The management of adolescents with neurogenic urinary tract and bowel dysfunction.

Most children with neurogenic bladder dysfunction arrive into adolescence with reasonably managed lower urinary tract function only to experience bladder and kidney function deterioration after puberty. The aim of this article is to identify issues that contribute to adverse changes in bladder and renal function during adolescence and to highlight strategies to preserve urinary tract integrity, social continence, patient autonomy, and independence. Surveillance of bladder function requires patient attendance at review appointments and compliance with treatment plans. While encouraging independence and treatment compliance the clinician also needs to consider altered mental concentrating ability and fine motor skills of these patients. A keen eye for imminent loss of patient compliance to treatment protocol should be the mainstay of each encounter during puberty and adolescence. Annual surveillance of adolescent neurogenic bladder patients facilitates early identification of risk factors for urinary tract deterioration. Investigations include renal and bladder ultrasonography, urodynamic study when indicated, substantiated by videocystometry when anatomical status dictates. Serum creatinine should be measured and renal scintigraphy performed when upper urinary tract dilation, renal scarring, or atrophy are suspected. Optimal management of adolescents with neurologic disease of the urinary tract included strategies to reduce elevated detrusor pressure, maintain bladder compliance, and maximize dryness. Antimuscarinic medications, botulinum toxin A, and surgical procedures are enhanced by bowel management regimens and regular nurse or urotherapist patient contact. Caring for the patient as a whole requires discussion of sexuality, fertility status, and behaviors that increase the risk of progressive urinary tract damage.

Assessment of non-neurogenic incontinence and lower urinary tract symptoms in adolescents and young adults.

AIMS: The aim of this article is to provide insight to clinicians who principally treat adults, about non-neurogenic lower urinary tract symptoms (LUTS) either pre-dating or presenting in adolescence. Assessment fundamentals, diagnostic classification, and rationale behind the process of care are discussed. METHODS: Standardized terms are used to describe the current classification of symptoms of LUT dysfunction in young adults. The etiology and symptomatology of continuous and organic incontinence, along with the intermittent presentations of incontinence, nocturnal enuresis, and bowel dysfunction are presented. Minimally acceptable assessment processes are defined. Indications for the inclusion of urodynamic investigations are presented. Throughout the review specific needs of adolescents, as they apply to clinical management of LUTS, are highlighted. RESULTS: Puberty and growth are likely to challenge compensatory mechanisms for a safe urinary system in young adults with organic/structural/developmental LUT disorders. The priority of care is to screen for and detect precursor signs of renal deterioration. In adolescents with non-neurogenic bladder dysfunction a clear diagnosis and identification of both incomplete bladder emptying and high detrusor pressure will minimize permanent changes to both the upper and lower urinary tracts. CONCLUSIONS: The assessment of adolescents with LUTS requires time, thoughtful enquiry, and communication. Dysfunction pre-dating young adulthood commonly inhibits autonomy, recreational and social activities thus impacting on the adolescent's self-esteem and adherence to treatment regimes.

The natural history of daytime urinary incontinence in children: a large British cohort.

AIM: Few studies have looked at the prevalence of daytime incontinence in a longitudinal cohort of children. This study set out to determine the prevalence of daytime incontinence and relationships between daytime incontinence and bedwetting, faecal incontinence and urgency in a large cohort of British children. METHODS: Parents of children taking part in the Avon Longitudinal Study of Parents and Children (ALSPAC) were asked questions concerning the child's daytime wetting, bedwetting and faecal incontinence at different time points, 4.5, 5.5, 6.5, 7.5 and 9.5 years. The difference between the sexes for these different conditions was compared. RESULTS AND LIMITATIONS: Data were available for 10 819 of the 13 973 children who entered the study. The prevalence of any daytime incontinence declined from 15.5% at 4.5 years to 4.9% at 9.5 years, and was mainly described as infrequent. Daytime incontinence was more common in girls than boys and frequent (DSM-IV) incontinence was more commonly related to urgency, bedwetting and faecal incontinence than infrequent incontinence. CONCLUSIONS: Daytime incontinence is relatively common among children of primary school age and frequent incontinence more commonly coexists with other conditions, such as bedwetting and urgency. This study suggests the need for treatment to focus on children with frequent incontinence.

Urinary symptoms and incontinence in women: relationships between occurrence, age, and perceived impact.

BACKGROUND: The prevalence of urinary symptoms that impact on quality-of-life will be important in determining resource allocation in primary care groups. AIM: To determine the prevalence of urinary symptoms and their perceived impact in a community population of women. METHOD: A postal survey using a validated self-completed questionnaire among all women aged over 18 years and registered with one general practice in a major British city. The prevalence rates and perceived impact of a wide range of urinary symptoms and their relationship with age was determined. Data were analysed using the chi-squared test and the chi-squared test for trend. Spearman's rank correlation was used to assess the relationship between symptom severity and perceived impact. RESULTS: The number of completed questionnaires returned was 2075, giving an 80% response rate. Of these, the number of women who reported some degree of incontinence in the previous month was 1414 (69%), although only 578 (30%) indicated that it had social or hygienic impact. Other lower urinary tract symptoms reported included nocturia (19%), poor stream (19%), urgency (61%), and dysuria (23%). The most troublesome symptoms were incontinence for no obvious reason, nocturnal incontinence, and nocturia, with 73%, 69%, and 63% of sufferers, respectively, finding these symptoms troublesome. CONCLUSIONS: Incontinence and other urinary symptoms are more common than previously thought. These symptoms are not always perceived as bothersome or as having a social or hygienic impact, and therefore many women who report urinary leakage do not require treatment. Nocturnal symptoms in women are commoner than might have been supposed and are extremely troublesome to sufferers.

