BERKELEY, CA (UroToday.com) - The valve bladder as described being the decompensated result of outlet obstruction in patients with posterior urethral valves (PUV) is recognized as perhaps the single most important determinant of long-term outcome. Puri et al give their insight into the etiopathogenesis and management of valve bladders. Their study was designed to evaluate bladder dysfunction in PUV patients and to assess their response to imipramine with serial urodynamic studies (UDS). They had 30 patients from 1998 - 2001 who had PUV and documented bladder dysfunction on UDS. Patients with poorly compliant or unstable bladders were treated with imipramine (1.5 - 2 mg/kg). All the patients in the study were 5 years or older and toilet trained. Assessment of continence and side effects of the drug was performed after 3 months and repeat UDS were done at 3 - 6 months, 1 and 2 years. They found that there were two surgical groups of patients; a fulguration group (n = 10, 33.3 %) and a vesicostomy group (n = 20, 66.6 %). Symptomatic voiding dysfunction was present in 27 of the 30 patients (90 %). Two patterns of urodynamic abnormalities were noted: 1) unstable bladders with single or multiple uninhibited contractions (18/30 patients, 60 %); and 2) small capacity, hypocompliant, hypertonic bladder (12/30 patients, 40 %). Post imipramine therapy significant symptomatic improvement was noted in 16/30 patients. On serial UDS following one year of imipramine therapy, there was an 18 - 20 % increase in maximum cystometric capacity (MCC) and 30 - 35 % increase in pressure specific bladder volume (PSBV) in 16/30 patients and 11/30 patients, respectively. 4 patients failed to show any improvement in MCC and PSBV with imipramine. These four patients had been initially diverted with a vesicostomy and later required augmentation cystoplasty. The group concluded that patients with an unstable bladder and those with marginal bladder capacity and compliance showed the best response to imipramine therapy. Not surprisingly, fibrotic, small capacity, hypertonic bladders were less responsive to imipramine. They felt that a trial of imipramine therapy is still warranted in these patients, as only 4/12 (33.3 %) patients with fibrotic hypertonic bladders failed to show any response and ultimately required augmentation cystoplasty. They ended by stating that Imipramine qualifies as an effective and cheap drug for valve bladders. Eur J Pediatr Surg 15: 347-353, November 2005 | 
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