Effects of oxybutynin on vesicoureteral reflux in children

Outcomes of targeted treatment for vesicoureteral reflux in children with nonneurogenic lower urinary tract dysfunction

PURPOSE

There is a known association between nonneurogenic lower urinary tract conditions and vesicoureteral reflux. Whether reflux is secondary to the lower urinary tract condition or coincidental is controversial. We determined the rate of reflux resolution in patients with lower urinary tract dysfunction using targeted treatment for the underlying condition.

MATERIALS AND METHODS

Patients diagnosed and treated for a lower urinary tract condition who had concomitant vesicoureteral reflux at or near the time of diagnosis were included. Patients underwent targeted treatment and antibiotic prophylaxis, and reflux was monitored with voiding cystourethrography or videourodynamics.

RESULTS

Vesicoureteral reflux was identified in 58 ureters in 36 females and 5 males with a mean age of 6.2 years. After a mean of 3.1 years of treatment reflux resolved with targeted treatment in 26 of 58 ureters (45%). All of these patients had a history of urinary tract infections before starting targeted treatment. Resolution rates of vesicoureteral reflux were similar for all reflux grades. Resolution or significant improvement of reflux was greater in the ureters of patients with dysfunctional voiding (70%) compared to those with idiopathic detrusor overactivity disorder (38%) or detrusor underutilization (40%).

CONCLUSIONS

Vesicoureteral reflux associated with lower urinary tract conditions resolved with targeted treatment and antibiotic prophylaxis in 45% of ureters. Unlike the resolution rates reported in patients with reflux without a coexisting lower urinary tract condition, we found that there were no differences in resolution rates among grades I to V reflux in patients with lower urinary tract conditions. Patients with dysfunctional voiding had the most improvement and greatest resolution of reflux. Additionally grade V reflux resolved in some patients.

[Non-neurogenic bladder dysfunction and vesicoureteral reflux in children]

Various types of bladder dysfunction are associated with urinary tract infection, renal damage and vesicoureteral reflux (VUR). In this article the influence of functional bladder disturbances such as detrusor instability (overactive bladder, OAB) and bladder sphincter dyssynergia (dysfunctional voiding), on the resolution of vesicoureteral reflux are reviewed. In summary, it is important to distinguish between children with dysfunctional voiding (increased activity of the pelvic floor during voiding) and those with OAB (detrusor overactivity during filling) because the latter has less effects on VUR.

Urodynamic abnormalities in toilet trained children with primary vesicoureteral reflux

PURPOSE

We investigated associated urodynamic abnormalities in toilet trained children with vesicoureteral reflux.

MATERIALS AND METHODS

A total of 298 toilet trained children with primary vesicoureteral reflux underwent urodynamic evaluation. Urodynamic parameters were reviewed and correlated with age, gender, presence of lower urinary tract symptoms and reflux severity.

RESULTS

Symptomatic lower urinary tract symptoms were present in 111 children (37.2%, group 1). Children with lower urinary tract symptoms had significantly decreased severity of vesicoureteral reflux compared to children without these symptoms (187 patients, group 2). The majority of the patients had normal early bladder compliance regardless of presence of lower urinary tract symptoms or reflux grade. On the other hand, decreased late bladder compliance was more common in group 1 vs group 2. Ratio of cystometric bladder capacity to expected bladder capacity was higher in group 2. Detrusor overactivity was observed in 28.5% of the children, and the incidence was significantly higher in group 1 vs group 2, and in mild vs moderate or severe reflux. Dysfunctional voiding from bladder sphincter dyscoordination was seen in 32% of children 2.5 to 4 years old with vesicoureteral reflux and lower urinary tract symptoms, compared to 8% in children 5 to 16 years old.

CONCLUSIONS

The presence of lower urinary tract symptoms in children with vesicoureteral reflux correlated well with some urodynamic findings suggestive of overactive bladder and negatively correlated with reflux severity. In contrast, dysfunctional voiding was more common in younger children with reflux and lower urinary tract symptoms. These findings suggest that treatment of voiding dysfunction should be directed toward the specific type of abnormality in children with vesicoureteral reflux.

Bladder volume on voiding cystourethrogram correlates with indications and results in male infants

OBJECTIVES

To evaluate whether the bladder size on the voiding cystourethrogram (VCUG) might be a proxy for voiding abnormalities. Voiding abnormalities have been implicated in the development of hydronephrosis, reflux, and urinary tract infections.

