Self-catheterization during adolescence

Continence management in children with severe caudal regression syndrome: role of multidisciplinary team and long-term follow-up

PURPOSE

Caudal regression syndrome (CRS) is a rare congenital abnormality including orthopedic deformities, urological, anorectal, and cardiac malformations. The clinical spectrum of CRS varies in severity, therefore multiple surgeries and complex medical care may be required with the efforts and support of a multidisciplinary team to ensure the most accurate treatment and the best outcome. The aim of our retrospective study was to evaluate the role of a multidisciplinary treatment and the long-term outcome in patients with severe CRS.

METHODS

Clinical, surgical and psychological data were collected for all patients with diagnosis of CRS, treated at our Pediatric Hospital from January 1995 to December 2020. Patients with a severe form of CRS according to Pang's classification were included in the study. All patients have been followed by a multidisciplinary team composed by urologists, neurosurgeons, neonatal and digestive surgeons, orthopedic surgeon, physiatrists and psychologists. On admission, patients were screened for CRS with sacrum, spine and legs X-ray, spine MRI, renal ultrasound, voiding cystography and urodynamic, and renography. Clinical data about bowel function were evaluated.

RESULTS

During the study period, 55 patients with CRS were treated at our Institution. Six out of 55 (10.9%), presented with severe form of CRS (5 pts with type 1; 1 pt, with type 2) and represent our study group. Diagnosis of severe CRS was made at birth because of the typical deformities of the pelvis (fusion of the iliac wings), and of the lower extremities (undeveloped legs with flexion of the knees, clubfoot). All patients presented with neurogenic bladder, 4/6 (66.6%) with vesicoureteral reflux (VUR) and 2/6 (33.3%) with renal agenesia and contralateral ectopic hypoplastic kidney. Bowel symptoms occurred in 5/6 pts (83.3%). All patients were started with an earlier clean intermittent catheterization (CIC) regimen. In 3 patients oxybutynin has been effective or well tolerated, while in other 3 onabotulinumtoxin A has been used. Vesicoureteral reimplantation has been performed in 1 patient, 2 required endoscopic treatment of VUR. On long-term, 2 patients required bladder augmentation with ileum and appendicostomy (Mitrofanoff). Low adherences in CIC have been observed in three patients, mainly at puberty. Two patients presented with chronic renal failure. One patient reported suicide proposal. Regarding social life, only one is regularly performing sport activity.

CONCLUSION

CRS is characterized by maldevelopment of the caudal half of the body with variable involvement of the gastrointestinal, genitourinary, skeletal, and nervous systems. Management of CRS includes a wide variety of interventions to address the full spectrum of possible anatomical abnormalities. Hence, a multidisciplinary team is also mandatory for a correct bladder and bowel management, in order to maintain continence and preserve renal function, improve quality of life and increase self-esteem.

In Their Own Words: Adults' Lived Experiences With Intermittent Catheterization

PURPOSE

The aim of this study was to identify themes related to barriers and facilitators to the integration of intermittent catheterization (IC) in the daily lives or persons using the form of bladder evacuation.

DESIGN

Descriptive, qualitative study.

SUBJECTS AND SETTING

A purposive sample of 25 adults from 5 countries (United States, United Kingdom, Germany, France, and the Netherlands) was assembled. All participants had used IC as their primary method of bladder emptying for at least 1 year and, in that time, had used as least 2 different IC products.

METHODS

Guided telephone interviews with each participant were conducted by professional staff fluent in each participant's local language as well as trained in qualitative data collection. Interviews were digitally recorded and subsequently transcribed verbatim into English for analysis. We used ATLAS.ti qualitative analysis software (version 7.5.11) to assist with data organization and identification of major themes. Descriptive statistics (eg, mean, standard deviation, or frequency) were used to characterize the sample in terms of sociodemographic and clinical characteristics as collected during the interview.

RESULTS

Analysis revealed 9 main themes around individuals' lived experiences of IC: initial fear, urinary tract infection, pain/discomfort, independence, choice, community, life quality, resilience, and acceptance.

DISCUSSION

Our results indicate that IC is perceived as a burden by some, but not all, users. The challenge, and opportunity, is to learn more about what has gone right for those who have adapted and to leverage the clinical, practical, psychological, and social factors that enable individuals to integrate IC into the rhythm of their daily lives.

