Reflux and voiding abnormalities in children

Endoscopic treatment with stabilized nonanimal hyaluronic acid/dextranomer gel is effective in vesicoureteral reflux associated with bladder dysfunction

PURPOSE

Endoscopic injection of stabilized nonanimal hyaluronic acid/dextranomer gel is an established treatment for vesicoureteral reflux in children. We performed a subgroup analysis to assess this treatment in reflux associated with bladder dysfunction.

MATERIALS AND METHODS

Of 308 consecutive children treated endoscopically with stabilized nonanimal hyaluronic acid/dextranomer gel for dilating vesicoureteral reflux 54 were observed retrospectively to have bladder dysfunction. Initial followup consisted of voiding cystourethrogram at 3 and 12 months after injection, with positive response defined as reflux grade 0 or I. At 7 to 12 years following treatment patient charts were checked for urinary tract infections and bladder dysfunction, and a followup survey (postal questionnaire) was administered.

RESULTS

A positive response to therapy (cure) was observed in 45 children (83%) after 1 to 3 endoscopic treatments. Concurrently, bladder dysfunction had resolved in 32 patients (59%). After the last stabilized nonanimal hyaluronic acid/dextranomer gel implantation 45 patients (83%) were free of urinary tract infections. Questionnaire results were similar to chart based findings. Stabilized nonanimal hyaluronic acid/dextranomer gel implantation was well tolerated, with no associated complications.

CONCLUSIONS

Endoscopic treatment with stabilized nonanimal hyaluronic acid/dextranomer gel appears to be similarly effective in patients with vesicoureteral reflux with and without bladder dysfunction. These data indicate that bladder dysfunction should not be considered a contraindication to endoscopic treatment for reflux.

Treatment of Bladder Dysfunction and High Grade Vesicoureteral Reflux Does Not Influence the Spontaneous Resolution Rate

PURPOSE

We investigated whether the treatment of bladder dysfunction in infants with congenital high grade vesicoureteral reflux could influence the spontaneous resolution rate of the reflux and the number of recurrent urinary tract infections.

MATERIALS AND METHODS

A total of 115 infants with high grade vesicoureteral reflux were included in a followup study of bladder function and reflux resolution between 1993 and 1999. The present study deals with 20 of these infants with mainly grade V reflux, most of whom had recurrent urinary tract infections in combination with high post-void residual and high bladder capacity. Treatment with clean intermittent catheterization was instituted during infancy in these 20 patients and continued until a median age of 4 years.

RESULTS

Bladder capacity was high at presentation and at all followup investigations in the clean intermittent catheterization treated group. Moreover, residual urine was high at presentation and especially between ages 1 and 2 years. However, after bladder control was achieved this residual decreased and consisted mainly of reflux urine. In only 1 girl did reflux resolve spontaneously during the 4-year followup period. A total of 18 patients were treated surgically at the end of this period, and clean intermittent catheterization could be stopped a few months later in all but 2. Urinary tract infection recurrences were uncommon after the institution of treatment.

CONCLUSIONS

The treatment of bladder dysfunction characterized by a high capacity bladder with poor emptying in infants with congenital high grade reflux does not influence the rate of spontaneous resolution. On the other hand, the tendency toward recurrent urinary tract infections appears to decrease with treatment.

[Efficacy in endoscopic treatment of secondary vesicoureteral reflux with polydimethylsiloxane]

OBJECTIVE

To value the efficacy in endoscopic treatment of the vesicoureteral reflux (VUR).

MATERIAL AND METHOD

We have realized a prospective study in patients with RVU treated with endoscopic polydimethylsiloxane, from January 1999 until December 2001, analyzing the results after an average pursuit of 30 months. We included 144 patients, 92 girls and 52 children, with 213 VUR (124 primary ones and 89 of secondary etiology). The initial efficacy of the treatment was defined as the finished absence of RVU in the isotopic cystography, realized three months after the puncture.

RESULTS

The global efficacy of the endoscopic treatment in secondary etiology reflux was lower than the reached one in the treatment of the primary RVU (77.7% against 86.2%) but the differences did not reach statistical significance (p=0,226). We do not also find significant differences on having compared the injected volume and the valuation of resolution of the ebb between the different causes of secondary RVU (p=0.361). We found recurrence in patients with RVU due to lower urinary tract dysfunction (4.34%).

CONCLUSIONS

Endoscopic treatment of the secondary VUR is a minimally invasive skill, presents scarce morbidity and it is effective in chosen patients. The risk of a long term recurrence is grater in VUR secondary to functional alterations (neurogenic bladder and functional instability), for what, pursuit has to be established according to the base pathology.

