Use of the dysfunctional voiding symptom score to predict resolution of vesicoureteral reflux in children with voiding dysfunction

Does urination position have an effect on evaluation of lower urinary tract function ın children? A uroflowmetric study

Background

We aimed to determine whether different urination positions had significant impact on the parameters of uroflowmetry performed by healthy individuals and children with voiding dysfunction.

Methods

The study was conducted with a prospective and comparative design. Children between 5 and 15 years of age who met the inclusion–exclusion criteria of the study were enrolled. Children in the study were divided into two groups. Participants whose voiding dysfunction symptom score was ≥ 9 points were classified in group 1 and the remaining individuals were classified in group 2. Girls urinated in two different positions as sitting and squatting while boys urinated in three different positions as sitting, squatting and standing. Also, habitual urination position was asked and recorded for each individual participated in the study. Uroflowmetry parameters were compared for different urination positions in two groups separately and a p value of ≤ .05 was accepted for statistical significance.

Results

Voided volume, maximum flow rate (Qmax), time to reach Qmax, urination time and postvoid residual volume measured by abdominal ultrasound were recorded in every participant for each urination position in both groups. In group 1, girls with voiding dysfunction presented a significantly higher postvoid residual volume in squatting position compared to sitting position (the p value = 0.02). In group 2, healthy boys presented a significantly higher Qmax in standing position compared to sitting and squatting positions (the p value = 0.01). All participants provided a better uroflowmetry pattern in their habitual urination positions.

Conclusion

Urination position may affect uroflowmetry results; however, its impact on lower urinary tract function requires further research.

Screening and management of bladder and bowel dysfunction in general pediatric outpatient clinic: a prospective observational study

BACKGROUND

Bladder and bowel dysfunction (BBD) is a common disorder in children that is often associated with psychosocial and behavioral problems. Data specific to BBD in Asian children are comparatively scarce. Accordingly, this study aimed to investigate the prevalence of BBD and the response to standard urotherapy among Thai children attending the general pediatric outpatient clinic of Siriraj Hospital - Thailand's largest national tertiary referral center.  METHODS: Children aged 4-12 years were recruited to complete the Dysfunctional Voiding Symptom Score (DVSS) questionnaire to screen for BBD during 2018 to 2020. Standard urotherapy, which consists of education and behavior management, was prescribed to those with a DVSS score that suggests the presence of BBD. Enrolled children and their caregivers were followed-up at 3 and 6 months. The Strengths and Difficulties Questionnaire (SDQ) was completed at baseline. DVSS scores at baseline, and at 3 months and 6 months after standard urotherapy were compared using repeated measures analysis of variance (ANOVA).

RESULTS

A total of 1,042 children completed the DVSS during the study period, and 90 (8.6%) were deemed to have BBD. The mean age of BBD children was 6.9 ± 2.2 years, and the female to male ratio was 2.9:1. The most common symptoms were defecation frequency (80.0%), difficult defecation (80.0%), curtsying (74.4%), urgency (68.9%), infrequent voiding (43.3%), and daytime incontinence (32.2%). Forty-one BBD children completed the SDQ, and 32.5% had scores suggestive of hyperactivity problems. Among the 24 BBD patients who were followed-up after 3 and 6 months of standard urotherapy, there was a significant improvement in DVSS results (9.5 ± 3.1 at baseline vs. 6.9 ± 3.4 at 3 months vs. 4.4 ± 3.9 at 6 months; p < 0.01). Nine of 12 patients with urinary incontinence showed complete response at 6 months. The overall Bristol stool score significantly improved from 2.6 ± 0.7 at baseline to 3.2 ± 1.0 at 6 months (p = 0.03).

CONCLUSIONS

BBD is a prevalent condition among Thai children that is often associated with emotional and behavioral problems. Standard urotherapy prescribed in a general pediatric outpatient clinic setting yielded favorable outcomes in Thai children with BBD.

Development and Validation of a Scoring System for Assessment of Clinical Failure after Pediatric Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation: A Multi-Center Study

We aimed to develop and validate a scoring system as an objective assessment tool for predicting clinical failure after pediatric robotic extravesical ureteral reimplantation. Data for this multi-institutional retrospective cohort was obtained from two tertiary referral hospitals. We defined clinical failure as incomplete radiographic resolution or post-operative febrile UTI. Patients were stratified into low, intermediate, and high-risk groups according to the score. External validation was performed using the model projected to the external validation cohort. An amount of 115 renal units in the development cohort and 46 renal units in the validation cohort were analyzed. The prediction score was calculated with weighted points to each variable according to their regression coefficient as age (year) + BMI + BBD times 10 + VUR grade times 7 + console time (h) + hospital stay times 6. The C-index of our scoring system was 0.850 and 0.770 in the development and validation cohorts, respectively. Clinical failure was significantly different among risk groups: 0% (low-risk), 3.3% (intermediate-risk), and 22.2% (high-risk) (p = 0.004) in the development cohort. A novel scoring system using multiple pre- and intra-operative variables provides a prediction of children at risk of failure after robotic extravesical ureteral reimplantation.

