Cerebral microglial activation in patients with hepatitis C: in vivo evidence of neuroinflammation.

Patients with chronic hepatitis C infection may exhibit neuropsychological symptoms and cognitive impairment. Post-mortem studies of hepatitis C virus HCV quasispecies and replicative intermediates indicate that the brain might act as a separate compartment for viral replication and microglia may be the locus for infection and subsequent neuroinflammatory activity. We sought to use two independent in vivo imaging techniques to determine evidence of neuroinflammation in patients with histologically mild chronic hepatitis C. Using positron emission tomography (PET) with a ligand for microglial/brain macrophage activation, (11)C-(R)-PK11195 (PK11195) and cerebral proton magnetic resonance spectroscopy, we determined whether there was evidence of neuroinflammation in a pilot study of 11 patients with biopsy-proven mild chronic hepatitis C, compared to healthy volunteers. Patients were characterized by cognitive testing and the fatigue impact scale to assess for CNS impairment. PK11195 binding potential was significantly increased in the caudate nucleus of patients, compared to normal controls (P = 0.03). The caudate and thalamic binding potential were more significantly increased in six patients with genotype 1 infection (P = 0.007) and positively correlated with viraemia (r = 0.77, P = 0.005). Basal ganglia myo-inositol/creatine and choline/creatine ratios were also significantly elevated in patients with chronic hepatitis C compared to normal controls (P = 0.0004 and P = 0.01, respectively). Using PET, we demonstrated evidence of microglial activation, which positively correlated with HCV viraemia and altered cerebral metabolism in the brains of patients with mild hepatitis C. This provides further in vivo evidence for a neurotropic role for HCV.

Does acute hepatitis C infection affect the central nervous system in HIV-1 infected individuals?

Central nervous system (CNS) manifestations of chronic hepatitis C virus (HCV) and chronic human immune deficiency virus-1 (HIV-1) infections have been reported, but the impact of acute HCV infection on the CNS is unknown. A total of 10 individuals with chronic stable HIV-1 with documented acute HCV (HCV-RNA polymerase chain reaction positive and HCV antibody negative, group 1) underwent cerebral proton magnetic resonance spectroscopy (MRS) using acquisition parameters to quantify myo-inositol/creatine (mI/Cr) ratio in the right basal ganglia (RBG). Two matched control groups also underwent MRS; group 2: ten with chronic HIV-1 and no evidence of HCV, and group 3: ten with no evidence of HIV or HCV. Subjects also underwent computerized neurocognitive assessments (CogState). RBG mI/Cr ratio in group 1 (acute HCV in a background of HIV) was significantly lower than that in groups 2 and 3 [2.90 (+/-0.7) vs 3.34 (+/-0.4) and 3.43 (+/-0.4), mean (SD) for group 1 vs 2 and 3 respectively, P = 0.049], with 50% of subjects in group 1 having a mI/Cr ratio below the lowest observed ratio in either of the other groups. On neurocognitive testing, significant defects in the monitoring domain were observed in group-1, compared with matched controls (P = 0.021). Acute HCV in HIV-1 infected subjects is associated with CNS involvement. Clinicians should be vigilant of early CNS involvement when assessing subjects with acute HCV.

Pre-operative manometry of the blind rectal pouch to predict post-operative potential for continence in anorectal malformation.

AIM: Despite technical advances in the surgical repair of anorectal malformation, many children suffer post-operative faecal incontinence. There are many ways to assess postoperative continence in these patients but there is no manometry-based method to assess and make predictions pre-operatively. In this pilot study an attempt was made to correlate the pre- and postoperative manometry and electromyography findings in order to use the pre-operative findings to predict the postoperative potential for continence. METHODS: Ten patients aged 12 to 54 months were subjected to pre-posterior sagittal anorectoplasty manometry by introducing the balloon catheter probe through the distal colostomy into the blind rectal pouch. Electromyography activity in the striated muscle complex was also studied by placing electromyography needles in the midline in the anal dimple. A second study was repeated after posterior sagittal anorectoplasty (PSARP), the probe was introduced into the rectum via the neo-anus and the electromyography needles were placed on either side of the neo-anus. A third study was done, similar to the second study, after colostomy closure along with Kelly's scoring. Results of the three studies were compared. RESULTS: Pre-posterior sagittal anorectoplasty rectal pouch pressures were in the range of 18.3-93.3 cm H2O and electromyographic activity was between 43.6 and 383.0 microv. Post-posterior sagittal anorectoplasty studies showed anal canal pressure in a similar range of 16.0-95.5 cm H2O and electromyographic activity between 57.0-340.7 microv. The post-colostomy closure anal canal pressures ranged from 22.7 to 99.1 cm H2O and electromyographic activity ranged from 65.7 to 335.7 microv. The Kelly's score ranged from 1-6. CONCLUSION: Since, the pre-and postoperative manometry findings are quite similar and they correlate well with the surgical outcome, it may be possible to predict such an outcome before PSARP. Also, the pressure profiles and EMG activity in post-operative assessments suggest intact neural pathways despite blind pouch mobilisation.

