Health-related quality of life among children, adolescents, and adults with bladder exstrophy–epispadias complex: a systematic review of the literature and recommendations for future research

  • Michaela Dellenmark-BlomEmail author
  • Sofia Sjöström
  • Kate Abrahamsson
  • Gundela Holmdahl



Bladder exstrophy–epispadias complex (BEEC) is a rare spectrum of genitourinary malformations. Children risk long-term urinary and genital dysfunctions. To achieve a comprehensive understanding, this study aimed to review the literature on generic and disease-specific health-related quality of life (HRQOL) in BEEC patients, and methodologies used.


A literature search was conducted in Pubmed/CINAHL/Embase/PsycINFO/Cochrane, from inception to May 2018. A meta-analysis of HRQOL in BEEC patients compared to healthy references was performed.


Twenty-one articles (published 1994–2018), describing HRQOL of children and adolescents (n = 5) and adults only (n = 5), or integrated age populations (n = 11), were identified (median sample size 24, loss to follow-up 43%, response rate 84%). Overall HRQOL was reduced in BEEC patients compared to healthy references in 4/4 studies. Impaired physical or general health in BEEC patients has been described in 9 articles, diminished mental health in 11, restricted social health in 10, and sexual health/functioning or body perception impairments in 13 articles. Urinary incontinence was the most common factor related to worse HRQOL (12 studies). In six studies, HRQOL was better than healthy norms. In eligible studies (n = 5), the pooled estimate of the effect of BEEC indicated worse HRQOL for children and adults (0 > effect sizes < 0.5). Thirty-six HRQOL assessments were used, none developed and validated for BEEC.


HRQOL in BEEC patients may be negatively impacted, particularly considering mental and social HRQOL. Sexual health/functioning or body perception impairments may be present in adolescents and adults. However, HRQOL is heterogeneously assessed and subsequent findings are differently reported. Additional research is warranted and can be improved.


Bladder exstrophy Epispadia Bladder exstrophy–epispadias complex Malformation Health-related quality of life Patient-reported outcome 



Bladder exstrophy is a congenital malformation with a closing defect of the lower part of the abdominal wall. When the child is born, the bony pelvis is open in the front; the bladder and urethra are open and exposed on the outside of the abdomen; the belly button low; and genital malformations are present (see epispadias)


Bladder exstrophy–epispadias complex refers to a spectrum of birth defects including epispadias (mildest form), bladder exstrophy (intermediate form), and cloacal exstrophy (severest form), which involves malformations of the urinary tract, intestinal tract, genital tract, musculoskeletal system, and sometimes the spinal cord


Bladder neck repair refers to different reconstructive procedures/methods of the bladder neck in order to improve urinary continence by increasing the outlet resistance


Clean intermittent catheterization is a method to empty the bladder of urine by passing a thin, plastic tube through the urethra or a catheterizable stoma intermittently under clean but not sterile conditions


Cloacal exstrophy is an abdominal defect with the urinary bladder and parts of the intestines exposed externally on the abdomen. The bony pelvis is open. Imperforate anus is common. Spinal defects may also be present. In males, the penis is short, split or even missing. In females, the clitoris is split and there may be duplication anomalies of the internal genitalia.


Epispadias, isolated or in combination with bladder exstrophy, is a closing defect of urethra. In boys, the urethra is opened like a plate on the dorsal side of the penis. The penis is most often short and broad, and curved dorsally. In girls, the urethra opens between a bifid, split clitoris. The vaginal opening may be narrow and ventrally displaced


Effect size


Health-related quality of life


Kidney stones


Strength and Difficulties Questionnaire


Urinary diversion encompasses surgical procedures which reroute and drain urine flow from its normal pathway. It may include detaching the ureters and connecting them to an intestinal segment creating a stoma on the abdominal surface. The patient will wear an ostomy bag into which the urine drains continuously (non-continent urinary diversion). It can also refer to an internal reservoir with a bowel segment, together with the residual bladder or not, to store urine between intermittent catheterizations through a continent stoma (continent urinary diversion)


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Research involving human and animal participants

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

For this type of study, formal consent is not required.

Supplementary material

11136_2019_2119_MOESM1_ESM.pdf (223 kb)
Supplementary material 1 (PDF 223 KB)
11136_2019_2119_MOESM2_ESM.pdf (220 kb)
Supplementary material 2 (PDF 220 KB)
11136_2019_2119_MOESM3_ESM.pdf (172 kb)
Supplementary material 3 (PDF 172 KB)


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Michaela Dellenmark-Blom
    • 1
    • 2
    Email author
  • Sofia Sjöström
    • 1
    • 2
  • Kate Abrahamsson
    • 1
    • 2
  • Gundela Holmdahl
    • 1
    • 2
  1. 1.Department of Pediatric Surgery, The Queen Silvia Children’s HospitalSahlgrenska University HospitalGothenburgSweden
  2. 2.Department of Pediatrics, The Queen Silvia Children’s Hospital, Institute of Clinical SciencesSahlgrenska Academy, Gothenburg UniversityGothenburgSweden

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