Translation, cross-cultural adaptation and validation of the Short Screening Instrument for Psychological Problems in Enuresis for use in Brazil (SSIPPE-Br)

Abstract Objective: Enuresis is associated with attentional and emotional comorbidities in 20 to 30 % of cases. The Short Screening Instrument for Psychological Problems in Enuresis (SSIPPE) is a questionnaire that allows the initial screening of these comorbidities. This study aimed to translate, culturally adapt, and validate the SSIPPE for Brazilian children and adolescents (SSIPPE-Br). Methods: Six steps were performed for translation and cross-cultural adaptation: translation, synthesis of translations, back-translation, preparation of the pre-final version of the translated instrument, test of comprehensibility of the pre-final version of the tool, and elaboration of the instrument cross-culturally adapted for Brazil, named 13-itens version SSIPPE-Br. To validate the SSIPPE-Br, a cross-sectional study was carried out, in which the validated Brazilian version of the Child and Adolescent Behavior Inventory (CABI) was used. Results: Validation was performed on 127 children and adolescents with a mean age of 9.7 ± 2.8 years, 48 % male. The reliability was estimated using Cronbach's alpha, ranging from 0.86 to 0.89, indicating good internal consistency. The factorial analysis had a good agreement adjustment (KMO 0.755, Bartlett's test < 0.001) and explained 70.5 % of the data variability. In the reproducibility analysis, the Kappa coefficient ranged from 0.94 to 1, which can be considered almost perfect. A highly significant (p-value < 0.001) and direct correlation existed between the three SSIPPE-Br domains and all evaluated CABI domains. Conclusion: The SSIPPE-Br is a valid and reliable tool for emotional problems screening and ADHD symptoms in children and adolescents with enuresis whose first language is Brazilian Portuguese.

Dynamic and static ultrasound features predictive of vesicoureteral reflux and renal damage in children and adolescents with neurogenic bladder

ABSTRACT Purpose: This study aimed to analyze the diagnostic accuracy of dynamic and static ultrasound (DSUS) in detecting vesicoureteral reflux (VUR) and renal scarring in a cohort of children with neurogenic bladder (NB). Materials and Methods: A retrospective, longitudinal, observational study was conducted using the Reporting Diagnostic Accuracy Studies guideline. The DSUS (index test) data were compared with voiding cystourethrography (VCUG) and renal scintigraphy 99mTc-dimercaptosuccinic (reference tests). Overall performance for predicting VUR and renal scarring was assessed using renal pelvic diameter (RPD)/distal ureteral diameter and renal parenchymal thinning on DSUS, respectively. Results: A total of 107 patients (66 girls, median age 9.6 years) participated. Seventeen patients (15.9%) presented VUR, eight bilateral. For overall reflux grade, the AUC was 0.624 for RPD and 0.630 for distal ureteral diameter. The diagnostic performance for detecting high-grade VUR was slightly better for DSUS parameters. The AUC was 0.666 for RPD and 0.691 for distal ureteral diameter. The cut-offs of 5 mm for RPD and 6.5 mm for distal ureteral diameter presented the best diagnostic odds ratio (DOR) to identify high-grade VUR. The increase of RPD during detrusor contractions showed an accuracy of 89.2%. The thinness of renal parenchyma presented an accuracy of 88% for renal scarring. Conclusion: DSUS predicts VUR and renal scarring in children with NB with fair to good accuracy, and all measurements exhibited a high negative predictive value (NPV). The increase in RPD during voiding or detrusor contractions proved to be the most accurate parameter for indicating the presence of VUR in this study.

