Overactive bladder (OAB): A symptom in search of a disease - Its relationship to specific lower urinary tract symptoms and conditions

BACKGROUND

The ICCS defines OAB by the subjective symptom of urgency; detrusor overactivity (DO) is only implied. While no other symptom is required, OAB can also be associated with urinary frequency, decreased functional bladder capacity, and incontinence.

OBJECTIVE

We sought to determine how often these associated findings occur in OAB and what if any uroflow/EMG-defined conditions are found to be associated with it.

METHODS

The charts of 548 children (231M, 318F; mean age 9.0 years, range 3-20) who presented sequentially with urgency (OAB), over a period of 2 years, were reviewed paying particular attention to whether or not there was a history of frequency and/or daytime incontinence in addition to the urgency. All patients had been previously diagnosed with one of the following four lower urinary tract (LUT) conditions based on specific uroflow/EMG findings: 1. dysfunctional voiding (DV; active pelvic floor EMG during voiding); 2. idiopathic detrusor overactivity disorder (IDOD; OAB with a short EMG lag time (<2 s), and quiet pelvic floor EMG during voiding); 3. detrusor underutilization disorder (DUD; willful infrequent voiding with %EBC >125%, quiet EMG during voiding); and 4. primary bladder neck dysfunction (PBND; prolonged EMG lag time (>6 s), quiet EMG during voiding, and depressed uroflow curve). Mean %EBC was compared between patients with urgency alone and those with urgency plus other symptoms. Any association with gender was analyzed.

RESULTS

Urgency was accompanied by either frequency or daytime incontinence in 91% of the children (summary Table). Daytime incontinence was reported in 398 (72.6%) and frequency in 268 (48.9%). Mean %EBC was 80.9. Females were more likely to report daytime incontinence (76.7% vs. 66.7%, p = 0.02) and frequency was found more often in males (63.6% vs. 38.1%, p < 0.001). %EBC was less in males (70.0 vs. 88.8, p < 0.001). The majority of patients with urgency were diagnosed with IDOD (62%), while 15% had DV, 5% PBND, 3% DUD, and in 15%, the uroflow/EMG was not diagnostic.

CONCLUSIONS

%EBC was usually normal or mildly increased in OAB when urgency is the only symptom but significantly decreases with each additional LUTS. OAB is more common in girls and they tend to have a lower incidence of frequency, more incontinence, and >%EBC than boys. Because urgency in an anatomically and neurologically normal child is the only required criterion for diagnosing OAB, it must be realized that OAB can be associated with any of a number of objectively defined LUT conditions. Thus OAB appears to be a symptom, not a condition, that is often associated with other symptoms.

Can children with either overactive bladder or dysfunctional voiding transition from one into the other: Are both part of a single entity?

BACKGROUND

In 1998 it was postulated by the ICCS that urge syndrome, later termed overactive bladder (OAB), and dysfunctional voiding (DV) might not be separate entities and instead represent transitional stages between each other, and that DV may be the evolutionary end product of OAB. The aim of this study was to determine not only if OAB sometimes transitions into DV but also if the reverse occurs, and, if so, might they indeed be parts of one entity.

MATERIALS AND METHODS

To create an objective study of these two conditions, specific "qualifiers" supporting the diagnosis of each condition were introduced: 1) DV included the qualifier of an active EMG during voiding on two studies; 2) OAB included the qualifiers of a short lag time (<2 s) as a surrogate for detrusor overactivity (DO) and a quiet EMG during voiding. Two separate cohorts (one for DV and one for OAB) of 77 consecutive patients each were reviewed. All DV patients were treated with biofeedback and some with antimuscarinics. All OAB patients were treated with antimuscarinics. Both cohorts also received standard therapy and bowel management when indicated. All patients had multiple uroflow/EMG evaluations before and during therapy and were followed for a minimum of 6 months.

RESULTS

Mean follow-up was 17.5 months and median age at diagnosis was 6.6 years for DV and 6.4 years for OAB. Of the OAB children none transitioned into DV, although two demonstrated transient DV-like EMG activity on interval testing that did not require biofeedback. Of DV children, following the initiation of biofeedback therapy, the EMG became quiet on follow-up uroflow/EMG after a mean of 9.3 months in 70 of 77 (91%). With EMG quieting, however, a short EMG lag time suggesting DO became apparent in those children with persistent irritative symptoms. This short lag time became apparent in 25 of 31 (81%) children treated with biofeedback alone versus only 8 of 39 (21%) on biofeedback plus antimuscarinics.

