Invest Clin 62(2): 103 - 111, 2021 https://doi.org/10.22209/IC.v62n2a01

Corresponding author: Jian Wang .

Department of General Surgery, Children’s Hospital of Soochow University,

Suzhou, China. E-mail :wang.medical23@gmail.com

Currarino Syndrome: lower urinary tract

function, treatment plan and outcomes.

Hongliang Xia

, Mingcui Fu

, Hangzhou Wang

, Xu Cao

, Xiangming Yan

, Yun Zhou

and Jian Wang

Department of Urology, Children’s Hospital of Soochow University, Suzhou, China.

Department of Neurosurgery, Children’s Hospital of Soochow University, Suzhou,

China.

Department of General Surgery, Children’s Hospital of Soochow University, Suzhou,

China.

Key words: Currarino syndrome (CS); video-urodynamics (VUDS); neurogenic bladder;

children; multidisciplinary.

Abstract. Currarino syndrome (CS) is a rare congenital disorder char-

acterized by anorectal malformation, sacral agenesis and presacral mass. We

performed video-urodynamics (VUDS) assessment of patients with CS to char-

acterize the lower urinary tract function, individualize management plans and

to follow outcomes. We conducted a cross-sectional study on 11 patients diag-

nosed with CS at the spina bifida multidisciplinary clinic. Lower urinary tract

function was assessed by VUDS from three months to 12 months after neuro-

surgery. All patients had sacral agenesis; nine patients had anorectal malforma-

tion (9/11, 81.8%) and five patients had a presacral mass (5/11, 45.5%). The

average age at neurosurgery was 7.9 months (range, 2–19). One patient had

bilateral vesicoureteral reflux (VUR) with increasing detrusor pressure at the

end of filling. In two patients, the detrusor activity showed weakening during

urination, while no other lower urinary tract abnormality was identified on uro-

dynamic evaluation. Six patients underwent VUDS before and after surgery; of

these, two patients showed improved bladder function after surgery, while the

remaining four patients showed no change in urodynamics. The average dura-

tion of follow-up was 27.5 months (range, 9–51). Renal function was normal

in all patients. We can conclude that patients with CS often exhibit associated

neurological abnormalities. VUDS assessment may help detect lower urinary

tract dysfunction at an early stage and facilitate timely urological intervention

to avoid kidney damage.

104 Xia et al.

Investigación Clínica 62(2): 2021

Síndrome de Currarino: función del tracto urinario inferior,

plan de tratamiento y resultados.

Invest Clin 2021; 62 (2): 103-111

Palabras clave: síndrome de Currarino (SC); videourodinámica (VUDS); vejiga neuró-

gena; niños; multidisciplinario.

Resumen. El síndrome de Currarino (SC) es un trastorno congénito poco

común que se caracteriza por malformación anorrectal, agenesia sacra y masa

presacra. Realizamos una evaluación por video-urodinamia (VUDS) de pacien-

tes con SC para caracterizar la función del tracto urinario inferior, planes de

manejo individualizados y el seguimiento terapéutico posterior. Realizamos un

estudio transversal en 11 pacientes diagnosticados de SC en la clínica multidis-

ciplinaria de espina bífida. La función del tracto urinario inferior se evaluó me-

diante VUDS de 3 a 12 meses después de la neurocirugía. Todos los pacientes

tenían agenesia sacra; nueve pacientes tenían malformación anorrectal (9/11,

81,8%) y cinco pacientes tenían una masa presacra (5/11, 45,5%). La edad

promedio en el momento de la neurocirugía fue de 7,9 meses (rango, 2-19). Un

paciente tenía reflujo vesicoureteral (RVU) bilateral con aumento de la presión

del detrusor al final del llenado. En dos pacientes, la actividad del detrusor

mostró debilitamiento durante la micción, mientras que no se identificó nin-

guna otra anomalía del tracto urinario inferior en la evaluación urodinámica.

Seis pacientes se sometieron a VUDS antes y después de la cirugía; de estos,

dos pacientes mostraron una mejor función de la vejiga después de la cirugía,

mientras que los cuatro pacientes restantes no mostraron cambios en la urodi-

námica. La duración media del seguimiento fue de 27,5 meses (rango, 9-51).

