Characteristics Among Premenarchal Girls With Lichen Sclerosus.

OBJECTIVES: Lichen sclerosus (LS), a chronic inflammatory dermatosis localized in the anogenital region, is known to be associated with lower urinary tract symptoms (LUTS) in postmenopausal women; however, there is a paucity of data on prepubertal girls. We sought to characterize the relationship between LS, LUTS, and constipation among premenarchal girls. MATERIALS AND METHODS: We conducted a retrospective chart review of premenarchal girls presenting at the pediatric adolescent gynecology and pediatric urology clinics at our institution diagnosed with vulvar LS during a 4-year period. Demographics, clinical presentation, time from onset of urinary and/or bowel symptoms to LS diagnosis, and treatment response were assessed. Analysis was completed using median, range, and nonparametric statistical analysis where appropriate. RESULTS: Nineteen premenarchal girls with LS met inclusion criteria. The median age at LS diagnosis was 6.2 years (range = 3.3-13.3 yrs). Most girls (12/19, 63.2%) presented with LUTS during LS evaluation, and 11 (57.9%) of 19 patients had constipation. Pruritus and hypopigmentation were the most frequently encountered LS symptom and sign, respectively. Fourteen (73.7%) of the 19 girls had resolution/improvement of LS symptoms after LS treatment. Of the 12 patients with LUTS, 7 (58.3%) had resolution/improvement of LUTS symptoms, 3 (25.0%) had unchanged voiding symptoms, and 2 (16.7%) had unknown changes. CONCLUSIONS: Although further studies are needed to better characterize the relationship between LUTS, constipation, and LS, our findings suggest that premenarchal subjects presenting with LUTS should be assessed for LS. Likewise, patients presenting with LS should be assessed for LUTS and constipation.

Predicting Breakthrough Urinary Tract Infection: Comparative Analysis of Vesicoureteral Reflux Index, Reflux Grade and Ureteral Diameter Ratio.

PURPOSE: The vesicoureteral reflux index is a simple, validated tool for predicting resolution of reflux. Along with likelihood of spontaneous resolution identification of children at risk for febrile urinary tract infection impacts management. We evaluated the usefulness of the vesicoureteral reflux index as a predictive factor for breakthrough febrile urinary tract infection compared to reflux grade and distal ureteral diameter ratio. MATERIALS AND METHODS: Children with primary vesicoureteral reflux and detailed voiding cystourethrogram data were identified. A 1 to 6-point index was assigned, and ureteral diameter ratio was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between L1 to L3 vertebral bodies. Random forest modeling and logistic multivariable regression were employed to estimate the predictive ability of grade, ureteral diameter ratio and vesicoureteral reflux index with regard to breakthrough febrile urinary tract infection. RESULTS: We analyzed 94 girls and 45 boys with a mean±SD age of 5.4±4.7 months at diagnosis. Mean±SD length of followup was 32.1±24.5 months. A total of 13 children (9.4%) experienced breakthrough febrile urinary tract infection. On univariate analysis ureteral diameter ratio (p=0.01) and vesicoureteral reflux index (p=0.0005) were associated with breakthrough urinary tract infection, while grade (p=0.09) did not reach significance. Area under the curve was generated as a measure of accuracy for each variable and was 0.77 for the vesicoureteral reflux index, 0.71 for ureteral diameter ratio and 0.68 for grade, indicating superiority of the vesicoureteral reflux index for predicting breakthrough febrile urinary tract infection. CONCLUSIONS: Children with higher vesicoureteral reflux index are at increased risk for breakthrough febrile urinary tract infection independent of reflux grade. The vesicoureteral reflux index provides valuable prognostic information about infection risk, facilitating improved clinical decision making.

Accuracy of subjective vesicoureteral reflux timing assessment: supporting new voiding cystourethrogram guidelines.

