Does sacral ratio have any impact on success rate of biofeedback therapy in children with lower urinary tract dysfunction?

INTRODUCTION: To evaluate the possible impact of patients' sacral ratios (SRs) on response to biofeedback (BF) therapy in pediatric patients with lower urinary tract dysfunction (LUTD). MATERIALS AND METHODS: In this retrospective cohort conducted from 2016 to 2018 in our tertiary medical center, we included the medical records of all pediatric patients with LUTD who were nominated for BF due to having abnormal uroflowmetry patterns and simultaneous increase in electromyography (EMG) activity. Ten sessions of weekly animated BF were performed for each patient. All patients underwent a complete urological evaluation, uroflowmetry with simultaneous EMG and post-void residual measurement before and after treatment. SRs were calculated based on plain anteroposterior lumbosacral radiographs. Patients were then divided into normal SR (≥0.74) and low SR (<0.74) and outcomes were compared between them. RESULTS: Of the total 86 patients included in our study, 48 (55.8%) had a normal SR (≥0.74), while 38 (44.2%) had a low SR (<0.74). Our data revealed that BF therapy significantly improved maximum and average urinary flow rates, urine volume, daytime urinary incontinence, enuresis, urinary urgency and constipation; irrespective of the patients' SRs (all P < 0.001). Our between-groups analyses showed that after the completion of BF, the SR ≥ 0.74 group had significantly higher maximum urinary flow rate (mean difference [95%CI]: 7.7 [5.4, 10.0], P < 0.001) (Figure) and urine volume (mean difference [95%CI]: 49.9 [19.5, 80.4], P = 0.002) and significantly lower diurnal urinary incontinence (4.2% vs. 21.1%, P = 0.020), enuresis (4.2% vs. 18.4%, P = 0.040) and constipation (2.1% vs. 23.7%, P = 0.004) compared to the SR < 0.74 group. DISCUSSION: SR has been proposed as a reliable indicator of bony pelvis growth and subsequent lumbosacral neurodevelopment. Additionally, larger SR values are associated with better postoperative sphincter function in children with urological and anorectal malformations. Our results demonstrated that after completion of BF, the normal SR group had a significantly better improvement of some of the uroflowmetry indicators and LUTD-associated symptoms compared to the low SR group. CONCLUSION: Our findings implied that although BF therapy is an efficient treatment for children with LUTD, irrespective of their sacral development; children with enhanced sacral development may benefit from better clinical response, especially in terms of LUTD-associated symptoms.

Management of Intractable Functional Constipation in Children by Interferential Therapy: Transabdominal or Pelvic Floor.

BACKGROUND: To compare the effectiveness of pelvic floor interferential (IF) therapy with trans-abdominal IF therapy in children with intractable functional constipation. METHODS: Information of 64 children (38 boys, 26 girls; mean age: 6.6 ± 2.2) with functional constipation who had been treated with IF therapy were considered for this retrospective study. Group A (n = 32) underwent pelvic IF electrical stimulation + pelvic floor muscle (PFM) exercises while the group B (n = 32) received transabdominal IF therapy + PFM exercises. A complete bowel habit diary, a constipation score questionnaire and a seeable pain scores had been recorded before, after the ending of treatment courses and six months later for children in both groups. Additionally, children had been assessed with a constipation-related quality of life questionnaire before and six months after treatment. RESULTS: The number of patients who compiled the diagnostic criteria for constipation significantly decreased in both groups after treatment, in which 27/32 (84.3%) of patients in each group had no constipation after the ending of therapy courses (P = 1). Fecal soiling episodes reduced in both groups after treatment, this finding was significantly higher in group A than in group B after the ending of therapy courses (P = 0.05) and six months later (P = 0.01). CONCLUSION: Results of this study showed that using IF therapy both pelvic floor and transabdominal significantly boosts the effects of treatment among patients with functional constipation. Pelvic floor IF therapy is more effective in patients who had concomitant fecal soiling.

Non-retentive faecal incontinence in children: Conventional therapy alone or combined electrical stimulation.

