External sphincter activity and recurrent urinary tract infection in girls

Multi-center randomized controlled trial of cognitive treatment, placebo, oxybutynin, bladder training, and pelvic floor training in children with functional urinary incontinence

OBJECTIVE

Functional urinary incontinence causes considerable morbidity in 8.4% of school-age children, mainly girls. To compare oxybutynin, placebo, and bladder training in overactive bladder (OAB), and cognitive treatment and pelvic floor training in dysfunctional voiding (DV), a multi-center controlled trial was designed, the European Bladder Dysfunction Study.

METHODS

Seventy girls and 27 boys with clinically diagnosed OAB and urge incontinence were randomly allocated to placebo, oxybutynin, or bladder training (branch I), and 89 girls and 16 boys with clinically diagnosed DV to either cognitive treatment or pelvic floor training (branch II). All children received standardized cognitive treatment, to which these interventions were added. The main outcome variable was daytime incontinence with/without urinary tract infections. Urodynamic studies were performed before and after treatment.

RESULTS

In branch I, the 15% full response evolved to cure rates of 39% for placebo, 43% for oxybutynin, and 44% for bladder training. In branch II, the 25% full response evolved to cure rates of 52% for controls and 49% for pelvic floor training. Before treatment, detrusor overactivity (OAB) or pelvic floor overactivity (DV) did not correlate with the clinical diagnosis. After treatment these urodynamic patterns occurred de novo in at least 20%.

CONCLUSION

The mismatch between urodynamic patterns and clinical symptoms explains why cognitive treatment was the key to success, not the added interventions. Unpredictable changes in urodynamic patterns over time, the response to cognitive treatment, and the gender-specific prevalence suggest social stress might be a cause for the symptoms, mediated by corticotropin-releasing factor signaling pathways.

Non-neurogenic elimination disorders in children

Non-neurogenic elimination disorders cover a wide spectrum of lower urinary tract and bowel dysfunctions, observed in the absence of a neurological background or lower urinary tract malformation. We reviewed conditions responsible for incontinence during bladder filling with normal voiding patterns (such as overactive bladder, giggle incontinence, post-void dribbling), and dysfunctional voiding syndromes. Dysfunctional elimination syndrome usually includes detrusor-sphincter dyscoordination, small-capacity overactive bladder or decompensated large poorly contractile bladder, and large-volume post-micturition residuals, occasionally associated with bowel dysfunction. At the most severe end of the spectrum lies the non-neurogenic neurogenic bladder syndrome, characterized by the association of a severe impairment of the upper urinary tract with a dysfunctional elimination syndrome. It must be emphasized that if the term 'non-neurogenic' relates to the absence of a neurological lesion, it is however conceivable that these conditions actually do have an underlying neurological cause that remains to be identified.

Diagnosis and management of urinary incontinence and functional fecal incontinence (encopresis) in children

The ability to maintain normal continence for urine and stools is not achievable in all children by a certain age. Gaining control of urinary and fecal continence is a complex process, and not all steps and factors involved are fully understood. While normal development of anatomy and physiology are prerequisites to becoming fully continent, anatomic abnormalities, such as bladder exstrophy, epispadias, ectopic ureters, and neurogenic disturbances that can usually be recognized at birth and cause incontinence, will require specialist treatment, not only to restore continence but also to preserve renal function. Most forms of urinary incontinence are not caused by an anatomic or physiologic abnormality and, hence, are more difficult to diagnose and their management requires a sound knowledge of bladder and bowel function.

Medical management of vesicoureteral reflux--quiz within the article. Don't overlook placebos

Vesicoureteral reflux (VUR) in children is associated with increased risk of urinary tract infection (UTI). Recurrent UTI in the presence of the VUR is believed to cause renal scarring, which carries a risk of subsequent hypertension, toxemia of pregnancy, and significant renal damage, including end-stage renal disease. The natural history of VUR is to improve or resolve completely with time in most of the patients. The traditional management consists of prompt treatment of UTI, long-term anti-microbial prophylaxis until the VUR resolves, or surgical intervention in those with persistent high grade VUR, recurrent UTI in spite of prophylaxis with anti-microbial agent, allergy to anti-microbial agents, and patient/parent non-compliance with the medical management. Voiding dysfunction and constipation play an important role, and their diagnosis and appropriate management helps reduce the frequency of UTI and promote the resolution of the VUR. Patients with renal scarring need to be monitored for potential complications such as hypertension, proteinuria, and progression of the renal damage. In patients with hypertension and/or proteinuria, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are the drugs of choice, because of their reno-protective properties. Recent studies have revealed that there is no convincing evidence that UTI in the presence of VUR predicts renal injury or that the use of long-term anti-microbial prophylaxis or surgical intervention prevents renal scarring or its progression. However, until proven otherwise by a prospective, placebo-controlled, randomized study, it is advisable to err on the side of caution and consider VUR and UTI risk factors for renal scarring and treat each patient on individual basis.

