Treatment of daytime urinary incontinence: A standardization document from the International Children's Continence Society

Management and treatment of nocturnal enuresis-an updated standardization document from the International Children's Continence Society

BACKGROUND

Enuresis is an extremely common condition, which, although somatically benign, poses long-term psychosocial risks if untreated. There are still many misconceptions regarding the proper management of these children.

AIM

A cross-professional team of experts affiliated with the International Children's Continence Society (ICCS) undertook to update the previous guidelines for the evaluation and treatment of children with enuresis.

METHODS

The document used the globally accepted ICCS terminology. Evidence-based literature served as the basis, but in areas lacking in primary evidence, expert consensus was used. Before submission, a full draft was made available to all ICCS members for additional comments.

RESULTS

The enuretic child does, in the absence of certain warning signs (i.e., voiding difficulties, excessive thirst), not need blood tests, radiology or urodynamic assessment. Active therapy is recommended from the age of 6 years. The most important comorbid conditions to take into account are psychiatric disorders, constipation, urinary tract infections and snoring or sleep apneas. Constipation and daytime incontinence, if present, should be treated. In nonmonosymptomatic enuresis, it is recommended that basic advice regarding voiding and drinking habits be provided. In monosymptomatic enuresis, or if the above strategy did not make the child dry, the first-line treatment modalities are desmopressin or the enuresis alarm. If both these therapies fail alone or in combination, anticholinergic treatment is a possible next step. If the child is unresponsive to initial therapy, antidepressant treatment may be considered by the expert. Children with concomitant sleep disordered breathing may become dry if the airway obstruction is removed.

Complete resolution of urinary incontinence with treatment improved the health-related quality of life of children with functional daytime urinary incontinence: a prospective study

Background

To assess the health-related quality of life (HRQOL) of children with daytime urinary incontinence (DUI) based on pre- and post-treatment self-reports and parent proxy-reports.

Methods

The study population comprised 117 children with at least one episode of DUI per week and their caregivers as well as 999 healthy children (control group). The Pediatric Quality of Life Inventory 4.0 (PedsQL) questionnaire was administered to assess the HRQOL of children. To assess the degree of improvement in HRQOL, we categorized children into two groups: group A achieved complete response (CR) to treatment within 12 months and group B did not achieve CR within 12 months. CR was defined as the complete resolution of symptoms or alleviation of symptoms to < 1 DUI episode/month.

Results

Valid responses were collected from 84 children [53 boys and 31 girls; mean age: 7.9 ± 1.5 years (range, 6–12)]. Sixty-two patients (73.8%) were classified into group A and 22 (26.1%) into group B. Based on self-reports, significant post-treatment improvement was observed in the scores of all PedsQL items (mean total score: 82.2 ± 11.3 vs. 87.2 ± 9.8; P = 0.003). Group A showed significant improvement in the scores of all PedsQL items after achievement of CR based on child self-reports; however, this was improvement not observed in group B.

Conclusions

To the best of our knowledge, this is the first study to demonstrate the complete resolution of DUI with treatment for improving the HRQOL of these children.

"Posterior Tibial Nerve" or "Tibial Nerve"? Improving the reporting in health papers

AIMS

The primary objective of this study is to identify which term is the most appropriate to use according to anatomical nomenclature: "posterior tibial nerve" or "tibial nerve." Furthermore, this paper intends to show how the use of these terms in papers indexed in important health databases is numerous and to describe the anatomical characteristics of such nerve, to improve future scientific publications.

METHODS

This is a descriptive study about the importance of standardizing the use of the terms "posterior tibial nerve" and "tibial nerve" and its anatomy. It comprises three phases: the first is a search in the main databases to identify the use of the terms "posterior tibial nerve" and "tibial nerve." The second phase refers to the consultation of international anatomical terminology to identify the most appropriate term to refer to the nerve, while the third phase is related to the study of the anatomy of this nerve.

RESULTS

The term "tibial nerve" is more commonly used, but the use of the term "posterior tibial nerve" is still very substantial. According to international anatomical terminology, the correct term is "tibial nerve," which is a branch of the sciatic nerve.

CONCLUSIONS

"Tibial nerve" is the term standardized by international anatomical terminology. The use of terms in accordance with Terminologia Anatomica is important to facilitate the process of teaching and learning, as well as to improve the reporting and interpretation of papers regarding health, and the evidence-based clinical practice.

