Parasacral transcutaneous electrical neural stimulation versus urotherapy in primary monosymptomatic enuresis: A prospective randomized clinical trial.

OBJECTIVE: To evaluate the clinical response of parasacral transcutaneous electrical neural stimulation (parasacral TENS) associated with urotherapy in children with primary monosymptomatic nocturnal enuresis (PMNE) compared to urotherapy alone. MATERIAL AND METHODS: This prospective controlled clinical trial enrolled 72 children over 5 years of age with PMNE. Children were randomly divided into two groups, control group (CG), treated with urotherapy and scapular stimulation, and experimental group (EG), treated with urotherapy and parasacral TENS. In both groups, 20 sessions were performed, 3 times weekly, for 20 min each, with 10 Hz frequency, 700 µS pulse width and intesity determinated by the patient threshold. The percentages of dry nights were analyzed for 14 days before treatment (T0), after the 20th session (T1), 15 (T2), 30 (T3), 60 (T4), and 90 (T5) days after the end of the sessions. Patients of both groups were followed with intervals of 2 weeks in the first month and monthly for three consecutive months. RESULTS: Twenty-eight enuretic children, 14 girls (50%) with a mean age of 9.09 ± 2.23 years completed the study. There was no difference in mean age between groups. Mean percentage of dry nights in EG at T0 was 36%, at T1 49%, at T2 54%, at T3 54%, at T4 54%, and 57% at T5; while in CG, these percentages were 28%, 39%, 37%, 35%, 36%, and 36%, respectively. CONCLUSIONS: Parasacral TENS associated with urotherapy improves the percentage of dry nights in children with PMNE, although no patient had complete resolution of symptoms in this study.

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.

Magnetic resonance image connectivity analysis provides evidence of central nervous system mode of action for parasacral transcutaneous electro neural stimulation - A pilot study.

INTRODUCTION: Parasacral transcutaneous electriconeural stimulation (pTENS) is a common treatment modality for patients with overactive bladder (OAB). Its mechanism of effectiveness has yet to be elucidated. Recent studies with fMRI in adults with implanted sacral nerve stimulators impute its effectiveness on changes in the brain involving the anterior cingulate cortex (ACC) and prefrontal cortex (PFC). AIM: The study set out to evaluate brain connectivity utilizing functional MRI to the outline the mechanism of action of pTENS in the brain. METHODS: Ten adult volunteers without urinary tract symptoms underwent fMRI. Electrodes were placed on the skin at sacral level (S2) (Experimental Stimulation - pTENS) and on the right scapular region (Sham Stimulation - sTENS). Stimulation was done twice on each site for 6 min at a frequency of 10 Hz and pulse width of 260 µs and intensity determined by the motor threshold. A 6 min resting state fMRI was also done twice as control. Functional connectivity data was acquired during each state (resting, pTENS and sTENS). Standard functional connectivity preprocessing was performed. Seed connectivity was examined to investigate changes in ACC functional connectivity between the stimulations and resting-state conditions. Significance was assessed at p < 0.05 corrected for multiple comparisons. RESULTS: For all conditions (pTENS, sTENS, and rest), standard patterns of ACC connectivity were detectable with strong connectivity between the ACC and subcortical regions and between the ACC and the frontal lobe. Functional connectivity between ACC seed and the dorsal lateral prefrontal cortex (DLPFC) was significantly increased during pTENS compared to rest. sTENS did not increase connectivity between the ACC seed and DLPFC when compared to rest. DISCUSSION: Preliminary results indicate that ACC is a major site of activation during pTENS. Increased connectivity between ACC and DLPFC may be a possible mechanism of pTENS effectiveness, which appears to be specific to pTENS compared to sTENS. This study is limited to the small size at this time which prevents further investigation at other sites in the brain. CONCLUSIONS: The study confirms our original aim which was to define if parasacral TENS actually has a central effect.

Brazilian consensus on vesicoureteral reflux-recommendations for clinical practice

ABSTRACT Introduction Vesicoureteral Reflux (VUR) is characterized by a retrograde flow of urine from the bladder into the ureters and kidneys. It is one of the most common urinary tract anomalies and the major cause of urinary tract infection (UTI) in the first years of life. If not properly diagnosed and treated can lead to recurrent UTI, renal scar and, in severe cases, to end stage renal disease. Despite recent advances in scientific and technological knowledge, evaluation and treatment of VUR is still controversial and there is still considerable heterogeneity in evaluation methods and therapeutic approaches. The aim of the present consensus is to give a practical orientation on how to evaluate and treat VUR. Methods The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Vesicoureteral Reflux evaluation and treatment and elaborated a draft of the document. On November 2017 the panel met to review, discuss and write a consensus document. Results and Discussion Vesicoureteral Reflux is a common and challenging problem in children. Children presenting with Vesicoureteral Reflux require careful evaluation and treatment to avoid future urinary tract infections and kidney scars. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.

