A bladder outside the body is rare

* According to the mother, the outer cover of the bladder, at times produces pus and blood By Kikonyogo Ngatya When little Richard Byakatonda (3) screams in pain and anguish while passing urine, you can hardly hold back your tears. Born to Jacqueline Nabulima and Benon Barugahare of Namagunga, near Namawojjolo on Kampala-Jinja highway, Byakatonda has a protruding bladder. Whenever it fills up, urine oozes out without his control. A mere touch of the delicate bladder will send him crying out in pain. According to the mother, the outer cover of the bladder at times produces pus and blood. Byakatonda's mother claims that her baby was admitted to Mulago Hospital in 1997 but was never operated upon because she could not raise the money for the operation. According to Dr Stephen Watya, a urologist surgeon at Mulago hospital, Byakatonda has a bladder exstrophy. He says that at an advanced stage, the complication becomes life- threatening because it exposes the patient to bladder cancer which may cause death. Watya has offered to carry out the operations free in order to correct the complication. Bladder exstrophy is a defect in the formation of the bladder inside the womb during child development. The top surface of the bladder near the front of the body does not fully close, nor do the skin, muscle, and pubic bone that usually cover the bladder. As a result, there is an abnormal opening in the skin, at the bottom of the abdomen. The back of the bladder pushes through this opening and bulges outside the body at birth. Watya says that the urethra, a tube that carries the urine from the bladder to the outside, remains open all the time. The problem occurs in both males and females but it is more common in males than in females. Uganda has no official figures on the prevalence of the disorder. In females, apart from the bladder coming out ,it also leads to the narrowing of the vagina with the clitoris splitting into two. " In order to understand this complication it is important that you understand the normal urinary system which consists of two kidneys, two ureters, the bladder and the urethra, Watya explains. Normally, each kidney filters waste products out of the bloodstream and converts the waste to urine. The urine collects in the ureter, where it flows down into the bladder," he explains. The bladder then stores the urine until it is ready to be released through the urethra. At the outlet of the bladder is a muscle called a sphincter that the child normally learns to control when he or she is toilet trained. This sphincter muscle closes to prevent urine from leaving the bladder until we pass it out. When the bladder is full, we let this muscle relax, and then the bladder contracts and urine passes through the urethra to the outside. The doctor explains that in the child with exstrophy, there is not a complete sphincter, therefore, urine that reaches the bladder simply spills out of the opening onto the abdomen. Eight cases have been reported at Mulago of which, five have been successfully corrected free of charge. On completion of surgery, patients can lead normal lives, have sex and children without complications. Watya says that a number of operations are needed to separate the exposed bladder from the abdominal wall and close the bladder (bladder repair). The surgery prevents bladder infections that could also affect kidney function. It also allows the child to develop normal urinary control and avoid future problems with sexual function "Because the pelvis bones are separated, the child will also need to have the pelvic bones surgically attached to each other," he says. According to a recent report by the American Foundation for Urology diseases " There is no research that has shown that bladder exstrophy can be inherited from one person to another." The report says that in a family with a child suffering from bladder exstrophy, the likelihood of a second child being born with exstrophy is one in 100. The risk of having a child with exstrophy is one in 70, if either or both parents have suffered from bladder exstrophy.