An 11 year old boy has had diabetes for only a few years, treated at present with 2 units of Actrapid with 2 units of Mixtard before meals, and his A1c is estimated to be 6.6%. For the last few months, he has had difficulty passing urine, and he usually needs to be catheterized. His full bladder volume is 534 milliliters and after void residual volume is 439 milliliters. His other significant reports are: a random blood sugar of 254 mg/dl [mmol/L], a BUN of 93.1 mg/dl, and a creatinine of 2.7 mg/dl. An abdominal ultrasound shows a mildly trabeculated bladder wall, and the doctor’s conclusion is that he has changes in his lower urinary tract causing obstruction or a neurogenic bladder. What can be done for this child?

I find it difficult to accept that an eleven year old boy with an hemoglobin A1c of 6.6% and on a very small dose of insulin has a neurogenic bladder outlet obstruction due to a diabetic autonomic neuropathy. I think it is much more likely that his symptoms are due to some bladder abnormality such as a congenital posterior urethral membrane which has already induced sufficient chronic urinary tract obstruction as to produce some degree of renal failure.

The clinical spectrum of this condition is very variable which could explain why he has only developed symptoms relatively recently. Diagnosis really requires a voiding cystogram as cystoscopy is less satisfactory. At this stage he needs the help of a genito-urinary surgeon, and if at all possible a paediatric one, to correct the problem.

DOB