THE DYSFUNCTIONAL VOIDING SCORING SYSTEM: QUANTITATIVE STANDARDIZATION OF DYSFUNCTIONAL VOIDING SYMPTOMS IN CHILDREN

Outcomes of para-sacral transcutaneous electric nerve stimulation in treatment of primary and refractory overactive bladder among children

BACKGROUND

Overactive bladder (OAB) is the most prevalent lower urinary tract dysfunction among children. Refractory OAB lacks response to the first line treatments, including anticholinergic, and it is a major clinical challenge. This study aims to compare the efficacy of para-sacral transcutaneous electric nerve stimulation (PS-TENS) in the treatment of primary and refractory OAB among children.

METHODS

A prospective, randomized clinical study included 64 children aged 5-12 years with OAB divided equally into two groups: group (1) included 32 children with treatment-naive OAB, while group (2) included 32 children with refractory OAB who failed complete course of anticholinergics. Both groups received PS-TENS three times weekly for 12 weeks. Detailed medical history, voiding diary, ultrasound, and uroflowmetry with EMG were performed at baseline and after 12 weeks of treatment. Filling cystometry was performed for children with refractory OAB before and after PS-TENS.

RESULTS

After the end of treatment the number of children with urge incontinence decreased significantly among the two groups: from 25 to 13 and 27 to 15 for the primary and refractory groups, respectively. Micturition frequency per 24 h decreased significantly among children with primary OAB. Bladder capacity increased significantly and the resting detrusor pressure decreased significantly among children with refractory OAB.

CONCLUSIONS

PS-TENS is an effective and safe treatment option for children with OAB. The magnitude of improvement is higher among children with primary as compared to refractory OAB.

Does sacral ratio have any impact on success rate of biofeedback therapy in children with lower urinary tract dysfunction?

INTRODUCTION

To evaluate the possible impact of patients' sacral ratios (SRs) on response to biofeedback (BF) therapy in pediatric patients with lower urinary tract dysfunction (LUTD).

MATERIALS AND METHODS

In this retrospective cohort conducted from 2016 to 2018 in our tertiary medical center, we included the medical records of all pediatric patients with LUTD who were nominated for BF due to having abnormal uroflowmetry patterns and simultaneous increase in electromyography (EMG) activity. Ten sessions of weekly animated BF were performed for each patient. All patients underwent a complete urological evaluation, uroflowmetry with simultaneous EMG and post-void residual measurement before and after treatment. SRs were calculated based on plain anteroposterior lumbosacral radiographs. Patients were then divided into normal SR (≥0.74) and low SR (<0.74) and outcomes were compared between them.

RESULTS

Of the total 86 patients included in our study, 48 (55.8%) had a normal SR (≥0.74), while 38 (44.2%) had a low SR (<0.74). Our data revealed that BF therapy significantly improved maximum and average urinary flow rates, urine volume, daytime urinary incontinence, enuresis, urinary urgency and constipation; irrespective of the patients' SRs (all P < 0.001). Our between-groups analyses showed that after the completion of BF, the SR ≥ 0.74 group had significantly higher maximum urinary flow rate (mean difference [95%CI]: 7.7 [5.4, 10.0], P < 0.001) (Figure) and urine volume (mean difference [95%CI]: 49.9 [19.5, 80.4], P = 0.002) and significantly lower diurnal urinary incontinence (4.2% vs. 21.1%, P = 0.020), enuresis (4.2% vs. 18.4%, P = 0.040) and constipation (2.1% vs. 23.7%, P = 0.004) compared to the SR < 0.74 group.

DISCUSSION

SR has been proposed as a reliable indicator of bony pelvis growth and subsequent lumbosacral neurodevelopment. Additionally, larger SR values are associated with better postoperative sphincter function in children with urological and anorectal malformations. Our results demonstrated that after completion of BF, the normal SR group had a significantly better improvement of some of the uroflowmetry indicators and LUTD-associated symptoms compared to the low SR group.

CONCLUSION

Our findings implied that although BF therapy is an efficient treatment for children with LUTD, irrespective of their sacral development; children with enhanced sacral development may benefit from better clinical response, especially in terms of LUTD-associated symptoms.

Urotherapy and biofeedback resistant dysfunctional voiding: How to deal with?

OBJECTIVES

To analyze the management strategies in the children who had treatment-resistant dysfunctional voiding (DV).

METHODS

Among 75 children with DV who underwent pelvic floor biofeedback therapy (BF) between 2013 and 2020, 16 patients (14 girls, 87.5%) with a mean age of 9.81 ± 2.53 years that showed incomplete clinical response following urotherapy and initial BF sessions were retrospectively reviewed. The demographic and clinical characteristics, DVSS, and uroflowmetry parameters were recorded before and after the initial BF sessions. Subsequent treatments after initial BF and clinical responses of patients were noted.

RESULTS

Clinical success was observed in one patient by addition of an anticholinergic and in three patients with combination of salvage BF sessions and anticholinergics, whom had predominant overactive bladder (OAB) symptoms. The success rate of TENS alone and in combination with other treatment modalities was 88.8% (8/9 patients). In addition, salvage BF sessions (range 2 to 3) enabled clinical success in five (50%) of 10 cases as a combination with anticholinergics or TENS. In case of incomplete emptying without OAB, adequate clinical response to Botulinum-A was observed during an average follow-up of 29 months in two boys who did not respond to alpha-blockers, even though one required repeat injection after 10 months. The total clinical success rate was 87.5% (14/16 patients) after a median follow-up of 24 months. VV-EBC and Qmax increased by a mean of 30.89% and 7.13 mL/min, respectively, whereas DVSS decreased by a mean of 8.88 points and PVR-EBC decreased by a median of 19.04%.

CONCLUSIONS

Our findings showed that clinical success in resistant DV was achieved by various combination treatments in the majority of children. However, a small group may still have persistent, bothersome symptoms despite multiple treatment modalities.

The Role of Secondary Conservative Management Strategies in Bladder and Bowel Dysfunction: A Systematic Review and Meta-analysis

OBJECTIVE

We sought to determine the effect of secondary management strategies in addition to urotherapy on bowel bladder dysfunction outcomes.

STUDY DESIGN

The review protocol was prospectively registered (CRD42023422168). MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and Scopus (database initiation until June 2023) were searched. Comparative studies of secondary management strategies vs conventional urotherapy alone were included. Two authors independently screened titles, abstracts, and reviewed full-text articles. Two authors extracted data related to study characteristics, methodology, subjects, and results.

RESULTS

In this systematic review and meta-analysis of 18 studies and 1228 children, secondary management strategies (home-based education, biofeedback, and physical therapy) were associated with reduced symptom burden, fewer recurrent urinary tract infections, and improved uroflowmetry findings than children treated solely with urotherapy for conservative management.

CONCLUSIONS

Although there is significant reporting heterogeneity, secondary conservative management strategies such as home education, biofeedback or cognitive behavioral therapy, and physiotherapy-based education are associated with less urinary incontinence, fewer infections, and fewer abnormal uroflowmetry findings.

Bowel bladder dysfunction in control children in a pediatric urology office

INTRODUCTION

Bowel bladder dysfunction (BBD) is common in children. Risk factors for BBD include age, gender, obesity, and behavioral issues such as ADHD. We investigated the modified Swedish Bowel-Bladder questionnaire as a sensitive indicator of BBD in healthy children.

OBJECTIVES

We tested the usefulness of the Swedish Bowel-Bladder Questionnaire (BBQ) as an indicator of BBD in children not complaining of bowel/bladder dysfunction at the time of their visit to a pediatric urologist. Our secondary aim was to identify correlations between BBQ scores and risk factors such as gender, BMI, and ADHD.

STUDY DESIGN

All families in our Pediatric Urology practice with patients >30 months old who were reportedly toilet trained were provided the Swedish BBQ. Total score as well as sub-scores for storage, emptying, and constipation were prospectively collected. Presenting diagnosis, gender, BMI, and ADHD history were collected. BBQ scores for patients with voiding dysfunction were compared to controls: a) those with genital problems (e.g. hydrocele/undescended testes), b) those with CAKUT (congenital anomalies of the kidneys and urinary tract). BBQ scores were analyzed as a continuous variable vs the potential risk factors (ADHD, obesity, age, and gender) using univariable/multivariable regression analysis.

RESULTS

The median BBQ score for the 328 control patients (95 CAKUT and 233 genital) was 2.25 with an IQR: 1 to 6. In contrast, the median BBQ was higher for those with possible voiding dysfunction; n = 282; 9 with an IQR: 5 to 15). Total BBQ score exceeded 6 in 16% (52/328) of control patients. On multivariable analysis, age-adjusted total BBQ scores increased with ADHD in our controls (p = 0.03) but were unaffected by gender or BMI. On multivariable analysis of the voiding dysfunction group, total BBQ scores similarly decreased with age (p < 0.001) and increased with ADHD (p < 0.001) and were affected by gender (p = 0.024). BMI percentile had no significant effect in either cohort.