Trends in Urologic Indications for Pediatric Renal Transplantation Over a 27-Year-period United Network for Organ Sharing (UNOS) Database

OBJECTIVE

To elucidate the trends in urologic causes for renal transplant in the pediatric population using a national database. Little is known about the specific pediatric urologic conditions and resultant trends that precede renal transplantation.

MATERIAL AND METHODS

We reviewed the United Network for Organ Sharing (UNOS) database for pediatric patients (<18 years old) who underwent renal transplantation from January 1988 to September 2015. We included those patients who received a renal transplant because of a urologic condition.

RESULTS

Over 27 years, 7291 of 20,213 children (36%) underwent renal transplant secondary to a urologic condition. The 2 most common indications were hypoplasia/dysplasia/dysgenesis/agenesis (HDDA, 35.1%) and congenital obstructive uropathy (COU, 25.7%). The incidence of COU has increased from 18% to 30%, and the incidence of Wilms tumor has remained relatively consistent at 1.8% per year. In addition, 68% of all urologic renal transplants were performed in men compared with women. However, a higher percentage of women required transplantation because of Wilms tumor (3.1% vs 1.2%) and chronic pyelonephritis (17.6% vs 7.9%). Overall, the majority of patients (61.5%) who underwent renal transplantation were white, 18.8% Hispanic, and 15.3% black.

CONCLUSION

HDDA and COU consistently have been the most common urologic indications for renal transplantation. Both are the leading causes in men, whereas HDDA and chronic pyelonephritis are predominant in women. Higher rate of renal transplant during the ages of 11-17 years is suggestive of increased burden on poorly functioning kidneys during times of adolescent growth.

Analysis of Factors Associated with Patient or Caregiver Regret following Surgery for Fecal Incontinence

PURPOSE

Malone antegrade continence enema has been a successful and widely used procedure for achieving fecal continence in children. We present data on the previously uninvestigated issue of patient and caregiver regret following surgery for intractable constipation and fecal incontinence.

MATERIALS AND METHODS

We reviewed all patients undergoing antegrade continence enema or cecostomy creation at a single institution between 2006 and 2016. Patients and caregivers were assessed for decisional regret using the Decisional Regret Scale. Results were correlated with demographics, surgical outcomes and complications.

RESULTS

A total of 81 responses (49 caregivers and 32 patients) were obtained. Mean followup was 49 months. Decisional regret was noted in 43 subjects (53%), including mild regret in 38 (47%) and moderate to severe regret in 5 (6%). No statistical difference in regret was noted based on gender, complications or performance of concomitant procedures. On regression analysis incontinence was strongly associated with decisional regret (OR 4.4, 95% CI 1.1-18.1, p <0.001) and regret increased as age at surgery increased, particularly when patients were operated on at age 13 to 15 years (OR 2.6, 95% CI 1.0-6.4 for age 13 years; OR 2.9, 95% CI 1.1-7.8 for age 14 years; OR 3.1, 95% CI 1.1-8.8 for age 15 years).

CONCLUSIONS

This is the first known study describing decisional regret following surgery for fecal incontinence. Surgical factors aimed at achieving continence may be effective in decreasing postoperative regret. The finding of increased regret in teenage patients compared to younger children should be shared with families since it may impact the age at which surgery is pursued.

What is the outcome of paediatric gastrocystoplasty when the patients reach adulthood?

OBJECTIVE

To document the long-term outcomes of paediatric augmentation gastrocystoplasty (AGC) in terms of preservation of renal function and maintenance of dryness, and to analyse the rate of complications.

PATIENTS AND METHODS

The medical records of children who had undergone AGC between 1992 and 2000 (minimum time interval of 15 years) were reviewed retrospectively. The following data were collected: age at surgery, the cause of bladder dysfunction, functioning of the AGC, any complications, and the long-term outcome of the patients. All of the patients were re-contacted by telephone.

RESULTS

A total of 11 AGCs were carried out between 1992 and 2000, at a median (range) age of 11 (6.5-14) years. The diagnosis of patients undergoing AGC included myelomeningocele (four), bladder exstrophy (four), posterior urethral valves (one), irradiated bladder (one), and Prune Belly syndrome (one). The median [interquartile range (IQR)] follow-up was 17 (15-19.5) years. Renal function was preserved or improved in seven of the 11 patients and nine patients were dry after AGC. Seven of the 11 patients reported symptoms linked to haematuria-dysuria syndrome, which was resistant to treatment in one case and requiring excision of the gastric patch. Three of the 11 patients developed a tumour on the gastric graft after a median (range) delay of 20 (11-22) years after the initial procedure. All had gastric adenocarcinoma of which two were metastatic at the time of diagnosis requiring pelvectomy with pelvic lymph node dissection and adjuvant chemotherapy. Seven of the 11 patients underwent excision of the gastric patch after a median (IQR) time of 11 (8.5-20.5) years.

