LETTERS TO THE EDITOR
|Year : 2023 | Volume
| Issue : 1 | Page : 87-88
Bowel–Bladder dysfunction: Putative and serendipitous management
Uday Sankar Chatterjee1, Indranil Chatterjee2
1 Pediatric Surgery, Park Medical Research and Welfare Society, Kolkata, West Bengal, India
2 Pediatric Surgery, B.C. Roy Children Hospital, Kolkata, West Bengal, India
|Date of Submission||29-Aug-2022|
|Date of Decision||08-Oct-2022|
|Date of Acceptance||12-Oct-2022|
|Date of Web Publication||10-Jan-2023|
Uday Sankar Chatterjee
356/3, S.K. Bose Sarani, Kolkata - 700 030, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chatterjee US, Chatterjee I. Bowel–Bladder dysfunction: Putative and serendipitous management. J Indian Assoc Pediatr Surg 2023;28:87-8
|How to cite this URL:|
Chatterjee US, Chatterjee I. Bowel–Bladder dysfunction: Putative and serendipitous management. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Feb 2];28:87-8. Available from: https://www.jiaps.com/text.asp?2023/28/1/87/367380
We treated six male patients of lower urinary tract dysfunction (LUTD) serendipitously and found good outcome.
Six male patients presented with a complaint of pant wetting, increased frequency, and poor flow even after ablation of posterior urethral valve (PUV). Fulguration was done in four and Abraham needle ablation in two. All patients were from poor educa-economic status. On inquiry, all had a history of constipation which was, as if, not bothering parents and patients. Uroflowmetry curve was vibratory, but flow was not very poor. They were advised regular normal saline enema but failed regularity.
As previous micturating cystourethrogram (MCU) looked similar to PUV [Figure 1], we suspected residual PUV or stricture and proceed for endoscopy. In all six patients, we found trabeculations and mild sacculation in three patients. Three patients had elevation of bladder neck; we did BNI. However, PUV was mini or almost no residual valve in all six patients. Nevertheless, we fulgurated the “seems to be PUV.” Per urethral catheter was kept for seven days. We did low-energy anal stretching along with.
|Figure 1: Picture of MCU showing bilateral VUR, hypertrophy of bladder neck, and dilated posterior urethra. Looks alike inadequate PUV fulguration (Courtesy: Koyle MA, Lorenzo AJ. Management of defecation disorders. In: Partin AW, editor. Campbell-Walsh-Wein Urology. 12th Edition (International), Ch. 36, Philadelphia: Elsevier; 2021. p. 667). MCU: Micturating cystourethrogram, VUR: Vesico ureteric reflux|
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After removal of the catheter, pant wetting and frequency stopped; and flow increased in five out of six patients clinically and in uroflowmetry. One patient did not return at follow-up.
We were surprised on outcome! Did we treat post ablated PUV? Or bowel–bladder dysfunction (BBD)/(dysfunctional elimination syndrome (DES)/LUTD!
As per literature, LUTD or BBD or DES found to be due to dyscoordination or delayed coordination or inappropriate “crosstalk” between autonomic (detrusor) and somatic nervous system (Rhabdo sphincter/external sphincter). Damage of renal function is directly proportional to the duration of delay in development of coordination between autonomic and somatic system.
From the outcome, we putatively explain that, we were able to decrease spasm of Rhabdosphincter or external sphincter of urethra following reablation of mini PUV. Similarly, we were able to decrease the perineal sphincter by anal stretching. Vricella et al. have tried botulinum neurotoxin type A (BoNTA) to decrease Rhabdosphincter spasm with good outcome. However, the effect of BoNTA lasts for 6–9 months. So repeat application of BoNTA might be necessary. Anal stretching is controversial in fissure in ano. Nevertheless, it is recommended by some authors.
We also did low-energy stretching in anus with intact mucosa not in fissure in ano. Chance of fibrosis in intact anal mucosa and sphincter is remote, unlike in fissure-in-ano.
Intimate association between bowel and bladder function is well known and dysfunction of bowel–bladder is similarly well known annoyance both for parents and patients; socially and psychologically.
We hope this putative management, found serendipitously, might help manage LUTD following further studies. This correspondence is only to convey our observation. Further study with subjective digital rectal examination (DRE) or objective manometry will be necessary for clinical application.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chatterjee US, Basu AK, Mitra D. Insight into posterior urethral valve from our experience: Paradigm appended to abate renal failure. J Indian Assoc Pediatr Surg 2020;25:297-305. [Full text]
Vricella GJ, Campigotto M, Coplen DE, Traxel EJ, Austin PF. Long-term efficacy and durability of botulinum-A toxin for refractory dysfunctional voiding in children. J Urol 2014;191:1586-91.
Gaj F, Biviano I, Candeloro L. Low energy manual anal stretch: An approach in the treatment of chronic anal fissure. Minerva Chir 2017;72:103-7.