Functional vesico-sphincteric disorders in children: clinical, urodynamic and evolutionary profile / Les troubles vésico-sphinctériens fonctionnels de l'enfant : profil clinique, urodynamique et évolutif

Background: Childhood vesico-sphincteric disorders are the cause of functional and psychological disability. They are also responsible for serious uronephrologic complications akin to neuro-bladder complications. In this study, we looked for the clinical manifestations linked to these disorders as well as the paraclinical and urodynamic anomalies and their therapeutic management. Methods: We carried out a retrospective and descriptive study of patients with vesico-sphincteric disorders, followed in the pediatrics department of Charles Nicolle hospital in Tunis. Results: In total 26 patients were included in our study. The median age at the first consultation in a pediatric nephrology department was 9 years (IQR 25 = 6 years; IQR 75 = 11 years). There was a predominance of girls: 19 boys and 43 girls. The filling phase and the voiding phase were dominated by the combination of three or more symptoms. Bladder tenderness was reduced in 12% of cases. Nineteen percent of patients reported post micturition dribble in the post-voiding phase. The flow rate curve was polyphasic in 36% of cases and flat in 11% of cases. The median of the post void residual was 62, 2 mL (IQR 25 = 25 mL; IQR 75 = 102 mL). Cystometry showed reduced bladder sensation in 14% of cases, detrusor overactivity in 65% of cases, bladder hypocontractility in 8% of cases, hypocompliant bladder in 42% of cases and small capacity in 88% of cases. Sphincter dysynergia was noted in 34% of patients. Anticholinergics were the most used in the treatment of disorders (53%). Renal failure was noted in 45% of the patients of which 11% had end-renal stage failure. During follow-up 16% of our patients required kidney replacement therapy. Conclusion: Given the seriousness of vesico-sphincteric disorders in children and the late discovery in the majority of cases at the complication stage, targeted primary prevention must be carried out based on continuous training of primary care physicians to minimize the appearance of complications involving the functional and vital prognosis of these children.

Introduction: Les troubles vésico-sphinctériens de l'enfant sont à l'origine d'un handicap fonctionnel et psychologique. Ils sont également responsables de complications uronéphrologiques graves s'apparentant aux complications des neuro-vessies. Le but de cette étude était d'étudier les manifestations cliniques liées à ces troubles ainsi que les anomalies paracliniques et urodynamiques et leur prise en charge thérapeutique. Méthodes: Dans ce travail, nous avons effectué une étude rétrospective et descriptive à propos de patients porteurs de troubles vésico-sphinctériens, suivis dans le service de pédiatrie de l'hôpital Charles Nicolle de Tunis. Résultats: Au total, 62 enfants ayant des troubles vésico-sphinctériens fonctionnels ont été inclus dans notre étude. La médiane d'âge à la première consultation dans un service de néphrologie pédiatrique était de 9 ans (IQR 25 = 6 ans ; IQR 75 = 11 ans). Il y avait une prédominance féminine : 19 garçons et 43 filles. La phase de remplissage et la phase mictionnelle étaient dominées par l'association de trois symptômes ou plus. La sensibilité vésicale était diminuée dans 12 % des cas. Dix-neuf pour cent des patients rapportaient des gouttes retardataires dans la phase post-mictionnelle. La courbe de débimétrie était polyphasique dans 36 % des cas et plate dans 11 % des cas. La médiane du résidu post-mictionnel était de 62,2 mL (IQR 25 = 25 mL ; IQR 75 = 102 mL). La cystomanométrie a montré une sensibilité vésicale réduite dans 14 % des cas, une hyperactivité détrusorienne dans 65 % des cas, une hypocontractilité vésicale dans 8 % des cas, une vessie hypocompliante dans 42 % des cas et de petite capacité dans 88 % des cas. Une dyssynergie vésico-sphinctérienne a été notée chez 34 % des patients. Les anticholinergiques étaient les plus utilisés dans le traitement des troubles (53 %). Une insuffisance rénale était notée dans 45 % des cas dont 11 % au stade terminal. Au cours du suivi, 16 % de nos patients avaient nécessité le recours à l'épuration extra-rénale. Conclusion: Compte tenu de la gravité des troubles vésico-sphinctériens chez l'enfant et la découverte tardive dans la majorité des cas au stade de complications, une prévention primaire ciblée doit être menée en s'appuyant sur une formation continue des médecins de première ligne pour minimiser l'apparition des complications mettant en jeu le pronostic fonctionnel et social de ces enfants.

Neurogenic non-neurogenic bladder in childhood: complications and prognostic factors.

BACKGROUND: Neurogenic non-neurogenic bladder is a common problem in clinical practice. Untreated, complications can be serious. AIM: Identify complications of neurogenic non-neurogenic bladder and determine the predictive factors of their occurrence. METHODS: Prospective, cross-sectional and analytical study (September 2016-September 2017) on a series of cases of children carrying VNNN, followed in the nephrology pediatric department of Charles Nicolle Hospital in Tunis. RESULTS: Twenty-four patients were included in the study. The predictive criteria for neurogenic non-neurogenic bladder complications that we were able to highlight were: female sex, phasic detrusor bladder overactivity, bladder hypocompliance, and midstream hypercontractility. CONCLUSION: Neurogenic non-neurogenic bladder is a common pathology in pediatrics, it is important to diagnose and manage appropriately and early to avoid its complications.

Urodynamic assessment in the management of the child's posterior urethral valves.