METHODS

We evaluated the volume of contrast infused for 617 consecutive VCUGs. We compared the actual volume infused during the VCUG to the expected bladder capacity. We correlated the percentage of predicted capacity with (a) the reason for the VCUG; (b) the VCUG results; (c) the patient's sex; and (d) their body mass index. We analyzed the results for the entire group, as well as by age, sex, reflux grade, and body mass index. We also examined the findings from those patients undergoing consecutive studies.

RESULTS

The bladder size on the VCUG was greater than predicted (1.74 times predicted). This was particularly true for patients <2 years old (2.22 vs 1.41 times predicted; P < .001) and for boys (2.01 vs 1.63 times predicted; P < .001). Both the reason for the VCUG (more prenatal patients with hydronephrosis than others; P < .001) and the VCUG findings (new reflux found more than others) had a relationship with the bladder size on the VCUG (P < .001). The body mass index did not correlate with the bladder size on the VCUG. Of the 87 patients undergoing 2 studies, the 53 patients with either no or improved reflux on the second study tended to have a larger than predicted bladder size on the VCUG (P = .07).

CONCLUSIONS

The bladder volume on the VCUG was greater than predicted for male infants with prenatal hydronephrosis and reflux. In other groups, the marked variation within groups prevented the use of the bladder volume on the VCUG as a proxy for voiding dysfunction.

Non-neurogenic elimination disorders in children

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

Bladder dysfunction and vesicoureteral reflux

In this overview the influence of functional bladder disturbances and of its treatment on the resolution of vesicoureteral reflux (VUR) in children is discussed. Historically both bladder dysfunction entities, the overactive bladder (OAB) and the dysfunctional voiding (DV), have been described in conjunction with VUR. Treatment of the dysfunction was also considered to influence spontaneous resolution in a positive way. During the last decades, however, papers have been published which could not support these results. Regarding the OAB, a prospective study with treatment of the bladder overactivity with anticholinergics, did not influence spontaneous resolution rate in children with a dysfunction including also the voiding phase, DV and DES (dysfunctional elimination syndrome), most studies indicate a negative influence on the resolution rate of VUR in children, both before and after the age for bladder control, both with and without treatment. However, a couple of uncontrolled studies indicate that there is a high short-term resolution rate after treatment with flow biofeedback. It should be emphasized that the voiding phase dysfunctions (DV and DES) are more severe than the genuine filling phase dysfunction (OAB), with an increased frequency of UTI and renal damage in the former groups. To be able to answer the question if treatment of bladder dysfunction influence the resolution rate of VUR in children, randomized controlled studies must be performed.

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.

Correlation between ultrasonographic bladder measurements and urodynamic findings in children with recurrent urinary tract infection

OBJECTIVE

To evaluate the role of bladder variables measured by ultrasonography (US) in assessing bladder dysfunction in children with urinary tract infections (UTIs).

PATIENTS AND METHODS

Children presenting with recurrent UTI (with or with no vesico-ureteric reflux) were prospectively recruited. At entry, each patient had US and both natural- filling (NFC) and conventional-filling (CFC) cystometry. Bladder volume and wall thickness index (BVWI) was calculated, and based on US studies and the bladder pattern on US, were classified as thick (BVWI <70), normal (70-130) and thin (>130) as previously reported. The criteria for diagnosing urodynamic patterns included normal, overactive and hypocontractile, as reported previously. The correlation between the US measured variables and urodynamic findings were then evaluated. Sixty-one children (38 boys and 23 girls; mean age 4.82 years, range 1-11) were selected for further evaluation.

RESULTS

Of the 61 children, 16 had a normal BVWI, 36 a 'thick' value and nine 'thin'. When the BVWI was correlated with the urodynamic findings, 14 of 16 with a normal BVWI had a normal bladder pattern, whereas 92% of the patients with a BVWI of <70 had overactive bladder (P < 0.001). Among children with a BVWI of >130, six of nine had a hypocontractile pattern. The mean (sd) bladder capacity (on CFC) compared to that expected for age was significantly lower, at 56.7 (32.3)% in 'thick' bladders, vs children with normal and thin bladders, at 91.3 (23.8)% and 98.7 (31.8)%, respectively (P < 0.001). A high voiding detrusor pressure was significantly associated with children who had a thick bladder rather than normal or thin bladder (P < 0.001).

CONCLUSIONS

This study further confirmed that the BVWI is a sensitive tool for diagnosing bladder dysfunction in children, and it can be used as a reliable guide for the appropriate choice of further invasive urodynamic studies.

[Primary vesicoureteral reflux treatment in childhood: comparsion of two systematic review]

Many medical practices are being carried out unawares of their efficiency, or of their actual impact on the health of the patients, therefore it is necessary to consider the support of professional recommendations with scientific evidence.

