Treating asthma in patients with enuresis: repercussions on urinary symptoms.

BACKGROUND: Children presenting enuresis are more likely to be asthmatics. The association between enuresis and sleep-disordered breathing has already been demonstrated and several studies have shown at least partial improvement of two thirds or more of the cases of enuresis adenoidectomy. Studies have already described associations between enuresis and allergies but do not assess the repercussions of allergy treatment in enuretics. OBJECTIVE: This study aims to evaluated whether asthma treatment alters the course of enuresis and whether there is any predictive factor associated with this improvement. MATERIALS AND METHODS: Twenty patients (5 - 12 years old) with uncontrolled enuresis and asthma, received treatment for asthma. Children were also assessed for the presence of rhinitis and other allergies. The control of asthma was confirmed by a validated questionnaire and primary enuresis by clinical history and wet night diaries. Patients received only asthma treatment. RESULTS: At least partial improvement of enuresis was observed in 55% of the patients with an increase in 64.4% in the number of dry nights at the end of the study (p=0.01). The "presence of other allergies" and "obstruction seen in nasal endoscopy" positively influenced the improvement of urinary symptoms (OR = 3.350; CI 0.844-13.306) and (OR=1.272; CI 0.480-3.370), respectively. DISCUSSION: Until now, only patients presenting upper airway obstruction were known to benefit from the improvement of urinary symptoms when undergoing treatment for their respiratory problems. In our study, we found at least partial improvement in enuresis in 55% of our patients, with only clinical asthma treatment. CONCLUSION: Controlling asthma in children with primary enuresis resulted in a significant increase in dry nights.

One-day voiding diary in the evaluation of Lower Urinary Tract Symptoms in children.

INTRODUCTION: Voiding diary (VD) is an important tool in the evaluation of children with voiding symptoms. Voiding frequency, maximal voided volume (MVV), average voided volume (AVV) and nocturnal volume (NV) can be extracted and are valuable in diagnosing and monitoring these disorders. Recently, ICCS has reduced the period of data recording on VD from 3 to 2 days.We hypothesized that one day voiding diary would be enough for guiding treatment. MATERIALS AND METHODS: Children with overactive bladder (OAB) and primary monosymptomatic enuresis (PMNE) were oriented to fulfill a 3-day VD. Data obtained from VD were evaluated for the first day (1dVD), the first two days (2dVD), and all 3 days (3dVD) and compared according to the MVV, AVV, frequency, NV and expected bladder capacity (EBC). The Friedman, Student's t test and the Fisher's exact was used. ANOVA was used for multiple comparisons. We also used Pearson correlation test. RESULTS: Ninety-eight children were included, 59 had PMNE and 30 OAB. Frequency, AVV and VN were similar regardless how many days the voiding episodes were recorded. Only MVV was higher by a mean of only 32 mL on 3dVD compared to 1dVD. A 1dVD has a sensitivity of 93,9% and a positive likelihood ratio of 2.2. As for the correlation of MVV and EBC it was observed that in 83% of children, MVV was lower than EBC. MVV corresponds to 67% and 69% of EBC in children with PMNE and OAB, respectively. CONCLUSION: We believe that 1dVD is sufficient to assess these children. It has a high sensitivity and good correlation to 3dVD in evaluating these children. Bladder capacity in this population, evaluated by maximum voided volume, was close to 68% of that obtained by the EBC.

Enuresis and upper airway obstruction: BNP and ADH hormones behavior before and after airway surgery.