BACKGROUND: Bladder volume at the onset of vesicoureteral reflux (VUR) is an important prognostic indicator of spontaneous resolution and the risk of pyelonephritis. OBJECTIVE: We aim to determine whether pediatric urologists and pediatric radiologists can accurately estimate the timing of reflux by examining voiding cystourethrogram (VCUG) images without prior knowledge of the instilled contrast volume. MATERIALS AND METHODS: Total bladder volume and the volume at the time of reflux were collected from VCUG reports to determine the volume at the onset of VUR. Thirty-nine patients were sorted into three groups: early-/mid-filling reflux, late-filling and voiding only. Thirty-nine images were shown to three pediatric urologists and two pediatric radiologists in a blinded fashion and they were then asked to estimate VUR timing based on the above categories. A weighted kappa statistic was calculated to assess rater agreement with the gold standard volume-based report of VUR timing. RESULTS: The mean patient age at VCUG was 3.1±2.9 months, the median VUR was grade 3, and 20 patients were female. Overall agreement among all five raters was moderate (k=0.43, 95% confidence interval [CI] 0.36-0.50). Individual agreement between rater and gold standard was slight to moderate with kappa values ranging from 0.13 to 0.43. CONCLUSION: Pediatric radiologists and urologists are unable to accurately and reliably characterize VUR timing on fluoroscopic VCUG. These findings support the recently published American Academy of Pediatrics protocol recommending the routine recording of bladder volume at the onset of VUR as a standard component of all VCUGs to assist in a more accurate assessment of the likelihood of resolution and risk of recurrent urinary tract infections.

Evolving surgical management of pediatric vesicoureteral reflux: is open ureteral reimplantation still the 'Gold Standard'?

Vesicoureteral reflux, the retrograde flow of urine from the bladder into the upper urinary tract, is one of the most common urologic diagnoses in the pediatric population. Once detected, therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose prophylactic antibiotics to a variety of operative interventions. While a standardized algorithm is lacking, it is generally accepted that management be tailored to individual patients based on various factors including age, likelihood of spontaneous resolution, risk of subsequent urinary tract infections with renal parenchymal injury, and parental preference. Anti-reflux surgery may be necessary in children with persistent reflux, renal scarring or recurrent pyelonephritis after optimization of bladder and bowel habits. Open, laparoscopic/robot-assisted and endoscopic approaches are all successful in correcting reflux and have been shown to reduce the incidence of febrile urinary tract infections.

New trends in voiding cystourethrography and vesicoureteral reflux: Who, when and how?

Vesicoureteral reflux, retrograde flow of urine from the bladder into the upper urinary tract, is one of the most common urological diagnoses in the pediatric population. Diagnosis and subsequent management of urinary reflux have become increasingly debated in the past decade, with divergent opinions over which patients should be evaluated for reflux, and when detected, which children should receive intervention. Although some argue that vesicoureteral reflux is a "phenotype" that often resolves without intervention, others contest that untreated reflux has the potential to cause irreversible renal damage over time. Voiding cystourethrogram images the urethra and bladder during both bladder filling and emptying, as well as the ureters and kidneys when reflux is present, and is considered the gold standard for diagnosing vesicoureteral reflux. Once detected, therapeutic options for urinary reflux are diverse, ranging from observation with or without low-dose antibiotic prophylaxis to a variety of operative interventions. Management should be based on a multitude of factors including patient age, risk of subsequent urinary tract infections, risk of renal parenchymal injury, a given child's projected clinical course and parental preference. Over the past two decades, investigators have elucidated many crucial voiding cystourethrogram findings in addition to grade that provide significant prognostic information and are useful in determining the best course of action for a child on a more individualized basis.

Distal Ureteral Diameter Ratio is Predictive of Breakthrough Febrile Urinary Tract Infection.