Current and future applications of magnetic resonance imaging and spectroscopy of the brain in hepatic encephalopathy.

Hepatic encephalopathy (HE) is a common neuro-psychiatric abnormality, which complicates the course of patients with liver disease and results from hepatocellular failure and/or portosystemic shunting. The manifestations of HE are widely variable and involve a spectrum from mild subclinical disturbance to deep coma. Research interest has focused on the role of circulating gut-derived toxins, particularly ammonia, the development of brain swelling and changes in cerebral neurotransmitter systems that lead to global CNS depression and disordered function. Until recently the direct investigation of cerebral function has been difficult in man. However, new magnetic resonance imaging (MRI) techniques provide a non-invasive means of assessment of changes in brain volume (coregistered MRI) and impaired brain function (fMRI), while proton magnetic resonance spectroscopy (1H MRS) detects changes in brain biochemistry, including direct measurement of cerebral osmolytes, such as myoinositol, glutamate and glutamine which govern processes intrinsic to cellular homeostasis, including the accumulation of intracellular water. The concentrations of these intracellular osmolytes alter with hyperammonaemia. MRS-detected metabolite abnormalities correlate with the severity of neuropsychiatric impairment and since MR spectra return towards normal after treatment, the technique may be of use in objective patient monitoring and in assessing the effectiveness of various treatment regimens.

Early primary biliary cholangitis is characterised by brain abnormalities on cerebral magnetic resonance imaging.

BACKGROUND: Brain change can occur in primary biliary cholangitis (PBC), potentially as a result of cholestatic and/or inflammatory processes. This change is linked to systemic symptoms of fatigue and cognitive impairment. AIM: To identify whether brain change occurs early in PBC. If the change develops early and is progressive, it may explain the difficulty in treating these symptoms. METHODS: Early disease brain change was explored in 13 patients with newly diagnosed biopsy-proven precirrhotic PBC using magnetisation transfer, diffusion-weighted imaging and 1 H magnetic resonance spectroscopy. Results were compared to 17 healthy volunteers. RESULTS: Cerebral magnetisation transfer ratios were reduced in early PBC, compared to healthy volunteers, in the thalamus, putamen and head of caudate with no greater reduction in patients with greater symptom severity. Mean apparent diffusion coefficients were increased in the thalamus only. No 1 H magnetic resonance spectroscopy abnormalities were seen. Serum manganese levels were elevated in all PBC patients, but no relationship was seen with imaging or symptom parameters. There were no correlations between neuroimaging data, laboratory data, symptom severity scores or age. CONCLUSIONS: This is the first study to be performed in this precirrhotic patient population, and we have highlighted that neuroimaging changes are present at a much earlier stage than previously demonstrated. The neuroimaging abnormalities suggest that the brain changes seen in PBC occur early in the pathological process, even before significant liver damage has occurred. If such changes are linked to symptom pathogenesis, this could have important implications for the timing of second-line-therapy use.

Urodynamics-based evidence for the beneficial effect of imipramine on valve bladders in children.