La función renal fue normal en todos los pacientes. Podemos concluir que los

pacientes con SC suelen presentar anomalías neurológicas asociadas. La eva-

luación de VUDS puede ayudar a detectar la disfunción del tracto urinario infe-

rior en una etapa temprana y facilitar la intervención urológica oportuna para

evitar daño renal.

Received: 13-11-2020 Accepted: 23-01-2021

INTRODUCTION

Currarino syndrome (CS) is a rare au-

tosomal dominant genetic disease, which

was first described by Currarino et al. in

1981 (1). The cardinal characteristics of CS

include sacral agenesis, anorectal malfor-

mation and a presacral mass (also referred

to as the Currarino triad)(2,3). The presa-

cral mass, which may lead to sacral nerve

compression or traction, is usually a my-

elomeningocele, lipomyelomeningocele, or

teratoma; in rare cases, the mass may be a

lipoma or an enterogenous cyst. CS may be

associated with intraspinal abnormalities,

such as filum terminal lipoma, intraspinal

dermoid cyst, or intraspinal lipoma, leading

to tethered cord (TC). Therefore, patients

with CS may exhibit signs of sacral nerve

dysfunction, such as constipation, lower

urinary tract symptoms, and lower limb

sensorimotor deficit (2,3).

Currarino syndrome treatment 105

Vol. 62(2): 103 - 111, 2021

Patients with CS (especially those who

require neurosurgery for correction of neu-

ral tube closure defect and release of TC) re-

quire evaluation of lower urinary tract func-

tion, urological treatment, and follow-up of

renal function. Urological evaluation and

treatment of children with spina bifida has

been shown to prevent renal damage and im-

prove life expectancy and quality of life (4).

Apart from ultrasound, magnetic resonance

imaging and renal function tests, video-uro-

dynamics (VUDS) is a particularly useful ap-

proach for assessment of lower urinary tract

function and to predict the possibility of

upper urinary tract injury in these patients

(5). Till date, only a few case reports have

described urological intervention in patients

with CS (6,7).

In this study, we retrospectively ana-

lyzed the urological evaluation and treat-

ment of patients with CS who underwent

neurosurgery at our spina bifida multidisci-

plinary clinic. Our experience may help pro-

mote individualized management of patients

with CS with the objective to better preserve

the upper urinary tract function.

MATERIALS AND METHODS

Patient selection

This was a cross-sectional study on pa-

tients diagnosed with CS at the spina bifida

multidisciplinary clinic between 2014 and

2018. The diagnostic criteria for patients

enrolled in our study were presence of sacral

agenesis in combination with one or more

of the following: presacral mass, anorectal

malformation, genitourinary malformation,

or other malformations. Data pertaining

to medical history, clinical characteristics,

investigations (ultrasound, magnetic reso-

nance imaging (MRI), renal function tests

and VUDS) and treatment outcomes were

reported.

Surgical treatment

In the spina bifida multidisciplinary

clinic, the general surgeons determined the

necessity of surgical treatment of anorectal

malformation, while the neurosurgeons de-

termined the necessity of surgical treatment

of the presacral mass, spina bifida, and/or TC.

After the surgical protocol was determined by

the general surgeon and the neurosurgeon,

the urologist evaluated the patient’s urinary

system before and after surgery.

VUDS assessment

We performed comprehensive VUDS ex-

amination of patients, including cystometry,

imaging (X-ray) monitoring, and sphincter

electromyography. Data obtained from the

examination included: bladder volume, blad-

der compliance, detrusor activity, detrusor

leak-point pressure (DLPP) or end-filling

pressure (EFP), detrusor-sphincter synergy,

bladder morphology, and presence or ab-

sence of vesicoureteral reflux (VUR).

