Urodynamic abnormalities in neurologically normal children with micturition dysfunction

High Yield of Urodynamics Performed for Refractory Nonneurogenic Dysfunctional Voiding in the Pediatric Population

PURPOSE

In the pediatric population urodynamic evaluation for nonneurological causes has been previously reported as a low yield endeavor when considering patients with a primary diagnosis of dysfunctional voiding. We evaluated the rate of clinically significant urodynamic findings that would drive therapeutic intervention for a spectrum of urological disorders in pediatric patients without neurological deficit in whom initial conventional management had failed.

MATERIALS AND METHODS

We retrospectively reviewed the charts of patients who had undergone urodynamics in the last 7 years. Patients with known neurological deficits were excluded.

RESULTS

A total of 805 pediatric urodynamic evaluations were performed from December 1997 to July 2004 at our institution, including 89 in patients with no known neurological diagnosis and charts available for review. Of the urodynamic studies 33 (37.1%) were reported as normal and 56 patients (62.9%) had clinically significant discoveries. Storage phase abnormalities were the predominant finding in 37 patients (66.1%), including uninhibited detrusor contractions in 31 (55.4%). Emptying phase abnormalities were less common (19 patients or 33.9%). There was no difference in the percent of patients with positive urodynamics findings depending on sex.

CONCLUSIONS

In our analysis evaluation of all recent urodynamics performed at a single institution revealed a high rate of pathological findings in patients with various nonneurological diagnoses.

Retrospective Analysis of Efficacy and Tolerability of Tolterodine in Children with Overactive Bladder

OBJECTIVE

To evaluate the efficacy and tolerability of tolterodine in children with an overactive bladder, treated in a single incontinence centre.

MATERIALS AND METHODS

A retrospective analysis of a database of a total of two hundred and fifty-six patients (175 boys and 81 girls, age range 3 years to 17 years, mean age 8.33 years) with urodynamically confirmed bladder overactivity was performed. All children received tolterodine tartrate (dose range of 0.5-4 mg orally). In group I (n=205) tolterodine tartrate replaced anticholinergic drugs (AC) (oxybutinin chloride or oxyphencyclimin hydrochloride). A subgroup of patients switched because of intolerance due to serious adverse events (60.4%) or because of lack of improvement in micturition variables (39.6%). In group II tolterodine was prescribed as initial therapy (n=51). Tolerability was assessed by a standardised questionnaire on adverse events at every outdoor clinic visit. Efficacy assessment was based on micturition diary variables, mean change of maximum bladder capacity and number of incontinence episodes/24 h.

RESULTS

The mean treatment time was 9.32 months with a range from 1.5 months to 23.4 months. The final dose was 0.1mg/kg orally daily divided into two doses. In group I central nervous system disorders (81%) were the most common adverse events, 26.2% showed flushing, 12.2% accommodation problems and 25.2% had gastrointestinal complaints (constipation, encopresis, abdominal pain). Withdrawal of the non-selective antimuscarinic drug resulted in total recovery from adverse events. Introduction of tolterodine in group I and II caused no serious adverse events. Nine patients (3.5%) reported side-effects and only two discontinued treatment. There were no reports of flushing, troubles of visual accommodation, hyperpyrexia. In group I we observed a mean decrease in urgency by 38.7%, a mean increase in maximal bladder capacity by 33.6% and the number of incontinence episodes decreased by 64.8%. In group II we observed equivalent values with a significant (p<0.001) change in maximal bladder capacity (49.7%), incontinence episodes (64.8%) and micturition episodes/24 h.

CONCLUSIONS

The results of this retrospective analysis suggest that tolterodine is well tolerated in children and offers an effective treatment for urinary symptoms due to overactive bladder. Tolterodine is superior to non-selective antimuscarinic drugs, with respect to adverse events, allowing more compliance and more effective treatment in children.

Voiding dysfunction in pediatric patients

The goals of this study were to describe the pattern of voiding disorders in children in our community, to describe clinical criteria for making the specific diagnoses, and to comment on management. The medical records of 226 children referred because of voiding dysfunction or urinary tract infections (UTI) were evaluated. Children with normal voiding patterns when uninfected, with monosymptomatic nocturnal enuresis, and with known neurologic or anatomic abnormalities were excluded. Detrusor instability, an abnormal voiding pattern characterized by urgency with or without frequency, was the diagnosis in 175 of the 226 children. Children with detrusor instability who used various posturing maneuvers to avoid urinary incontinence had a significantly higher incidence of UTIs than those who did not attempt to obstruct urine outflow. Detrusor instability appeared to be secondary to constipation in 19 of the children. The other diagnoses were extraordinary daytime urinary frequency, infrequent voiding, monosymptomatic daytime wetting, transient voiding dysfunction, giggle incontinence, dysfunctional voiding, and unexplained dysuria. It is concluded that children with detrusor instability who use posturing maneuvers to avoid incontinence are at high risk for recurrent UTIs. Constipation is 1 cause of detrusor instability. Dysfunctional voiding, the form of voiding dysfunction most likely to result in renal damage, was present in only 2 of 226 children seen for voiding disorders.

