The nonneurogenic neurogenic bladder of early infancy

Insight into Posterior Urethral Valve from Our Experience: Paradigm Appended to Abate Renal Failure

Objective:

The objective of the study was to share our experience of management of posterior urethral valve (PUV) and to suggest a paradigm to impede upstaging of chronic kidney disease (CKD) and prevent end-stage renal failure (ESRF).

Patients and Methods:

We have treated 332 patient of PUV from March 2005 to April 2016, Of which 272 case records had adequate data to be analyzed. The mean age was 2.48 years (range: 1 day–18 years). We did primary fulguration in 231 patients, of which five patients needed bilateral ureterostomy for obstinate high creatinine level. The remaining 36 patients had primary fulguration done elsewhere.

Results:

The mean duration of follow-up was 7.8 years (range 3–14 years). In the end of this study, 10 patients had down staging in CKD, 36 patients had up staging in CKD, and 9 patients ended in ESRF (3.8%).

Conclusions:

Detection of deterioration of renal function with creatinine clearance along with identifying the causes of deterioration and necessary interventions would help to arrest upstaging of CKD otherwise that might end in ESRF. From this study and reviewing the literature, we presume that the rhabdosphincter spasm underneath actually renders bladder outlet obstruction, and cusps of PUV, particularly in neonates, amplify the obstruction, following that bladder outlet obstruction cascades detrusor hypertrophy, bladder neck hypertrophy/obstructions, and ureterovesical junction obstruction/reflux, causing gradual damage to the bladder and upper tract and deterioration of renal function as a consequence.

Urologic symptoms and functional neurologic disorders

The term functional urologic disorders covers a wide range of conditions related broadly to altered function rather than structure of the lower urinary tract, mainly of impaired urine voiding or storage. Confusingly, for a neurologic readership, these disorders of function may often be due to a urologic, gynecologic, or neurologic cause. However, there is a subset of functional urologic disorders where the cause remains uncertain and, in this chapter, we describe the clinical features of these disorders in turn: psychogenic urinary retention; Fowler's syndrome; paruresis (shy-bladder syndrome); dysfunctional voiding; idiopathic overactive bladder, and interstitial cystitis/bladder pain syndrome. Some of these overlap in terms of symptoms, but have become historically separated. Psychogenic urinary retention in particular has now largely been abandoned as a concept, in part because of the finding of specific urethral electromyogram findings in patients with this symptom now described as having Fowler's syndrome, and their successful treatment with sacral neurostimulation. In this chapter we review the poorly researched interface between these "idiopathic" functional urologic disorders and other functional disorders (e.g., irritable-bowel syndrome, fibromyalgia) as well as specifically functional neurologic disorders. We conclude that there may be a relationship and overlap between them and that this requires further research, especially in those idiopathic functional urologic disorders which involve disorders of the urethral sphincter (i.e., voluntary muscle).

Best practice in the assessment of bladder function in infants

The purpose of this article is to review normal developmental bladder physiology in infants and bladder dysfunction in conditions such as neurogenic bladder, posterior urethral valves and high grade vesicoureteric reflux. We contrast the classical concept that bladder function in nontoilet-trained children is thought to be 'reflexive' or 'uninhibited', with the results of more recent research showing that infants most commonly have a stable detrusor. The infant bladder is physiologically distinct from the state seen in older children or adults. The voiding pattern of the infant is characterized by an interrupted voiding stream due to lack of proper urinary sphincter relaxation during voiding. This is called physiologic detrusor sphincter dyscoordination and is different from the pathologic 'detrusor sphincter dyssynergy' seen in patients with neurogenic bladder. Urodynamic abnormalities in neonates born with spina bifida are common and depend on the level and severity of the spinal cord malformation. Upper neuron lesions most commonly lead to an overactive bladder with or without detrusor sphincter dyssynergy while a lower neuron lesion is associated with an acontractile detrusor with possible denervation of the external urinary sphincter. In infants with neurogenic bladder, the role of 'early prophylactic treatment (clean intermittent catheterization and anticholinergics)' versus initial 'watchful waiting and treatment as needed' is still controversial and needs more research. Many urodynamic-based interventions have been suggested in patients with posterior urethral valves and are currently under scrutiny, but their impact on the long-term outcome of the upper and lower urinary tract is still unknown. Cumulative data suggest that there is no benefit to early intervention regarding bladder function in infants with high-grade vesicoureteric reflux.

Lower urinary tract dysfunction in childhood

Lower urinary tract syndrome is common in children. Incontinence, urinary tract infection, vesicoureteral reflux, and constipation are commonly associated with this syndrome. Examining the clinical history of the afflicted patient plays a major role in the accurate diagnosis and treatment of lower urinary tract disorder. Along with pharmacologic treatment, pelvic floor muscle retraining, biofeedback therapy, and adaptation of a healthy lifestyle are advocated for rapid recovery of patients.

[The non-neurogenic neurogenic bladder (Hinman's syndrome) in children: What are pronostic criteria based on a 31 cases multicentric study]

PURPOSE

To identify in children the pejorative estimated criteria of a extreme dysfunctional voiding can leading to a Hinman syndrome.

