Management of the Obstructed Urinary Tract Associated with Neurogenic Bladder Dysfunction

Team Approach: The Management of Adolescents and Adults with Scoliosis and Spina Bifida

»

Globally, the prevalence of myelomeningocele, the most common subtype of spina bifida, is 0.2 to 6.5 per 1,000 live births. In the U.S., adults account for >67% of the overall population with spina bifida.

»

With an estimated prevalence of up to 50%, scoliosis is one of the most common and severe orthopaedic conditions in patients with myelomeningocele.

»

The variable effects that scoliosis can have on an individual, the comorbidities associated with progressive scoliosis, and the risks associated with spine surgery call for a strong partnership and care coordination between medical and surgical teams to deliver a patient-centered approach.

»

A coordinated, structured, planned, and incremental team approach can help individuals achieve the overall goals of functionality and independence, as well as successful transition to adulthood.

»

Teams should consider a patient's social determinants of health (e.g., poverty or language barriers) and the effect of scoliosis on quality of life before proceeding with spinal deformity correction.

Urologic guidelines for the care and management of people with spina bifida

PURPOSE

The life expectancy for people with spina bifida has increased, thus resulting in greater need for guidelines in urologic care in order to protect normal renal function, to develop strategies for urinary continence, and to advance independence through adult years.

METHODS

The English literature was assessed from 2002-2015; greater than 300 publications identified. Case reports and opinion pieces were eliminated leaving 100 for in depth review. Clinical questions were then established for each age group that allowed for focused assessment.

RESULTS

There was no Level 1 evidence for any of the defined clinical questions. This resulted in group consensus for all questions throughout all age groups. Guidelines were provided for identifying a symptomatic urinary infection, the role of urodynamic bladder testing and identification of bladder hostility, determining methods of renal function assessment and surveillance, the initiation of continence control, and transitioning to self-care through the teen and adult years.

CONCLUSION

Urologic guidelines continue to be based on clinical consensus due to the lack of high level evidence-based research. Further research is required in all aspects of urologic management. While not the "Standard of Care," these guidelines should be considered "Best Practice".

Comparing a novel hand held device (Peritron+) to standard urodynamics in measuring intravesical pressure

AIMS

Peritron+ is a new handheld device, which can be attached to a urethral catheter to measure intravesical pressures (Pves). The goal of this study was to assess if Pves recorded by standard urodynamics (UDs) are comparable to those recorded by the Peritron+.

METHODS

Patients with voiding dysfunction and an indication for UD underwent measurement of Pves with nonvideo UD and Peritron+. Pves were recorded at volumes of 50, 100, and 200 mL for the supine and sitting positions. A failure of the Peritron+ was considered to be a discrepancy of Pves values >3 cmH₂ O between Peritron+ and UD recordings. Two-way ANOVA was used to assess for statistical significance. P-values < 0.05 were considered significant.

RESULTS

Ten female patients, mean age 51 years old, were enrolled in the study. The difference in Pves measurements between Peritron+ and UD were ≤3 cmH₂ O at all bladder volumes measured in a supine and sitting positions. There were no adverse events and there were no malfunctions of the Peritron+ device during the study.

CONCLUSIONS

Peritron+ handheld device accurately assessed Pves at different intravesical volumes when compared to UD measurements. The Peritron+ is a simple and safe device, which can be used in the office by a clinician and at home by a patient to monitor Pves and help to select patients who may require standard UD re-evaluation. This will be a valuable tool in managing patients with neurogenic and nonneurogenic bladders who are at a risk of upper urinary tract deterioration.

Outcomes of living donor renal transplantation in children with lower urinary tract dysfunction: a comparative retrospective study

OBJECTIVES

To compare outcomes of renal transplantation (RTx) in children with end-stage renal disease (ESRD) resulting from lower urinary tract dysfunction (LUTD) vs other causes.

PATIENTS AND METHODS

A database of children (<18 years old) who underwent RTx between May 2008 and April 2012 was reviewed. Patients were divided into those with LUTD (group A, n = 29) and those with other causes of ESRD (group B, n = 74). RTx was performed after achieving low intravesical pressure (<30 cmH2 O) with adequate bladder capacity and drainage. The groups were compared using Student's t-test, Mann-Whitney, chi-squared or exact tests. Graft survival rates (GSRs) were evaluated using Kaplan-Meier curves and the log-rank test.