AIMS: To compare the effects of functional electrical stimulation (FES) with conventional therapy and conventional therapy alone on improvement of faecal incontinence (FI) symptoms in a number of children with functional non-retentive FI. METHODS: Data of 28 children with FI were accepted for this retrospective study. The case group (n = 14) underwent FES + conventional therapy and the control group (n = 14) received conventional therapy only. Data of children with faecal retention, inflammatory, anatomic, metabolic and neurological disorders were excluded. Children were assessed with a paediatric FI score questionnaire, and a bowel habit diary both before treatment sessions, after they ended, and after 6 months. A FI quality of life questionnaire was completed before and after treatment for all children. RESULTS: Full response to the treatment (100% reduction in FI episodes) was significantly observed in 8/14 (57.1%) of children in the case group compared to 2/14 (14.2%) of children in the control group after the ending of treatment sessions (P = 0.005). The baseline mean ± SD of FI episodes per week was 3.7 ± 2.1 among both groups which significantly decreased after the ending of treatment sessions in the case group compared to the control group (1.4 ± 2.1 vs 3 ± 2.7; P = 0.05). Mean ± SD of FI score was significantly reduced in the case group compared to the controls after the ending of treatment sessions (3.9 ± 4.5 vs 8 ± 4.7; P = 0.02) and maintained after 6 months (P = 0.05). CONCLUSIONS: Functional electrical stimulation is a safe, effective, non-invasive, inexpensive, reproducible and easy-to-use modality for treatment of functional non-retentive faecal incintinence in children.

Management of post-surgical faecal incontinence due to anorectal malformations by pelvic floor rehabilitation.

AIM: Many patients with anorectal malformations (ARM) experience a long-lasting problem with faecal incontinence (FI). We assessed the effectiveness of a pelvic floor rehabilitation program including transcutaneous functional electrical stimulation (TFES) in combination with pelvic floor muscle (PFM) exercises on post-surgical FI in children with ARM. METHODS: Data of 40 children at the age of 4 years or older who had undergone surgical correction for ARM and suffered from persistent FI referring for pelvic floor rehabilitation were analysed respectively. Patients underwent TFES and PFM exercises for 20 sessions. TFES was applied for 20-min during each session, two times a week. A paediatric FI score questionnaire and a bowel habit diary were completed both before and after the treatment for all children. We completed a FI quality of life questionnaire before the therapy and again after treatment for all patients. RESULTS: Twenty-two out of 40 (55%) patients responded completely to the treatment (100% reduction in FI episodes) after the completion of treatment sessions, sustained in 19/40 (47.5%) patients after 6 months. Mean ± SD of FI score was 4.9 ± 3.6 at baseline that significantly reduced to 2.4 ± 1.3 and 2.4 ± 1.8 after completion of treatment sessions and 6 months later, respectively (P < 0.05). CONCLUSIONS: Our results show that TFES and PFM exercises have a considerable beneficial impact on post-surgical FI in children with ARM.

Comparative Efficacy of Transcutaneous Functional Electrical Stimulation With or Without Biofeedback Therapy on Functional Non-retentive Fecal Incontinence in Children: A Randomized Clinical Trial.

BACKGROUND: We compared the effects of transcutaneous functional electrical stimulation (TFES) and biofeedback therapy with TFES alone in a cohort of children with functional non-retentive fecal incontinence (FNRFI). METHODS: This prospective, single-center randomized clinical trial was performed on 40 children with FNRFI. Patients were randomly allocated into two equal treatment groups. Group A (n = 20) underwent TFES + biofeedback therapy, and group B (n = 20) received TFES alone. All patients were assessed with a pediatric fecal incontinence (FI) score questionnaire, a visual pain score, and a bowel habit diary both before and at the end of treatment sessions and also at 6 months of follow-up. In addition, a FI quality-of-life (QoL) questionnaire was recorded for all patients before and 6 months after the treatment. RESULTS: FI significantly improved in 13/20 (65%) patients in group A and 11/20 (55%) patients in group B (P < 0.05). A significant reduction in FI score was seen in each group at the end of treatment sessions and maintained at 6 months of follow-up (P < 0.05). A significant improvement in FI-QoL scores was seen in both groups at 6 months of follow-up in which there was no significant difference in terms of FI-QoL scores improvement between both groups after treatment. CONCLUSIONS: The use of electrical stimulation in combination with other treatment methods improves symptoms in patients with FNRFI who are refractory to conventional treatment.

