Bladder Exstrophy and Epispadias

Introduction Exstrophy and epispadias are part of a spectrum of anomalies characterised by exposure of part or all of the mucosa of the lower urinary tract (bladder and urethra) to the external environment through a defect in the anterior abdominal wall. At one end of this spectrum is cloacal exstrophy, which is the most complex of these anomalies. It is characterised by exposure of the bladder mucosa together with the mucosa of the hind gut to the external environment through an anterior abdominal wall defect. At the other end of the spectrum is epispadias, which is characterised by a normal abdominal wall and bladder with a dorsal external urethral meatus, which may be anywhere from the base of the penis to the glans and may or may not be associated with an incompetent bladder neck and sphincter mechanism. Between these two extremes exist variations in pathology, with the most prevalent being classic bladder exstrophy. In most of the anomalies in this spectrum, there is concomitant bone involvement with diastasis of the symphysis pubis. The most prevalent condition, classic bladder exstrophy, is characterised by exposure of the bladder and posterior urethral mucosa through a defect in the anterior abdominal wall. It is associated with a complete epispadias in boys and bifid clitoris in girls. At neonatal presentation, this anomaly results in the continuous dribbling of urine and exposure of bladder and urethral mucosa to the external environment. It leads to chronic irritation of this mucosa as well as social and emotional complications in Africa due to isolation of the affected person. The medical literature on treatment of the epispadias-exstrophy complex presents many techniques. There is no ultimate excellent technique. Techniques used depend on various factors, such as extent of the abnormality, surgeon’s experience, hospital staff and skills, and possibilities for follow-up, among many others. This chapter presents examples of how to tackle the problem, specifically in the African situation. This chapter is not intended to be the final state-of-the-art approach to exstrophy; rather, the goal is to inspire those who are confronted with a child presenting with the epispadias exstrophy complex.