Urotherapy in the treatment of children and adolescents with bladder and bowel dysfunction: a systematic review

OBJECTIVE

To identify and describe the protocols and clinical outcomes of urotherapy interventions in children and adolescents with bladder bowel dysfunction.

METHOD

Systematic review carried out in June 2018 on Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL),Excerpta Medica dataBASE (EMBASE), Scientific Electronic Library Online (SciELO), Cochrane Library, and PsycInfo databases. Clinical trials and quasi-experimental studies carried out in the last ten years in children and/or adolescents with bladder and bowel symptoms and application of at least one component of urotherapy were included.

RESULTS

Thirteen clinical trials and one quasi-experimental study were included, with moderate methodological quality. The heterogeneity of the samples and of the methodological design of the articles prevented the performance of a meta-analysis. The descriptive analysis through simple percentages showed symptom reduction and improvement of uroflowmetry parameters. The identified urotherapy components were: educational guidance, water intake, caffeine reduction, adequate voiding position, pelvic floor training, programmed urination, and constipation control/management.

CONCLUSION

This review indicates positive results in terms of symptom reduction and uroflowmetry parameter improvement with standard urotherapy as the first line of treatment for children and adolescents with bladder bowel dysfunction. It is recommended that future studies bring contributions regarding the frequency, number, and time of urotherapy consultations.

Pelvic floor rehabilitation in children with functional LUTD: does it improve outcome?

INTRODUCTION

If children do not experience satisfactory relief of lower urinary tract dysfunction (LUTD) complaints after standard urotherapy is provided, other treatment options need to be explored. To date, little is known about the clinical value of pelvic floor rehabilitation in the treatment of functional voiding disorders.

OBJECTIVE

Therefore, we compared pelvic floor rehabilitation by biofeedback with anal balloon expulsion (BABE) to intensive urotherapy in the treatment of children with inadequate pelvic floor control and functional LUTD.

STUDY DESIGN

A retrospective chart study was conducted on children with functional incontinence and inadequate pelvic floor control. All children referred for both intensive inpatient urotherapy and pelvic floor rehabilitation between 2010 and 2018 were considered for inclusion. A total of 52 patients were eligible with 25 children in the group who received BABE before inpatient urotherapy, and 27 children in the group who received BABE subsequently to urotherapy. Main outcome measurement was treatment success according to International Children's Continence Society criteria measured after treatment rounds and follow-up.

RESULTS

Baseline characteristics demonstrate no major differences between the BABE and control group. There was a significant difference in improvement between BABE and inpatient urotherapy after the first and second round of treatment (round 1: BABE vs urotherapy; 12% vs 70%, respectively, round 2: urotherapy vs BABE; 92% vs 34%, respectively, both P < .001). In both cases, the urotherapy group obtained greater results (Fig. 1). When the additional effect of BABE on urotherapy treatment is assessed, no significant difference is found (P = .355) in the children who received BABE; 30 (58%) showed improvement on pelvic floor control.

DISCUSSION

Our findings imply that training pelvic floor control in combination with inpatient urotherapy does not influence treatment effectiveness on incontinence. Intensive urotherapy contains biofeedback by real-time uroflowmetry; children receive direct feedback on their voiding behaviour. Attention offered to the child and achieving cognitive maturity with corresponding behaviour is of paramount importance. It is known that combining several kinds of biofeedback does not enhance the outcome. However, our results do not provide a conclusive answer to the effectiveness of pelvic floor physical therapy in the treatment of children with LUTD because we specifically investigated BABE.

CONCLUSION

In this study, we could not prove that pelvic floor rehabilitation by BABE has an additional effect on inpatient urotherapy on incontinence outcomes. Considering the invasive nature of BABE, the use of BABE to obtain continence should therefore be discouraged.

SENS-U: clinical evaluation of a full-bladder notification - a pilot study

INTRODUCTION

Urinary incontinence is one of the most commonly treated disorders in children at school age. Recently, a new, wearable bladder sensor became available, the SENS-U Bladder Sensor. The SENS-U is a small, wireless ultrasonic sensor, which continuously monitors the bladder filling and provides a personalized notification when it is time to go to the toilet. In this study, the aim was to examine the performance of the SENS-U as a full-bladder-based notification system in children during daily life activities.

