Isolated coronal urethral duplication in an adolescent presenting with enuresis.

SUMMARY: This report describes an isolated urethral duplication in the coronal plane in a child referred with primary 'enuresis'. This presentation is unique because duplications usually occur in the sagittal plane. In patients with suspected urethral duplication, magnetic resonance imaging in conjunction with catheterisation of the distal duplicate opening accurately delineates the abnormality, so that individualised treatment strategies can be considered.

Etiology and pathology of enuresis among primary school children in Isfahan, Iran.

OBJECTIVE: To determine the etiology and pathogenesis of enuresis among primary school children by using a special ultrasound (US) protocol for the assessment of bladder dysfunction and to compare excretion of urinary sodium and calcium in enuretic children. METHODS: We conducted this cross sectional study on 66 enuretic children aged 6-12 years from September 2005 to January 2006 in Isfahan University of Medical Sciences, Iran. Ultrasound (US) was designed for the evaluation of bladder parameters using bladder volume and wall thickness index (BVWI%), and expected percentage bladder volume index for kidney volume. RESULTS: Sixty children (90.9%) had nocturnal enuresis, 5 (7.5%) had diurnal enuresis and one child (1.6%) had nocturnal and diurnal enuresis. Urinary infection was detected in one child (1.5%). The incidence of urinary system abnormalities was 10.6% in all enuretic children. Hypercalciuria was seen in 9.2% and natriuresis in 20.3%. Normal bladder function (BVWI 70% to <130%) was seen in 67%, small bladder with a thick wall (BVWI <70%) in 27% and large bladder capacity with a thin wall (BVWI >130%) was seen in 6% of children with primary nocturnal enuresis (PNE). There was a significant difference in BVWI between children with PNE and secondary nocturnal enuresis (p=0.01). CONCLUSION: Enuresis is a common problem among school children and associated urinary abnormalities are not uncommon. Our results show that US measured bladder parameters can provide useful clues for the underlying bladder dysfunction and may help to guide clinical management.

[Functional disorders of the lower urinary tract in children]. / Funktionelle Störungen des unteren Harntrakts im Kindesalter.

Functional disorders of the lower urinary tract as well as vesicoureteral reflux involved in the disease complex of urinary tract infection/permanent renal parenchymal damage can be considered predisposing or risk factors. Two main forms can be distinguished, i.e., unstable bladder and dysfunctional voiding, while transitional forms between the two exist. Functional disorders of the lower urinary tract obstruct spontaneous resolution of vesicoureteral reflux. They are found in about 50% of cases in all children with urinary tract infection and are associated with an increased risk of developing renal parenchymal scars. They are observed during the newborn period up to school age. In the first few months of life, particularly boys with bilateral high-grade reflux and congenital renal parenchymal damage are affected. At later ages girls are also affected, but in this age group bladder instability predominates. Incontinence as the leading clinical symptom appears in approximately 70% of all cases and is closely correlated with chronic constipation. Imaging procedures in addition to urodynamic methods are of decisive importance for diagnosis and treatment, but noninvasive approaches such as sonography should be given preference.

Ultrasound bladder measurements in patients with primary nocturnal enuresis: a urodynamic and treatment outcome correlation.

PURPOSE: Accurate assessment of bladder dysfunction associated with voiding dysfunctions often necessitates invasive urodynamic (UD) studies. We evaluate the use of a special ultrasound (US) protocol for the assessment of bladder dysfunction compared with urodynamic findings, and for prediction of treatment outcome in children with primary nocturnal enuresis (PNE). MATERIALS AND METHODS: US measurements were performed on 514 children 5 to 18 years old (mean age 11.2) with PNE, and compared with those of 339 normal age matched children. A US protocol was specially designed for the evaluation of bladder parameters using bladder volume and wall thickness index (BVWI %), and expected percentage bladder volume index for kidney volume. Of the enuretic children 218 had severe enuretic symptoms with more than 3 wet nights a week. They underwent urodynamic studies for detailed assessment of any underlying bladder dysfunction. A standard 4-week course of desmopressin was given to these children after the US and UD studies. The US bladder parameters were then correlated with the UD findings and treatment response to desmopressin. RESULTS: Comparing the BVWI in normal and enuretic children in correlation with functional bladder capacities we were able to delineate bladder wall thickness and capacity as BVWI less than 70-small capacity bladder with thick wall, BVWI 70 to 130-normal bladder capacity with normal wall thickness and BVWI greater than 130-large bladder capacity with thin wall. There were statistically significant correlations between BVWI and treatment response. In addition, there was a high predictive value of normal bladder function with a normal BVWI. Patients with good response to treatment had normal BVWI, whereas poor response to treatment was significantly associated with pathological bladder conditions, that is small bladder capacity with thick bladder wall or large bladder capacity with thin bladder wall (p <0.0001). Of note, abnormalities detected by UD correlated well with bladder abnormalities measured by US. CONCLUSIONS: PNE comprises a diverse spectrum of conditions resulting in a mismatch of nocturnal urine production in excess of nocturnal functional bladder capacity, and underlying bladder dysfunction has an important role in the pathophysiology especially in refractory cases. This US protocol can provide useful predictive clues, which may be helpful to differentiate treatment subtypes, guide clinical management and minimize the need for invasive urodynamic studies.