CONCLUSION

OAB with qualifiers and DV are two distinct LUT conditions and children do not appear to transition from the one to the other. While some children with DV did demonstrate a short lag time during follow-up, this is because once the EMG quieted in response to biofeedback, it improved our ability to document the already existing DO secondary to their previous DV. A dysfunctional voiding sequence with the postulated initial step being the transition of OAB into DV does not seem to be likely as the age at initial diagnosis was similar in both groups.

Outcomes of vesicoureteral reflux in children with non-neurogenic lower urinary tract dysfunction treated with dextranomer/hyaluronic acid copolymer (Deflux)

OBJECTIVE

There has been hesitancy to use dextranomer/hyaluronic acid copolymer (DHXA, Deflux for vesicoureteral reflux (VUR) in the setting of lower urinary tract (LUT) dysfunction because of the limited number of published studies, the possibility of less success, and the manufacturer's recommendations contraindicating its use in patients with active LUT dysfunction. We report on our experience using DXHA in this subset of patients whose VUR persisted despite targeted therapy for their LUT condition.

MATERIALS AND METHODS

We reviewed patients diagnosed with both a LUT condition and VUR who underwent subureteric DXHA while still undergoing treatment for their LUT dysfunction. Persistence of VUR was confirmed by videourodynamic studies (VUDS)/VCUG (voiding cystourethrogram) and all patients were on targeted treatment (TT) and antibiotic prophylaxis prior to and during DXHA injection. VUR was reassessed post-injection.

RESULTS

Fifteen patients (22 ureters; 21F,1M) met inclusion criteria (mean age 6.1 years, range 4-12). Following one to three DXHA injections, VUR resolved in 17 ureters (77%) including eight of nine ureters in dysfunctional voiding (DV) patients, five of nine in idiopathic detrusor overactivity disorder (IDOD), and four of four in detrusor underutilization disorder (DUD) patients.

CONCLUSIONS

DXHA is safe and effective in resolving VUR in children with associated LUT dysfunction, even before their LUT condition has fully resolved. Highest resolution rates were noted in patients with either DV or DUD or who were least symptomatic prior to injection.

The bladder of willful infrequent voiders: underactive or underutilized?

OBJECTIVE

We previously described a lower urinary tract (LUT) condition (detrusor underutilization disorder, DUD) characterized by chronic or episodic willful deferment of voiding resulting in an expanded capacity in patients with LUT symptoms. We now further characterize these DUD patients.

MATERIALS AND METHODS

We reviewed our database identifying neurologically/anatomically normal children diagnosed with DUD. Bladder capacity had to be at least >125% EBC for age to be included. LUTS, diaries and uroflow/EMG findings were analyzed.

RESULTS

Fifty-five children (mean age 10.5 years, range 3.7-20.2; 34F, 19M) with LUTS were diagnosed with DUD. The most common reasons for presentation included incontinence (43.6%), history of urinary tract infection (UTI) (49.1%), and urgency (30.9%). Mean percent estimated bladder capacity for age was 1.67 and following treatment mean %EBC decreased to 1.10.

CONCLUSIONS

DUD patients typically present with infrequent voiding, incontinence, urgency, and UTIs. They have less bowel dysfunction and frequency, and larger bladder capacities than typically found in children with overactive bladder and dysfunctional voiding. Although the symptoms associated with DUD overlap in part with those considered by the International Children's Continence Society to be typical for "underactive bladder" and "voiding postponement", DUD, we feel, is a stand-alone diagnosis.

Use of non-invasive uroflowmetry with simultaneous electromyography to monitor patient response to treatment for lower urinary tract conditions

OBJECTIVE

Non-invasive uroflowmetry with simultaneous electromyography (uroflow/EMG) has previously been reported as effective in triaging patients into four specific non-neurogenic lower urinary tract (LUT) conditions for targeted treatment. In this study we sought to determine if the same parameters would be useful for measuring response to treatment.

MATERIAL AND METHODS

We reviewed our database of normal children with LUT dysfunction, screened with uroflow/EMG, and diagnosed with a LUT condition: (1) dysfunctional voiding (DV); (2) idiopathic detrusor overactivity disorder (IDOD); (3) detrusor underutilization disorder (DUD); (4) primary bladder neck dysfunction (PBND). Pre- and on-treatment (minimum 3 months) uroflow/EMG parameters and subjective improvements were compared.

RESULTS

Of 159 children (71 boys, 88 girls; median age 7.0 years, range 3.5-18.0 years), median follow up was 13.1 months (range 3-43 months). On targeted treatment, DV patients showed relaxation of pelvic floor during voiding and significant decrease in PVR on biofeedback; IDOD patients had normalization of short lag time and increased capacity on antimuscarinics; DUD patients had a decrease in capacity on timed voiding; PBND patients on alpha-blocker therapy showed improved uroflow rates and a decrease in mean EMG lag time (all p < 0.05).