DISCUSSION AND CONCLUSION

The Swedish BBQ was used in a U.S population and demonstrated trends towards increased voiding dysfunction associated with younger age, female gender, and ADHD. We learned that voiding dysfunction in children with ADHD is not associated with constipation and improves over time. Additionally, 16% of children with genital or urinary abnormalities and no voiding complaints have noticeable BBD uncovered by the BBQ. Hence, we conclude that the Swedish BBQ is a sensitive indicator of BBD even in children not complaining of those problems.

Antimicrobial prophylaxis for vesicoureteral reflux: which subgroups of children benefit the most?

BACKGROUND

While the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial found that long-term antimicrobial prophylaxis reduced the risk of urinary tract infection (UTI) recurrences by 50%, 10 children had to be treated for one to benefit (i.e., observed number needed to treat (NNT) of 10). Accordingly, we re-analyzed RIVUR data to systematically identify subgroups of children with vesicoureteral reflux (VUR) with a smaller NNT.

METHODS

Using patient-level data from the RIVUR trial, we applied penalized regression methods including the baseline age, VUR grade, type of index UTI, and bowel-bladder dysfunction (BBD) as covariates to identify subgroups.

RESULTS

We identified four relevant subgroups of children that appear to benefit from long-term antimicrobial prophylaxis, all with observed NNTs smaller than or equal to 5: children with grade IV VUR, BBD, and febrile index UTI (1% of the sample), children with BBD and febrile index UTI (7% of the sample), children with BBD (12% of the sample), and children with grade IV VUR (8% of the sample).

CONCLUSIONS

Use of long-term antimicrobial prophylaxis appears to be particularly relevant for children with BBD (and any grade of VUR) and those with grade IV VUR (regardless of BBD status). However, because details regarding the treatment of BBD are not available, further studies are needed to fully determine the role of prophylactic antimicrobials in the management of children with VUR who have BBD.

Urinary Tract Infections in Children

Despite the American Academy of Pediatrics guidelines for the evaluation, treatment, and management of urinary tract infections (UTIs), UTI diagnosis and management remains challenging for clinicians. Challenges with acute UTI management stem from vague presenting signs and symptoms, diagnostic uncertainty, limitations in laboratory testing, and selecting appropriate antibiotic therapy in an era with increasing rates of antibiotic-resistant uropathogens. Recurrent UTI management remains difficult due to an incomplete understanding of the factors contributing to UTI, when to assess a child with repeated infections for kidney and urinary tract anomalies, and limited prevention strategies. To help reduce these uncertainties, this review provides a comprehensive overview of UTI epidemiology, risk factors, diagnosis, treatment, and prevention strategies that may help pediatricians overcome the challenges associated with acute and recurrent UTI management.

Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux

We present updated, evidence-based clinical practice guidelines from the Indian Society of Pediatric Nephrology (ISPN) for the management of urinary tract infection (UTI) and primary vesicoureteric reflux (VUR) in children. These guidelines conform to international standards; Institute of Medicine and AGREE checklists were used to ensure transparency, rigor, and thoroughness in the guideline development. In view of the robust methodology, these guidelines are applicable globally for the management of UTI and VUR. Seventeen recommendations and 18 clinical practice points have been formulated. Some of the key recommendations and practice points are as follows. Urine culture with > 104 colony forming units/mL is considered significant for the diagnosis of UTI in an infant if the clinical suspicion is strong. Urine leukocyte esterase and nitrite can be used as an alternative screening test to urine microscopy in a child with suspected UTI. Acute pyelonephritis can be treated with oral antibiotics in a non-toxic infant for 7-10 days. An acute-phase DMSA scan is not recommended in the evaluation of UTI. Micturating cystourethrography (MCU) is indicated in children with recurrent UTI, abnormal kidney ultrasound, and in patients below 2 years of age with non-E. coli UTI. Dimercaptosuccinic acid scan (DMSA scan) is indicated only in children with recurrent UTI and high-grade (3-5) VUR. Antibiotic prophylaxis is not indicated in children with a normal urinary tract after UTI. Prophylaxis is recommended to prevent UTI in children with bladder bowel dysfunction (BBD) and those with high-grade VUR. In children with VUR, prophylaxis should be stopped if the child is toilet trained, free of BBD, and has not had a UTI in the last 1 year. Surgical intervention in high-grade VUR can be considered for parental preference over antibiotic prophylaxis or in children developing recurrent breakthrough febrile UTIs on antibiotic prophylaxis.

Does KUB play a role in the diagnosis of bladder bowel dysfunction?

INTRODUCTION

Kidney ureter bladder radiography (KUB) is widely used for the evaluation of constipation in children with bladder and bowel dysfunction (BBD); however, there is varying evidence to support its routine diagnostic use. One drawback to KUB is radiation exposure. The dangers of radiation in children are well-documented, and per As Low As Reasonably Achievable, non-beneficial radiation should be avoided. This risk is especially high in children who undergo repeated imaging in the follow up of constipation treatment.

OBJECTIVE

We sought to assess the utility of KUB in diagnosing children with BBD by comparing it to four diagnostic tests and/or validated instruments: the Dysfunctional Voiding Symptom Score (DVSS), Rome IV criteria, rectal diameter on ultrasound (RD), and the Bristol Stool Form Score (BSFS).

STUDY DESIGN

We prospectively enrolled a cohort of patients presenting to an academic pediatric urology practice with symptoms of BBD. Severity of stool burden on KUB (mild, moderate, or severe), RD on ultrasound (≥3.4 cm), DVSS, Rome IV, and BSFS were obtained for each patient. All imaging was interpreted by a pediatric radiologist and pediatric urologist. Primary outcomes were the association between the four diagnostic tests and KUB stool burden. Bivariate analysis of all individual variables versus KUB was performed, as well as multivariate regressions to determine if multiple measures were predictive of KUB stool burden when combined.

RESULTS

Between October 2020 and May 2022, 50 patients were enrolled. All children were under the age of 18, with a median age of 8 years (IQR 3-13). 38 % were male. Median BMI-for-age-percentile was 80.8 (IQR 50.3-98.3). When comparing individual variables to KUB in bivariate analyses, it was found that RD on ultrasound is predictive of significant stool burden on KUB (p = 0.03). No other individual variables were predictive. In the multivariate analyses, no combination of tests was found to be predictive of KUB.

DISCUSSION

We compared the effectiveness of four commonly used diagnostic tests in children with BBD to validate the use of KUB. In conclusion, our results support the use of RD on ultrasound as a non-radiating alternative to KUB to assess stool burden. Data also suggest that KUB for fecal load does not correlate with urinary (DVSS) or bowel (Rome IV, BSFS) symptoms in BBD, and that symptoms scores should still be used independently for diagnosis and monitoring of treatment response.

CONCLUSION

In conclusion, KUB has a limited role in the diagnosis of BBD.

Measurement properties of the childhood bladder and bowel dysfunction questionnaire

OBJECTIVES

The childhood bladder and bowel dysfunction questionnaire (CBBDQ) was previously found feasible, structurally valid, with good internal consistency. The purpose of this study was to evaluate the remaining measurement properties according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN).

METHODS

A prospective cohort study among parents of children aged 5-12 years was conducted. Calculated were the area under the curve (AUC) (criterion validity, responsiveness, interpretability) and intra-class correlation coefficients (ICCagreement ) (construct validity and test-retest reliability).

RESULTS

One hundred and seventy-two parents were included from March 2019 to April 2021. Correlating the bladder subscales of the CBBDQ with the Vancouver symptom score for dysfunctional elimination (VSSDES) and proxy-reported pediatric incontinence quality of life (p-PinQ) showed convergent validity (ICCsagreement : 0.76 and 0.74). Divergent validity was found when correlating the bowel subscales of the CBBDQ with the VSSDES (ICCagreement : 0.52). Excellent criterion validity (AUC: 0.98); excellent test-retest reliability (ICCagreement : 0.94) and, at 6 months, fair responsiveness (AUC: 0.74) were found. The minimal important change was 4.5, with cut-off value of 11.

CONCLUSION

The CBBDQ has been developed according to COSMIN standards. The items were defined using the consensus-based ICCS standards and Rome-III criteria. The measurement properties were identified using enough participants. Although interpretability is not considered a measurement property, interpretability aspects are reported here as they refer to what instrument scores mean. The 18-item-CBBDQ met the measurement properties of validity, reliability, and responsiveness, as defined by COSMIN. The CBBDQ is suitable for self-administration by parents, and completion takes little time.

Implementation of a standardized clinical pathway in a dedicated posterior urethral valves clinic: short-term outcomes

BACKGROUND

To determine if the implementation of a posterior urethral valves (PUV) clinic and standardized management pathway improves the short-term kidney outcomes of infants with PUV.

METHODS

From 2016-2022, 50 consecutive patients were divided into groups after the implementation of the clinic (APUV, n = 29) and before (BPUV, n = 21) during a comparable timeframe. Assessed data included age at initial visit, timing and type of surgery, frequency of follow-up visits, medications, nadir creatinine, and development of CKD/kidney failure. Data are shown as median with interquartile range (IQR) and odds ratios (OR) with 95% confidence interval (CI).