PURPOSE: Distal ureteral diameter ratio is an objective measure that is prognostic of spontaneous resolution of vesicoureteral reflux. Along with likelihood of resolution, improved identification of children at risk for recurrent febrile urinary tract infections may impact management decisions. We evaluated the usefulness of ureteral diameter ratio as a predictive factor for breakthrough febrile urinary tract infections. MATERIALS AND METHODS: Children with primary vesicoureteral reflux and detailed voiding cystourethrogram were identified. Ureteral diameter ratio was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between L1 and L3 vertebral bodies. Demographics, vesicoureteral reflux grade, laterality, presence/absence of bladder-bowel dysfunction, and ureteral diameter ratio were tested in univariate and multivariable analyses. Primary outcome was breakthrough febrile urinary tract infections. RESULTS: We analyzed 112 girls and 28 boys with a mean ± SD age of 2.5 ± 2.3 years at diagnosis. Vesicoureteral reflux was grade 1 to 2 in 64 patients (45.7%), grade 3 in 50 (35.7%), grade 4 in 16 (11.4%) and grade 5 in 10 (7.2%). Mean ± SD followup was 3.2 ± 2.7 years. A total of 40 children (28.6%) experienced breakthrough febrile urinary tract infections. Ureteral diameter ratio was significantly greater in children with (0.36) vs without (0.25) breakthrough febrile infections (p = 0.004). Controlling for vesicoureteral reflux grade, every 0.1 U increase in ureteral diameter ratio resulted in 1.7 times increased odds of breakthrough infection (95% CI 1.24 to 2.26, p <0.0001). CONCLUSIONS: Children with increased distal ureteral diameter ratio are at greater risk for breakthrough febrile urinary tract infections independent of reflux grade. Ureteral diameter ratio provides valuable prognostic information about risk of recurrent pyelonephritis and may assist with clinical decision-making.

Vesicoureteral Reflux Index: Predicting Primary Vesicoureteral Reflux Resolution in Children Diagnosed after Age 24 Months.

PURPOSE: The Vesicoureteral Reflux Index is a validated tool that reliably predicts spontaneous resolution of reflux or at least 2 grades of improvement for patients diagnosed before age 24 months. We evaluated the Vesicoureteral Reflux Index in children older than 2 years. MATERIALS AND METHODS: Patients younger than 18 years who were diagnosed with primary vesicoureteral reflux after age 24 months and had undergone 2 or more voiding cystourethrograms were identified. Disease severity was scored using the Vesicoureteral Reflux Index, a 6-point scale based on gender, reflux grade, ureteral abnormalities and reflux timing. Proportional subdistribution hazard models for competing risks identified variables associated with resolution/improvement at different time points. RESULTS: A total of 21 males and 250 females met inclusion criteria. Mean ± SD age was 4.0 ± 2.1 years and patients had a median vesicoureteral reflux grade of 2. The Vesicoureteral Reflux Index score improved by 1 point in 1 patient (100%), 2 points in 25 (67.6%), 3 points in 48 (37%), 4 points in 18 (21.4%) and 5 to 6 points in 4 (18.2%). Female gender (p = 0.005) and vesicoureteral reflux timing (late filling, p = 0.002; early/mid filling, p <0.001) independently predicted nonresolution. Median resolution time based on Vesicoureteral Reflux Index score was 2 months or less in 15.6% of patients (95% CI 11.0-13.8), 3 months in 34.7% (95% CI 25.4-44.1), 4 months in 55.9% (95% CI 40.1 to infinity) and 5 months or more in 30.3% (95% CI 29.5 to infinity). High grade (IV or V) reflux was not associated with resolution at any point. Ureteral abnormalities were associated with lack of resolution in the first 12 to 18 months (HR 0.29, 95% CI 0.29-0.80) but not in later followup. Vesicoureteral Reflux Index scores of 3, 4 and 5 were significantly associated with lack of resolution/improvement compared to scores of 2 or less (p = 0.031). CONCLUSIONS: The Vesicoureteral Reflux Index reliably predicts primary vesicoureteral reflux improvement/resolution in children diagnosed after age 24 months. Spontaneous resolution/improvement is less likely as Vesicoureteral Reflux Index score and time from diagnosis increase.

Dysfunctional Voiders-Medication Versus Urotherapy?

PURPOSE OF REVIEW: Dysfunctional voiding is defined as "habitual contraction of the urethral sphincter during voiding." Children with dysfunctional voiding remain a challenge, and the approach to and management of LUT dysfunction varies widely among programs and providers with the role of pharmacotherapy being ill defined. RECENT FINDINGS: Animated biofeedback is the current treatment modality of choice in children who are not responsive to standard urotherapy. Comprehensive biofeedback programs incorporate continued elimination education, voiding diaries, and home exercises with high success rates. Recent studies suggest botulinum toxin A results in persistent satisfactory results in select children with refractory dysfunctional voiding. Conservative measures including an aggressive bowel regimen and timed voiding are the mainstays of treatment, and motivated children with persistent symptoms often respond favorably to escalating urotherapy with biofeedback. Pharmacotherapy plays an ancillary role in the management of dysfunctional voiding.