Asian guidelines for urinary tract infection in children

The followings are the level of evidence (LE) and grade of recommendation (GR) on pediatric UTI in Asia. Classification according to the sites of infection (lower versus upper tract), the number of episode (first versus recurrent), the severity (simple versus severe), or the existence of complicating factor (uncomplicated versus complicated) is useful to differentiate children with UTI whether they are at risk of renal damage or not (LE: 2, GR: B). Diagnosis of UTI requires both urinalysis that suggests infection and positive urine culture (LE:3, GR B). For pre-toilet trained children, urine specimen for culture should be collected by urethral catheterization or suprapubic aspiration. For toilet trained children, midstream clean catch urine is reliable (LE: 3, GR: A). Urine culture is considered positive if it demonstrates growth of a single bacterium with the following colony counts: (1) any growth by suprapubic aspiration, (2) >5 × 104 CFU/ml by urethral catheterization, or (3) >105 CFU/ml by midstream clean catch (LE:3, GR: B). For children with febrile UTI, renal and bladder ultrasonography (RBUS) should be routinely performed as soon as possible (LE: 3, GR: C). RBUS should be followed up 6 months later in children with acute pyelonephritis and/or VUR (LE: 3, GR: C). Acute DMSA scan can be performed when severe acute pyelonephritis or congenital hypodysplasia is noted on RBUS or when the diagnosis of UTI is in doubt by the clinical presentation (LE: 3, GR: C). Late DMSA scan (>6 months after the febrile UTI) can be performed in children with severe acute pyelonephritis, high-grade VUR, recurrent febrile UTIs, or abnormal renal parenchyma on the follow-up RBUS (LE: 3, GR: C). Top-down or bottom-up approach for febrile UTI is suggested for the diagnosis of VUR. For top-down approach, VCUG should not be performed routinely for children after the first febrile UTI. VCUG is indicated when abnormalities are apparent on either RBUS or DMSA scan or both (LE: 2, GR: B). VCUG is also suggested after a repeat febrile UTI (LE:2, GR: B). Appropriate antibiotic should be given immediately after urine specimen for culture has been obtained (LE:2, GR: A). Initiating therapy with oral or parenteral antibiotics is equally efficacious for children (>3 months) with uncomplicated UTI (LE: 2: GR: A). The choice of empirical antibiotic agents is guided by the expected pathogen and the local resistance patterns (LE: 2, GR: A). For children with febrile UTI, the total course of antibiotic therapy should be 7-14 days (LE: 2, GR: B). Circumcision may, but not definitively, reduce the risk of febrile UTI in males and breakthrough febrile UTI in males with VUR. Circumcision should be offered to uncircumcised boys with febrile UTI and VUR in countries where circumcision is accepted by the general population (LE: 3, GR: B), while in countries where childhood circumcision is rarely performed, other measures for febrile UTI/VUR should be the preferred choice (LE: 4, GR: C). Bladder bowel dysfunction (BBD) is one of the key factors of progression of renal scarring (LE: 2). Early recognition and management of BBD are important in prevention of UTI recurrence (LE:2, GR: A). Antibiotic prophylaxis to prevent recurrent febrile UTI is indicated in children with moderate to high grade (III-V) VUR (LE: 1b, GR: A). Surgical intervention may be used to treat VUR in the setting of recurrent febrile UTI because it has been shown to decrease the incidence of recurrent pyelonephritis (LE: 2, GR: B).

Traditional Biofeedback vs. Pelvic Floor Physical Therapy-Is One Clearly Superior?

PURPOSE OF REVIEW

Pelvic floor physical therapy is a worldwide accepted therapy that has been exclusively used to manage many pelvic floor disorders in adults and children. The aim of this review is to suggest to clinicians an updated understanding of this therapeutic approach in management of children with non-neuropathic voiding dysfunction.

RECENT FINDINGS

Today, pelvic floor muscle training through biofeedback is widely used as a part of a voiding retraining program aiming to help children with voiding dysfunction which is caused by pelvic floor overactivity. Biofeedback on its own, without a pelvic floor training component, is not an effective treatment. Biofeedback is an adjunct to the pelvic floor training. In the current review, we develop the role of pelvic floor physical therapy in management of children with non-neuropathic voiding dysfunction and compare it with biofeedback therapy alone.

Usefulness of the classification of urinary dysfunction for the prognosis of the first endoscopic treatment of vesicoureteral reflux in children over the age of 3

OBJECTIVES

To assess the diagnostic performance of urinary dysfunction patterns associated with vesicoureteral reflux (VUR) in children over the age of 3 according to the result of the first endoscopic treatment (ENDT1), grouped into a classification designed by our group (CMD.URI-La Fe). Comparison with other current classifications such as that of Van Batavia et al. MATERIAL AND METHODS: Ambispective cross-cutting study of a sample of 50 children.

EXCLUSION CRITERIA

previous ENDT, age ≤ 3 years, anatomical or neurological anomalies and a history of ureteral or abdominopelvic surgery. Prior to the ENDT1, a bladder voiding function assessment by uroflowmetry+electromyography (UF-EMG) and post-mictional residue (ultrasound). Other variables from the bladder diary, pre-mictional bladder wall thickness and other clinical variables. The correction of VUR was assessed by isotope cystography 3 months after the treatment. Urinary patterns were classified according to the significant variables (URI-La Fe), and the diagnostic performance of this classification was assessed, comparing it to the classification of patients as proposed by Van Batavia et al. RESULTS: Mean age: 6.8±2.28 years. Males/females (44%/56%). Grades of VUR (mild/moderate/severe). ENDT1 VUR correction rate: 77% (n=38). Diagnostic performance (Van Batavia; URI-La Fe): correct prediction (37.5%; 75%), sensitivity (32.4%; 87.8%), specificity (54.5%; 46.6%), positive predictive value (70.6; 78.3%) and negative predictive value (19.4%; 63.6%).

CONCLUSIONS

Our results show the usefulness of the non-invasive test and the classification of urinary dysfunction in children aged over 3 years prior to the first endoscopic treatment of VUR.

Can we predict vesicoureteral reflux resolution in patients with non-neurogenic lower urinary tract dysfunction?

OBJECTIVE

To analyze factors influencing reflux resolution in patients with the coexistence of non-neurogenic lower urinary tract dysfunction and vesicoureteral reflux.

METHODS

The data of 153 children who were diagnosed with vesicoureteral reflux and accompanying non-neurogenic lower urinary tract dysfunction between 2010 and 2015 were retrospectively evaluated. Patients with neurogenic and anatomical malformations, monosymptomatic nocturnal enuresis, previous history of vesicoureteral reflux surgery, irregular and/or incomplete follow-up data were excluded. After exclusion of 55 patients, 98 patients were enrolled in this study. Patients were divided into two groups according to the presence of spontaneous vesicoureteral reflux resolution during the follow-up period. Group 1 consisted of 54 children with spontaneous vesicoureteral reflux resolution, whereas group 2 included 44 children without resolution. Medical history, physical examination, urinalysis, uroflowmetry combined with electromyography, ultrasonography, as well as the Dysfunctional Voiding and Incontinence Symptom Score questionnaire were also evaluated.