RESULTS

APUV had higher rates of prenatal diagnoses (12/29 vs. 1/21; p = 0.0037), earlier initial surgical intervention (8 days; IQR 0, 105 vs. 33 days; IQR 4, 603; p < 0.0001), and higher rates of primary diversions (10/29 vs. 0/21; p = 0.0028). Standardized management led to earlier initiation of alpha blockers (326 days; IQR 6, 860 vs. 991; IQR 149, 1634; p = 0.0019) and anticholinergics (57 days; IQR 3, 860 vs. 1283 days; IQR 477, 1718; p < 0.0001). Nadir creatinine was reached at earlier ages in APUV (105 days; IQR 2, 303 vs. 164 days; IQR 21, 447; p = 0.0192 BPUV). One patient progressed to CKD5 in APUV compared to CKD3, CKD5 and one transplant in BPUV.

CONCLUSION

Implementing the PUV clinic with standardized treatment expedited postnatal management and resulted in a higher number of cases detected prenatally, a shift in primary treatment, younger ages at initial treatment, reduced time to nadir creatinine, and timely initiation of supportive medications. A higher resolution version of the Graphical abstract is available as Supplementary information.

Personalized Pre-clinic Nursing Telemedicine Visit: An Efficient and Efficacious Approach for Bowel and Bladder Dysfunction in Children

OBJECTIVES

To evaluate the effectiveness and efficacy of a Registered Nurse (RN) led educational pre-clinic telephone call on compliance and outcomes in children with bowel and bladder dysfunction (BBD).

METHODS

A retrospective chart review of a prospectively applied protocol in a single academic institution was performed for children aged 4-17 presenting with BBD. All children underwent a pre-clinic RN telemedicine visit where they were educated on pathophysiology of BBD, provided personalized urotherapy and bowel recommendations and instructed to complete pre-clinic questionnaires and voiding diaries. Patients were evaluated by a provider 4weeks following RN call. Data collected included compliance with forms, bowel management and need for imaging/testing, medications, and biofeedback. Patients were considered to improve with urotherapy alone if they were discharged from urology without the need for medications and/or biofeedback.

RESULTS

In total, 277 patients completed an RN call and 224 patients attended a provider visit between December 2020 and June 2022. Mean age was 9.4years (3:1 Female to Male ratio). During the RN call, 154 (56%) patients had bowel management initiated. Of the 224 patients seen by a provider, 69% (n = 154) had symptom improvement or resolution with urotherapy alone. Thirty-eight patients (17%) enrolled in biofeedback with 7 (3%) completing all 8 sessions. Thirty-two patients (14%) required medication for daytime bladder symptoms.

CONCLUSION

Our novel RN-led pre-clinic telemedicine visit demonstrates excellent compliance and patient outcomes for children with BBD and can reduce the use of unnecessary imaging, medications, and time-consuming treatments such as biofeedback.

Antimicrobial prophylaxis for vesicoureteral reflux: which subgroups of children benefit the most?

Background

While the Randomized Intervention for children with Vesicoureteral Reflux (RIVUR) trial found that long-term antimicrobial prophylaxis reduced the risk of urinary tract infection (UTI) recurrences by 50%, 10 children had to be treated with long-term antimicrobial prophylaxis for one to benefit (i.e., observed number needed to treat (NNT) of 10). Accordingly, we re-analyzed RIVUR data to systematically identify subgroups of children with vesicoureteral reflux (VUR) with a smaller NNT.

Methods

Using patient-level data from the RIVUR trial, we applied penalized regression methods including the baseline age, VUR, and bowel-bladder dysfunction (BBD) as covariates to identify subgroups that consider the trade-off between absolute risk difference and size.

Results

We identified three relevant subgroups of children that appear to benefit from long-term antimicrobial prophylaxis, all with NNTs smaller than the NNT of 10. Children with grade IV VUR and BBD, 1% of the RIVUR sample, had a NNT of 2; children with BBD, 12% of the RIVUR sample, had a NNT of 4; children with BBD (and any grade VUR) or with grade IV VUR (regardless of BBD status), which was the combination of the first two subgroups and included 19% of children in the RIVUR sample, had a NNT of 4.

Conclusions

Use of long-term antimicrobial prophylaxis appears to be particularly relevant for children with BBD (and any grade of VUR) or those with grade IV VUR (regardless of BBD status) who were at high risk of UTI recurrences.

At-home use of parasacral transcutaneous electrical nerve stimulation for pediatric voiding dysfunction: a randomized controlled trial to assess its safety and feasibility

Introduction

Treating pediatric voiding dysfunction involves behavioral changes that require significant time or medications that are often avoided or discontinued due to side effects. Using parasacral transcutaneous electrical nerve stimulation (PTENS) has shown to have reasonable efficacy, but the safety and feasibility of its off-label use for pediatric voiding dysfunction are not well-established. Concerns have also been raised over treatment adherence. In-home therapy might improve adherence compared with office-based therapy; however, no studies have evaluated in-home feasibility to date. This study aims to assess the safety and feasibility of off-label use of PTENS for pediatric voiding dysfunction.

Materials and methods

A single-institution prospective, randomized controlled study was conducted from March 2019 to March 2020. Participants aged 6-18 years diagnosed with voiding dysfunction, overactive bladder, or urinary incontinence were eligible for the study. Those with known neurologic disorders, implanted electrical devices, anatomic lower urinary tract abnormality, and recurrent urinary tract infections and those taking bladder medications were excluded. Children with primary monosymptomatic nocturnal enuresis were also excluded due to previous work suggesting a lack of efficacy. Participants were randomly assigned to receive 12 weeks of urotherapy alone (control) or urotherapy plus at-home PTENS treatment. Families were contacted weekly to assess for adverse events (AEs) and treatment adherence. The primary and secondary outcomes were safety, defined as the absence of AEs and treatment adherence, respectively.

Results

A total of 30 eligible participants were divided into two groups, with 15 participants in each arm. The median age was 9.4 years (interquartile range: 7.7-10.6). In total, 60% were male. Baseline demographics and urotherapy compliance were similar between the two groups. With PTENS use, two AEs were reported, including mild pruritus at the pad site and discomfort when removing pads, while no AEs were noted in the control group. In total, 60% of patients completed three 30-min sessions per week, and all participants were able to complete treatment sessions for at least 10 weeks, involving 30 min of PTENS treatment each time.

Conclusion

This randomized controlled study confirms that at-home use of PTENS is feasible with reasonable treatment adherence and minimal AEs. Future collaborative, multi-institutional studies may better determine the efficacy of this treatment modality.

Urogenital urobiome of healthy children does not differ from that of children with bladder and bowel dysfunction

INTRODUCTION

The pediatric urinary microbiome (urobiome) has been studied in the context of healthy children and children with genitourinary pathologies including neuropathic bladder, urinary tract infection (UTI) and nephrolithiasis. Little is known about the urobiome of children with bladder and bowel dysfunction (BBD), a condition that is an established risk factor of UTI. We hypothesized that the symptoms of a child with BBD may be related to urobiome composition.

OBJECTIVE

To evaluate the urogenital urobiome's role in BBD, we compared the urogenital urobiomes of children with and without BBD.

STUDY DESIGN

We performed a prospective case-control pilot study at a single large, academic children's hospital. Cases included toilet trained prepubertal females over 2 years of age with BBD established through a validated scoring system and controls included asymptomatic, presumably healthy, children. Children were excluded if they had symptoms or lab work consistent with a concurrent UTI or antibiotic course for any reason within the prior 14 days. We performed 16 S ribosomal RNA gene sequencing and expanded quantitative urine culture on clean catch urine samples. To compare within sample (alpha) diversity, we used the Kruskal-Wallis test. To compare between sample (beta) diversity, we calculated the Bray-Curtis distance and performed the PERMANOVA test.

RESULTS

Data from 25 children with BBD and 8 asymptomatic controls were analyzed. The demographic and clinical characteristics of the two comparison groups were similar, though a higher proportion of Black children were included in the asymptomatic control group. Neither alpha diversity nor beta diversity was significantly different between the two groups. The core microbiome of the BBD group included all the genera in the core urogenital urobiome of the controls, plus additional genera associated with opportunistic infection and/or UTI, including Escherichia, Campylobacter and Streptococcus.

DISCUSSION

The results of both the 16 S sequencing and expanded quantitative urine culture in this small study suggest that the urogenital urobiomes of children with BBD do not differ significantly from those of asymptomatic children. However, the core urogenital urobiome of children with BBD included genera associated with opportunistic infection and/or UTI. This study was limited by the sample collection method ("clean catch" midstream voided urine samples, which introduce the possibility of vulvovaginal contamination), small sample size, and unequal balance of patient characteristics between the two study groups.

CONCLUSION

The urogenital urobiomes of children with and without BBD do not appear to significantly differ. Larger studies are needed to confirm these findings.

Pediatric incontinence questionnaire (PINQ): translation and transcultural adaptation to Brazilian Portuguese

OBJECTIVE

Lower urinary tract symptoms (LUTS) affect approximately 10% of children worldwide and are related to psychosocial manifestations and compromised quality of life, both for children and their families. The assessment of emotional conditions of LUTS in children is recommended by International Children's Continence Society; however, there is no specific instrument in the Brazilian Portuguese language. Therefore, the aim of this study was to translate, culturally adapt and assess the internal consistency of the Brazilian Portuguese version of the Pediatric Incontinence Questionnaire (PINQ).

