Immediate effect of transcutaneous electrical nerve stimulation on urodynamic parameters of children with myelomeningocele.

OBJECTIVE: To evaluate the immediate response of electrical stimulation in children with neurogenic bladder (NB) due to myelomeningocele, using the urodynamic study (UDS). METHODS: This is a nonrandomized intervention study with 26 children with neurogenic overactive bladder and low bladder compliance due to myelomeningocele, aged 5 to 15 years. Each child performed a routine UDS and then a second UDS, during which the electrical stimulation was applied in the parasacral region. The main outcome was the difference in the maximum bladder pressure observed between the two urodynamic studies, analyzed from the paired t test. RESULTS: We found that 77% of the patients had a lower maximum bladder pressure in the test with electrostimulation compared with the ones without electrostimulation. On average, the pressure reduction after stimulation was 7.24 cmH2 O (95% confidence interval [CI], 0.35-14.14; P = .04). The reduction was even higher in children under 12 years of age, compared with the children above 12 years (11.29 cmH2 O, 95% CI, 3.47-19.12; P = .01). CONCLUSION: The use of transcutaneous electrical nerve stimulation had a significant immediate effect on reducing the maximum bladder pressure during the urodynamic studies among the tested pediatric patients with NB. The results were more significant among children under 12 years of age.

Bone mineral density in pediatric patients with meningomyelocele.

PURPOSE: The aim of this study was to determine the bone mineral density (BMD) and the factors leading to reduction in BMD in children diagnosed with meningomyelocele. METHODS: A total of 31 patients with meningomyelocele (mean (SD) age, 8.5 (3.9) years; 51.6%were females) and 22 healthy children were included. BMD of femoral neck and spinal L1­ L4 levels and markers for bone metabolism were recorded. RESULTS: BMD of femoral neck (p=0.001) and spinal L1­L4 (p = 0.01), serum calcium (p = 0.031), and urinary deoxypyridinoline (p=0.015) levels were significantly lower in patients than in controls. Mobilization was significantly reduced in lumbar (p=0.001) and thoracic (p=0.002) level meningomyelocele compared to controls, while a significant positive correlation was noted between BMD of spinal L1­L4 and mobility (r=0.58, p=0.015). CONCLUSIONS: Our findings suggest a decrease in BMD in meningomyelocele patients being associated with osteoporosis rather than nutritional and hormonal factors and the negative impact of higher levels of lesion on the mobility.

Accuracy of Urinalysis for UTI in Spina Bifida.

OBJECTIVES: Urinary tract infections (UTIs) are common, but overdiagnosed, in children with spina bifida. We sought to evaluate the diagnostic test characteristics of urinalysis (UA) findings for symptomatic UTI in children with spina bifida. METHODS: Retrospective cross-sectional study using data from 2 centers from January 1, 2016, to December 31, 2021. Children with myelomeningocele aged <19 years who had paired UA (and microscopy, when available) and urine culture were included. The primary outcome was symptomatic UTI. We used generalized estimating equations to control for multiple encounters per child and calculated area under the receiver operating characteristics curve, sensitivity, and specificity for positive nitrites, pyuria (≥10 white blood cells/high-powered field), and leukocyte esterase (more than trace) for a symptomatic UTI. RESULTS: We included 974 encounters from 319 unique children, of which 120 (12.3%) met our criteria for UTI. Pyuria had the highest sensitivity while nitrites were the most specific. Comparatively, nitrites were the least sensitive and pyuria was the least specific. When the cohort was limited to children with symptoms of a UTI, pyuria remained the most sensitive parameter, whereas nitrites remained the least sensitive. Nitrites continued to be the most specific, whereas pyuria was the least specific. Among all encounters, the overall area under the receiver operating characteristics curve for all components of the UA was lower in children who use clean intermittent catheterizations compared with all others. CONCLUSIONS: Individual UA findings have moderate sensitivity (leukocyte esterase or pyuria) or specificity (nitrites) but overall poor diagnostic accuracy for symptomatic UTIs in children with spina bifida.