THE PRIMARY OBJECTIVE

To perform a systematic review (SR) of the therapeutic management of primary VUR in pediatric urology.

MATERIAL AND METHODS

A systematic review has been performed, including scientific evidence-based medicine criteria, of the articles published in all of the available databases. Inclusion criteria concerning basic quality of the articles were considered essential, as well as exclusion criteria to be able to reject the articles.

RESULTS AND DISCUSSION

Subsequently, and following the critic reading of greater than 320 articles, statistical study of the grouped data was performed according to the type of treatment and to the benefits contributed by each treatment, and also to their undesirable effects. Finally we have made a comparison between our results and recent Cochrane Systematic Review. The following Conclusions were drawn from the results obtained and from the analysis of the texts. Both medical and surgical treatment present with similar effectiveness concerning resolution of grades I, II and III of VUR, and the former one is the recommended initial treatment following diagnosis. Endoscopic treatment is exactly as effective as open surgery for grades I, II and III with fewer undesirable effects secondary. There are no differences concerning the efficacy of the different injected substances. Not enough evidences exist for degrees IV and V that may recommend or advise against any of the treatments. In any degree of VUR, open surgical treatment is superior as far as medical treatment is concerned only regarding the number of acute pyelonephritis episodes during followup. This conclusion cannot be applied on endoscopic treatment.

Voiding dysfunction in children

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

Radionuclide voiding patterns in children with vesicoureteral reflux

The purpose of this study was to evaluate bladder function in children with vesicoureteral reflux (VUR) by means of indirect radionuclide cystography (IRNC), and to investigate whether IRNC can identify those children with voiding dysfunction. The study enrolled 74 neurologically intact children, 14 boys and 60 girls aged 2-14 years, with VUR documented using contrast micturating cystourethrography as the initial method. In all patients, IRNC was performed using technetium-99m diethylene triamine penta-acetate (DTPA). Based on the urodynamic findings, three groups were distinguished: a group with VUR and normal urodynamic findings ( n=27), a group with VUR and detrusor hyper-reflexia ( n=43) and a group with VUR and detrusor-sphincter dyssynergia ( n=4). A control group comprised 64 healthy children, aged 2-13 years, without any symptoms of lower urinary tract dysfunction. The dynamics of bladder emptying were studied in the posterior view after intravenous injection of 37 MBq/10 kg b.w. DTPA, with acquisition of 90 2-s frames during voiding. The parameters evaluated were: voided urine volume (VV), bladder capacity, functional bladder capacity (FBC), residual urine, voiding time, average flow rate, peak flow rate (PFR) and ejection fraction (EF). With regard to the final urodynamic diagnosis, FBC, PFR and EF were found to be significant IRNC predictor variables using the logistic regression method. If abnormality on at least two of the three significant predictor variables was taken as the criterion of voiding dysfunction, the overall sensitivity, specificity and accuracy of IRNC in the detection of voiding dysfunction were 81%, 78% and 80%, respectively. Three radionuclide voiding patterns were detected in children with VUR: (1) a normal voiding pattern characterised by normal FBC with near-normal PFR and EF values, (2) a markedly reduced FBC with significantly reduced VV, PFR and EF values (in children with bladder instability), and (3) a higher bladder volume with a near-normal value for PFR and a slightly reduced or near-normal EF (in children with detrusor-sphincter dyssynergia). This study confirmed the association between lower urinary tract dysfunction and congenital VUR. IRNC was found to be a simple, non-invasive method which allows reliable differentiation of voiding patterns in patients with VUR. IRNC can be used as a first-line method for screening in children with VUR to identify those with abnormal voiding patterns.

Is ureteral reimplantation necessary during augmentation cystoplasty in patients with neurogenic bladder and vesicoureteral reflux?

PURPOSE

We assessed the outcome of vesicoureteral reflux after augmentation cystoplasty in patients with neurogenic bladder.

MATERIALS AND METHODS

Since May 1992, 112 male and 18 female patients with neurogenic bladder have undergone augmentation cystoplasty with a generous detubularized segment of bowel and no effort to correct existing reflux. Patients were treated conservatively at the beginning but the response was unsatisfactory. All patients had various degrees of vesicoureteral reflux (197 refluxing units). Mean age at operation was 21.6 years (range 1.5 to 57). Preoperatively assessment included urinalysis, urine culture, kidney function tests, voiding cystourethrography, urodynamic evaluation, ultrasonography or excretory urography and cystoscopy when indicated. The status of vesicoureteral reflux, renal hydronephrosis and clinical pyelonephritis were studied during an average followup of 44.5 months.