CONCLUSION

Non-invasive uroflow/EMG is useful not only for diagnosing specific LUT conditions, but also in objectively monitoring treatment efficacy. Subjective improvement on targeted therapy correlates well with objective improvements in uroflow/EMG parameters lending validation to this simplified approach to diagnosis.

Short pelvic floor EMG lag time II: use in management and follow-up of children treated for detrusor overactivity

OBJECTIVE

To determine utility of short pelvic floor electromyography (EMG) lag time in monitoring therapeutic response in children with idiopathic detrusor overactivity (DO) and quiet EMG during voiding (idiopathic detrusor overactivity disorder, IDOD).

PATIENTS AND METHODS

162 consecutive normal children (77M, 85F) diagnosed with IDOD and short EMG lag time were reviewed. All were treated with combined standard urotherapy and anticholinergics. Pre-treatment uroflow/EMG parameters were compared with on-treatment parameters.

RESULTS

Median age at evaluation was 6.8 years and median EMG lag time was 0 s; 110 children had repeat uroflow/EMG studies while on anticholinergic therapy. With a median follow-up of 18.7 months, mean EMG lag time increased from 0.7 to 2.2 s and % expected bladder capacity for age (EBC) increased from 0.68 to 0.98 (both p < 0.01). EMG lag time increased in all patients while on therapy and normalized in 83 patients (75%).

CONCLUSION

A short EMG lag time on noninvasive uroflow/EMG in a patient with urgency can be a surrogate for urodynamics study (UDS) in diagnosing DO and objectively monitoring response to therapy. When effectively treated, children with DO have amelioration of their lower urinary tract symptoms (LUTS) and normalization of both EMG lag time and bladder capacity.

Outcomes of targeted treatment for vesicoureteral reflux in children with nonneurogenic lower urinary tract dysfunction

PURPOSE

There is a known association between nonneurogenic lower urinary tract conditions and vesicoureteral reflux. Whether reflux is secondary to the lower urinary tract condition or coincidental is controversial. We determined the rate of reflux resolution in patients with lower urinary tract dysfunction using targeted treatment for the underlying condition.

MATERIALS AND METHODS

Patients diagnosed and treated for a lower urinary tract condition who had concomitant vesicoureteral reflux at or near the time of diagnosis were included. Patients underwent targeted treatment and antibiotic prophylaxis, and reflux was monitored with voiding cystourethrography or videourodynamics.

RESULTS

Vesicoureteral reflux was identified in 58 ureters in 36 females and 5 males with a mean age of 6.2 years. After a mean of 3.1 years of treatment reflux resolved with targeted treatment in 26 of 58 ureters (45%). All of these patients had a history of urinary tract infections before starting targeted treatment. Resolution rates of vesicoureteral reflux were similar for all reflux grades. Resolution or significant improvement of reflux was greater in the ureters of patients with dysfunctional voiding (70%) compared to those with idiopathic detrusor overactivity disorder (38%) or detrusor underutilization (40%).

CONCLUSIONS

Vesicoureteral reflux associated with lower urinary tract conditions resolved with targeted treatment and antibiotic prophylaxis in 45% of ureters. Unlike the resolution rates reported in patients with reflux without a coexisting lower urinary tract condition, we found that there were no differences in resolution rates among grades I to V reflux in patients with lower urinary tract conditions. Patients with dysfunctional voiding had the most improvement and greatest resolution of reflux. Additionally grade V reflux resolved in some patients.

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 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.

Primary bladder neck dysfunction in children and adolescents II: results of treatment with alpha-adrenergic antagonists

PURPOSE

Little has been reported on the occurrence of primary bladder neck dysfunction (PBND) in the pediatric patient, particularly as it relates to the use of alpha-blocker therapy, the mainstay of medical therapy in adults. Diagnosed on videourodynamics (VUDS), PBND is characterized by the constellation of prolonged opening time, incomplete bladder neck funneling, quiet pelvic floor electromyogram (EMG) during voiding and abnormal pressure flow parameters. We report the VUDS findings in PBND and our experience with alpha-blocker therapy in the pediatric and adolescent population.

MATERIALS AND METHODS

A total of 34 symptomatic patients met all VUDS criteria for PBND, and alpha-blocker therapy was initiated in 26. All patients were monitored with serial noninvasive uroflow studies with pelvic floor EMG (uroflow/EMG) before and after initiation of alpha-blocker therapy. Objective clinical response was assessed by measuring average and maximum uroflow rates, post-void residual urine volumes and pelvic floor EMG lag time, a correlate of opening time.