INTRODUCTION: Upper airway obstruction (UAO) is a common condition in all pediatric population, with a 27% prevalence. Primary monosymptomatic nocturnal enuresis (PMNE) is a condition related to UAO in 8% to 47% of these children. The specific pathophysiological mechanism of this bond is not well understood. Some authors suggest a connection between brain natrituretic peptide (BNP) and anti-diuretic hormone (ADH) during sleep. The aim of this study was to evaluate hormone profile (ADH and BNP) and improvement in dry nights in a sample of children before and after surgical treatment of the UAO. METHODS: This is a longitudinal prospective interventionist study in children, 5 to 14 years of age, with UAO and PMNE recruited in a specialty outpatient clinic. Children presenting UAO and PMNE were evaluated with a 30-day dry night diary and blood samples were collected to evaluate ADH and BNP before and after upper airway surgery. Data were analyzed prior to surgery and 90-120 days after surgery. RESULTS: Twenty-one children with a mean age of 9.7 years were included. Mean BNP before surgery was 116.5 ± 126.5 pg/mL and 156.2 ± 112.3 pg/mL after surgery (p<0.01). Mean ADH was 5.8 ± 3.2 pg/mL and 14.6 ± 35.4 before and after surgery, respectively (p=0.26). The percentage of dry nights went from 32.3 ± 24.7 before surgery to 75.4 ± 33.4 after surgery (p˂0.01). CONCLUSION: Surgery for airway obstruction contributed to an increase in BNP without increasing ADH. A total of 85.8% of the children presented partial or complete improvement of their enuresis.

Psychological Intervention with Parents Improves Treatment Results and Reduces Punishment in Children with Enuresis: A Randomized Clinical Trial.

PURPOSE: This study aims to evaluate the impact of psychological intervention with parents of children with enuresis on treatment outcome. MATERIALS AND METHODS: A total of 66 children with enuresis were randomized into 2 groups. All children received urotherapy orientation and psychological counseling. Psychological intervention was performed with parents in the experimental group and not in the control group. All parents answered a questionnaire to evaluate violence against their children (Parent-Child Conflict Tactics Scale) and the Tolerance Scale. The Child Behavior Checklist was applied to evaluate behavior problems. Children responded to the Impact Scale and the Children and Youth Self-Concept Scale. Treatment results were assessed with a 14-day wet night diary. RESULTS: Mean age and gender were similar in both groups. Parent-Child Conflict Tactics Scale showed less violence after the treatment in the experimental group (p=0.007). The Tolerance Scale indicated that parents of children with enuresis were intolerant and that, after treatment, intolerance had a greater decrease in the experimental group (p <0.001). The Impact Scale showed that children suffer some impact from enuresis, and that in those in the experimental group this impact was smaller after treatment (p=0.008). No differences were seen in the Child Behavior Checklist or Children and Youth Self-Concept Scale after intervention. After treatment the percentage of dry nights had a greater improvement in the experimental group (52%, range 30% to 91%) than in the control group (10%, range 3% to 22.5%; p <0.001). Children in the experimental group had a 6.75 times greater chance of having a complete response to treatment. CONCLUSIONS: Psychological intervention with parents of children with enuresis during their treatment improved the percentage of dry nights and the impact of enuresis, while their parents started coping better with the problem and became more tolerant, reducing punishment toward their children.

Quality of life in enuretic children.

INTRODUCTION: Nocturnal enuresis is a highly incident chronic disorder that generates countless problems to the child and their parents. Bed-wetting has significant negative impacts on self-esteem and the performance of children. The aim of the current study is to assess the quality of life of enuretic children, as well as its association to sex and age. PATIENTS AND METHODS: Thirty-nine enuretic children (23 boys) and 49 healthy children (27 boys) without any history of previous treatment for enuresis or voiding dysfunction were included. Age ranged between 6 and 11 years old. The "AUQEI" questionnaire was applied in a private environment to all children by the same researcher (psychologist) to evaluate quality of life. RESULTS: Enuretic children displayed loss in quality of life when compared to non-enuretic (35.9% of enuretic x 16.3% of non-enuretic, p=0.035). They were mostly affected in their daily activities (p=0.02). No significant differences were found in the association of sex and gender with quality of life. These results suggest that, children with nocturnal enuresis have 2.87 times more chances of having loss in quality of life compared to non-enuretic. CONCLUSIONS: Enuresis has a great impact in quality of life of children. This impact is not related to the age or sex of the child.

Correlation between pelvic floor strength and physical activity level in healthy men.

