Is it time to reconsider how we document pediatric uroflow studies?: A study from the SPU Voiding Dysfunction task force.

BACKGROUND: Uroflowmetry is a non-invasive study used in the diagnosis and monitoring of treatment response for lower urinary tract disorders. For optimal clinical utility, uroflow studies rely on careful clinical interpretation by a trained provider, but currently there is a lack of accepted standardized normal values for the measured uroflow parameters in children. The International Children's Continence Society proposed standardizing the terminology for uroflow curve shapes. However, the patterning of curves is largely at the physician's subjective discretion. OBJECTIVES: The aims of this study were to understand inter-rater reliability in interpreting uroflow curves and to define characteristics of uroflow curves that could be used to provide definitive criteria for uroflowmetry parameters. METHODS: All members of the SPU Voiding dysfunction Task Force were invited to contribute deidentified uroflows to a centralized HIPAA complaint receiving database. All studies were then distributed to all raters for review. Each observer's findings were recorded according to ICCS criteria (ICCS), additional readings were done using a previously reported system which defined curves as smooth or fractionated (SF) and whether the shape resembled a bell, tower, or plateau (BTP). Flow indexes (Qact/Qest) (FI) for Qmax and Qavg were generated using formulas previously reported for children 4-12 and for patients≥12 years. RESULTS: A total of 119 uroflow studies were read by 7 raters and curves were contributed from 5 sites. Kappa scores for the 5 readers from different institutions were 0.34 and 0.28 for the ICCS and BTP methods, respectively (both considered fair agreement). Kappa for smooth and fractionated curves was 0.70 (for each; considered substantial agreement), which were the two highest agreement scores obtained throughout the study. Discriminant analysis (DA) revealed that the FI Qmax was the dominant vector, and that the ICCS uroflow parameters have a total of 42.8% prediction rate in the training sample. Using DA of a smooth/fractionated system, the total prediction rates were 72% and 65.5% for smooth and fractionated, respectively. DISCUSSION: Given the poor inter-rater agreement for analyzing uroflow curve pattern based on ICCS criteria in this study and others, one may find it reasonable to consider alternative approaches to describing and characterizing uroflow curves. Our study is limited by lack of EMG and post-void residual data. CONCLUSIONS: For a more objective uroflow interpretation and comparison of studies among different centers, we recommend using our proposed system (based on FI, and smooth vs. fractionated curve pattern), which is more reliable.

Imipramine for refractory daytime incontinence in the pediatric population.

INTRODUCTION AND OBJECTIVE: Lower urinary tract (LUT) and voiding dysfunction constitute a large percentage of pediatric urology referrals. Children with urinary incontinence unresponsive to behavioral modifications and traditional pharmacotherapy including anticholinergics and alpha blockers remain a challenge. We evaluated the impact of imipramine on treatment outcomes in children with refractory incontinence. STUDY DESIGN: Children ≤18 years of age with refractory non-neurogenic daytime incontinence prescribed imipramine were identified. Patient demographics and baseline testing were assessed, as well as medication dosing and side effects of all patients. The Vancouver Symptom Score (VSS) was completed at the initial consultation and each subsequent clinic visit. The questionnaire was self-administered and completed by patients and/or parents. Treatment success was defined as per the International Children's Continence Society (ICCS). RESULTS: One hundred and three patients (55 males and 48 females) met the inclusion criteria. The intention-to-treat response rate was 65% (complete 44, partial response 23). Sixteen (15.6%) patients were non-responders and 20 (19.4%) were lost to follow-up. There was no statistical difference between all groups with regards to age, baseline VSS, and dose. Of those children with complete follow-up (n = 83), 44 (53%) experienced complete treatment response. Pre- and post-VSS were statistically different in both complete and partial response groups (complete 19.5-9.5; p < 0.0001; partial 19.7-13; p = 0.0002) (Table). Side effects were reported by 11 out of 83 (13.3%) patients; partial responders experienced a higher likelihood of side effects (26.1%; p = 0.03). DISCUSSION: The mainstay of LUT dysfunction management in children is implementation of a bowel program and timed voiding regimen, with additional treatment modalities and pharmacotherapy added depending upon prevailing symptomatology. Daytime incontinence refractory urotherapy, anticholinergics, and/or non-selective alpha blockers can be difficult to treat, and can be unresponsive to parasacral transcutaneous electrical nerve stimulation (TENS) and percutaneous tibial nerve stimulation (PTNS). We observed that over half of children with refractory daytime incontinence reported complete resolution of daytime accidents with imipramine. Limitations of the study include the retrospective nature, relatively small sample size and lack of control group. CONCLUSIONS: Two-thirds of children with refractory daytime incontinence experienced treatment response to imipramine, adding a valuable tool to the pediatric urologist's armamentarium in managing select, challenging patients.