RESULTS

The mean age at presentation was 7.57 ± 0.23 years (range 5-13 years), and the mean follow-up period was 28.3 months. Significant differences were noted between the two groups in terms of dysfunctional voiding and incontinence symptom score, bladder wall thickness, and the post-void residual urine volumes. In addition, lower urinary tract symptoms, namely frequency, urgency and daytime incontinence, were found to be higher in group 2. In multivariate analysis, post-void residual urine volume and Dysfunctional Voiding and Incontinence Symptom Score were found to affect reflux resolution rates (P = 0.002, P = 0.002, respectively).

CONCLUSIONS

The absence of significant post-void residual urine volume, and a low Dysfunctional Voiding and Incontinence Symptom Score increase the likelihood of spontaneous resolution rates of vesicoureteral reflux in children with non-neurogenic lower urinary tract dysfunction.

Assessment of pediatric bowel and bladder dysfunction: a critical appraisal of the literature

OBJECTIVE

Bowel and bladder dysfunction (BBD) is a clinical syndrome defined by the coexistence of constipation and lower urinary tract symptoms. Although BBD is a common condition in pediatric urology and can cause significant stress to patients/parents, clinical diagnosis of BBD has not been standardized. Bowel and bladder dysfunction instruments have gained popularity over the past decade to aid in diagnosis. In this review, the currently published BBD symptom questionnaires were summarized and an analysis on their psychometric validation process was provided.

SUBJECTS/PATIENTS

PubMed was searched for articles on BBD symptom questionnaires/instruments/surveys since 2000. Two investigators (R.Y.J. & M.S.K.) conducted the search in duplicate. The search was limited to English language. The included search terms were 'dysfunctional elimination syndrome', 'bowel and bladder dysfunction', 'dysfunctional voiding', 'voiding dysfunction symptom score', and 'dysfunctional voiding symptom scale'. Reference lists of included studies were screened for missed studies. Unpublished abstracts presented at the following scientific meetings were also manually searched for: the American Urological Association, the Society for Pediatric Urology, and the American Academy of Pediatrics Section on Urology. Exclusion criteria included articles in languages other than English, articles not related to BBD questionnaires, and articles not pertaining to pediatric patients.

RESULTS

After initial search, a total of 54 articles were obtained. Of the seven questionnaires reviewed, only one did not measure sensitivity or specificity. Almost all questionnaires showed excellent discriminative property with an Area under the curve (AUC) >0.85. Criterion validity was not reported in any of the questionnaires. Known-group validation was used as a common method to evaluate construct validity. Internal consistency was reported in 2 studies, and only 1 study measured questionnaire responsiveness during initial validation.

CONCLUSIONS

Although BBD is a common pediatric urology condition; a large amount of heterogeneity exists in the questionnaires' psychometric testing and validation process. To further improve the diagnosis and management of BBD in pediatric patients, there is a need for consensus on the gold standard questionnaire measure.

Diagnostic scores, questionnaires, quality of life, and outcome measures in pediatric continence: A review of available tools from the International Children's Continence Society

PURPOSE

We reviewed and collated information concerning the available tools for the measurement of symptoms and outcomes in pediatric continence.

MATERIALS AND METHODS

MEDLINE, EMBASE, and CINHAL databases were searched for relevant articles published prior to December 2016 and independently screened by two researchers. Expert opinion was also widely sought through consultation with the ICCS Board membership and their professional networks and the multidisciplinary authorship group. The most relevant materials were then selected for analysis and inclusion and resulted in a document available on the ICCS website for all members to review. Insights and feedback were considered with consensus and agreement reached to modify the document.

RESULTS AND CONCLUSIONS

A variety of useful tools for the assessment and measurement of bladder and bowel dysfunction and quality of life and behavioral comorbidities are presented together with their indications and potential pitfalls. ICCS cannot recommend one over another as the most useful for each clinician will vary depending on the clinical setting, available time, and patient population. We provide a framework for choosing those that are most appropriate based on our findings.

An Integrated Nurse Practitioner-Run Subspecialty Referral Program for Incontinent Children

INTRODUCTION

Evidence suggests that urinary and fecal incontinence and abnormal voiding and defecation dynamics are different manifestations of the same syndrome. This article reports the success of an innovative program for care of children with incontinence and dysfunctional elimination. This program is innovative because it is the first to combine subspecialty services (urology, gastroenterology, and psychiatry) in a single point of care for this population and the first reported independent nurse practitioner-run specialty referral practice in a free-standing pediatric ambulatory subspecialty setting. Currently, services for affected children are siloed in the aforementioned subspecialties, fragmenting care.

METHODS

Retrospective data on financial, patient satisfaction, and patient referral base were compiled to assess this program.

RESULTS

Analysis indicates that this model is fiscally sound, has similar or higher patient satisfaction scores when measured against physician-run subspecialty clinics, and has an extensive geographic referral base in the absence of marketing.

DISCUSSION

This model has potential transformative significance: (a) the impact of children achieving continence cannot be underestimated, (b) configuration of services that cross traditional subspecialty boundaries may have broader application to other populations, and (c) demonstration of effectiveness of non-physician provider reconfiguration of health care delivery in subspecialty practice may extend to the care of other populations.