AIMS: In an era, in which valve bladder is recognised as perhaps the single most important determinant of long-term outcome in patients with posterior urethral valves (PUV), an insight into the etiopathogenesis and management of valve bladders is warranted. The present study was designed to evaluate bladder dysfunction in PUV and to assess the response to imipramine in these patients, both subjectively and objectively, by serial urodynamic studies (UDS). METHODS: From 1998-2001, 30 patients with PUV who had documented bladder dysfunction on UDS were studied. Patients with non-compliant or unstable bladders were treated with imipramine (1.5 - 2 mg/kg). All the patients in the present study were 5 years or older and hence old enough to be toilet trained. Assessment of continence and side effects of the drug was done after 3 months and repeat UDS were done at 3-6 months, 1 and 2 years. RESULTS: On the basis of initial treatment, the patients were divided into 2 groups; a fulguration group (n = 10, 33.3 %) and a vesicostomy group (n = 20, 66.6 %). Symptomatic voiding dysfunction was present in 27 of the 30 patients (90 %). Two patterns of urodynamic abnormalities were noted in the present study; 1) unstable bladders with single or multiple uninhibited contractions (18/30 patients, 60 %), and 2) small capacity, hypocompliant, hypertonic bladder (12/30 patients, 40 %). Post imipramine therapy significant symptomatic improvement was noted in 16/30 patients. On serial UDS, there was a 18-20 % increase in maximum cystometric capacity (MCC) and 30-35 % increase in pressure specific bladder volume (PSBV) following one year of imipramine therapy in 16/30 patients and 11/30 patients, respectively. 4 patients failed to show any improvement in MCC and PSBV with imipramine, they had been initially diverted with vesicostomy and later required augmentation cystoplasty. CONCLUSION: Unstable bladders and those with marginal bladder capacity and compliance showed the best response to imipramine therapy. Fibrotic, small capacity, hypertonic bladders are less responsive to imipramine. However, a trial of imipramine therapy is still warranted in these patients, as only 4/12 (33.3 %) patients with fibrotic hypertonic bladders failed to show any response and ultimately required augmentation cystoplasty. Imipramine qualifies as an effective and cheap drug for valve bladders.

Manometric evaluation of postoperative patients of esophageal atresia and tracheo-esophageal fistula.

Symptoms related to esophageal dysmotility are common following successful repair of esophageal atresia (EA) and tracheo-esophageal fistula (TEF). Esophageal manometry was performed in 27 survivors of EA/TEF at a mean age of 30.5 +/- 30.3 months and in 25 age-matched controls (mean age 36.8 +/- 22.6 months). The patients were also evaluated clinically to grade them into 3 result-oriented groups "Excellent", "Good" and "Fair", depending on pre-existing criteria evaluating the ability and ease of swallowing. Gastroesophageal reflux (GER) was evaluated with the help of a radionuclide scan. The mean esophageal and peak esophageal pressures and therefore also the lower esophageal sphincter (LES) pressure were lower in the patients (12.4 +/- 5.5, 34.9 +/- 20.4 and 12.2 +/- 6.8 mm Hg, respectively) compared to the controls (21.1 +/- 6.9, 62.3 +/- 19.3 and 16.8 +/- 4.3 mm Hg, respectively). The mean body pressures were highest with "Excellent" results and lowest with "Fair" results and the LES pressures followed a similar trend. Likewise, in the patients with GER, LES pressure was 12.0 +/- 7.1, 12.3 +/- 3.7, 11.0 +/- 5.7 and 6.9 +/- 5.6 mm Hg with nil, mild, moderate and severe GER, respectively. The pressure and contractility profile of the esophagus was abnormal in the majority of patients, even in the absence of symptoms.

Manometric evaluation of postoperative patients with anorectal anomalies.

AIM: To evaluate the outcome of surgical treatment in patients with anorectal malformations and to correlate the clinical, manometric and electromyographic studies in assessment of postoperative continence in these patients. METHODS: Forty-one patients operated on for anorectal malformations were evaluated retrospectively. These included 13 patients with low anomalies, 24 with high anomalies, and 4 with congenital pouch colon. Functional results after surgical correction were assessed on clinical basis using the Kelley's scoring system and by anorectal manometry. In addition, the electrical activity of contraction of the external sphincter muscle was studied using electromyography. RESULTS: There was direct correlation between anal canal pressures and Kelley's score in patients with both high and low anomalies; Kelley's score of 6, 5, 4, 3 and less had pressures ranging between 60-75, 45-59, 30-44, 15-29 and less than 15 cm H2O, respectively. However, the electromyographic activity did not correlate well with Kelley's score. CONCLUSIONS: Anorectal manometry correlates well with Kelley's scoring system and may be a more objective method of analyzing the results of surgery. Poor correlation between Kelley's score and electromyography may be a reflection of poor compliance with instructions to voluntarily contract the muscles of continence.

Neurogenic bladder: urodynamic and surgical aspects.