MATERIAL AND METHODS

This cross-sectional study was performed at two referral centers for childhood voiding dysfunction. The 20-item PINQ was translated into Brazilian Portuguese and culturally adapted according to Beaton, 2000. His-standard methodology consists of 6 phases: translation, synthesis, back-translation, expert committee, and pre-test. The internal consistency was assessed using Cronbach's alpha.

RESULTS

The PINQ-br version was developed, validated by a committee of experts, and pre-tested on 44 children diagnosed with lower urinary tract symptoms, 23 boys and 21 girls (mean age: 9.7 and 9.6 years old respectively), as well as on their parents. The internal consistency was considered satisfactory, reaching Cronbach's alpha coefficient of 0.74 when applied to children and 0.82 when applied to parents.

CONCLUSIONS

The PINQ was translated and culturally adapted to Brazilian Portuguese to assess the impact of LUTS on the health-related quality of life in Brazilian children and adolescents.

The Treatment of Lower Urinary Tract Dysfunction via Treatment of Obsessive-compulsive Disorder in a Pediatric Patient

Lower urinary tract dysfunction in the pediatric patient can be associated with mental health issues, such as anxiety and obsessive-compulsive disorder (OCD). In fact, 20%-40% of pediatric patients with daytime urinary incontinence have concomitant diagnosis of mental health disease.¹ Here, we present a case of lower urinary tract dysfunction in the setting of OCD, with symptom resolution following appropriate treatment of OCD. This case report demonstrates the importance of clinicians including mental health disorders in the differential of children with voiding dysfunction.

Updates of Overactive Bladder in Pediatrics

Overactive bladder (OAB) is clinically defined as urinary urgency with or without urinary incontinence. It is associated with daytime frequency or constipation and has a prevalence of approximately 5%-12% among 5- to 10-year-olds. The appropriate functional exchange between the pontine micturition center, periaqueductal gray matter, and prefrontal cortex is important for proper micturition control. Several studies on pediatric cases observed a link between OAB and neuropsychiatric problems, such as anxiety, depression, and attention deficit, and treatment of these comorbidities improved patient symptoms. In this review, we present the pathophysiology of OAB, its associated conditions, and aspects related to updates in OAB treatment, and we propose a step-by-step treatment approach following this sequence: behavioral therapy, medical treatment, and invasive treatment. Although anticholinergic drugs are the mainstay of OAB medical treatment, beta-3 agonists and alpha-blockers are now recommended as a result of significant advancements in pharmacologic treatment in the last 10 years. Electrical stimulation techniques and botulinum toxin are also effective and can be used, especially in conventional treatment-refractory cases.

Arabic translation and validation of pediatric lower urinary tract symptom score (PLUTSS)

Objectives

To develop and validate an Arabic version of the pediatric lower urinary tract symptom score (PLUTSS).

Methods

The linguistic translation of the PLUTSS into Arabic was carried out by following the guidelines that have been set out for cross-cultural adaptation of health-related QoL measures (Translation, Reconciliation, Retranslation, Review of retranslation, Debriefing and final review). The questionnaires were applied to 80 patients, 40 patients seeking urology clinic for lower urinary tract symptoms (LUTS) and 40 patients visiting a pediatric clinic without urological compliant. The discrimination validity and strength of association were tested using Mann-Whitney and chi-square tests. Reliability of translation was tested for internal consistency using the Cronbach's α and ROC Curve was used to evaluate the ability of the questionnaire to discriminate between cases and controls.

Results

Patients with LUTS had a higher PLUTSS score and QoL score than controls (P < 0.001). The value of Cronbach's alpha of the 13 items (excluding Qol) evaluated on the scale was 0.717 (95% CI: 0.616-0.800). The ROC curve determined the ability of the questionnaire to discriminate between cases and controls where the area under the curve was 0.901 (95% CI: 0.830-0.972).

Conclusion

The Arabic translated version of the PLUTSS is an acceptable and reliable tool for assessing and evaluating pediatric patients with LUTS in Arabic-speaking countries.

Pediatric Psychology in a Urology Division: Unifying Complex Medical and Mental Health Treatment

PURPOSE OF REVIEW

Although pediatric psychology is heavily involved in many medical divisions, its involvement in a urology division is still relatively new and its role continuously evolving and growing.

RECENT FINDINGS

This article reviews the limited research on the use of psychology in a urology division, including psychosocial struggles across urology diagnoses, dysfunctional voiding, and anxiety surrounding medical procedures and surgery. Urinary diagnoses and presenting problems seen by pediatric psychologists and medical providers at an urban children's hospital are also included. Based on the complex conditions and varied presenting concerns in a urology division, potential assessments and future research are suggested to help gather data for this population moving forward and expand the literature on urology psychology.

Modified unilateral periureteral injection technique in the treatment of patients with high-grade vesicoureteral reflux: A study of primary findings

Objective

Although endoscopic treatment has been used by many pediatric urologists for the treatment of vesicoureteral reflux (VUR), it has no considerable success in high-grade VUR. We aimed to describe the primary outcomes of unilateral periureteral injection technique (PIT), as well as bilateral PIT in high-grade VUR.

Methods

In this prospective study, we examined 92 ureters in 45 boys and 40 girls from February 2010 to May 2018. Bilateral PIT and unilateral PIT were applied in 67 and 25 refluxing units, respectively. In the unilateral PIT, the subureteral injection site was only at the 5- or 7-o'clock position. However, in the bilateral PIT, the subureteral injection sites were at 5- and 7-o'clock position. Pre- and post-operative reflux grades were evaluated by voiding cystourethrography 6 months after surgery.

Results

Seven patients had bilateral reflux. Overall, 75 (81.5%) ureters showed Grade IV VUR, while 17 (18.5%) had primary Grade V VUR. The mean age of the subjects was 39.2 months. In unilateral PIT ureters, VUR was resolved in 23 (92.0%) refluxing units. It was downgraded to Grade III in one ureter (4.0%) and to Grade II in another ureter (4.0%). In addition, in bilateral PIT cases, VUR was resolved in 60 (89.6%) ureters; it downgraded to Grades II and III in 3 (4.5%) and 4 (6.0%) refluxing units, respectively.

Conclusion

Unilateral PIT can be highly effective in the treatment of selected ureters of high-grade VUR. However, further studies are needed to confirm our results.

Prevalence of Lower Urinary Tract Symptoms in Children with Attention-Deficit/Hyperactivity Disorder: Comparison of Hospital and Population-Based Cohorts of 13,000 Patients

Background: This study investigates the prevalence of lower urinary tract symptoms (LUTS) in school-age children with Attention-Deficit/Hyperactivity Disorder (ADHD) based on hospital-based and population-based cohorts. Methods: The hospital-based sample comprised 42 children with ADHD and 65 without ADHD aged 6−12 years. Voiding dysfunction was assessed by the Dysfunctional Voiding Scoring System (DVSS) questionnaire. We compared the baseline data, DVSS score, and uroflowmetry between the two groups. For the population-based cohort in the national insurance database, we included 6526 children aged 6−12 years, whose claims record included the diagnosis of ADHD, and another 6526 control subjects matched by gender and age. We compared the presence of LUTS diagnosis codes between the two groups. Results: Our results showed that, for the hospital-based cohort, the mean total DVSS score and the proportion of significant LUTS in children in the ADHD group were significantly higher than in subjects in the non-ADHD group. The DVSS subscales showed that the item “I cannot wait when I have to pee” item was significantly higher in the ADHD group (1.62 ± 1.17 vs. 0.90 ± 1.09, p = 0.002). For the population-based cohort, children with ADHD had a significantly higher likelihood of storage symptoms (5.53% vs. 2.91%, p < 0.001) and enuresis (3.28% vs. 1.95%, p < 0.001) compared with those of the no ADHD group. Conclusions: Children with ADHD have a higher prevalence of significant LUTS, especially storage symptoms and enuresis, than children without ADHD. The observed correlations between ADHD and LUTS provided the supporting evidence to evaluate the concomitant voiding dysfunction in children with ADHD.

Dysfunctional Voiding and Incontinence Scoring System for Children and Adolescents: A Tool to Predict Clinical Course and Outcome

INTRODUCTION

 Lower urinary tract symptoms (LUTS) in children are common. In 2005, Akbal et al published the dysfunctional voiding and incontinence scoring system (DVAISS) to assess patient's symptoms. Our study aimed to determine the value of this scoring system for predicting the severity and clinical course of voiding abnormalities in children and adolescents.

MATERIAL AND METHODS

 Patients' symptoms were scored using the DVAISS in children and adolescents with LUTS presenting for the first time to our pediatric urology department between January 2010 and December 2015. We correlated the calculated score with voiding volume, clinical course, and outcome.

RESULTS

 A total of 168 patients (113 boys, 55 girls; age 5-18 years) with isolated LUTS were included. In 53 patients (group 1), the DVAISS score was less than or equal to 8.5 and in the other 115 patients (group 2), the score was greater than 8.5 suggestive for relevant voiding abnormalities. Patients in group 1 showed a significantly higher average voiding volume (200 vs. 110 mL, p = 0.001). The median time for symptom resolution was significantly higher in group 2 than group 1 (14 vs. 8 months; p = 0.018). The severity of LUTS could be determined by these parameters.