Classification of bladder risk

We classified the bladder status into

four categories according to the urodynamic

classification method proposed by Joseph

(8) and Routh et al. (4): (1) high-risk blad-

der: EFP/DLPP ≥ 40 cm H

O, or neurogenic

detrusor overactivity (NDO) with detrusor

sphincter dyssynergia (DSD); (2) interme-

diate-risk bladder: NDO, decreased bladder

compliance, 25 cm H

O ≤ EFP/DLPP < 40

cm H

O; (3) low-risk bladder (also known

as safe bladder): EFP/DLPP < 25 cm H

detrusor contraction < 60 cm H

O without

DSD; (4) normal bladder: normal bladder

volume, bladder compliance detrusor pres-

sure change < 15 cm H

O, no NDO, no DSD,

detrusor contraction < 60 cm H

O, normal

post-void volume. We improved the classifi-

cation method according to the VUDS ex-

amination. If grade I–IV VUR appeared dur-

ing inspection, the risk may increase by one

level. A high-risk bladder may be defined if

V-level VUR get appeared.

Urological management

We used a combination of clean inter-

mittent catheterization (CIC) and oral anti-

106 Xia et al.

Investigación Clínica 62(2): 2021

cholinergic drugs for high-risk bladders, and

guided urination training for patients with

weakened detrusor activity during urination.

Follow-up plan

We developed a follow-up plan for all

patients based on bladder risk and age. The

follow-up plan included renal and bladder

ultrasound (RBUS), VUDS, and renal func-

tion tests. Occurrence of lower urinary tract

symptoms (such as a febrile urinary tract in-

fection) during follow-up is an indication for

immediate RBUS. In the event of detection

of a new abnormality on RBUS, VUDS should

be performed. Renal function tests were

concomitantly performed with RBUS; renal

function was calculated using the Schwartz

serum creatinine clearance formula (9):

eGFR=kL/SCr

where k is a constant (k value is 0.33 for pre-

mature infants < 1 year of age; 0.45 for full-

term infants < 1 year of age; 0.55 for chil-

dren aged 2–12 years and adolescent women

aged 13–21 years; 0.7 for adolescent males

aged 13–21 years). L refers to height (cm),

and SCr refers to serum creatinine (mg/dL).

Statistical analysis:

Descriptive statistics were used to re-

port continues data by Mean ± SD and cat-

egorical data by number and percent. No

further analytical statistical analysis was

conducted.

RESULTS

Patient characteristics

Our study included 11 patients (8

males, 3 females) with CS. The mean age at

diagnosis was 7.3 ± 5.2 months (range, 0–19

months). The characteristics of enrolled pa-

tients are summarized in Table I.

Outcomes of general surgical treatment

All 11 patients had sacral agenesis.

Eight patients had anorectal malformations

(8/11, 72.72%); seven patients had congen-

ital anal atresia, and one patient had anal

stenosis. Among the other malformations,

one patient had Hirschsprung disease. Of

the seven patients with anal atresia, four pa-

tients had rectoperineal fistula. Out of the

seven children with anal atresia, two were

first diagnosed as CS at the spina bifida

multidisciplinary clinic because of the com-

plication of lipomyelomeningocele, while

the remaining five patients were first diag-

nosed in the general surgery department.

All seven patients underwent surgery within

three days after birth (two underwent sig-

moidostomy and five underwent anoplasty).

Patients with stricture of anus underwent

anoplasty at the age of five months. Patients

with Hirschsprung underwent Pull-through

Procedure at 6-month-old.

Outcomes of neurosurgical treatment

The average age of patients at the time

of neurosurgery was 7.9 ± 4.9 months (range,

2–19). Sacrococcygeal MRI performed at the

spina bifida multidisciplinary clinic revealed

TC in six patients. Three patients had filum

terminal lipoma, two patients had intraspi-

nal masses (intraspinal dermoid cyst and

intraspinal lipoma, respectively), and one

patient had pilonidal sinus. All six patients

underwent mass resection and TC release

in neurosurgery. Five patients had presacral

mass (5/11, 45.5%); of these, three patients

had a lipomyelomeningocele, one had sacro-

coccygeal teratoma, and one had sacrococ-

cygeal lipoma. Lipoma resection and neural

tube reconstruction was performed in pa-

tients with lipomyelomeningocele. Tumor

resection and TC release were performed

in patients with sacrococcygeal lipoma and

teratoma.

Outcomes of urological evaluation

and treatment

All patients underwent VUDS exami-

nation at 3–12 months after neurosurgery.