Interferential Electrical Stimulation Efficacy in the Management of Lower Urinary Tract Dysfunction in Children: A Review of the Literature.

BACKGROUND: Lower urinary tract dysfunction (LUTD) is the most common problem of the referral children to the pediatric urology clinics. If this condition does not treat early in life, it will be a lifelong problem. During recent decades, electrical stimulation therapy has been expanded and extensively used for the treatment of LUTD in both adults and children. The aim of this review is to suggest clinicians an updated understanding of effects of interferential (IF) electrical stimulation therapy in management of LUTD in children. MATERIALS AND METHODS: The search was performed in databases of Medline, PubMed, Google Scholar, ,and Scopus for information about  IF electrical stimulation and its application using search words such as " IF electrical stimulation", "transcutaneous IF electrical stimulation" ,  "IF therapy " , " electrical stimulation", "voiding dysfunction" , " LUTD", " urinary incontinence" and " children". As this review focuses on the answer of this question "Does transcutaneous IF electrical stimulation has effect on management of LUTD in children?" we included the reference list of articles identified by this search strategy and selected those we judged relevant according to our keywords. Clinical trial studies that publishing in English were included. Categorical data were reported as frequencies and percentages. RESULTS: Eleven studies were included in this review. The success rate of IF therapy in these studies has been reported from 61% to 90% of children with LUTD and urinary incontinence. CONCLUSION: IF electrical stimulation is an effective, safe and reproducible option to manage LUTD and urinary incontinence in children.

Intrarectal Electromotive Botulinum Toxin Type A Administration in Children With Intractable Constipation: A Randomized Clinical Trial.

INTRODUCTION: Children with refractory constipation might not respond to conventional medical treatments. In this study, we assessed the effectiveness of intrarectal botulinum toxin type A/electromotive drug administration (BoNTA/EMDA) on constipation in these children and compared its efficacy with routine intrasphincteric BoNTA injection. METHODS: From 2017 to 2019, 60 children aged 5-13 years who fulfilled Rome III criteria for intractable constipation were enrolled and randomly assigned into 2 treatment groups. EMDA group (n = 30) underwent BoNTA/EMDA, whereas the control group (n = 30) received injection of BoNTA into the internal anal sphincter. A complete bowel habit diary (with data on the frequency of defecation per week, stool form, and the number of fecal soiling episodes), a constipation score questionnaire, and a visual pain score were recorded before treatment and at 1 month and 6 months after treatment. In addition, children in both groups were assessed with a constipation-related quality of life questionnaire. RESULTS: After 1-month follow-up, treatment reduced the number of patients fulfilling the diagnostic criteria in both EMDA (24/30, 80%) and injection (25/30, 83.3%) groups (P < 0.001). The stool form was normalized in 73.3% (22/30) in EMDA group and 80% (24/30) in injection group after treatment. The median of constipation score and pain score decreased significantly in both groups after treatment (P < 0.001 and P < 0.001, respectively). DISCUSSION: BoNTA/EMDA seems to be as effective as intrasphincteric BoNTA injection for treatment of intractable constipation. In addition, this technique is associated with less comorbidity, is less costly, and can be performed in an office-based setting without general anesthesia.

Management of Bladder Bowel Dysfunction in Children by Pelvic Floor Interferential Electrical Stimulation and Muscle Exercises: A Randomized Clinical Trial.