The male pelvic floor muscles comprise a pair of compound muscle layers referred to as the levator ani. Studies have shown that pelvic floor muscle strength is affected by physical activity. This study aimed to assess male pelvic floor muscle strength through manometry of the external anal sphincter and evaluation of its association with physical activity level, BMI, and rectal pressure in healthy men. To assess physical activity level over the previous week, we used the International Physical Activity Questionnaire 8 (IPAQ). Pelvic floor muscle strength was assessed via anorectal manometry. The results shows a negative correlation between resting pressure and MET, a positive correlation between rectal pressure and resting and maximum pressure. The novel finding of this study is a negative correlation between walking and pelvic floor strength. This study raises new questions about the understanding of the interaction among physical activity, intraabdominal pressure, and pelvic floor strength in the physiology of continence in men.

Dynamic lumbopelvic stabilization for treatment of stress urinary incontinence in women: Controlled and randomized clinical trial.

OBJECTIVES: To compare the results of the dynamic lumbopelvic stabilization (DLS) exercises with exercises for the pelvic floor muscles (PFM) in women with stress urinary incontinence. METHODS: Randomized controlled clinical trial comparing 17 women submitted to the DLS with 16 women submitted to the exercises for the PFM. The evaluated outcomes were incontinence severity, quality of life (QoL), and impression of improvement in three moments. Significance was set at 5%. RESULTS: For socio-demographic and clinical variables, only climacteric was more prevalent in the DLS group (82% vs. 44%, P = 0.02). Soon after the intervention, there was no difference between the groups in relation to the outcomes evaluated. In the evaluation after 90 days, the DLS group presented better values for the severity of the losses (4.1 ± 2.6 vs. 5.7 ± 2.4, P = 0.006, d = 0.64), daytime frequency (4.6 ± 0.4 vs. 6.2 ± 0.6, P < 0.001, d = 2.67), and nighttime frequency (0.4 ± 0.3 vs. 1.4 ± 0.5, P < 0.001, d = 2.50), QoL and impression of improvement (P < 0.001). CONCLUSIONS: After treatment, the DLS plus PFM exercise patients had results similar to those performing PFM exercises alone. However, the DLS plus PFM exercises were superior in the outcomes of incontinence severity, QoL, and impression of improvement in the post-90-day evaluation, showing longer lasting effect.

Increased Risk of Physical Punishment among Enuretic Children with Family History of Enuresis.

PURPOSE: Some parents blame their children for bedwetting and, therefore, punish them. This study aimed to assess the rate of punishment experienced by enuretic children and associated causative factors. MATERIALS AND METHODS: A total of 87 children 6 to 15 years old with monosymptomatic enuresis were assessed individually. Parents answered the questions in the tolerance scale. The forms of punishment were classified as verbal, chastisement and physical aggression. Family history of enuresis was considered only when 1 or both parents had experienced enuresis. RESULTS: Of the 35 girls and 52 boys with a mean ± SD age of 9.3 ± 2.3 years 67 had a family history of enuresis. Of the 67 parents 57 (85.0%) had a history of being punished due to enuresis. All children experienced some sort of verbal punishment. Children who had a family history of enuresis were more prone to being punished by physical aggression than those without such a family history (32 of 67 or 47.8% vs 4 of 20 or 20%, OR 3.7, 95% CI 1.1-12.1, p = 0.03). Punishment was found 3 times more frequently in girls than in boys (20 of 35 or 57.1% vs 16 of 52 or 30.8%, OR 3.0, 95% CI 1.2-7.3). Parents of 79 of the 87 children (90.8%) had high scores on the tolerance scale regardless of the history of enuresis. CONCLUSIONS: Enuretic children are at a high risk for experiencing some kind of punishment. Children whose parents had enuresis are at risk for being physically punished. Parents should be taught about the involuntary nature of enuresis and the fact that no punishment would help improve the condition.

Association between Asthma and Primary Nocturnal Enuresis in Children.

