Transition from childhood to adolescence: steps to be taken.

PURPOSE OF REVIEW: The aim of this article is to give an overview of recent literature on transitional care of children with complex urological disease. RECENT FINDINGS: Most studies on transitional care concerned spina bifida patients. Assessment of current practices revealed that formalized clinics for transitional care may improve healthcare. However, there is still little consensus among healthcare providers on how to organize transitional care. A widely recognized problem is a lack of interested, dedicated, and well-trained staff for transitional care and lifelong follow-up of complex urological patients and also a lack of funding. The timing of the pediatric urologist's transfer to adult care may be helped by measuring transitional readiness in adolescent patients. Outcomes could also expose specific issues as were patients need assistance or education. Introduction of a transitional protocol made patients feel more ready for transition. However, even in established transitional clinics, there is a lack of disease-specific awareness of sexuality and fertility issues among patients. SUMMARY: Although there is growing awareness of the importance of well-organized and protocolled transitional care for young patients with complex urological disease, this is by no means sufficiently implemented. Furthermore, there is shortage of dedicated and experienced healthcare providers and a lack of funding.

[Efficacy of the percutaneous tibial nerve stimulation in the treatment of lower urinary tract symptoms]. / A percutan nervus tibialis stimuláció szerepe egyes kismedencei kórképek kezelésében.

Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive, safe and well-tolerated neuromodulation technique for the lower urinary tract dysfunctions. PTNS delivers neuromodulation to the pelvic floor through the S2-4 junction of the sacral nerve plexus via the route of the posterior tibial nerve. Using the fine needle electrode insertion above the ankle, the tibial nerve is accessed, which connected to the stimulator. To date despite of its excessive clinical use, PTNS mechanism of action still remains unclear. The technique seems to be an efficacious and safe treatment for overactive bladder syndrome (OAB). It could be recommended according to the Urinary Incontinence Guideline of the European Association of Urology in women who did not have adequate improvement or could not tolerate anti-muscarinic therapy. The success rate is comparable to sacral nerve stimulation in OAB patients. PTNS has been used for fecal incontinence since 2003, however, many of the published studies are of poor quality. PTNS has also been shown to have positive effects on chronic pelvic pain, when the usual therapeutic steps did not result in satisfactory improvement. No major complications are reported in the literature, following PTNS treatment. Orv Hetil. 2018; 159(43): 1735-1740.

Transcutaneous interferential electrical stimulation for the management of non-neuropathic underactive bladder in children: a randomised clinical trial.

OBJECTIVES: To assess the efficacy of transcutaneous interferential electrical stimulation (IFES) and urotherapy in the management of non-neuropathic underactive bladder (UAB) in children with voiding dysfunction. PATIENTS AND METHODS: In all, 36 children with UAB without neuropathic disease [15 boys, 21 girls; mean (sd) age 8.9 (2.6) years] were enrolled and then randomly allocated to two equal treatment groups comprising IFES and control groups. The control group underwent only standard urotherapy comprising diet, hydration, scheduled voiding, toilet training, and pelvic floor and abdominal muscles relaxation. Children in the IFES group likewise underwent standard urotherapy and also received IFES. Children in both groups underwent a 15-session treatment programme twice a week. A complete voiding and bowel habit diary was completed by parents before, after treatment, and 1 year later. Bladder ultrasound and uroflowmetry/electromyography were performed before, at the end of treatment course, and at the 1-year follow-up. RESULTS: The mean (sd) number of voiding episodes before treatment was 2.6 (1) and 2.7 (0.76) times/day in the IFES and control groups, respectively, which significantly increased after IFES therapy in IFES group, compared with only standard urotherapy in the control group [6.3 (1.4) vs 4.7 (1.3) times/day, P < 0.002). The mean (sd) bladder capacity before treatment was 424 (123) and 463 (121) mL in the control and IFES groups, respectively, which decreased significantly at 1 year after treatment in the IFES group compared with the controls, at 227 (86) vs 344 (127) mL (P < 0.01). Maximum urine flow increased and voiding time decreased significantly in the IFES group compared with controls at the end of treatment sessions and 1 year later (P < 0.05). All the children had abnormal flow curves at the beginning of the study. The flow curve became normal in 14/18 (77%) of the children in the IFES group and six of 18 (33%) in the control group by the end of follow-up (P < 0.007). At the end of the treatment course, night-time wetting was improved in all children who had this symptom before the treatment in the IFES group (P < 0.01). CONCLUSION: Combining IFES and urotherapy is a safe and effective therapy in the management of children with UAB.