OBJECTIVE: To assess efficacy of combined pelvic floor interferential (IF) electrical stimulation and muscle exercises on bladder bowel dysfunction (BBD) in children. MATERIALS AND METHODS: A total of 34 children with BBD (6 boys, 28 girls; mean age 7.4 ± 2.2) were included in this study. Children were evaluated with kidney and bladder ultrasounds, uroflowmetry + electromyography (EMG), and a complete voiding and bowel habit diary before treatment. Exclusion criteria were neuropathic disease, anatomical defects, and mental retardation. Participants were randomly allocated into 2 treatment groups including group A (n = 17) who underwent IF electrical stimulation in addition to pelvic floor muscle (PFM) exercises and group B (n = 17) who received PFM exercises alone. All children were re-evaluated by kidney and bladder ultrasounds, uroflowmetry + EMG and a voiding and bowel habit diary at the end of treatment sessions and 6 months later. RESULTS: Constipation improved in 14 of 17(82%) and 8 of 17(47%) children in group A and B respectively at the end of treatment sessions (P = .03). Daytime incontinence improved in all children in group A and 2 of 8(25%) children in group B after the treatment (P = .007). Urinary tract infection improved in 8 of 10(80%) and 5 of 13(38.4%) children in group A and B respectively, 6 months after the treatment (P = .02). No significant difference was observed in uroflowmetry measures between 2 groups after the treatment. CONCLUSION: Combination of IF electrical stimulation and PFM exercises is an effective and safe modality for treatment of BBD in children.

Resolution of Hydronephrosis in Children with Dysfunctional Voiding After Biofeedback Therapy: A Randomized Clinical Trial.

We assessed efficacy of biofeedback therapy and home pelvic floor muscle exercises in children with dysfunctional voiding (DV) associated with mild to moderate hydronephrosis. This prospective study comprised fifty seven children (21 boys, 36 girls; mean age 8.9 ± 2.6) with DV and mild to moderate hydronephrosis. Children were randomly allocated into two treatment groups including control group who underwent standard urotherapy and case group who received biofeedback therapy in addition to standard urotherapy. A 99mTc diethylenetriamine pentaacetic acid (99mDTPA) scan, voiding cystoureterography, kidney and bladder ultrasounds, voiding diary and uroflowmetry with electromyography (EMG) were performed in all study participants at the baseline. Children with evidence of complete obstruction in DTPA scan and vesicoureteral reflux were excluded from enrollment. A complete voiding diary, kidney and bladder ultrasounds and uroflowmetry/EMG were also performed 6 months and 1 year after completion of the treatment. We noted a more significant decline in anteroposterior pelvic diameter in case group compared to control group (P < 0.05). The mean maximal urine flow rate prior to treatment was 16.5 ± 2.6 and 16.1 ± 3 ml/s in case and control groups, respectively. This finding increased significantly 1 year after the treatment in case group compared to controls (25 ± 7.2 ml/s vs. 18.4 ± 5.9 ml/s, respectively; P < 0.001). Improvement of various parameters in voiding diary was also more significant in the case group. Biofeedback therapy can effectively resolve non-refluxing and non-obstructive hydronephrosis in children with DV.

Botulinum Toxin Type A Therapy: Intravesical Injection or Electromotive Drug Administration.

OBJECTIVES: To compare the outcomes of intravesical injection of botulinum toxin A (BoNTA) with intravesical electromotive drug administration (EMDA) of BoNTA on urinary incontinence secondary to neuropathic detrusor overactivity (NDO) in children with myelomeningocele (MMC). MATERIALS AND METHODS: A total of 26 children with MMC (11 boys, 15 girls) who had urinary incontinence secondary to NDO were retrospectively enrolled in the study. Patients in EMDA group (n = 14), using an electrode-catheter, 10 IU/kg of BoNTA were inserted into the bladder for EMDA without anesthesia and on an outpatient basis. The EMDA equipment was connected to the electrode of indwelling catheter and 2 dispersive electrodes, a pulsed current generator delivered 10-20 mA for 20 minutes. Patients in injection group (n = 12) were received interavesical injection of 10 IU/kg of BoNTA via rigid cystoscope on an inpatient basis. All patients had been evaluated by a voiding diary, urodynamic study, renal, and bladder ultrasounds before, 6 months and 1 year after the treatment. RESULTS: Six months after the treatment, 12 of 14 (85.7 %) and 8 of 12 (66.6%) patients in EMDA and injection groups respectively became completely dry between 2 consecutive clean intermittent catheterizations, which maintained in 11 of 14 (78.5%) of patients in EMDA group compared to 6 of 12 (50%) of patients in injection group, 1 year after the treatment. CONCLUSION: Patients in both groups improved after the treatment; however improvement in EMDA group was more prominent with better sustained effects. BoNTA/EMDA is a feasible, reproducible, cost benefit, and pain free method as an outpatient basis and no need for anesthesia.