RESULTS

Of the 130 patients 111 (85.4%) no longer had reflux, 14 (10.8%) had improvement, 4 (3%) had no change and 1 (0.8%) had worsening reflux. All refluxing units with grades I to III, 105 of 120 with grade IV (87.5%) and 8 of 13 with grade V (61.5%) showed complete cessation of reflux. Renal hydronephrosis improved in 127 renal units (97.7%). In 8 individuals (6.2%) without reflux after cystoplasty episodes of clinical pyelonephritis occurred.

CONCLUSIONS

Augmentation cystoplasty without ureteral reimplantation is effective and adequate treatment for high pressure, noncompliant neurogenic bladder when conservative management fails.

Preliminary study of the safety and efficacy of extended-release oxybutynin in children

OBJECTIVES

To test the safety and efficacy of extended-release oxybutynin in children with bladder dysfunction. The efficacy of oxybutynin in children has been limited by side effects. A new extended-release formulation of oxybutynin has some benefits versus traditional oxybutynin but has never been evaluated in children.

METHODS

A retrospective study was performed on 25 children who had been treated with extended-release oxybutynin. Fourteen had neurogenic bladder dysfunction and 11 had urinary frequency and urgency and urge incontinence but no neurologic abnormalities. Patients and families were asked to semiquantitatively (0 to 10 grading with 10 = severe) assess the effects of the medication on efficacy, as well as side effects and compliance with medication schedules.

RESULTS

All 25 patients had improvement in incontinence and/or voiding dysfunction on extended-release oxybutynin. Twelve (48%) experienced no side effects. Of the 13 who did, 10 complained of dry mouth (grade 4.6 plus minus 0.5), 4 had constipation (grade 5.8 plus minus 1.8), 4 had heat intolerance (grade 5.1 plus minus 0.9), and 3 had drowsiness (grade 5.3 plus minus 2.4). Of patients previously treated with oxybutynin, the extended-release oxybutynin was equally or more efficacious and had the same or fewer side effects, especially less dry mouth. Families reported much better patient compliance with the medication regimen using extended-release oxybutynin compared with oxybutynin. Patient and family satisfaction was very high, and 21 of 25 have continued using the medication.

CONCLUSIONS

Extended-release oxybutynin is safe and efficacious in children. In this preliminary evaluation, it had benefits over traditional, immediate-release oxybutynin.

Neurogenic and non-neurogenic bladder dysfunction

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

The relationship between dysfunctional voiding and congenital vesicoureteral reflux

Voiding dysfunction may play an etiological role in congenital vesicoureteral reflux in otherwise normal children. There is increasing evidence to suggest that in some infants and older children, vesicoureteral reflux is associated with congenital structural deficiency of the trigonal ureterovesical junction valve mechanism as well as aberrant lower urinary tract function. In the youngest infants this abnormal function can be present at birth, whereas in older children it may be acquired and learned during the toilet training years, if it is not already present. Voiding dysfunction may spontaneously improve or require additional therapy. Increased rates of breakthrough infection, renal scarring and surgical failure have been associated with undiagnosed and untreated lower urinary tract dysfunction, emphasizing the importance of its recognition. Controversy remains regarding the role of invasive urodynamics and anticholinergic medication, and further large-scale prospective studies are necessary before either modality becomes routine when assessing and treating these children.

Vesicoureteral reflux and videourodynamic studies: results of a prospective study

OBJECTIVES

To study the influence of bladder instability on the conservative management and surgical treatment of children with vesicoureteral reflux (VUR), 102 children were included in a prospective study.

METHODS

During a 5-year period all children suspected to have VUR underwent a videourodynamic study to determine VUR grade and bladder function. This resulted in a group of 36 boys and 66 girls who were followed up for well over 5 years.

RESULTS

Bladder instability was found in 41 of 102 children (40%). The 102 children were either treated conservatively or surgically. Of the 77 children who were treated conservatively, bladder instability was found in 35 patients. In the conservatively treated group with bladder instability, reflux resolved in 57%; whereas in those with normal bladder function, reflux resolved in 67%. Of the 25 patients who were treated surgically, the operation was successful in 91%. Breakthrough infections occurred in 22 girls and 3 boys, including 14 of 41 patients with bladder instability (34%) and 11 of 61 patients with normal bladder function (18%).