Validation of the Vancouver Symptom Score Questionnaire for bladder and bowel dysfunction for Brazilian children and adolescents

ABSTRACT Objective: This study aimed to translate, and perform a cross-cultural adaptation, and validation of the Vancouver Symptom Score (VSS) for bladder and bowel dysfunction (BBD) for Brazilian children and adolescents Materials and Methods: Six steps were performed for the translation and cross-cultural adaptation: (1) translation, (2) synthesis of translations, (3) back-translation, (4) pre-final version of the translated instrument, (5) pilot test and degree of comprehensibility and (6) elaboration of the Brazilian version of the VSS. For validation, the Brazilian Dysfunctional Voiding Score (DVSS) questionnaire was used. Results: Validation was performed on a sample of 107 children and adolescents with a mean age of 9.2 ± 2.84 years, presenting BBD and 107 without BBD (control group-CG). There was a positive correlation (r = 0.91, 95% CI 0.88 to 0.93, p < 0.0001) between total VSS score and total DVSS score. VSS was higher in patients with BBD (p < 0.0001). The internal consistency estimated by Cronbach's alpha was 0.87 for patients with BBD. The VSS showed excellent diagnostic accuracy in detecting cases, with an area under the ROC curve of 98% (95% CI 0.96 to 0.99, p < 0.001). A cut-off value of >11 points produced a sensitivity of 100% (95% CI 96.4% to 100%) and a specificity of 91.8% (95% CI 85.1% to 95.6%). Conclusion: The translated, cross-culturally adapted, and validated VSS for the Brazilian population is a reliable and valid tool to identify symptoms of BBD in children and adolescents aged five to 16 years, whose first language is Brazilian Portuguese.

Relationship between primary monosymptomatic enuresis and process toilet training: a case-control

ABSTRACT Objective: Primary monosymptomatic nocturnal enuresis (PMNE) is a prevalent condition in childhood, and the pathophysiology is multifactorial. This study investigated the relationship between the toilet training process (TT) and PMNE in children and adolescents. Patients and Methods: A case-control study was carried out from 2015 to 2020. The presence of PMNE was identified according to International Children's Continence Society criteria. A semi-structured questionnaire was applied to assess TT. Results: The study included 103 children and adolescents with PMNE and 269 participants with normal psychomotor development without PMNE (control group [CG]). Readiness signals were more remembered and less frequent in participants with PMNE (p=0.001) when compared to control group. No differences were found between the groups regarding the onset age of the daytime TT (p= 0.10), the nocturnal TT (p=0.08), the acquisition of daytime continence (p=0.06), and the type of equipment used for the TT (p=0.99). The use of Child-Oriented approach in group of children with enuresis was lower than in controls [87.4% (90/103) versus 94% (250/266)], respectively (OR= 0.44, 95% CI 0.21-0.94, p = 0.039). Conclusions: The age of onset of TT, acquisition of daytime continence, and the type of equipment were not associated with higher occurrence of PMNE. On the other hand, the Child-Oriented approach was a protective factor for the occurrence of PMNE.

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

ABSTRACT 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.

Association between Attention Deficit Hyperactivity Disorder and lower urinary tract symptoms in children and adolescents in a community setting

ABSTRACT Introduction: The present study aims to investigate the prevalence of lower tract urinary symptoms (LUTS) and symptoms of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents and their association in a community setting using validated scoring instruments. Materials and Methods: A cross-sectional study was carried out from February 2015 to December 2019, during which the parents or guardians of 431 children and adolescents from 5 to 13 years of age, attending a general pediatric outpatient clinic were interviewed. Results: The prevalence of ADHD symptoms and LUTS were 19.9% and 17.9%, respectively. Of the 82 children and adolescents with ADHD, 28% (23) had LUTS (OR 2.31, 95% CI 1.28 to 3.75, p=0.008). Mean total DVSS score in children in the group of children presenting ADHD symptom was significantly higher than those without ADHD symptom (10.2±4.85 vs. 4.9±2.95, p=0.002). Urgency prevailed among LUTS as the most frequent symptom reported by patients with ADHD symptoms (p=0.004). Analyzing all subscales of the DVSS, the items "When your child wants to pee, can't he wait? "Your child holds the pee by crossing his legs, crouching or dancing?" were higher in those with ADHD symptoms (p=0.01 and 0.02, respectively). Functional constipation was present in 36.4% of children with LUTS and 20.7% without LUTS (OR 4.3 95% CI 1-5.3 p=0.001). Conclusion: Children and adolescents with ADHD symptoms are 2.3 times more likely to have LUTS. The combined type of ADHD was the most prevalent among them.