The effect of fluid intake on urinary symptoms in women.

PURPOSE: We determined the effect of caffeine restriction and fluid manipulation in the treatment of patients with urodynamic stress incontinence and detrusor overactivity. MATERIALS AND METHODS: This was a 4-week randomized, prospective, observational crossover study in 110 women with urodynamic stress incontinence (USI) or idiopathic detrusor overactivity (IDO) to determine the effect of caffeine restriction, and of increasing and decreasing fluid intake on urinary symptoms. Data were recorded in a urinary diary for the entire study period on urgency episodes, frequency, pad weight increase, wetting episodes and quality of life. RESULTS: A total of 69 women with a mean age of 54.8 years completed the study, including 39 with USI and 30 with IDO. In the IDO group decreasing fluid intake significantly decreased voiding frequency, urgency and wetting episodes with improved quality of life. In the USI group there was a significant decrease in wetting episodes when fluid intake was decreased. Changing from caffeine containing to decaffeinated drinks produced no improvement in symptoms. CONCLUSIONS: Conservative and life-style interventions are first line treatments in the management of incontinence and storage lower urinary tract symptoms. This study shows that a decrease in fluid intake improves some of these symptoms in patients with USI and IDO and, therefore, it should be considered when treating such patients.

Pediatric urodynamics: baseline audit and effect on management.

OBJECTIVES: To undertake a baseline audit of our pediatric urodynamic service, identifying areas for improvement, and to determine whether clinical management was affected by urodynamic results. PATIENTS AND METHODS: All pediatric urodynamic studies during one calendar year were reviewed to determine the quality of reports that were issued and to assess any problems encountered. A postal questionnaire was sent to all referring doctors to determine whether the urodynamic report had influenced management. RESULTS: In all, 48 children attended for videocystometry, with successful tests in 39 (81%); 97% of written reports were judged to contain adequate information. In all, 33 postal questionnaires were returned (85%); in 30 (91%) the referring clinician felt that the urodynamic result had directly influenced management. CONCLUSION: The audit highlighted areas for improvement, which have been addressed. The response from the postal questionnaire showed that urodynamics directly influenced the management of children with complex urological and neurological abnormalities.

Trying to predict 'dangerous' bladders in children: the area under the curve concept.

OBJECTIVE: Children with neurological and non-neurological lower urinary tract dysfunction normally undergo video urodynamics. One reason is to try to diagnose 'dangerous' bladders. Currently, bladder compliance is used to predict 'dangerous' bladders; however, in children there are no standardized methods of measurement and thus no 'cut-off' values. Compliance may also be normal even though high-pressure detrusor overactivity waves may exist during the filling phase of urodynamics. We tried to determine whether measuring the area under the detrusor pressure curve (AUC) during the filling phase of urodynamics would be a useful parameter in predicting 'dangerous' bladders. PATIENTS AND METHODS: Children referred to the urodynamics unit at Southmead Hospital, a tertiary referral centre, from 2000 to 2004 were investigated. Although 130 patients were identified, only 15 patients had raw data which were analysable using the available computer software. RESULTS: There was no correlation between the AUC and predicting 'dangerous' bladders possibly due to limitations in the computer software. CONCLUSION: Although the study did not reveal any correlation between the AUC and 'dangerous' bladders, it revealed the limitations of the available computer software in determining AUC, and highlighted the need for new standardized software and multinational, multi-centre trials to look into the concept of AUC. There is also a need for the International Continence Society to standardize methods and terminology in predicting 'dangerous' bladders.

Nocturnal polyuria in community-dwelling women.

OBJECTIVE: To determine the age prevalence of nocturnal polyuria among older women in the community, and to investigate the relationship between nocturnal polyuria and nocturia. PATIENTS AND METHODS: In all, 1183 women aged > or = 50 years, who were registered with a family doctor practice and who had taken part in a prevalence study, were sent brief questionnaires and a frequency/volume chart (FVC) to complete. RESULTS: There were 227 FVCs with adequate data and 264 completed questionnaires available for analysis. The prevalence of nocturnal polyuria increased disproportionately with age. There was no clear relationship between nocturia or nocturnal polyuria and daytime frequency, nor was there a clear relationship between diuretic use and nocturnal polyuria. CONCLUSION: Nocturnal polyuria is common among women in the community and not obviously related to daytime frequency. Night-time symptoms are common in women as well as men, and are troublesome to them.

Role of ambulatory urodynamic monitoring in clinical urological practice.