CONCLUSIONS

Bladder instability is a frequent finding and an important factor in the treatment of children with VUR. To determine if a patient has VUR and bladder instability a videourodynamic study has proved to be an easy and efficient diagnostic tool. When bladder instability is treated with anticholinergic medication, almost the same results can be expected from conservative treatment as from surgical treatment compared to children with a normal bladder function. Breakthrough urinary tract infections occur more often in girls and tend to occur more often in children with bladder instability.

Classification and treatment of functional incontinence in children

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

Voiding function study with ultrasound in male and female neonates

BACKGROUND

The neonatal period has been characterized as a time when males have a much higher incidence of urinary infection and severe ureteral reflux than females. However, little information about the voiding function in the neonatal period is available.

METHODS

The bladder urine volumes, before and after voiding, and urinary flow rates were determined with the use of noninvasive voiding-provocation maneuvers and ultrasound in the apparently normal neonates.

RESULTS

There was no significant difference in the prevoid bladder urine volume between the two sexes. After they were stimulated to enhance the tension of their abdominal wall musculature, 65 of 118 females (55.1%) and 64 of 115 males (55.7%) voided. The voiding was observed in 94 (81.0%) of the 116 neonates who had had a prevoid volume above 12 ml. The residual urine expressed as a percentage of the prevoid volume was significantly higher in the males (median, 12.0% in males vs. 3.0% in females, P < 0.01), with the values being above 20% in 26 (41%) of the 64 males compared with 10 (15%) of the 65 females (P < 0.01). Urinary flow rates, determined in 52 neonates, were significantly smaller in males than in females (mean +/- SD, 2.6 +/- 0.9 g/second vs. 3.8 +/- 1.3 g/second, respectively, P < 0.001).

CONCLUSION

This voiding function study with ultrasound using noninvasive voiding-provocation maneuvers successfully revealed that male neonates have a larger residual urine volume and smaller urinary flow rates than female neonates. This study should be useful for the diagnosis of voiding dysfunction in children with abnormal urinary symptoms.

Comprehensive management of dysfunctional voiding

OBJECTIVE

Dysfunctional voiding is a major problem leading to daytime-wetting and recurrent urinary tract infection (UTI). Our center is devoted to treating children with dysfunctional voiding. We offer a multidisciplinary approach with a pediatric nephrologist, nurse practitioners, and a psychologist. This article is the first to describe the efficacy of this approach on a large population of American children.

PATIENTS

Between 1992 and 1995, 366 children with symptoms of voiding dysfunction were referred for urodynamic studies. Criteria were based on the child's age, symptoms, and failure to respond to empirical therapy. Females made up 77% of the population, and the mean age at referral was 8.5 years (range, 4 to 18 years). Day-wetting occurred in 312 (89%), night-wetting in 278 (79%), recurrent UTI in 218 (60%), and vesicoureteral reflux (VUR) in 48 (20%) of those undergoing voiding cystourethrography.

RESULTS

A minimum of 6 months' follow-up data (mean, 22 months) is available on 280 children (77% studied). Urge syndrome was the predominant urodynamic finding in 52%, followed by bladder sphincter dysfunction in 25%. Treatment consisted of antibiotic prophylaxis (59%), anticholinergic medication (49%), biofeedback (25%), and psychological counseling (15%). Of the 222 children with daytime-wetting (45%), 100 are cured (off all medication, no wetting) and 82 (37%) are improved (on medication or >50% reduction in symptoms). Improvement or cure was seen in 69% of children with night-wetting. Of the 199 children with UTI, 127 (64%) never developed another infection. Vesicoureteral reflux resolved in 16 of 30 (53%) children undergoing repeat voiding cystourethrography.

CONCLUSION

Our comprehensive approach demonstrates a favorable outcome that promises to reduce the medical and psychological morbidity seen in patients with voiding dysfunction.

Pharmacokinetics and effects of intravesical oxybutynin on the paediatric neurogenic bladder

OBJECTIVE

To evaluate the pharmacokinetics of both oxybutynin and its active metabolite, N-desethyl oxybutynin (NDO), when the drug is instilled directly into the bladder in children with myelodysplasia and neurogenic bladder disturbance, in whom it may improve continence and decrease the risk of upper urinary tract deterioration.

PATIENTS AND METHODS

The study comprised 13 children (five girls and eight boys, mean age 9.3 years, range 1-15) with neurogenic bladders who were treated using clean intermittent catheterization and intravesical instillation of a sterile, pharmacy-produced solution of oxybutynin. Steady-state minimum plasma levels of oxybutynin and NDO, together with their effect on urodynamic variables and incontinence, were evaluated. The dose (0.04-0.17 mg/kg, mean 0.1 mg/kg) was instilled twice daily.