Prolonged toilet training in children with Down syndrome: a case-control study / Treinamento esfincteriano em crianças com síndrome de Down: estudo caso-controle

Abstract Objectives Children with Down syndrome have delayed psychomotor development, which is a factor that influences the level of difficulty in toilet training. The current study aims to estimate the age toilet training starts and completes in children with DS compared to children with normal psychomotor development and to evaluate the method and type of toilet training most frequently used, as well as its association with lower urinary tract symptoms and functional constipation. Methods A case-control study was carried out from 2010 to 2015. All parents completed a questionnaire designed to assess the toilet training process. Lower urinary tract symptoms were assessed through the application of the Dysfunctional Voiding Symptom Score. The presence of functional constipation was assessed according to the Rome III criteria. Results The study included 93 children with Down syndrome and 204 children with normal psychomotor development (control group [CG]). The mean age of toilet training onset was 22.8 months in those with DS and 17.5 months in the CG (p = 0.001). In children with DS, the mean age when completing toilet training was 56.2 months and 27.1 months in the CG (p = 0.001). Among children with DS, females completed toilet training earlier (p = 0.02). The toilet training method used most often was child-oriented approach in both groups. No association was observed with the presence of lower urinary tract symptoms or functional constipation and the age of beginning and completing toilet training in both groups. Conclusion Children with Down syndrome experienced prolonged toilet training time. Prospective longitudinal studies are essential to gain insight into the toilet training of these children.

Resumo Objetivos Crianças com síndrome de Down apresentam desenvolvimento psicomotor atrasado, fator que influencia o nível de dificuldade do treinamento esfincteriano. O presente estudo tem como objetivo estimar a idade em que o treinamento esfincteriano é iniciado e concluído em crianças com SD em comparação com crianças com desenvolvimento psicomotor normal, avaliar o método e o tipo de treinamento esfincteriano utilizado com maior frequência, bem como sua associação com sintomas do trato urinário inferior e constipação funcional. Métodos Um estudo caso-controle foi realizado de 2010 a 2015. Todos os pais preencheram um questionário destinado a avaliar o processo de treinamento esfincteriano. O sintomas do trato urinário inferior foram avaliados por meio da aplicação do Dysfunctional Voiding Symptom Score. A presença de constipação funcional foi avaliada de acordo com os critérios Roma III. Resultados O estudo incluiu 93 crianças com síndrome de Down e 204 crianças com desenvolvimento psicomotor normal (Grupo de Controle [GC]). A idade média em que as crianças iniciaram o treinamento esfincteriano foi de 22,8 meses naquelas com SD e 17,5 meses no GC (p = 0,001). Em crianças com SD, a idade média ao concluir o treinamento esfincteriano foi de 56,2 meses e 27,1 meses no GC (p = 0,001). Entre as crianças com SD, as do sexo feminino concluíram o treinamento esfincteriano mais cedo (p = 0,02). O método de treinamento esfincteriano mais utilizado foi a abordagem voltada para a criança em ambos os grupos. Não houve associação com a presença de sintomas do trato urinário inferior ou constipação funcional e a idade no início e na conclusão do treinamento esfincteriano em ambos os grupos. Conclusão Crianças com síndrome de Down apresentaram tempo de treinamento esfincteriano prolongado. Estudos longitudinais prospectivos são essenciais para obter uma visão do treinamento esfincteriano dessas crianças.

Prolonged toilet training in children with Down syndrome: a case-control study.