Endoscopic treatment with polydimethylsiloxane in children with dilating vesico-ureteric reflux

OBJECTIVE

To report our experience of treating dilating vesico-ureteric reflux (VUR) in children, using an injectable form of polydimethylsiloxane (Macroplastique, MPQ; Uroplasty BV, Geleen, The Netherlands), as medical treatment for moderate or severe VUR is associated with a high proportion of persistence or development of new scars.

PATIENTS AND METHODS

The study included 32 children (40 ureters) with VUR; 13 (32%) were grade III, 20 (50%) grade IV and seven (18%) grade V. They were treated over a period of 42 months, 66% for some form of bladder dysfunction and 38% had associated diseases. The main indications were VUR grade, recurrent urinary tract infection and progression of reflux nephropathy. MPQ was injected under general anaesthesia via an 11 F cystoscope, x 30 objective, with a 5 F working channel.

RESULTS

The mean (sd) follow-up was 28.5 (10.2) months; VUR resolved in 80% of patients and improved to minimal VUR in the remaining 20%. The resolution/improvement rate was 72% after the first injection, 97% after the second and 100% after the third. There were no significant complications.

CONCLUSION

The endoscopic implantation of MPQ always corrected VUR even though 68% of the cases were grade IV-V. It should become the treatment of choice for severe VUR.

Use of the dysfunctional voiding symptom score to predict resolution of vesicoureteral reflux in children with voiding dysfunction

PURPOSE

Dysfunctional voiding influences the presence and persistence of vesicoureteral reflux. We used a standardized published instrument, the dysfunctional voiding symptom score, to evaluate the association of dysfunctional voiding with vesicoureteral reflux. We report its use for monitoring improvement in and resolution of vesicoureteral reflux.

MATERIALS AND METHODS

In 1998, 114 patients with dysfunctional voiding were placed on behavioral modification. Of 58 patients (51%) who presented with urinary tract infection 27 (47%) had abnormal voiding cystourethrography, including 19 with reflux only. Baseline and followup dysfunctional voiding symptom score was determined in these 19 patients, who underwent prospective observational therapy and behavioral modification. We correlated the dysfunctional voiding symptom score with the evolution of vesicoureteral reflux.

RESULTS

Vesicoureteral reflux was present in 19 of the 58 patients (33%) with dysfunctional voiding and urinary tract infection. All affected patients were female with a mean age of 6.7 years and a mean followup of 24 months. Reflux grade in the 24 units was I to IV in 7, 9, 7 and 1, respectively. Mean dysfunctional voiding symptom score was 13.3 in patients with normal voiding cystourethrography and 11.7 in the vesicoureteral reflux group (p = 0.6). Reflux resolved in 3, 2 and 2 cases of grades I, II and III disease, respectively, while improvement (decrease of 2 or more grades) was noted in 4. Initial dysfunctional voiding symptom score in these 11 cases decreased from a mean of 9.6 (range 4 to 18) to 3.7 (range 0 to 12, p = 0.01). The 8 patients with persistent reflux had an initial dysfunctional voiding symptom score of 14.4 (range 4 to 21), which decreased to 11.1 (range 1 to 19, p = 0.18).

CONCLUSIONS

A significant decrease in the dysfunctional voiding symptom score appears to confirm compliance with behavioral modification and predicts ultimate reflux resolution. The dysfunctional voiding symptom score provides a noninvasive means of monitoring compliance with therapy during expectant treatment of patients with vesicoureteral reflux.

Relationship among pediatric voiding dysfunction and vesicoureteral reflux and renal scars

OBJECTIVES

To analyze the relationship among non-neurogenic voiding dysfunction, vesicoureteral reflux (VUR), and renal scarring, taking into consideration whether the reflux was unilateral or bilateral. VUR is a common problem in the pediatric age group. Although unilateral reflux is usually due to primary insufficiency of the vesicoureteral junction, bilateral reflux can also be the result of underlying voiding dysfunction.

METHODS

Between 1993 and 1998, 80 children, 52 girls and 28 boys, median age 5.7 years (range 3.8 to 14), were evaluated because of VUR. Eighteen patients who presented with associated anomalies and obvious neuropathic bladder dysfunction were excluded from the study. Complete urologic, neurologic, and urodynamic investigations were performed in all patients.