Brazilian consensus in enuresis-recomendations for clinical practice

ABSTRACT Introduction Enuresis, defined as an intermittent urinary incontinence that occurs during sleep, is a frequent condition, occurring in about 10% of children at 7 years of age. However, it is frequently neglected by the family and by the primary care provider, leaving many of those children without treatment. Despite of many studies in Enuresis and recent advances in scientific and technological knowledge there is still considerable heterogeneity in evaluation methods and therapeutic approaches. Materials and Methods The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Enuresis and elaborated a draft of the document. On September 2018 the panel met to review, discuss and write a consensus document. Results and Discussion Enuresis is a multifactorial disease that can lead to a diversity of problems for the child and family. Children presenting with Enuresis require careful evaluation and treatment to avoid future psychological and behavioral problems. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.

Echocardiographic evaluation of left ventricular mass index in children with hypospadias after hormonal stimulation with topical testosterone: A randomized controlled trial.

INTRODUCTION: Testosterone is often used in the preoperative period of hypospadias surgery. Previous studies have demonstrated the presence of androgen receptors in cardiac myocytes that can modulate the phenotype. The use of supraphysiological doses of androgens can lead to toxicity on the heart muscle and, in some cases, to left ventricular hypertrophy. This randomized double blind controlled clinical trial aims to evaluate the effect of topical testosterone on left ventricular mass index in boys with hypospadias. MATERIALS AND METHODS: Boys with hypospadias aged 6 months to 9 years were included. Children were divided into two groups: G1 - boys who received testosterone propionate 1% ointment twice a day for 30 days, and G2 - boys receiving placebo ointment in the same regimen. All children were submitted to bi-dimensional echocardiographic evaluation to compare the left ventricular mass index, blood pressure, and body mass index before and after treatment (30 and 90 days). Levels of serum testosterone, LH, and FSH were measured. RESULTS: Thirty-five children were analyzed: 17 in G1 and 18 in G2. No differences were found in left ventricular mass index (left ventricular mass indexed by body surface area) prior to treatment. Left ventricular mass index was 59.21 ± 11.91 g/m2 in G1 and 55.12 ± 8.29 g/m2 in G2 (p = 0.244) after 30 days of treatment, and 61.13 ± 11.69 g/m2 in G1 and 62.84 ± 35.99 g/m2 in G2 (p = 0.852) after 90 days. Serum testosterone levels were 12 (7-80) ng/dL in G1 and 5 (5-7) ng/dL in G2 (p = 0.018) after 30 days of treatment, and 10 (5-11) ng/dL in G1 and 5 (4-5) ng/dL in G2 (p = 0.155), after 90 days (Figure). There was a small increase in systolic blood pressure (SBP) after 30 days (83.82 ± 7.18 mmHg) in the group who receive testosterone (G1) compared with controls (77.5 ± 6.69 mmHg) (p = 0.010). After 90 days, SBP levels returned to basal levels in G1 (82.35 ± 5.62 mmHg) and in G2 (81.38 ± 4.79 mmHg) (p = 0.588). CONCLUSION: Topical testosterone can be considered safe in the preoperative period of children with hypospadias with no risk of left ventricular hypertrophy. An increase in systolic blood pressure occurs while using testosterone but it is transitory, returning to normal levels after 90 days.

Are lower urinary tract symptoms in children associated with urinary symptoms in their mothers?

