Persistence of the infant bladder as a cause for urinary infection in girls

Simultaneous Renal Transplantation With Bilateral Nephrectomy and Ureterocystoplasty

Bladder augmentation (BA) may be required before renal transplantation in children with end stage renal disease (ESRD). Herein we report a case of a 7-year-old boy with ESRD, contracted bladder and severe bilateral reflux secondary to posterior urethral valve (PUV), successfully managed by simultaneous bilateral nephrectomy, bilateral ureterocystoplasty and renal transplantation.

Dysfunctional voiding: Challenges of disease transition from childhood to adulthood

N/A

Randomized, double-blind, placebo-controlled trial of polyethylene glycol (MiraLAX®) for urinary urge symptoms

OBJECTIVE

Polyethylene glycol (PEG) is common first-line therapy for urinary symptoms despite minimal evidence-based support. We performed a randomized, double-blind, placebo-controlled study of PEG for initial treatment of overactive bladder (OAB) symptoms in children.

PATIENTS AND METHODS

Patients aged >3 years underwent baseline urinary symptom questionnaire (USQ, scored 0-16), bowel symptom questionnaire (scored 0-20) and abdominal X-ray (KUB). Patients were randomized to placebo/PEG regardless of parent's perception of constipation. After 1 month, patients completed follow-up questionnaires and KUB. Improvement was defined as decrease in USQ (ΔUSQ) ≥ 3 points. Secondary analyses compared urinary and bowel symptoms to KUB.

RESULTS

Of 138 enrolled patients, 71 (51.4%) completed 1 month of therapy. Analyses of those randomized to placebo vs. PEG and non-completers demonstrated similar demographics, baseline symptoms, and KUB. Patients treated with placebo and PEG both had significant improvement in USQ scores (p < 0.0001). Patients treated with placebo and PEG responded similarly to placebo (ΔUSQ 3.7 vs. 3.4, p = 0.773), with improvement in nearly half (48.5% PEG vs. 44.7% placebo). There was no correlation between KUB and urinary or bowel symptoms.

CONCLUSIONS

Nearly 50% of patients with urinary urge symptoms treated with either placebo or PEG for 1 month had improvement in urinary symptoms. KUB did not correlate with baseline or follow-up urinary or bowel symptoms.

Diagnosis and management of dysfunctional voiding

PURPOSE OF REVIEW

This review will focus on the diagnosis and management of voiding dysfunction in neurologically and anatomically normal children. The discussion will highlight recent developments and research in the clinical approach as well as the etiology and classification of these disorders.

RECENT FINDINGS

Voiding dysfunction in children encompasses a wide spectrum of clinical entities, recently classified collectively as dysfunctional elimination syndromes. Voiding dysfunction typically presents after toilet training and may originate from behavioral issues that arise around this time in childhood development. The spectrum of disorders includes urge syndrome, dysfunctional voiding with an uncoordination between the detrusor and urinary sphincter, and enuresis. Clinical symptoms may vary from mild incontinence to severe disorders with endpoints of irreversible bladder dysfunction with vesicoureteral reflux, urinary tract infection and resulting nephropathy. Diagnosis relies heavily on a good history and physical examination, but also includes radiologic and urodynamic evaluation. Treatment generally consists of medical therapy, primarily with anticholinergics as well as behavioral therapy to modify learned voiding patterns that contribute to the voiding dysfunction.

SUMMARY

This overview of voiding dysfunction in children outlines the established approaches to its diagnosis and treatment and highlights the most recent developments in the field.

A multivariate analysis of dysfunctional elimination syndrome, and its relationships with gender, urinary tract infection and vesicoureteral reflux in children

PURPOSE

We explored and quantified the relationships between dysfunctional elimination syndrome (DES), and gender, urinary tract infection (UTI) and vesicoureteral reflux (VUR) in children.

MATERIALS AND METHODS

Data on 2,759 pediatric patients treated at a referral practice who underwent renal sonography and voiding cystourethrography were summarized. The patients were children with VUR or normal genitourinary anatomy who presented with UTI or dysfunctional voiding and children screened for genitourinary problems such as hematuria, sibling reflux or bedwetting. A multivariate logistic regression approach was used to model and quantify the associations between DES and other pediatric urology factors.

