There are several different strategies to try to find out exactly what might be the cause of the problem they’re having. If it’s a problem with incontinence, we would have the family document in a diary form the date, time of catheterization or attempted catheterization, and volume that they get with that catheter. We would also have them record when the child’s wet in between: is it immediately after catheterizing, is it an hour, two hours, three hours later? So we give them a bit of homework to try to help us: it’s one facet of our data gathering, a history of the problem itself. Next a urodynamics study, or a bladder function study, is done to help us appreciate whether it’s a bladder storage problem (too small a capacity), or a compliance problem (too high a pressure), or a bladder muscle stability problem (overactive bladder muscle), that’s responsible for the incontinence. We can also look at the pressures within the valve or continence mechanism where that tube inserts into the bladder: is there appropriate pressure there that should stop urine from leaking out on the abdomen, or is there not? The third step would be imaging – ultrasound, but more specifically imaging of the bladder and the conduit anatomy with a fluoroscopic cystogram, also known as a VCUG. And of course we want to examine the patient and talk directly with the family as much as we can. Does leaking occur during certain activities, is it certain times of the day, is it with infection only?

We use many of these same strategies if there’s difficulty passing the catheter, but the primary one there is imaging. Sometimes if imaging does not clearly identify the problem we look with a telescope in the operating room.
If there’s a problem with the bladder – too small, too high pressure, overactive – we might augment the bladder, making it a better reservoir. If there’s a problem with the continence mechanism, we revise that, make that better, and check it in the operating room as I described. If there’s problem with catheterizing, we might straighten out the channel if it’s taking a serpiginous course, trying to improve ease of catheterization. Sometimes there are medications that can help the incontinence; it’s not always surgery thankfully.

Joseph Borer, MD, Department of Urology