BACKGROUND: The association between parents who suffered daytime incontinence as children and children who are incontinence has been reported. However, the association of lower urinary tract (LUT) dysfunction in children and urinary symptoms in mothers has not been studied. OBJECTIVE: To test the hypothesis that the children of mothers with lower urinary tract symptoms (LUTS) are more likely to have urinary symptoms. STUDY DESIGN: A cross-sectional multicenter study was conducted in two cities in Brazil. Children/adolescents of 5-17 years of age and their mothers were interviewed. Children with neurological problems, previously detected urinary tract abnormalities or who refused to sign the informed consent or assent form were excluded. The DVSS questionnaire was used to evaluate the presence of LUTS in the children and the ICIQ-OAB questionnaire was used to evaluate their mothers. Constipation in the children was investigated using the ROME III criteria. RESULTS: A total of 827 mother-child pairs were included, with 414 of the children (50.06%) being male. Mean age was 9.1 ± 2.9 years for the children and 35.9 ± 6.5 years for the mothers. Urinary symptoms (occurring at least once or twice a week) were present in 315 children (38.1%), incontinence in 114 (13.8%) and urinary urgency in 141 (17%). Of the mothers, 378 (45.7%) had at least one LUTS, with 103 (12.5%) having incontinence and 153 (18.5%) urgency. According to the DVSS, the overall prevalence of LUT dysfunction was 9.1%. The children's DVSS scores were significantly associated with the mothers' ICIQ-OAB scores (p < 0.0010). Mothers with urinary symptoms were 2.5 times more likely to have a child with LUT dysfunction (95%CI: 1.52-4.17; p < 0.001), while mothers with overactive bladder were 2.8 times more likely to have a child with an overactive bladder (95%CI: 1.63-4.86; p < 0.001). In the multivariate analysis, these same characteristics were confirmed as independent predictive factors of the presence of LUT dysfunction in the child. Children of mothers with incontinence and urinary urgency were also more likely to have incontinence and urgency. CONCLUSION: Mothers with typical symptoms of overactive bladder are more likely to have a child with LUT dysfunction. This correlation is also positive for the isolated symptoms of urinary urgency and incontinence. Independent predictive factors of the presence of LUT dysfunction in children were: being female, enuresis, constipation, and having a mother with LUTS.

Biometry of the hypospadic penis after hormone therapy (testosterone and estrogen): A randomized, double-blind controlled trial.

INTRODUCTION: The use of preoperative hormonal stimulation before hypospadias surgery aims to increase penile size and achieve better surgical results; however, the rules are not clear in the literature. We evaluated the effects of topical testosterone and estrogen in the hypospadic penis regarding biometric measures, side effects, and serum hormonal levels. To our knowledge, this is the first study using estradiol prior to hypospadias surgery. PATIENTS AND METHODS: Sixty-nine children with hypospadias were randomly divided into three study groups: a control group (CG) of 17 children given placebo cream; a testosterone group (TG) of 28 children who used 1% testosterone propionate; and an estradiol group (EG) of 24 children using 0.01% estradiol. All subjects applied the topical ointment on the entire penis, twice daily for 30 days before surgical correction. Biometric evaluation of the penis included penile length and diameter, glans diameter, distance from the urethral meatus to the tip, and the width of the urethral plate. These measurements as well as serum hormone level, and side effects were evaluated prior to hormone use, and 30 and 90 days after. RESULTS: After 30 days an increase in penile diameter and length and diameter of the glans were observed in TG (p < 0.05). The width of the urethral plate and distance from meatus to the tip increased in TG, although not significantly. The most frequent side effects were appearance of pubic hair and darkening of the genital skin, mainly in TG, but these were transient and disappeared after 90 days of treatment. No significant variations were seen in serum hormonal levels (Table). CONCLUSION: As in previous studies, an increase in penile length and diameter, and glans diameter was observed with the use of testosterone. Proximal urethral plate width and distance from the meatus to the tip of the penis had a tendency to increase also in TG. Estradiol did not change biometric measure of the penis. Few side effects occurred after both hormones, and any that did improved after 90 days follow-up and did not change hormone serum levels. CONCLUSION: Preoperative use of topical testosterone increases penile size, diameter of the penis and glans. The use of estradiol does not change penile biometry. Side effects occur mainly with the use of testosterone and are transient. No significant and persistent hormonal changes were observed.

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.

Hormone therapy in hypospadias surgery: a systematic review.

Surgical correction of hypospadias is proposed to improve the aesthetic and functional quality of the penis. Hormone therapy preceding surgical correction is indicated to obtain better surgical conditions. However, there is divergence in the literature regarding the hormone therapy of choice, time of its use before surgery, appropriate dose, and route of application. To try to elucidate this matter, an electronic survey of the databases PubMed and Cochrane Central Library was conducted, limited to articles in English published since 1980. Search strategy identified 14 clinical trials that matched the inclusion criteria. Analysis was made in terms of study design, classification of hypospadias, association with chordee and cryptorchidism, type of hormone, route of application, dose and duration of treatment, penile length before and after hormone therapy, glans circumference before and after hormone therapy, adverse effects, and surgical complications. From the trials evaluated it was not possible to determine the ideal neoadjuvant treatment. A preference for use of testosterone was observed. Intramuscular administration seems to have fewer adverse effects than topical treatment. Side effects were seldom described, and treated patients were not followed on a long-term basis. The scarcity of randomized and controlled clinical trials regarding the topic impairs the establishment of a protocol. In conclusion, although preoperative hormone therapy is currently used before hypospadias surgery, its real benefit in terms of improvement of the penis and surgical results has not been defined.