RESULTS

A total of 26 patients with PBND (20 males, 6 females) 5.5 to 20 years old at initiation of therapy (mean age 12.8 years) were treated with alpha-blockers. Mean average and maximum uroflow rates improved from 5.5 to 12.6 cc per second and from 10.3 to 19.7 cc per second, respectively, while mean EMG lag time decreased from 24.4 to 5.7 seconds and post-void residual urine volume from 98.9 to 8.9 cc (all p <0.001). Mean followup was 31 months, with all patients reporting significant symptomatic improvement. No patient experienced any major adverse side effects. The 8 patients with PBND who refused alpha-blocker therapy had no improvement symptomatically or urodynamically with time, and those who discontinued therapy had a return to pretreatment values.

CONCLUSIONS

PBND is an often overlooked but significant cause of voiding dysfunction in children and adolescents. In our experience alpha-blockers are clinically effective therapy for PBND and have been reasonably well tolerated in our young patients for what may possibly be a lifelong problem.

PRIMARY BLADDER NECK DYSFUNCTION IN CHILDREN AND ADOLESCENTS I: PELVIC FLOOR ELECTROMYOGRAPHY LAG TIME—A NEW NONINVASIVE METHOD TO SCREEN FOR AND MONITOR THERAPEUTIC RESPONSE

PURPOSE

One of the key findings for making the diagnosis of primary bladder neck dysfunction (PBND) on videourodynamics (VUDS) is prolongation of the time between the start of a voluntary detrusor contraction and the start of urine flow (opening time). Since normally this dynamic event is immediately preceded by pelvic floor relaxation, we determined if the interval between pelvic floor relaxation on pelvic floor electromyography (EMG) and the start of flow (pelvic floor EMG lag time), approximated opening time.

MATERIALS AND METHODS

Opening time measured on VUDS and pelvic floor EMG lag time measured on noninvasive uroflowmetry/EMG were compared in 22 consecutive patients with a mean age of 13.8 years diagnosed with PBND and a control group of 17 normal children. In addition, 19 patients with PBND were placed on alpha-blocker therapy, and pretreatment and on treatment uroflowmetry and pelvic floor EMG lag time values were compared.

RESULTS

Mean opening time and mean pelvic floor EMG lag time were statistically indistinguishable from each other in the PBND and normal groups (27.4 vs 23.9 and 1.1 vs 1.3 seconds, respectively, p >0.550), but they differed significantly between the normal and PBND groups (p <0.001). On alpha-blocker therapy a decrease in mean pelvic floor EMG lag time from 24.47 to 6.67 seconds (p <0.001) corresponded with improved flow parameters, while no improvement was noted in untreated patients.

CONCLUSIONS

Pelvic floor EMG lag time directly correlates with opening time and, when prolonged and associated with abnormal uroflowmetry, it is highly suggestive of PBND, thereby, justifying more invasive evaluation with VUDS or the initiation of empirical drug therapy. Most importantly, it provides an objective means of monitoring treatment response in a disorder that often has lingering symptoms.

WHEN CAN PERSISTENT HYDROURETERONEPHROSIS IN POSTERIOR URETHRAL VALVE DISEASE BE CONSIDERED RESIDUAL STRETCHING?

PURPOSE

Persistent hydroureteronephrosis (HUN) is often seen in boys with a history of a posterior urethral valve even years after valve ablation and it is often assumed to represent residual stretching. We determined the association of HUN with urodynamic abnormalities, the effect on HUN of treating these abnormalities and when persistent HUN could be considered residual stretching.

MATERIALS AND METHODS

Of 71 patients with a posterior urethral valve evaluated after valve ablation 20 (28.2%) had persistent HUN in a total of 32 renal units (RUs). The degree of HUN was graded as mild, moderate or severe. Videourodynamics were performed in all patients with persistent HUN and abnormal urodynamic findings were aggressively treated. HUN was then reassessed and categorized as resolved, improved or unchanged.

RESULTS

Abnormal urodynamic findings, primarily hypocompliance and instability, were noted in all 20 patients with HUN. All patients compliant with treatment showed dramatic improvement or complete resolution of abnormal urodynamic parameters. The 32 RUs with persistent HUN were initially graded as mild (8), moderate (13) and severe (11). HUN resolved in 15 RUs and improved to a lower grade in 11 in 26 of the 27 RUs (96.3%) in the 17 patients compliant with treatment. The 3 boys (5 RUs) who were noncompliant with treatment had neither decreased HUN nor improved urodynamic parameters. The 12 of 27 RUs (44.4%) in the treatment group in which HUN failed to resolve completely had no distal ureteral obstruction or identifiable persistent urodynamic abnormality and, thus, they can be labeled as having residual stretching.