Impact of transcutaneous interferential electrical stimulation for management of primary bladder neck dysfunction in children.

INTRODUCTION: Several studies have revealed that electrical stimulation is an effective modality for treatment of lower urinary tract (LUT) dysfunction via raising the capacity or compliance of the bladder or maybe by pelvic floor relaxation and reducing detrusor pressure as well. OBJECTIVE: This study aimed to assess the efficacy of transcutaneous interferential (IF) electrical stimulation on LUT symptoms as well as urine flow parameters in children with primary bladder neck dysfunction (PBND). STUDY DESIGN: We reviewed the charts of all children with persistent LUT symptoms who underwent IF electrical stimulation between 2010 and 2017. Twenty-three neurologically and anatomically normal children (mean age: 7.7 years, range: 5-13) with LUT symptoms were included in this study. Children had different LUT symptoms such as hesitancy, straining, urinary incontinence and constipation with no sufficient response to medical treatment (α -blocker) for at least 6 months. IF electrical stimulation was performed for 15 sessions, two times per week. All children were symptomatic and had abnormal urine flow pattern with an electromyographic (EMG) lag time of more than 6 s on uroflowmetry with EMG. A voiding chart, uroflowmetry with EMG and kidney and bladder ultrasounds were performed before and after the treatment for all children. Maximum and average urine flow rates, EMG lag time and postvoid residual volume were analyzed. In addition, alpha blocker therapy was continued during IF therapy. RESULTS: Mean maximum and average urine flow rates improved from 14.1 to 7.6-19.7 ml/s and 9.5 ml/s, respectively, while mean EMG lag time decreased from 11.7 to 5.2 s after the treatment (all P < 0.05). Also postvoid residual volume decreased significantly from 35.6 to 7.6 ml at the end of treatment courses. DISCUSSION: Pelvic floor EMG lag time, a documented parameter on uroflowmetry with EMG, defined as the time from the start of pelvic floor relaxation during a volitional voiding effort (the first stage of normal voiding) to the start of urine flow. Results showed that IF therapy decreased pelvic floor EMG lag time in children with PBND. In addition, increase in mean maximum and average urine flow rates in our patients indicated that pelvic IF therapy and behavioral modification improved voiding dysfunction in most of the patients and probably decreased bladder neck activity during voiding. Future studies with larger sample size are needed to support this finding. CONCLUSION: IF therapy appears safe, effective and reproducible in improvement of PBND in children.

Intravesical Electromotive Botulinum Toxin Type A (Dysport) Administration in Children With Myelomeningocele.