RESULTS

The mean ± sd (range) age of the study cohort was 5.05 ± 12.4 (2.2-18) years. Causes of LUTD were posterior urethral valve (PUV; 41.4%), vesico-ureteric reflux (VUR; 37.9%), neurogenic bladder (10.3%), prune belly syndrome (3.4%), obstructive megaureter (3.4%) and urethral stricture disease (3.4%). There was no significant difference in age, dialysis duration or donor type. In group A, 25 of the 29 patients (86.2%) underwent ≥1 surgery to optimize the urinary tract for allograft. Pretransplant nephrectomy was performed in 15 of the 29 patients (51.7%), PUV ablation in nine patients (31%) and ileocystoplasty in four patients (13.7%). The mean ± sd follow-up was 4.52 ± 1.55 and 4.07 ± 1.27 years in groups A and B, respectively. There was no significant difference in creatinine and eGFR between the groups at different points of follow-up. The GSRs at the end of the study were 93.1 and 91.1% in groups A and B, respectively (P = 1.00). According to Kaplan-Meier survival curves, there was no significant difference in the GSR between the groups using the log-rank test (P = 0.503). No graft was lost as a result of urological complications. In group B, one child died from septicaemia. The rate of urinary tract infections was 24 and 12% in groups A and B, respectively, but was not significant. No significant difference was found between the groups with regard to the incidence of post-transplantation hydronephrosis. Of the 22 patients who had hydronephrosis after transplantation, three were complicated by UTI. Injection of bulking agents was required in two patients for treatment of grade 3 VUR. In the third patient, augmentation cystoplasty was needed.

CONCLUSION

Acceptable graft function, survival and UTI rates can be achieved in children with ESRD attributable to LUTD. Thorough assessment and optimization of LUT, together with close follow-up, are key for successful RTx.

Screening for depression and anxiety in childhood neurogenic bladder dysfunction

INTRODUCTION

Patients with chronic illnesses are known to have anxiety disorders and are likely to be depressed. Anxiety and depression (A/D) has been studied in adults with spina bifida (SB), however, no study has directly screened for A/D in pediatric patients with neurogenic bladder (NB) and their caregivers.

OBJECTIVE

The aims of our study were to determine the prevalence of A/D in caregivers of all children with SB and other NB dysfunction and in adolescents with validated screening measures.

STUDY DESIGN & PATIENTS

This was a preliminary cross-sectional screening investigation for A/D in pediatric patients with NB and their caregivers and adolescents with NB. Pediatric patients were defined as ages birth to 19 years and adolescents as ages 10 years-19 years. A caregiver was self-defined as a primary parent/guardian who took care of the pediatric patient for a majority of their time on a daily basis.

MATERIALS AND METHODS

We contacted 75 families by mail, of which 15 returned the consent and completed the questionnaires. Subsequently, 25 consecutive families whose children were seen for routine office appointments by the pediatric urology service at the Albany Medical Center in New York participated in person. 22 adolescents completed the Hospital Anxiety and Depression Scale (HADS). 47 caregivers completed both the HADS and the Center for Epidemiologic Studies Depression Scale (CES-D).

RESULTS

Depression among adolescents: Of the 22 adolescents who completed the HADS, the median HADS score was 5.5 (Inter-quartile range (IQR): 1.75-8.75) for anxiety and 1.5 (IQR: 0-4.25) for depression; both scores were within the normal range (<8/21). Individual abnormal HADS scores (≥8/21) were seen in 6/22 (27%) for anxiety and 1/22 (5%) for depression. Anxiety and depression among caregivers: Of the 47 caregivers who completed the HADS and CES-D, the median HADS score was 7 (IQR: 4-11) for anxiety and 4 (IQR: 1-7) for depression; both scores were within the normal range. Individual abnormal HADS scores were seen in 23/47 (49%) for anxiety and 10/47 (21%) for depression. Abnormal CES-D scores (>15) were seen in 15/47 (32%). The median CES-D scores were 8 (IQR: 3-19).