OBJECTIVES: Children with Down syndrome have delayed psychomotor development, which is a factor that influences the level of difficulty in toilet training. The current study aims to estimate the age toilet training starts and completes in children with DS compared to children with normal psychomotor development and to evaluate the method and type of toilet training most frequently used, as well as its association with lower urinary tract symptoms and functional constipation. METHODS: A case-control study was carried out from 2010 to 2015. All parents completed a questionnaire designed to assess the toilet training process. Lower urinary tract symptoms were assessed through the application of the Dysfunctional Voiding Symptom Score. The presence of functional constipation was assessed according to the Rome III criteria. RESULTS: The study included 93 children with Down syndrome and 204 children with normal psychomotor development (control group [CG]). The mean age of toilet training onset was 22.8 months in those with DS and 17.5 months in the CG (p=0.001). In children with DS, the mean age when completing toilet training was 56.2 months and 27.1 months in the CG (p=0.001). Among children with DS, females completed toilet training earlier (p=0.02). The toilet training method used most often was child-oriented approach in both groups. No association was observed with the presence of lower urinary tract symptoms or functional constipation and the age of beginning and completing toilet training in both groups. CONCLUSION: Children with Down syndrome experienced prolonged toilet training time. Prospective longitudinal studies are essential to gain insight into the toilet training of these children.

Association between renal cysts and abdominal aortic aneurysm: A case-control study.

OBJECTIVE: To investigate the positive association between the presence of simple renal cysts (SRCs) and abdominal aortic aneurysm (AAA). METHOD: In a retrospective case-control study including subjects aged > 50 years, we evaluated the incidence of SRCs on computed tomography (CT) scan. We compared 91 consecutive patients with AAA referred from the Division of Vascular Surgery and 396 patients without AAA, randomly selected after being matched by age and gender from 3,186 consecutive patients who underwent abdominal CT. SRC was defined as a round or oval low-attenuation lesion with a thin wall and size > 4 mm on CT without obvious evidence of radiographic enhancement or septations. Patients were considered as having AAA if the size of aorta was greater than 3.0 cm. RESULTS: Patients with AAA and without AAA were similar in terms of age (67.9± 8.41 vs. 68.5±9.13 years) (p=0.889) and gender (71.4 vs. 71.2% of male subjects, respectively) (p=0.999). There was no difference in the prevalence of SRC between case and controls. Among individuals with AAA, 38 (41.8%; [95CI 32.5-52.6]) had renal cysts compared to 148 (37.4%; [95CI 32.7-42.2]) in the control group (p=0.473), with a prevalence ratio (PR) of 1.16 (95CI 0.80-1.68). CONCLUSION: We found no significant differences in the prevalence of SRCs among patients with AAA and controls. Our findings suggest that the presence of SRCs is not a risk factor or a marker for AAA.

Smoking and its association with cryptorchidism in Down syndrome.

INTRODUCTION: Cryptorchidism is a common and prevalent condition in patients with Down syndrome. Environmental factors, such as smoking, can be associated with malformations during fetal development. The study of the prevalence of cryptorchidism and its association with parental tobacco use in Down syndrome can contribute to alert health care professionals, patients and family members regarding the prevention of the harms caused by cryptorchidism and its possible predisposing factors. OBJECTIVE: To evaluate the prevalence of cryptorchidism in Down syndrome and its association with maternal and paternal smoking. METHOD: Forty (40) patients of a public clinic specialized in Down syndrome were evaluated, using a semi-structured questionnaire for evaluation of antecedents and sociodemographic characteristics, as well as physical and complementary examinations. RESULTS: Cryptorchidism was observed in 27.5% of the patients (95CI 15.98-42.96). Of these, 55% (5/9) were the children of mothers who smoked during pregnancy, and 19.35% (6/31) were the children of mothers who did not smoke during pregnancy (OR = 5.26 [95CI 1.06-25.41]; p=0.032). Similarly, paternal smoking was also observed in greater frequency among the parents of cryptorchid patients compared with subjects with descended testis, 63.36% (7/11) and 31.03% (9/29), respectively (OR = 3.89 [95CI 0.91-16.73]; p=0.060). CONCLUSION: The prevalence of cryptorchidism is high in patients with Down syndrome. We can show a strong association between smoking parents and the occurrence of cryptorchidism, especially when it comes to maternal smoking.