RESULTS

Of the girls 36.0% with unilateral VUR had DES, while 36.1% with bilateral VUR had DES. The corresponding rates for boys were 20.5% and 21.2%. The higher rate of DES in girls was independent of UTI and VUR status. While UTI was not associated with DES in boys or girls without VUR, in patients with VUR and UTI the risk of DES almost doubled (OR 1.97). Reflux alone without UTI was negatively associated with DES in boys (OR 0.50, 95% CI 0.34, 0.73) and girls (OR 0.26, 95% CI 0.19, 0.36).

CONCLUSIONS

Girls had a significantly higher rate of DES than boys in all UTI and VUR subgroups in the current data. UTI significantly impacts the DES occurrence in patients with VUR. No statistically significant difference was detected in the DES rate between the unilateral and bilateral VUR groups, and the reflux group as a whole did not seem to have a higher rate of DES in boys or girls.

Etiology of urinary tract infection in scholar children

OBJECTIVE

To prospectively assess the prevalence of vesicourethral dysfunction in children over 3 years old, comparing it with the occurrence rate for other potential factors that cause urinary infection in this age range.

MATERIALS AND METHODS

36 girls and 9 boys were assessed, with mean age of 6.4 years, ranging from 3 to 13.9 years. These children were prospectively assessed regarding the presence of symptoms of lower urinary tract dysfunction. These data were compared with the retrospective assessment of other potential risk factors for urinary infection. Ultrasonography was performed in 28 children and voiding cystourethrogram was performed in 26 patients.

RESULTS

Vesicourethral dysfunction was diagnosed in 39 (87%) of the 45 children with urinary infection. Among these 39 patients, all had voiding urgency, 30 (77%) had urinary incontinence, 12 (31%) pollakiuria and 3 (8%) presented infrequent voiding. Vaginal discharge was evidenced in 8 (22%) girls and phimosis in 2 (22%) boys. Obstipation was diagnosed in 10 (22%) cases. Significant post-voiding residue was detected in 4 (13%) of the 28 cases assessed. Vesicoureteral reflux was evidenced in 5 (19%) of the 26 patients who underwent voiding cystourethrogram. In only 2 (4%) cases there was not an apparent cause for the infection.

CONCLUSION

Vesicourethral dysfunction is a major cause of urinary infection in children with ages above 3 years old. In cases where voiding dysfunction in not present, other predisposing factors must be assessed. However, only 4% of the patients did not present an apparent urologic cause for the infection.

Augmentation ureterocystoplasty with ipsilateral renal preservation in the management of patients with compromised renal function secondary to dysfunctional voiding

We evaluated the role of ureterocystoplasty with ipsilateral renal preservation in the management of patients with neurovesical dysfunction and impaired renal function. The procedure was carried out on 6 patients with a mean age of 8.5 years. All patients had vesicoureteric reflux (VUR) secondary to neuropathic bladders, recurrent urinary tract infections, day time incontinence, impaired and deteriorating renal function. All patients were followed up with a mean of 22.5 months (range 6-30). Renal function stabilized in 4 patients and improved in 2 patients. Adequate urinary bladder capacity was achieved in all patients. Bladder volume increased from a mean of 210+/-71 to 382+/-66, this increase was statistically significant (p<0.001). All patients were dry by day including the children who at presentation were in diapers. We conclude that the results of this operative intervention are satisfactory and promising in the management of this difficult group of patients while avoiding the side effects of enterocystoplasty procedures.

Some new insights into bladder function in infancy

OBJECTIVES

To evaluate normal bladder function and micturition patterns in infants.

PATIENTS, SUBJECTS AND METHODS

Twenty-one infants (16 boys, five girls; mean age 5.9 months) with no lower urinary tract pathology underwent natural filling cystometry. Micturition patterns were also observed simultaneously with polysomnography in 26 healthy neonates (16 boys, 10 girls; mean age 7.4 days).

RESULTS

In infants, cystometry showed (95% CI) a capacity of 42-53 mL, a maximum rise in detrusor pressure during voiding of 95-120 cmH2O and a voiding efficiency (voided volume/capacity) of 0.86-0.91. On micturition, urinary flow was discoordinated from peak detrusor pressures in 10 infants. Detrusor instability occurred in one of 21 infants. Micturition was observed only during wakefulness or on arousal from sleep. In neonates, 17 of 61 recorded voids (28%) were during full wakefulness and 44 (72%) during arousal from sleep. Notably, none of the recorded voids occurred during quiet sleep.

