Constant urinary dribbling due to an ectopic ureter and delays in diagnosis.

We present 2 patients who had a solitary kidney visualized on ultrasound imaging and experienced constant urinary dribbling. Further imaging modalities defined the anatomy and visualized the contralateral kidney and ectopic ureter causing the dribbling. Both patients went on to have curative surgical procedures. These cases reinforce the point that in a toilet-trained girl with normal voiding at normal intervals experiencing constant urinary dribbling, the diagnosis of an ectopic ureter must be considered early and referral made for appropriate imaging. Because of the abnormal anatomy, ultrasound imaging is particularly limited in such cases, but if used, one should take account of antenatal and postnatal scans. Referral is advocated, based on history alone, for appropriate imaging and investigation.

Resolution of diurnal incontinence and nocturnal enuresis after adenotonsillectomy in children.

PURPOSE: Adenotonsillar hyperplasia causes upper airway obstruction, leading to obstructive sleep apnea. We reviewed the incidence of nocturnal enuresis in a population of children with adenotonsillar hyperplasia. In addition, we investigated the rate of resolution or improvement in enuresis following surgery for relief of adenotonsillar hyperplasia. MATERIALS AND METHODS: We studied 86 consecutive prepubertal children, 46 boys and 40 girls, who underwent adenotonsillectomy. Severity of adenotonsillar obstruction was graded on a scale of 1 to 4. A questionnaire regarding voiding problems, including nocturnal enuresis, voids per day and daytime enuresis episodes, was filled out preoperatively and postoperatively by the patients and their parents. RESULTS: Among the 86 patients who underwent adenotonsillectomy 36 (42%) had nocturnal enuresis. In patients with nocturnal enuresis the number of episodes was significantly less after adenotonsillectomy. Overall, 12 patients (33%) had complete resolution, 11 (31%) had significant improvement and 13 (36%) showed no change. In addition, we noted a significant decrease in daytime enuresis episodes and voids per day. CONCLUSIONS: Children with upper airway obstruction have a high rate of nocturnal enuresis that improves at twice the anticipated rate after treatment of the airway obstruction. In addition, we observed that daytime voiding dysfunction improves in these patients.

[The diagnosis and treatment of ureteral enuresis in a girl aged 14 with unexpected explanation of the cause of the disorder--a case report]. / Przebieg diagnostyki i leczenia moczenia moczowodowego u 14-letniej dziewczynki z nieoczekiwanym wyjasnieniem przyczyny dolegliwosci--opis przypadku.

In our case report we present the course of diagnosis and treatment of primary urinary incontinence in a girl aged 14. In abdominal ultrasound examination we found features of double renal pelvis on the left side. Intravenous urography confirmed that anatomical variant. Moreover it gave the suggestion of duplicated left ureter. Regarding the clinical data and the results of ultrasonography and urography, we suspected that the symptoms might be connected with the ectopic orifice of one from the left ureters, probably that one associated with the upper renal pelvis. We managed to find this ectopic ureteral orifice in the vaginal vestibule. But when we performed antegrade pyelography through that orifice, we found that it constituted the ending of additional right ureter, which was not imaged in previous examinations. That diagnosis was very unexpected. The child was operated on. During the operation a small, hypoplastic additional right kidney was discovered. That kidney was excised together with the ectopic ureter. The urine incontinence stopped immediately after the operation.

Ortodoncia y vías aéreas superiores / Orthodontics and upper airway

Entre los objetivos generales del tratamiento en ortodoncia y los combinados de ortodoncia y cirugía ortognática, están lograr una buena oclusión y una mejoría estética, sobre todo en el caso de deformidades dentoesqueléticas severas. Sin embargo, en muchas ocasiones no se tienen en cuenta los parámetros de la vía aérea superior a la hora de realizar los objetivos del tratamiento convencional. Los pacientes con alteraciones obstructivas durante el sueño, representan para los odontólogos y estomatólogo un tipo de paciente diferente al normal, en los que el tratamiento, va dirigido a mejorar la saturación de oxígeno. Aquí, las consideraciones funcionales se imponen a las puramente estéticas. Es conveniente a la hora de realizar un diagnóstico ortodoncico, quirúrgico o mixto de un paciente, tener en cuenta las connotaciones inherentes a la vía aérea superior (VAS) que el tratamiento pueda a acarrear. No podemos pretender conseguir una buena estética a expensas de generar pacientes más propensos a los transtornos estenosantes de la VAS . (AU)

Management of intrinsic sphincter deficiency in adolescent females with normal bladder emptying function.