Association between renal cysts and abdominal aortic aneurysm: A case-control study / Associação entre cistos renais e aneurismas da aorta abdominal: Um estudo de caso-controle

Summary Objective: To investigate the positive association between the presence of simple renal cysts (SRCs) and abdominal aortic aneurysm (AAA). Method: In a retrospective case-control study including subjects aged > 50 years, we evaluated the incidence of SRCs on computed tomography (CT) scan. We compared 91 consecutive patients with AAA referred from the Division of Vascular Surgery and 396 patients without AAA, randomly selected after being matched by age and gender from 3,186 consecutive patients who underwent abdominal CT. SRC was defined as a round or oval low-attenuation lesion with a thin wall and size > 4 mm on CT without obvious evidence of radiographic enhancement or septations. Patients were considered as having AAA if the size of aorta was greater than 3.0 cm. Results: Patients with AAA and without AAA were similar in terms of age (67.9± 8.41 vs. 68.5±9.13 years) (p=0.889) and gender (71.4 vs. 71.2% of male subjects, respectively) (p=0.999). There was no difference in the prevalence of SRC between case and controls. Among individuals with AAA, 38 (41.8%; [95CI 32.5-52.6]) had renal cysts compared to 148 (37.4%; [95CI 32.7-42.2]) in the control group (p=0.473), with a prevalence ratio (PR) of 1.16 (95CI 0.80-1.68). Conclusion: We found no significant differences in the prevalence of SRCs among patients with AAA and controls. Our findings suggest that the presence of SRCs is not a risk factor or a marker for AAA.

Resumo Objetivo: Avaliar uma possível associação entre presença de cistos renais simples (CRS) e aneurisma aórtico abdominal (AAA). Método: Em um estudo de caso versus controle com sujeitos com idade > 50 anos, avaliamos a prevalência de CRS detectados por tomografia computadorizada (TC). Comparamos os achados de 91 pacientes consecutivos com AAA oriundos da Divisão de Cirurgia Vascular com 396 pacientes sem AAA, randomicamente selecionados e ajustados por idade e gênero dentre 3.186 pacientes consecutivos que se submeteram a TC abdominal. Cisto simples foi definido como lesão hipodensa oval ou arredondada com paredes finas, maiores do que 4 mm em TC sem realce contrastual ou septação. Pacientes foram considerados com AAA quando o diâmetro da aorta era maior que 3,0 cm. Resultados: Pacientes com AAA e sem AAA eram semelhantes quanto a idade (67,9±8,41 vs. 68,5±9,13 anos) (p=0,889) e gênero (71,4 vs. 71,2% dos indivíduos masculinos, respectivamente) (p=0,999). Não havia diferença de prevalência de CRS entre casos e controles. Dentre indivíduos com AAA, 38 (41,8%; [IC95% 32,5-52,6]) tinham cistos renais, comparados com 148 (37,4%; [IC95% 32,7-42,2]) no grupo controle (p=0,473), com uma razão de prevalência (RP) de 1,16 (IC95% 0,80-1,68). Conclusão: Não observamos diferenças significativas na prevalência de CRS entre pacientes com AAA e controles. Nossos resultados sugerem que presença de CRS não é fator de risco ou preditor para AAA.

Smoking and its association with cryptorchidism in Down syndrome / Associação entre tabagismo e criptorquidia na síndrome de Down