Diagnosis and management of dysfunctional voiding

PURPOSE OF REVIEW

This review will focus on the diagnosis and management of voiding dysfunction in neurologically and anatomically normal children. The discussion will highlight recent developments and research in the clinical approach as well as the etiology and classification of these disorders.

RECENT FINDINGS

Voiding dysfunction in children encompasses a wide spectrum of clinical entities, recently classified collectively as dysfunctional elimination syndromes. Voiding dysfunction typically presents after toilet training and may originate from behavioral issues that arise around this time in childhood development. The spectrum of disorders includes urge syndrome, dysfunctional voiding with an uncoordination between the detrusor and urinary sphincter, and enuresis. Clinical symptoms may vary from mild incontinence to severe disorders with endpoints of irreversible bladder dysfunction with vesicoureteral reflux, urinary tract infection and resulting nephropathy. Diagnosis relies heavily on a good history and physical examination, but also includes radiologic and urodynamic evaluation. Treatment generally consists of medical therapy, primarily with anticholinergics as well as behavioral therapy to modify learned voiding patterns that contribute to the voiding dysfunction.

SUMMARY

This overview of voiding dysfunction in children outlines the established approaches to its diagnosis and treatment and highlights the most recent developments in the field.

DYSFUNCTIONAL ELIMINATION SYNDROME AS AN ETIOLOGY OF IDIOPATHIC URETHRITIS IN CHILDHOOD

PURPOSE

Idiopathic urethritis (IU) of childhood or urethrorrhagia is a common problem characterized by blood spotting in the underwear between voiding. A clear etiology has not been established and treatments vary. We postulate that idiopathic urethritis is a manifestation of underlying dysfunctional elimination syndrome (DES).

MATERIALS AND METHODS

During a 5-year period we reviewed the records of all children diagnosed with IU in our practice. In total 72 children fit the analysis criteria. There were 68 boys and 4 girls. All children presented with either gross blood per urethra or microhematuria. Children with active infection, immunodeficiency, neurogenic bladder, vesicoureteral reflux, infravesical obstruction, urethral trauma or other genitourinary anomalies were excluded. Evaluation included thorough history and physical examination, urinalysis and urine culture. Renal and bladder ultrasound, voiding cystourethrogram and uroflow/electromyogram/post-void residual volume were obtained in select patients. Study children were divided into 2 cohorts. The first cohort (group 1, 37 patients) was treated with traditional remedies using antibiotics, urinary analgesics and/or anticholinergics. The second cohort (group 2, 35 patients) was treated by bowel and bladder regimens, laxatives when necessary, and biofeedback and/or alpha-blockers when sphincter dyssynergia was identified.

RESULTS

A total of 13 patients in group 1 (35%) had a full response to treatment, 6 (16%) had a partial response and 18 (49%) failed to respond. A total of 29 patients in group 2 (83%) had a full response to treatment, 2 (6%) had a partial response and 4 (11%) had no response. It took an average of 12.1 months to respond fully in group 1, while in group 2 the same full response took an average of 5.2 months. Of the 18 children who crossed over from group 1 to group 2, 15 (83%) had a full response with an average response time of 7.3 months.

CONCLUSIONS

Our data clearly reveal a higher cure rate when children with urethritis are treated according to DES guidelines. IU of childhood is a manifestation of underlying DES and should be treated as such.

Voiding dysfunction in children

The practicing urologist commonly sees children with lower-urinary tract dysfunction who wet or have recurrent urinary tract infections. This article identifies the proposed etiologies of such behavior in children in whom there are no anatomic or neuropathic causes, outlines the approach to evaluating affected children, and describes a stepwise,interdisciplinary approach to treatment.