OBJECTIVE: Electromotive drug administration (EMDA) presents a minimally invasive method of intravesical instillation of therapeutic agents without the need for general anesthesia.1 It employs a combination of iontophoresis, electrophoresis, and electroporation to deliver drugs into deep tissue layers using an electrical current created between 2 electrodes.2 This video shows feasibility of botulinum toxin type A (BoNTA) EMDA in myelomeningocele children with urinary incontinence secondary to neuropathic detrusor overactivity. METHODS: In this technique (Video 1), catheterization was performed with a 10-Fr (CE-DAS, UROGENICS/Ag 9900 (pediatric), Mirandola, Italy) catheter electrode, after providing a local transurethral anesthesia with 2% lidocaine gel. The cuff of the catheter was filled by 2 cc saline solution. The bladder was then drained and irrigated with 0.9% saline solution until the catheter outflow became clear. The bladder was subsequently filled with sterile water to its maximal capacity. BoNTA (Dysport) at a dose of 10 IU/kg was added to the intravesical solution. Negative electrode as 2 dispersive electrodes was placed on the abdomen. Positive electrode was connected to the intravesical catheter. A pulsed current generator (Physionizer 30, Physion srl, Mirandola, Italy), delivered a current with frequency of 2,800 Hz, interval of 50 µs and amplitude of 10-20 mA for 20 minutes. At the end of the procedure, the bladder was emptied. RESULTS: For the first time, BoNTA/EMDA was performed on myelomeningocele patients with urinary incontinence in our center.3 According to our prior reports, urinary incontinence improved in 75% of the patients between 2 consecutive clean intermittent catheterizations at 1-year follow-up.4 Mean maximal cystometric capacity significantly increased from 148 ± 62 mL at baseline to 239 ± 73 mL 1 year after the treatment.4 CONCLUSION: This technique is a feasible, safe, reproducible, cost effective, long lasting, and pain free method, on an outpatient basis with long-term duration of effects and without anesthesia or cystoscopy procedure.

Traditional Biofeedback vs. Pelvic Floor Physical Therapy-Is One Clearly Superior?

PURPOSE OF REVIEW: Pelvic floor physical therapy is a worldwide accepted therapy that has been exclusively used to manage many pelvic floor disorders in adults and children. The aim of this review is to suggest to clinicians an updated understanding of this therapeutic approach in management of children with non-neuropathic voiding dysfunction. RECENT FINDINGS: Today, pelvic floor muscle training through biofeedback is widely used as a part of a voiding retraining program aiming to help children with voiding dysfunction which is caused by pelvic floor overactivity. Biofeedback on its own, without a pelvic floor training component, is not an effective treatment. Biofeedback is an adjunct to the pelvic floor training. In the current review, we develop the role of pelvic floor physical therapy in management of children with non-neuropathic voiding dysfunction and compare it with biofeedback therapy alone.

Pelvic floor electrical stimulation and muscles training: a combined rehabilitative approach for management of non-neuropathic urinary incontinence in children.

PURPOSE: To assess the efficacy of combined transcutaneous interferential (IF) electrical stimulation and pelvic floor muscle training through biofeedback on non-neuropathic urinary incontinence in children. METHODS: This prospective study comprised of 46 anatomically and neurologically normal children (9 boys, 37 girls; mean age of 8.4 ±â€¯2.2 years old) with non-neuropathic urinary incontinence. All children were evaluated by kidney and bladder ultrasounds, uroflowmetry with electromyography (EMG), a complete voiding diary and a dysfunctional voiding scoring questionnaire at the baseline. Children were randomly allocated into two treatment groups including group A (n = 23) who underwent biofeedback therapy in addition to IF electrical stimulation and group B (n = 23) who received only biofeedback therapy. Re-evaluation was performed 6 months and one year after completion of the treatment sessions. RESULTS: Improvement of non-neuropathic urinary incontinence was significantly higher in group A in comparison to group B at two follow ups (P < 0.05). Daytime incontinence was improved in 19/23(82%) and 13/23(56.5%) of children in groups A and B respectively after the treatment (P < 0.01). There was no significant difference in uroflowmetry measures between two groups after the treatment. CONCLUSIONS: Combination of biofeedback therapy and transcutaneous IF electrical stimulation is a potential effective modality in treating non-neuropathic urinary incontinence in children. LEVEL OF EVIDENCE: Type of study: Treatment study. Level I: Randomized controlled trials with adequate statistical power to detect differences (narrow confidence intervals) and follow up >80%.