DISCUSSION

In this preliminary screening study, we found considerable anxiety in adolescents with NB and both A/D in caregivers. When screening by two validated surveys, adolescents with NB had median scores for A/D that were normal; yet 27% of these patients exhibited scores for anxiety that outwit the normal range. For the caregivers, the median scores were also normal; yet 49% and 32% had scores for A/D, respectively, that were abnormal. SB among pediatric patients has been shown to result in alterations in daily functioning and to increase the dependency on adult care, factors that are associated with altered self-concept, psychological distress, including A/D. Our findings underscore such results from previous studies. In caregivers, we observed a higher prevalence of anxiety than adolescents; similar findings have been reported for caregivers of other chronic conditions. Surprisingly, in caregivers, a lower percentage of scores for depression was observed. Although we have no data on the cause of this finding this may be related to a caregiver's ability to adapt to the demands of the situation in chronic illness or perhaps, lower expectations. The cross-sectional nature of our study limited us to draw any causal relationships for anxiety or depression between neurogenic patients and their caregivers.

CONCLUSION

Despite our study limitations, the prevalence of anxiety in adolescents and in the caregivers is striking. Our data highlight that clinicians should screen for A/D more aggressively in pediatric patients with NB dysfunction and in their caregivers.

Treatment outcomes according to neuropathic bladder sphincter dysfunction type after treatment of oxybutynin chloride in children with myelodysplasia

PURPOSE

We investigated the treatment outcomes according to neuropathic bladder sphincter dysfunction (NBSD) type after oral oxybutynin (OBT) treatment in children with NBSD caused by myelodysplasia.

METHODS

Among 334 pediatric patients who were diagnosed with NBSD caused by myelodysplasia, only children treated with oral OBT for more than 1 year with pre- and post-treatment urodynamic studies and dimercaptosuccinic acid (DMSA) were retrospectively reviewed. We compared pre- and post-treatment urodynamic parameters including maximum cystometric capacity (MCC), MCC/estimated bladder capacity (EBC), and compliance by NBSD type in children. We also compared renal scarring on pre- and post-treatment DMSA by NBSD type in children.

RESULTS

Our study population was comprised of 81 children (45 boys and 36 girls), with a mean age of 4.2 ± 3.4 years. The mean follow-up duration was 4.5 (range 1.0-15.1) years. After OBT treatment, MCC was increased significantly in all types of NBSD from 110.3 ± 62.2 to 202.3 ± 103.9 ml (p < 0.05), compliance was significantly improved from 6.4 ± 6.1 to 11.1 ± 9.6 ml/cmH2O (p < 0.05), but MCC/EBC was slightly decreased from 75.2 ± 46.9 to 69.8 ± 33.3 % (p = 0.40). Sub-analyzed by NBSD type, the pre-treatment compliance of children with acontractile detrusor with spastic sphincter (n = 16) was markedly decreased compared with other types of NBSD. Acontractile detrusor with spastic sphincter demonstrated the worst renal deterioration on DMSA.

CONCLUSIONS

Although increases in MCC/EBC were limited, oral OBT treatment markedly improved MCC and compliance in all NBSD types. Children who had acontractile detrusor with spastic sphincter had a relatively high probability of renal deterioration and required specific attention.

The neurogenic bladder: medical treatment

Neurogenic bladder sphincter dysfunction (NBSD) can cause severe and irreversible renal damage and bladder-wall destruction years before incontinence becomes an issue. Therefore, the first step in adequate management is to recognize early the bladder at risk for upper- and lower-tract deterioration and to start adequate medical treatment proactively. Clean intermittent catheterization combined with anticholinergics (oral or intravesical) is the standard therapy for NBSD. Early institution of such treatment can prevent both renal damage and secondary bladder-wall changes, thereby potentially improving long-term outcomes. In children with severe side effects or with insufficient suppression of detrusor overactivity despite maximal dosage of oral oxybutynin, intravesical instillation is an effective alternative. Intravesical instillation eliminates systemic side effects by reducing the first-pass metabolism and, compared with oral oxybutynin, intravesical oxybutynin is a more potent and long-acting detrusor suppressor. There is growing evidence that with early adequate treatment, kidneys are saved and normal bladder growth can be achieved in children so they will no longer need surgical bladder augmentation to achieve safe urinary continence in adolescence and adulthood.