Summary Introduction: Cryptorchidism is a common and prevalent condition in patients with Down syndrome. Environmental factors, such as smoking, can be associated with malformations during fetal development. The study of the prevalence of cryptorchidism and its association with parental tobacco use in Down syndrome can contribute to alert health care professionals, patients and family members regarding the prevention of the harms caused by cryptorchidism and its possible predisposing factors. Objective: To evaluate the prevalence of cryptorchidism in Down syndrome and its association with maternal and paternal smoking. Method: Forty (40) patients of a public clinic specialized in Down syndrome were evaluated, using a semi-structured questionnaire for evaluation of antecedents and sociodemographic characteristics, as well as physical and complementary examinations. Results: Cryptorchidism was observed in 27.5% of the patients (95CI 15.98-42.96). Of these, 55% (5/9) were the children of mothers who smoked during pregnancy, and 19.35% (6/31) were the children of mothers who did not smoke during pregnancy (OR = 5.26 [95CI 1.06-25.41]; p=0.032). Similarly, paternal smoking was also observed in greater frequency among the parents of cryptorchid patients compared with subjects with descended testis, 63.36% (7/11) and 31.03% (9/29), respectively (OR = 3.89 [95CI 0.91-16.73]; p=0.060). Conclusion: The prevalence of cryptorchidism is high in patients with Down syndrome. We can show a strong association between smoking parents and the occurrence of cryptorchidism, especially when it comes to maternal smoking.

Resumo Introdução: A criptorquidia é uma condição comum e prevalente em pacientes com síndrome de Down. Fatores ambientais, como o tabagismo, estão associados a malformações fetais. A avaliação da prevalência do criptorquidismo e a associação com tabagismo dos pais na síndrome de Down podem contribuir para alertar os profissionais de saúde e familiares sobre a prevenção dos danos causados pelo criptorquidismo e os possíveis fatores predisponentes. Objetivo: Avaliar a prevalência de criptorquidismo na síndrome de Down e a associação com tabagismo materno e paterno. Método: Quarenta (40) pacientes acompanhados em um centro de referência para atendimento da síndrome de Down foram avaliados por meio de questionário semiestruturado para avaliação de antecedentes parentais e características sociodemográficas, bem como de exames físico e laboratoriais complementares. Resultados: Criptorquidia foi observada em 27,5% dos pacientes (IC95% 15,98-42,96). Nesses pacientes, o criptorquidismo foi encontrado em 55% (5/9) das crianças cujas mães fumavam e em 19,35% (6/31) daquelas cujas mães não fumavam (OR = 5,26 [IC95% 1,06-25,41]; p=0,032). Do mesmo modo, o tabagismo paterno foi observado com maior frequência entre crianças com criptorquidia, 63,36% (7/11) e 31,03% (9/29), respectivamente (OR = 3,89 [IC95% 0,91-16,73]; p=0,060). Conclusão: A prevalência de criptorquidismo é alta em pacientes com síndrome de Down. Podemos mostrar uma forte associação entre hábito tabágico dos pais e ocorrência de criptorquidismo, especialmente no caso de tabagismo materno.

Constipation and Lower Urinary Tract Dysfunction in Children and Adolescents: A Population-Based Study.

OBJECTIVE: To evaluate the correlation between constipation and lower urinary tract dysfunction (LUTD) and nocturnal enuresis in a population-based study. MATERIAL AND METHODS: This is a cross-sectional study. The criteria for inclusion were children and adolescents of between 5 and 17 years and who agreed to sign the informed consent form. The study excluded students with neurological problems or who had documented abnormalities of the urinary tract. To identify the presence and severity of LUTD, we used the Voiding Dysfunction Symptom Score (DVSS). To evaluate the presence of constipation, Rome III questionnaire was used. RESULTS: We interviewed 829 children and adolescents, of which 416 (50.18%) were male. The mean (SD) age was 9.1 (±2.9) years. The overall prevalence of LUTD was 9.1%, predominantly in girls (15 versus 3.1%, p < 0.001). Constipation was found in 9.4% of boys and 12.4% of girls (p = 0.169). Constipated children were 6.8 times more likely to have LUTD than those not constipated (p < 0.001, coefficient and correlation of 0.411). Constipation was found in 8.2% of children without LUTD and in 35.2% of children with LUTD. We performed multivariate analysis to identify urinary symptoms that are independent predictors of the presence of constipation. The presence of infrequent urination (p = 0.004) and holding maneuvers (p < 0.001) were independent predictors. It was noted also noted that constipated children, according to the Rome III criteria, possess a worse DVSS (p < 0.001). Regarding the presence of nocturnal enuresis, 12.6% of children and adolescents had constipation in association with this symptom. However, this relationship was not statistically significant (p = 0.483). CONCLUSION: Constipated children were 6.8 times more likely to have LUTD than those not constipated. Among the urinary symptoms, infrequent voiding and holding maneuvers are independent factors of urinary expressions in constipated children. Children with more severe constipation have more prominent urinary symptoms. The presence of enuresis was not associated with constipation.