Special considerations of the overactive bladder in children

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

The outcome of voiding dysfunction managed with clean intermittent catheterization in neurologically and anatomically normal children

OBJECTIVE

To describe the tolerability and efficacy of clean intermittent catheterization (CIC) in the management of dysfunctional voiding in patients who are neurologically and anatomically normal.

PATIENTS AND METHODS

The medical records were reviewed in 23 patients (16 girls, mean age 9 years, range 6-14.5, and seven males, mean age 8 years, range 5-20.5) with urinary incontinence and/or urinary tract infection (UTI) who were offered CIC because they had a large postvoid residual urine volume (PVR). All had extensive instruction before starting CIC. All patients underwent urodynamic studies, and urinary and fecal elimination habits were recorded. Detrusor hyperactivity, when present, was treated with anticholinergic medication. The follow-up evaluation included tolerance of CIC, continence status and the incidence of UTI. Behavioural modification or biofeedback training was not used in any patient.

RESULTS

Of the 23 patients, 13 presented with both UTI and urinary incontinence, five with incontinence only, four with UTI only, one with frequency and no incontinence, and one with haematuria. Associated symptoms included frequency/urgency, constipation or soiling, and straining to void or incomplete emptying (in nine each), and infrequent voiding in six. CIC was performed within 2 days by 15 patients, while four others required up to 2 weeks to master CIC. However, three of the four patients (all older girls) who needed 2 weeks to learn the technique did not tolerate CIC and discontinued it within 3 weeks. Four other adolescents (three girls and one boy) refused to learn CIC. Of the 16 patients remaining on CIC only three had cystitis; no patient had a febrile UTI. Once successfully instituted, all patients became continent while on CIC. Six boys (mean follow-up 4 months) had a marked decrease in their PVR. CIC was discontinued in three girls who voided normally to emptiness within 6 months of starting CIC; they remained dry and infection-free 16 months (two) and 6 years later.

CONCLUSION

CIC is a viable therapeutic option for the treatment of dysfunctional voiding, associated with a large PVR, in the absence of any neurological abnormality. CIC is well tolerated in the sensate patient and provides a means for expeditiously achieving continence and improving bladder emptying cost-effectively.

Enuresis and incontinence in children

The terminology used to describe wetting children is defined. The etiologies of monosymptomatic nocturnal enuresis and nonneuropathic bladder-sphincter dysfunction are described. Treatment strategies and the results of recent large scale studies are presented.

Sacral neuromodulation for urinary retention caused by sexual abuse

OBJECTIVE

This case report describes the use of sacral neuromodulation to treat urinary retention after sexual abuse.

METHODS

Sacral neuromodulation was added to therapeutic regimen of a 38-year-old woman in whom chronic, complete urinary retention developed after psychological and sexual abuse during childhood.

RESULTS

The combination of psychotherapy and neuromodulation restored the patient's ability to void, whereas psychotherapy alone had not.

CONCLUSIONS

Although a multifactorial etiology of retention cannot be ruled out in this patient, neuromodulation might effectively treat urinary retention in cases of a conversion disorder after sexual abuse.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

The use of radiography, urodynamic studies and cystoscopy in the evaluation of voiding dysfunction

PURPOSE

Children with dysfunctional voiding disorder often undergo radiological, cystoscopic or urodynamic evaluation to identify an anatomical or organic cause. We determined the role of these studies in the evaluation, management and ultimate outcome of a large patient population with voiding dysfunction at a single institution.

MATERIALS AND METHODS

We retrospectively evaluated the records of 1, 153 children with dysfunctional voiding disorder treated from 1990 to 1999. A thorough history and physical examination with specific emphasis on voiding patterns were done and urinalysis was performed in all cases. Ultrasound of the urinary system and excretory urography were done in 1,050 (91%) and 24 (2%) patients, respectively, while voiding cystourethrography was performed in 672 (58%), including 564 with a history of nonfebrile urinary tract infection. Cystoscopy and a formal urodynamic study were performed in 61 (5%) and 40 (3.5%) cases, respectively.