Vesicoureteral Reflux Index: 2-Institution Analysis and Validation.

PURPOSE: The vesicoureteral reflux index is a novel tool designed to predict spontaneous reflux resolution in infants younger than 2 years. We performed a multi-institutional validation study to confirm the discriminatory power of the vesicoureteral reflux index to predict the vesicoureteral reflux resolution rate in young children. MATERIALS AND METHODS: We identified patients diagnosed with primary vesicoureteral reflux before age 24 months who had 2 or more voiding cystourethrograms available. Demographics, vesicoureteral reflux grade and timing, ureteral anomalies and radiographic outcomes were evaluated. The C-index was estimated for time to event model assessment. RESULTS: A total of 219 girls and 150 boys met study inclusion criteria. Mean ± SD age at diagnosis was 4.7 ± 4.9 months. Of the patients 101 (27.4%) had early to mid filling, 214 (58%) had late filling and 54 (14.6%) had voiding only vesicoureteral reflux. High grade reflux was present in 87 patients (23.6%) and ureteral anomalies were observed in 50 (13.6%). A vesicoureteral reflux index of 1, 2, 3, 4 and 5 or greater showed an improvement/resolution rate of 88.2%, 77.3%, 62.3%, 32.1% and 14.3%, respectively. On time to event analysis children with filling phase vesicoureteral reflux (p <0.001), grade 4-5 reflux (p <0.001) and ureteral anomalies (p = 0.003) had significantly longer median time to resolution. Median time to spontaneous resolution was 12.6, 12.7, 15.1, 25.6 and 31 months or greater for a vesicoureteral reflux index of 1, 2, 3, 4 and 5 or greater, respectively (C-index 0.305, 95% CI 0.252-0.357). During the study period 65 patients (17.6%) underwent surgical intervention. CONCLUSIONS: The vesicoureteral reflux index is a simple tool that reliably predicts significant improvement and spontaneous resolution of primary reflux in patients diagnosed at younger than 2 years. The index provides valuable prognostic information, facilitating individualized patient care.

Urodynamic catheter moisture sensor: A novel device to improve leak point pressure detection.

AIMS: High-quality urodynamic studies in patients with neurogenic lower urinary tract dysfunction are important, as UDS may be the only reliable gauge of potential risk for upper tract deterioration and the optimal tool to guide lower urinary tract management. Reliance on direct visualization of leakage during typical UDS remains a potential source of error. METHODS: Given the necessity of accurate leak point pressures, we developed a wireless leak detection sensor to eliminate the need for visual inspection during UDS. RESULTS: A mean decrease in detrusor leak point pressure of 3 cm/H2 0 and a mean 11% decrease in capacity at leakage was observed when employing the sensor compared to visual inspection in children undergoing two fillings during a single UDS session. CONCLUSION: Removing the visual inspection component of UDS may improve accuracy of pressure readings. Neurourol. Urodynam. 35:647-648, 2016. © 2015 Wiley Periodicals, Inc.

Bladder volume at onset of vesicoureteral reflux is an independent risk factor for breakthrough febrile urinary tract infection.