[Urology]. / Urologie.

This article is addressed to general practitioners and summarizes some of the latest developments in urology. Recent advances in screening, diagnosis and medical as well as surgical treatments of common urological diseases are reviewed.

[Abdominal pain and ascites formation in a 72-year-old woman]. / Abdominale Schmerzen und neu aufgetretener Aszites bei einer 72-jährigen Patientin.

A 72-year-old woman presented with abdominal pain after micturition. Abdominal ultrasound screening revealed ascites associated with acute renal failure. Paracentesis of the peritoneal fluid was performed. Biochemical analysis indicated a peritoneal transsudate and increased creatinine. Cystoscopy detected a rupture of the urinary bladder. Catheterization and antibiotic therapy resulted in an improvement of pain and closure of the hole in the urinary bladder wall. Several different disorders can induce a rupture of the urinary bladder. In this case, severe chronic constipation was the most probable causative disease.

[Non-infectious cystalgias]. / Cystalgies non infectieuses.

The trophicity of women's urogenital tissues depends on the hormone level and on the quality of the vaginal flora. Stresses of these mucous membranes, seemingly minor, give rise to complaints of a perceived perineal discomfort, which is disproportionate to the causes. Population in Occident has access to the best medical care and hygiene conditions ever. Yet, expenditures on treatment of these minor disorders are unwarranted. Cystalgia leads to a large number of consultations to general practitioner, gynaecologist and urologist. The aging of our societies is another reason. While life expectancy was 51 in 19th century, it is now 83. Women will now live a third of their life after menopause'. Complaints due to these hormonal withdrawal symptoms need to be heard as they are leading to specific psychological behaviours, which are disconcerting for the clinician. Patients will strive by all means to obtain treatments which are often inappropriate and which sometimes entails the risk of evolving to a chronicity of the pains.

Adult care of children from pediatric urology.

PURPOSE: In this article we highlight the difference, from established adult urology, in required approach to the care of adolescents and young adults presenting with the long-term consequences of the major congenital anomalies of the genitourinary tract. We review some abnormalities of the kidneys, progressive renal failure and disorders of bladder function from which general conclusions can be drawn. MATERIALS AND METHODS: The published literature was reviewed and augmented with material from our institutional databases. For renal function the CAKUT (congenital abnormalities of the kidney and urinary tract) database at University College London Hospitals was used, which includes 101 young adult patients with CAKUT in whom the urinary tract has not been diverted or augmented. For bladder function some data are from patient records at Boston Children's Hospital. RESULTS: Adolescents who grow up with the burden of a major congenital anomaly have an overwhelming desire to be normal. Many achieve high levels of education and occupy a wide range of employment scenarios. Babies born with damaged kidneys will usually experience improvement in renal function in the first 3 years of life. Approximately 50% of these cases will remain stable until puberty, after which half of them will experience deterioration. Any urologist who treats such patients needs to test for proteinuria as this is a significant indicator of such deterioration. In its absence, the urologist must have a reasonable strategy for seeking a urological cause. The most effective management for nephrological renal deterioration is with angiotensin converting enzyme inhibitors, which slow but do not prevent end stage renal failure. Renal deterioration is generally slower in these patients than in those with other forms of progressive renal disease. The bladder is damaged by obstruction or by functional abnormalities such as myelomeningocele. Every effort should be made to stabilize or reconstruct the bladder in childhood. A dysfunctional bladder is associated with or causes renal damage in utero, but continued dysfunction will cause further renal damage. Bladder function often changes in puberty, especially in boys with posterior urethral valves who may experience high pressure chronic retention. Dysfunction is managed with antimuscarinic drugs, clean intermittent self-catheterization and intestinal augmentation. Adult urologists must be able to manage the long-term problems associated with these treatments. CONCLUSIONS: Pediatric conditions requiring management in adolescence are rare but have major, lifelong implications. Their management requires a broad knowledge of pediatric and adult urology, and could well be a specialty in its own right. Therefore, adult urologists must remain aware of the conditions, the problems that they may encounter and the special management required for these patients to live normal lives.

A UK consensus on the management of the bladder in multiple sclerosis.