RESULTS

Mean patient age at referral was 6 years (range 3 to 14). Of the children 74% were girls and 26% were boys. Physical examination of the abdomen, back, genitalia and neurological system was unremarkable in all cases. Ultrasound of the upper urinary system was normal in 1,018 patients (97%) and showed insignificant pyelectasis in 32 (3%). All 24 excretory urography studies were normal and voiding cystourethrography was normal in 470 of 672 cases (70%). Unilateral and bilateral low grade, and unilateral high grade reflux was present in 108, 19 and 3 patients, respectively. Urodynamic studies were performed in 40 children who did not respond to standard treatment. We noted detrusor instability in 16 patients, detrusor-sphincter dyssynergia in 6 and sensory abnormality in 3, while the study was completely normal in 10. Cystoscopy revealed normal findings in 17 cases, trabeculations in 21, inflammation in 20 and type 1 posterior urethral valves in 2.

CONCLUSIONS

The incidence of upper tract changes and positive anatomical findings in children with voiding dysfunction is too low to justify routine radiological evaluation and cystoscopy. However, in those who present with a nonfebrile urinary tract infection there remains an important role for voiding cystourethrography. We do not recommend routine urodynamics in children with voiding disorder because this study does not change therapy or influence the final outcome. Thorough history and physical examination lead to the correct diagnosis and treatment in the majority of children. A focus on correcting faulty voiding behavior with the judicious administration of antibiotics and anticholinergic therapy leads to a favorable outcome in most cases.

The overactive bladder in childhood: long-term results with conservative management

PURPOSE

Idiopathic detrusor overactivity has not been thoroughly investigated and its natural history remains largely anecdotal. Bladder overactivity resulting from a neurogenic, anatomical or medical condition has been well described. Therefore, we assessed the long-term results of conservative treatment of children with idiopathic symptomatic refractory detrusor instability.

MATERIALS AND METHODS

We reviewed the records of 58 patients who had an isolated finding of uninhibited contractions on urodynamics performed for refractory enuresis and daytime wetting between 1988 and 1994. Study exclusion criteria were chronic urinary tract infection, neurological lesion, anatomical abnormality of the lower urinary tract and less than 12 months of followup.

RESULTS

Of the 30 children who met our study inclusion criteria 26 (87%) had complete (21) or significant (5) symptom resolution. Average time to resolution was 2.7 years (range 0.2 to 6.6). Patients with a 50% to 90% bladder capacity expected for age were more likely to benefit from therapy than those with a bladder capacity outside of this range. Age and gender were not significant predictors of resolution although girls were more likely to have resolution than boys.

CONCLUSIONS

Idiopathic detrusor instability is amenable to conservative management in the majority of patients during a prolonged period. We advocate thorough urological and urodynamic evaluation to identify idiopathic detrusor instability as an etiology of enuresis and daytime wetting in complicated cases.

Pelvic-floor therapy in girls with recurrent urinary tract infections and dysfunctional voiding

OBJECTIVE

To analyse the treatment of girls with recurrent urinary tract infections (UTIs, at least two periods confirmed) and urodynamically confirmed dysfunctional voiding with pelvic-floor therapy.

PATIENTS AND METHODS

Forty-two girls with recurrent UTIs were treated prospectively during a study period of 18 months. Training consisted of an individually adapted voiding and drinking schedule, pelvic-floor relaxation biofeedback, instructions on toilet behaviour and biofeedback uroflowmetry; residual urine was estimated by ultrasonography. All the girls received prophylactic antibiotics during treatment and those girls with urodynamically proven detrusor instability (33) received anticholinergics. Therapy was considered successful when the girls remained free of infection with no further prophylactic antibiotics for at least 6 months.

RESULTS

Four girls younger than 6 years all suffered nocturnal and diurnal incontinence and two had reflux. Treatment was effective for recurrent UTI in all and the reflux resolved in two. All four girls became dry during the day and one became dry at night. In the 38 girls older than 6 years, the treatment was successful for recurrent UTI in 24 from the out-patient and in all three from the clinical programme. Reflux, which was seen in six of these girls, resolved in five; one girl underwent bilateral reimplantation. Incontinence was treated in all 23 girls with incontinence problems before treatment (four of whom were initially dry). Twelve girls needed a wetting alarm to become dry during the night. In four girls the treatment was effective for recurrent UTI but the incontinence persisted; in seven the treatment was considered unsuccessful as they all had UTIs after treatment; all remained incontinent. Reflux persisted in all four girls in this group who had reflux before treatment.

