Bladder dysfunction s/p ureteral reimplantation in 2 yr old

[DenieceRN]

My son has bilateral relux grade 4/5.  After no improvment in VCUG despite being infection free surgery was recommended at two years.  The surgery was technically difficult,his bladder is long front to back and narrow.  The ureters were first crossed and implanted under the bladder but were noted to be "kinking " off and so the surgeon went directly on top of the bladder. He stated this was not his preference due to the nerve placement but he felt it his only option.  He did not taper the ureters.  After surgery he had a great deal of bladder spasm which was expected but with B&O suppositories and morphine was managed.  After d/c the pain grew worse daily. After two days of being blown off I took him to the pediatrician who immediately called the surgeon.  He seemed to be constantly straining as if he needed to deficate and it was felt he was constipated 2nd to ditropan so he was put on a bowel regime and the ditropan was stopped.  After two days of diarhea (diarrhea) and no improvement I wanted him evaluated or readmitted for pain mgmt. (He screamed for 4 hours until he had no voice and was shaking).  I am an pediatric SICU nurse who does open heart and I can only equate it to fresh unmanaged post-op type pain.  I brought him to the surgeon who did an ultrasound and found him in gross urinary distention with bilateral hydronephrosis.  A foley was placed and my child who would not eat for 11 days asked for pizza two hours later.  He was fine with no pain with the foley in.  We tried 4 times over the next three weeks to remove it using pyridium and even adding cardura with no sucess.  Each time he would urinate in an overflow fashion with a great deal of pain and gross distention on US.  The surgeon felt he was voluntarily holding and wanted to put in a suprapubic cath, let him urinate and drain residual until it decreased and he was able to urinate.  I disagreed that he was holding as nights were worse and I couldn't imagine he would hold in his sleep, and he strained so hard when he urinated that every time he would also deficate.  It seemed incompatible that you could hold with a full bladder while increasing intrathoracic pressure to deficate.  Nevertheless we went ahead.  The catheter has been in two weeks clamped after two days and only opened for discomfort with one void when he was screaming as we drained 200cc.  We are now adding on Urokoline and going for an MRI next week.  When I ask him to go pee pee he strains and really tries and he says " I can't it's stuck", and he often has a BM if he tries hard enough but no urine.  He does seem to strain more to deficate despite very soft stool.  Q. Have you ever heard of this problem and what is the possible cause and prognosis?   What is he looking for with MRI? How long can he have the suprapubic and what is next if it doesn't improve? Most importantly, what is the best pediatric urology center in the US for eval and 2nd opinion we heard chop and Boston but would welcome any input.  Thanks

[Kevin Pho, MD]

As I am not a pediatric urologist, I am not personally familiar with this problem.  However, it certainly makes sense that the discomfort is related to the urinary retention.  

Typically suprapubic catheters can remain for a long-term timeframe.  With the MRI, I suspect that your physician is looking for possible neurological damage (i.e. nerve impingement) that is affecting the urinary symptoms of your son.  One alternative method of treatment would be subtrigonal injection of collagen.  It results in successful improvement of symptoms in 65 to 70 percent of cases.

As I am based in New England, I can certainly recommend Children's Hospital in Boston as it is consistently ranked as one of the top hospitals in the nation.  Their web site is found here:
http://web1.tch.harvard.edu/

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.