CONCLUSIONS

Persistent HUN following valve ablation should not be considered residual dilatation until a thorough urodynamic evaluation has been done and any abnormal parameters are addressed. With correction of these abnormal parameters one can expect significant lessening of HUN and hopefully improved long-term preservation of renal function.

Myogenic failure in posterior urethral valve disease: real or imagined?

PURPOSE

It has been suggested that hypocontractility or myogenic failure develops in older boys with a history of 9 posterior urethral valved as the hyperactive, poorly compliant bladders decompensate with age. Also a much higher prevalence of myogenic failure has been reported than we have observed. We determine the prevalence of myogenic failure in boys with a posterior urethral valve and whether myogenic failure was a consequence of earlier detrusor instability or diminished compliance.

MATERIALS AND METHODS

We retrospectively reviewed the urodynamic findings of 51 boys after transurethral ablation of a posterior urethral valve. Group 1 (longitudinal group) consisted of 11 boys 12 to 19 years old who had undergone at least 1 serial urodynamic study before and 1 after age 10 years. Group 2 (younger group) included 33 boys whose urodynamic testing was performed before age 10 years. Group 3 (older group) comprised 7 previously treated boys whose initial urodynamic study was done after age 12 years.

RESULTS

Overall, myogenic failure was noted in 3 (all group 1) of 51 (5.9%) patients. Each of the 3 boys initially had a hypocompliant bladder, and myogenic failure developed only after institution of anticholinergic therapy and resolved once anticholinergics were discontinued. An additional 34 boys treated with anticholinergics did not have myogenic failure. No tendency towards myogenic failure or marked increase in bladder capacity for age was noted in the older boys.

CONCLUSIONS

In our experience myogenic failure is uncommon and more likely secondary to anticholinergic therapy than a preordained consequence of valve disease. We postulate that our proactive, early aggressive use of urodynamic studies and pharmacotherapy to identify and manage the secondary effects of valve disease reduces the incidence of myogenic failure.

Biofeedback therapy for children with dysfunctional voiding

OBJECTIVES

Biofeedback therapy has been recognized as a treatment option for children with classic dysfunctional voiding (DV) where there is inadequate pelvic floor relaxation during voiding. However, there are few articles that discuss methodology and limited sites where it is available. In the hope of making biofeedback a more practical and accessible option, we report our indications, easy to duplicate methodology, and results.

METHODS

Twenty-one consecutive children diagnosed with DV refractory to standard therapy were enrolled in our biofeedback program. Therapy consisted of extensive age-appropriate explanations of DV and demonstrations of normal and abnormal voiding patterns. Cyclic uroflow studies with pelvic floor electromyography are performed, which the child monitors on analog chart and audio recorders. The child returns weekly until consistent relaxation of the pelvic floor during voiding is demonstrated. Timing between sessions is then increased to monitor progress and retention of concepts previously taught.

RESULTS

An excellent clinical response was one in which there was consistent relaxation of the pelvic floor throughout voiding, normal flow pattern, and no residual urine volume (urodynamic response), coupled with profound resolution of voiding symptoms. Seventeen of 21 (81%) had an excellent response, 3 (14%) had a fair response, and 1 (5%) was too inconsistent to rate. The average number of sessions to achieve a consistent urodynamic response was 3.7 (range 2 to 14) and full clinical response somewhat longer. Average follow-up since beginning therapy has been 34 months (range 14 to 51).

CONCLUSIONS

Biofeedback therapy is an effective method for treating DV with poor pelvic floor relaxation. Although initially labor intensive, it yields sustained positive results in most patients in a short time.

Desmopressin for nocturnal incontinence in the spina bifida population

PURPOSE

We report our experience with the use of desmopressin in the spina bifida population that is dry during the day but wet at night.

MATERIALS AND METHODS

From 1994 to 1996, 18 patients with myelodysplasia were treated with desmopressin for persistent nocturnal enuresis. Initial dose was 40 mcg. before bedtime, decreased by intervals of 10 mcg. every 3 weeks. Patients were kept on the minimum dose required to keep them dry. We reviewed morning catheterized volumes, side effects and dosages needed to stay dry, and compared augmented patients with nonaugmented patients.

RESULTS

Of 18 patients 14 (78%) reported marked improvement in nocturnal enuresis. Of 6 augmented patients 5 (83%) are dry compared to 9 of 12 nonaugmented patients (75%). There were no adverse side effects from the use of desmopressin. Average dose to stay dry was 20 mcg. for augmented and 30 mcg. for nonaugmented patients. Of the 4 patients who had persistent nocturnal incontinence despite desmopressin 3 (75%) became dry with a single catheterization in the middle of the night.