Children with spina bifida often have vesico-urethral dysfunction manifesting either as upper urinary tract deterioration or voiding dysfunction, chiefly incontinence. Surgery of the back and presence of or increase in hydrocephalus may contribute to neuro-urologic worsening; secondary cord tethering and syrinx or hydromyelia may be additional factors coming into play later in life. Urodynamic assessment using simple modalities like uroflowmetry, external sphincter EMG, residual urine volume and cystometry provide data useful to classify patients according to detrusor and sphincter activity. Besides diagnosis, urodynamic studies are useful in guiding therapy of children with vesico-urethral dysfunction, and for their follow-up to detect sub-clinical deterioration. They also help to prognosticate risk of upper tract deterioration and the possible success of measures to contain incontinence. Urodynamic data in thirty one patients with spinal dysraphism who presented to us with urologic symptoms were analysed. Twenty-three children had hyper-reflexic bladders while in the other 8 the bladder was areflexic. 13 children showed upper tract dilatation. The leak point volume was significantly lower in this group of patients compared to those who did not show upper tract dilatation. Our results are comparable to earlier similar studies.

The assessment of lower urinary tract function in children with anorectal malformations before and after PSARP.

BACKGROUND: Lower urinary tract dysfunction (LUTD) with anorectal malformations (ARM) is usually associated with sacral and spinal abnormalities and less commonly due to iatrogenic pelvic nerve damage during surgery. Posterior sagittal anorectoplasty (PSARP) is believed to have a minimal deleterious effect on lower urinary tract function. AIM: The aim of this study was to assess the effects of PSARP on lower urinary tract function by means of urodynamic studies (UDS) performed before and after the definitive surgery in patients with ARM. MATERIALS AND METHODS: The study was conducted between January 2003 and July 2005, in 17 cases of ARM (high/supralevator, n = 13 and low/infralevator, n = 4). All patients were subjected to preoperative UDS and then again 6 weeks after the PSARP. The parameters observed were maximum cystometric capacity (MCC), leak point pressure or end filling pressure (LPP/EFP), uninhibited detrusor contractions (UDCs) and compliance. RESULTS: Associated vertebral anomalies were present in 38.5 % (5 of 13) in high ARM compared with 25 % in low ARM. The incidence of preoperative lower urinary tract dysfunction in various forms was found to be 70.5 % (12 of 17 patients) and postoperatively the incidence was found to be 76.4 % (13 of 17 patients). The pre- and postoperative mean MCC, volume at P (det) < 20 cm, volume at P (det) < 30 cm and LPP were compared and found to be statistically not significant (p = 0.578, p = 0.551, p = 0.875 and p = 0.863, respectively). UDCs were present in 29.4 % patients (5 of 17) preoperatively and 35.3 % (6 of 17) patients postoperatively; however, only 16.6 % (2 of 12) developed fresh UDCs. The incidence of LUTD did not differ if the patient had undergone PSARP or required abdominal dissection with PSARP. All 6 patients with vertebral or sacral anomaly had LUTD. CONCLUSION: There seems to be a high incidence of LUTD in ARM even in the absence of clinical and radiological evidence of lower urinary tract abnormalities. In addition, it was noted that there are changes, although statistically insignificant, in the neurovesical function of these patients following PSARP.

Urodynamic evaluation in boys treated for posterior urethral valves.

This study describes the urodynamic findings in 22 patients with posterior urethral valves and discusses their association with urinary incontinence, age, mode of primary treatment, renal function, and changes in the upper tracts. The patients' ages ranged from 3 to 26 years and 27% were either adolescents or older. The urodynamic findings were categorized into 5 main patterns, although mixed patterns were also observed; (1) normal capacity and compliance with normal detrusor contractility (2/22 patients, 9.1%); (2) small-capacity, hypocompliant bladder (8/22 patients, 36.4%); (3) unstable bladder (2/22 patients, 9.1%); (4) large-capacity, hypotonic bladder with decreased detrusor contractility (2/22 patients, 9.1%); and (5) normal capacity and compliance but with decreased detrusor contractility (8/22 patients, 36.4%). More than one-half of the patients (57.1%) evacuated their bladders incompletely, and this seemed to be associated with post-treatment episodes of urinary-tract infection. The commonest symptom was daytime frequency, urgency, and leak with nocturnal enuresis, which urodynamically correlated with a small-capacity, hypocompliant or unstable bladder or to incomplete evacuation of the bladder, leading to significant post-void residue. Significant detrusor dysfunction was identified in 2 asymptomatic patients as well, emphasizing the need to perform a routine urodynamic work-up on all valve patients. Urodynamic properties seemed to be associated with age. Small, hypocompliant, and unstable bladders were almost always seen in prepubertal boys and in the first 5 years following undiversion, whereas large, hypotonic bladders with impaired contractility were seen in post-pubertal boys. While the current policy is to avoid high diversion, data in this study suggest that disorders of detrusor capacity, compliance, and contractility exist in children treated by primary valve ablation and vesicostomy and that abnormal detrusor dynamics seem to be a reflection of inherent developmental detrusor dysfunction consequent to congenital infravesical obstruction.

