A comparative analysis of pediatric uroflowmetry curves.

AIMS: This study was conducted to try to objectify assessment of pediatric uroflowmetry curves. MATERIALS AND METHODS: Nine professionals in pediatric incontinence care judged 480 pediatric uroflows. On a 1-5 scale, where 1 = anomalous and 5 = normal, uroflows were assessed on four items: staccato, interrupted, flow time and obstruction. Eighty uroflows were re-evaluated for intra-observer agreement. After staccato and interrupted flow had been defined more sharply, another 100 uroflows were analyzed. Cohen's Kappa test for nominally classified data was applied to assess agreement. Kappa value of <0.20 denoted poor agreement, 0.21-0.40 fair, 0.41-0.60 moderate, 0.61-0.80 substantial and 0.81-1.0 perfect or almost perfect agreement. A second analysis was done using a 3 point scale, anomalous, intermediate and normal. RESULTS: For interobserver agreement, Kappas were 0.45 for staccato flow, 0.67 for interrupted, 0.59 for flow time, and 0.66 for obstruction. For intra-observer agreement, Kappas were 0.47 for staccato, 0.65 for interrupted, 0.55 for flow time, and 0.65 for obstruction. On a three-point scale, anomalous, intermediate, and normal, interobserver agreement was equal to 0.80 or above. In the second 100 uroflows, the interobserver agreement Kappas were 0.44 for staccato, 0.95 for interrupted, 0.71 for flow time and 0.73 for obstruction. CONCLUSION: Moderate to substantial agreement on uroflowmetry curves can be reached, except for staccato. Agreement increases if staccato and interrupted flows are defined more sharply. Staccato is defined as three or more peaks and troughs of more than the square root of maximal flow without touching 0, whereas interrupted flow needs at least one 0 passage. In a normal, uninterrupted uroflow, flow time is under 15 sec.

Efficacy and safety of urethral de-obstruction in boys with overactive bladder complaints.

OBJECTIVE: To gain insight into the efficacy and safety of urethral de-obstruction in boys with overactive bladder (OAB) complaints refractory to conservative treatment. MATERIALS AND METHODS: All boys, older than 5 years, referred in 2009 for OAB complaints were included, n = 180. Nine had abdominal or penile pain as predominant complaint. 82% were tertiary referrals after unsuccessful conservative treatment with antimuscarinic medication and/or urotherapy for OAB. In 121, urethral obstruction was urodynamically proven or seriously suspected, and they underwent urethrocystoscopy with relief of obstruction, when present. Average duration of unsuccessful conservative pre-treatment in this group of patients was 1.2 years. Postoperative results, in terms of relief of complaints, were analyzed. Safety was assessed by analyzing those patients who had a secondary transurethral procedure in the same year, or in the 3 years after primary treatment. RESULTS: Of 106 boys with OAB, urge incontinence or therapy-resistant bedwetting, after de-obstruction 33 became free of complaints and 39 showed significant improvement, totaling 72 (68%); dry after additional urotherapy 11 (10%); no change 21 (20%). Nine boys had de-obstruction because of penile or abdominal pain, with 5 completely cured after the procedure. Follow-up treatment was cognitive training in 39, temporary anticholinergic treatment in 26 and CIC in 2 cases. Recurrence of obstruction was seen in 10% during the 3-year follow-up period. CONCLUSION: After failure of conservative therapy, one should actively look for any urethral obstruction as underlying cause of OAB. For such patients, urethral de-obstruction is highly effective, with only a few minor late complications resulting in recurrence of obstruction.

Long-term follow-up of incontinence and urge complaints after intensive urotherapy in childhood (75 patients followed up for 16.2-21.8 years).

OBJECTIVE: To reassess the incontinence and urge complaints in adults who had undergone inpatient urotherapy during childhood and compare the results with the short-term outcomes. METHODS: From 1987 to 1990, 95 children (13 boys and 82 girls; age 6-17 years) underwent hospitalized urotherapy to treat functional lower urinary tract symptoms. This group was traced and a questionnaire was administered by telephone. The long-term data on incontinence and urge complaints were compared with the results at 6 months after training. RESULTS: Of the 95 patients, 92 were traced, and a cohort of 75 could be analyzed. At long-term follow-up (mean 17.9 years), of the 75 patients, 63 (84%) had a good, 8 (11%) a moderate, and 4 (5%) a poor outcome. At short-term follow-up, 56 of the current 75 patients had had a good outcome, and at long-term follow-up, 47 of these 56 patients still had a good score. However, during the intervening period, 3 of these 56 patients developed incontinence recurrence and scored a poor result, and 6 others scored a moderate result. Originally, after 6 months of follow-up, 7 patients had had a moderate outcome; 5 of these had improved to good, 1 still scored moderate, and 1 had deteriorated over time to poor. Twelve patients had originally had a poor outcome at short-term follow-up. Of these, 11 had spontaneously improved to good and 1 to moderate. CONCLUSION: If the original outcomes of pediatric intensive inpatient urotherapy are good, they tend to remain so over time in most patients.