CONCLUSIONS

Desmopressin is successful in treating nocturnal enuresis in the spina bifida patient with diurnal continence.

The management of unilateral poorly functioning kidneys in patients with posterior urethral valves

PURPOSE

There is no uniform agreement on how to manage the unilateral nonfunctioning or poorly functioning kidney associated with posterior urethral valves. We studied the results of treatment of our patients to make recommendations regarding management of these kidneys.

MATERIALS AND METHODS

We reviewed the records of 13 boys with a history of posterior urethral valves and a unilateral nonfunctioning or poorly functioning kidney, defined as less than 10% of total renal function on 99mtechnetium dimercapto-succinic acid renal scans. Variables investigated included pyelonephritis, hypertension, vesicoureteral reflux, nephroureterectomy, ureteral reimplantation and spontaneous cessation of reflux. We also evaluated how the management of abnormal urodynamic parameters influenced the results of reimplantation or medically induced cessation of reflux.

RESULTS

Three of the 6 boys with grade 5 reflux ipsilateral to the poorly functioning kidney required nephroureterectomy at a mean age of 21 months because of recurrent urinary tract infections. Another 4 boys underwent successful ureteral reimplantation, including 2 who had bilateral grade 5 reflux, and 2 who had ipsilateral grade 4 reflux, and grade 3 (1) and grade 2 (1) contralateral reflux. Of 4 boys ipsilateral grade 3 reflux in 3 and bilateral grade 5 reflux in 1 disappeared without surgery after treatment of urodynamic abnormalities. Two patients with poorly functioning kidneys and no reflux did not undergo surgery. Overall 10 of the 13 poorly functioning renal units were not removed, and these patients were free of pyelonephritis and hypertension. Ureteral reimplantation (4 ipsilateral and 3 contralateral) was performed only after urodynamic abnormalities were addressed. All reimplantations were successful.

CONCLUSIONS

Based on our results we believed that unilateral poorly functioning kidneys in patients with posterior urethral valves can be safely preserved in select patients without hypertension and pyelonephritis. Reimplantation to correct reflux may be preferable to nephroureterectomy in specific situations, such as when contralateral function is suboptimal and the contralateral ureter needs reimplantation. When indicated, reimplantation can be performed successfully if abnormal urodynamic parameters are addressed preoperatively. In fact, treating abnormal urodynamic findings may lead to spontaneous reflux resolution.

Management of posterior urethral valves on the basis of urodynamic findings

PURPOSE

Abnormal urodynamic findings are common in boys with a history of posterior urethral valves. However, to our knowledge there are few reports on the results of treating these abnormal findings. We analyzed the treatment of abnormal urodynamic parameters and its outcome in 21 boys who underwent valve ablation.

MATERIALS AND METHODS

After valve ablation multichannel urodynamic studies were performed in 31 boys, including 21 in whom studies were done before and after therapy was started for abnormal parameters. Detrusor instability and impaired bladder compliance were treated with anticholinergics or augmentation cystoplasty, and impaired detrusor contractility was managed with clean intermittent catheterization.

RESULTS

Before therapy 17 of 21 boys had impaired compliance and detrusor instability, 2 had impaired compliance without instability and 2 had instability alone. After treatment 8 boys had impaired compliance and 4 had detrusor instability. After anticholinergics were initiated new onset myogenic failure in 2 boys necessitated clean intermittent catheterization. Of the 13 patients who presented with urinary incontinence 10 became dry and 3 had improvement with therapy. Vesicoureteral reflux in 10 boys at the time of the initial urodynamic study resolved in 7 with anticholinergic medication and in 1 after clean intermittent catheterization was begun for severely impaired compliance. All 21 boys were treated with anticholinergics and 2 were ultimately treated with augmentation cystoplasty. Clean intermittent catheterization was also instituted in 5 patients, including the 2 who required clean intermittent catheterization after myogenic failure developed. Five boys with high voiding pressures were found to have outlet obstruction due to residual valve tissue in 2, bladder neck obstruction in 2 and urethral stricture in 1 despite normal flow rates in 2.

CONCLUSIONS

Urodynamic studies are helpful in guiding therapy in boys after valve ablation. Anticholinergic therapy can improve compliance, decrease detrusor instability, improve continence and eliminate vesicoureteral reflux in the majority of boys, although there is an associated risk of myogenic failure. Flow rates and fluoroscopic voiding studies are often unable to detect outlet obstruction and must be obtained in conjunction with voiding pressure measurements to make this diagnosis.