PATIENTS AND METHODS

In this pilot study, children (6-16 years) who were admitted for an inpatient bladder training were included. Parallel to one training day, the child would wear the SENS-U to estimate the bladder filling and it informed the child when the bladder was almost full. When the child received a full-bladder notification, the child was taught to inform the urotherapist/researcher, in order to determine the level of response.

RESULTS

Fifteen patients (boys/girls: 7/8; mean age: 11.5 ± 1.7 years) were included. Based on a personalized volume-based threshold, the SENS-U notified these children of a full bladder with a median notification rate of 92.9%. In the remaining cases, children voided before the threshold was reached (e.g. defecation). Children responded positively to the notification of the SENS-U, resulting in a median level of response equal to 100%.

CONCLUSION

The SENS-U was able to monitor the natural bladder filling accurately during activities of daily living and provided a personalized notification to the children when it was almost time to go to the toilet. Future research will focus on investigating the efficacy of the SENS-U compared to daily clinical practices.

Traditional Biofeedback vs. Pelvic Floor Physical Therapy-Is One Clearly Superior?

PURPOSE OF REVIEW

Pelvic floor physical therapy is a worldwide accepted therapy that has been exclusively used to manage many pelvic floor disorders in adults and children. The aim of this review is to suggest to clinicians an updated understanding of this therapeutic approach in management of children with non-neuropathic voiding dysfunction.

RECENT FINDINGS

Today, pelvic floor muscle training through biofeedback is widely used as a part of a voiding retraining program aiming to help children with voiding dysfunction which is caused by pelvic floor overactivity. Biofeedback on its own, without a pelvic floor training component, is not an effective treatment. Biofeedback is an adjunct to the pelvic floor training. In the current review, we develop the role of pelvic floor physical therapy in management of children with non-neuropathic voiding dysfunction and compare it with biofeedback therapy alone.

The Diagnosis and Treatment of Enuresis and Functional Daytime Urinary Incontinence

BACKGROUND

Elimination disorders in childhood are common and treatable. Approximately 10% of 7-year-olds wet the bed at night, and 6% are affected by incontinence during the daytime. Two main types of disturbance are distinguished: nocturnal enuresis and functional (i.e., non-organic) daytime urinary incontinence. Each type contains a wide variety of subtypes. Effective treatment requires precise identification of the subtype of elimination disorder.

METHODS

This review is based on a selection of current publications, including principally the German S2k-AWMF guideline and the recommendations of the International Children's Continence Society (ICCS).

RESULTS

Diagnostic assessment focuses on the clinical picture, is non-invasive, and can be carried out in most health care settings. If the child is suffering from multiple types of elimination disorder at once, then fecal incontinence or constipation is treated first, daytime urinary incontinence next, and enuresis last. 20-50% of children with elimination disorders have a comorbid mental disorder that also needs to be treated. With standard urotherapy, 56% of patients with daytime urinary incontinence become dry within a year. This conservative, symptom-oriented approach consists of educating the patient and his or her parents to promote behavior changes with respect to drinking and micturition. Elements of specific urotherapy are provided only if indicated. For enuresis, the treatment of first choice is alarm therapy, with which 50-70% of the affected children become dry. Pharmacotherapy, e.g., with desmopressin, can be a helpful adjunctive treatment. In intractable cases, training techniques have been found useful.

CONCLUSION

Childhood elimination disorders can be treated effectively after targeted diagnostic evaluation and the establishment of specific indications for treatment. In view of the emotional distress these disorders cause, the associated physical and mental disturbances, and their potential persistence into adolescence, they should be evaluated and treated in affected children from the age of five years onward.

Does a serious game increase intrinsic motivation in children receiving urotherapy?

INTRODUCTION

Urotherapy is considered the treatment of choice for children suffering daytime urinary incontinence (DUI). Urotherapy intends to improve bladder dysfunction for children with DUI. For children with refractory DUI, an intensive inpatient bladder training program exists, which focuses on relearning, concentration on, and awareness of the bladder. Children's motivation and adherence are key determinants of a successful training outcome. It is hypothesized that motivation endurance throughout the treatment process may be enhanced by a serious game training tool, which could make the training more appealing and rewarding.

OBJECTIVE

The study explores intrinsic motivation in children receiving bladder training for DUI and whether using a serious game improves their intrinsic motivation.