(Table II) Six patients underwent both pre-

and post-operative VUDS. Of these, two pa-

Currarino syndrome treatment 107

Vol. 62(2): 103 - 111, 2021

tients who had intermediate-risk bladder on

preoperative VUDS assessment (right grade

III VUR and DLPP 28cm H

O, respectively)

showed low-risk bladder on postoperative

VUDS assessment (resolution of right VUR

and decrease of DLPP to 20 cm H

O, respec-

tively). One patient had preoperative EFP 35

cm H

O with right grade II VUR, which was

classified as high-risk bladder. This patient

had postoperative EFP 44 cm H

O with bilat-

eral VUR (left grade II, right grade III), and

worse postoperative lower urinary tract func-

TABLE I

CHARACTERISTICS OF THE PATIENTS.

No Gender Age at

diagnosis

Sacral

agenesis

ARM Age at

ARM

surgery

Presacral mass Other

malformations

Age at

Neurosurgery

1 F 5 m Ye s Anal atresia 5 m,

2 d

No Pilonidal sinus,

Right solitary

kidney

6 m

2 F 1 d Ye s

Anal atresia

with fistula

2 d

Lipomyelo-

meningocele

Hydrocephalus 3 m

3 M 7 m Ye s Anal atresia 2 d No

Intraspinal

dermoid cyst,

Craniostenosis,

Dextrocardia

with VSD

7 m

4 M 11 m Ye s

Anal atresia

with fistula

1 d No

Intraspinal

lipoma,

Syringomyelia

11 m

5 M 8 m Ye s No No

Sacrococcygeal

lipoma

No 8 m

6 M 13 m Ye s

Anal atresia

with stula

1 d No

Filum terminal

lipoma

13 m

7 F 19 m Ye s

Rectal

stenosis

5 m No

Filum terminal

lipoma

19 m

8 M 7 m Ye s Anal atresia 6m, 1d No

Filum terminal

lipoma

7 m

9 M 6 m Ye s

Hirschsprung

disease

6 m

Lipomyelo-

meningocele

Left duplex

kidney

9 m

10 M 2 m Ye s No No

Sacrococcygeal

teratoma

Polydactyly 2 m

11 M 1 d Ye s Anal atresia

with fistula

3 d Lipomyelo-

meningocele

Left solitary

kidney with

hydronephrosis,

Bilateral

cryptorchidism,

Right radial

deficiency

2 m

ARM: anorectal malformation; m, months; d, days; VSD, ventricular septal defect.

108 Xia et al.

Investigación Clínica 62(2): 2021

TABLE II

UROLOGICAL EVALUATION AND MANAGEMENT.

No VUDS before

neurosurgery

Neurosurgery VUDS after

neurosurgery

Urological

management

Follow-

up(months)

eGFR

(mL/

min/1.73m

)