CONCLUSION

 Based on the DVAISS, a prediction of the clinical course and approximate treatment duration is possible. Therefore, the DVAISS is useful to assess LUTS in children and is also a valuable tool in rating the severity of the disease. It is also a quite precise predictor of the time needed to resolve the symptoms.

Neurogenic Bladder-Induced Stone in a Pelvic Kidney of a Caudal Regression Syndrome Patient: Management of a Complex Case

Percutaneous nephrolithotomy (PCNL) is a difficult treatment for treating kidney stones, especially when there are orthopedic or skeletal abnormalities. Here, in a 19-year-old male, we describe a two-step PCNL with a case of caudal regression syndrome (CRS) and a pelvic kidney, with an extremely deformed neurogenic bladder on intermittent catheterization. Our conclusion is that PCNL may be done safely with minimum morbidity in patients with caudal regression syndrome by utilizing adult equipment for heavy stone burdens, allowing full and rapid stone removal.

Screening and management of bladder and bowel dysfunction in general pediatric outpatient clinic: a prospective observational study

BACKGROUND

Bladder and bowel dysfunction (BBD) is a common disorder in children that is often associated with psychosocial and behavioral problems. Data specific to BBD in Asian children are comparatively scarce. Accordingly, this study aimed to investigate the prevalence of BBD and the response to standard urotherapy among Thai children attending the general pediatric outpatient clinic of Siriraj Hospital - Thailand's largest national tertiary referral center.  METHODS: Children aged 4-12 years were recruited to complete the Dysfunctional Voiding Symptom Score (DVSS) questionnaire to screen for BBD during 2018 to 2020. Standard urotherapy, which consists of education and behavior management, was prescribed to those with a DVSS score that suggests the presence of BBD. Enrolled children and their caregivers were followed-up at 3 and 6 months. The Strengths and Difficulties Questionnaire (SDQ) was completed at baseline. DVSS scores at baseline, and at 3 months and 6 months after standard urotherapy were compared using repeated measures analysis of variance (ANOVA).

RESULTS

A total of 1,042 children completed the DVSS during the study period, and 90 (8.6%) were deemed to have BBD. The mean age of BBD children was 6.9 ± 2.2 years, and the female to male ratio was 2.9:1. The most common symptoms were defecation frequency (80.0%), difficult defecation (80.0%), curtsying (74.4%), urgency (68.9%), infrequent voiding (43.3%), and daytime incontinence (32.2%). Forty-one BBD children completed the SDQ, and 32.5% had scores suggestive of hyperactivity problems. Among the 24 BBD patients who were followed-up after 3 and 6 months of standard urotherapy, there was a significant improvement in DVSS results (9.5 ± 3.1 at baseline vs. 6.9 ± 3.4 at 3 months vs. 4.4 ± 3.9 at 6 months; p < 0.01). Nine of 12 patients with urinary incontinence showed complete response at 6 months. The overall Bristol stool score significantly improved from 2.6 ± 0.7 at baseline to 3.2 ± 1.0 at 6 months (p = 0.03).

CONCLUSIONS

BBD is a prevalent condition among Thai children that is often associated with emotional and behavioral problems. Standard urotherapy prescribed in a general pediatric outpatient clinic setting yielded favorable outcomes in Thai children with BBD.

Systematic review and meta-analysis: relationships between attention-deficit/hyperactivity disorder and urinary symptoms in children

Lower urinary tract symptoms (LUTS), e.g., urinary frequency, pressure, urgency, and overactive bladder syndrome, are commonly reported in children with attention-deficit/hyperactivity disorder (ADHD). Understanding the co-occurrence of these conditions has implications regarding clinical approaches, treatments, and improved quality of life. We conducted a systematic review and meta-analysis to examine the relationships between LUTS and ADHD in children. We searched for articles published between January 1990 and July 2019, in PubMed, CENTRAL, and PsycNet. Two authors independently screened all articles and extracted data. We performed random-effect meta-analyses for ADHD with pooled outcomes for LUTS. We identified 119 relevant articles in the literature and 18 articles fulfilled the inclusion criteria for the systematic review, of which, 5 articles had sufficient data for meta-analysis. Examining ADHD among individuals with LUTS, the odds ratio was 2.99 (95% CI 1.13, 7.88, p < 0.001), compared to controls. In multiple studies, the mean overall score for LUTS, using a standardized measure, was significantly higher in patients with ADHD in comparison to controls, and the severity of ADHD was positively associated with the severity of LUTS. Younger age in children was correlated with a higher LUTS score. Different subtypes of urinary incontinence demonstrated differences in behavioral problems and psychiatric comorbidity. Sex differences in LUTS were not consistent across articles. Our results indicate clinically significant associations between ADHD and LUTS in children. Because LUTS and ADHD are common disorders in children, clinicians should be aware of these associations as they inform optimal assessment and treatment strategies.

Risk Factors for the Development of Febrile Recurrences in Children with a History of Urinary Tract Infection

OBJECTIVE

To identify risk factors for febrile recurrence of urinary tract infections (UTIs) in children with a history of UTI.

STUDY DESIGN

We included 500 children aged 2-72 months with a history of UTI who were followed prospectively for approximately 2 years in the context of 2 previously conducted studies (Randomized Intervention for Children with Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation). We identified significant risk factors for febrile recurrences among children not receiving antimicrobial prophylaxis using univariate and multivariate logistic regression.

RESULT

On univariate analysis, non-Black race, febrile index UTI, bowel-bladder dysfunction, grade IV vesicoureteral reflux, renal scarring at baseline, and renal-bladder ultrasound abnormalities were associated with febrile recurrence. On multivariate analysis, the following variables independently increased the odds of febrile recurrences (OR; 95% CI): non-Black race (7.1; 1.5-127.9), bowel-bladder dysfunction (2.6; 1.1-5.3), febrile index UTI (2.5; 1.1-6.9), abnormalities on renal-bladder ultrasound scan (2.6; 1.2-5.6), grade IV vesicoureteral reflux (3.9; 1.4-10.5), and renal scarring at baseline (4.7; 1.2-19.1).

CONCLUSIONS

Non-Black race and grade IV vesicoureteral reflux increased the odds of febrile recurrence of UTI. Although our findings should stimulate other studies to further explore the relationship between race and UTIs, given that the link between race and UTI recurrence is unclear, race should not be used to make decisions regarding management of children with a UTI.

Uroterapia y mindfulness en el tratamiento de niños con disfunción vesical e intestinal: protocolo para un ensayo clínico

Objetivo:

Presentar un protocolo para ensayo clínico controlado y aleatorizado que estudie los resultados de la asociación entre técnicas de uroterapia estándar y mindfulness en la adhesión al programa y reducción de síntomas de disfunción vesical e intestinal en escolares.

Método:

Presentación descriptiva del protocolo.

Resultados:

El grupo de control deberá recibir orientaciones de medidas comportamentales gradualmente en visitas semanales, durante cuatro semanas. Tales medidas deberán contemplar: control de la ingesta de agua, intervalo de evacuación, ingestión de potenciales irritantes de la vejiga, y entrenamiento muscular del fondo pélvico. El grupo experimental deberá ser sometido al mismo protocolo, además de las técnicas de atención plena (mindfulness), previamente al inicio de cada consulta de uroterapia.

Conclusión:

Se espera estimular la aplicación de este protocolo en diferentes escenarios y así evaluar la contribución de la práctica de atención plena en la adhesión al tratamiento y en la reducción de síntomas.

Outcome of Urinary Bladder Dysfunction in Children

Bladder dysfunction in children is common, the most frequent underlying causes are neurologic bladder (NB), dysfunctional voiding syndrome (DVS), and the valve bladder syndrome (VBS). The aim of this study was to determine the 10-y survival rate and the associated morbidities in children with bladder dysfunction. One hundred ninety-nine children were included in the study; 60 with VBS, 75 DVS, and 64 NB. The mean age was 44 mo (CI: 37-50.9) and mean GFR 50.1 (CI 44.6-55.6) mL/min/1.73m². The 10-y survival rate was 89%. Compared with patients with VBS, the mortality was 11 times higher among patients with NB (p = 0.02) but not significantly higher than patients with DVS (p = 0.2). GFR < 15 mL/min/1.73 m² increases mortality rate by 6 times compared with normal GFR (p = 0.007). Late age at presentation (> 5 y) increases mortality risk and/or the need for renal replacement therapy (RRT) by almost 5 times (p = 0.013). It was concluded that the etiology of bladder dysfunction, baseline GFR, and the age at presentation significantly influence the survival rate and morbidities.

Risk factors for breakthrough urinary tract infection in children with vesicoureteral reflux receiving continuous antibiotic prophylaxis

BACKGROUND

To investigate the risk factors for breakthrough urinary tract infection (BT-UTI) in children with vesicoureteral reflux (VUR) receiving continuous antibiotic prophylaxis (CAP).