A better understanding of urogenital tuberculosis pathophysiology based on radiological findings.

PURPOSE: To assess the radiological findings of urogenital tuberculosis (UGT) in patients at different disease stages, for a better understanding of its pathophysiology. PATIENTS AND METHODS: We retrospectively reviewed the radiological exams of 20 men (median age 41 years; range: 28-65) with urogenital tuberculosis diagnosis. The patients were classified in the following groups: (1) bilateral renal tuberculosis with predominantly parenchymatous involvement; (2) unilateral renal tuberculosis; (3) unilateral renal tuberculosis with bladder tuberculosis and (4) bilateral renal tuberculosis with bladder tuberculosis. RESULTS: One AIDS patient had multiple bilateral renal tuberculosis abscesses (group 1). Six patients had unilateral renal tuberculosis with hydronephrosis due to stenosis and thickening of the collecting system, without involvement of the bladder or contralateral kidney (group 2). Six patients had bladder tuberculosis with diffuse thickening of the bladder wall, with one very low or no function kidney while the other kidney was normal (group 3). Seven patients had bladder tuberculosis associated to a very low or no function kidney with the other kidney with high-grade vesicoureteral reflux-associated ureterohydronephrosis (group 4). In two patients, sequential exams showed evolution of tuberculosis from a unilateral renal and ureteral lesion to contracted bladder and dilatation of the contralateral kidney secondary to high-grade reflux. CONCLUSIONS: UGT may have variable radiological presentations. However, in two of our cases we have seen that tuberculosis involvement of the urinary tract may be sequential. Further evidences are necessary to confirm this hypothesis.

Spinal dysraphism: a neurosurgical review for the urologist.

Spinal neural tube defects are congenital malformations of the spine and spinal cord (eg, myelomeningocele) and are frequently seen in pediatric urology practice. These neurologic problems have many consequences in a child's life and affect different parts of the body, such as the brain, spinal cord, limbs, bladder, and bowels. Because of the complexity and neurologic aspects of spinal dysraphism, many related terms and aspects of the disease are unfamiliar to the urologist. This review addresses some of the most commonly used neurosurgical terms and concepts related to spinal dysraphism.

Surgical treatment of varicocele in children with open and laparoscopic Palomo technique: a systematic review of the literature.

PURPOSE: We systematically reviewed the results of varicocelectomy by Palomo procedure in children and adolescents. MATERIALS AND METHODS: We performed a search of the English literature through the MEDLINE((R)) database and the Cochrane Central Search library. The key words used were "varicocele and children" and "varicocele and adolescents." Of 264 articles published with data on varicocele surgery in children and adolescents 27 concerned the classic Palomo procedure and 20 dealt with the modified Palomo technique, in which the testicular artery was spared. Laparoscopic Palomo varicocelectomy was compared with the open Palomo technique. RESULTS: Totals of 1,344 and 496 patients were treated with the laparoscopic and open Palomo techniques, respectively. The rates of hydrocele in the open and laparoscopic groups were 9.7% and 6.9%, respectively (p = 0.81). The rate of recurrence was 2.9% in the open group and 4.4% in the laparoscopic group (p = 0.146). A modified Palomo procedure was used in 715 operations and the classic technique in 1,454. Hydrocele was diagnosed in 3.2% of patients in the modified group and 7.7% in the classic group (p <0.001). Varicocele recurred in 4.2% of patients undergoing the modified procedure and 3.4% of those undergoing the classic procedure (p = 0.506). Mean +/- SD testicular catch-up growth was 54.7% +/- 38.9% in the modified group and 66.7% +/- 19.9% in the classic group (p = 0.584). Three studies documented improvement of the quality of semen examination postoperatively compared to a control group of uncorrected cases. No study evaluated the rate of fertility after varicocelectomy. CONCLUSIONS: The rate of hydrocele is high with the classic Palomo technique and less with the modified technique. The rate of varicocele recurrence is around 3% to 4% with both procedures. The percentage of testicular catch-up growth is variable.

Splenogonadal fusion diagnosed by Doppler ultrasonography.

Splenogonadal fusion usually presents as a left scrotal mass but rarely is the diagnosis suspected preoperatively. Herein, we present the first report of a left splenogonadal fusion which was suspected preoperatively by doppler ultrasonography in a 2 year old boy.