Bladder symptoms in multiple sclerosis (MS) are common and distressing but also highly amenable to treatment. A meeting of stakeholders involved in patients' continence care, including neurologists, urologists, primary care, MS nurses and nursing groups was recently convened to formulate a UK consensus for management. National Institute for Health and Clinical Excellence (NICE) criteria were used for producing recommendations based on a review of the literature and expert opinion. It was agreed that in the majority of cases, successful management could be based on a simple algorithm which includes using reagent sticks to test for urine infection and measurement of the post micturition residual urine volume. This is in contrast with published guidelines from other countries which recommend cystometry. Throughout the course of their disease, patients should be offered appropriate management options for treatment of incontinence, the mainstay of which is antimuscarinic medications, in combination, if necessary, with clean intermittent self-catheterisation. The evidence for other measures, including physiotherapy, alternative strategies aimed at improving bladder emptying, other medications and detrusor injections of botulinum toxin A was reviewed. The management of urinary tract infections as well as the bladder problems as part of severe disability were discussed and recommendations agreed.

Embolotherapy for lower urinary tract hemorrhage.

The patient characteristics, techniques used, and outcomes of 11 patients with lower urinary tract hemorrhage treated with embolotherapy are described. The authors focus on bilateral superselective embolization of the arterial supply to the bladder and techniques to embolize multiple small vessels supplying the bladder when the vascular anatomy is complicated and superselective catheterization is not possible. The immediate success rate was 100%, with three later recurrences. One procedure was complicated by asymptomatic occlusion of the posterior division of the internal iliac artery. Embolotherapy can provide at least short-term success adequate to improve quality of life for palliation with few complications.

[Efficacy of electroacupuncture nerve stimulation therapy for interstitial cystitis/bladder pain syndrome].

OBJECTIVE: To explore the clinical efficacy of electroacupuncture nerve stimulation therapy (ENST) for interstitial cystitis/painful bladder syndrome (IC/PBS). METHODS: A total of 68 patients with IC/PBS were randomly divided into an observation group and a control group, 34 cases in each one. The patients in the observation group were treated with ENST; abdominal four acupoints and sacral four acupoints were connected with a pair of electrodes and treated alternately every other day. The ENST was given 50 min per times, three times a week for 3 months. The patients in the control group were treated with perfusion therapy of four-medication combination (heparin sodinm, lidocaine, sodium bicarbonate, gentamicin sulfate), twice a week for the first 6-8 weeks, followed by twice per month for 3 months. The infusion fluid remained for 1 h before discharging. The O' Leary-Sant score, including interstitial cystitis symptom index (ICSI) and interstitial cystitis problem index (ICPI), 24 h urination frequency, visual analogue scale (VAS) and maximum bladder volume were observed before treatment and treatment of 1 month, 3 months and 6 months after treatment respectively; the adverse events during the treatment were also recorded. RESULTS: Compared before treatment, the O'Leary-Sant score (ICSI, ICPI), 24 h urination frequency, VAS and maximum bladder volume in the two groups were improved after 1, 3 months treatment and 6 months after treatment (all P<0.05). The scores of ICSI, ICPI, VAS and 24 h urination frequency in the observation group were significantly lower than those in the control group (P<0.05). The maximum bladder volume in the observation group was significantly higher than that in the control group (P<0.05). Six months after treatment, the total effective rate in the observation group was 87.5% (28/32), which was higher than 69.7% (23/33) in the control group (P<0.01). No significant adverse events occurred during the treatment. CONCLUSION: ENST could effectively relieve the clinical symptoms of IC/PBS, but its long-term efficacy needs further observation.

Interstitial cystitis/painful bladder syndrome: appropriate diagnosis and management.

Interstitial cystitis/painful bladder syndrome (IC/PBS) is characterized by urinary frequency, urgency, and pelvic pain in the absence of any other identifiable pathology. Initial identification of IC/PBS is challenging, as patients may have a range of symptoms that overlap with other disorders, including urinary tract infection (UTI). These patients may be treated empirically with antibiotics; however, many patients with such symptoms are actually culture negative and are later diagnosed with IC/PBS. This review describes the importance of recognizing the symptom overlap between IC/PBS and UTI and focuses on approaches to the diagnosis and management of IC/PBS. Physicians can improve patient care by considering IC/PBS early in the differential diagnosis.

Intravesical explosions during transurethral endoscopic procedures.

