Angiography of the testicular artery as a diagnostic aid in boys with nonpalpable testis.

Selective angiography of the testicular artery was performed in 12 boys (age 3-14 yr) with nonpalpable testis. The angiographic, operative, and microscopic findings are described. True aplasia was diagnosed in seven patients. In three patients previously operated upon, the second exploration was facilitated by angiography. This method might be a valuable diagnostic aid in selected cases previously operated for gonadal disorders or inadequately explored for cryptorchism in order to avoid more extensive surgical exploration.

Efficacy, safety, and dosing of desmopressin for nocturnal enuresis in Europe.

Desmopressin is a potent antidiuretic for nocturnal enuresis with few and mostly insignificant adverse reactions. Almost 80 years ago, the antidiuretic effects of extracts of the posterior pituitary were first reported. The molecular structure of the peptide vasopressin arginine vasopressin (AVP) became known in 1956, and by 1967, a synthesized modification of AVP, known as DDAVP, or desmopressin, was introduced. Toxicity studies performed on experimental animals support the conclusion that desmopressin is considerably more potent as an antidiuretic than AVP and has an exceptional safety margin. Further, clinical experience reveals that from 1974 to June 1992 only 21 patients using desmopressin had serious adverse reactions (water intoxication), and no fatalities occurred. Seven of 10 children with nocturnal enuresis who receive desmopressin stop their bedwetting completely or reduce it significantly, with best results noted in children over 10 years of age. Given these results, the preferred treatment in Europe for children with nocturnal enuresis is the sequential combination of desmopressin and the enuresis alarm.

Medical or surgical management for children with vesico-ureteric reflux?

A critical survey of the literature on treatment of children with vesico-ureteric reflux was carried out in order to create a basis for the new Swedish management policy. There are few studies that meet modern standards of scientific methodology and provide adequate patient numbers. The only large investigations that randomized patients to operative or non-operative treatment were the Birmingham Reflux Study and the International Reflux Study in Children. In these studies, long-term outcome of renal status and renal function, as well as the number of recurrent infections, were independent of treatment modality. Although pyelonephritic recurrences were less common in the surgically managed group, this did not influence appearance of renal damage. There is no evidence to indicate clear superiority of either medical or surgical management. Further studies are needed to address such questions as the optimal duration of antibacterial prophylaxis and the effect of a dilating reflux that persists into adulthood.

Vesico-ureteric reflux and other risk factors for renal damage: identification of high- and low-risk children.

This article reviews the literature with respect to various risk factors for permanent renal damage in children with urinary tract infection. Vesico-ureteric reflux is an important risk factor, but renal damage can occur in the absence of reflux. Renal damage does not always occur in the presence of gross reflux. Renal scars always develop at the same site as a previous infection in the kidney. Recurrent pyelonephritis and delay in therapy increase the likelihood of renal damage, although it is not known how long a delay is dangerous to the human kidney. Recent studies using 99mtechnetium-dimercaptosuccinic acid (DMSA) scintigraphy have not confirmed the findings of previous studies showing that children below 1 y of age are more vulnerable to renal damage. It is more likely that all children run the risk of renal scarring in cases of acute pyelonephritis. The role of bladder pressure is still not entirely understood. Therefore more studies are needed in order to determine the relationship between high voiding pressures in some, otherwise healthy, children with urinary tract infection and renal scarring. The importance of bacterial virulence in the development of renal scarring is unclear. DMSA scintigraphy and voiding cystourethrography are the most reliable tools for identifying children at risk of renal scarring. As a single method DMSA scintigraphy appears to be better than voiding cystourethrography.

[A suggested treatment algorithm in nocturnal enuresis with emphasis on partial responders]. / Therapiealgorithmus bei Enuresis nocturna.