Voiding habits and wetting in a population of 4,332 Belgian schoolchildren aged between 10 and 14 years

OBJECTIVE

To determine the prevalence of daytime- with/without night-time wetting, in Belgium, in a group of 10 to 14 year old schoolchildren, and to study the voiding habits.

SUBJECTS AND METHODS

A questionnaire of 41 questions was developed and completed by 4,332 parents at home.

RESULTS

Wetting or soiling episodes were reported by a total of 528 (12%) of the children: monosymptomatic nocturnal enuresis by 62 (1%), daytime wetting with/without night-time wetting by 343 (8%), and faecal soiling by 123 (3%). We found significantly more girls in the wetting group, and the capacity to regularly postpone the voiding was significantly lower in this group. Significantly more children had nocturia in the group with wetting.

CONCLUSIONS

Children with daytime wetting with/without night-time wetting have very often bladder-sphincter dysfunctions, which is in turn correlated with recurrent urinary tract infections. Eight percent of the 10 to 12 year old schoolchildren report daytime wetting with/without night-time wetting with some frequency. Surprisingly few parents, especially in the daytime wetting group, searched for medical help. Physicians and paediatricians should be encouraged to be more attentive to wetting in children and initiate discussion about urinary en faecal problems with parents and children.

The role of pelvic-floor therapy in the treatment of lower urinary tract dysfunctions in children

The pelvic-floor is under voluntary control and plays an important role in the pathophysiology of lower urinary tract (LUT) dysfunctions in children, especially of non-neuropathic bladder sphincter dysfunction. The following therapeutic measures can be applied to try to influence the activity of the pelvic-floor during voiding: proprioceptive exercises of the pelvic-floor (manual testing), visualization of the electromyographic registration of relaxation and contraction of the pelvic-floor by a curve on a display (relaxation biofeedback), observation of the flow curve during voiding (uroflow biofeedback), learning of an adequate toilet posture in order to reach an optimal relaxation of the pelvic-floor, an individually adapted voiding and drinking schedule to teach the child to deal consciously with the bladder and its function and a number of simple rules for application at home to increase the involvement and motivation of the child. In children however with persisting idiopathic detrusor instability additional therapeutic measures may be necessary to improve present urologic symptoms (incontinence problems, frequency, urge) and to increase bladder capacity. Intravesical biofeedback has been used to stretch the bladder and seems to be useful in case of sensory urge. Recently a less invasive technique, called transcutaneous electrical nerve stimulation (TENS), has been applied on level of S3 with promising results in children with urodynamicaly proven detrusor instability, in which previous therapies have failed.

Special considerations of the overactive bladder in children

The overactive bladder (OAB) in children is defined as both involuntary detrusor contractions and urethral instability. The development of urinary control plays a key role in its incidence and in our understanding of its pathogenesis. It is seen in a number of conditions but by far is most common among patients with dysfunctional voiding. Urinary infection can be both a cause and an effect of OAB. In some instances, vesicoureteral reflux may result from detrusor overactivity because its successful resolution has been shown to depend on abolition of the hyperactivity. Early diagnosis and appropriate treatment can affect upper urinary tract function and drainage and ultimate bladder function. Recognition is noted via a thorough history and careful physical examination. Urodynamic assessment is indicated in neurologically normal children >5 years old and is combined with a voiding cystourethrogram in boys and a radionuclide cystogram in girls who have a history of recurrent urinary infection. Treatment consists of prophylactic use of anticholinergic agents in patients with neurologic dysfunction, as an early adjunctive measure in boys after ablation of posterior urethral valves, and in children with vesicoureteral reflux. The dose must be carefully titrated in children with cerebral palsy to prevent the appearance of elevated residual urine. Behavioral therapy and biofeedback techniques are effective alternatives to anticholinergic agents for children with dysfunctional voiding.

Neurogenic and non-neurogenic bladder dysfunction

Children with a neurological defect have a clear cause for their bladder dysfunction; however, in neurologically normal children the cause of their incontinence is usually unclear. When no anatomical abnormalities seem to be present a functional problem is generally the cause. This type of incontinence is referred to as 'functional incontinence'. The different forms of bladder and sphincter dysfunction will be discussed and treatment modalities described. As the treatment modalities in children with neuropathic bladders focus on medical and especially surgical options, special attention is paid to new developments in surgical treatment. For those with functional incontinence treatment options are more variable and the new developments are described.