Cystometric evaluation of reconstructed classical bladder exstrophy.

OBJECTIVE: To evaluate the association of urodynamic variables with continence and upper tract status after reconstruction in patients with classical bladder exstrophy. PATIENTS AND METHODS: Thirty-one patients with bladder exstrophy were assessed 1 year after a modified bladder neck reconstruction. The evaluation included a detailed history, radioisotope renography, voiding cysto-urethrography, ultrasonography and artificial slow-filling cystometry. RESULTS: Fifteen of the 31 patients were satisfactorily continent; their maximum cystometric capacity was higher than that of the incontinent patients. The compliance, assessed as the maximum bladder capacity at a detrusor pressure of < 20 cmH2O, was significantly higher in the continent patients. There was a 45% incidence of unstable contractions in the 31 patients. Persistent sphincteric activity was detected on electromyography in 10 patients during voiding. Twenty-one patients could initiate a detrusor contraction during voiding. The residual volume was significant in nine of the 21 patients who attempted to void. Patients with a high end-fill pressure (> 40 cmH2O) had a significantly higher incidence of unobstructive hydronephrosis than had patients who had an end-fill pressure of < 40 cmH2O. CONCLUSIONS: Bladder abnormalities are common after reconstruction of bladder exstrophy, with poor compliance, small capacity and unstable contractions. These factors hinder any increase in capacity and cause persistent incontinence. Hypocompliance and high end-fill pressure can lead to upper tract damage even in continent patients. Detailed urodynamic evaluation is vital to assess the results and to plan subsequent treatment.

Initial surgical treatment as a determinant of bladder dysfunction in posterior urethral valves.

Bladder function in patients with posterior urethral valves (PUV) has an immense impact on long-term continence and renal function. Bladder dysfunction was corelated with the initial surgical treatment in 67 patients with PUV treated between 1985 and 2000. Age at presentation, current age, duration of follow-up, initial surgical treatment (diversion or valve fulguration), trends of renal function tests, voiding disturbances, and changes in the upper tracts were recorded. Urodynamic studies were done in all patients to determine urine flow rates, residual volume, maximal cystometric capacity (MCC), bladder compliance, involuntary detrusor activity, and pressure-specific bladder volume (PSBV) at 30 cm water. The patients were divided into three groups depending on the initial treatment: fulguration (n = 38), vesicostomy (n = 25), and ureterostomy (n = 4). At the time of this study voiding symptoms persisted in 45 patients. Mean percent MCC (% MCC) was 62%, 96%, and 100% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively (P = 0.002). Large-capacity bladders were seen in 10.9% of patients, mostly in pubertal and post-pubertal boys who were treated initially by either fulguration or ureterostomy; vesicostomy adversely affected bladder capacity and compliance (P = 0.007). PSBV was decreased in 48% of patients in the vesicostomy group and was significantly lower in the other groups (P = 0.01). Mean percent PSBV was 75%, 95%, and 96% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively. Uninhibited contractions were present in 21 patients (14 in the vesicostomy group) (P = 0.01). The highest incidence of upper-tract deterioration was seen with %MCC below 60% of normal (P = 0.001). The predominant urodynamic patterns were: (1) fulgurated group: good-capacity, compliant bladder; (2) vesicostomy group: small-capacity, hyperreflexic bladder; and (3) ureterostomy group: good capacity, compliant bladder. Primary valve ablation is associated with better bladder function than vesicostomy and should be the treatment of choice in PUV. Also, vesicostomy and ureterostomy have distinctly different effects on bladder function.

The role of imipramine therapy in bladder exstrophy after bladder neck reconstruction.

OBJECTIVE: To assess the role of imipramine therapy after bladder neck reconstruction in patients with bladder exstrophy. PATIENTS AND METHODS: Seventeen children with bladder exstrophy who achieved partial continence after bladder neck reconstruction received imipramine (1.5-2 mg/kg body weight) for a mean duration of 9.5 months. Assessment before and after therapy included an objective classification of the continence status and artificial slow-fill cystometry. RESULTS: Eleven of the 17 patients had a good clinical response to imipramine, with an increase in the continent period to > 2 h, and in nocturnal continence. The urodynamic findings showed a significant improvement in the capacity, end-fill pressure, uninhibited contractions and '20 below' capacity. Only minor side-effects of the drug were reported. CONCLUSION: Imipramine has a role in patients who achieve partial continence after reconstruction, and who have a moderately small capacity bladder with poor compliance and uninhibited contractions.