Monotherapeutic strategies often have only partial success in primary nocturnal enuresis (PNE). This analysis evaluated whether adjuvant treatment strategies improve outcomes. PNE children were submitted to a distinct therapeutic strategy including urotherapy (behavioral modifications), a first-line and, if necessary, a second-line treatment period. Outcome was the relief of bedwetting, the follow-up was 3-79 months. Urotherapy was applied. Nonresponders were assigned to desmopressin as first-line treatment. For complete responders a structured withdrawal program was applied. Partial responders were assigned to adjuvant second-line treatment according to their individual symptomatology, masked at basic investigations, incorporating either anticholinergics (propiverine hydrochloride), biofeedback, alpha-blocker (alfuzosin), alarm or psychotherapy, in addition to desmopressin. Nonresponders were referred to specialized management. The study included 259 children suffering from PNE (92 girls, 167 boys, aged 5-18 years): 42 children were relieved from bedwetting after urotherapy and 136 children had a complete response to desmopressin. Three nonresponders were assigned to specialized management, 61 partial responders had adjuvant treatments, and 17 partial responders had no further treatment. The suggested treatment algorithm resulted in 227 complete responders, 29 partial responders, and 3 nonresponders. The need for preliminary urotherapy is evident. The proposed desmopressin monotherapeutic strategy, incorporating a structured withdrawal program, is more effective than the standard desmopressin treatment module. Applying adjuvant treatment modules improves the complete response rate up to 88%. In partial responders overall efficacy rates are improved further. Nonresponders (1.2%) will be referred to specialized management, but many partial responders will gain improvement sufficient to refrain from invasive procedures.

Urodynamics in normal infants and children.

Urodynamic examination yields invaluable information about lower urinary tract function in infants and children in the following clinical situations: Daytime urinary incontinence, suspected infravesical obstruction, overt or suspected neurogenic bladder dysfunction, vesico-ureteral reflux with upper tract dilatation and chronic or recurrent bacteriuria. A normal development of lower urinary tract function during the first 5 years of life means that detrusor contractility will be successively more inhibited; furthermore, the child will become aware of bladder filling and will be able to postpone or initiate micturition. A disturbed or delayed development may well be the most important cause of dysfunctional states in the lower urinary tract later in life. Most urodynamic variables are age-dependent. Normal bladder capacity can be fairly well assessed by: Bladder capacity in ml = 30 + (age in years x 30). Normal maximum urinary flow during micturition (in ml/s) should approximately equal the square root of voided volume (in ml). The normal range (+/- 2SD) is given by the value thus obtained +/- 7 ml/s. Intravesical pressure is lower in girls than in boys, and lower in infants than in older children, but otherwise it does not vary with age. A tense and apprehensive child will not produce reliable urodynamic data. This is, no doubt, the most important source of error when examining children. It is strongly emphasized, therefore, that the examination has to be performed in a kind, understanding and relaxed atmosphere.

Urinary incontinence in children: suggestions for definitions and terminology.

The definition of childhood urinary incontinence, used here, is leakage of at least 1 ml of urine, at least once a week, in a child from 5 years of age. The types of incontinence are defined as detrusor incontinence (daytime urge incontinence and night-time enuresis), sphincter incontinence (presenting clinically as stress incontinence in the less serious form, as continuous dribbling of urine in the more serious one), and combined incontinence (the combination of detrusor hyperactivity and sphincter incompetence found in many children with neurogenic bladder dysfunction). Urinary incontinence in children is subdivided into night-time (most common) and daytime incontinence. Day wetting is aetiologically subdivided into incontinence due to organic or functional causes. The organic causes can be either structural (e.g. epispadias) or neurogenic. Functional day wetting is incontinence not caused by disease, injury or congenital malformation, and is almost always urge incontinence due to an unstable bladder. Unstable bladder in children may activate the sphincteric guarding reflex, leading to dyscoordination between the sphincter and the detrusor, and, eventually, overdistension of the bladder with a reduced contraction power of the detrusor ('lazy bladder'). Ultimately, Hinman's syndrome (non-neurogenic neurogenic bladder) may develop. The term enuresis should be used to denote incontinent, complete micturitions and should thus be reserved for bedwetting and giggle enuresis.

Functional daytime incontinence: definitions and epidemiology.

The definition of childhood urinary incontinence, used here, is leakage of at least 1 ml of urine at least once a week in a child from 5 years of age. Functional day wetting is incontinence not caused by disease, injury or congenital malformation, and is almost always urge incontinence due to an unstable bladder. The following figures for prevalence are quoted from the Gothenburg study of 35567-year-old school entrants. Any kind of urinary incontinence at least once a week was reported by 6% of the children. Day wetting at least once a week was found in 3.1% of the girls and 2.1% of the boys. Most of the day wetting children also had urgency which was reported in 82% of the girls and 74% of the boys. Bedwetting at least once a week was reported by 2.9% of the girls and 3.8% of the boys. The bedwetting was monosymptomatic (no additional symptoms, no day wetting) in 39% of the girls and 59% of the boys with nocturnal enuresis. Combined daytime and night-time incontinence was reported by 17% of the children, while 22% wet only by day, and 61% only by night. None of the 3556 children had a previously undetected organic cause for their incontinence. There is a strong association between bacteriuria and day wetting in girls, but not in boys. We do not know whether the bacteria cause the disturbance of bladder function, or vice versa. The cause and effect may work in both directions.