PURPOSE: Improved identification of children with vesicoureteral reflux at risk for recurrent febrile urinary tract infection may impact management decisions. We hypothesized that reflux occurring earlier during bladder filling increases the duration of exposure of the kidneys to bacteria, and, therefore, increases the risk of pyelonephritis. MATERIALS AND METHODS: Children with vesicoureteral reflux and detailed voiding cystourethrogram data were identified. Bladder volume at onset of reflux was normalized for age. Demographics, reflux grade, laterality, presence/absence of bladder-bowel dysfunction and breakthrough febrile urinary tract infections were assessed. Median followup was 24 months (IQR 12 to 52). RESULTS: A total of 208 girls and 47 boys were analyzed with a mean ± SD age at diagnosis of 3.1 ± 2.6 years. On univariate analysis history of febrile urinary tract infection (HR 2.17, 95% CI 1.33-2.85, p = 0.01), dilating vesicoureteral reflux (HR 1.6, 95% CI 1.05-2.42, p = 0.03) and bladder-bowel dysfunction (HR 1.66, 95% CI 0.99-2.75, p = 0.05) were associated with an increased risk of breakthrough febrile urinary tract infection. Median bladder volume at onset of reflux in children with breakthrough febrile urinary tract infection was significantly less (33.1%) than in those without infection (49.5%, p = 0.003). Reflux onset at 35% predicted bladder capacity or less was associated with a significantly increased risk of breakthrough febrile urinary tract infection on multivariate analysis (HR 1.58, 95% CI 1.05-2.38, p = 0.03). CONCLUSIONS: Children with early filling vesicoureteral reflux are at increased risk for breakthrough febrile urinary tract infection independent of reflux grade. Bladder volume at onset of reflux should be recorded during cystograms since it provides additional prognostic information about the risk of pyelonephritis and resolution, and may assist with counseling and clinical decision making.

Early effect of American Academy of Pediatrics Urinary Tract Infection Guidelines on radiographic imaging and diagnosis of vesicoureteral reflux in the emergency room setting.

PURPOSE: In 2011 the AAP revised practice parameters on febrile urinary tract infection in infants and children 2 to 24 months old. New imaging recommendations invigorated the ongoing debate regarding the diagnosis and management of vesicoureteral reflux. We compared evaluations in these patients with febrile urinary tract infection before and after guideline publication. MATERIALS AND METHODS: During 2 separate 6-month periods 350 patients 2 to 24 months old were evaluated in the emergency room setting. Demographics, urine culture, renal-bladder ultrasound, voiding cystourethrogram and admission status were assessed. RESULTS: A total of 172 patients presented with initial febrile urinary tract infection in 2011, of whom 47 (27.3%) required hospitalization, while 42 of 178 (23.6%) were admitted in 2012. Admission by year did not significantly differ (p = 0.423). After guideline revision 41.2% fewer voiding cystourethrograms were done (72.1% of cases in 2011 vs 30.9% in 2012, p <0.001). A 17.2% decrease in renal-bladder ultrasound was noted (75.6% in 2011 vs 58.4% in 2012, p <0.001). Of 55 voiding cystourethrograms 21 (38.2%) were positive in 2012 compared to 36.3% in 2011 (p = 0.809). Mean ± SD maximum vesicoureteral reflux grade was unchanged in 2011 and 2012 (2.9 ± 1.2 and 2.5 ± 0.93, respectively, p = 0.109). There was no association between abnormal renal-bladder ultrasound and voiding cystourethrogram positivity (p = 0.116). CONCLUSIONS: AAP guidelines impacted the treatment of infants and young children with febrile urinary tract infection. We found no relationship between renal-bladder ultrasound and abnormal voiding cystourethrogram, consistent with previous findings that call ultrasound into question as the determinant for additional imaging. Whether forgoing routine voiding cystourethrogram results in increased morbidity is the subject of ongoing study.

Controversies in the Management of Vesicoureteral Reflux.

Vesicoureteral reflux (VUR) is the abnormal retrograde flow of urine from the bladder into the upper urinary tract. Diagnosis and subsequent management of VUR have become increasingly controversial, with differing opinions over which children should be evaluated for reflux, and when detected, who should undergo treatment. Management goals include prevention of recurrent febrile urinary tract infection (fUTI) and renal injury while minimizing the morbidity of treatment and follow-up. Management options include observation with or without continuous antibiotic prophylaxis and surgical correction via endoscopic, open or laparoscopic/robotic approaches. Management should be individualized and based on patient age, health, risk of subsequent renal injury, clinical course, renal function, and parental preference.

Emergency Hospital Admissions for Initial Febrile Urinary Tract Infection: Do Patient Demographics Matter?