One thousand video-urodynamic studies in children with non-neurogenic bladder sphincter dysfunction

OBJECTIVE

To ascertain the aetiology and epidemiology of non-neurogenic bladder sphincter dysfunction (NNBSD) by assessing the results of prospective video-urodynamic studies (VUD) in 1000 children.

PATIENTS AND METHODS

During a 4-year study period (January 1995 to December 1998) 1000 children prospectively underwent VUD to further define their NNBSD. After a noninvasive screening assessment consisting of a history, voiding diary, clinical examination, urine analysis, ultrasonography and uroflowmetry, those children who would benefit from further VUD were selected. The selection criteria included a history of urinary tract infection (UTI), a small bladder capacity not responding to training, dysfunctional uroflow, ultrasonographic abnormalities and resistance to therapy. During the study period 3500 children were screened for incontinence problems, including monosymptomatic nocturnal enuresis; 1000 of these were selected for VUD (524 boys and 476 girls).

RESULTS

The urodynamic diagnosis was of normal bladder-sphincter function in 62 (6.2%, male : female 44 : 56), urge syndrome in 582 (58%, 58 : 42), dysfunctional voiding in 316 (32%, 49 : 51) and 'lazy bladder' in 40 (4%, 20 : 80). Boys diagnosed with a 'lazy bladder' were younger than those with urge syndrome and dysfunctional voiding. Girls with dysfunctional voiding were younger than those with urge syndrome. The incidence of UTI was significantly higher in girls than in boys; boys with NNBSD had no greater risk for UTI and in girls the general risk was 34%. Only in girls with a lazy bladder was there a significantly higher incidence of UTI (53%). Reflux occurred equally in all groups, with an overall incidence of 15%. The incidence of obstipation was significantly higher in girls with a lazy bladder, and overall was 17%.

CONCLUSION

These results from a large series provide a new insight into the epidemiology and pathophysiology of NNBSD. The age distribution provides evidence against a dysfunctional voiding sequence. The risk of developing UTI in NNBSD is greater only in girls. In children with a lazy bladder the risk is also significantly higher, indicating that residual urine is a greater risk factor than detrusor instability. Urge syndrome and dysfunctional voiding in girls carry the same risk for developing UTI, indicating that bladder instability is a higher risk factor for UTI than detrusor sphincter discoordination. All dysfunctions carry an equal risk for developing secondary reflux. Children with NNBSD have different primary diseases but all have a common risk of incontinence, UTIs, reflux and obstipation.

A 14-year follow-up of conservative treatment for vesico-ureteric reflux

OBJECTIVE

To determine renal function in patients with vesico-ureteric reflux (VUR) during 14 years of conservative treatment (no surgery).

PATIENTS AND METHODS

Sixty patients with VUR were consecutively included between 1981 and 1982. The degree of VUR was determined by conventional voiding cysto-uretherography (VCUG) after 3 months of prophylactic antibiotics. The VUR was grade I-IV, with grades III and IV characterized as high-grade VUR. In all patients, any urinary tract infections and bladder-urethral dysfunction were treated. Renal function and reflux were monitored by renal and bladder scintigraphy using 123I-hippuran and the glomerular filtration rate (GFR) was determined using the plasma clearance of 51Cr-ethylaminediamine tetra-acetic acid.

RESULTS

Of the 60 patients who entered the study, 51 were followed for a mean of 13.7 years; nine patients were lost to follow-up. None of the patients underwent antireflux surgery. All patients were in good health and normotensive (except two with borderline hypertension). Of the 51 patients 21 had low-grade, 21 unilateral high-grade and nine bilateral high-grade reflux. In those with low-grade reflux both the mean renal split function on the most refluxing kidney and the GFR remained stable during the whole monitoring period. Eighteen patients who had a persistent reduction in renal split function or initially had had a significantly reduced functional share to the most refluxing kidney had their GFR re-assessed in adolescence. However, the body surface-corrected GFR remained constant. Total GFR and single kidney GFR increased significantly.

CONCLUSION

A conservative treatment regimen in patients with VUR can ensure stable kidney function, although kidneys with a lower renal function at referral seem to have an impaired functional growth potential.