Desmopressin treatment: current status.

Desmopressin has a proven pharmacological effect in most enuretic patients, although a clinical response is not seen in all patients. Numerous questions about the current treatment status of desmopressin include the specific anti-enuretic effect of desmopressin, the effect of desmopressin on sleep and the use of desmopressin as a possible cure for enuresis. The Swedish Enuresis Trial has produced some very positive results on the long-term use of desmopressin, showing a 61% response rate (> 50% reduction in wet nights). Desmopressin has proven to be highly effective when used in combination with other treatments, including the alarm and oxybutinin, and after urotherapy. It is suggested that imipramine should not be used to treat enuresis unless the patient has attention deficit hyperactivity disorder. Bladder instability is also an important factor to consider when selecting treatment for enuresis. Bladder dysfunction (detrusor overactivity) can be the cause of lack of clinical response to either desmopressin or alarm treatment; in such cases, following a cystometrogram, patients should be treated with detrusor-relaxing drugs, and urotherapy should be considered as the first treatment option. The most effective treatment for enuresis is the treatment chosen by the patient and their families. Desmopressin and urotherapy have had promising results, with desmopressin acting as a bridge until spontaneous or treatment-induced remission occurs.

What is an acceptable treatment outcome?

Nocturnal enuresis is a multifactorial condition and, as such, is accessible to a variety of treatment modalities. In order to evaluate and compare the efficacies of different treatments in patients with specific pathophysiologies, studies should describe fully the patient population under investigation. In addition, many of the studies conducted to date have applied different outcome measures, making comparisons difficult. Therefore, it is necessary to define standard outcome measures that should be used universally. These may relate to the effect of the treatment on the number of wet nights per week, the effect on the family economy of a reduction in the number of episodes of enuresis and the effect on the child's self esteem and/or quality of life.

Functional daytime incontinence: pharmacological treatment.

The basis for the treatment of functional daytime incontinence in children is the bladder regimen, i.e. to teach the children to void regularly by the clock. Drug treatment may be needed as an adjunct to the regimen in children with gross detrusor instability. There is no evidence from properly controlled studies that tricyclic antidepressants or anticholinergic drugs are of value for the child with daytime wetting. Terodiline is a new drug combining anticholinergic and calcium-blocking effects. In two randomized, double-blind studies of terodiline compared with placebo in children with urge incontinence (i.e. functional day wetting), continence improved significantly over placebo in the terodiline group. Only a few mild adverse reactions were noted. Children with symptomatic urinary tract infection and day wetting should receive chemotherapy, but covert bacteriuria should best be left untreated. There is no evidence that eradication of the bacteriuria improves continence. Instead, there is a great risk of symptomatic recurrence of the urinary tract infection after antibacterial treatment.

Enuresis--background and treatment.

Nocturnal urinary continence is dependent on 3 factors: 1) nocturnal urine production, 2) nocturnal bladder function and 3) sleep and arousal mechanisms. Any child will suffer from nocturnal enuresis if more urine is produced than can be contained in the bladder or if the detrusor is hyperactive, provided that he or she is not awakened by the imminent bladder contraction. Urine production is regulated by fluid intake and several interrelated renal, hormonal and neural factors, foremost of which are vasopressin, renin, angiotensin and the sympathetic nervous system. Detrusor function is governed by the autonomic nervous system which under ideal conditions is under central nervous control. Arousal from sleep is dependent on the reticular activating system, a diffuse neural network that translates sensory input into arousal stimuli via brain stem noradrenergic neurons. Disturbances in nocturnal urine production, bladder function and arousal mechanisms have all been firmly implicated as pathogenetic factors in nocturnal enuresis. The group of enuretic children are, however, pathogenetically heterogeneous, and two main types can be discerned: 1) Diuresis-dependent enuresis - these children void because of excessive nocturnal urine production and impaired arousal mechanisms. 2) Detrusor-dependent enuresis - these children void because of nocturnal detrusor hyperactivity and impaired arousal mechanisms. The main clinical difference between the two groups is that desmopressin is usually effective in the former but not in the latter. There are two first-line therapies in nocturnal enuresis: the enuresis alarm and desmopressin medication. Promising second-line treatments include anticholinergic drugs, urotherapy and treatment of occult constipation.