Controversies Regarding Management of Vesico-ureteric Reflux

The primary goal in the management of a child with urinary tract infection (UTI) is to prevent recurrence of UTI and acquired renal damage. Approximately 15% of children develop renal scarring after a first episode of febrile UTI. Vesico-ureteric reflux (VUR) is diagnosed in 30-40% of children imaged after first febrile UTI. The 'top-down' approach involving ultrasound and dimercaptosuccinic acid scan (DMSA) first after an appropriate interval following UTI, can help in avoiding voiding cystourethrogram (VCUG), an invasive test with higher radiation exposure. The majority view remains that VCUG should be done after the second attack of UTI in girls and first attack of UTI in boys. Although the evidence in favour of antibiotic prophylaxis remains doubtful in preventing renal scars associated with VUR, it remains the first line treatment for high-grade reflux (grade 3-5) with an aim to prevent UTI and allow spontaneous resolution of VUR. Early identification and appropriate treatment of associated bowel bladder dysfunction is an essential part of successful medical management of VUR. Endoscopic treatment of VUR, using a bulking agent, is useful in grade 3 VUR. The main controversy regarding intervention (endoscopic/open surgical intervention) involves absence of strong evidence for these interventions in reducing renal scarring on randomized controlled trials. However, several recent trials have found the surgical interventions to be effective in reducing recurrent pyelonephritis and repeated hospital admissions.

The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children's Continence Society

AIM

The impact of the original International Children's Continence Society (ICCS) terminology document on lower urinary tract (LUT) function resulted in the global establishment of uniformity and clarity in the characterization of LUT function and dysfunction in children across multiple healthcare disciplines. The present document serves as a stand-alone terminology update reflecting refinement and current advancement of knowledge on pediatric LUT function.

METHODS

A variety of worldwide experts from multiple disciplines within the ICCS leadership who care for children with LUT dysfunction were assembled as part of the standardization committee. A critical review of the previous ICCS terminology document and the current literature was performed. Additionally, contributions and feedback from the multidisciplinary ICCS membership were solicited.

RESULTS

Following a review of the literature over the last 7 years, the ICCS experts assembled a new terminology document reflecting current understanding of bladder function and LUT dysfunction in children using the resources from the literature review, expert opinion and ICCS member feedback.

CONCLUSIONS

The present ICCS terminology document provides a current and consensus update to the evolving terminology and understanding of LUT function in children. Neurourol. Urodynam. 35:471-481, 2016. © 2015 Wiley Periodicals, Inc.

[Cross-cultural validated adaptation of dysfunctional voiding symptom score (DVSS) to Japanese language and cognitive linguistics in questionnaire for pediatric patients]

PURPOSE

Validated questionnaire for evaluation of pediatric lower urinary tract symptoms (LUTS) is of a great need. We performed cross-cultural validated adaptation of Dysfunctional Voiding Symptom Score (DVSS) to Japanese language, and assessed whether children understand and respond to questionnaire correctly, using cognitive linguistic approach.

METHODS

We translated DVSS into two Japanese versions according to a standard validation methodology: translation, synthesis, back-translation, expert review, and pre-testing. One version was written in adult language for parents, and the other was written in child language for children. Pre-testing was done with 5 to 15-year-old patients visiting us, having normal intelligence. A specialist in cognitive linguistics observed the response by children and parents to DVSS as an interviewer. When a child could not understand a question without adding or paraphrasing the question by the parents, it was defined as 'misidentification'.

RESULTS

We performed pretesting with 2 trial versions of DVSS before having the final version. The pre-testing for the first trial version was done for 32 patients (male to female ratio was 19 : 13). The pre-testing for the second trial version was done for 11 patients (male to female ratio was 8 : 3). In DVSS in child language, misidentification was consistently observed for representation of time or frequency. We completed the formal validated translation by amending the problems raised in the pre-testing.

CONCLUSION

The cross-cultural validated adaptation of DVSS to child and adult Japanese was completed. Since temporal perception is not fully developed in children, caution should be taken for using the terms related with time or frequency in the questionnaires for children.

A single-center cohort of Canadian children with VUR reveals renal phenotypes important for genetic studies

BACKGROUND

Many genes and loci have been reported in genetic studies of primary vesicoureteral reflux (VUR), but few have been reproduced in independent cohorts, perhaps because of phenotype heterogeneity. We phenotyped children with VUR who attended urology clinics so we could establish criteria to stratify patients based on the presence or absence of a renal malformation.

METHODS

History, chart review, and DNA were obtained for 200 children with VUR from 189 families to determine the grade of VUR, the mode of presentation, and the family history for each child. Kidney length measured on ultrasound (US) and technetium dimercaptosuccinic acid (DMSA) scans at the time of VUR diagnosis were used to establish the presence of a concurrent renal malformation and identify the presence of renal scarring.

RESULTS

There was an even distribution of girls and boys, and most patients were diagnosed following a urinary tract infection (UTI). Thirty-four percent of the children had severe VUR, and 25 % had undergone surgical correction. VUR is highly heritable, with 15 % of the families reporting multiple affected members. Most patients had normally formed kidneys as determined by US and DMSA imaging. Of the 93 patients who underwent DMSA imaging, 17 (18 %) showed scarring, 2 (2 %) showed scarring and diffuse reduction in uptake, and 13 (14 %) showed an isolated diffuse reduction in uptake.

CONCLUSION

Prospective long-term studies of patients with primary VUR combined with renal phenotyping using US and DMSA imaging are needed to establish the presence of a renal malformation. The majority of patients in our study had no renal malformation. This cohort is a new resource for genetic studies of children with primary VUR.

Vesicoureteral reflux and urodynamic dysfunction

INTRODUCTION

The concept of vesicoureteral reflux (VUR) as a consequence of congenital anomaly of vesicoureteral junction has undergone changes owing to the finding that such children may have lower urinary tract dysfunction, which produces high intravesical pressure and consequently a predisposition for VUR.

PATIENTS AND METHODS

The urodynamics was investigated by pressure-flow-EMG study in 132 children with VUR and 162 refluxing units.

RESULTS

Only 33 (25.0%) patients had normal urodynamic finding. The most frequent pathological finding was overactive bladder (OAB), found in 59 (44.7%) children, followed by dysfunctional voiding (DV) in 25 (18.9%) children. Children with VUR grades I and II had a higher percentage of pathological urodynamic findings than children with VUR grades III and IV. OAB was more frequent in children under 5 years of age with unilateral and lower grade VUR. It was found equally in children with and without uroinfections. DV was more frequent in children older than 5 years, with bilateral VUR, higher grade VUR and uroinfections.