PATIENTS AND METHODS

Retrospective and multicentric study of 31 patients (19 boys and 12 girls), resulting from three universitary medical center (Besancon, Lyon, Nantes), which were divided into three groups according to their evolution: A - forms with a serious uronephrologic outcome. B - intermediate forms with persistent voiding dysfunction. C - forms with uneventful outcome.

RESULTS

The initial urologic examination was done, on average, on 6.4 years old children (1-16) and the diagnosis at 12.2 years (1.8-26.9). Eighty-four percent of the patients presented initial urologic symptoms, including 35 % of enuresis and 48 % with large amount of stool in the rectal vault (constipation and encopresis in 93 %). Thirty-five percent undergoing significant familial life stresses. In group A, urinary incontinence was present in 29 %. Sixty-two percent were improved by an intermittent catheterisme and 50 % by anticholinergic drugs solely. In group B, 46 % presented major constipation or encopresis and 60 % an urinary infection. A voiding retraining and an intermittent catheterisme improved 71 and 75 % respectively. In group C, no patient presented initial low urinary infection, encopresis or stool impaction. The boys presented more febrile urinary infection (20 % vs. 8 %), more rectal disorders (encopresis: 31 % vs. 8 %) and less urinary incontinence. In this group voiding retraining improved 67 %.

CONCLUSION

The Hinman's syndrome is a serious and unusual outcome of the "dysfunctional elimination syndrome". At diagnosis, the patterns of a pejorative outcome are the male sex, the severe fecal retention, the serious psychological disorders, the delay of diagnosis and treatment.

An infantile case of Hinman syndrome with severe acute renal failure

A 1-year-6-month-old Japanese girl with Hinman syndrome manifested urosepsis and severe obstructive nephropathy. Her voiding cystourethrogram (VCUG) revealed high-grade vesicoureteral reflux with hydronephrosis; urodynamic study was compatible with detrusor-sphincter dyssynergia. She was treated conservatively, including clean intermittent catheterization. At 3 years old, bladder function had not improved, and estimated creatinine clearance was in the subnormal range. Hinman syndrome is a potential cause of acute and chronic renal failure in infancy. Taking account of the possibility of this condition in any neonates or infants who present urinary tract infection (UTI) appears to be necessary, since early recognition and proper management of this syndrome may prevent serious complications.

Identification of nonneurogenic neurogenic bladder in infants

OBJECTIVES

To report the third series of the severe neonatal form of Allen-Hinman syndrome. Hinman and Baumann (1973) and Allen (1977) reported the first two series (14 and 21 patients, respectively) of children with severe functional vesicourethral dysfunction producing changes indistinguishable from an obstructive factor.

MATERIAL AND METHODS

From January 1995 to April 2006, 7 boys with Allen-Hinman syndrome were observed. They had been symptomatic since early infancy with a poor stream and chronic urinary retention. They had bilateral hydroureteronephrosis on renal ultrasonography and intravenous urography (grade 4 to 5 vesicourethral reflux) during the first year of age. They were initially thought by urologists to have a posterior urethral valve. When cystoscopy excluded anatomic obstruction, the urologists were unable to provide an alternative diagnosis.

RESULTS

The patients' age on referral ranged from 5 months to 15 years (mean 6 years). They had been followed up for a period of 2 weeks to 6 years. Four patients had been treated with chronic catheterization and were referred after the age of 5 years with end-stage renal failure. One of them underwent cutaneous vesicotomy after the onset of chronic renal failure and the need for dialysis. I recommended early vesicotomy for the remaining 3 patients. One boy had undergone vesicotomy during the first 6 months of age and had been followed up for 6 years. At 6 years of age, the dilation had disappeared and his renal function had been preserved.

CONCLUSIONS

The nonneurogenic neurogenic bladder represents a rare, severe form of dysfunctional voiding that can present even in the neonatal period and can lead to renal failure.

Neuropathic bladder as a cause of chronic renal failure in children in developing countries

Neuropathic bladder is considered a threat to the kidneys if not managed appropriately. In this study, we report our experience with neuropathic bladder at King Abdulaziz University Hospital (KAUH) as a cause of chronic renal failure (CRF) in the pediatric age group. This retrospective study included all children diagnosed with neuropathic bladder who presented with moderate or severe CRF over a 4-year period from December 2000 to December 2004 [glomerular filtration rate (GFR) at presentation <50 ml/min per 1.73 m2]. Fifteen patients were diagnosed with neuropathic bladder; group A consisted of ten patients with spina bifida and one with sacral agenesis and group B consisted of four patients with nonneurogenic neurogenic bladders (NNNB). The mean age+/-SD at presentation was 6.2+/-3.8 years, GFR was 24.2+/-12.4 ml/min per 1.73 m2, and creatinine was 289.9+/-253.2 micromol/l. There were no differences in the age at presentation to a pediatric nephrologist or the degree of renal failure at presentation between the two groups. Clean intermittent catheterization (CIC) was not started in all patients before presentation to KAUH, except in two children. Five children required dialysis as they were in end-stage renal failure (ESRF). All except one received peritoneal dialysis (PD). Their mean age at the start of dialysis was 10.8+/-1.7 years. Neuropathic bladder due to spina bifida or NNNB is an important cause of CRF in developing countries. There was a considerable delay in the diagnosis of NNNB and a significant delay in starting CIC in all neuropathic patients.