METHODS

This was a single-centre cohort study (January 2016 to December 2019). The clinical data of 256 children with grade I-V VUR receiving CAP were analysed. In this study, exposure variables were sex, younger age at the initial diagnosis of UTI ≤12 months, high-grade VUR, bilateral VUR, aetiology, presence of renal scarring at the initial diagnosis, presence of renal function impairment at the initial diagnosis, ultrasound abnormalities, antibiotic used and bladder and bowel dysfunction (BBD). Outcome was BT-UTI.

RESULTS

BT-UTI occurred in 81 out of 256 children with grade I-V VUR who received CAP, an incidence of 31.64%. Univariate analysis showed that younger age at the initial diagnosis of UTI (≤12 months), bilateral VUR, renal scarring on the dimercaptosuccinic acid (DMSA) scan at the initial diagnosis of UTI and BBD were correlated with the occurrence of BT-UTI. Multivariate analysis showed that younger age at the initial diagnosis of UTI (≤12 months) [hazard ratio (HR): 4.629; 95% confidence interval (CI): 1.302-16.462], bilateral VUR (HR: 2.078; 95% CI: 1.084-4.022) and BBD (HR: 3.194; 95% CI: 1.243-8.206) were independent risk factors for the occurrence of BT-UTI.

CONCLUSIONS

For VUR children receiving CAP, younger age at the initial diagnosis of UTI (≤12 months), bilateral VUR, and BBD were independent risk factors for the occurrence of BT-UTI.

Pelvic Floor Muscle Resting Tone in Children With Dysfunctional Voiding Symptomology Following Simple Gross Motor Exercises

PURPOSE

The study aimed to understand the effects of a set of simple gross motor exercises on pelvic floor muscle (PFM) resting tone (RT) in children with dysfunctional voiding symptomology.

METHODS

The study compared PFM RT for a single-sample before and after 2 protocols: exercise versus relaxation (metric standard).

RESULTS

Participants included 27 children ages 5.00 to 10.92 years. Preintervention PFM RT was similar between the interventions: 63% (exercise) and 78% (relaxation) of children decreased PFM RT following intervention. Between-intervention post-minus-prechanges in PFM RT were compared. Between-intervention differences were similar.

CONCLUSIONS

Exercise and relaxation protocols were comparable in lowering PFM RT in children with voiding dysfunction. Findings are clinically worthy in that either exercises or relaxation prior to toileting may assist with more complete emptying in children with symptoms.

Can lockdown and homeschooling change the outcome of urotherapy for lower urinary tract dysfunction in children?

OBJECTIVE

Lower urinary tract dysfunction (LUTD) are still important for both children and pediatric urologists. Urotherapy is recommended in LUTD treatment management. In our country, all citizens under the age of 20 were banned from going out of their homes due to Covid-19 and the homeschooling system has been adopted The aim of this study is to investigate the effect of lockdown and homeschooling on the effectiveness of urotherapy used for LUTD treatment.

METHODS

83 patients were included in the study group. Besides 306 patients were determined as the control group (pre-Covid). The patients in the study group and the control group were compared in terms of improvement in Dysfunctional voiding and incontinence scoring system (DVISS), quality of life scores, bladder diary, Bristol stool scale, and treatment responses at 3rd and 6th months.

RESULTS

The study group and control group were compared in terms of DVISS, voiding frequency and incontinence in the voiding diary, quality of life score, and Bristol stool scale at admission visit and the group characteristics were similar. During the 6th month visit, the mean DVISS of the study group was found to be significantly lower (7.12 ± 3.48; 8.58 ± 4.06 respectively (p 0.002)). Daily voiding frequency was similar in the study group and the control group during the 2nd and 3rd visit. The study group's mean number of daily incontinence was significantly lower at visit 3 (0.57 ± 0.9; 0.94 ± 0.27, respectively (p 0.02).After six months of treatment, 13.3% of the study group patients had a complete response, 44.6% had a partial response, whereas 42.2% non-responders. In the control group, the response rates were as 5.9%, 39.2% and 54.9% respectively (p 0.02).

CONCLUSIONS

LUTD is still very common in pediatric urology. Standard urotherapy is widely used in treatment management. According to our results, the success of standard urotherapy increases with lockdown and homeschooling. We have shown that the success of standard urotherapy can be improved by regulating environmental conditions. In terms of LUTD management, environmental conditions can be regulated to provide a better quality of life and a better cure in a more economical way.

Evaluation of autonomic function in children and adolescents with overactive bladder

Aims:

To evaluate autonomic activity in children/adolescents with isolated overactive bladder.

Materials and Methods:

Descriptive, analytical, non-interventional, cross-sectional study conducted between February 2017 and January 2018 with individuals aged between 5 and 17 years old, with overactive bladder (OAB group) or asymptomatic (control). Neurological or anatomical abnormalities, diabetes mellitus and kidney failure constituted exclusion criteria. The DVSS and the Rome III questionnaire were applied, and heart rate variability (HRV) was assessed. The chi-square test, Student's t-test, ANOVA and the Mann Whitney U test were used in the statistical analysis.

Results:

41 patients with OAB and 20 controls were included. In the OAB group, there were more girls (p=0.23), more overweight/obese and constipated patients. The DVSS score was higher in the OAB group. HRV showed a higher heart rate variability at the frequency domain and LF/HF variation in the control group (p=0.02 and p=0.05 respectively). In the intergroup evaluation, LF (Hz) was predominant in the control group at the post-voiding evaluation moment (p=0.03).

Conclusion:

The control group demonstrated a physiological heart rate variation during the voiding process, with a predominance of sympathetic activity during urinary storage.

Association between Attention Deficit Hyperactivity Disorder and lower urinary tract symptoms in children and adolescents in a community setting

INTRODUCTION

The present study aims to investigate the prevalence of lower tract urinary symptoms (LUTS) and symptoms of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents and their association in a community setting using validated scoring instruments.

MATERIALS AND METHODS

A cross-sectional study was carried out from February 2015 to December 2019, during which the parents or guardians of 431 children and adolescents from 5 to 13 years of age, attending a general pediatric outpatient clinic were interviewed.

RESULTS

The prevalence of ADHD symptoms and LUTS were 19.9% and 17.9%, respectively. Of the 82 children and adolescents with ADHD, 28% (23) had LUTS (OR 2.31, 95% CI 1.28 to 3.75, p=0.008). Mean total DVSS score in children in the group of children presenting ADHD symptom was significantly higher than those without ADHD symptom (10.2±4.85 vs. 4.9±2.95, p=0.002). Urgency prevailed among LUTS as the most frequent symptom reported by patients with ADHD symptoms (p=0.004). Analyzing all subscales of the DVSS, the items "When your child wants to pee, can't he wait? "Your child holds the pee by crossing his legs, crouching or dancing?" were higher in those with ADHD symptoms (p=0.01 and 0.02, respectively). Functional constipation was present in 36.4% of children with LUTS and 20.7% without LUTS (OR 4.3 95% CI 1-5.3 p=0.001).

CONCLUSION

Children and adolescents with ADHD symptoms are 2.3 times more likely to have LUTS. The combined type of ADHD was the most prevalent among them.

Translation and cross-cultural adaptation of the Childhood Bladder and Bowel Dysfunction Questionnaire (CBBDQ)

OBJECTIVE

To translate and cross-culturally adapt the Childhood Bladder and Bowel Dysfunction Questionnaire (CBBDQ) for use in Brazilian Portuguese. The CBBDQ is an 18-item tool covering 10 bladder and 8 bowel symptoms that was developed for use with children of 5 to 12 years of age with bowel and bladder dysfunction (BBD). The instrument has already been validated for use in Dutch and English.

METHOD

In the process of translation and cultural adaptation from English to Portuguese, the CBBDQ was submitted to undergo the required steps as established by the international methodological criteria: forward translation, synthesis, back-translation, expert panel review and pre-testing.

RESULTS

Ninety-three parents of children with lower urinary tract dysfunction answered the questionnaire. The mean age of the children was 7.6±2.1 years and 54 were female. Internal consistency was excellent, with a Cronbach's alpha of 0.91 to 0.96. Additionally, reliability was high, with an intraclass correlation coefficient of 0.94 (95%CI: 0.85-0.93; p<0.0001).

CONCLUSION

The translation and cultural adaptation of the CBBDQ enabled a quantitative evaluation of bladder and bowel symptoms to be performed in Brazilian children. The scores achieved allow the severity of BBD to be evaluated, as well as the patient's progress during treatment. The use of this questionnaire in clinical practice and research will allow more consistent data on BBD to be obtained.

Urgency in children with overactive bladder or voiding postponement: What's the difference?

INTRODUCTION

Overactive bladder (OAB) and voiding postponement (VP) can share the same symptom of urgency, but with different pathophysiology, including the cerebral interpretation of bladder filling. The objective of the present study was to compare the clinical, psychological and sociodemographic features of children with urgency for OAB with those who presented urgency for VP (UrVP).

METHODS

A retrospective cross-sectional study with an analytical component was conducted with patients of 5-14 years of age with urinary urgency between January, 2014, and January, 2019. Urinary symptoms were evaluated using the Dysfunctional Voiding Scoring System (DVSS) questionnaire, constipation using the Rome IV criteria and psychological symptoms using the Strengths and Difficulties Questionnaire (SDQ). All the patients had bell-shaped or tower-shaped curves at uroflowmetry and no significant post-void residual volume at ultrasonography. Patients were classified as having OAB or UrVP depending on whether they voided >3 or ≤3 times/day, respectively.