RESULTS

Of 62 patients, 25 (40.3%) had unilateral and 37 (59.6%) had bilateral reflux. Voiding dysfunction was found in 7 patients (28%) with unilateral reflux and in 27 patients (72.9%) with bilateral reflux (P <0.01 ). Two (25%) of the 8 patients with unilateral reflux and renal scarring had voiding dysfunction but no demonstrable urinary tract infection, and 10 (55.5%) of the 18 patients with bilateral reflux and renal scarring had voiding dysfunction and no demonstrable urinary tract infection (P <0.01).

CONCLUSIONS

If VUR is bilateral, the prevalence of existing underlying voiding dysfunction seems to be higher. The first step in management should be a detailed evaluation of bladder function to choose an appropriate treatment modality and to prevent renal deterioration.

Dysfunctional voiding syndromes and vesicoureteral reflux

Micturition disorders simulating neurogenic bladder disease have been loosely termed "dysfunctional voiding". No underlying neuropathy can be found. A variety of voiding disturbances have been identified since the early 1970s, each with its own characteristics and clinical relevance. We have classified voiding dysfunctions into mild, moderate and severe, according to their potential impact on the upper tracts. Bladder instability, the Hinman syndrome and the Ochoa syndrome are the only dysfunctional voiding syndromes that are associated with reflux or ureterovesical obstruction. Each syndrome is briefly described.

The importance of urinary tract infection in the evaluation of the incontinent child

Diurnal incontinence secondary to dysfunctional voiding is a problem that is commonly encountered by the pediatric urologist. We have observed that reflux is more common in these children and hypothesized that urinary tract infection would influence the rate of reflux as well as the rate of significant urinary tract abnormalities, such as renal scarring. We prospectively evaluated 308 incontinent children with a voiding cystourethrogram and upper tract studies. Of these patients 162 (53%) had had previous culture proved urinary tract infection, while 146 (47%) had no history of infection. A total of 90 patients (29%) had an abnormal voiding cystourethrogram, which demonstrated reflux in all but 1. Among the patients with a history of urinary tract infection reflux was found in 34% compared to 23.3% in those with no history of urinary tract infection (p = 0.82). Five patients had significant cortical scarring, of whom 4 had grade III or greater reflux along with urinary tract infection. We conclude that urinary tract infection is not helpful in determining which patients with dysfunctional voiding will exhibit vesicoureteral reflux but it is important in detecting significant upper tract abnormalities, such as renal scarring. We discuss appropriate evaluation in children who present with incontinence secondary to dysfunctional voiding with or without urinary tract infections.

Pronounced detrusor hypercontractility in infants with gross bilateral reflux

In this study the prevalence of bladder dysfunction in 18 children with gross bilateral reflux was investigated via cystometric recordings. In all except 1 infant maximal voiding detrusor pressure was 100 cm. or greater water (range 86 to 244). Pronounced instability during filling (overt instability) with pressure waves above baseline (mean 65 cm. water, range 42 to 194) was found in 9 infants. Another 5 children had evidence to suggest an uninhibited bladder, not manifested as unstable contractions during filling but as covert instability, meaning that the first unstable contraction was transformed into a premature and forceful voiding contraction. The high detrusor pressures found in 18 children with gross bilateral reflux during the voiding phase but also during the filling phase in half of the children suggest that a hypercontractile detrusor may be a contributory factor for the development of reflux even in this age group.

The relationship of sibling reflux to index patient dysfunctional voiding

The rate of sibling reflux in index patients with and without dysfunctional voiding symptoms was compared. Of the siblings of index patients with reflux and dysfunctional voiding 20 per cent demonstrated reflux compared to 38 per cent of siblings of those without symptom of bladder dysfunction. The difference is significant and suggests an interaction of genetic and environmental factors. These factors are discussed. There remains a need to screen siblings of patients with reflux regardless of symptoms of either the index patient or the sibling.

The role of dysfunctional voiding in failure or complication of ureteral reimplantation for primary reflux

Detrusor and/or urethral sphincter dysfunction is associated with increased failure or complication of ureteral reimplantation. A group of 400 children who underwent ureteral reimplantation was reviewed and the failure rate was determined. Those patients in the primary reflux category who failed were reviewed in detail for voiding dysfunction. Excluding technical error or ureteral dysfunction, the greatest risk for failure or complication of ureteral reimplantation seems to be related to detrusor and/or urethral sphincter dysfunction. Voluntary detrusor-sphincter discoordination seems particularly prevalent in this high risk group. The findings are discussed in relation to the over-all management of these patients.