Urethral length in girls with lower urinary tract symptoms and forme fruste of female epispadias.

PURPOSE: To investigate systematically the length of the urethra in girls with lower urinary tract symptoms. MATERIALS AND METHODS: In a group of 121 consecutive girls presented at a tertiary referral clinic for urinary incontinence or recurrent urinary tract infections, urethral length was measured by perineal ultrasound. The urethra was measured with the patient in supine position without anesthesia. Mean age of the patients was 7.8 (0-15) years. RESULTS: Average urethral length was 26 mm. Minimum length was 12 mm, measured in a 5-year-old girl with dribbling incontinence. Maximum measured length was 40 mm in a 15-year-old girl. In four girls (3.3%), aged 1-10 years (mean 6.3), a short urethra was detected, with measured lengths of 12 and 14 mm. All four had normal genitalia, and were referred with therapy-resistant urinary incontinence or urinary tract infections. A gradual increase in average urethral length was measured from 23 mm at birth to 32 mm at 15 years. CONCLUSION: Urethral length can be measured accurately by ultrasound. Although a short urethral length is rarely detected by ultrasound in girls with incontinence, it may be associated with therapy-resistant incontinence. In such cases, different treatment options are available.

Colonic washout enemas for persistent constipation in children with recurrent urinary tract infections based on dysfunctional voiding.

OBJECTIVES: To describe the use of colonic washout enemas for persistent constipation in children treated for dysfunctional voiding by cognitive and biofeedback training. METHODS: We treated 50 children, who had dysfunctional voiding and persistent dilatation of the rectum notwithstanding adequate oral laxatives, with colonic washout enemas. We performed retrograde filling of the rectum with 20 mL/kg water, starting once daily for 2 weeks, then 3 times per week for 6 to 12 months. RESULTS: During the 6-month follow-up, 30 children were free from urinary tract infections. In 20 children we observed partial relief of complaints. On ultrasound all children showed a normalized diameter of the rectum. In 33 patients washout treatment could be stopped with continuing success. Relapse of a distended rectum triggered the need for chronic intermittent enema therapy in 17 patients. A few patients reported pain during enema treatment; otherwise, we noted no counter-effect. CONCLUSIONS: Dysfunctional voiding combined with constipation in children can be cured by washout enemas if oral laxatives fail.

Behavior profiles in children with functional urinary incontinence before and after incontinence treatment.

OBJECTIVE: The purpose of this work was to analyze prospectively the prevalence of behavioral disorders in children with urinary incontinence because of nonneuropathic bladder-sphincter dysfunction before and after treatment for incontinence. METHODS: A total of 202 children with nonneuropathic bladder-sphincter dysfunction were enrolled in the European Bladder Dysfunction Study, in branches for urge syndrome (branch 1) and dysfunctional voiding (branch 2); 188 filled out Achenbach's Child Behavior Checklist before treatment and 111 after treatment. Child Behavior Checklist scales for total behavior problems were used along with subscales for externalizing problems and internalizing problems. RESULTS: After European Bladder Dysfunction Study treatment, the total behavior problem score dropped from 19% to 11%, the same prevalence as in the normative population; in branch 1 the score dropped from 14% to 13%, and in branch 2 it dropped from 23% to 8%. The prevalence of externalizing problems dropped too, from 12% to 8%: in branch 1 it was unchanged at 10%, and in branch 2 it dropped from 14% to 7%. The decrease in prevalence of internalizing problems after treatment, from 16% to 14%, was not significant. CONCLUSION: More behavioral problems were found in dysfunctional voiding than in urge syndrome, but none of the abnormal scores related to the outcome of European Bladder Dysfunction Study treatment for incontinence. With such treatment, both the total behavior problem score and the score for externalizing problems returned to normal, but the score for internalizing problems did not change. The drops in prevalence are statistically significant only in dysfunctional voiding.

Effect of biofeedback training on paradoxical pelvic floor movement in children with dysfunctional voiding.