CONCLUSIONS

The normal infant's bladder was stable and emptied almost completely. Voiding with incomplete co-ordination between detrusor contraction and urinary sphincter relaxation could be normal. Micturition never occurred during quiet sleep. There was cortical arousal in response to a full bladder even in new-born infants. This contradicts the traditional concept of a totally uninhibited bladder in infancy. There are potential implications for the management of children with nocturnal enuresis.

The sensitivity of pressure specific bladder volume versus total bladder capacity as a measure of bladder storage dysfunction

Assessment of bladder storage function requires an accurate measure of bladder capacity and pressure. Pressure specific bladder volume is the volume that a bladder can accommodate at a specific pressure. A total of 21 consecutive children with neurogenic bladders who were candidates for bladder augmentation based on standard clinical criteria (upper urinary tract deterioration, incontinence and infection) was studied to determine the efficacy of pressure specific bladder volume as a measure of bladder dysfunction. Urodynamic indexes were compared to previously established nomograms. All 21 patients had bladder volumes at pressures of 30 cm. water or less, which decreased below the 5th percentile as determined by the nomogram. In 7 patients (33%) normal total bladder capacity was achieved at the expense of elevated storage pressures. Pressure specific bladder volume provides a better measure of bladder storage function than total bladder capacity because it relates volume to intravesical pressure, does not rely on a subjective end point to bladder filling, and is objective and reproducible.

Bladder augmentation: ureterocystoplasty versus ileocystoplasty

The primary advantages of augmentation ureterocystoplasty include the absence of mucus, lack of electrolyte absorption from the augmenting segment and the avoidance of gastrointestinal complications. We tested whether the ureteral patch offers sufficient biomaterial to increase adequately the storage efficiency of dysfunctional bladders. Between April 1989 and November 1992, 8 children with unilaterally dilated and tortuous ureters underwent bladder augmentation using detubularized reconfigured megaureter. Clinical and urodynamic outcomes were compared between these patients and a control group of 8 children matched in age and diagnosis who had undergone ileocystoplasty during the same time. Total bladder capacity, pressure specific bladder volume at pressure less than 30 cm. water, dynamic analysis of bladder compliance, continence and upper tract status were compared between the 2 groups before and after augmentation. Preoperatively, all 16 patients were incontinent with high pressure, small capacity bladders, and all had upper tract changes. Postoperatively, the mean total bladder capacity was 417 ml. in the ureterocystoplasty group and 381 ml. in the ileocystoplasty group (p > 0.05), while the mean pressure specific bladder volume was 413 and 380 ml. (p > 0.05), respectively. Pressure specific bladder volume and dynamic bladder compliance were normal in 7 of 8 patients (87.5%) in the ureterocystoplasty group. All patients in the ileocystoplasty group had normal postoperative urodynamics. We conclude that megaureters subtending effete kidneys may be used to improve the storage function of dysfunctional bladders to the same extent as that achieved with ileum without the complications pursuant to ileocystoplasty, and that the improvement is maintained long term.

Double antimicrobial prophylaxis in girls with breakthrough urinary tract infections

OBJECTIVE

Some girls receiving antimicrobial prophylaxis for recurrent urinary tract infections (UTIs) experience breakthrough infections. The clinical characteristics of girls experiencing a breakthrough UTI and the efficacy of an antimicrobial combination was studied.

METHODS

Girls were managed by frequent timed voiding, anticholinergic medication for bladder instability, and double antimicrobial prophylaxis consisting of nitrofurantoin (NFN) 2 mg/kg every morning and trimethoprim/sulfamethoxazole (TMP/SMZ) 2/10 mg/kg at bedtime.

RESULTS

A total of 31 girls had experienced sixty-four UTIs during three hundred sixty-seven months (17.4 UTIs/100 patient-months) while receiving TMP/SMZ and/or NFN as single-drug prophylaxis. Of the girls, 21 (68%) had reflux, 15 (49%) had detrusor instability/voiding dysfunction, 8 (26%) had both reflux and voiding dysfunction, and 3 (10%) had neither voiding dysfunction nor reflux. While receiving double antimicrobial prophylaxis, 8 girls (26%) experienced a UTI and only 3 (10%) showed a UTI resistant to both TMP/SMZ and NFN. There were only sixteen breakthrough UTIs during four hundred thirty-nine months of double prophylaxis (3.6 UTIs/100 patient-months) (P < 0.001).