Pelvic floor electromyography and urine flow patterns in children with vesicoureteral reflux and lower urinary tract symptoms

ABSTRACT Objective: To determine the different urine flow patterns and active pelvic floor electromyography (EMG) during voiding in children with vesicoureteral reflux (VUR) as well as presenting the prevalence of lower urinary tract symptoms in these patients. Materials and Methods: We retrospectively reviewed the charts of children diagnosed with VUR after toilet training from Sep 2013 to Jan 2016. 225 anatomically and neurologically normal children were included. The reflux was diagnosed with voiding cystourethrography. The study was comprised an interview by means of a symptom questionnaire, a voiding diary, uroflowmetry with EMG and kidney and bladder ultrasounds. Urine flow patterns were classified as bell shape, staccato, interrupted, tower and plateau based on the current International Children's Continence Society guidelines. Results: Of 225 children with VUR (175 girls, 50 boys), underwent uroflowmetry + EMG, 151 (67.1%) had an abnormal urine flow pattern. An active pelvic floor EMG during voiding was confirmed in 113 (50.2%) children. The flow patterns were staccato in 76 (33.7 %), interrupted in 41 (18.2%), Plateau in 26 (11.5%), tower in 12 (5.3%) and a bell shape or normal pattern in 70 (31.5%). Urinary tract infection, enuresis and constipation respectively, were more frequent symptoms in these patients. Conclusions: Bladder/bowel dysfunction is common in patients with VUR that increases the risk of breakthrough urinary tract infections in children receiving antibiotic prophylaxis and reduces the success rate for endoscopic injection therapy. Therefore investigation of voiding dysfunction with primary assessment tools can be used prior to treating VUR.

Pelvic floor electromyography and urine flow patterns in children with vesicoureteral reflux and lower urinary tract symptoms.

OBJECTIVE: To determine the different urine flow patterns and active pelvic floor electromyography (EMG) during voiding in children with vesicoureteral reflux (VUR) as well as presenting the prevalence of lower urinary tract symptoms in these patients. MATERIALS AND METHODS: We retrospectively reviewed the charts of children diagnosed with VUR after toilet training from Sep 2013 to Jan 2016. 225 anatomically and neurologically normal children were included. The reflux was diagnosed with voiding cystourethrography. The study was comprised an interview by means of a symptom questionnaire, a voiding diary, uroflowmetry with EMG and kidney and bladder ultrasounds. Urine flow patterns were classified as bell shape, staccato, interrupted, tower and plateau based on the current International Children's Continence Society guidelines. RESULTS: Of 225 children with VUR (175 girls, 50 boys), underwent uroflowmetry + EMG, 151 (67.1%) had an abnormal urine flow pattern. An active pelvic floor EMG during voiding was confirmed in 113 (50.2%) children. The flow patterns were staccato in 76 (33.7 %), interrupted in 41 (18.2%), Plateau in 26 (11.5%), tower in 12 (5.3%) and a bell shape or normal pattern in 70 (31.5%). Urinary tract infection, enuresis and constipation respectively, were more frequent symptoms in these patients. CONCLUSIONS: Bladder/bowel dysfunction is common in patients with VUR that increases the risk of breakthrough urinary tract infections in children receiving antibiotic prophylaxis and reduces the success rate for endoscopic injection therapy. Therefore investigation of voiding dysfunction with primary assessment tools can be used prior to treating VUR.

Pharmacological treatments available for the management of underactive bladder in neurological conditions.

INTRODUCTION: Underactive bladder (UAB) is a common cause of lower urinary tract dysfunction which has an increasing incidence with aging. It is characterized as an incompetent detrusor contraction with reduced strength and/or duration to completely empty the bladder. UAB is observed in both men and women. The exact definition, classification, and pathophysiological mechanism responsible for UAB is still debatable, however neurologic, myogenic, and iatrogenic causes are explained. The symptom complex related to UAB includes hesitancy, diminished sensation of bladder filling, a slow urinary stream, increased post-void residue, and etc. Areas covered: We reviewed the current understanding of UAB with special focus on pharmacological treatments and potential pharmacotherapy options particularly in neurological conditions. Also, the definition, etiology, symptoms, diagnosis and management of UAB were discussed in this review. Expert commentary: The underlying mechanism of UAB is not clear yet. Therefore; the lack of efficient pharmacotherapies is evident in such patients. Prior to any decision for pharmacological or surgical interventions, the underlying causes of UAB and detrusor impairment in each patient should be distinguished. Future researches need to address the exact dynamics of detrusor contraction and the muscular and neurological contributors to UAB.