CONCLUSION

The training programme was effective in treating recurrent UTI in 35 of 42 girls (83%). The persistence of incontinence problems is a bad prognostic factor for the recurrence of UTI after the training programme. Pelvic-floor therapy seems a reasonable and meaningful component in the treatment of recurrent UTIs in which detrusor-sphincter dyssynergia plays a role.

Evaluation of the enuretic child

Nocturnal enuresis is a symptom of environmental, physical, and psychosocial factors. In addition to a physical examination, the initial workup of the enuretic child should include a careful voiding, psychosocial, and family history. Studies have shown that the parents of enuretic children often have a history of enuresis. An increased incidence of enuresis has also been demonstrated in children from large families and lower socioeconomic groups. Daytime voiding symptoms (e.g., frequency, urgency, or enuresis) suggest the possibility of underlying voiding dysfunction. A complete urinalysis and urine culture also should be performed to exclude urinary infection and certain metabolic or nephrologic disorders. Finally, it is important that the treating physician understand the attitudes of both the child and the family concerning enuresis. Parents who feel that the child is at fault need to be educated and reassured. A careful, complete evaluation will allow the physician to tailor treatment to the individual child and family.

Lower urinary tract dysfunction in cerebral palsy

The clinical features and management of 27 children with cerebral palsy referred with symptoms of lower urinary tract dysfunction were reviewed. The mean age at referral was 9.9 years. Daytime urinary incontinence was the commonest presenting symptom. Videourodynamic studies were abnormal in 23 patients (85%). Only two children had evidence of upper renal tract damage. Treatment was determined by urodynamic findings, and led to improvement in symptoms in all patients for whom there was follow up information. Urinary incontinence may be improved or cured in children with cerebral palsy. These children would therefore benefit from early referral for assessment and treatment.

[Acquisition of bladder control in children]

Urinary control in Child occurs during the first five years of life; the first step is daytime control, quickly followed by nocturnal dryness. The bladder is mature when the child is able to initiate micturition at any degree of bladder filing and to differ or inhibit voiding at anytime. Micturition control depends on central nervous system maturation but training by parents is also important. Voiding dysfunction may occur if those mechanisms fail or are delayed: different pathologic patterns can be seen, such as daytime incontinence and enuresis or nonneurogenic neurogenic bladder if dyssynergia is associated.

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

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

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.

Sleep cystometries in children with nocturnal enuresis

A combined analysis was done of sleep and bladder filling during sleep. Cystometry did not specifically affect sleep, since most of the cystometry studies in cases of enuresis did not lead to sleep stage changes on electroencephalography. Bladder instability was not accompanied by lighter sleep. Increasing patient age did not appear to have any influence on sleep or bladder behavior. We conclude that it is possible to provoke enuresis at any sleep stage and that sleep is unaffected by bladder filling in enuretic patients.

The daytime urinary frequency syndrome of childhood

We reviewed retrospectively 43 completely toilet trained children who suddenly developed isolated daytime urinary frequency. Patient age ranged from 2 to 12 years. The condition lasted 2 days to 16 months and resolved spontaneously in all patients. The recurrence rate was 3 per cent unless nocturnal symptoms of nocturia or enuresis coexisted, whereupon it increased to 40 per cent. Anticholinergic medication characteristically produced no improvement in symptoms. Noninvasive investigation included a history and physical examination, urinalysis and renal ultrasonography, and appeared to be sufficient for diagnosis. The etiology is unknown but it may be predominantly behavioral. The daytime urinary frequency syndrome of childhood appears to be a benign self-limited condition that does not require extensive urological evaluation.

Biofeedback training for children with bladder sphincter incoordination

We studied 35 children with voiding dysfunction and detrusor-sphincter incoordination. More than 90 per cent of these patients had a history of repeat urinary tract infections, and medication and surgical treatment of the voiding dysfunction had failed. Of the patients 22 (63 per cent) experienced significant improvement or resolution of the voiding dysfunction when biofeedback was used to teach normal bladder sphincter coordination as part of the over-all treatment regimen. A review of our experience with these patients indicates that with proper patient selection an even higher rate of success may be possible.

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.

Videourodynamic assessment of diurnal urinary incontinence

Persistent daytime incontinence is a fairly uncommon but important problem. Videourodynamic studies were carried out in 215 children presenting with this problem in whom there were no neurological signs and who had not responded to simple measures. Over 90% of symptomatic children were shown to have an abnormality, of which over half had detrusor instability and a fifth had the wide bladder neck anomaly. We consider that it is important that these children are fully assessed as many can be helped.