STUDY DESIGN

In this pragmatic study, 50 children were allowed to choose among receiving bladder training with (intervention group) or without the application of a serious game (control group). At 4, 8, and 12 weeks of training, children and parents were asked to complete the Intrinsic Motivation Inventory (IMI). Children also completed the Pediatric Urinary Incontinence Quality of Life Tool (PinQ) before the start of the training and 6 months thereafter. At 6-month follow-up, patients were ask to participate in two focus groups, wherein the children discussed how they used the serious game and which improvements they would prefer.

RESULTS

Children who received standard bladder training with the addition of a serious game did not differ in terms of intrinsic motivation from children who underwent standard bladder training only. Training results were equal in both the groups, with 80% good or improved. Incontinence-related quality of life (QoL) improved accordingly.

DISCUSSION

In contrast to the study expectations, this game did not increase intrinsic motivation. Findings on training and QoL results are consistent with those of previous studies in both interventions. Although a randomized design could have yielded more valid results than this preference-based approach, the latter is more congruent with clinical practice. In contrast to existing bladder diary apps, this game offers a combination of child-friendly instructions, explanation of bladder (dys)function, and keeping a bladder diary. Mobile devices are playing an increasingly important role in health care; therefore, an urotherapy app can be a complementary therapeutic tool.

CONCLUSION

Most children find it attractive to combine bladder training with a serious game. However, no added value was found regarding intrinsic motivation and training results. All children with persistent DUI in this cohort were highly motivated to complete an intensive bladder training program.

Diagnosis and management of bladder bowel dysfunction in children with urinary tract infections: a position statement from the International Children's Continence Society

BACKGROUND

We present a consensus view from the International Children's Continence Society (ICCS) on the evaluation and management of bladder bowel dysfunction (BBD) in children with urinary tract infection (UTI). The statement aims to highlight the importance of BBD in the development and recurrence of childhood UTI and its management to reduce its associated morbidity and sequelae.

METHODS

A systematic literature search was done on PubMed, Embase, and Scopus databases until August 15, 2016. Relevant publications concerning BBD and its relationship with UTI among children were reviewed and aggregated for statements of recommendation. Discussion by the ICCS Board and a multi-disciplinary core group of authors resulted in a document available on its website for all ICCS members to review. Insights and feedback were considered with consensus and agreement reached to finalize this position statement.

RESULTS

BBD in children with UTI is summarized. Details regarding epidemiology, pathophysiology, and recommendations for general and family practitioners and pediatricians relating to the evaluation and management of this condition are presented.

CONCLUSIONS

This document serves as the position statement from ICCS, based on literature review and expert opinion providing our current understanding of BBD in children with UTI.

Enuresis Management in the Primary Care Pediatrics Clinic

Enuresis is a frequent complaint not always volunteered by parents or patients. The pediatric clinician has to inquire about enuresis to break the secrecy surrounding this symptom that could be related to a more serious underlying renal, endocrine, or psychosocial disease. Determining the type of enuresis is crucial to offer optimal treatment. We present a review for the pediatric clinician to optimize their care of the child with monosymptomatic enuresis. [Pediatr Ann. 2018;47(10):e390-e395.].

Standard urotherapy as first-line intervention for daytime incontinence: a meta-analysis

According to the International Children's Continence Society (ICCS) guidelines for the treatment of daytime urinary incontinence (DUI) in children and adolescents, the first-line intervention for all types of DUI is standard urotherapy (SU). Despite this recommendation there is still no meta-analysis available on the effectiveness of SU. The aim of this study is to provide a meta-analytic evaluation of the intervention. This meta-analysis is based on Odds Ratios (OR) and consists of 26 patient samples out of 19 studies (N = 1609), collected from well-established medical databases. Remission rates after SU are compared to spontaneous remission rates, which are matched to the individual follow-up period. The meta-analysis shows that SU is an effective treatment of DUI. Compared to a spontaneous remission rate of 15.40% per year, urotherapy increases the probability to recover by a factor of 7.27 (6.57 if corrected for publication bias). After exclusion of three outlying samples this effect can be generalized for all types of SU and all patient populations. Moderator analyses cannot identify variables which significantly influence the variance of effect sizes. However, RCTs seem to be associated with lower effects, even when the control group is not considered for effect size calculation. Based on the present meta-analysis, SU is an effective intervention for treating DUI in children and adolescents. Of 100 patients in 1 year, approximately 56 patients (54 if corrected for publication bias) remit after being treated with SU, while only 15 out of 100 remit spontaneously. However, to further quantify the effect size of SU in comparison to spontaneous remission rates and other treatments, additional RCTs are still needed.