CONCLUSIONS

Girls with breakthrough UTIs usually have voiding dysfunction and/or reflux, and in these girls double antimicrobial prophylaxis and attention to voiding dynamics were effective in preventing further UTIs.

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.

Rational use of CT in acute pyelonephritis: findings and relationships with reflux

Enhanced renal CT scanners were performed in 38 children (82% girls) to rule out acute pyelonephritis. Patients were divided in 2 groups on the basis of clinical presentation and bacteriology data. In patients of group A (n = 16, preliminary study), upper urinary tract infection (UTI) was certain. CT confirmed the diagnosis in all but 3 patients (a 2-year-old child and 2 patients with UTI developed on prior obstruction). In subsequently studied patients of group B (n = 22), clinical findings or bacteriology data were negative or questionable. CT made the diagnosis of acute pyelonephritis in 11 patients. As well as DMSA scintigraphy, CT scanner can help to diagnose or to rule out upper UTIs in difficult cases. In all boys of both groups, ipsilateral vesico-ureteric reflux (VUR) was found by subsequent voiding cystourethrography (VCUG) on the side of pyelonephritis. In girls, this correlation was shown in only 7 of the 25 kidneys with pyelonephritis. This result supports the hypothesis of a gender-dependent contamination. We believe that absence of radiologic reflux cannot exclude the possibility of bacterial crossings of ureteric meatus capable to lead to genuine upper UTIs.

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.

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.

Incontinence and enuresis

Most children with incontinence not associated with known neurologic impairment will have either functional immaturity of the nervous system or inflammatory conditions of the lower urinary tract as the etiology for incontinence. By using the criteria outlined in this article, one can manage selective urologic evaluation of the diurnally incontinent and enuretic child, saving most patients the cost and stress of more in-depth diagnostic evaluations.

Nonneurogenic neurogenic bladder (the Hinman syndrome)--15 years later

Every child with day and night wetting is a suspect for vesicourethral dysfunction on a behavioral basis, which, when severe, appears as a syndrome that we have called the nonneurogenic neurogenic bladder. Futile attempts by the child at sphincteric urinary control in the face of uncontrollable bladder contractions not only produce the symptoms but also the anatomical and functional changes: vesical trabeculation, distortion of the ureterovesical orifices and dilatation of the upper tracts, along with residual urine and consequent bacteriuria. These changes are indistinguishable from obstructive or, particularly, neurogenic factors, although these causes must be ruled out. Urodynamic investigations in these children show incoordination between detrusor contraction and the expected but not forthcoming urethral sphincteric relaxation. Since these children usually are toilet trained initially, the incoordination appears to be a learned behavior or habit, perhaps as a response to under-appreciated detrusor contractions. Reversal of the syndrome is achieved by suitable medication and by some form of suggestion or retraining. Reparative operations will fail if done before the system is balanced.

Effects of oxybutynin on vesicoureteral reflux in children

We reviewed retrospectively 40 children seen from 1980 to 1984 with vesicoureteral reflux in 53 ureters. All patients had a hyperreflexic bladder on urodynamic evaluation with or without vesicoperineal dyssynergia but they were otherwise neurologically normal. All except 1 child received prophylactic antibiotics. Of the children 37 received oxybutynin therapy for bladder hyperreflexia for 3 to 18 months. Reflux disappeared or became grade I in 62.3 per cent of the ureters. Of the children manifesting urinary incontinence at the time of urodynamic study reflux disappeared or became grade I in 78.6 per cent. Reflux resolved or became grade I in 20 per cent of the children with no urinary incontinence. Of those patients with recurrent reflux at the onset of urinary incontinence and bladder instability reflux resolved or became grade I in 80 per cent. Oxybutynin therapy for hyperreflexic bladder resulted in an average increase in bladder capacity of 97 cc (54.2 per cent), which was maintained after cessation of treatment. These data suggest that bladder instability can be an important factor in causing and perpetuating reflux. Therapy aimed at decreasing intravesical pressure will enhance resolution or downgrading of reflux.