CONCLUSIONS

Children with VUR have a high incidence of urodynamic disorders. The results of the study indicate the possible role of urodynamic dysfunction in the pathogenesis of VUR, especially mild one.

Dysfunctional voiding: A review of the terminology, presentation, evaluation and management in children and adults

Dysfunctional voiding (DV) is a voiding disorder characterized by dyssynergic striated sphincteric activity in the absence of a proven neurological etiology. It can present at any age with a spectrum of storage and voiding symptoms that may resemble florid neurogenic bladder. There is a striking lack of clarity regarding what this entity represents, the diagnostic methodology and treatment. The limitations of existing guideline documents are analyzed. Specifically, use of the term "habitual", the assumption that bladder changes are secondary to the outlet, the emphasis on "staccato" voiding and the implication of striated urethral sphincter are discussed. Literature shows that DV may also present with continuous slow flow or normal flow. Dyssynergia may be at the level of the striated urethral sphincter, the pelvic floor or both, better termed "striated urethral sphincter-pelvic floor complex" (SUS-PFC).A diagnostic algorithm is provided so that patients are evaluated on merit rather than on the basis of different philosophies of individual centers. High-risk markers such as hydronephrosis, vesicoureteral reflux, renal failure or marked voiding difficulty should prompt a formal urodynamics evaluation and imaging for neurological etiology. Patients with predominantly storage symptoms with incidental staccato voiding can be managed initially, on the basis of non-invasive evaluation. Conservative urotherapy including biofeedback is appropriate initial management for patients without high risk factors. Treatment and evaluation should be escalated based on response. Patients with severe DV will need treatment similar to neurogenic bladder including clean intermittent catheterization and measures to control storage pressures.

Evaluation of consistency between physician clinical impression and 3 validated survey instruments for measuring lower urinary tract symptoms in children

PURPOSE

Since many children with lower urinary tract symptoms are treated based on history and physical, it is important to know which symptom survey correlates best with the physician clinical impression. We evaluated 3 tools that have been demonstrated to predict severity of lower urinary tract symptoms, the Dysfunctional Voiding Symptom Score, the Akbal survey and the Nelson survey. Total scores from each survey were compared to clinical impression.

MATERIALS AND METHODS

Participants consisted of 36 males and 35 females referred to our pediatric urology center for lower urinary tract symptoms. A total of 37 children 4 to 10 years old completed the Dysfunctional Voiding Symptom Score with the help of their parents, and 34 of these parents completed the Akbal survey. A total of 35 children 11 to 17 years old completed the Nelson survey. Scores from the 3 instruments were compared to the clinical impression of a pediatric urologist using rank correlation (Kendall's tau-b test).

RESULTS

Mean total symptom scores were increased relative to physician rating for all 3 surveys. Symptoms reported by younger children using the Dysfunctional Voiding Symptom Score correlated better with physician rating of symptom severity (tau-b 0.43) compared to symptoms reported by parents using the Akbal survey (tau-b 0.41). Older children reporting symptoms using the Nelson survey had the strongest correlation with physician clinical impression (tau-b 0.48).

CONCLUSIONS

All 3 surveys were statistically significantly correlated with the physician impression of severity for lower urinary tract symptoms, with the Nelson survey being the most accurate.

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.

School Nurse Interventions in Managing Functional Urinary Incontinence in School-Age Children

Uncomplicated urinary incontinence (UI) in school-age children is a prevalent yet underrecognized problem that has remained in the shadow of other concerns commonly perceived as more prominent or urgent. There is good evidence that functional UI in children can be treated and managed effectively. When there is no structural or neurologic abnormality and the underlying cause of the UI is related to either the storage or voiding phase of the bladder cycle then it is considered functional. School nurses are in an ideal position to identify, manage, and help children with functional UI cope effectively while maintaining healthy psychosocial well-being and educational success.

Rationale and design issues of the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study

OBJECTIVE

Our goal is to determine if antimicrobial prophylaxis with trimethoprim/sulfamethoxazole prevents recurrent urinary tract infections and renal scarring in children who are found to have vesicoureteral reflux after a first or second urinary tract infection.

DESIGN, PARTICIPANTS, AND METHODS

The Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study is a double-blind, randomized, placebo-controlled trial. Six hundred children aged 2 to 72 months will be recruited from both primary and subspecialty care settings at clinical trial centers throughout North America. Children who are found to have grades I to IV vesicoureteral reflux after the index febrile or symptomatic urinary tract infection will be randomly assigned to receive daily doses of either trimethoprim/sulfamethoxazole or placebo for 2 years. Scheduled follow-up contacts include in-person study visits every 6 months and telephone interviews every 2 months. Biospecimens (urine and blood) and genetic specimens (blood) will be collected for future studies of the genetic and biochemical determinants of vesicoureteral reflux, recurrent urinary tract infection, renal insufficiency, and renal scarring.

RESULTS

The primary outcome is recurrence of urinary tract infection. Secondary outcomes include time to recurrent urinary tract infection, renal scarring (assessed by dimercaptosuccinic acid scan), treatment failure, renal function, resource utilization, and development of antimicrobial resistance in stool flora.

CONCLUSIONS

The RIVUR study will provide useful information to clinicians about the risks and benefits of prophylactic antibiotics for children who are diagnosed with vesicoureteral reflux after a first or second urinary tract infection. The data and specimens collected over the course of the study will allow researchers to better understand the pathophysiology of recurrent urinary tract infection and its sequelae.

