Postpubertal Urodynamic and Upper Urinary Tract Changes in Children With Conservatively Treated Myelomeningocele Fayez Almodhen, Jean Paul Capolicchio, Roman Jednak and Mohamed El Sherbiny* From the Division of Pediatric Urology, Montreal Children’s Hospital and McGill University Health Center, Montreal, Quebec, Canada Purpose: We examined the urodynamic and upper urinary tract changes in children with myelomeningocele treated conservatively through puberty at our institution between 1980 and 2006. Materials and Methods: A total of 40 patients were exclusively treated conservatively with or without anticholinergics and/or clean intermittent catheterization through puberty at our institution. The records of 37 patients (17 males and 20 females) were available for review and constituted the subject matter for our study. The neurological lesion was sacral in 4 patients, lumbosacral in 5, thoracic in 12 and lumbar in 16. Clinical evaluations, radiological imaging studies of the upper urinary tract and urodynamic studies were repeated every 6 to 12 months. Data were collected and comparisons were made with respect to prepubertal (age 10 years) and postpubertal (15) continence status, urodynamic parameters and upper urinary tract changes. Children spontaneously achieving urinary continence postpubertally were examined in a similar fashion as a separate subgroup. Continence was defined as a dry interval of 4 hours or more. Results: Of the 26 patients with urinary incontinence before puberty 12 (2 males and 10 females, 45%, p 0.003) achieved continence following puberty. Hydronephrosis remained stable in 4 patients, improved in 3 and was new onset in 3 (p 0.05). Vesicoureteral reflux persisted in 1 patient, resolved in 4 and was new onset in 1 (p 0.05). Total cystometric bladder capacity, maximum detrusor pressure and detrusor leak point pressure all increased significantly after puberty, from 277  82 to 487  140 ml, 45  17 to 54  20 cm H 2 O and 49  16 to 59  21 cm H 2 O, respectively. In patients achieving urinary continence following puberty total cystometric bladder capacity increased significantly from 284  58 to 473  93 ml (p 0.005). Maximum detrusor pressure and detrusor leak point pressure showed insignificant changes after puberty, increasing from 45  11 to 47  16 cm H 2 O and from 46  11 to 55  21 cm H 2 O, respectively. Conclusions: This study demonstrates that total cystometric bladder capacity, maximum detrusor pressure and detrusor leak point pressure increase significantly in patients with myelomeningocele following puberty. The increase in bladder capacity could be attributed to increasing bladder outlet resistance resulting from prostate gland enlargement in males and estrogenization in females. A significant number of patients spontaneously achieve continence at puberty, and continence becomes more likely when increased total cystometric bladder capacity is not associated with an increase in maximum detrusor pressure. Finally, no significant postpubertal upper urinary tract deterioration was observed in our series. Key Words: meningomyelocele, urinary incontinence, urodynamics, puberty M ost patients with myelomeningocele have some de- gree of neurogenic bladder dysfunction and require intensive bladder treatment regimens. The focus of care is on maintaining healthy upper urinary tracts and establishing urinary continence. Notably, some incontinent patients spontaneously achieve continence following pu- berty. This finding has been attributed to an increase in bladder outlet resistance stemming from enlargement of the prostate gland in boys and estrogenization of the urethra in girls. Naturally, this finding raises concerns about upper urinary tract deterioration. Rickwood et al reported that the incidence of renal dam- age almost a doubles in postpubertal patients treated con- servatively through puberty. 1 Lewis et al reported that the prevalence of parenchymal damage in children older than 10 years (27.3%) was twice that of the children younger than 5 years (13.3%). 2 It is not clear whether this increased risk of renal damage is related to the deterioration of bladder func- tion with increased outlet resistance, or represents a rebel- lion of teenagers against the discipline of CIC. Literature is lacking concerning postpubertal outcomes in patients with conservatively treated myelomeningocele. A longitudinal study examining bladder urodynamics and the upper uri- nary tracts of children from childhood through puberty is warranted. We examined the urodynamic parameters and upper tract changes before and after puberty in children with myelomeningocele treated conservatively, with partic- ular emphasis placed on patients spontaneously achieving urinary continence postpubertally. MATERIALS AND METHODS We identified the records of all patients with myelomenin- gocele followed in the spina bifida clinic at our institution between 1980 and 2006. Only those patients without a his- tory of surgical urological intervention were included in this study. A total of 164 patients were identified, of whom Submitted for publication February 15, 2007. * Correspondence: 2300 Tupper St., Room C5.27, Montreal, Que- bec, H3H 1P3, Canada (telephone: 514-412-4366; FAX: 514-412- 4384). 0022-5347/07/1784-1479/0 Vol. 178, 1479-1482, October 2007 THE JOURNAL OF UROLOGY ® Printed in U.S.A. Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/j.juro.2007.05.171 1479