A retrospective review was conducted of 125 ambulatory monitoring (AM) studies performed on 111 women and 11 men between 1992 and 1996. All patients had had conventional cystometry prior to AM. All tests were interpreted with the aid of event markers and urinary diaries. Ambulatory traces were reported using the definitions derived from Coolsaet's work. To assess the role of AM in routine clinical urological practice, ambulatory diagnoses were compared with those of conventional cystometry. A survey of patient management was carried out by postal questionnaire or review of hospital notes to determine whether AM had influenced patient management. The study showed that 53 of 94 (56.3%) patients with symptoms suggestive of detrusor overactivity had detrusor instability diagnosed on AM. Of those with symptoms suggestive of stress incontinence, 5 (29%) had genuine stress incontinence and 5 (29%) had detrusor instability. The remainder (42%) had normal tests. Overall in 79 of 125 tests (63.2%), additional urodynamic findings were made that correlated with symptoms. Following the survey of patient management, AM was shown to influence management in all but 8.7% patients. In summary, AM was felt to have been shown to be a useful additional tool in clinical urological practice for those patients where conventional cystometry had failed to explain their symptoms.

Nocturnal incontinence in women: a hidden problem.

PURPOSE: We determined the prevalence of nocturnal incontinence and its association with other storage symptoms in a community population of women MATERIALS AND METHODS: We mailed the validated self-reporting Bristol female lower urinary tract symptom questionnaire to all 2,641 women 19 years old or older registered at a family physician practice in a major British city and analyzed the results. Main outcome measures were the prevalence of nocturnal incontinence and its correlation with other storage symptoms. RESULTS: A total of 2,075 completed questionnaires (80%) were returned. The overall prevalence of nocturnal incontinence was 5.8%. However, the majority of women had nocturnal incontinence only occasionally and only 1% had it more than a third of the time. The prevalence of nocturnal incontinence increased in a linear fashion with age (chi-square test for linear trend p <0.005). Of the women with nocturnal incontinence 69% considered it troublesome. The odds of nocturnal incontinence were significantly increased when urge and stress incontinence, incontinence with no obvious cause, urgency, straining and nocturia were reported. CONCLUSIONS: Nocturnal incontinence in women is more common than generally supposed and troublesome. The rate of nocturnal incontinence increases with coexisting storage symptoms.

The Bristol Female Lower Urinary Tract Symptoms questionnaire: development and psychometric testing.

OBJECTIVE: To develop a questionnaire that is sensitive to changes in the symptomatology of the female lower urinary tract, particularly urinary incontinence, providing an instrument that can characterize symptom severity, impact on quality of life and evaluate treatment outcome. PATIENTS, SUBJECTS AND METHODS: Items covering as wide a range of urinary symptoms as possible were devised after consultation with clinicians and a health scientist, a literature review and discussion with patients. Additional items assessed the degree of 'bother' that symptoms were causing. Eighty-five women with clinical symptoms attending for urodynamic assessment and 20 women with none were asked to self-complete the questionnaire. The instrument's validity was assessed by interviewing patients and measuring levels of missing data, comparing symptom scores between clinical and non-clinical populations and comparison with frequency/volume charts and data from pad tests. The instrument's reliability was assessed by measuring both internal consistency and stability, using a 2-week test-retest analysis. RESULTS: The questionnaire was completed by the patients with a mean of only 2% of items missing; most questions were easily understood. Construct validity was good, with the instrument easily differentiating clinical and non-clinical populations. Criterion validity, as tested against frequency/volume charts and pad-test data, was acceptable, with Kappa coefficients of 0.29-0.79 for frequency/volume data and Spearman rank correlations of 0.50-0.97 and 0.31-0.67 for frequency/volume and pad-test data, respectively. The reliability of the instrument was good; a Cronbach's alpha of 0.78 indicated that the symptom questions had high internal consistency, while stability was excellent, with 78% of symptoms and problems answered identically on two occasions, and Spearman rank correlations of 0.86 and 0.90, respectively. CONCLUSION: The instrument has good psychometric validity and reliability. The stability demonstrated at baseline and the ability to differentiate clearly between community and clinical populations suggest that it should be ideal for measuring changes following therapeutic intervention. The addition of life-impact items and a 'bother' factor may provide the opportunity to identify those women who wish treatment for their symptoms; this dimension requires further exploration.

The natural history of urinary symptoms during adolescence.

OBJECTIVE: To determine the prevalence and natural history of urinary symptoms and incontinence among healthy adolescent schoolchildren. SUBJECTS AND METHODS: A prospective longitudinal study using a confidential questionnaire administered to an original cohort of 1176 local schoolchildren at 11-12 years and again at 15-16 years old. RESULTS: There was a decrease in the prevalence of urinary symptoms with age. Daywetting was reported by 12.5% of children aged 11-12 years and 3.0% of children aged 15-16 years. Nocturnal enuresis was reported by 4.7% of children at 11-12 years and 1.1% at 15-16 years. Some of the children reporting daywetting and nocturnal enuresis at 15-16 years old had not reported these symptoms at 11-12 years old. CONCLUSION: Urinary symptoms become less prevalent with age, but are reported by a significant number of healthy schoolchildren.