RESULTS

Median age of the 101 children/adolescents included was 9 years, with no significant difference between the groups. The prevalence of OAB was 60.4%. Girls constituted 57.4% of the sample but 67.5% of the postponement group, although no independent association was found between sex and diagnosis. The prevalence of constipation was 75.2%, with no difference between the groups. The children with OAB had higher behavioral hyperactivity scores and more intense externalizing symptoms, although there was no significant difference between the groups for the SDQ total difficulties score. In the multivariate analysis, the independent clinical factors associated with a diagnosis of OAB were behavioral hyperactivity (OR = 5.134), urge incontinence (OR = 4.694) and MVV/EBC (%) (OR = 0.983).

CONCLUSION

More behavioral problems, particularly hyperactivity, were found in children with OAB compared to those with UrVP. No statistically significant difference was found between the groups evaluated insofar as their sociodemographic characteristics are concerned. Furthermore, as expected, there was a strong association between the symptom of urge incontinence and lower MVV/EBC in the children and adolescents with OAB compared to those with voiding postponement.

Neurodevelopmental and psychiatric disorders in pediatric bladder and bowel dysfunction

BACKGROUND

Bladder and bowel dysfunction (BBD) is a common pediatric problem that describes a constellation of lower urinary tract symptoms associated with constipation and/or encopresis. Its association with neurodevelopmental and psychiatric (NDP) problems is not well understood.

OBJECTIVES

Our primary aim was to identify pre-existing NDP disorders in children with BBD. Secondarily, we aimed to screen for new behavioral problems and evaluate the association between bladder or bowel symptoms and behaviors symptoms.

METHODS

A cross sectional study was conducted in urology clinics. New patients referred for BBD between 4 and 17 years old were recruited and completed: a demographics survey, Dysfunctional Voiding Score System questionnaire, assessment of bowel movements with the Bristol Stool Scale, and Strength and Difficulties questionnaire (SDQ). Those with known spinal dysraphism were excluded. SDQ scores were evaluated for abnormal screens in different subscales and total difficulties scores. Pearson correlation analyses were conducted for association.

RESULTS

We included 61 participants (age 9.5 ± 4.1 years), including 33 females and 28 males. One or more pre-existing NDP disorder(s) was reported in 14 (23%) children; most commonly being learning disability (43%) and attention deficit hyperactivity disorder (29%). This cohort had more severe BBD symptoms as reflected in DVSS scores. SDQ scores demonstrated that 12 patients without pre-existing NDP diagnoses scored in the clinical range, with hyperactivity as the most common difficulty (6/12; 50%).

CONCLUSIONS

A significant proportion of children with BBD have a comorbid NDP disorder and present with more severe symptomatology. The SDQ can be used as a behavioral screening tool this population for the identification of children who may benefit from formal developmental pediatrics assessment.

Desmopressin response in nocturnal enuresis without nocturnal polyuria in Japanese children

OBJECTIVES

To evaluate whether the efficacy of desmopressin differs between patients with and without nocturnal polyuria.

METHODS

A total of 65 treatment-naïve children with monosymptomatic nocturnal enuresis were enrolled (45 boys; median age 8.9 years). Patients received desmopressin as their first-line treatment. Four different standards were used (Akashi and Hoashi >0.9 mL/kg/sleeping hour; Hamano >[age + 2] × 25 × 130% mL; the International Children's Continence Society >[age + 1] × 30 × 130% mL; and Rittig >[age + 9] × 20 mL) to assess nocturnal polyuria. The effectiveness of desmopressin was compared between patients with and without nocturnal polyuria according to each standard. A response was defined as a reduction in wet nights of >50%.

RESULTS

The desmopressin treatment efficacy rate was 54% for polyuria and 67% for non-polyuria patients (P = 0.20), 45% for polyuria and 68% for non-polyuria patients (P = 0.08), 54% for polyuria and 59% for non-polyuria patients (P = 0.80), and 52% for polyuria and 61% for non-polyuria patients (P = 0.61), for the Akashi and Hoashi's, Hamano's, International Children's Continence Society and Rittig's standards, respectively.

CONCLUSIONS

No difference was observed in the short-term clinical efficacy of desmopressin regardless of the presence of nocturnal polyuria. Thus, this might be a feasible treatment option for patients with nocturnal enuresis without nocturnal polyuria.

Recognition and management of bladder bowel dysfunction in children with autism spectrum disorder

Children with autism spectrum disorder (ASD) with rigidities, anxiety or sensory preferences may establish a pattern of holding urine and stool, which places them at high risk of developing bladder bowel dysfunction (BBD). BBD, despite being common, is often unrecognised in children with ASD. With this case report of a 7-year-old girl with ASD presenting with acute retention of urine, we attempt to understand the underlying factors which may contribute to the association between BBD and ASD. Literature review indicates a complex interplay of factors such as brain connectivity changes, maturational delay of bladder function, cognitive rigidities and psychosocial stressors in children with ASD may possibly trigger events which predispose some of them to develop BBD. Simple strategies such as parental education, maintaining a bladder bowel diary and treatment of constipation may result in resolution of symptoms.

Respiratory sleep disorders, nasal obstruction and enuresis in children with non-syndromic Pierre Robin sequence

INTRODUCTION

Obstructive sleep apnea is highly prevalent in non-syndromic Pierre Robin sequence patients. Studies have found a probable relationship between obstructive sleep apnea and nasal obstruction and between obstructive sleep apnea and enuresis. Assessment of the relationship between these variables in non-syndromic Pierre Robin sequence patients is scarce.

OBJECTIVE

The present study aims to evaluate the relationship between symptoms of obstructive sleep apnea, nasal obstruction and enuresis, determining the prevalence of symptoms suggestive of these conditions, in schoolchildren with non-syndromic Pierre Robin sequence, and describe the prevalence of excessive daytime sleepiness habitual snoring and voiding dysfunction symptoms associated with enuresis.

METHODS

This was a prospective analytical cross-sectional study developed at a reference center. Anthropometric measurements and a structured clinical interview were carried out in a sample of 48 patients. The instruments "sleep disorders scale in children" "nasal congestion index questionnaire" (CQ-5), and the "voiding dysfunction symptom score questionnaire" were used. Statistical analysis was performed for p < 0.05.

RESULTS

Positive "sleep disorders scale in children" scores for obstructive sleep apnea and CQ-5 for nasal obstruction were observed in 38.78% and 16.33%, respectively. Enuresis was reported in 16.33% of children, being characterized as primary in 71.43% and polysymptomatic in 55.55%; according to the "voiding dysfunction symptom score questionnaire". There was a significant relationship between nasal obstruction and obstructive sleep apnea symptoms (p < 0.05), but no significance was found between obstructive sleep apnea symptoms and enuresis, and between nasal obstruction and enuresis. The prevalence of excessive daytime sleepiness was 12.24% and of habitual snoring, 48.98%. A family history of enuresis, younger age in years and a positive "voiding dysfunction symptom score questionnaire" score were associated with a higher prevalence of enuresis (p < 0.05).

CONCLUSION

Children with non-syndromic Pierre Robin sequence are at high risk for obstructive sleep apnea symptoms and habitual snoring, with a correlation being observed between nasal obstruction and obstructive sleep apnea symptoms. In addition, the study showed that non-syndromic Pierre Robin sequence, obstructive sleep apnea and nasal obstruction symptoms were not risk factors for enuresis in these patients.

Urinary continence after high urogenital sinus repair conducted with posterior prone approach: electromyography-uroflowmetric assessment

PURPOSE

We aimed to present the results of urinary continence assessment objectively with electromyography (EMG)-uroflowmetry after high urogenital sinus (HUGS) repair with posterior prone approach without division of rectum.

METHODS

The records of patients who underwent HUGS repair via posterior prone approach between January 2005 and July 2018 were reviewed retrospectively. Incontinence, dysuria, hesitation, and straining during urination were evaluated during the clinical follow-up. Dysfunctional voiding scoring system was used as a questionnaire. Patients were re-evaluated with EMG-uroflowmetry in terms of voiding volume and pattern, voiding time, maximum flow rate, average flow rate, maximum flow time, and post-voiding residual volume.

RESULTS

Seven patients with HUGS were treated with a posterior prone approach. The median age of the patients was 18 months (8-21 months). The median UGS length was 4.4 cm (3.6-5.5 cm), urethral length was 1.1 cm (1.0-1.5 cm), and vaginal length was 4.9 cm (4.1-5.1 cm). No urination or defecation problems were described by the patients or their parents. When the results of the dysfunctional voiding scoring systems questionnaire were analyzed, results scored 7 (range 5-8). EMG-uroflowmetric test graphics of the patients showed normal flow curves without plateau, intermittency or irregularity. Pelvic EMG assessment was normal in all patients.

CONCLUSION

EMG-uroflowmetry has shown objectively that urinary continence and normal voiding pattern are preserved after HUGS repair with posterior prone approach without division of rectum.