Urinary zinc and metallothionein in children with spina bifida.

Defective embryonic cellular zinc utilization may contribute to abnormal neural tube formation and such a defect may be detectable in children with spina bifida (SB). To investigate this possibility, we examined urinary excretion of zinc and metallothionein (Mt), a cytoplasmic metal-binding protein, in 10 girls and 6 boys (ages 6 months to 19 years) with SB and 16 age-matched control subjects. Mean urinary zinc and Mt concentrations in the SB group were 65% and 72% greater than controls, respectively (p less than 0.05). There was was no evidence of renal dysfunction as judged by urinary creatinine and total protein excretion in the SB children. Increased excretion of zinc and Mt in some children with SB may reflect one or more underlying defects of zinc utilization.

The assessment of thiol status in children with neurogenic bladder caused by meningomyelocele.

PURPOSE: Oxidative stress can cause tissue damage in many diseases. Oxidative status depends on the balance between total oxygen radical absorbance capacity and antioxidants. Neurogenic bladder (NB) is a special state where oxidative status can influence urinary tract function. We decided to measure antioxidant (thiol) status in patients with NB and assess the effect of NB on the urinary antioxidant status and to correlate it with urodynamic findings. MATERIALS AND METHODS: The investigation was conducted on two groups. The first group, constituted of 41 children with NB. The second group, consisted of 20 healthy children with no abnormality in urinary and nervous systems. The antioxidant status was assessed based on the enzyme-linked immunosorbent assay of thiols. RESULTS: The median value of urinary protein thiol level was significantly lower in NB patients than in reference group [median 48 (0.0-633.33) and 221.55 (0.17-1293] µmoL/g protein, respectively (P < .01). We found out the statistically significant differences in urinary thiol level between patients with and without overactivity (P = .017) and between catheterized and noncatheterized patients (P = .048). CONCLUSION: This study demonstrates that antioxidant status in patients with NB decreased and the level of thiol status depends on the grade of bladder overactivity. Oxidative stress may be involved in the pathophysiology of bladder dysfunction related to neurogenic damage.

Glycosaminoglycans: urinary excretion in children with myelomeningocele.

BACKGROUND: The main consequences of neurogenic bladder dysfunction are renal damage related to high intravesical pressure, vesicoureteral reflux (VUR) and urinary tract infections (UTIs). Neurologic impairment, UTIs and VUR are known to be linked with a potential for renal scarring. Of paramount importance as predisposing conditions for UTIs in neurogenic bladder are poor bladder drainage and detrusor-sphincter dyssynergy which cause further abnormalities on the internal bladder surface and, consequently, a bladder wall rich in glycosaminoglycans (GAGs). MATERIALS AND METHODS: The aim of this study is to investigate the correlation between GAG excretion and bladder wall degeneration in 43 patients affected by spina bifida (SB) and 40 healthy age-matched control children. RESULTS: The amounts of GAGs excreted vary greatly in SB patients aged from 0 to 5 years, and values are comparable to those observed in normal controls. They are significantly higher in children over 5 years of age. CONCLUSION: The increased excretion of GAGs in older SB patients is an important parameter in the evaluation of the physiopathological condition of the bladder wall and hence may be considered a possible marker for monitoring the beginning of bladder damage.

Quantitation of urinary Tamm-Horsfall protein in children with urinary tract infection.