The dysfunctional voiding scoring system: quantitative standardization of dysfunctional voiding symptoms in children

PURPOSE

Academic research on pediatric nonneurogenic voiding dysfunction has long been hampered by the lack of a standardized reporting system for voiding symptoms. We evaluated the performance of a newly devised, objective instrument to quantify or grade the severity of abnormal voiding behaviors of children.

MATERIALS AND METHODS

There were 10 voiding dysfunction parameters that were assigned scores of 0 to 3 according to prevalence, and possible total scores ranged from 0 to 30. The Dysfunctional Voiding Symptom Score was completed by 2 groups of patients. Group 1 consisted of patients 3 to 10 years old presenting to the pediatric urology clinic with a history of diurnal urinary incontinence, urinary tract infections or abnormal voiding habits. Group 2 consisted of an age matched cohort with no history of urological complaints presenting to hospital clinics outside of urology. Patients diagnosed with organic or anatomical disease, such as posterior urethral valves or meningomyelocele, were excluded from our analysis.

RESULTS

Group 1 consisted of 104 patients (female-to-male ratio 4:1) with a median symptom score of 14 and group 2 consisted of 54 patients (female-to-male ratio 1.3:1) with a median score of 4. The dysfunctional voiding odds ratio was 2.93 for females compared to that of males. Using receiver operating characteristics the optimum cutoff score was 6.026 (sensitivity 92.77% and specificity 87.09%) for females and 9.02 (sensitivity of 80.95% and specificity of 91. 30%) for males. In addition, we found certain questions to be more reflective than others of dysfunctional voiding symptoms in our population.

CONCLUSIONS

The Dysfunctional Voiding Symptom Score appears to provide accurate and objective, that is, numerical, grading of voiding behaviors of children. Comparative research studies of dysfunctional voiding diagnosis and response to therapy as well as objective measurements of treatment efficacy and outcomes analysis should be aided greatly by this system.

Classification and treatment of functional incontinence in children

Functional urinary incontinence in children may be caused by disturbances of the filling phase, the voiding phase or a combination of both. Detrusor overactivity may cause frequency and urgency, with or without urge incontinence. Girls present with symptoms of detrusor overactivity more often than boys, but sometimes other symptoms, e.g. urinary tract infections or constipation, prevail. Frequent contractions of the detrusor may cause the pelvic floor muscles to become overactive, resulting in staccato or fractionated voiding. When incontinence is the result of a voiding disorder the term 'dysfunctional voiding' is used. Bladder function in these children may be normal, but instability may be present. In children with a 'lazy' bladder, voiding occurs with no detrusor contractions, and postvoid residual volumes and overflow incontinence are the main characteristics. Diagnosis is based on the medical and voiding history, a physical examination, bladder diaries and uroflowmetry. The upper urinary tract should be evaluated in children with recurrent infections and dysfunctional voiding (reflux). Uroflowmetry can be combined with pelvic floor electromyography to detect overactivity of the pelvic floor muscles. Urodynamic studies are usually reserved for patients with dysfunctional voiding and those not responding to anticholinergic drugs. Treatment is usually a combination of 'standard therapy', behavioural therapy, bladder training, physiotherapy and medical treatment. The role of alpha-blockers needs to be evaluated further. Also, neuromodulation may have a place in treatment but the exact indications need to be defined. Clean intermittent self-catheterization is sometimes necessary in children with a lazy bladder and large residual volumes who do not respond to a more conservative approach. Future research needs to be directed towards improving understanding of the pathophysiology, epidemiology, classification and treatment modalities of functional incontinence in children.

The office management of recurrent urinary tract infection and vesicoureteral reflux in children

Recurrent urinary tract infections (UTIs) and vesicoureteral reflux are common diagnosis' in infants and children who are referred to a urologist. Recurrent UTIs in these patients can be challenging, especially when radiographic evaluation reveals no structural abnormality. Prophylaxis and correction of voiding and bowel dysfunction are important treatment strategies. Febrile UTIs are commonly associated with reflux and should be treated aggressively to avoid renal scarring and its sequelae. Based on a comprehensive survey of the literature, long-term treatment strategies for children with reflux are now available.