PURPOSE: Intrinsic sphincter deficiency is rare in adolescent females with normal bladder emptying function. Information regarding the long-term outcome of therapy in this group of patients is sparse. We report our long-term experience with 3 adolescent females with intrinsic sphincter deficiency and normal bladder function who were treated with an artificial urinary sphincter. We critically reviewed the literature regarding experience with anti-incontinence surgery in adolescent females, not only regarding the outcome of the surgical technique, but also issues not usually considered in older adults, including the impact of physical development and future childbearing. MATERIALS AND METHODS: The charts of 3 adolescent females with intrinsic sphincter deficiency were reviewed. In addition, relevant peer reviewed articles were selected by a MEDLINE search. The results of the artificial urinary sphincter, pubovaginal sling and periurethral injection of bulking agents were reviewed. Long-term efficacy, the complication rate, impact of pregnancy and physical development were assessed. RESULTS: The 3 patients had an excellent long-term outcome with the artificial urinary sphincter, including 1 with 2 pregnancies that ended in a normal vaginal delivery. The literature showed that a good long-term outcome was consistently achieved with the artificial urinary sphincter. An equally good outcome was achieved with the pubovaginal sling but long-term data are lacking. While periurethral injection of a bulking agent provides good initial results, they do not appear to be durable. In addition, the artificial urinary sphincter does not appear to impact pregnancy or physical development negatively. CONCLUSION: Data support the artificial urinary sphincter and pubovaginal sling as effective therapies in adolescent females with intrinsic sphincter deficiency. However, long-term data on the pubovaginal sling are not available. When considering the impact on future childbearing and physical development, the artificial urinary sphincter is a favorable option.

[Ektopic ureter - a not considered cause of persisting enuresis in girls]. / Ektoper Ureter - eine verkannte Ursache des Einnässens bei Mädchen.

BACKGROUND: Ectopic ureter - especially in a duplicated collecting renal system - is a specific cause of incontinence in young girls. Although the symptom of continuous dribbling of urine is characteristic for this malformation, diagnosis is often delayed, as the possibility of ectopic ureters is not considered in treating girls with delayed toilet training. CASE REPORT: We present the case of a young girl with a variety of unnecessary invasive diagnostic and therapeutic procedures due to a misunderstood "enuresis", before incontinence was cured by upper pole heminephrectomy. CONCLUSIONS: Girls, who never have been dry and who loose urine all the time do have an ectopic ureter, unless evidence to the contrary has been put forward. Only considering the possibility of ectopic ureters will avoid unnecessary diagnostic and therapeutic procedures in these girls.

Clam ileocystoplasty in adult nocturnal enuresis.

OBJECTIVE: We investigated the effect of clam ileocystoplasty in patients with nocturnal enuresis with urodynamically proven detrusor instability which was recalcitrant to conservative therapy. MATERIAL AND METHODS: Twelve patients (10 males, 2 females) with ages ranging between 22 and 44 years (mean 32) underwent clam ileocystoplasty. In addition to cystometry all patients underwent pressure flow evaluation. Patients with obstruction; poor contractility and poor compliance that was diagnosed by pressure flow studies were not operated. RESULTS: In a mean 38 months of follow-up all patients were cured symptomatically and urodynamically except one. In this patient, symptomatic improvement was observed despite the persistence of detrusor instability. No patient needed intermittent self catheterization. There were no postoperative complications except an incisional hernia diagnosed after two years postoperatively and corrected surgically. CONCLUSION: Clam procedure could be the best treatment for patients with life long nocturnal enuresis recalcitrant to conservative therapy with coexistence of proven detrusor instability.

Urethral obstruction in patients with nighttime wetting: urodynamic evaluation and outcome of surgical incision.

The aim of this study was to investigate urodynamic findings and the outcome of surgical incision in patients with nighttime wetting due to urethral obstruction. A total of 239 patients with nighttime wetting (157 males and 82 females; mean age, 8.7; range, 4-18 years) was studied. One hundred and ten patients had monosymptomatic enuresis alone and 129 both nighttime wetting and daytime symptoms, that is, the majority was not simple bedwetters, but had signs of bladder overactivity. All patients were first treated with bladder training and fluid intake after dinner was restricted. The non-responders were then treated with tricyclic antidepressants, anticholinergics, or intra-nasal desmopressin and conditioning therapy. Ninety-seven patients who did not respond to these conventional treatments were investigated by voiding cystourethrography, bougie à boule, and urodynamic study. Urethral obstruction was noted in 34 patients (14.2%); posterior urethral valves in three males, ring stricture of the bulbar urethra in 26 males and distal urethral stenosis in five females. Detrusor instability was noted in 30 (94%) of 32 patients. Three patients had <15 mL/s of maximum flow rate and none had post-void residual urine. Pressure at maximum flow (PQ(max)) was 106.5 +/- 26.3 cm H(2)O in pressure/flow study. After surgery, nighttime wetting was cured in 25 patients (73.5%), improved in four (11.8%). Detrusor instability disappeared in six of 16 patients studied (37.5%) and improved in 8 (50%), and PQ(max) decreased significantly after operation (P = 0. 0034). In conclusion, most of the patients with urethral obstruction have detrusor instability and high pressure voiding, and these conditions improved after operation.