Incidental spina bifida occulta in functional enuresis observed during laser reflexo therapy.

The etiology of persistent functional enuresis in children is ill understood. A wide range of therapeutic modalities have been tried. During investigations preceding a trial of laser reflexo therapy in functional enuretic children aged 7 to 10 years spina bifida occulta was observed in 86.6% of subjects. The lesions were predominantly at the L5-6 level. There were no cutaneous stigmata in the form of lipoma, tufts of hair, or dermal sinus at the back. Neurologic examination was unremarkable and there were no associated skeletal malformations. This strong association of spina bifida occulta with functional enuresis is higher than the reported incidence of 16.5% to 34% in normal children. This strong association hitherto unreported, raises an interesting issue in the search for the etiopathogenesis of functional enuresis.

Treatment of nocturnal enuresis with an ultrasound bladder volume controlled alarm device.

PURPOSE: Current treatment regimens for nocturnal enuresis are suboptimal. Medications such as desmopressin are efficacious for preventing the enuretic event but they offer little potential for a permanent cure and have side effects. Although the moisture alarm has good potential for a permanent cure, the child is mostly wet during treatment. Furthermore, the moisture alarm requires that the child make the somewhat remote association between the alarm event and a full bladder after the bladder has emptied. In this exploratory study bladder volume alarming, a new approach to treating nocturnal enuresis, was investigated. MATERIALS AND METHODS: A total of 40 sequential children 6 to 16 years old with nonorganic nocturnal enuresis who had had at least 1 wetting episode weekly for greater than a year were divided into 2 groups. Each child wore a modified PCI 5000 miniature bladder volume measurement instrument during sleep. An alarm sounded when bladder volume reached 80% of the typical daytime voided volume in group 1 and at 80% of the typical enuretic volume in group 2. Group 2 patients also performed daytime bladder retention exercises in regard to instrument measured bladder volume versus a progressing target volume. RESULTS: In groups 1 and 2 the mean dryness rate before study initiation versus during the study was 32.9 and 9.3 versus 88.7 and 82.1%, respectively. Nighttime bladder capacity increased 69% in group 1 and 78% in group 2, while the cure rate was 55% (mean treatment period 10.5 months) and 60% (mean treatment period 7.2 months), respectively. CONCLUSIONS: Bladder volume tracking seems to approach the goals of ideal treatment for nocturnal enuresis in that it prevents the enuretic event, appears to facilitate a permanent cure and is noninvasive.

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.

Design of a miniaturized ultrasonic bladder volume monitor and subsequent preliminary evaluation on 41 enuretic patients.

Nocturnal incontinence (enuresis) affects 20% of children over four years old, and this figure typically decreases by 15% each year. At the age of 18, 1% of those people remain enuretic. Nocturnal enuresis can be treated by means of a conditioning device that awakens the patient once the urine level has reached a preestablished threshold of the capacity of his or her bladder. We have designed and implemented a portable miniaturized ultrasonic monitor, which permits estimation of the urine volume with an accuracy of 75%. Prototypes have been completed and validated on 41 patients (children) at Ste. Justine Hospital (Montréal). On the first group of 33 patients, we used a hand-held transducer to determine the volume detection range, which is accurate for volumes between 40 and 400 mL. With the second group of 8 patients, the device was mounted on an elastic belt around the abdomen. Measurements were taken in order to validate the accuracy of urine threshold detection and the activation of the corresponding alarm.