CONCLUSIONS

Our long-term data confirmed that most patients undergoing AGC had preservation of their renal function and were continent. However, long-term, AGC was associated with a significant risk of malignant transformation and a high rate of surgical re-intervention involving removal of the gastric patch. These results question the use of this technique for bladder augmentation, irrespective of the indication. We highlight the importance of strict endoscopic follow-up of all patients already having undergone an AGC and the need to inform and educated patients about tumour-related symptoms.

Association between health literacy and child and adolescent obesity

OBJECTIVE

We tested the association between child and parental health literacy (HL) and odds of child and adolescent obesity.

METHODS

We conducted an anonymous cross-sectional survey of a convenience sample of English-speaking child-parent dyads. Newest Vital Sign (NVS) measured HL. We used multivariable logistic regression to test adjusted association between child and parental NVS and obesity. Analyses were stratified for school-aged children (aged 7-11) vs. adolescents (aged 12-19).

RESULTS

We surveyed 239 child-parent dyads. Median child age was 11 [inter-quartile range 9-13]; 123 (51%) were male; 84% Medicaid recipients; 27% obese. For children, the odds of obesity [adjusted odds ratio (95% confidence interval)] decreased with higher parent NVS [0.75 (0.56,1.00)] and increased with parent obesity [2.53 (1.08,5.94)]. For adolescents, odds of obesity were higher for adolescents with the lowest category of NVS [5.00 (1.26, 19.8)] and older parental age [1.07 (1.01,1.14)] and lower for Medicaid recipients [0.21 (0.06,0.78)] and higher parental education [0.38 (0.22,0.63)].

CONCLUSION

Obesity in school-aged children is associated with parental factors (obesity, parental HL); obesity in adolescents is strongly associated with the adolescent's HL.

PRACTICE IMPLICATIONS

Strategies to prevent and treat obesity should consider limited HL of parents for child obesity and of adolescents for adolescent obesity.

A web-based programme for person-centred learning and support designed for preschool children with long-term illness: a pilot study of a new intervention

For children living with long-term illness, school age is a risk period with regard to psychosocial ill health and poor compliance with treatment. There is a need for methods to promote health, well-being, and self-esteem. This study describes a new concept for supporting children, person-centred web-based learning and support, which has been tested in 12 preschool children and incorporates learning about feelings, relationships, and the right to integrity. SKYPE was used for conversations between the child and the web teacher. Methods. The programme was developed and tested in two steps. The conversations were tape-recorded and analysed using phenomenography. The questions addressed concerned the quality of the intervention process: accessibility of intervention, learning content and support, and identification of measurable items and patterns. Findings. The children found it interesting to communicate with their web teacher using SKYPE. The story about Max and Sara served as a good basis for discussion, and development was found in the learning process. The children were able to talk about relations and feelings and developed an understanding for use in new situations in their daily lives. Items and patterns that are useful for research and documentation were identified, for example, well-being, resources, needs, and wishes.

Parent and child experiences using a hydrophilic or reused PVC catheter for intermittent catheterisation

AIMS AND OBJECTIVES

To highlight the challenges faced in adjusting to intermittent catheterisation for families and children affected by spina bifida.

BACKGROUND

Toileting is a particular issue for children with spina bifida resulting in difficulty emptying their bladder. Management of incomplete emptying is intermittent catheterisation, which is now part of routine clinical care. The physical benefits of intermittent catheterisation are critical to renal health, and significant attention has been paid to this; less attention has been given to the personal aspects for the family or older child.

DESIGN

A descriptive study of satisfaction with two products for intermittent catheterisation: polyvinyl chloride and hydrophilic catheters based on data obtained from a randomised controlled trial on urinary tract infections in catheter users.

METHODS

At the end of each of the polyvinyl chloride and hydrophilic study arms, parents or older children completed a 'Satisfaction Questionnaire' and then participated in a follow-up interview. Data were analysed for emerging themes.

CONCLUSIONS

Three themes emerged: adjustment, ease of use and self-reliance. Key findings include: increased independence and confidence of the child catheterising using the hydrophilic catheter, self-management strategies to successfully manipulate the slippery hydrophilic catheter and reasons for the lack of success, and identification of participants who preferred polyvinyl chloride catheters. Descriptive data revealed potential areas where a hydrophilic catheter could improve the lives of the family and child as well as noting the need for user choice in product selection.