PURPOSE: Enuresis, sleep respiratory disorders and asthma compromise the quality of sleep in children and may occur in association with each other. An association between sleep respiratory disorders and enuresis has already been demonstrated. According to united airways disease abnormalities of the upper and lower airways may coexist. A child who wheezes has a greater chance of snoring and having obstructive sleep apnea. Since asthma and sleep respiratory disorders may be associated, and sleep respiratory disorders are associated with enuresis, we determined the possibility of an association between asthma and enuresis. MATERIALS AND METHODS: Between August 20 and March 2015 parents/guardians of children 6 to 14 years old from 16 elementary schools in our area were randomly chosen for study. Children with nonmonosymptomatic enuresis and urological or neurological disease were excluded. The Tucson and ISAAC (International Study of Asthma and Allergies in Childhood) questionnaires were used to assess sleep respiratory disorders and asthma, respectively. RESULTS: A total of 523 children (283 males and 240 females) with a mean ± SD age of 9.42 ± 2.46 years were included in analysis. The overall prevalence of enuresis was 15.87% (95% CI 12.98-19.26). Asthmatic children with wheezing in the last 12 months were 2.33 times more likely to have had enuresis at some point in life (OR 2.33, 95% CI 1.37-3.95, p = 0.0017). If enuresis was present, the chance increased to 2.78 (95% CI 1.38-5.61, p = 0.0041). Enuretic children were 5.34 times more prone to have apnea reported by parents (95% CI 2.19-13.03, p = 0.0002). CONCLUSIONS: These findings demonstrate that asthma as well as sleep respiratory disorders is associated with primary nocturnal enuresis.

Transcutaneous parasacral electrical neural stimulation in children with primary monosymptomatic enuresis: a prospective randomized clinical trial.

PURPOSE: Parasacral transcutaneous electrical neural stimulation is widely used to treat hyperactive bladder in children and adults. Its use in nonmonosymptomatic enuresis has demonstrated improvement in number of dry nights. We assessed the effectiveness of parasacral transcutaneous electrical neural stimulation in the treatment of monosymptomatic primary enuresis. MATERIALS AND METHODS: This prospective randomized clinical trial included 29 girls and 16 boys older than 6 years with primary monosymptomatic enuresis. Children were randomly divided into 2 groups consisting of controls, who were treated with behavioral therapy, and an experimental group, who were treated with behavioral therapy plus 10 sessions of parasacral transcutaneous electrical neural stimulation. Neural stimulation was performed with the electrodes placed in the sacral region (S2/S3). Sessions always followed the same pattern, with duration of 20 minutes, frequency of 10 Hz, a generated pulse of 700 µs and intensity determined by the sensitivity threshold of the child. Sessions were done 3 times weekly on alternate days. Patients in both groups were followed at 2-week intervals for the first month and then monthly for 6 consecutive months. RESULTS: Rate of wet nights was 77% in controls and 78.3% in the experimental group at onset of treatment (p = 0.82), and 49.5% and 31.2%, respectively, at the end of treatment (p = 0.02). Analyzing the average rate of improvement, there was a significantly greater increase in dry nights in the group undergoing neural stimulation (61.8%) compared to controls (37.3%, p = 0.0038). At the end of treatment percent improvement in children undergoing electrical stimulation had no relation to gender (p = 0.391) or age (p = 0.911). CONCLUSIONS: Treatment of primary monosymptomatic enuresis with 10 sessions of parasacral transcutaneous electrical neural stimulation plus behavioral therapy proved to be effective. However, no patient had complete resolution of symptoms.

A prospective evaluation of plastibell® circumcision in older children.