Every Urologist, during the course of fulguration treatment of bladder tumours, has at some time or another experienced small intravesical explosions usually manifesting as a "pop". Major intravesical explosions are rare but potentially devastating complications of transurethral endoscopic resections. The damage to the bladder can range from small mucosal tears to bladder rupture, which can either be intraperitoneal (requiring laparotomy and open bladder repair) or extraperitoneal. We review the literature on intravesical explosions to determine the aetiology of these explosions and suggest strategies to prevent these. A comprehensive literature search was performed using Medline and Ovid to obtain information using search terms: intravesical explosions, transurethral procedures, endoscopic procedures, diathermyIntravesical explosions occur due to the production of explosive gases during use of diathermy on human tissues. The most dangerous combination is hydrogen and oxygen. Hydrogen alone is not explosive and it only becomes explosive when admixed with oxygen. Oxygen is not produced in sufficient quantity during diathermy to cause explosions but can enter into the bladder from the atmosphere during endoscopic procedures. Careful operative technique (correct use of the Ellick evacuator bulb and reducing the frequency of manual irrigations of the bladder) with minimisation of the operative time and using the coagulation current at moderate power as well as judicious coagulation of tissues can reduce the risk of this dangerous complication arising.

[Postoperative urological complications of transurethral electrosurgical interventions on the prostate for adenoma].

The aim of the study was comparison of urological complications after transurethral resection and its low-invasive alternatives: vaporization, rotoresection, vaporization resection, prostatic incision. Case histories were studied of 5401 patients operated endoscopically for prostatic adenoma in 1991-2003. Standard TUR was made in 5003 patients, incision--in 112, vaporization--in 119, vaporizing resection--in 107, rotoresection--in 60 patients. Of early complications after TUR hemorrhage was the most dangerous, hemotransfusion was made in 3.9% cases. No hemorrhagic complications occurred in rotoresection, no hemotransfusions were made in vaporization and vaporizing resection, prostatic incision was complicated by hemorrhage only in 0.9% cases. By infection complications rate (0.9-7.5%), the differences were not significant. Of late complications, sclerosis of the urinary bladder cervis was most frequent (10.7-11.2%) after rotoresection and vaporizing resection, urethral stricture--after TUR (6.9%). By number of complications, incision was least invasive. Thus, basic problem after TUR is hemorrhage. Low-invasive alternative methods resolve this problem. But they have limitations. The best way out is improvement of intraoperative hemostasis during TUR.

[Pelvic lipomatosis]. / Lipomatosis pelvis.

Pelvic lipomatosis is a rare benign disease characterized by increased pelvic fatty tissue of unknown origin, which leads to encroachment on the pelvic organs. This can lead to symptoms due to narrowing of the bladder and in some cases also of the rectum as well as distal obstruction of the ureter. Symptomatic disease seems to occur more commonly in men with unspecific lower urinary tract symptoms, constipation and hydronephrosis. Obstruction of the upper urinary tract necessitates operative treatment. As the etiology is unclear an appropriate causal treatment is not available.

[Neuromodulation - new techniques]. / Neuromodulation - neue Techniken.

Neuromodulative procedures have become an inherent component in the therapy of functional urinary bladder and pelvic floor function disorders. Sacral neuromodulation has been used in Germany for more than 20 years and reresents the standard neuromodulative therapy. Technical improvements in the field of test stimulation and the phasing out of the large pulse generator models represent current changes with the resulting advantages and disadvantages. Pudendal neuromodulation (PNM) has been known for many years as a procedure for treatment of chronic diseases of the urinary bladder and the lesser pelvis and is predominantly used as second-line neuromodulative therapy; however, for pelvic pain syndromes and in particular for pudendal neuralgia, it represents a promising minimally invasive first-line therapy. Due to the technically demanding puncture procedure, PNM has so far only been used in Germany in specialized centers. Through the development of new operation techniques, the prerequisites for a wider multicentric use, with the future aim of approval of the procedure, have been achieved. External transdermal pudendal neuromodulation is a promising therapeutic approach and after further testing in randomized studies could find an application as a conservative step before minimally invasive pudendal neuromodulation. Although the technique of laparoscopic electrode placement on neural structures of the lesser pelvis is technically attractive, it predominantly finds a monocentric use and must in due course be critically compared with established minimally invasive procedures.

Underactive Bladder in Older Adults.

Overactive bladder is one of the most common bladder problems, but an estimated 20 million Americans have underactive bladder (UAB), which makes going to the bathroom difficult, increases the risk of urinary tract infections, and even leads to institutionalization. This article provides an overview of UAB in older adults, and discusses the prevalence, predisposing factors, cause, clinical investigations, and treatments. At present, there is no effective therapy for UAB. A great deal of work still needs to be done on understanding the pathogenesis and the development of effective therapies.

Drug-induced bladder and urinary disorders. Incidence, prevention and management.