RELEVANCE TO CLINICAL PRACTICE

Listening to the stories of children and families increases the nurse's ability to act as a guide as families struggle to assist their children in reaching their potential. Incontinence has been demonstrated to be the cause of self-isolation potentially leading to a decreased sense of self-worth. Ambulatory care nurses play a large role in helping families find the routine and resources necessary to reduce the incidence of incontinence, in children with spina bifida.

Urodynamic parameters development and complications of clean intermittent self-catheterization in Chinese schoolchildren with neurogenic underactive bladder

OBJECTIVE

To evaluate the urodynamic parameters, development of bladder function and complications of clean intermittent self-catheterization (CIC) in Chinese schoolchildren with neurogenic underactive bladder.

METHODS

Ninety-three children with neurogenic underactive bladder were successfully treated with CIC or combined with oxybutynin for two years follow-up. According to bladder compliance before CIC, they were subdivided into a normal bladder compliance (NBC) group and a low bladder compliance (LBC) group. Urodynamic parameters and complications were recorded.

RESULTS

At follow-up, the incidence of neurogenic detrusor overactivity was found to have significantly decreased in both groups. Moreover, maximum cystometric capacity (CC) and relatively safe CC in the NBC group was significantly higher than those before CIC. However, relatively safe CC was significantly lower than that before CIC, and detrusor leakage point pressure was significantly higher than that before CIC in the LBC group. The incidences of bacteriuria, vesicureteral reflux (VUR), febrile urinary tract infections (UTI) and macroscopic hematuria were, respectively, 62, 13, 25 and 15%, and those of VUR and febrile UTI in the LBC group were significantly higher than those in the NBC group.

CONCLUSION

For these cases, the complications of CIC are rare, and bladder compliance seems to be correlated with the development of bladder function and complications during CIC.

Relationship between child health literacy and body mass index in overweight children

OBJECTIVE

To test the relationship between child health literacy and body mass index (BMI) Z-score in overweight children.

METHODS

Cross-sectional survey of overweight children and parents. Parent and child health literacy was measured by the Short Test of Functional Health Literacy (STOFHLA). Linear regression tested for predictors of childhood BMI Z-score, adjusting for confounders.

RESULTS

Of 171 total children, 107 (62%) participated, of whom 78 (73%) had complete data for analysis. Mean child BMI Z-score (SD) was 2.3 (0.40); median child age (interquartile range) was 11.5 (10-16); 53% were female; 80% were Medicaid recipients. Mean child STOFHLA was 22.9 (9.0); mean parental STOFHLA was 29.1 (8.6). Child STOFHLA correlated negatively with BMI Z-score (r=-0.37, p=0.0009) and positively with child eating self-efficacy (r=0.40, p<0.0001). After adjusting for confounders, child STOFHLA was independently associated with child BMI Z-score (standardized B=-0.43, p<0.0001). Overall adjusted r-squared for the regression model was 38%. Child STOFHLA contributed 13% to the overall model.

CONCLUSIONS

Child health literacy was negatively correlated with BMI Z-scores in overweight children, suggesting the need to consider health literacy in the intersection between self-efficacy and behavior change when planning interventions that aim to improve child BMI.

Patient experience with hydrophilic catheters used in clean intermittent catheterization

OBJECTIVE

To evaluate patient experience of hydrophilic catheters used for clean intermittent catheterization (CIC).

PATIENTS AND METHODS

Out of 107 consecutive patients on a CIC programme, 100 filled in a questionnaire concerning the hydrophilic catheters they were using for CIC.

RESULTS

Sixty-four out of 100 patients were females and 83 had a neurogenic reason for CIC. The programme was started at median age 4 (range 0-32) years. The handling and sliding properties of the catheters were usually good, although 26% felt that the hydrophilic catheters were too slippery in the hands and 11% felt some sticking during catheter removal. Catheter packages got the most criticism. Pain experiences were rare, although 87 performed CIC through the urethra. In general, there were no differences between brands of catheter (LoFric (Astratech) vs Easi/SpeediCath (Coloplast)), although the patients had preferences.

CONCLUSIONS

Patients have individual preferences, although the technical properties of hydrophilic catheters are in general quite good and similar. As CIC treatment is demanding, the patient is justified in selecting the best catheter for them.