Study of the effect of external urethral sphincter contraction on the mechanical activity of the ureterovesical junction and urinary bladder: recognition of the sphinctero-ureterovesical reflex

OBJECTIVES

To study the effect of external urethral sphincter (EUS) contraction on the urinary bladder and ureterovesical junction (UVJ).

METHODS

The study was comprised of 9 healthy volunteers (7 men, 2 women; mean age 40.8 +/- 6.6 years). A manometric catheter was introduced into each of the two UVJs and urinary bladder. The EUS was made to contract by voluntary squeezing and by electromyographic stimulation with a needle electrode inserted into the sphincter. The response of the bladder and the UVJs to EUS contraction was determined before and after anesthetization of the EUS, bladder, and the two UVJs, each at a different time.

RESULTS

On voluntary squeezing or electromyographic needle stimulation of the EUS, the pressure in both the UVJs and the urinary bladder showed a significant drop (P < 0.05 in both instances). There was no pressure response in the UVJs or in the urinary bladder 10 minutes after separate anesthetization of either the EUS or the UVJs and the bladder; however, 2 hours later, the pressure response was similar to that before anesthesia (P > 0.05).

CONCLUSIONS

Bladder and UVJ relaxation on EUS contraction postulate a reflex relationship that was reproducible and absent on anesthetization of either of the suggested two arms of the reflex: the EUS on one end and the bladder and UVJs on the other end. We call this reflex the "sphinctero-ureterovesical reflex." Further studies are needed to evaluate the possible role of this reflex in the micturition mechanism and disorders.

Urinary tract infections in children. Epidemiology, evaluation, and management

Accurate documentation of UTIs in children is essential for proper evaluation and management. Urine cultures with multiple organisms or colony counts less than 50,000 to 100,000 CFU/ml should be considered suspect and require confirmation, particularly with clean-catch specimens. Children with well-documented UTIs should be evaluated based on their age and presenting symptoms. Infants and young children require imaging, usually with a cystogram and sonogram of the kidneys and bladder. Older girls with febrile UTIs and boys at any age should also be considered for urinary tract imaging. Renal cortical scintigraphy with 99mTc-DMSA has emerged as the imaging study of choice for acute pyelonephritis and renal scarring in children with UTIs. Treatment of UTIs in children ideally commences with culture-specific antimicrobial therapy, although treatment may be started in sick children before culture results are available. Short-course treatment (3-5 days) is sufficient for children with acute uncomplicated lower UTIs. Children with acute pyelonephritis require 10 to 14 days of antibiotics, which can be administered on an outpatient basis in older infants and children who are not toxic, as long as good compliance is expected. Patients with first-time UTIs who require imaging should be maintained on low-dose antibiotic prophylaxis until their workup is completed. Treatment of ABU does not seem necessary if the urinary tract is otherwise normal. Long-term antibiotic prophylaxis is indicated for children with frequent symptomatic recurrences of UTI and for those with known VUR. Diagnosis and treatment of underlying voiding dysfunction and constipation is an essential component of the successful management of UTIs in children.

Historical clues to the complex of dysfunctional voiding, urinary tract infection and vesicoureteral reflux. The International Reflux Study in Children

The prevalence of nonneuropathic bladder/sphincter dysfunction was assessed with a questionnaire in 310 of the 386 children enrolled in the European branch of the International Reflux Study in Children. Despite the exclusion criteria (neuropathic bladder, anatomical malformations other than vesicoureteral reflux and overt dysfunctional voiding or urge incontinence), the prevalence of bladder/sphincter dysfunction was as high as 18%. Four patterns of dysfunction emerged: urge syndrome, staccato voiding, fractionated and incomplete voiding, and voiding postponement. The questionnaire proved helpful in detecting low profile cases of bladder/sphincter dysfunction, as well as indicating the need for further urodynamic studies. A strong correlation was established between recurrences of urinary tract infections, as well as disappearance of vesicoureteral reflux (negative correlation) and nonneuropathic bladder/sphincter dysfunction. This finding implies that detection and treatment of bladder/sphincter dysfunction are essential in every child with the complex of recurrent urinary tract infection and vesicoureteral reflux.