Lower urinary tract problems in patients with enuresis.

OBJECTIVE(S): Two hundred and thirty-eight children (170 males, and 68 females) with nocturnal enuresis were retrospectively studied for lower urinary tract problems. Surgical correction of subclinical organic obstruction in the lower urinary tract was evaluated for the improvement of bed-wetting. METHODS: One hundred and fifty-five micturating cystourethrography (MCU), and 89 urodynamic studies were performed. Optic internal urethrotomy was done in a boy, and meatoplasty in a girl for urethral 'ring' stenosis (URS). RESULTS: Nocturnal enuresis was found in 153 cases and nocturnal enuresis associated with daytime enuresis in 67 cases. Vesicoureteral reflux was found in 30, URS in 42, and posterior urethral valve in 3 cases on MCU. Detrusor instability was recognized in 39.4% of 38 cases of nocturnal enuresis associated with daytime enuresis and in 25.0% of 51 cases of nocturnal enuresis. Surgery brought 73.8% improvement of bed-wetting in 42 cases. CONCLUSIONS: Surgical correction of subclinical obstruction in the lower urinary tract might contribute to the earlier resolution of bed-wetting in children with nocturnal and/or diurnal enuresis.

Experiences with clam ileocystoplasty.

Clam ileocystoplasty was performed in 18 patients with urge incontinence, total incontinence or enuresis with instable detrusor. Although the persistence of detrusor instability was observed in 33.33% of the patients, complete clinical cure was found in 72.23 and symptomatic improvement was 22.22%.

Bladder transection revisited.

OBJECTIVE: To ascertain the safety and effectiveness of bladder transection for the treatment of enuresis and urinary frequency. PATIENTS AND METHODS: Twelve patients who had an open bladder transection performed at the Victoria Infirmary, Glasgow, were followed up for a mean of 37 months. RESULTS: Of the 12 patients, three were 'cured', seven were better, two were no better and none were worse than before the operation. All six patients with preoperative enuresis were cured of this by the procedure. CONCLUSIONS: Bladder transection remains a useful procedure in selected patients and avoids the problems associated with enterocystoplasty.

Night studies for primary diurnal and nocturnal enuresis and preliminary results of the "clam" ileocystoplasty.

Modified conventional urodynamic apparatus was used to provide overnight monitoring of bladder and rectal pressure. A group of 26 patients with primary diurnal and nocturnal enuresis underwent both daytime rapid fill cystometry and overnight natural fill cystometry. The overnight study was effective in detecting detrusor instability in 10 patients deemed normal on rapid fill cystometry; 6 of these have now undergone clam ileocystoplasty and 5 are dry; 3 are awaiting this procedure. The clam remains very effective in the management of patients with resistant nocturnal and diurnal enuresis if careful selection is adopted. Overnight cystometry has proved to be an invaluable adjunct to the investigation of patients with primary diurnal and nocturnal enuresis previously felt to be urodynamically normal.

Treatment of persistent enuresis. Results of severing a tight filum terminale.

A tight filum terminale was severed in an attempt to treat intractable enuresis in 27 children. Urodynamic studies demonstrated pre-operative bladder instability in all cases. Although symptom scores for enuresis improved significantly 6 months after surgery, only 7 patients benefited clinically (3 were cured and enuresis was reduced in 4). An average of 26 months later, 12 patients were either dry or their enuresis was reduced, probably due to spontaneous cure rather than surgery. We found no clinical parameters able to predict a favourable outcome. It was concluded that although a tight filum terminale is a cause of intractable enuresis, transection of the filum is not recommended because of the low success rate.

The treatment of adult enuresis and urge incontinence by enterocystoplasty.

Fifteen adult patients with enuresis and/or severe urge incontinence have been treated by a modified form of enterocystoplasty, using sigmoid colon or ileum. Satisfactory results have been obtained in 13 patients, who are dry both by day and by night. Three patients have slight residual urgency. Two patients (one male, one female) had voiding difficulties following cystoplasty and are now managed by intermittent self-catheterisation. The incidence of complications has been acceptable. It is concluded that this method of enterocystoplasty is a reliable form of treatment in patients with severe urge incontinence and enuresis who have failed to respond to other treatment.

Sigmoidocystoplasty in adults with enuresis.

Sigmoidocystoplasty was performed upon 13 adult patients with enuresis to increase the small bladder capacity. Eleven patients were in the follow-up study. The mean observation time was 29.5 months with a range from 13 to 66 months. Ninety per cent of the patients were satisfied with the result.