Evaluation and treatment of incontinence after bladder neck reconstruction in exstrophy and epispadias.

Twenty-five children with exstrophy/epispadias who had had at least one bladder neck operation (but no augmentation) for incontinence underwent cystometrography (CMG) and urethral pressure profile (UPP) studies. The purpose of this study was to examine all components of lower urinary tract function and to determine how the properties of the bladder and the properties of the bladder neck/urethra interacted to achieve continence or to result in incontinence in the individual child. Examination of detrusor function during filling revealed involuntary contractions in 12 children and an end-fill pressure > 10 cm H2O in 8. Of the 21 children in whom voiding could be evaluated only 6 could initiate a detrusor contraction. In the 18 incontinent children leak pressure could be measured and was > or = 15 cm H2O in 12. Five of the 7 continent children also demonstrated at least one abnormality in lower tract function. The maximum pressure of the UPP did not agree with the leak pressure and may not be a valid measure of the closing pressure of the bladder neck/urethra in this patient population. Detailed urodynamic investigation is necessary in these children to guide the next step of management and to evaluate objectively each form of treatment.