Relationship of voiding dysfunction to urinary tract infection and vesicoureteral reflux in children

A total of 109 children were evaluated for urinary tract infections or for voiding dysfunction without infections. The relationship of voiding dysfunction to urinary infection and vesicoureteral reflux was then examined in girls. The number of males studied was too small for statistical analysis. While 40.6 percent of females with infections had voiding dysfunction, in 66.6 percent of those females having voiding dysfunction infections also developed. Voiding dysfunction was noted in 33.3 percent of females with reflux, probably due to the strong association of reflux and infections. However, all of females with voiding dysfunction, only 20.6 percent also had reflux. These findings were statistically significant (p = 0.01) and suggest that voiding dysfunction is common in girls with infections, perhaps even predisposing to the development of infections. However, voiding dysfunction in this population did not predispose to reflux.

Vesicoureteric reflux and renal injury

Renal injury associated with the intrarenal reflux (IRR) of urine that is either infected, under high pressure, or both, is a major cause of severe hypertension during childhood and adolescence and of chronic renal insufficiency in patients less than 30 years of age. Many, but not all, adolescent and adult patients with reflux nephropathy (RN) give a history of urinary tract infection (UTI) or unexplained fevers in infancy or early childhood, when the kidney is thought to be at greatest risk of injury. Although vesicoureteric reflux (VUR) is observed more commonly in infants than children with UTI, it is rare in uninfected patients at any age and should never be considered a normal finding during human development. Renal scarring may not be obvious in radiographic or radionuclear studies to medical management alone, no definite benefit of one over the other was observed, regardless of the grade of VUR. Moreover, progressive renal injury in scarred kidneys has been noted even after VUR had been corrected, when infection had been prevented, and while hypertension had been controlled satisfactorily. Focal glomerular sclerosis, a lesion found in patients with proteinuria and RN, has been identified not only in scarred kidneys, but also may be seen in contralateral, unscarred kidneys without VUR, which might suggest a humoral factor or, perhaps, a hyperfiltration phenomenon. RN is one of the most frequent causes of end-stage renal disease (ESRD) in children, adolescents, and young adults, which is potentially preventable. However, prevention will depend on early identification of patients at risk--infants and young children after the first UTI and siblings of patients with VUR--aggressive and effective treatment of UTI, minimizing intravesical pressure, and education of patients, parents, and physicians.

Pipemidic acid, a new treatment for recurrent urinary tract infection in small animals

A new chemotherapeutic agent, pipemidic acid, was used to treat 14 dogs and 2 cats with recurrent urinary tract infection caused by multiresistent strains of Escherichia coli and Proteus spp. Bacterial culture of the urine after treatment revealed disappearance of the microorganisms in all patients. It is concluded that pipemidic acid is a promising chemotherapeutic agent for urinary tract infections caused by multiresistant E. coli and Proteus spp., with the condition that bacterial culture during the course of treatment is obligatory.

Bladder-sphincter dysfunction in childhood

While it is obvious that the combination of elevated intravesical pressure, urinary tract infection, and reflux can be devastating to the upper urinary tracts, it has been appreciated only recently that a single mechanism, obstruction due to disorders of vesicourethral function, can produce all three pathologic phenomena in neurologically normal children. Advances in pediatric urodynamics now permit these patients to be recognized and their particular pattern of bladder and sphincter dysfunction to be diagnosed with certainty. Individualized therapy aimed at the underlying functional disturbance is often successful and may make surgical therapy unnecessary.

Voiding dysfunction in children

Superficially, the causes of voiding difficulties in children may seem quite simple, but a thorough understanding of the anatomy physiology and neurology of normal and abnormal lower urinary tract function is necessary in uncovering the etiology of often seemingly siple complaints. An ectopic ureter, neurogenic bladder, urinary tract obstruction, or simple urinary tract immaturity, for example, can all cause a child to present with the complaint of "wetting." A familiarity with all the possible causes of voiding dysfunction is required to distinguish significant from insignificant symptoms. While a "wait and see" attitude often results in the spontaneous resolution of a problem such as simple nocturnal enuresis, the misdiagnosis of a severe disorder, such as urinary outflow obstruction, may permit the insidious development of irreversible renal failure. Our purpose in writing this monograph was not to provide a comprehensive guide to the diagnosis of voiding dysfunction in children, but rather to enhance the clinician's appreciation of the complexity of these problems. Our hope is that the perspective that we have provided will obviate the diagnostic and therapeutic exaggeration of insignificant voiding complaints, while assuring that the presence of significant lesions is not overlooked.