Urodynamic effects of propiverine hydrochloride in children with neurogenic detrusor overactivity: a prospective analysis

OBJECTIVES

To evaluate prospectively the efficacy and tolerability of propiverine for treating neurogenic detrusor overactivity (NDO) in children.

PATIENTS AND METHODS

Twenty children (mean age 8.9 years; median 5.6) with NDO due to an upper motor neurone lesion were enrolled (17 had myelomeningocele). In the urodynamic examination, reflex volume (RV), maximum detrusor pressure (MDP), maximum cystometric bladder capacity (MCBC) and bladder compliance (BC) before and after a twice-daily propiverine hydrochloride regimen were determined. The urodynamic follow-up was after 3-6 months. Incontinence was assessed by an incontinence score.

RESULTS

The mean (sem) RV increased from 103.8 (21.3) to 174.5 (33.7) mL (P < 0.005), MDP decreased from 52.5 (7.9) to 40.1 (6.2) cmH(2)O (P < 0.05), MCBC increased from 166 (28.8) to 231.9 (34.8) mL (P < 0.005), and BC improved from 11.2 (2.8) to 30.6 (9.7) mL/cmH(2)O (P < 0.01), with propiverine treatment. The incontinence score (scale 0-3) improved from 2.4 (0.2) to 1.6 (0.3) (P < 0.05). Propiverine was well tolerated, although some children were given higher doses than recommended.

CONCLUSIONS

Propiverine hydrochloride is effective and well tolerated in the treatment of children with NDO. Because of its dual mode of action, it is well tolerated even in children who need higher doses. Propiverine hydrochloride is a preferable alternative to oxybutynin, the anticholinergic most frequently used in children with NDO to date.

O cuidar de crianças portadoras de bexiga neurogênica: representações sociais das necessidades dessas crianças e suas mães

Esta investigação buscou conhecer e analisar as representações e necessidades de crianças em idade escolar, portadoras de bexiga neurogênica, e de suas mães. A pesquisa foi de natureza qualitativa, sendo as representações sociais o processo metodológico adotado. Na interposição das categorias empíricas com as analíticas, o viver e o cuidar são representados respectivamente pelas mães como um "problema" e "tudo eu"; as crianças, por sua vez, interpretam com "num é justo" a interação diferenciada e preconceituosa que sofrem no contexto em que estão inseridas.

Intravesical application of a stable oxybutynin solution improves therapeutic compliance and acceptance in children with neurogenic bladder dysfunction

PURPOSE

To improve patient compliance with and acceptance of intravesical oxybutynin therapy for neurogenic bladder dysfunction we developed a stable oxybutynin solution that eliminates the complicated crushing procedure.

MATERIALS AND METHODS

From January 1995 to January 1997 we prospectively evaluated 15 children with a mean age of 6.1 years with persistent detrusor hyperactivity or significant side effects on oral oxybutynin therapy who received intravesically 0.2 mg./kg. (maximum 5 mg.) of a stable oxybutynin solution (5 mg./5 ml., pH 5.85) twice daily.

RESULTS

The oxybutynin solution remained stable up to 24 months. In 13 of the 15 children therapeutic compliance was excellent. Detrusor hyperactivity decreased and systemic side effects were absent or minimal. After 4 and 24 months mean cystometric bladder capacity plus or minus standard error of mean increased from 114+/-15.2 to 161+/-26.6 and 214+/-21.7 ml. (p <0.01), mean ratio of cystometric-to-expected bladder capacity increased from 0.88+/-0.12 to 1.18+/-0.14 and 1.24+/-0.16 (p <0.01), and end filling bladder pressure decreased from 57.0+/-7.1 to 25.6+/-4.4 and 30.8+/-4.4 cm. water (p <0.01), respectively.

CONCLUSIONS

Intravesical instillation of a specially prepared oxybutynin solution is safe and reliable in children with persistent detrusor hyperactivity or side effects on oral oxybutynin therapy. Eliminating the complex crushing preparation of the solution by the child or parent has made this therapy easy to use and acceptable in the long term.