Pre-operative manometry of the blind rectal pouch to predict post-operative potential for continence in anorectal malformation.

AIM: Despite technical advances in the surgical repair of anorectal malformation, many children suffer post-operative faecal incontinence. There are many ways to assess postoperative continence in these patients but there is no manometry-based method to assess and make predictions pre-operatively. In this pilot study an attempt was made to correlate the pre- and postoperative manometry and electromyography findings in order to use the pre-operative findings to predict the postoperative potential for continence. METHODS: Ten patients aged 12 to 54 months were subjected to pre-posterior sagittal anorectoplasty manometry by introducing the balloon catheter probe through the distal colostomy into the blind rectal pouch. Electromyography activity in the striated muscle complex was also studied by placing electromyography needles in the midline in the anal dimple. A second study was repeated after posterior sagittal anorectoplasty (PSARP), the probe was introduced into the rectum via the neo-anus and the electromyography needles were placed on either side of the neo-anus. A third study was done, similar to the second study, after colostomy closure along with Kelly's scoring. Results of the three studies were compared. RESULTS: Pre-posterior sagittal anorectoplasty rectal pouch pressures were in the range of 18.3-93.3 cm H2O and electromyographic activity was between 43.6 and 383.0 microv. Post-posterior sagittal anorectoplasty studies showed anal canal pressure in a similar range of 16.0-95.5 cm H2O and electromyographic activity between 57.0-340.7 microv. The post-colostomy closure anal canal pressures ranged from 22.7 to 99.1 cm H2O and electromyographic activity ranged from 65.7 to 335.7 microv. The Kelly's score ranged from 1-6. CONCLUSION: Since, the pre-and postoperative manometry findings are quite similar and they correlate well with the surgical outcome, it may be possible to predict such an outcome before PSARP. Also, the pressure profiles and EMG activity in post-operative assessments suggest intact neural pathways despite blind pouch mobilisation.

Manometric evaluation of postoperative patients with anorectal anomalies.

AIM: To evaluate the outcome of surgical treatment in patients with anorectal malformations and to correlate the clinical, manometric and electromyographic studies in assessment of postoperative continence in these patients. METHODS: Forty-one patients operated on for anorectal malformations were evaluated retrospectively. These included 13 patients with low anomalies, 24 with high anomalies, and 4 with congenital pouch colon. Functional results after surgical correction were assessed on clinical basis using the Kelley's scoring system and by anorectal manometry. In addition, the electrical activity of contraction of the external sphincter muscle was studied using electromyography. RESULTS: There was direct correlation between anal canal pressures and Kelley's score in patients with both high and low anomalies; Kelley's score of 6, 5, 4, 3 and less had pressures ranging between 60-75, 45-59, 30-44, 15-29 and less than 15 cm H2O, respectively. However, the electromyographic activity did not correlate well with Kelley's score. CONCLUSIONS: Anorectal manometry correlates well with Kelley's scoring system and may be a more objective method of analyzing the results of surgery. Poor correlation between Kelley's score and electromyography may be a reflection of poor compliance with instructions to voluntarily contract the muscles of continence.

Neurogenic bladder: urodynamic and surgical aspects.

Children with spina bifida often have vesico-urethral dysfunction manifesting either as upper urinary tract deterioration or voiding dysfunction, chiefly incontinence. Surgery of the back and presence of or increase in hydrocephalus may contribute to neuro-urologic worsening; secondary cord tethering and syrinx or hydromyelia may be additional factors coming into play later in life. Urodynamic assessment using simple modalities like uroflowmetry, external sphincter EMG, residual urine volume and cystometry provide data useful to classify patients according to detrusor and sphincter activity. Besides diagnosis, urodynamic studies are useful in guiding therapy of children with vesico-urethral dysfunction, and for their follow-up to detect sub-clinical deterioration. They also help to prognosticate risk of upper tract deterioration and the possible success of measures to contain incontinence. Urodynamic data in thirty one patients with spinal dysraphism who presented to us with urologic symptoms were analysed. Twenty-three children had hyper-reflexic bladders while in the other 8 the bladder was areflexic. 13 children showed upper tract dilatation. The leak point volume was significantly lower in this group of patients compared to those who did not show upper tract dilatation. Our results are comparable to earlier similar studies.