RESULTS

The effects of the drug on incontinence and urodynamic variables were pronounced, improving both in most cases. Minimum plasma levels were < 0.3-7.2 ng/mL for oxybutynin and 0.8-14 ng/mL for NDO. The ratio of oxybutynin to NDO was 0.29-0.83 (mean 0.47).

CONCLUSION

There was no clear relationship between minimum plasma levels of the drug or NDO and their clinical effects; however, the combination of oxybutynin and NDO seemed to be more strongly correlated with the clinical effects.

Detrusor properties in myelomeningocele patients: in vitro study

PURPOSE

To characterize detrusor properties of myelomeningocele (MMC) bladders which failed conventional therapy.

MATERIALS AND METHODS

Bladder strips from five end-stage MMC patients were compared with those from five patients with vesicoureteric reflux. The active and passive properties of the detrusor muscles and the effect of different blocking agents on the transmural nerve stimulation were studied.

RESULTS

A significant decrease in contractility (p = 0.003) and increased rigidity (p = 0.019) was found in MMC group. In the control group, atropine blocked 77.7% of the detrusor contractility and tetrodotoxin demonstrated an equal blocking effect. In MMC group, atropine blocked 58.2% and tetrodotoxin blocked 77.4% of the detrusor contractility.

CONCLUSION

MMC bladders showed decreased contractility and increased rigidity. In MMC group, the atropine-resistant component which is blocked by tetrodotoxin signifies the possible existence of non-adrenergic, non-cholinergic neurotransmitters (NANC). Further studies are needed to possibly improve the pharmacological therapy of the myelomeningocele detrusor.

Urodynamic patterns in infants with normal lower urinary tracts or primary vesico-ureteric reflux

OBJECTIVE

To compare bladder function in infants with primary vesico-ureteric reflux (VUR) and those with normal lower urinary tracts.

PATIENTS AND METHODS

The study comprised 42 patients (36 males) with VUR (grades III to V) and 21 (16 males) without VUR (mean age in both groups, 6 months). Intravesical catheters were placed suprapubically under general anaesthesia and, after at least 24 h, natural-tilling urodynamics were monitored for three or more filling and voiding cycles.

RESULTS

Various urodynamics patterns were defined: for infants without VUR these were either normal or normal-immature (discoordinated micturition) and none showed features indicating abnormal bladder function. By comparison, 24 of 42 infants with VUR showed abnormal urodynamic patterns (57%, 95% confidence interval 41% to 72%, P < 0.001). Seven (17%) were defined as unstable with small voided volumes, five (12%) had inadequate voiding dynamics, 10 (24%) showed a markedly dyssynergic pattern and two (5%) had obstructive patterns. The unstable, inadequate and obstructive patterns occurred only in boys. Detrusor activity during the filling phase occurred in 14 infants (13 boys) with VUR and in only one without VUR, when it was trivial. Post-void residual volumes of > 30% capacity were seen only in the VUR group (in 24 patients). There were 18 infants with VUR that showed the normal or immature urodynamics patterns, but for the 14 males the voiding pressures were higher than for those without VUR (mean maximum detrusor pressure, 161 and 117 cmH2O, respectively: P < 0.02).

CONCLUSIONS

There is an association between abnormal urodynamic variables and a diagnosis of primary VUR in young infants (notably males) that may have important implications for concepts about the genesis and persistence of VUR.

Enuresis and common voiding abnormalities

Voiding problems, and in particular nocturnal enuresis, can usually be evaluated and managed without resorting to complex procedures or invasive tests. A good history with attention to toilet habits and the possible presence of infection can help distinguish patients who may have significant organic pathologic conditions who require further investigation. Wetting alarms are effective with a low recidivism rate but are noisy. DDAVP is effective, works rapidly, and is discrete but has a higher recidivism rate. Treatment is aimed at correcting any poor toilet habits and using the appropriate alarm device or medication.

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.