Intravesical oxybutynin for neurogenic bladder dysfunction: less systemic side effects due to reduced first pass metabolism

PURPOSE

To unravel why intravesical oxybutynin is more effective and causes significantly fewer systemic side effects than oral oxybutynin in the treatment of neurogenic bladder dysfunction, we tested the hypothesis that the absorption and metabolism of oxybutynin are changed after intravesical instillation.

MATERIALS AND METHODS

A high-performance liquid chromatography assay was developed for both oxybutynin and its active metabolite, N-desethyl-oxybutynin. Plasma concentrations were quantified after intravesical (n = 11) and oral (n = 5) administration of oxybutynin in children under steady-state conditions. Pharmacokinetic parameters were calculated.

RESULTS

Oral administration of oxybutynin (0.2 mg./kg./dose) resulted in peak plasma concentrations for N-desethyl-oxybutynin which were 7.4 +/- 1.3 times higher than corresponding values for oxybutynin (n = 5). Also the AUC (area under the plasma concentration time curve) values were higher for N-desethyl-oxybutynin compared with those of oxybutynin, the ratio being 10.8 +/- 1.0 (n = 5). Intravesical instillation (0.2 mg./kg./dose), on the other hand, resulted in reduced metabolite generation and peak plasma concentrations for N-desethyl-oxybutynin which were in the same range as those for oxybutynin, the ratio being 1.2 +/- 0.1 (n = 11). The ratio for the AUC values for N-desethyl-oxybutynin and oxybutynin was 2.1 +/- 0.2 (n = 11).

CONCLUSIONS

The significantly lower AUC ratio of the N-desethyl metabolite over the mother compound, due to a reduced first pass metabolism, may explain the clinically relevant reduction of side effects that characterizes intravesical compared with oral oxybutynin therapy.

Electrovesicography in benign prostatic hyperplasia

The electric activity of the urinary bladder (UB) as demonstrated by electrovesicogram (EVG) was studied in 26 patients with benign prostatic hyperplasia (BPH) and in 10 healthy volunteers. Ten of the BPH patients were in the compensated stage and 16 were in the decompensated stage. Three electrodes were applied to the skin of the hypogastric area and one reference electrode was applied to the lower limb. Recordings were made from the full and empty UB and after the residual urine had been evacuated. In healthy volunteers, pacesetter potentials (PPs) were recorded as triphasic waves from the full and empty UB. Amplitudes were lower in the empty than in the full UB (p < .05), and were reproducible in the individual subject. The EVG of the compensated prostatic patients showed, in both the full and empty UB, PPs of higher frequency, amplitude, and velocity than that of the controls (p < .01 and p < .05, respectively), a condition called "tachyvesica." In the decompensated prostatic patients, the EVG showed a bradyarrhythmic pattern in the full UB and a silent pattern in the empty UB. It would appear that EVG recorded for BPH could be used to differentiate the compensated from the decompensated hyperplastic prostate. The technique is simple, easy, noninvasive, nonradiologic, and without complications when compared with other investigative methods.

The effect of medium-fill and slow-fill saline cystometry on detrusor pressure in infants and children with myelodysplasia

A total of 38 infants and children with myelodysplasia was selected for statistical comparison of the effects of medium-fill and slow-fill saline cystometry on detrusor pressure. Medium-fill cystometry was performed at 20% of estimated bladder capacity per minute (up to 25 cc per minute) and slow-fill cystometry at 2% (up to 2.5 cc per minute). In 26 cases the filling rate did not determine the change in detrusor filling pressure while in 12 the change in detrusor filling pressure was greater than 15 cm. water during medium-fill but not slow-fill cystometry (p = 0.001). In 24 cases the filling rate did not determine the occurrence of maximal detrusor pressure greater than 40 cm. water but in 14 such pressure was noted during medium-fill but not slow-fill cystometry (p = 0.0005). Excluding 10 children with coexisting vesicoureteral reflux, differences in the change of detrusor filling pressure greater than 15 cm. water and maximal detrusor pressure greater than 40 cm. water remained statistically significant (p = 0.01 and p = 0.005, respectively). It is concluded that detrusor pressure can be manipulated by varying bladder filling with saline solution.