INTRODUCTION AND OBJECTIVE: Circumcision is one of the oldest surgical procedures and one of the most frequently performed worldwide. It can be done by many different techniques. This prospective series presents the results of Plastibell® circumcision in children older than 2 years of age, evaluating surgical duration, immediate and late complications, time for plastic device separation and factors associated with it. MATERIALS AND METHODS: We prospectively analyzed 119 children submitted to Plastic Device Circumcision with Plastibell® by only one surgeon from December 2009 to June 2011. In all cases the surgery was done under general anesthesia associated with dorsal penile nerve block. Before surgery length of the penis and latero-lateral diameter of the glans were measured. Surgical duration, time of Plastibell® separation and use of analgesic medication in the post-operative period were evaluated. Patients were followed on days 15, 45, 90 and 120 after surgery. RESULTS: Age at surgery varied from 2 to 12.5 (5.9 ± 2.9) years old. Mean surgical time was 3.7 ± 2.0 minutes (1.9 to 9 minutes). Time for plastic device separation ranged from 6 to 26 days (mean: 16 ± 4.2 days), being 14.8 days for children younger than 5 years of age and 17.4 days for those older than 5 years of age (p < 0.0001). The diameter of the Plastibell® does not interfered in separations time (p = 0,484). Late complications occurred in 32 (26.8%) subjects, being the great majority of low clinical significance, especially prepucial adherences, edema of the mucosa and discrete hypertrophy of the scar, all resolving with clinical treatment. One patient still using diaper had meatus stenosis and in one case the Plastibell® device stayed between the glans and the prepuce and needed to be removed manually. CONCLUSIONS: Circumcision using a plastic device is a safe, quick and an easy technique with low complications, that when occur are of low clinical importance and of easy resolution. The mean time for the device to fall is shorter in children under 6 years of age and it is not influenced by the diameter of the device.

Ureteral obstruction may activate kidney latent tuberculosis. A qualitative study.

Objectives: To analyze the hypothesis that ureteral obstruction may activate kidney latent tuberculous though qualitative study of Urogenital Tuberculosis patients. Methods: A qualitative study was conducted using semistructured interviews in eight patients with Urogenital Tuberculosis. The progression of the disease from the initial symptoms was characterized through the analysis of the clinical and radiological data. The presence of ureteral obstruction prior to the onset of renal tuberculosis was observed in three patients. Results: Patient 1: A 58-year-old female had five episodes of acute left ureteral lithiasis in two years prior to left kidney tuberculosis. Patient 2: A 55-year-old male patient had a 1.2 cm proximal left ureteral stone and in the following six months, the diagnosis of tuberculosis was made in a nonfunctioning left kidney with ureteral thickening and stenosis. Patient 3: A 47-year-old male patient had a 1.2 cm stone in the proximal right ureter and developed urinary tuberculosis with a nonfunctioning right kidney and a contracted bladder. Conclusion: Kidney tuberculosis may appear in the same kidney that had previously suffered stone ureteral obstruction, which may have created local conditions for the activation of latent foci of renal tuberculosis.

Heart rate variability in men with lower urinary tract symptoms: a case-control study.

PURPOSE: Measurement of heart rate variability (HRV) allows evaluation of autonomic nervous system activity. Decreased HRV is associated with autonomic disbalance, poor health and higher mortality. Our objective is to evaluate the HRV in men with lower urinary tract symptoms (LUTS) through a case-control study. METHODS: LUTS were considered as the outcome and HRV variables were considered as exposure. The protocol included anamnesis, LUTS assessment, anthropometry, blood pressure and HRV measurement by analyzing the variation in the time interval between consecutive heartbeats or RR intervals. The mathematical study of HRV indicators allowed the assessment of the cardiac autonomic modulation of the volunteers. RESULTS: Eighty nine patients were included in the study, with 34 allocated to the case group (with LUTS) and 55 to the control group (without LUTS). The patients were similar in terms of age and systolic and diastolic blood pressure. Among the HRV variables, the mean VLF index for the very low frequency of the spectrum associated with the frequency domain was significantly higher in volunteers without LUTS. Control group patients presented a mean of 113.18 ± 166.74 ms2, while patients with LUTS presented a mean of 69.21 ± 61.98 ms2 (p = 0.032). CONCLUSIONS: Men 50-59 years of age without chronic diseases and with LUTS have an unfavorable cardiac autonomic profile indicated by significantly lower levels of the VLF component of HRV compared to men without LUTS.