The uninhibited bladder in children: effect of treatment on recurrence of urinary infection and on vesicoureteral reflux resolution

We studied and treated prospectively 62 neurologically normal children with vesicoureteral reflux using urodynamic techniques to identify uninhibited bladder contractions with voluntary sphincteric obstruction (dyssynergia). All children received antibiotic prophylaxis. Anticholinergic drugs were used additionally to treat uninhibited bladder contractions. During 6 years of followup treatment of uninhibited contractions produced a 4-fold reduction in the incidence of recurrent urinary infection and tripled the rate of reflux resolution compared to controls. These data suggest that uninhibited contractions with voluntary sphincter obstruction are an important prognostic finding in children with reflux, which when treated successfully can alter the disease course and may make surgical therapy of reflux unnecessary for some.

Urinary flow studies in normal kindergarten--and schoolchildren

The problems in the evaluation of children with suspected infravesical obstruction are shortly reviewed. Based upon literature studies it is concluded, that an isolated urinary flow measurement determining the Qmax is a suitable procedure of screening. Due to different shortcomings of earlier published normal materials, we investigated the spontaneous urination of 205 normal children aged 3 to 13 years in their normal environment. The mictiograph was installed in the toilet of two kindergartens and one school, enabling the children freely to void into the machine upon desire. From the flow curves the following parameters were calculated: Q1 sec, Qmax, Qmax time, and the micturition time, all of them being related to the square root of the voided volume. The data were non-parametrically statistically processed, and the limits of normal values (2 1/2% and 97 1/2% percentiles) are defined for different groups of age and sex. Furthermore, the different flow curve patterns are described, and it is found, that in 90% of the cases they are identical to the adult pattern.

Micturition symptoms and unstable bladder activity in girls with primary vesicoureteric reflux

A series of 37 girls with primary vesicoureteric reflux of grade II and greater severity underwent urodynamic investigations. Twenty-eight (75%) were found to have unstable bladder activity. Disordered micturition patterns were common and persisted after urinary tract infections had been eradicated. Twenty-six girls had urgency of micturition and 19 urge incontinence occurring once per week or more. The correlation between these symptoms and unstable bladder activity was significant (P less than 0.01), but there was no correlation between bladder instability and the incidence of renal scarring.

Voiding dysfunction in children

Superficially, the causes of voiding difficulties in children may seem quite simple, but a thorough understanding of the anatomy physiology and neurology of normal and abnormal lower urinary tract function is necessary in uncovering the etiology of often seemingly siple complaints. An ectopic ureter, neurogenic bladder, urinary tract obstruction, or simple urinary tract immaturity, for example, can all cause a child to present with the complaint of "wetting." A familiarity with all the possible causes of voiding dysfunction is required to distinguish significant from insignificant symptoms. While a "wait and see" attitude often results in the spontaneous resolution of a problem such as simple nocturnal enuresis, the misdiagnosis of a severe disorder, such as urinary outflow obstruction, may permit the insidious development of irreversible renal failure. Our purpose in writing this monograph was not to provide a comprehensive guide to the diagnosis of voiding dysfunction in children, but rather to enhance the clinician's appreciation of the complexity of these problems. Our hope is that the perspective that we have provided will obviate the diagnostic and therapeutic exaggeration of insignificant voiding complaints, while assuring that the presence of significant lesions is not overlooked.

Association of urinary tract infection and reflux with uninhibited bladder contractions and voluntary sphincteric obstruction

We studied 53 neurologically normal children with recurrent urinary tract infection who were found to have bladder-sphincter incoordination characterized by voluntary sphincteric constriction during involuntary uninhibited bladder contraction. Increased intravesical pressure was documented during these events and was associated with vesicoureteral reflux in nearly 50 per cent of the children and with abnormalities of the ureteral orifice in 30 per cent of those without reflux. We hypothesize that increased intravesical pressure causes urinary infection in these children and produces a spectrum of intravesical anatomic distortion that predisposes to vesicoureteral reflux. In a prospective uncontrolled study treatment of the uninhibited bladder contractions allowed 58 per cent of the patients to maintain sterile urine without subsequent antimicrobial therapy after cure of the initial infection.

