Dysfunctional Voiding in Children Secondary to Internal Sphincter Dyssynergia: Treatment with Phenoxybenzamine

Medical evaluation and management of male and female voiding dysfunction: a review

A significant workforce shortage of urologists available to serve the US population has been projected to occur over the next decade. Accordingly, much of the management of urologic patients will need to be assumed by other specialties and practitioners. Since primary care physicians are often first evaluate common urologic complaints, it makes sense that these physicians are in an excellent position to intervene in the management of these patients when appropriate. One of the most common complaints in urology is voiding dysfunction. The incidence of voiding dysfunction increases with age, with conservative estimates showing that over 50% of elderly patients suffer. Despite this high prevalence and its negative impact on quality of life, however, few seek or receive treatment, as many do not readily disclose these impactful yet personal symptoms. We sought to summarize the typical presentation, evaluation, assessment and therapeutic options for both male and female patients presenting with voiding dysfunction.

Primary bladder neck dysfunction in children and adolescents III: results of long-term alpha-blocker therapy

PURPOSE

Primary bladder neck dysfunction is a nonneurogenic voiding disorder frequently overlooked in pediatrics. The diagnosis classically is made by videourodynamics but can also be made with noninvasive uroflow studies with pelvic floor electromyography. We report our long-term results using alpha-blocker therapy in patients with primary bladder neck dysfunction.

MATERIALS AND METHODS

We reviewed 51 neurologically normal children (mean age 11.6 years, range 3.5 to 17.8) meeting criteria for primary bladder neck dysfunction who underwent alpha-blocker therapy for at least 1 year. All patients were symptomatic with abnormal flow parameters and an electromyogram lag time of 6 seconds or more on initial uroflow/electromyography. Pretreatment and on-treatment uroflow/electromyogram studies were performed in all patients. Average and maximum uroflow rates, electromyogram lag times and post-void residual volumes were compared.

RESULTS

After a mean followup of 46.2 months (range 12 to 124) mean average and maximum uroflow rates improved from 7.0 to 12.4 cc per second and from 12.4 to 20.3 cc per second, respectively, while mean electromyogram lag time decreased from 30.8 to 5.8 seconds (all p <0.01). Of the patients 85% reported subjective symptomatic relief. A total of 15 patients (29%) stopped alpha-blocker therapy for various reasons, none related to side effects. Repeat off-treatment uroflow/electromyogram studies showed that measured parameters reverted to pretreatment values (all p <0.05). Eight of these 15 patients eventually resumed alpha-blocker therapy, while only 3 remained asymptomatic off of the alpha-blocker.

CONCLUSIONS

alpha-Blocker therapy continues to benefit children with primary bladder neck dysfunction even after 3 years of treatment. Few patients can come off of alpha-blocker therapy without returning to their pretreatment state, suggesting the condition is likely chronic in most patients.

Primary bladder neck obstruction in men, women, and children

The understanding of the presentation, diagnosis, and treatment of primary bladder neck obstruction (PBNO) has evolved over the last 20 years. It was first identified 70 years ago, but the etiology is still unclear. There are multiple theories as to the etiology, including muscular and neurological dysfunction and fibrosis. Over the years, many voiding parameters and cut points and nomograms have been presented for diagnosis of nonneurogenic functional bladder outlet obstruction in young men. Until recently, there was a paucity of data on PBNO in women and children. Videourodynamics provide an accurate diagnosis of PBNO but for some patients are an invasive option. Treatments vary from watchful waiting to alpha-blockade to surgery, depending on the severity of symptoms, urodynamic findings, and response to medical therapy. This paper reviews the theories on etiology, incidence, presentation, and diagnostic evaluation, and briefly discusses treatment options for PBNO.

High-intensity, short-term biofeedback in children with Hinman's syndrome (non-neuropathic voiding dyssynergia)

OBJECTIVE

To evaluate the long-term response to high-intensity, short-term biofeedback in children with severe voiding dysfunction.

PATIENTS AND METHODS

We retrospectively reviewed patients who underwent short-term, high-intensity biofeedback therapy from 1996 to 2004. Improvement was classified based on clinical and radiographic findings. Patients were categorized as having Hinman's syndrome when, in addition to urinary incontinence, at least four of the following categories were present: sphincter dyssynergia, bladder trabeculation, large post-void residual (PVR), hydronephrosis, vesicoureteral reflux (VUR) and urinary tract infections. There were 14 patients (eight males and six females), 13 of whom had Hinman's syndrome. Age when biofeedback was initiated varied from 5.6 to 12.9 years (mu=8.9+/-2.2). Before biofeedback, all had large PVRs, bladder trabeculation and sphincter dyssynergia. Nine had hydronephrosis and five had VUR. One patient had renal failure.

RESULTS

Before biofeedback, the mean PVR was 109 ml (25-270 ml); after biofeedback, this decreased to 21 ml (0-150 ml), including two patients who eventually failed treatment. All 14 patients were able to relax their external sphincter and reduce the PVR during biofeedback and on short-term follow up. Long-term follow up (mu=59.4 months) in 12 patients established that seven had a durable response with remission of symptoms, reduced PVR and radiographic improvement. In three, symptoms partially recurred over time and two failed treatment completely.

CONCLUSION

Short-term, high-intensity biofeedback achieves a durable response in the majority of children with Hinman's syndrome. Long-term follow up is needed to assure compliance.

Primary bladder neck dysfunction: An overlooked entity in children

Primary bladder neck dysfunction is a non-neurogenic voiding disorder commonly diagnosed in young and middle age adult men, but frequently overlooked in children. Because these children typically present with lower urinary tract symptoms that also are associated with other more common forms of dysfunctional voiding, the diagnosis may be missed and treated with a variety of empiric modalities that ultimately fail. Although its underlying pathogenesis remains debated, the hallmark of the diagnosis is a failure of the bladder neck to properly open and allow for unimpeded urine flow. Videourodynamic evaluation is the only diagnostic tool that can urodynamically document the obstructive pressure/flow parameters of the condition while simultaneously localizing the functional obstruction to the bladder neck fluoroscopically. This article reviews the clinical and urodynamic findings of this entity in children and adolescents and our experience with a adrenergic antagonists, the current approach in medical therapy.

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.

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.

Abdominal wall electromyography: a noninvasive technique to improve pediatric urodynamic accuracy

Abdominal wall electromyography, using sticky surface patch electrodes placed on the rectus abdominus muscles, was used during noninvasive urodynamic studies in 60 children to detect straining. Straining, which usually was imperceptible to the examiner, occurred in 64 per cent of neurologically normal children. Urodynamics identified detrusor-sphincter dyssynergia during straining to void but reverted to normal when the same children voided without straining. Because the urodynamic findings that characterize detrusor-sphincter dyssynergia are mimicked by straining and other common urologic entities, the potential for misdiagnosis is great unless some assessment of intra-abdominal pressure is made during neurourologic testing.