of patients with exstrophy-epispadias complex (EEC), and to indicate that surgery by experienced teams can improve the long-term treatment forecast and the patient's body image.

PATIENTS AND METHODS

From 1978 to 2002, 71 patients diagnosed with EEC were treated in the authors' institution; 24 (aged 2-23 years) were selected to undergo different surgical procedures. The criterion for surgery considered interviews conducted by the psychology team with the parents and children. The plastic surgery and paediatric urology teams carried out the procedures jointly; the follow-up was 0.33-7 years.

RESULTS

Five female patients and six male had abdominoplasty to treat multiple scars; eight had intermittent catheterization conduits repositioned from the right iliac fossa to the umbilicus. Six female patients had plastic surgery of the external genitalia and three had a broad mobilization of the urogenital sinus. Thirteen male patients had a small penis and had the corpora cavernosa fully mobilized and the penis reconstructed. Five female patients and one male had anterior osteotomy. One patient with no left testis had it replaced and one patient with uterine prolapse had the uterus fixed to the posterior abdominal wall. Six patients had a second procedure, in two because the outcome of the initial operation was poor and in the others to complement the initial treatment. In all but one patient there was an improvement in the objective criteria, e.g. school absences, difficulty in establishing long-lasting social relationships and refusal to participate in sports activities. However, none of the patients would attempt sexual intercourse.

CONCLUSIONS

Body image, self-esteem, sexuality, sexual function and fertility are deemed crucial by adolescents; in patients with EEC customised surgical procedures can give a satisfactory aesthetic outcome, and be a further reason for adequately following occasional urinary complications and renal function, to avoid loss to follow-up.

Penile hemodynamics in hypogonadal men with micropenis

OBJECTIVES

To document the penile vascular and erectile response to intracavernous injection (ICI) of vasoactive agent in hypogonadal men with micropenis.

METHODS

A total of 15, previously untreated, hypogonadal men with micropenis (stretched penis length less than 2.5 SD below the mean of the normal population) underwent a detailed urologic and endocrinologic evaluation. Their mean age was 21.2 +/- 4.2 years. Penile hemodynamics were assessed by color Doppler ultrasonography before and after ICI of 5 microg of prostaglandin E(1) combined with manual genital self-stimulation.

RESULTS

Endocrinologic evaluation revealed that hypogonadism was hypogonadotropic in 10 (66.7%) and hypergonadotropic in 5 (33.3%). Karyotype analysis showed 46XY in all. Their mean stretched penile length was 6.2 +/- 1.4 cm (range 3 to 7.5) and increased to a mean of 6.96 +/- 1.5 cm (range 4 to 8.5) after ICI. The serum free testosterone levels ranged from 0.2 to 3.2 pg/mL (mean 1.9 +/- 0.92). None had had any previous sexual experience, and 14 (93.3%) reported a history of nocturnal erections. Penile color Doppler ultrasonography demonstrated a normal penile vascular system in 7 (46.7%) and penile arterial insufficiency in 4 (28.6%). All 11 of these patients (73.3%) achieved an adequate erectile response to ICI combined with manual stimulation. Mixed vascular disease was observed in the remaining 4 patients (28.8%), and they did not have a sufficient erectile response to ICI. Color Doppler ultrasonography revealed similar results in the hypogonadotropic and hypergonadotropic men.

CONCLUSIONS

Our data suggest that the erectile response to ICI combined with manual genital self-stimulation is effective in most hypogonadal men having a micropenis with low serum androgen levels.

Prospects for fertility in patients born with genitourinary anomalies

PURPOSE

The effect of congenital genitourinary anomalies on fertility and the impact of current therapies are reviewed.

MATERIALS AND METHODS

The literature of each of the 2 components was used to define the present status and to make proposals for future management.

RESULTS

Infertility may be caused by gonadal failure (intersex states), failure of sperm transport (exstrophy) or both (bilateral undescended testes). In some conditions it is uncertain whether there are any fertility problems despite an identifiable genital problem. In cases of unilateral undescended testis the fertility rate may be unaffected by surgery and be no different from that in the normal population. Techniques of in vitro fertilization, particularly intracytoplasmic sperm injection, have allowed previously untreatable patients to become parents. Successful pregnancies in patients who had the prune belly syndrome and Klinefelter's syndrome have been reported in the last year.

CONCLUSIONS

Prospects for fertility with current techniques and those that might be discovered in the next 20 years should strongly influence decisions about the treatment of infants and children.

Prospects for fertility in patients born with genitourinary anomalies

PURPOSE

The effect of congenital genitourinary anomalies on fertility and the impact of current therapies are reviewed.

MATERIALS AND METHODS

The literature of each of the 2 components was used to define the present status and to make proposals for future management.

RESULTS

Infertility may be caused by gonadal failure (intersex states), failure of sperm transport (exstrophy) or both (bilateral undescended testes). In some conditions it is uncertain whether there are any fertility problems despite an identifiable genital problem. In cases of unilateral undescended testis the fertility rate may be unaffected by surgery and be no different from that in the normal population. Techniques of in vitro fertilization, particularly intracytoplasmic sperm injection, have allowed previously untreatable patients to become parents. Successful pregnancies in patients who had the prune belly syndrome and Klinefelter's syndrome have been reported in the last year.

CONCLUSIONS

Prospects for fertility with current techniques and those that might be discovered in the next 20 years should strongly influence decisions about the treatment of infants and children.

Management of bladder exstrophy

The exstrophy-epispadias complex is a severe anomaly of the lower urinary tract. While the surgical reconstruction of normal anatomy in patients with this disorder was once considered impossible, modern management has made possible a near-normal reconstruction of the bladder and lower abdominal wall. Early operation in the neonatal period along with closure of the pelvic ring has been shown to significantly improve results in terms of continence and achievement of adequate bladder capacity. With the possibility of prenatal diagnosis, it is important that the counseling obstetricians and neonatologists should understand the basis of the surgical management and the outcome that can be expected.

Bladder exstrophy: staged reconstruction

The modern staged approach to bladder exstrophy reconstruction has undergone significant changes since it was first advocated by Jeffs and Cendron in the 1970s. Although varied surgical approaches have been tried in the bladder exstrophy condition, the staged approach to bladder exstrophy repair has withstood the test of time. Progress continues to be made in evaluating the outcome of older types of staged reconstruction, with continuing modification and improvements in the modern approach to staged reconstruction. This treatise will update the reader on recent advances in the treatment of bladder and cloacal exstrophy.

Assignment of sex in neonates with ambiguous genitalia

Sex assignment in the newborn with ambiguous genitalia has been based on the adequacy of the phallus in the male, potential fertility in the female, and cosmetic appearance of the reconstructed genitalia. Recent data from both the neurosciences and from clinical research, however, casts doubt on the validity of such criteria for clinical decision making. Current knowledge suggests a need to shift away from the current clinical approach and to incorporate these new data into decisions based on a broader understanding of the etiology of gender identity. Recognition of the primacy of psychosocial and psychosexual developmental outcomes for children with ambiguous genitalia is lending direction to longitudinal outcomes research. New approaches to sex assignment have been suggested, and the paradigm for sex assignment in the newborn period is in transition.