Differential diagnoses for nocturnal enuresis.

The symptom of nocturnal enuresis can be a feature of many conditions, including renal, neurological and organic disease states. It is important to differentiate primary nocturnal enuresis from secondary enuresis and from daytime incontinence with a nocturnal component. It is recommended that the routine investigation of enuretic children should comprise four components: structured interview, physical examination, urinalysis and ultrasound investigation. Additional intensified diagnostic and invasive procedures should be reserved for patients with suspected neurological disorders or urological dysfunction.

Isotope renography in childhood enuresis.

A retrospective review was performed of 100 enuretic children who underwent isotope renography during the period 1981-1989. Studies performed were Tc99mDMSA studies for renal size and to detect renal scarring and renography using Tc99mDTPA or MAG3 to evaluate excretion and detect vesicoureteric reflux. Fifty-five children had microbiological evidence of urinary tract infection (UTI), and 16 (29%) of these had abnormalities on their isotope studies. Forty-five had sterile urine and all had normal isotope studies. Thus despite recent reports of urodynamic abnormalities and increased incidence of reflux in patients with enuresis, our findings indicate that standard nuclear medicine renal studies show few abnormalities in patients with monosymptomatic enuresis. The 29% incidence of abnormal studies in patients with enuresis and UTIs suggests that the presence of infection should be an indication for further investigation in this subgroup of enuretic children.

[Infantile enuresis: epidemiologic, clinical, urodynamic, and radiologic data of a consecutive series of 100 cases]. / Enuresis infantil: datos epidemiológicos, clínicos, urodinámicos y radiológicos de una serie consecutiva de 100 casos.

The present paper reports the epidemiological, clinical, urodynamic and cystographic data of 100 consecutive patients (mean age 9.59 years) with nocturnal enuresis. These patients were divided into three groups: group I (4 to 7 years old), 23 patients; group II (8 to 11 years old), 51 patients; and group III (12 to 14 years old), 26 patients. Nocturnal enuresis was more frequent in group II (51%). It was more prevalent in males (51%) of groups I and II. Isolated nocturnal enuresis was more frequent (54%) than nocturnal enuresis associated with diurnal symptoms (46%) in all age groups. Urinary infection was observed in 16% and was more prevalent in girls (68.7%). Detrusor instability was the most common urodynamic finding (40%), particularly in group II and girls. Uncoordinated voiding was the second most common urodynamic finding (24%), particularly in group II and girls. Lower urinary tract infection was observed in 1% (males). No abnormal urodynamic data were observed in 19%. Neurogenic bladder was observed in 16%, mainly in group II (31%). Vesicoureteral reflux was detected in 18%, mainly in girls (66.6%) and a postvoiding residual urine in 10%. A diagnostic and prognostic system and a therapeutic strategy based on our data are proposed.

Urodynamics in enuretic children.

Although the incidence of an organic cause is low and most of the detected genitourinary anomalies are not responsible for enuresis, a simple, noninvasive screening test is preferable in the analysis of children with enuresis. Extension of standard radionuclide renography as a method of screening the upper as well as lower urinary tract function in one session is noninvasive and at least as good as conventional direct urine flow rate recording. This method was carried out in 124 children. In 30%, some abnormality probably related to the enuresis was identified. Upper urinary tract anomalies were identified in 5% of the children, anomalies of the upper and the lower urinary tract in 9.6%, and functional voiding disturbances in 16%.

Functional daytime incontinence: clinical and urodynamic assessment.

Assessment of children with daytime wetting starts with the distinction between 'enuresis diurna' and 'functional incontinence', incontinence being defined as any form of wetting caused by bladder/sphincter dysfunction. Standard history-taking does not allow for a sharp enough distinction: pertinent questions have to be asked about daytime wetting, night-time wetting, micturition, and about urge and reactions to urge. By using urodynamics to expose the pathophysiology behind the patterns of bladder/sphincter dysfunction, these questions were formulated and validated in a series of 156 children, referred with persistent daytime wetting to a programme for cognitive bladder training. With history-taking organized into a simple questionnaire, complemented by urodynamics, four patterns of bladder/sphincter dysfunction emerged: urge syndrome, staccato voiding, fractionated and incomplete voiding, and lazy bladder syndrome. A strong correlation was found between recurrent urinary tract infections and non-neuropathic bladder/sphincter dysfunction, implying that detection and treatment of bladder/sphincter dysfunction is essential in every child with recurrent urinary tract infections, especially in the presence of vesico-ureteral reflux.