It has been suggested that urinary Tamm-Horsfall protein (THP) prevents colonization of the urinary tract by binding uropathogens. We tested the hypothesis that low urinary THP levels may predispose to urinary tract infection (UTI) by measuring THP levels in children. We studied a cohort of 35 girls with uncomplicated recurrent UTI (group 1) that was compared with 27 patients with myelomeningoceles undergoing clean intermittent catheterization (group 2) and 16 female controls (group 3). We measured urinary THP in both aggregated (aTHP) and disaggregated form (dTHP), leukocyte esterase activity, urine chemistries and culture. No significant differences in dTHP or aTHP levels were seen between groups 1 and 3, but group-1 patients had higher dTHP levels than group-2 patients (p < 0.008). History of reflux or the presence of bacteriuria or pyuria at the time of urine collection did not affect dTHP levels; in contrast, pyuria or bacteriuria at the time of sampling was associated with markedly lower aTHP levels when compared with sterile samples (p < 0.0001). For all groups, measured quantities of dTHP did not correlate with aTHP levels. We conclude that excretion of dTHP in children with history of recurrent UTI is not reduced. In contrast, concentrations of aTHP are profoundly depressed in children during times of UTI, suggesting a role for THP in the pathogenesis of UTI. Assaying THP in its aggregated form may prove valuable when studying its physiologic function and merits further investigation.

Basic fibroblast growth factor in the urine of children with voiding pathology.

PURPOSE: Basic fibroblast growth factor is a mediator of tissue response to injury. Voiding pathology often results in bladder abnormalities. We prospectively determined whether basic fibroblast growth factor is elevated in the urine of children with bladder dysfunction compared to that of normal controls. MATERIALS AND METHODS: A total of 97 consecutive children with myelomeningocele and 32 with voiding pathology due to other etiologies underwent urodynamic testing, and 11 children with no bladder symptoms and sterile urine served as controls. Urinary basic fibroblast growth factor levels were assayed by enzyme-linked immunosorbent assay and normalized to urinary creatinine. RESULTS: Mean urinary basic fibroblast growth factor was higher in bladder dysfunction from myelomeningocele (6,673 pg./gm. creatinine, p = 0.0015) and other etiologies (5,665 pg./gm. creatinine, p = 0.0025) compared with urine from normal bladders (2,995 pg./gm. creatinine). In the myelomeningocele group urinary tract infection was associated with higher urinary basic fibroblast growth factor than in sterile urine (9,214 versus 5,642 pg./gm. creatinine, p = 0.018). Patient age, gender, remote bladder surgery, clean intermittent catheterization, detrusor hyperreflexia, detrusor compliance, age adjusted pressure specific bladder volume, low grade reflux and degree of trabeculation did not correlate with levels of basic fibroblast growth factor (p > 0.05). CONCLUSIONS: Urinary elevation of basic fibroblast growth factor, a critical mediator of wound repair, in children with voiding pathology and clinically abnormal bladders supports the paradigm that bladder dysfunction may result from generalized response-to-injury mechanisms. The role of fibrogenic cytokines, such as basic fibroblast growth factor, merits further directed investigation in bladder pathology.

Urine production and bladder function in fetuses with open spina bifida.

Hourly fetal urine production rate (HFUPR) and bladder filling and voiding were determined by real-time ultrasonography in 13 fetuses with open spina bifida (OSB) and compared with those of 101 normal fetuses from uncomplicated pregnancies at 16-40 weeks gestation. In normal pregnancy, the fetal bladder volume increases linearly with time and then decreases rapidly with micturition. The mean cycle length does not change significantly with gestation but both the mean bladder volume and HFUPR increase. In fetuses with OSB, ultrasonographic examination has demonstrated deviations from normal in both bladder filling and bladder emptying.

Measurement of intravesical and rectal pressures simultaneously with electromyography of anal sphincter in children with myelomeningocele.

This paper reports a technique for simultaneous measurement of intravesical pressure, intra-abdominal pressure, electromyographic activity of the external and sphincter and urinary flow. Using this technique during filling of the bladder and during micturition in 38 children with myelomeningocele and neurogenic bladder disturbance, it was possible to identify four main types of bladder dysfunction in these children. Once the type of bladder dysfunction is established for each child, adequate management can be planned far in advance of the detection of inherent upper urinary tract damage. This is particularly important in children with upper somatomotor lesions of bladder innervation in which detrusor-spincter dyssynergia may be present; this dyssynergia always causes some degree of obstruction at the level of the external urethral sphincter and is a constant threat to renal function.