Vesicoureteral reflux and lower urinary tract injury: the possible role of suprapubic cystostomy

Incidental vesicoureteral reflux was noted frequently during routine cystographic evaluation of patients who suffered vesicourethral trauma and who were managed by suprapubic cystostomy. Based on this observation we designed a retrospective study to document the prevalence of vesicoureteral reflux among 30 consecutive patients following vesicourethral trauma. In 9 patients drainage was instituted by urethral catheter and in 21 by suprapubic cystostomy. Of the latter 21 patients 10 (47.6%) had evidence of vesicoureteral reflux on cystography, which was associated with complete rupture of the urethra in 9 (90%). No patient who was treated initially with a urethral catheter had evidence of vesicoureteral reflux on cystography. We conclude that the prevalence of vesicoureteral reflux is significantly affected by the coexistence of severe vesicourethral injury and the presence of suprapubic cystostomy. The significance of this observation is in the potential risk of ascending upper urinary tract infections due to the hazardous combination of vesicoureteral reflux and frequent recurrent lower urinary tract infections. Presence of vesicoureteral reflux in these patients may necessitate a prophylactic antibiotic regimen. The specific mechanisms that lead to increased prevalence of vesicoureteral reflux in patients following severe vesicourethral injury are not defined by our results. However, we propose a multifactorial concept that may explain our observation.

Followup of conservatively treated children with high and low grade vesicoureteral reflux: a prospective study

A total of 202 children (mean age 31.5 +/- 23.3 months) with vesicoureteral reflux identified during the investigation that follows a urinary tract infection entered this prospective study dealing with the medical management of reflux. The diagnosis of vesicoureteral reflux was made significantly earlier in boys than in girls regardless of reflux grade (p < 0.001). At entry reflux nephropathy was present on a dimercaptosuccinic acid scan in 44% of 314 refluxing kidneys. There was no significant difference between boys and girls in the prevalence of reflux nephropathy. The renal lesions were more severe in boys independently of the grade of vesicoureteral reflux (p < 0.05). Breakthrough urinary tract infection was significantly more common in girls than in boys, regardless of vesicoureteral reflux grade (p < 0.05). Mean followup was 68.7 +/- 31.2 months. Patient age at the time of the first of 2 radionuclide cystograms without vesicoureteral reflux was considered the age of spontaneous resolution of reflux. Using life table estimations and analyzing data stratified to sex and grade of vesicoureteral reflux, we found that although reflux lasted longer in boys compared to girls, this difference was not statistically significant. During followup new scars developed in 7 patients related to breakthrough urinary tract infection. There was no significant difference between boys and girls in the development of new scars. To understand the natural history of vesicoureteral reflux children must be stratified by sex and grade of reflux.

Bladder augmentation in patients with neurogenic bladder and vesicoureteral reflux

Current treatment of noncompliant neurogenic bladder associated with significant vesicoureteral reflux that is refractory to intermittent self-catheterization and anticholinergic therapy includes bladder augmentation coupled with a procedure to eliminate reflux. Antireflux surgery is often difficult in such a clinical setting. The diseased and thickened detrusor makes reimplantation into the bladder difficult, and successful reimplantation into the intestinal component is tricky and time-consuming. Augmentation alone was done in 14 patients with significant vesicoureteral reflux in the face of a noncompliant, high pressure neurogenic bladder. No effort was made to correct reflux surgically because, in theory, reflux is secondary to abnormal bladder pressure. Of the 13 patients who have had adequate evaluation with postoperative cystograms 12 no longer have reflux. The reflux in the remaining patient has improved from grade IV to grade II. Postoperative cystometric examination in 12 patients demonstrated low pressure and adequate volume. Correction of bladder dynamics alone reversed the reflux. Conversely, persistence of reflux postoperatively is an indication that augmentation has not successfully returned the bladder to a low pressure reservoir. Our experience indicates that antireflux procedures are not routinely needed in this group of patients.

A practical approach to evaluating urinary tract infection in children

After a first urinary tract infection (UTI), all children require an evaluation with imaging studies to screen the urinary tract for anatomic abnormalities and for reflux. Ultrasonography and voiding cystography readily accomplish this and are recommended, knowing that such a recommendation is controversial. While the likelihood for reflux-induced renal damage is age related, the presence of reflux in any child with infection is clinically important for management. Abnormal screening results or recurrence of infection warrant further radiographic testing. However, imaging studies are necessary but do not constitute sufficient evaluation for UTI because the etiology of infection is only rarely identified with these tests. Sorely neglected in most recommended protocols for evaluating urinary infection is an investigation for micturitional disturbances which may be responsible for the infections. Treatment of these conditions may actually prevent recurrence of infection. Controversy surrounding the proper imaging evaluation for UTI appears to be mis-directed. Instead of arguing about which imaging study should be performed or which child with a first UTI should have a cystogram, our patients might be better served if we wondered why traditional protocols for evaluating UTI deal only with imaging studies.