Bladder dysfunction and vesicoureteral reflux

In this overview the influence of functional bladder disturbances and of its treatment on the resolution of vesicoureteral reflux (VUR) in children is discussed. Historically both bladder dysfunction entities, the overactive bladder (OAB) and the dysfunctional voiding (DV), have been described in conjunction with VUR. Treatment of the dysfunction was also considered to influence spontaneous resolution in a positive way. During the last decades, however, papers have been published which could not support these results. Regarding the OAB, a prospective study with treatment of the bladder overactivity with anticholinergics, did not influence spontaneous resolution rate in children with a dysfunction including also the voiding phase, DV and DES (dysfunctional elimination syndrome), most studies indicate a negative influence on the resolution rate of VUR in children, both before and after the age for bladder control, both with and without treatment. However, a couple of uncontrolled studies indicate that there is a high short-term resolution rate after treatment with flow biofeedback. It should be emphasized that the voiding phase dysfunctions (DV and DES) are more severe than the genuine filling phase dysfunction (OAB), with an increased frequency of UTI and renal damage in the former groups. To be able to answer the question if treatment of bladder dysfunction influence the resolution rate of VUR in children, randomized controlled studies must be performed.

Interactions of constipation, dysfunctional elimination syndrome, and vesicoureteral reflux

Vesicoureteral reflux (VUR) is simply described as incompetence of the unidirectional valve at the ureterovesical junction (UVJ), leading to backflow of urine to the kidney. Today, it is clear that VUR is not only related to the UVJ function but also to a combination of processes including immunity, bladder and pelvic floor function, dysfunctional voiding, and constipation. Although our surgical aims directed towards improving the valve coaptation at the UVJ, we understand today the importance of the diagnosis and treatment of constipation and dysfunctional voiding adjunctively.

Non-invasive evaluation of voiding function in asymptomatic primary school children

This study aimed to evaluate the voiding characteristics of primary school children by using questionnaires and non-invasive diagnostic tools. The voiding characteristics of 212 healthy children in two primary schools were evaluated with ultrasound for bladder wall thickness (BWT) in association with the Pediatric Lower Urinary Tract Symptom Score (PLUTSS), familial questionnaire, uroflowmetry (UF) and urinalysis. Most of the children (70%) had achieved urinary and fecal continence between the ages of 18 months and 36 months. Twenty-five per cent of healthy children void fewer than four times or more than seven times per day. Ninety percent of children had a PLUTSS within normal ranges (< 9). Fifteen percent of patients had a uroflowmetric pattern other than bell-shaped. The peak and average flow rates were higher in girls. Enuresis nocturna was detected in 10% of children. None of the children had documented urinary tract infection. The average BWT from posterior wall at full bladder in healthy children was 1.1 mm. The anterior and posterior BWT measurements before and after micturition were found to be thicker in boys. Regarding the UF pattern, in post-voiding measurements in children with abnormal UF pattern, the bladder walls were thicker. Non-invasive tests in non-symptomatic children showed a range of variability, and these deviations should be kept in mind during the evaluation of voiding characteristics of a child. The symptom scoring system, with the high sensitivity and specificity rates it possesses, is one of the promising tools for this purpose.

The current evidence based medical management of vesicoureteral reflux: The Sickkids protocol

Vesicoureteral reflux is a common clinical entity and is one of the keystones of the establishment of pediatric urology as a urological subspeciality. There has been continued evolution in the management of vesicoureteral reflux as new insights are gained on its role in renal damage. The optimal treatment algorithm remains controversial. This review aims to highlight the current literature on VUR and its association with urinary tract infections and renal damage. The protocol of management of a child with VUR followed at The Hospital for Sick Children, Toronto is described.

Efficacy of combined anticholinergic treatment and behavioral modification as a first line treatment for nonneurogenic and nonanatomical voiding dysfunction in children: a randomized controlled trial

PURPOSE

This randomized blinded clinical study was designed to compare the efficacy of tolterodine treatment combined with behavioral modification, behavioral modification alone and behavioral modification plus placebo in children with nonneurogenic, nonanatomical voiding dysfunction.

MATERIALS AND METHODS

A total of 72 children meeting inclusion criteria were randomly allocated to 1 of 3 groups. One group received tolterodine (1 mg twice daily) along with behavioral modification, 1 received behavioral modification only and 1 received placebo with behavioral modification. A dysfunctional voiding scoring system questionnaire was completed for all patients at the beginning of the study, and at 1 and 3 months of treatment.

RESULTS

A total of 71 patients were evaluated. The groups did not differ with respect to age, gender and symptom score before study enrollment (p >0.05). Repeated calculations of symptom scores at 1 month of the treatment revealed a significant decrease in symptoms in all 3 groups, with a significant decrease in patients receiving tolterodine. In addition, at month 3 the symptom score of the tolterodine group was significantly lower compared to month 1, while scores remained steady in the behavioral modification and behavioral modification plus placebo groups.

CONCLUSIONS

Tolterodine combined with behavioral modification for voiding dysfunction in children without neurological or anatomical abnormality can be recommended as a first line treatment before invasive evaluation.

Usefulness of a New Dysfunctional Voiding and Incontinence Scoring System in Predicting Treatment Effect in Children with Voiding Dysfunction

AIM

To assess the role of the dysfunctional voiding and incontinence scoring system (DVAISS) in children with voiding dysfunction.

METHODS

Ninety-three children were divided into three groups: those who had wetting only (group 1), recurrent urinary tract infections (UTIs) and wetting (group 2) and vesicoureteral reflux together with wetting and UTIs (group 3). Individualized multiple treatments modalities were applied. The success criteria defined by the reduction in the rate of wetting described as complete response (more than 90%), partial response (50-90%), no response (less than 50%).Also, in group 3, improvement was determined as a decrease of at least two grades in reflux. Scores of patients were determined before and after treatment.

RESULTS

Complete response rates for groups 1, 2 and 3 were 67.5, 88.8 and 85.71%, respectively. The specificity of the DVAISS in predicting the complete response was 79, 88 and 100%, respectively, and its sensitivity was 100% in all groups. In group 3, improvement rate was 71.4%. The specificity and sensitivity of the DVAISS in predicting the improvement were 83 and 100%, respectively.