Clinical management of nocturnal enuresis

Nocturnal enuresis (NE) is a common health problem. Approximately 10% of 7-year-old children wet the bed regularly during sleep. Enuresis can be categorized into monosymptomatic (MEN) and nonmonosymptomatic (NMEN) forms. MEN occurs without any other symptoms of bladder dysfunction. NMEN is associated with dysfunction of the lower urinary tract with or without daytime incontinence. The rate of comorbid gastrointestinal, behavioral, and emotional disorders is elevated depending upon the subtype of NE. A careful clinical history is fundamental to the evaluation of enuresis. Diagnostic procedures include medical history and psychological screening with questionnaires, bladder and bowel diary, physical examination, urinalysis, ultrasound, and examination of residual urine. The mainstay of treatment is urotherapy with information and psychoeducation about normal lower urinary tract function, the underlying cause of MEN, disturbed bladder dysfunction in the child with NMEN and instructions about therapeutic strategies. Alarm therapy and the use of desmopressin have been shown to be effective in randomized trials. Children with NMEN first need treatment of the underlying daytime functional bladder problem before treatment of nocturnal enuresis. In patients with findings of overactive bladder, besides urotherapy, anticholinergic drugs may be useful.

Is there "brain OAB" and how can we recognize it? International Consultation on Incontinence-Research Society (ICI-RS) 2017

AIMS

In light of mounting evidence supporting the association of brain regions with the control of urine storage and voiding, the high placebo effect in OAB studies as well as certain anecdotal observations from clinical practice with OAB patients, the role of the brain in OAB was explored.

METHODS

At the ICI-RS 2017 meeting, a panel of Functional Urologists and Basic Scientists presented literature data generating a proposal to discuss whether there is "brain OAB" and how we could recognize it.

RESULTS

Existing data point toward organic brain causes of OAB, in particular concerning white matter disease (WMD) and aging, but with currently speculative mechanisms. Imaging techniques have revealed connectivity changes between brain regions which may explain brain-peripheral interactions in OAB patients, further to acknowledged structural and functional changes in the central nervous system (CNS). Furthermore, psychological disorders like stress and depression have been identified as causes of OAB, with animal and human studies proposing a neurochemical and neuroendocrine pathophysiological basis, involving either the serotoninergic system or the hypothalamic-pituitary-adrenal axis. Finally, childhood data suggest that OAB could be a developmental disorder involving the CNS, although childhood OAB could be a different condition than that of adults in many children.

CONCLUSIONS

Future research should aim to identify the pathogenesis of WMD and the aging processes affecting the brain and the bladder, with possible benefits in prevention strategies, as well as connectivity disorders within the CNS, the pathophysiology of OAB in childhood and the neurochemical pathways connecting affective disorders with OAB.

Recent advances in pharmacological management of urinary incontinence

Lower urinary tract symptoms-in particular, storage disorders (for example, urinary incontinence) as well as bladder underactivity-are major health-related problems that increase with age. Yet lower urinary tract symptoms remain under-diagnosed and poorly managed, and incontinence has been cited as the major reason for institutionalization in elderly populations and is one of the most common conditions in primary care practice. Although lifestyle and behavior therapy has been used as a useful treatment regimen for urge incontinence, medications (often used as adjunct) can provide additional benefit. This review will include current therapies used for treatment of urinary incontinence.

Transcutaneous Electrical Nerve Stimulation Combined with Oxybutynin is Superior to Monotherapy in Children with Urge Incontinence: A Randomized, Placebo Controlled Study

PURPOSE

We evaluated whether combination therapy with transcutaneous electrical nerve stimulation and oxybutynin results in a superior treatment response compared to either therapy alone in children with urge incontinence.