OBJECTIVES: Dynamic perineal ultrasonography to assess the function of the pelvic floor muscles in children with micturition complaints shows that many children with daytime incontinence or recurrent urinary tract infections use their pelvic floor paradoxically. They strain when asked to withhold urine, or they have no voluntary control of the pelvic floor muscles at all. The aim of this study was to record the pelvic floor function and evaluate the physical therapy regimens for children with dysfunctional voiding (DV) and paradoxical pelvic floor function. METHODS: A total of 65 patients with DV, many who also had constipation, were diagnosed with paradoxical movement of the pelvic floor. The patients were asked to contract their pelvic floor muscles during a perineal dynamic ultrasound investigation. Of the 52 patients treated by physical therapists, 32 had a single 1-hour biofeedback session with rectal examination and anal balloon expulsion. In the remaining 20 patients, this was followed by 2 weeks of biofeedback balloon expulsion training at home. Forty control patients were observed. RESULTS: In 13 of the 65 patients, the diagnosis could not be confirmed by the physical therapists. At 6 to 10 months after training, 50 of the 52 other patients had normal voluntary pelvic floor muscle control. Of the 40 control patients, 39 had normal pelvic floor control. CONCLUSIONS: The results of this study have demonstrated that pelvic floor dysfunction occurs frequently in children with DV and can be cured by dedicated physical therapy. The clinical importance of this phenomenon is not yet clear. Prospective studies will teach us more about the true incidence and therapeutic effect of pelvic floor dysfunction on DV.

Functional urinary and fecal incontinence in neurologically normal children: symptoms of one 'functional elimination disorder'?

OBJECTIVE: To clarify the relationship between disordered defecation and non-neuropathic bladder-sphincter dysfunction (NNBSD) by comparing the prevalence of symptoms of disordered defecation in children with NNBSD before and after treatment for urinary incontinence (UI), and assessing the effect of such symptoms on the cure rate for UI. PATIENTS AND METHODS: In the European Bladder Dysfunction Study, a prospective multicentre study comparing treatment plans for children with NNBSD, 202 children completed questionnaires on voiding and on defecation, at entry and after treatment for UI. Four symptoms of disordered defecation were evaluated; low defecation frequency, painful defecation, fecal soiling, and encopresis. RESULTS: At entry, 17 of the 179 children with complete data sets had low defecation frequency and/or painful defecation (9%), classified as functional constipation (FC). Of the 179 children, 57 had either isolated fecal soiling or soiling with encopresis (32%), classified as functional fecal incontinence (FFI). After treatment for UI, FFI decreased to 38/179 (21%) (statistically significant, P = 0.035); for FC there were too few children for analysis. After treatment for UI, 19 of the 179 children (11%) reported de novo FFI. Symptoms of disordered defecation did not influence the cure rate of treatment for UI. CONCLUSIONS: FFI improved significantly after treatment for UI only, but not in relation to the outcome of such treatment. FFI did not influence the cure rate for UI. There was little to support a causal relation between disordered defecation and NNBDS ('functional elimination syndrome').

Ultrasound imaging of sacral reflexes.

OBJECTIVES: To investigate the reliability of examination of the guarding reflex of the pelvic floor by dynamic perineal ultrasonography in children with bladder dysfunction and in controls. METHODS: A total of 40 patients with nonneurogenic bladder/sphincter dyssynergia, 40 with spina bifida, and 40 controls underwent a dynamic ultrasound examination of the pelvic floor while coughing and while being tapped on the abdominal wall. The reflex action of the puborectal muscle in females, and the combined action of the puborectal muscle and external sphincter muscle in males, were recorded. RESULTS: Of the 40 patients with nonneurogenic bladder/sphincter dyssynergia, 38 had a normal reflex action of the puborectal muscle during the abdominal tap and 36 had a normal reflex action when coughing. Two of these patients had unexplained underactive bladder syndrome and were using clean intermittent catheterization, and two could not be assessed because of hypermobility of the bladder neck when coughing but had a normal reaction during abdominal tapping. Of the 40 patients with spina bifida, none had puborectal activity during coughing and 5 had some puborectal activity during tapping. Of the 40 controls, 39 had normal reflex activity during both coughing and tapping. CONCLUSIONS: The question of whether a child has nonneurogenic or neuropathic bladder/sphincter dysfunction is often difficult to answer on the basis of urodynamic studies alone. Dynamic perineal ultrasound recording of the S2-S4 reflex arches provides reliable additional information and is noninvasive to the patient.

Home uroflowmetry biofeedback in behavioral training for dysfunctional voiding in school-age children: a randomized controlled study.