CONCLUSION

The sensitivity of the DVAISS is higher in predicting the treatment effect; however, its specificity is decreased. The DVAISS may be an auxiliary diagnostic tool in voiding dysfunction patients.

Medical management of vesicoureteral reflux--quiz within the article. Don't overlook placebos

Vesicoureteral reflux (VUR) in children is associated with increased risk of urinary tract infection (UTI). Recurrent UTI in the presence of the VUR is believed to cause renal scarring, which carries a risk of subsequent hypertension, toxemia of pregnancy, and significant renal damage, including end-stage renal disease. The natural history of VUR is to improve or resolve completely with time in most of the patients. The traditional management consists of prompt treatment of UTI, long-term anti-microbial prophylaxis until the VUR resolves, or surgical intervention in those with persistent high grade VUR, recurrent UTI in spite of prophylaxis with anti-microbial agent, allergy to anti-microbial agents, and patient/parent non-compliance with the medical management. Voiding dysfunction and constipation play an important role, and their diagnosis and appropriate management helps reduce the frequency of UTI and promote the resolution of the VUR. Patients with renal scarring need to be monitored for potential complications such as hypertension, proteinuria, and progression of the renal damage. In patients with hypertension and/or proteinuria, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are the drugs of choice, because of their reno-protective properties. Recent studies have revealed that there is no convincing evidence that UTI in the presence of VUR predicts renal injury or that the use of long-term anti-microbial prophylaxis or surgical intervention prevents renal scarring or its progression. However, until proven otherwise by a prospective, placebo-controlled, randomized study, it is advisable to err on the side of caution and consider VUR and UTI risk factors for renal scarring and treat each patient on individual basis.

Predictive factors of resolution of primary vesico-ureteric reflux: a multivariate analysis

OBJECTIVE

To identify independent factors predicting the resolution of primary vesico-ureteric reflux (VUR) in a cohort of medically managed children.

PATIENTS AND METHODS

Between 1977 and 2003, 506 children were diagnosed with VUR and were conservatively managed and prospectively followed. All of the children were maintained on antibiotic prophylaxis. Follow-up imaging consisted of voiding cysto-urethrography (VCUG) or a direct isotope cystogram at intervals of 2-3 years. The predictive factors used are based on the patient data at the time of entry in the protocol. The dependent variable was VUR resolution. The criterion for resolution was based on a single negative VCUG or direct isotope cystogram. A survival analysis identified variables significantly associated with VUR resolution. Cox's regression model was applied to identify variables independently associated with the dependent variable.

RESULTS

After adjustment, four variables remained as independent predictors of VUR resolution: nonwhite race, relative risk (95% confidence interval) of 1.5 (1.1-1.9; P = 0.009); mild grade of VUR, 3.3 (2.1-5.3; P < 0.001); absence of renal damage, 3.3 (2.4-4.5; P < 0.001); and absence of dysfunctional voiding, 2.0 (1.4-3.1; P < 0.001). For mild VUR, three variables were significantly associated: male gender, 1.7 (1.1-2.6; P = 0.012); absence of renal damage, 3.4 (1.8-6.4; P < 0.001); and unilateral VUR, 1.6 (1.1-2.3; P = 0.004). For moderate/severe VUR, three variables were significantly associated: nonwhite race, 1.7 (1.1-2.6; P = 0.01); absence of renal damage, 3.0 (2.0-4.4; P < 0.001); and absence of dysfunctional voiding, 2.8 (1.4-5.5; P = 0.004).

CONCLUSION

Few factors are amenable to intervention to modify the natural history of VUR. According to our findings, there are only two possible interventions: avoiding renal scars and managing voiding dysfunction.

Vesicoureteral reflux

Vesicoureteral reflux, the abnormal flow of urine from the bladder into the ureter, is one of the most common congenital anomalies found in children. The association of vesicoureteral reflux with urinary tract infections and renal scarring has important clinical implications. New insights into pathogenesis and new surgical techniques are changing the approach to the management of this disorder.

Effect of Childhood Dysfunctional Voiding on Urinary Incontinence in Adult Women

OBJECTIVE

To determine whether a history of childhood dysfunctional voiding is associated with urinary incontinence in adulthood.

METHODS

Using a case-control study, we surveyed patients presenting with or without urinary incontinence. Cases were patients referred to a tertiary urogynecology clinic, and controls were patients referred to a general gynecology clinic. Patients completed a validated childhood questionnaire about dysfunctional voiding. A total score of 6 or more in girls is indicative of dysfunctional voiding, a condition characterized by urgency, frequency, constipation, urinary or fecal incontinence, and/or urinary tract infections. Using an alpha of 0.05, a power of 80%, and a baseline prevalence of dysfunctional voiding of 8%, we determined that 170 patients were needed to show a 3-fold difference between groups.

RESULTS

Cases (n = 84) and controls (n = 86) had similar baseline characteristics except for body mass index and incidence of previous pelvic surgery. Although the total dysfunctional voiding score was higher in cases than controls (7.3 versus 5.0, respectively; P = .001), the difference in the number (%) of patients with history of childhood dysfunctional voiding between the 2 groups was not significant (47 [56%] versus 36 [42%], respectively; odds ratio 1.76, 95% confidence interval 0.96-3.24; P = .07). When all patients from both groups were combined, there was a higher prevalence of a history of childhood dysfunctional voiding in women with or without current urinary frequency (P = .004), urgency (P = .03), stress incontinence (P = .01), and urge incontinence (P = .009).

CONCLUSION

Women with adult lower urinary tract symptoms may have a higher prevalence of history of childhood dysfunctional voiding.

LEVEL OF EVIDENCE

II-2.