Enuresis and the voiding cystourethrogram: a re-evaluation.

Eighty-three children with a chief complaint of nocturnal enuresis and no history of urinary tract infection (UTI) were prospectively evaluated with a contrast voiding cystourethrogram (VCUG). The following four historical details of presentation were noted: primary vs. secondary enuresis, daytime wetting, urgency, and frequency. Each of these four symptoms were treated as a dichotomous variable, and the prognostic value with respect to vesicoureteral (VUR) reflux was assessed using a linear logistic regression model. Nineteen ureters in 13 patients (16%) demonstrated VUR: grade I, 7 ureters; grade II, 5 ureters; grade III, 3 ureters; grade IV, 4 ureters; and grade V, 0 ureters. Three patients demonstrated renal scarring (16%) and 2 patients underwent surgery. The linear regression analysis revealed that no one symptom, group of symptoms, or absence of all four symptoms segregated those patients likely to have reflux with statistical validity. One of 6 children, therefore, who present with nocturnal enuresis and sterile urine will have reflux. Screening these children with a VCUG should be considered.

[Faulty voiding and drinking habits--a contribution to the genesis of enuretic syndrome?]. / Miktions- und Trinkfehlverhalten--Ein Beitrag zur Genese des enuretischen Syndroms?

In 122 children (85 girls, 37 boys) with nocturnal enuresis, information on drinking and voiding patterns was elicited. Many of them (60% of the girls and 40% of the boys) had previously been continent for 1-5 years. It turned out that the children tried to suppress voiding and had the habit of drinking primarily during the second half of the day. After changing these habits, 119 children became permanently continent.

[The quantitative analysis of the x-ray changes in the kidney calices in chronic pyelonephritis in children]. / Kolichestvennyi analiz rentgenologicheskikh izmeneniii chashechek pochek pri khronicheskom pielonefrite u detei.

As many as 89 patients aged 6 months to 14 years with microbial inflammatory diseases of the urinary tract and 40 controls of the same age were examined. Of the patients, 55 had chronic pyelonephritis, 21 acute pyelonephritis, and 13 an infection of the urinary tract. For examination use was made of the planimetric method of measuring the width of the fornix and the cervix of the renal calyces on excretory urography. The fornicocervical index, product of the indicated parameters of the calyces, was computed. In health, that index did not exceed 24 units. In the majority of patients suffering from chronic pyelonephritis, it turned out higher. The false negative results were obtained in 7 cases. The fornicocervical index remained unchanged in patients with acute pyelonephritis and urinary tract infection. It is suggested that the fornicocervical index be computed for use as an objective criterion in the diagnosis of chronic pyelonephritis in children.

Evaluation of the excretory urogram in adult enuresis.

Excretory urograms in 216 primary enuretic adult males aged between 18 and 20 years were retrospectively evaluated. In no patient was there a finding considered relevant to the complaint. It is considered that, in the absence of urinary infection or other urological complaint in a patient with normal neurological status, excretory urography is a non-contributory examination in the investigation of adult male enuresis.

The radiology of incontinence.

Incontinence is defined by the International Continence Society (Bates et al, 1979) as an involuntary loss of urine which can be objectively demonstrated and causes a social or hygienic problem. It is therefore both a symptom and a sign. Medical and surgical treatments are available and radiological investigation is helpful in many patients.

Current status of excretory urography. A premature epitaph?

Although there can be no doubt that the once lofty stature of the IVU in clinical urology has been gradually eroded by many forces, the study still retains an important place in urologic diagnosis. In spite of inroads made by CT, ultra-sonography, radionuclide scans, and other modalities, there is still diagnostic information that is best supplied by the IVU. It appears safe to say that the IVU will be with us for many years to come. Indeed, it seems fair to add that the practice of urology and uroradiology would be very difficult without it.