Urodynamic studies in children who wet

The value of urodynamic evaluation was assessed in children with diurnal and/or nocturnal enuresis without overt obstruction or neuropathy. The hypothesis that children with bladder instability and dysfunctional voiding represent 2 separate populations was also examined. A simplified urodynamic method was used to evaluate 191 children and they were divided into 3 groups: 64 had normal bladders which were stable during filling and voiding was co-ordinated and complete; 97 had unstable bladders but voiding was normal and co-ordinated; 30 had dyssynergic voiding and an increased volume of residual urine. The urodynamic evaluations were helpful in distinguishing the large number of children with normal findings in whom the problem was motivational. The children with unstable bladders had a physiological abnormality due to delayed maturation and in these cases anticholinergic and musculotrophic agents were usually helpful. The dysfunctional voiders had serious behavioural problems, were difficult to treat, and often required a multidisciplinary approach. These data indicate that there are indeed 2 distinct groups: 1 with instability alone and 1 with dysfunctional voiding with or without instability. Although infection and/or reflux are common in the former, the more devastating urinary tract changes, particularly heavy trabeculation and elongation of the bladder, occur in the latter group.

Vesicoureteric reflux in the adult male

The main prevalence of vesicoureteric reflux (VUR) is in the adult female population. Although recognised as a clinical entity in adult males, little detailed information is available on this subject. A retrospective analysis was carried out on the results of 1519 consecutive videocystometrograms performed on male patients. VUR had an overall incidence of 8.6% within this population, with a range of 5.1% in patients with normal urodynamics to 15.6% in those with detrusor-sphincter dyssynergia. The common denominator between VUR and urodynamic measurement appears to be the generation of high intravesical pressures. These findings suggest that VUR is not uncommon in the male population, is usually asymptomatic and should respond to the treatment of any underlying bladder abnormality.

Vesicoureteral reflux and voiding dysfunction: a prospective study

We prospectively studied 53 young children (45 less than 4 years old) between 1985 and 1988 with primary vesicoureteral reflux (grades I to V, 74 ureters). All patients had elevated bladder pressures during bladder filling and/or voiding on urodynamic evaluation, which sometimes were associated with abnormal perineal muscle activity. Baclofen, flavoxate, dicyclomine and diazepam were given individually or in combination for each type of dysfunction for 12 to 30 months. Reflux disappeared in 68 ureters (91.8 per cent) and it was downgraded in 6 (8.2 per cent). Urodynamic evaluation at the end of treatment revealed normal bladder pressures in 46 children (83.7 per cent of the ureters in which reflux resolved). Another group of 48 children with primary vesicoureteral reflux (grades I to IV, 67 ureters) seen between 1980 and 1985 was reviewed retrospectively. All patients had been treated with prophylactic antibiotics only. Reflux resolved in 53.7 per cent of the ureters, and it was downgraded in 19.4 per cent, unchanged in 22.4 per cent and upgraded in 4.5 per cent. Urodynamic studies performed in 1985 showed that all persistent cases of reflux in the retrospective group had urodynamic findings similar to those found in the prospective group. These data suggest that vesicoperineal incoordination as well as bladder instability can be important factors in causing and perpetuating reflux, and that medical treatment of these factors individually or in combination may affect therapeutic perspectives of this pathological condition.

Vesico-uretero-renal reflux and the kidney

The most frequent complications of non-obstructive vesico-uretero-renal reflux (VUR) are segmental renal scars. These scars are confined to segments with intrarenal reflux which are, in addition, exposed to bacterial infection. Primarily, only gaping collecting duct orifices, confined to compound papillae and mainly situated at the kidney poles, allow intrarenal reflux. Scar contraction and obstruction seem to be able to transform closed collecting duct orifices into gaping ones, thereby enlarging the parenchymal area prone to intrarenal reflux and to renal scarring. Contrary to earlier reports, a recent survey has documented that new scars in children develop with significant frequency beyond 5 years of age. There is a greater tendency for scarring to develop with more severe VUR, but new renal scars can develop with all grades of VUR. Early and adequate antibiotic treatment decreases the extent of scarring. The results of experimental studies in which renal scarring developed in piglets with bladder decompensation resulting from intravesical obstruction but without bacterial infection may be relevant to the few children with proximal urethral valves and hypertonic neurogenic bladders but not to the large number with non-neurogenic detrusor instability or detrusor sphincter dyssynergia. Prospective studies have not shown different recurrence rates of urinary tract infections in medically managed compared with surgically managed children. The frequency of acute pyelonephritic attacks decreased significantly after operation.

Urodynamics

Urologic problems constitute a very significant percentage of all clinical problems in pediatrics. Incorporation of urodynamic evaluation and followup is important in achieving optimal results in a significant number of these entities. In terms of cost effectiveness, it is particularly efficient in this age of extremely high-priced technology.