1 No Spinal cord

untethering

EFP 10 cm

O, Low risk

bladder

RBUS once a year 51 101.7

2 No Lipoma

resection and

neural placode

reconstruction

DLPP 18 cm

O, Low risk

bladder

RBUS once a year 48 123.6

3 EFP 35 cm

O, Right

VUR, High

risk bladder

Dermoid cyst

resection and

Spinal cord

untethering

EFP44 cm

O, Bilateral

VUR, High risk

bladder

CIC +

anticholinergics,

RBUS once every

6 m, VUDS once

a year

42 109.1

4 EFP 5 cm

O, Low

risk bladder

Lipoma resection EFP 11 cm

O, Low risk

bladder

RBUS once a year 36 140.3

5 EFP 14 cm

O, Low

risk bladder

Lipoma resection

and Spinal cord

untethering

EFP 9 cm

O, Low risk

bladder

RBUS once a year 33 102.5

6 EFP 18

cm H

Right VUR,

Intermediate

risk bladder

Filum terminal

transection

EFP 24 cm

O, VUR

disappeared,

Low risk

bladder

RBUS once every

6 m, VUDS once

every 2 y

24 128.1

7 Detrusor

underactivity,

Low risk

bladder

Filum terminal

transection

Detrusor

underactivity,

Low risk

bladder

Urination training,

RBUS once every

6 m, VUDS once

every 2 y

21 129.6

8 No Filum terminal

transection

Detrusor

underactivity,

Low risk

bladder

Urination training,

RBUS once every

6 m, VUDS once

every 2 y

15 109.8

9 No Lipoma

resection and

neural placode

reconstruction

EFP 7 cm

O, Low risk

bladder

RBUS once a year 12 111.3

10 No Teratoma

resection

EFP 12 cm

O, Low risk

bladder

RBUS once a year 12 104.7

11 DLPP 28

cm H

Intermediate

risk bladder

Lipoma

resection and

neural placode

reconstructionn

DLPP 20 cm

O, Low risk

bladder

RBUS once a year 9 93.7

VUDS, video-urodynamics; DLPP, detrusor leak-point pressure; EFP, end-filling pressure, VUR, vesicoureteral reflux;

RBUS, renal and bladder ultrasound.

Currarino syndrome treatment 109

Vol. 62(2): 103 - 111, 2021

tion. This patient was treated with CIC and

an oral anticholinergic drug (oxybutynin). In

the remaining three patients, both pre- and

post-operative VUDS revealed low-risk blad-

der. Five patients had undergone only post-

operative VUDS. Two patients who showed

low detrusor activity, prolonged urination

but less residual urine during urination,

were classified as low-risk bladder group.

Both patients underwent urination train-

ing. VUDS results in the remaining three pa-

tients showed low-risk bladder.

Outcomes of urology follow-up

The follow-up plan for individual pa-

tients was based on the bladder risk (Table

III). The mean follow-up time in the en-

tire cohort was 27.5±14.5 months (range,

9–51). One patient developed febrile urinary

tract infection. No new abnormal manifesta-

tions were detected by ultrasound examina-

tion in any of the patients. One patient had a

left solitary kidney with hydronephrosis and

the symptoms were not aggravated. Renal

function remained normal in all patients.

DISCUSSION

The embryological pathogenesis of CS

was elaborated by Currarino et al. in 1981(1).

In the early embryonic stage, the mesoderm

extends to the tail to surround the notochord

and form the vertebral body. Abnormal adhe-

sions between the endoderm and neuroec-

toderm prevent the fusion of the vertebral

body. Abnormal adhesion between the intes-

tine formed by endoderm and the neural tube

formed by the notochord leads to the main

characteristic malformation of CS. The three

main features of CS may not always manifest

simultaneously. Sacral agenesis (the primary

diagnostic criteria) may occur in combina-

tion with other malformations such as ano-

rectal malformation, urinary malformation,

reproductive system malformation, or ner-

vous system malformation.

In addition to the Currarino triad, we

observed the following malformations in-

volving multiple systems in our cohort. Uri-

nary system malformations: isolated kidney,

hydronephrosis, renal duplication. Nervous

TABLE III

FOLLOW-UP PLAN OF UROLOGY DEPARTMENT.

Multidisciplinary clinic after birth

Medical history, physical examination, spinal MRI, ultrasound

Multidisciplinary assessments in departments of general surgery, neurosurgery,

orthopedics, urology, and imaging.

VUDS examination before and after operation

High-risk bladder Age < 12 m, RBUS after 3 m,

VUDS after 6 m

Occurrence of lower urinary tract

symptoms (such as a febrile urinary

tract infection) during follow-up is an

indication for immediate RBUS. In the

event of detection of a new abnormality

on RBUS, VUDS should be immediately

performed.

Age ≥12 m, RBUS after 6 m,

VUDS after 1 year

Intermediate-risk

bladder

Age < 12 m, RBUS after 3 m,

VUDS after 1 year

Age≥ 12 m, RBUS after 6 m,

VUDS after 2 years

Low-risk and normal

bladder

Age <12 m, RBUS after 6 m,

VUDS after 1 year

Age ≥ 12 m, RBUS after 12 m,

VUDS after 2 years

VUDS, video-urodynamics; RBUS, renal and bladder ultrasound.

110 Xia et al.

Investigación Clínica 62(2): 2021

system malformation: hydrocephalus, cra-

niostenosis, TC, syringomyelia, intraspinal

mass. Limb malformations: absence of ra-

dius, polydactyly. Genital malformations:

cryptorchidism. Cardiovascular malforma-

tions: dextrocardia, ventricular septal de-

fect. Therefore, other factors apart from the

embryological abnormalities might lead to

multiple malformations.