BACKGROUND: Bladder dysfunction may be associated with valves of the posterior urethra. Their evaluation by urodynamic assessment is an important parameter for the therapeutic management. The objective of our study was to study the contribution of urodynamic assessment in the management of valves of the posterior urethra of the child. METHODS: Our study was descriptive, retrospective, involving 43 children with posterior urethral valves (PUV), followed at the pediatric ward at Charles Nicolle Hospital in Tunis from January 1995 to December 2015. All the children had an urodynamic assessment after valves of the posterior urethra treatment. RESULTS: The mean age was 15.8 months. Preoperatively, creatinine clearance was below 60 ml / min in 32 patients (74%). The worsening of renal function was noted in 32 (74%). A significant post-voiding residue proved in 34 patients (79%). Cystometry revealed a hypo compliant bladder in 24 (56%), low bladder capacity in 42% of cases; a hypertonic detrusor in 37% of cases. Bladder sphincter dyssynergia was diagnosed in 6 patients. Like urodynamic assessment data, bladder enlargement associated with a Mitrofanoff-type shunt was indicated and performed in 3 patients (7%). CONCLUSION: Through our study, the urodynamic profile made it possible to specify the type of vesico-sphincter dysfunctions persistent in patients operated for PUV, and subsequently to adapt the therapeutic conduct in these patients. Given the lack of management and the consequences on the health of the child as well as on his quality of life, reflections on the preventive and therapeutic approach after PUV treatment are necessary.

Effectiveness of ECG educational workshops among undergraduate medical students.

BACKGROUND: The electrocardiogram (ECG) remains one of the most important and commonly used diagnostic tools in medicine. At the faculty of Medicine of Tunis (FMT), teaching ECG interpretation to undergraduate medical students is an important part of the curriculum. AIMS: To assess the effectiveness of pedagogical workshops in ECG learning among students of First-year of the primary cycle of medical studies (PCMS 1). In addition, we aimed to assess the students' perceptions of the tutorials. METHODS: It was an exhaustive cross-sectional study that was carried out at the FMT during the academic year 2017-2018 and that included students from PCMS 1. All participants completed a pre-test, a workshop session and a post-test. Each of the tests consists of five Multiple Choice Questions (MCQs) covering the same topics. An evaluation of students' satisfaction with the tutorial was made at the end of the session. RESULTS: Ten workshops were held at the FMT, including 160 students. The overall score increased from 4 out of 10 points in the pre-test to 6.8 out of 10 points in the post-test (p <0.001). A statistically significant improvement was noted in all tests questions (p<0.001). Sixty-one learners (39.3%) were "Not satisfied" with the number of students per group. On the whole, 83.8% (n=130) of students found the session beneficial. CONCLUSIONS: Students indicated a positive attitude toward the workshop and its utility. More research among similar populations is needed to support these conclusions and to assess the effectiveness of medium- and long-term educational workshops on medical students.

Toxicological effects and ultrastructural changes induced by lanthanum and cerium in ovary and uterus of Wistar rats.

Rare earths have been widely used in a huge number of areas in industry and medicine. Therefore, they exist in the environment and possibly accumulated within the human body. However their effects in the living organism particularly in the female reproductive system are still unclear. In this work, the subcellular behavior of lanthanum and cerium was investigated through the Transmission Electron Microscopy (TEM), in different territories of the reproductive system of Wistar rats exposed intraperitoneally to soluble solution of these elements during 2 weeks. Ultrastructural investigations of ultrathin sections from uterus and ovary of treated rats revealed the existence of inclusions with high electron density and heterogeneous aspects in the lysosomes of uterus and ovary cells. Many disruptions of architecture were observed, accompanied with several changes like vacuolations, significant expansion of the endoplasmic reticulum, mitochondrial alterations and necrotic cells, demonstrating the toxicity of these elements with doses used. Phagolysosomes as well as eosinophils were also seen. Our experimental investigations revealed no intralysosomal inclusions in ultrathin sections of the uterus and ovary of pregnant control females. The original mechanism implicated in this insolubilization-concentration phenomenon of these elements, as non-soluble phosphate form, in the lysosomes is a biochemical one involving intralysosomal hydrolytic enzymes, the acid phosphatase.

The role of lysosomes in the phenomenon of concentration of aluminum and indium in the female reproductive system. An ultrastructural study.

The female reproductive system is one of the most complex systems in the body taking into account the hormonal fluctuations associated with ovarian and uterine menstrual cycles. The purpose of this work was to study the impact of aluminum nitrate and indium sulfate on the uterus and the ovary of a pregnant rat. The experiment was performed on adult female rats of Wistar strain weighing approximately 250g. The Transmission Electron Microscopy (TEM) showed the presence of electron-dense material in lysosomes of both uterine cells (myometrium and endometrium cells) and in the cells of the ovary (internal theca and granulosa cells). In addition to the presence of aluminum and indium deposits in the uterine and ovarian tissue, impaired endoplasmic reticulum, mitochondria and vacuolation were also identified. We concluded that lysosomes of uterus and ovary cells had the function to extract aluminum and indium introduced into the body in a soluble form. Then, the two elements were sequestrated within these organelles in an insoluble form most probably as phosphate salts such as reported for other kind of cells; kidney, liver, bone morrow Berry, 1996 [1]. This mechanism seems to be a defense one in which the lysosome would play a central role. Our results concerning the impact of the aluminum or indium presence in the lysosome of female reproductive system will be further used in order to assess their effects on the fertility and viability of oocytes in the pregnant treated rats.