Are seasonal and income variations accountable for bowel and bladder dysfunction symptoms in children?

AIMS: Certain illnesses tend to occur more commonly at certain times of the year. It is also known that individuals of different socioeconomic groups have a predilection for physical ailments that in some cases may be related to poor access to healthcare or may be related to environmental or work related causes. We hypothesized that there may be a difference between patients from season to season and from different socioeconomic groups and their presenting lower urinary tract symptoms (LUTS). METHODS: We reviewed our electronic medical record going back for 5 years, selecting out all patients who presented to all 10 of our offices in a wide geographic area that covers 22 million people of all races and income levels in the Tristate area of New York. RESULTS: We identified 13,346 patients, 6,010 males and 6,957 females, and 379 were excluded for not meeting age inclusion criteria. The descriptive statistics based on age, median income for both males and females can be found in Tables I, II, III, and IV, respectively. Of note, males were older than females at presentation (8.1 vs. 6.9 years) with no difference in median incomes between families. There were more UTIs in females and more dysuria complaints in males. Urinary incontinence also appeared to be more prevalent in females than males, while males had more issues with fecal soiling than the females. What was obvious was that urgency and frequency was positively correlated with high income groups. On the other hand urinary incontinence represented either by itself or combined with UUI was more prevalent in the high school group. Fecal soiling was also more prevalent in the high school group. UTIs were more prevalent in the high school group but surprisingly there was no difference in patients that were not able to empty their bladders. Conversely we found that constipation was more prevalent in the professional group than in the other groups which is the opposite of the FS findings. Lastly dysuria appeared to be more prevalent in the P group. CONCLUSIONS: It is clear that there are marked differences in the results between high school income and professional income groups in particular with the U and F, along with C which correlate with high income professionals' children. UUI, UI, UTI, along with FS are associated with high school income parents. Neurourol. Urodynam. 36:148-154, 2017. © 2015 Wiley Periodicals, Inc.

Can a simple question predict prolonged uroflow lag times in children?

OBJECTIVE: It is our experience that some children with bowel and bladder dysfunction (BBD) who have bladder neck dysfunction had a tendency to complain of dizziness when we subjected the patients with dizziness to tilt-table testing to confirm the diagnosis of autonomic dysfunction. From these findings we postulated that patients who complain of dizziness are likely to have prolonged lag times that are a proxy for bladder neck dysfunction (BND). STUDY DESIGN: This was an Institute Review Board-approved study in which we enrolled new patients in a sequential fashion who were referred to our outpatient urology offices for evaluation of BBD over a 3-month period. All patients were asked if they frequently experienced dizziness when they rapidly stood from a sitting or lying down position or when they raised their head rapidly. An analysis of the following parameters was undertaken: prevalence of dizziness, bladder neck dysfunction, and comorbid psychiatric problems. Uroflowmetry findings were analyzed as well. RESULTS: Tilt-table group: In the tilt-table group the median age of the patients was 14.5 (4.5-18) years for the five males and five females who were tested. All males and four out of five females experienced a blood pressure drops of 20 mmHg or more on table tilting and three experienced syncope. All patients had prolonged lag times, with an average lag time of 16.5 s. All these patients were able to tolerate alpha-blockers once they were adequately hydrated and salt loaded. Alpha-blocker dosing was increased gradually. In the questionnaire group, 212 patients were initially enrolled: 125 girls and 87 boys. Eleven of 12 males and eleven of 16 females had prolonged lag times when dizziness was present. Sensitivity was 92% and 69%, specificity was 80% and 91% respectively for male and females. Analysis of the psychiatric history revealed a statistically significant association with dizziness and neuropsychiatric problems in the patients and family members. CONCLUSION: We have been able to show a high degree of sensitivity in male patients and a high degree of specificity in female patients that a simple question, "Do you get dizzy on rising in the morning or with rapid standing?", is a reliable marker for BND in children. We have also seen that there is an association between dizziness and psychiatric problems in patients and in family members. It appears from our results and the available literature that autonomic dysfunction is commonly associated with BND and dizziness can be a simple proxy question to identify this problem.