Structural study of prepuce in hypospadias--does topical treatment with testosterone produce alterations in prepuce vascularization?

PURPOSE: Androgen stimulation before hypospadias surgery has resulted in increased penile size, fewer complications and improved cosmesis, and suggests increased neovascularization. To our knowledge the real effect on neovascularization remains to be proved. We studied the histological effects of testosterone on neovascularization. MATERIALS AND METHODS: A total of 26 boys with hypospadias were randomly allocated to 2 groups before surgical correction. Group 1 did not receive any treatment and group 2 received 1% testosterone propionate ointment twice daily for 30 days before surgery. During the surgical procedure a fragment of prepuce was excised and prepared for histological evaluation. The number and volume density of blood vessels were determined by labeling for von Willebrand's factor. Blood vessel quantification as volume density was done using a video microscopy system with a superimposed cycloid arch test system. RESULTS: The groups were similar in age and hypospadias classification. Testosterone treated prepuces (group 2) had an increased absolute number of blood vessels (mean ± SD 8.5 ± 1.3 vs 4.8 ± 1.8 vessels per field) and increased blood vessel volume density (mean 50.5% ± 7.8% vs 24.8% ± 8.6% vessels per point) (each p <0.001) compared to those in untreated patients (group 1). CONCLUSIONS: The use of 1% testosterone propionate ointment before hypospadias surgery produces neovascularization in absolute numbers and in volume density.

Evaluation of pedometer use in men with lower urinary tract symptoms: a randomized clinical trial.

PURPOSE: To assess the effect of a pedometer use in men aged between 50 and 59 years presenting lower urinary tract symptoms (LUTS). METHODS: A single-center, not blind clinical trial with two parallel groups and equal randomization was performed with 38 men aged 50-59 years with LUTS. All patients received guidance and encouragement to physical activity practice. Only the intervention group received a Pedometer with a goal of 10,000 steps/day. After a period of 12 weeks, the groups were compared through the following variables: number of steps/day, IPSS score, flexibility, anthropometric values and Maximum Oxygen Consumption (VO2max). RESULTS: The number of steps per day in the intervention group was 9753 ± 1549 compared to 6212 ± 1152 in the control group (p = 0.004). Pedometer use efficacy was a 50% risk reduction of not achieve the goal of 10,000 steps per day. Regarding IPSS score, the intervention group achieved lower scores (6.95 ± 2.85 vs. 10.16 ± 3.23, p = 0.007). Pedometer use efficacy was a 94% risk reduction of not achieve more than 30% reduction in IPSS score. In VO2max, the intervention group performed better than the control group (34.84 ± 3.25 vs. 32.58 ± 6.89; p = 0.011). There was no difference in flexibility and anthropometric values between the groups. CONCLUSIONS: The use of pedometer in LUTS patients provided an increase in the number of steps/day, a decrease in LUTS score and an improvement in VO2max measure. CLINICAL TRIAL REGISTRATION: Trial url: www.ensaiosclinicos.gov.br/rg/RBR-4vynk5/ . Register Number: RBR-4vynk5 .

Epidemiology of urogenital tuberculosis worldwide.

OBJECTIVES: To characterize the epidemiology of urogenital tuberculosis worldwide and to compare the features of patients from developing countries to those from developed countries. METHODS: A comprehensive search of articles published up to April 2008 using a combination of the terms 'tuberculosis', 'genitourinary', 'renal' and 'urogenital' was performed. RESULTS: Urogenital tuberculosis affects more men than women (2:1), with a mean age of 40.7 years (range 5-90). In 26.9% of cases there is a non-functioning unilateral kidney and in 7.4%, renal failure. Patients from developing countries are more likely to have a delayed diagnosis with a higher frequency of renal failure, unilateral non-functioning kidney, ablative surgery and contracted bladder. CONCLUSIONS: Urogenital tuberculosis is a worldwide disease with more destructive behavior in developing countries where urgent strategies for early detection are particularly warranted.