MATERIALS AND METHODS

In this placebo controlled study 66 children with a mean ± SD age of 7.3 ± 1.6 years who were diagnosed with urge incontinence were randomized to 3 treatment groups. Group 1 consisted of 22 children undergoing transcutaneous electrical nerve stimulation plus active oxybutynin administration. Group 2 included 21 children undergoing active transcutaneous electrical nerve stimulation plus placebo oxybutynin administration. Group 3 consisted of 23 children undergoing active oxybutynin administration plus placebo transcutaneous electrical nerve stimulation. The children received active or placebo transcutaneous electrical nerve stimulation over the sacral S2 to S3 outflow for 2 hours daily in combination with 5 mg active or placebo oxybutynin twice daily. The intervention period was 10 weeks. Primary outcome was number of wet days weekly. Secondary outcomes were severity of incontinence, frequency, maximum voided volume over expected bladder capacity for age, average voided volume over expected bladder capacity for age and visual analogue scale score.

RESULTS

Combination therapy was superior to oxybutynin monotherapy, with an 83% greater chance of treatment response (p = 0.05). Combination therapy was also significantly more effective than transcutaneous electrical nerve stimulation monotherapy regarding reduced number of wet days weekly (mean difference -2.28, CI -4.06 to -0.49), severity of incontinence (-3.11, CI -5.98 to -0.23) and daily voiding frequency (-2.82, CI -4.48 to -1.17).

CONCLUSIONS

Transcutaneous electrical nerve stimulation in combination with oxybutynin for childhood urge incontinence was superior to monotherapy consisting of transcutaneous electrical nerve stimulation or oxybutynin, although the latter only reached borderline statistical significance. Furthermore, transcutaneous electrical nerve stimulation was associated with a decreased risk of oxybutynin induced post-void residual urine greater than 20 ml.

Overactive bladder in children

Overactive bladder (OAB) is a highly prevalent disorder in the pediatric population. This condition is especially troublesome for pediatric patients and their families when associated with incontinence, since it negatively affects self-esteem and impairs children's development. From the patient's perspective, urgency and urge incontinence can have a significant impact, negatively affecting their quality of life. For a therapy to have true benefit, changes must not only be statistically significant, but must also be perceived as meaningful by the patient. A stepwise approach is favoured to treat this pathology, starting with behavioural therapy, followed by medical management, and eventually more invasive procedures. Antimuscarinic agents are the mainstay of medical treatment for OAB. Oxybutynin is the most commonly used antimuscarinic in the pediatric population. However, some patients have a suboptimal response to antimuscarinics and many experience bothersome side effects, which have been documented with all antimuscarinics to a significantly higher degree than placebo. Although there have been reports about the use of tolterodine, fesoterodine, trospium, propiverine, and solifenacin in children, to date, only oxybutynin has been officially approved for pediatric use by medical authorities in North America. This review will address alternative treatment options for pediatric patients presenting with OAB, from conservative measures to more invasive therapies.

Refractory Urinary Incontinence in Girls: The Role of the Bladder Neck

BACKGROUND

Prevalence of lower urinary tract dysfunction (LUTD) in children is between 6 and 9% with urinary incontinence (UI) being one of the most common symptom.

VARIOUS ASPECTS OF LOWER URINARY TRACT SYMPTOMS LUTS

Anatomical anomalies of the urinary tract as well as neurogenic underlying pathology can results in LUTS. Comorbidities and long-term consequences of the LUTD for the female patients as well as genetic issues are also briefly discussed.

THE ROLE OF THE BLADDER NECK

Thanks to urodynamics, we have learnt a lot about the lower urinary tract function, but the role of the bladder neck in the pathophysiology of LUTS in children is not clear. Secondary bladder neck hypertrophy is a well-described pathology, but there is no standardized treatment for this phenomenon. Primary bladder neck dysfunction has already been defined by the International Children's Continence Society.

REFRACTORY UI IN GIRLS

Uniform diagnostic protocols are used in these girls with UI. Treatment consists of standard urotherapy, additional interventions, and pharmacotherapy in selected cases. Those with refractory UI require careful reassessment to look for the unrecognized disorders. Invasive urodynamics should be done in those patients. Ultrasound of the bladder neck region and the pelvic floor can be helpful, but its interpretation is very subjective. In a small group bladder neck insufficiency can be found and those might benefit from a surgical intervention.

FUTURE PERSPECTIVE

Strict criteria of the bladder neck insufficiency in children must be defined. Early surgical intervention in girls with bladder neck insufficiency might reduce the long period of intensive conservative treatment.