Voiding dysfunction following transurethral resection of the prostate: symptoms and urodynamic findings

PURPOSE

Persistent voiding dysfunction following transurethral resection of the prostate is not uncommon. We determined the correlation, if any, between the subjective complaints in men with voiding dysfunction after transurethral resection of the prostate and the urodynamic findings.

MATERIALS AND METHODS

A total of 50 consecutive men with voiding dysfunction following transurethral resection of the prostate was evaluated with the American Urological Association symptom index and multichannel urodynamics. Patients with urethral stricture, urinary retention or prostate cancer were excluded from the study. Urodynamic parameters assessed included detrusor instability, bladder capacity, sphincteric insufficiency using the Valsalva leak point pressure, voiding pressure-flow studies as determined by the Abrams-Griffiths nomogram (obstructed, unobstructed or equivocal) and post-void residual.

RESULTS

Mean patient age was 71 years and mean interval from last transurethral resection of the prostate was 58 months (range 2 to 252). Mean total, obstructive and irritative symptom scores were 16.3, 5.8 and 10.5, respectively. A total of 20 patients (40%) complained of incontinence (14 urge and 6 stress). According to the Abrams-Griffiths nomogram 62% of the cases were unobstructed, 16% obstructed and 22% equivocal. Urodynamic abnormalities were demonstrated in 43 patients (86%), and included detrusor instability (54%), obstruction with or without detrusor instability (16%), sphincteric insufficiency (8%), detrusor hypocontractility (4%) and sensory urgency (4%). There was no difference in the total, irritative or obstructive scores among obstructed, unobstructed or equivocal cases. Similarly there was no difference in scores among patients with and without detrusor instability. Age, number of transurethral resections and interval since last transurethral resection were unrelated to pressure-flow results or detrusor instability. Post-void residual was significantly greater in obstructed cases and bladder capacity was significantly less in those with detrusor instability. The cause of incontinence was demonstrated in 19 of 20 patients (95%): 4 (20%) had sphincteric insufficiency and 15 (75%) had detrusor instability.

CONCLUSIONS

Symptoms are unreliable in predicting urodynamic findings with respect to obstruction and detrusor instability. There is a high incidence of detrusor instability in patients with voiding dysfunction after transurethral resection of the prostate. Urodynamic obstruction is a less likely occurrence.

A new technique for assessing detrusor leak point pressure in patients with spina bifida

PURPOSE

We report a new modification of the technique used to measure detrusor leak point pressure in patients with myelodysplasia and discuss its clinical implications.

MATERIALS AND METHODS

We assessed detrusor leak point pressure during standard multichannel urodynamics in 77 patients with spina bifida. At leakage and in the absence of a detrusor contraction detrusor pressure is noted and the catheter is removed. With the cessation of leakage the catheter is reinserted and detrusor pressure is again noted. This cycle is repeated several times and the average difference is noted. In 23 patients there was no identifiable detrusor leak point pressure. The remaining 54 patients with a detrusor leak point pressure are included in this report. Also reviewed were renal ultrasound studies and voiding cystourethrograms for each patient.

RESULTS

Three groups of patients were identified: 1 (20 patients)-detrusor leak point pressure greater than 40 and less than 40 cm. water with the catheter in and out, respectively; 2 (29)-detrusor leak point pressure consistently less than 40 cm. water with the catheter in and out, and 3 (5)-detrusor leak point pressure consistently greater than 40 cm. water with the catheter in and out. There was a 5% incidence of upper tract changes in group 1 and a 40% incidence in group 3. All patients in group 2 had normal upper tracts.

CONCLUSIONS

A difference in upper tract changes was noted between groups 1 and 3, although in both groups detrusor leak point pressure was greater than 40 cm. water using standard measurement techniques and similar rates of upper tract changes would have been expected. Our modification may be a more accurate measurement of detrusor leak point pressure. It provides a better means of identifying patients at increased risk for renal deterioration and assessing outlet resistance.

The role of urodynamics in the evaluation of voiding dysfunction in men after cerebrovascular accident

PURPOSE

The etiology of voiding dysfunction was determined in men after a cerebrovascular accident who were at risk for obstructive uropathy to evaluate whether the cause of voiding dysfunction could be predicted by the type (obstructive or irritative) or onset of symptoms.

MATERIALS AND METHODS

We evaluated 38 men with complaints of voiding dysfunction following a cerebrovascular accident. All patients were of the age when bladder outlet obstruction secondary to benign prostatic hyperplasia would otherwise be prevalent. After a comprehensive history and physical examination, all patients underwent multichannel urodynamic studies at a medium fill rate (20 to 50 ml. per minute). Findings were classified by the Abrams-Griffiths nomogram as obstruction, no obstruction or equivocal.