Dysfunctional voiding: update on evaluation and treatment

PURPOSE OF REVIEW

This review will be covering dysfunctional voiding, its diagnosis, and treatment options. This will focus primarily on dysfunctional voiding rather than all lower urinary tract dysfunction and we will focus on some of the newer findings and progress within this disease.

RECENT FINDINGS

Dysfunctional voiding is the inappropriate sphincter and pelvic floor constriction during voiding in an otherwise neurologically normal child. This has a wide spectrum of symptoms and can lead to a number of complications such as chronic kidney disease and poor quality of life if not appropriately addressed. Dysfunctional voiding is diagnosed with a careful examination and history with further imaging including a renal ultrasound and uroflowmetry to confirm the diagnosis. Urotherapy and biofeedback are the first and second-line treatments respectively and lead to significant improvement or cure in the majority of patients. For refractory patients, additional therapy options include use of α-blockers, botulinum injection, and electroneurostimulation, though the majority of the literature surrounding the use of these therapies consists of small studies with heterogenous causes of voiding dysfunction.

SUMMARY

Dysfunctional voiding is a common urologic complaint that has many excellent options for improving the patient's voiding issues and should be considered in patients with voiding dysfunction.

Preoperative Bladder Bowel Dysfunction Is the Most Important Predictive Factor for Postoperative Urinary Retention After Robot-Assisted Laparoscopic Ureteral Reimplantation via An Extravesical Approach: A Multi-Center Study

Introduction: Postoperative acute urinary retention (pAUR) is a known occurrence after robot-assisted laparoscopic ureteral reimplantation via an extravesical approach (RALUR-EV). We hypothesized that the risk factor of pAUR after RALUR-EV might be similar to that of pAUR after open reimplantation. We aimed at performing a retrospective multi-institutional study to evaluate the risk factors for pAUR after RALUR-EV. Materials and Methods: Perioperative data collected from two tertiary referral hospitals included demographics and perioperative variables such as bladder bowel dysfunction (BBD) status, vesicoureteral reflux (VUR) grade, and laterality. pAUR was defined as the need for urethral catheter replacement after removal of the initial postoperative catheter. Univariate and multivariate analyses were performed to identify risk factors for pAUR. Results: A total of 117 patients with 174 renal units from the 2 hospitals were enrolled in this study. The median age at the time of surgery was 5 (0.3-19) years. Bilateral RALUR-EV was performed in 57 (48.7%) cases. pAUR rate was 3.4% in all patients and 7.0% in 57 patients with bilateral VUR. All four cases of pAUR occurred after bilateral surgery. Univariate analysis showed age (p = 0.037), weight (p = 0.039), height (p = 0.040), and bilaterality (p = 0.037) as risk factors of pAUR. In a multivariate analysis, BBD was the only significant risk factor of pAUR (p = 0.037). Conclusion: Urinary retention after RALUR-EV occurred less frequently when compared with the previously reported open surgery series. pAUR was seen only in bilateral cases in our series. Preoperative history of BBD, but not male gender or length of surgical time, was the only risk factor of pAUR after RALUR-EV.

Bladder/bowel dysfunction in pre-school children following febrile urinary tract infection in infancy

BACKGROUND

An association between bladder-bowel dysfunction (BBD) and urinary tract infection (UTI) is well-known. However, a question less explored is whether children with UTI early in life also have increased prevalence of BBD after they are toilet-trained. In this study, consecutively selected children with pyelonephritis during their first year of life were assessed for BBD at pre-school age.

METHODS

Ninety-two children (51 boys) hospitalized due to pyelonephritis during their first year of life were assessed for BBD at median age 5.4 years. A validated BBD questionnaire, along with urine flow and residual volume measurements, was used for diagnosing BBD. During follow-up, the group was well-characterized regarding renal status, vesicoureteral reflux (VUR), and recurrent UTI.

RESULTS

BBD was diagnosed in 35/92 (38%), of which the majority was sub-diagnosed with dysfunctional voiding (DV). There was a strong association between BBD and recurrent UTI during follow-up (p < 0.0001), but only a slight association with VUR status at presentation. Nevertheless, in the group with both BBD and VUR, recurrent UTI was four times higher (12/13, 92%) than in children who had neither VUR nor BBD (23%), (p = 0.0008). BBD was also associated with kidney damage (p = 0.017).

CONCLUSION

In children with pyelonephritis during the first year of life, 38% had BBD at pre-school age, regardless of whether they had VUR or not. The study shows an important association between BBD and recurrent UTI, so an assessment of BBD is therefore recommended for pre-school children with UTI, especially when they have history of pyelonephritis during infancy.

Caudal regression syndrome and a pelvic kidney: case report

Caudal regression syndrome (CRS) is a rare congenital variation. A high incidence of renal and genitourinary malformations has been observed in patients with CRS, with the most common being neurogenic bladder and renal agenesis. We report a rare case report documenting both CRS and a pelvic kidney found during a diagnostic magnetic resonance imaging. Although renal anatomy variants are found in patients with CRS, a pelvic kidney is normally not part of the constellation of findings in this malformation. As seen in our patient, a pelvic kidney should be considered in patients suspected of having CRS.

Corticosteroids to prevent kidney scarring in children with a febrile urinary tract infection: a randomized trial

BACKGROUND

To evaluate the efficacy of adjuvant systemic corticosteroids in reducing kidney scarring. A previous study suggested that use of adjuvant systemic corticosteroids reduces kidney scarring in children radiologically confirmed to have extensive pyelonephritis. Efficacy of corticosteroids for children with febrile urinary tract infection (UTI) has not been studied.

METHODS

Children aged 2 months to 6 years with their first febrile UTI were randomized to corticosteroids or placebo for 3 days (both arms received antimicrobial therapy); kidney scarring was assessed using ^99mTc-dimercaptosuccinic acid kidney scan 5-24 months after the initial UTI.

RESULTS

We randomized 546 children of which 385 had a UTI and 254 had outcome kidney scans (instead of the 320 planned). Rates of kidney scarring were 9.8% (12/123) and 16.8% (22/131) in the corticosteroid and placebo groups, respectively (p = 0.16), corresponding to an absolute risk reduction of 5.9% (95% confidence interval: - 2.2, 14.1).

CONCLUSION

While children randomized to adjuvant corticosteroids tended to develop fewer kidney scars than children who were randomized to receive placebo, a statistically significant difference was not achieved. However, the study was limited by not reaching its intended sample size.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov , NCT01391793, Registered 7/12/2011 Graphical abstract.

Prevalence of smooth muscle dysfunction among children with Duchenne muscular dystrophy

Smooth muscle dysfunction in Duchenne muscular dystrophy (DMD) has been rarely studied. A cross-sectional study was conducted to estimate the prevalence of smooth muscle dysfunction (vascular, upper gastrointestinal, and bladder smooth muscle) in children with DMD using questionnaires (Pediatric Bleeding Questionnaire, Pediatric Gastroesophageal Symptom Questionnaire, and Dysfunctional Voiding Symptom Score). Investigations included bleeding time estimation, nuclear scintigraphy for gastroesophageal reflux, and uroflowmetry for urodynamic abnormalities. Ninety-nine subjects were included in the study. The prevalence of vascular, upper gastrointestinal, and bladder smooth muscle dysfunction was 27.2%. Mean bleeding time was prolonged by 117.5 seconds. The prevalence of gastroesophageal reflux was 21%. Voided volume/estimated bladder capacity over 15% and abnormal flow curves on uroflowmetry were seen in 18.2% and 9.7% of the subjects, respectively. Our study highlights the need for addressing issues related to smooth muscle dysfunction in the routine clinical care of patients with DMD.

Therapeutic effects of desmopressin in primary monosymptomatic noctural enuresis treatment depending on Patients'Age

PURPOSE

To test the therapeutic effects of Desmopressin (dDAVP) in primary monosymptomatic nocturnal enuresis (PMNE) treatment depending on patients'age.

MATERIAL AND METHODS

The prospective research was carried out in the 2014-2018 period, during which 89 patients were observed who were treated with dDAVP due to the previously diagnosed PMNE. The patients were divided into two age groups. The first group (Group 1) consisted of 43 patients age 5 to 6, with the average age of 5.6 ± 0.5, out of whom 35 (81.4%) were boys, and 8 (18.6%) girls. The second group (Group 2) consisted of 46 patients age over 7 to 12, with the average age of 9.7 ± 1.6, out of whom 30 (65.2%) were boys, and 16 (34.8%) were girls. There was no statistically relevant difference according to sex (p = 0.086). After the 3-month treatment, all the patients in both groups were tested for the effects of dDAVP in PMNE treatment.

RESULTS

The average enuresis frequency in the first group (Group 1) before therapy was 26.0 ± 6.2 per month, whereas the average enuresis frequency after therapy was 11.0 ± 8.0 per month (p = 0.040). The average enuresis frequency in the second group (Group 2) before therapy was 23.1 ± 6.2 per month, whereas the average enuresis frequency after therapy was 3.8 ± 3.6 per month (p = 0.036). ANOVA data analysis of repeated measurements has indicated that there is a statistically relevant interaction between the groups (p = 0.006), i.e. enuresis frequency decreases considerably more in the second group (Group 2).

CONCLUSION

PMNE with dDAVP is noticeably more effective with patients over 7 years of age.