Association between exclusive maternal breastfeeding during the first 4 months of life and primary enuresis.

INTRODUCTION: Although the relationship between enuresis and breastfeeding is still poorly documented in the literature, a possible association is speculated as both are strongly associated with children's development. Therefore, the main objective of this study was to evaluate whether there is an association between primary enuresis and the duration of exclusive breastfeeding. MATERIAL AND METHODS: This is an observational, case-control study, involving 200 children and adolescents from 6 to 14 years old, who were divided into two groups: the enuresis group (EG), composed of 100 children with primary enuresis; and the control group (CG) of 100 matched children without enuresis. The matching criteria were sex, age, and socioeconomic level. Adults responsible for each infant answered a structured questionnaire to identify biological and behavioral factor, as well as the duration of maternal breastfeeding. Children whose parents could not comprehend the questionnaire or children with neurological or psychiatric disorders or secondary enuresis were not included in the study. RESULTS AND DISCUSSION: Evaluating the duration of exclusive breastfeeding, 72% of the subjects of the EG and 42% of the CG had been breastfed for less than 4 months (p < 0.001) (Figure). In bivariate analysis, there was a strong association between symptoms of enuresis with a positive family history of enuresis and duration of exclusive breastfeeding (p < 0.001), and also association with full breastfeeding duration (p = 0.044), number of children (p = 0.045), and parents' education (p = 0.045). After logistic regression, primary enuresis continued to be associated with duration of exclusive breastfeeding and family history of enuresis. The proportion of children that had been exclusively breastfed for more than 4 months was significantly higher in the CG 58% (58/100) than in the EG 28% (28/100) (p < 0.001, OR 4.35, 95% CI 1.99-9.50). CONCLUSIONS: This study confirmed the association between primary enuresis and various factors that have already been studied, with the addition of a new factor, duration of exclusive breastfeeding for less than 4 months, which is strongly associated with primary enuresis.

Transcutaneous parasacral electrical stimulation vs oxybutynin for the treatment of overactive bladder in children: a randomized clinical trial.

PURPOSE: We determined the effectiveness of 2 methods to treat overactive bladder in children using intragroup and intergroup comparisons in a randomized clinical trial. MATERIALS AND METHODS: Nine boys and 19 girls with a mean ± SD age of 6.4 ± 2.18 years were randomly divided into group 1-parasacral transcutaneous electrical stimulation with placebo drug and group 2-oxybutynin with sham scapular electrical therapy. Success was assessed by 1) the rate of complete symptom resolution, 2) a visual analog scale of 0 to 10, 3) the dysfunctional voiding score system, 4) voiding diary records, 5) Rome III criteria and 6) side effect frequency in each group. RESULTS: A total of 13 and 15 patients were randomized to groups 1 and 2, respectively. Symptoms completely resolved in 6 patients in group 1 (46%) and 3 in group 2 (20%) (p = 0.204). A statistically significant improvement was found in the 2 groups in the dysfunctional voiding score system and voiding diary records. However, no statistically significant difference was found between the groups in the visual analog scale score, voiding frequency, and maximum and mean voided volume (p = 0.295, 0.098, 0.538 and 0.650, respectively). Constipation improved in 100% of group 1 patients but in only 55% in group 2 (p = 0.031 vs 0.073). Group 1 showed no side effects while dry mouth, hyperthermia and hyperemia developed in 58%, 25% and 50% of group 2 patients (p = 0.002, 0.096 and 0.005, respectively). Treatment was discontinued by 13.3% of patients in group 2. CONCLUSIONS: Parasacral transcutaneous electrical stimulation was as effective as oxybutynin to treat overactive bladder in children. However, transcutaneous parasacral electrical stimulation was more effective against constipation and showed no detectable side effects. Oxybutynin was more effective for decreasing voiding frequency.