Transurethral treatment of urethral diverticula in women

Six women with urethral diverticulitis and a history of having had previous operations for diverticula were subjected to transurethral diverticulotomy with a knife electrode. Each patient had multiple diverticula, some compartmented, located in the mid or most proximal segments of the urethra. All patients have been relieved of the symptoms and infection during the postoperative period, varying from 1 1/2 to 7 years.

Cystourethritis

We believe this review lists the major factors and mechanisms considered responsible for producing cystourethritis. Knowledge of these factors and mechanisms is essential before effective investigation of this disease can be undertaken. We suggest a rational scheme for investigation of these patients. We believe successful treatment depends on establishing the probable cause in each individual patient. In view of the multifactorial etiology of the disease, attempts to find a single effective medical or surgical therapy will be doomed to failure.

External sphincter activity and recurrent urinary tract infection in girls

Urodynamic investigations, including pressure studies, anal sphincter electromyography, and cystourethrography, done in young girls having symptomatic urinary infection show hyperreflexive activity of both striated sphincter and detrusor muscles, due to increased afferent input. In our series, this activity ranged froma a pattern similar to "uninhibited" bladder contractions, with normal voiding, to hyperactivity causing frequency, with voiding interrupted by frank sphincter spasms. The wide range and epidemiology of urinary infection in girls suggest that urethral dilatation (or urethrotomy) with long-term chemoprophylaxis is indicated only at one extreme--where the hyperactivity persists in the absence of infection. The role of persistent hyperactivity of detrusor and sphincter in recurrent urinary infection of childhood needs to be defined by a long-term longitudinal study; the high over-all recurrence rates of both covert bacteriuria and overt infection in girls still constitute a major medical problem.

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

Ninety-one children with nocturnal enuresis or enuresis plus daytime urgency incontinence were studied by cystometry. Seventy-two per cent of the girls and 62 per cent of the boys had evidence of bladder instability. Sixty-eight children in whom abnormalities were found on preliminary voiding urodynamics or voiding cystourethrography also underwent calibration and endoscopic examination under anesthesia. An atropine-suppression test was also performed preoperatively in some children with a markedly unstable bladder demonstrated on preoperative cystometry. In the majority of children tested suppression of bladder instability with atropine was demonstrable. Voluntary detrusor sphincter dyssynergia was demonstrated in a majority of the children with daytime urgency incontinence. Sixty-five per cent of the boys and 81 per cent of the girls were treated for urethral obstructive lesions suspected to be of functional urodynamic significance. Postoperative cystometry showed marked improvement in bladder stability in 57 per cent of the girls and 63 per cent of the boys treated for suspected urethral obstructive pathology. The anticholinergic suppression test was found to have no significant predictive value relative to the cause or surgical curability of bladder instability. The pathophysiologic significance of overactivity of integral voiding reflexes 6 through 11 is described.

Integral storage and voiding reflexes. Neurophysiologic concept of continence and micturition

It is a common clinical misconception to regard the spinal micturition reflex center as fundamentally overactive and dependent on cerebral inhibition. Initiation and cessation of micturition is simplistically viewed as a manifestation of voluntary withdrawal and resumption of inhibitory corticospinal "regulation''. This view is in conflict with basic neurophysiologic experimental data. Actually, the organization of the micturition reflex is extremely complex. It is affected by multiple sources of facilitative and inhibitory influence, peripheral as well as central. During the past half century, at least twelve reflexes involved in urine storage and coordinated micturition have been described by various neurologic investigators. In this article the integral reflexes are identified and described. A functional organization of the integral reflexes which includes a modern concept of their role in the physiology of urine storage and micturition is presented. It is implicit that overactivity or functional failure of any one or combination of the integral reflexes may cause a significant disorder of lower urinary tract function.

Further observations on self-catheterization

A non-sterile technique of intermittent self-catheterization was used for 218 patients with an inability to void in a normal fashion because of obstructive uropathy, decompensated detrusor or neurogenic bladder. Marked improvement was noted in urinary continence, urinary infection, renal function, bladder emptying and, perhaps most important, the mental and emotional status of the patient and/or parents. The extremely low incidence of complications and its therapeutic efficacy clearly make clean, intermittent self-catheterization an outstanding weapon in the urological armamentarium and a most persuasive reminder that host resistance is still the primary factor in the occurrence of infection.