PURPOSE: We studied the added value of home uroflowmetry for biofeedback training compared to added attention and standard therapy in a multicomponent behavioral training program for voiding disorders in school-age children. Little is known about the role of biofeedback by home uroflowmetry for dysfunctional voiding due to NNBSD in children. MATERIALS AND METHODS: A randomized controlled study was conducted at an outpatient pediatric incontinence university clinic from January 2000 to June 2003. A total of 192 children 6 to 16 years old who were suffering from recurrent urinary tract infections with or without urge incontinence were screened for NNBSD. Of 143 eligible patients 44 were randomly allocated to receive 8 weeks of standard therapy (outpatient behavioral therapy), 46 to receive 8 weeks of home video instructions together with standard therapy and 53 to receive 8 weeks of home uroflowmetry biofeedback together with standard therapy. After 8 weeks all treatment groups proceeded with standard therapy for 16 weeks, after which prophylaxis with antibiotics was stopped and patients were followed for another 6 months. Main outcome measurement was total relief of complaints, namely urinary tract infections and, if present, incontinence, at 12 months after randomization. RESULTS: At baseline there was no reason to predict major incomparabilities between the groups. In an intent to treat analysis there was no difference in total relief between standard treatment (44%) and added video instruction (42%, RR 0.96, 95% CI 0.59 to 1.56). Total relief in the added home uroflowmetry group (55%) was higher than with standard therapy (RR 1.24, 95% CI 0.80 to 1.93), although the difference was not statistically significant. A per protocol analysis suggested that the groups with added home uroflowmetry showed better total relief than the pooled groups with standard therapy and those with added video (RR 1.40, 95% CI 0.98 to 2.00). CONCLUSIONS: Home uroflowmetry appears to be a useful adjunctive treatment for the reduction of complaints in children with dysfunctional voiding due to nonneurogenic bladder-sphincter dyssynergia.

Colposuspension in girls: clinical and urodynamic aspects.

OBJECTIVES: To investigate the effect of colposuspension on bladder function and urinary incontinence in girls with structural stress incontinence. PATIENTS AND METHODS: A Burch colposuspension was performed in 26 incontinent girls for congenital bladder neck insufficiency (10), incontinence after urethrotomy (seven), hypospadias (five) and ectopic ureterocele (four). The indication for surgery was failure of conservative therapy (consisting of cognitive and biofeedback bladder training, physical therapy and/or antimuscarinic drugs in 23 children) and a severe anatomical defect of the bladder outlet in three. Colposuspension was combined with reconstruction of the distal urethra in three patients and of the bladder neck in seven. All girls had urodynamic tests before and after colposuspension. RESULTS: After surgery 14 of the 26 patients (54%) were completely dry, four (15%) had improved and eight (31%) still had incontinence requiring pads. In 17 patients (65%) additional conservative therapy was given and three (12%) had additional surgery. After a median follow-up of 62 months, 65% were completely dry, 19% had improved and 15% were incontinent. Of 25 patients who had recurrent urinary tract infections before colposuspension, 14 had none afterwards. Bladder overactivity in 10 patients before colposuspension resolved in five and de novo overactivity was detected in four. CONCLUSIONS: In a selected group of girls with structural urinary incontinence, Burch colposuspension can be used when medical treatment, cognitive and biofeedback bladder training fail. It is reasonably effective for resolving incontinence and safe for bladder function.

The diameter of the rectum on ultrasonography as a diagnostic tool for constipation in children with dysfunctional voiding.

PURPOSE: We proved the accuracy of the transverse diameter of the rectum on ultrasonography as an additional parameter for diagnosing constipation in children with lower urinary tract dysfunction. MATERIALS AND METHODS: The diameter of the rectum on bladder ultrasonography in a constipated group of patients with dysfunctional voiding was compared to this diameter in a control group of patients with a normal defecation pattern. A total of 49 children were included. Group 1 consisted of 23 patients with a positive history of dysfunctional voiding and, according to pediatric gastroenterological practice, constipation. Control group 2 consisted of 26 patients without lower urinary tract dysfunction and a normal defecation pattern. In each group a defecation questionnaire was administered and physical examination of the abdomen was done. In all patients a 7.5 MHz probe was used to measure the transverse diameter of the rectum behind the bladder on ultrasonography. The probe was applied on the abdominal skin approximately 2 cm above the symphysis. Measurement was performed with a filled bladder at an angle of about 15 degrees downward from the transverse plane. RESULTS: In constipated group 1 the mean diameter of the rectum was 4.9 cm (95% CI 4.4 to 5.3). In the control group the mean diameter of the rectum was 2.1 cm (95% CI 1.8 to 2.4). In group 1 the diameter of the rectum was significantly larger than in group 2 (p < 0.001). None of the patients had a sensation to defecate during the investigation. There was no significant difference in age between the 2 groups (p = 0.20) and no significant difference between them in the period between the last time that stool was passed prior to the time of rectal measurement (p = 0.16). CONCLUSIONS: The transverse diameter of the rectum measured by lower abdominal ultrasound provides an additional accurate parameter with which to diagnose constipation in patients with nonneurogenic bladder-sphincter dyssynergia.