Prevalence of lower urinary tract symptoms in individuals with Down syndrome.

OBJECTIVES: Down syndrome (DS), which is caused by the trisomy of chromosome 21, is the most frequent of all genetic syndromes. The current study aims to estimate the prevalence of lower urinary tract symptoms (LUTS) in individuals with DS buy using the Dysfunctional Voiding Symptom Score (DVSS) and correlate with functional constipation, age, and gender, as well as determine the most sensitive and specific factors associated with LUTS. METHODS: LUTS was assessed in individuals with DS using a cross-sectional study through the application of a validated and adapted version of the DVSS for the Brazilian population. The presence of functional constipation was evaluated according to the Rome III criteria. RESULTS: Of the 114 individuals assessed, 84 were included in the study (median age 16 ± 5.0 years, 66.7% female). The prevalence of LUTS was 27.3%. The symptoms were more frequent in males (OR 3.0, 95% CI 1.1-8.3, p = 0.03) and in individuals younger than 10 years of age (OR 5.2, 95% CI 1.8-14, p = 0.001). Functional constipation was observed in 50% of subjects. It was detected in 95.65% of the individuals with LUTS and 32.78% without LUTS (OR 45.1, 95% CI 5.66-301, p = 0.001). The symptom listed in question 8 ("push to pee") was the most specific indicator. When present, this symptom indicated a higher probability of LUTS (LR+ = 6.3), while the symptom listed in question 4 ("push for bowel movements to come out") showed high sensitivity and, when absent, indicated a lower probability of LUTS (LR- = 0.1). CONCLUSIONS: LUTS was more prevalent in young males with DS and appeared to improve with age. Functional constipation was strongly associated with LUTS. These findings will contribute to raising the awareness of professionals involved in the follow-up of individuals with DS regarding the clinical manifestations and the need for a standardized investigation of LUTS.

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.

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.

Assessment of pain and hemodynamic response in older children undergoing circumcision: comparison of eutectic lidocaine/prilocaine cream and dorsal penile nerve block.

OBJECTIVE: To evaluate whether dorsal penile nerve block (DPNB) or local topical anesthesia (LT) provided better postoperative analgesia and less hemodynamic stimulation during and after circumcision surgery with Plastibell in older children. METHODS: Forty-one subjects (age: 2-13 years) undergoing circumcision with Plastibell were randomly divided into LT and DPNB groups. Inhalation induction was performed with an 8% end-tidal sevoflurane concentration. In the LT group, a eutectic ointment of 5% lidocaine and 5% prilocaine was applied to the foreskin 1 h before surgery. At 10 min after anesthesia induction, the end-tidal sevoflurane concentration was decreased to 2%. In the other group, a DPNB was performed with 0.5% bupivacaine (1 mg/kg). Heart rate (HR), respiratory rate, mean arterial pressure (MAP), and involuntary movements were evaluated at anesthesia induction (T0), 1 min after DPNB (T1), 1 min after incision (T2), and 1 min after surgery (T3). Pain was evaluated at 1 and 24 h after surgery, and complications were evaluated at 24 h after surgery. RESULTS: The groups were homogeneous with respect to age, weight, glans diameter, penile length, Kayaba classification, and surgical duration. The LT group showed increased HR (p = 0.073) and MAP (p = 0.046) at T2 as compared to T0. No hemodynamic changes were observed in the HPDB group. The LT group showed a higher pain score at 1 h after surgery than the DPNB group, whereas the DPNB group had a higher incidence of hematoma (p = 0.02) at 24 h after surgery. CONCLUSION: Anesthesia with 5% lidocaine and 5% prilocaine cream during circumcision of older children with Plastibell under general anesthesia with sevoflurane does not provide satisfactory perioperative hemodynamic stability or postoperative analgesia.