In our study, three patients with CS had

lipomyelomeningocele and postoperative

VUDS assessment revealed low-risk bladder

in all of them. However, long-term follow-

up of bladder function is required. Other

causes of lower urinary tract dysfunction

may include primary or secondary TC, sacral

nerve development defect, intraspinal mass,

sphincter complex injury during anoplasty,

or nerve injury during neurosurgery.

The present study focuses on the urolog-

ical evaluation and management of patients

with CS. Lee et al. retrospectively analyzed

the urinary symptoms and urodynamics be-

fore and after TC release in 14 patients with

CS (6). Pio et al. reported the clinical symp-

toms, imaging findings, and urodynamics

of 16 patients with CS (7). Our study used

VUDS to evaluate the bladder function of pa-

tients with CS. The risk of bladder function

was classified based on the results of VUDS.

According to the severity of bladder risk, we

performed individualized clinical manage-

ment to protect renal function.

In 2007, Joseph developed a risk index

for bladder based on urodynamic assessment

comprising of DLPP, NDO, and DSD (8).

Tarcan et al. proposed that the predictive

sensitivity of DLPP 20 cm H

O for upper uri-

nary tract injury is higher than that of 40 cm

O (10). However, there are several deter-

minants of the risk of upper urinary tract in-

jury in these patients. The bladder risk classi-

fication proposed by Joseph is an important

tool to guide treatment decision-making for

neurogenic bladder. However, the risk rating

does not incorporate the results of imagen

examination. Therefore, we incorporated the

results of imaging examination in the risk

classification of bladder. For grade I to IV

VUR and/or lack of smoothness of the blad-

der wall, the bladder risk increases by one

level. A high-risk bladder should be defined

when V grade VUR occurs.

Based on our experience, we have de-

veloped a comprehensive multidisciplinary

diagnostic, therapeutic, and long-term fol-

low-up plan for these patients (Table III).

We hope that this plan will provide a viable

treatment for CS and all other diseases that

may lead to neurogenic bladder disease.

Some limitations of this study should

be acknowledged. First of all, CS is a rare

disease, since the spina bifida multidisci-

plinary clinic was established in 2014, lim-

ited sample-sized patients with CS have

received standardized and comprehensive

treatment at our center. This low sample

size has limited us to only perform a cross-

sectional study and no analytical assessment

was possible. So, the proposed interpreta-

tions and approaches are concluded qualita-

tively, as there was a huge heterogeneity in

terms of the differences in the disease mani-

festations, surgeries that patients received,

and their urological managements. Sec-

ondly, patients enrolled in the study did not

undergo systematic genetic studies. Thirdly,

the follow-up time of patients in this study

was relatively short, and the function of the

lower urinary tract of patients with CS may

change over time. Therefore, long-term fol-

low-up is necessary. Finally, our study did not

research the lower urinary tract symptoms.

Since most of the patients were too young

to receive systematic urination training, we

were unable to assess the lower urinary tract

symptoms, such as urgency or urinary incon-

tinence. In addition, most of the symptoms

were reported by the parent or the caregiver,

which may have introduced an element of

bias.

We conclude that CS has a complex

phenotype. The diagnosis and treatment ne-

cessitates multidisciplinary collaboration.

Urologists play an important role in protect-

ing renal function, preventing progression

Currarino syndrome treatment 111

Vol. 62(2): 103 - 111, 2021

to end-stage renal disease, and in prolonging

life expectancy. Patients with CS often ex-

hibit sacral nerve development abnormality

or injury to sacral nerves. VUDS assessment

may help detect lower urinary tract dysfunc-

tion before the onset of lower urinary tract

symptoms. A comprehensive urological in-

tervention plan should be formulated based

on the results of VUDS assessment.

ACKNOWLEDGEMENT

General Project of Jiangsu Commission

of Health (Grant No. H2017067), Project of

Suzhou Science and Technology Plan (Grant

No.SYSD2019117).

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O detrusor leak point pres-

sure cut-off reliable for upper urinary tract

protection in children with myelodysplasia?

Neurourol Urodyn 2017;36:759-763.