The bladder is vulnerable to the adverse effects of drugs because of its complex control and the frequent excretion of drug metabolites in the urine. Incontinence results when bladder pressure exceeds sphincter resistance. Stress incontinence because of sphincter weakness occurs with antipsychotics and alpha-blockers, especially in women. Urge incontinence and irritative symptoms may be caused by drugs. Anticholinergics, anaesthetics and analgesics cause urinary retention because of failure of bladder contraction. They are more likely to cause retention in men because of prostatic enlargement. Cyclophosphamide and tiaprofenic acid can cause chemical cystitis, and should be withdrawn if a patient develops irritative symptoms or haematuria. Cyclophosphamide may also induce bladder tumours. Adverse effects of cyclophosphamide can be reduced with prophylactic administration of mesna and adequate hydration. Mitomycin, doxorubicin or bacillus Calmette-Guerin (BCG) instilled locally to treat bladder tumours can cause cystitis, contracture and calcification. Their administration should be limited to 1 hour per week for a maximum of 8 weeks. Retroperitoneal fibrosis and urine discolouration may be caused by drugs. Ureteric calculi may result from any drug causing nephrolithiasis.

The overactive bladder: an overview for primary care health providers.

The overactive bladder, with symptoms of frequency, urgency and urge incontinence, substantially affects the life styles of millions of people throughout the world. The symptoms are associated with significant social, psychological, occupational, domestic, physical, and sexual problems. Despite the considerable impact of the condition on quality of life, sufferers are often reluctant to discuss their problem with family members or health care professionals. This state of affairs is unfortunate, for much can be done to alleviate the symptoms of this distressing condition. It is therefore of utmost importance that medical education about symptoms of the overactive bladder and other related problems be improved, to help health care professionals identify and treat patients who will benefit from therapy. This article reviews current thinking regarding definition, epidemiology, quality of life effects, evaluation and management. Emphasis is placed on knowledge particularly useful in primary care, especially, noninvasive modalities of therapy.

[Bladder dysfunction and surgery in the small pelvis. Therapeutic possibilities]. / Blasendysfunktion und Operationen im kleinen Becken.Therapiemöglichkeiten.

The more extensive a surgical procedure in a small pelvis, the higher the risk for the lower urinary tract with its nerve supply and nerve plexus. This concerns mainly the sympathetic chains, the parasympathetic structures and, rarely, the visceral supply of the pelvic floor. Direct trauma to the bladder and its vascular supply as well as indirect injury by displacement of the bladder need to be seriously considered. Problems with micturition and impaired storage capacity of the bladder are the result. Complete urodynamic examination and follow-up can help in differentiating between temporary and persisting disturbances and in taking therapeutical decisions. The most evident postoperative complication is disturbed micturition, managed initially by suprapubic urinary diversion, followed as soon as possible by intermittent self-catheterisation. This is the only way to avoid overstretching of the bladder, recurring urinary tract infection and damage to the upper urinary tract. Restoration of spontaneous micturition can be supported by drug treatment with parasympatholytics and/or alpha-blockers if the measured bladder pressure and residual urine are within tolerable limits. For electrostimulation of micturition, intravesical therapy, although timeconsuming, is best suited because it can easily be done on an outpatient basis. More promising seems bilateral sacral neuromodulation, which, however, is a rather complicated and expensive procedure. Surgical procedures to reduce the voiding resistance of the bladder involve the risk of postoperative incontinence because the sphincter function in those patients is often disturbed too. Persisting problems with bladder storage capacity as a result of tumor surgery in the small pelvis are frequently secondary to retention of urine (overflow incontinence). In these cases, regular evacuation of the bladder by intermittent self-catheterisation can lead to social acceptance. Reduced bladder compliance and lowering of the urethral leak pressure point may result in stress and urge incontinence, which, according to the established rules, should be managed by physiotherapy and behaviour therapy as well as drug therapy and only in exceptional cases by surgical measures. Prevention of postoperative bladder dysfunction can be tried by tissue- and nerve-sparing surgical techniques, but is always determined by oncological aspects.

[Giant fecal impaction as a cause of female incontinence (Fecaloma) and bladder instability. Contribution with one case]. / Fecaloma gigante como causa de incontinencia e inestabilidad vesical femenina. Aportación de un caso.

We present a case of a 60 years old female patient, with previous depressive disorders, an attempted suicide with pelvic injuries, who comes showing two years evolution of emergence incontinence. The was diagnosed with a giant fecal impaction occuping almost all the pelvic zone and leading to a bladder displacement and right ureteral ectasis.