RESULTS

Mean patient age was 70 years (range 54 to 87). Patients were grouped according to the presenting voiding complaints (purely irritative in 42%, purely obstructive in 34% or mixed in 24%). In 34 patients (89%) the onset of symptoms paralleled the occurrence of the cerebrovascular accident. Detrusor hyperreflexia was noted in 82% of the patients. There was no statistically significant difference in the occurrence of detrusor hyperreflexia among the 3 symptom groups (Fisher's exact test). Pressure-flow analysis clearly showed obstruction in 24 patients (63%), no obstruction in 9 (24%) and equivocal results in 5 (13%) according to the nomogram. There was no statistically significant difference in the incidence of obstruction among the 3 symptom groups (Fisher's exact test).

CONCLUSIONS

Presenting symptoms did not predict the urodynamic findings of bladder outlet obstruction or detrusor hyperreflexia. The significant incidence of onset of symptoms after stroke suggests that the cerebrovascular accident induced voiding dysfunction in the face of preexisting bladder outlet obstruction may exacerbate the symptoms of the latter condition or vice versa.

Correlation of Valsalva leak point pressure with subjective degree of stress urinary incontinence in women

PURPOSE

We correlated symptoms of stress urinary incontinence in women with intrinsic urethral function, as measured by Valsalva leak point pressure. In addition, we assessed the effects of urethral hypermobility, baseline resting abdominal pressure, patient age and menopausal status on Valsalva leak point pressure.

MATERIALS AND METHODS

We evaluated 64 consecutive women (mean age 50 years, range 20 to 79) with complaints of stress urinary incontinence. Initially the patient history was obtained and the subjective degree of stress urinary incontinence was graded as 1, 2 or 3 according to the SEAPI-QMN classification. Multichannel video urodynamics were then performed. At a volume of 150 to 200 ml. (or half bladder capacity when functional capacity was less than 150 ml.) filling was stopped. Resting, coughing and progressive Valsalva maneuvers were performed to determine Valsalva leak point pressure and the presence of urethral hypermobility. Valsalva leak point pressure was defined as the minimum total vesical pressure required to cause urinary incontinence in the absence of a detrusor contraction. Urodynamics were completed and detrusor instability or stress induced instability was noted.

RESULTS

Of the 64 women 52 (81.3%) had stress urinary incontinence. The exact test for trend demonstrated a statistically significant difference in the number of patients with a Valsalva leak point pressure of 90 cm. water or less (p = 0.0002) and 60 cm. water or less (p = 0.0002) among the 3 symptom groups. There was no correlation between Valsalva leak point pressure and resting vesical (which equals abdominal) pressure, patient age or menopausal status, or urge incontinence or detrusor instability among the 3 groups.

CONCLUSIONS

The subjective degree of stress urinary incontinence can predict intrinsic urethral function as measured by Valsalva leak point pressure. Higher grades of stress urinary incontinence have a higher likelihood of a low Valsalva leak point pressure. Many women with grade 2 or 3 stress urinary incontinence have a Valsalva leak point pressure of 90 cm. water or less despite urethral hypermobility and they may have a component of intrinsic urethral deficiency.

Significance of rectal contractions noted on multichannel urodynamics

Independent rectal contractions are frequently noted when performing multichannel urodynamics and are often considered to be artifactual. In an effort to determine if this activity is indeed significant, we reviewed 430 consecutive multichannel urodynamic studies performed on 289 patients. All studies were performed using an analog recorder at 0.5 mm/sec paper speed. Multichannel pressures included total vesical pressure measured by a urethral catheter, total abdominal pressure measured by a rectal balloon catheter, subtracted detrusor pressure (vesical minus abdominal), and uroflow measurement when possible. Rectal contractions were defined as multiple fluctuations in abdominal pressure as measured by the rectal balloon catheter which were independent of changes in total vesical pressure. These fluctuations could not be reproduced by abdominal stressing or Kegel-type maneuvers. Contractions were noted to be of high or low amplitude, continuous or intermittent. Of the 289 patients, 109 (38%) had a study positive for rectal contractions. Similarly, 168 of 430 studies (38%) were positive. In patients with neurologic disease, rectal contractions were noted in 61/120 (51%). In patients with no history of neurologic disease, 48/169 (29%) had rectal contractions (P < 0.001). Furthermore, when patients without a history of neurologic disease were evaluated with respect to the presence of detrusor instability, a positive study was noted in 27/67 (40%) with instability but in only 21/102 (21%) of patients without instability (P = 0.005). Rectal contractions also occurred with a higher frequency in patients with bladder hyperactivity of any etiology.(ABSTRACT TRUNCATED AT 250 WORDS)