Studies of enuresis. VIII. Detrusor and sphincter instability caused by overactivity of integral voiding reflexes

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.

Effect of intravaginal electrical stimulation on pelvic floor muscle strength

The aim of this study was to evaluate the effect of intravaginal electrical stimulation (IES) on pelvic floor muscle (PFM) strength in patients with mixed urinary incontinence (MUI). Between January 2001 and February 2002, 40 MUI women (mean age: 48 years) were studied. Urge incontinence was the predominant symptom; 92.5% also presented mild stress urinary incontinence (SUI). Selection criteria were clinical history and urodynamics. Pre-treatment urodynamic study showed no statistical differences between the groups. Ten percent of the women in each group had involuntary detrusor contractions. Patients were randomly distributed, in a double-blind study, into two groups. Group G1 (n=20), effective IES, and group G2 (n=20), sham IES, with follow-up at 1 month. The following parameters were studied: (1) clinical questionnaire, (2) examiner's evaluation of perineal muscle strength, (3) objective evaluation of perineal muscle by perineometry, (4) vaginal weight test, and (5) urodynamic study. The IES protocol consisted of three 20-min sessions per week over a 7-week period using a Dualpex Uro 996 at 4 Hz. There was no statistically significant difference in the demographic data of both groups. The number of micturitions per 24 h after treatment was reduced significantly in both groups. Urge incontinence, present in all patients before treatment, was reduced to 15% in G1 and 31.5% in G2 post-treatment. The subjective evaluation of PFM strength demonstrated a significant improvement in G1. Objective evaluation of PFM force by perineometer showed a significant improvement in maximum peak contraction post-treatment in both groups. In the vaginal weight test, there was a significant increase in average number of cone retentions post-treatment in both groups. With regard to satisfaction level, after treatment, 80% of the patients in G1 and 65% of the patients in G2 were satisfied. There was no statistically significant difference between the groups. There was a significant improvement in PFM strength from both effective and sham electrostimulation, questioning the effectiveness of electrostimulation as a monotherapy in treating MUI.

Studies of enuresis. IX. Evidence of a mild form of compensated detrusor hyperreflexia in enuretic children

We studied 41 consecutive enuretic boys and girls by supine cystometry followed by a cystometrogram in the standing position. The micturition stop test was performed on 30 of the 41 patients. The standard cystometrogram proved to be superior to the supine study in detecting stage II (overt) detrusor hyperreflexia. Furthermore, the stop test effectively demonstrated the presence of stage I (compensated) hyperreflexia, a mild degree of detrusor unsubstantiated but assumed to be present in many children with simple enuresis. Stage I detrusor hyperreflexia may now be defined clinically by normal standing and supine cystometrograms, and a positive micturition stop test.

Incontinence of urine due to instability of micturition reflexes. Part II. Pudendal nucleus instability

Overinhibition or underfacilitation of the pudendal nucleus may cause profound involuntary relaxation of the striated muscles of the pelvic floor and perineum, including the "external" striated urethral sphincter. Pudendal nucleus instability may adversely affect urethral closure pressure and preclude a successful voluntary "recovery" effort to limit stress incontinence. It may also result in the involuntary loss of an important source of inhibition to the sacral micturition reflex center, which can lead to detrusor instability. The bilateral reciprocal relationship which exists between the detrusor reflex and the pelvic floor muscle tonus is fundamental to micturition instability syndromes. In this article, the pathophysiology of interaction of pudendal nucleus instability, detrusor reflex instability, and stress is described, and the importance of careful diagnostic evaluation of each case of incontinence is emphasized.

Incontinence of urine due to instability of micturition reflexes: Part I. Detrusor reflex instability

Micturition reflex instability may result from malfunction of the detrusor reflex or instability of the pudendal nucleus which innervates the pelvic floor muscles and external sphincter. Detrusor instability is the result of sacral micturition reflex center (SMRC) hyperexcitability. This may be caused by underinhibition or overfacilitation of the SMRC, and there are both central and peripheral causes of each. Detrusor hypertrophy may invoke chronic overactivity of the detrusodetrusor facilitative reflex causing SMRC overfacilitation. Similarly, distal urethral stricture and/or chronic urethritis causing chronic overactivity of the urethrodetrusor facilitative reflex is a common cause of SMRC overfacilitation. Pathologic relaxation and weakness of the striated muscles of the pelvic floor and perineum resulting in underactivity of the perineodetrusor inhibitory reflex, is a common cause of SMRC underinhibition. In adult women these factors often coexist. Each may predispose to stress-induced detrusor instability and are often seen in association with, or are confused with, true stress incontinence. The distinguishing characteristics of detrusor hypertonicity and detrusor hyperreflexia are reviewed, and the various mechanisms of pseudostress incontinence and of urgency incontinence are discussed in detail.

Childhood enuresis

Enuresis is not a disease, but rather a benign clinical disorder that is very common in young children. In considering the many facets of enuresis, physicians caring for children with this disorder should always remember the dictum "Primum non nocere". Most children with enuresis will be found to have primary enuresis, that is, no organic disease or psychopathology will be found. Physicians should proceed cautiously and should avoid costly, harmful and unnecessary workups. Treatment of few disorders is more dependent on the art and skill of clinical medicine than that of childhood enuresis. All of the physician's talents and compassionate nature enter into the proper evaluation of and therapy for this disorder. Physicians must keep in mind the high spontaneous cure rate. This factor alone should encourage them to be extremely optimistic about the outcome of enuresis in their pateints.