BACKGROUND: In 2011, the American Academy of Pediatrics revised practice parameters regarding febrile urinary tract infection (fUTI) in children aged 2-24 months. The Section on Urology opposed the omission of voiding cystourethrogram (VCUG), and expressed concern that potential untoward consequences of deferring VCUG may be most felt by children on Medicaid. OBJECTIVE: We ascertained imaging and characteristics of children presenting to the Emergency Department (ED) with initial fUTI to determine the impact of patient demographics on admissions for pyelonephritis. METHODS: Children aged 2-24 months presenting to the ED with initial fUTI were identified. Demographics, insurance status, laboratory studies, renal-bladder ultrasound (RBUS), VCUG, and hospital admission status were evaluated. RESULTS: Three-hundred fifty patients met inclusion criteria; 88 (25.1%) were admitted. Admitted patients were significantly (p < 0.001) younger (mean 0.31 ± 0.33 years) than those managed as outpatients (mean 0.91 ± 0.7 years). On univariate analysis, male gender (p < 0.001), Medicaid insurance (p < 0.05), and non-Hispanic race (p < 0.05) were associated with admission. Race retained significance on multivariate analysis; Caucasian children were 2.35 times (95% confidence interval [CI] 0.79-7.23) and African-American children 3.8 times more likely to be admitted than Hispanic patients (95% CI 1.88-7.63). Children with abnormal RBUS were 12.8 times more likely to require admission (95% CI 4.44-37.0). Medicaid was also independently predictive of admission; such patients were 2.6 times more likely to be admitted than those with private insurance (95% CI 1.15-5.88). CONCLUSIONS: Abnormal ultrasound, non-Hispanic race, and public insurance were strongly associated with hospital admission in children presenting to the ED with initial febrile urinary tract infection.

Temporal pattern of vesicoureteral reflux on voiding cystourethrogram correlates with dynamic endoscopic hydrodistention grade of ureteral orifice.

PURPOSE: The double hydrodistention implantation technique uses ureteral hydrodistention to visualize injection site(s) and determine required bulking agent volume. Along with grade, early vesicoureteral reflux on voiding cystourethrogram provides prognostic information regarding spontaneous resolution of reflux. We hypothesized that reflux timing is predictive of endoscopic hydrodistention grade. MATERIALS AND METHODS: We identified children undergoing the double hydrodistention implantation technique for primary vesicoureteral reflux between 2009 and 2012. Hydrodistention grade (0 to 3) was assigned prospectively, and compared to vesicoureteral reflux grade and timing on voiding cystourethrogram. RESULTS: A total of 196 children with a mean ± SD age of 3.94 ± 2.58 years underwent injection of 332 ureters. Mean ± SD vesicoureteral reflux grade was 2.8 ± 0.9. Of the ureters 52.4% demonstrated early to mid filling, 39.2% late filling and 8.4% voiding only reflux. Mean ± SD reflux grade was 3.1 ± 0.81 for early filling, 2.6 ± 0.81 for late filling and 2.1 ± 1.1 for voiding only (p <0.0001). Vesicoureteral reflux and hydrodistention grades correlated, with higher reflux grades associated with grade 3 hydrodistention (p <0.001). There was a significant relationship between reflux timing and hydrodistention grade (p <0.001), with a high percentage of ureters with grade 3 hydrodistention displaying early reflux compared to those with grade 1 disease. Significantly increased mean injected volume for ureters with grade 3 hydrodistention (1.6 ml) was observed compared to those with grade 1 or 2 disease (1.25 ml, p <0.001). CONCLUSIONS: Hydrodistention grade correlates with vesicoureteral reflux grade, timing of reflux and injected volume. Early to mid filling vesicoureteral reflux is associated with abnormal hydrodistention (grade 2 to 3). Temporal pattern of vesicoureteral reflux on voiding cystourethrogram may be used to predict ureteral orifice competency and thus aid in predicting resolution of reflux.

Functional supernumerary testis in a child with testicular torsion and review of polyorchidism.

Histologically confirmed polyorchidism is an uncommon condition. The majority of cases are asymptomatic and associated with inguinal hernia or cryptorchidism. There are few reported cases of pediatric supernumerary testis presenting with testicular torsion. We present a case of missed torsion with incidentally detected triorchidism as well as an overview of pediatric polyorchidism.