Controversies in the diagnosis and management of urinary tract infections in children

Urinary tract infection (UTI) is one of the most common childhood bacterial infections, after upper respiratory tract and middle ear infections. The current goal of management is to prevent detrimental effects of UTI by early detection and treatment. Recommendations for the imaging of children depend upon age at presentation and sex. All children aged <5 years who have had a febrile UTI require a radiologic evaluation to identify any underlying genitourinary pathology. Older children can undergo a more tailored work-up depending on whether there is a febrile UTI or cystitis-type symptoms. Dysfunctional voiding and urge syndrome significantly increase the risk of developing UTIs in children. Vesicoureteral reflux can increase the risk of pyelonephritis and renal scarring in children with UTIs. For the most part, pyelonephritis can be diagnosed on clinical grounds in the majority of patients and a subsequent (99m)Tc-dimercaptosuccinic acid scan can be reserved to identify post-nephritic renal scarring. When renal scarring is identified, the child and parents need to be educated regarding the possibility of hypertension, proteinuria, progressive nephropathy, and the risk of complications in future pregnancies. Treatment of UTI is started in the unwell child before the culture results are available and subsequently changed to culture-specific antimicrobial therapy. A short course of treatment is required for acute uncomplicated UTIs. A child with acute pyelonephritis requires 10-14 days of antibacterial treatment. The oral route in young children often causes vomiting, which implies therapeutic delay, a well known risk factor for scarring.

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.

Symptom score for lower urinary tract dysfunction in pediatric urology

Lower urinary tract dysfunction is a common component of virtually every pediatric urologist's practice. Although lower urinary tract dysfunction should be considered more of a social nuisance than a true medical condition, if left unchecked, real comorbidities may occur. A thorough history, physical examination, voiding diary, and noninvasive urodynamic studies, such as flow rate or flow rate with electromyography, generally are used to make an accurate diagnosis. Once the diagnosis is established, a wide range of therapies are available and their use may be based on the age of the child, duration of symptoms, etiology of the lower urinary tract dysfunction and associated urologic disease, and physician or family preferences. Symptom scoring systems have been devised to confirm diagnosis of lower urinary tract dysfunction, classify its severity, and serve as a monitoring instrument to determine response to treatment.

Subureteral injection of Deflux for correction of reflux: analysis of factors predicting success

OBJECTIVES

To review, prospectively, our experience with endoscopic Deflux injection and evaluate the volume injected, grade, endoscopic appearance after injection, and presence or absence of voiding dysfunction as predictors of success. Subureteral injection of dextranomer/hyaluronic acid copolymer (Deflux) has become an effective treatment of vesicoureteral reflux.

METHODS

A total of 52 patients (50 females and 2 males; 80 ureters) were treated with a single subureteral injection of Deflux. The mean patient age was 7.6 years (range 14 months to 22 years). The presence or absence of voiding dysfunction was evaluated with a preoperative questionnaire and patient history. The volume of Deflux injected in each ureter was recorded. The endoscopic appearance after injection was recorded as "volcano" or "other." Success was defined as no reflux on postoperative voiding cystourethrography.

RESULTS

The success rate by grade of reflux in individual ureters was 82%, 84%, 78%, and 73% for grade 1, 2, 3, and 4 vesicoureteral reflux, respectively. No statistically significant difference was found in the cure rate by grade (P = 0.76). The overall cure rate by ureter was 80% and by patient was 71%. New contralateral reflux developed in 12.5% of patients. No statistically significant difference was found in the cure rate with respect to the volume injected or the presence or absence of voiding dysfunction. The ureteral cure rate with volcano and alternate morphology was 87% and 53%, respectively (P = 0.004).

CONCLUSIONS

Mound morphology was the only statistically significant predictor of a successful outcome, with an associated cure rate of 87%. Concomitant voiding dysfunction did not have an adverse effect on the cure rate. In our experience, no statistically significant difference was found in the cure rate for grades 1 through 4 vesicoureteral reflux after a single injection of Deflux.

Efficacy of tolterodine as a first-line treatment for non-neurogenic voiding dysfunction in children

OBJECTIVE

To assess the effect of antimuscarinic treatment with tolterodine combined with behavioural modification as a first-line treatment, before invasive investigation, in children with non-neurogenic voiding dysfunction but no obvious anatomical or neurogenic cause.

PATIENTS AND METHODS

The study comprised 44 children presenting with voiding dysfunction (30 girls and 14 boys, mean age 7 years, range 5-14); all had a noninvasive evaluation consisting of a history, urine analysis, renal and bladder ultrasonography and physical examination, with specific emphasis on the voiding pattern. Anticholinergic treatment with tolterodine (1 mg twice daily) was started in all patients; they were also informed about conservative management, including timed voiding, double voiding and relaxation of the pelvic floor during voiding. At the start and after 3 months, the dysfunctional voiding symptom score (DVSS) was completed twice by all patients.

RESULTS

For all patients the mean (sd) DVSS was 14.0 (2.67) and 6.68 (3.67) before and after treatment, respectively; the difference was statistically significant (P < 0.001). The mean scores for girls and boys, respectively, were 13.8 (2.79) and 14.5 (2.44) before and 6.43 (3.79) and 7.50 (3.34) after treatment.

CONCLUSION

Tolterodine combined with behavioural modification for dysfunctional voiding in children with no neurological or anatomical abnormality can be recommended as a first-line treatment before invasive evaluation. Additionally, the DVSS appears to provide accurate and objective data for monitoring the effect of treatment in such children.

Functional voiding disorders: actual aspects in diagnosis and treatment

PURPOSE OF REVIEW

This is a review of the recent advances in the diagnosis and therapy of dysfunctional voiding. We aim to point out the fact that there are many modalities which are effective in the treatment of dysfunctional voiding but that the standard therapy is still not agreed upon.

RECENT FINDINGS

Fifteen recent articles are reviewed. The two most interesting reviews are (1) the diagnosis of dysfunctional voiding and vesicoureteral reflux with contrast-enhanced ultrasonography and (2) the use of a scoring system to monitor the outcome of therapy and family compliance to the therapy.

SUMMARY

Periodic, critical, and objective reviews on this subject should help the attending physicians arrive at sound management plans.