The standardization of terminology of lower urinary tract function in children and adolescents: update report from the Standardization Committee of the International Children's Continence Society

Constipation in nocturnal enuresis may interfere desmopressin management success

BACKGROUND

Previous studies indicated that the prevalence of constipation in enuretic patients is higher than that in the general population. Several studies have revealed that successful treatment of constipation may be helpful in resolving enuresis. However, constipation affecting the efficacy of desmopressin in treating enuresis remains to be clarified.

OBJECTIVE

This study aimed to determine whether the presence of constipation is associated with the efficacy of desmopressin in treating enuresis.

STUDY DESIGN

Patients diagnosed with nocturnal enuresis (NE) were studied prospectively. Treatment responses in different stratified groups of patients with NE were compared by Chi-squared tests or Wilcoxon rank sum test. A logistic regression model was performed to investigate the relationship between the possible factors and the effectiveness of desmopressin.

RESULTS

In children with severe enuresis, patients with constipation had significantly lower complete response rate compared with patients without constipation. The presence of constipation was always related to the effectiveness of desmopressin whether in monosymptomatic NE or non-monosymptomatic patients with NE. With stratification for dose of desmopressin, non-constipated patients who received 0.2 mg of desmopressin had significantly higher complete response rate than patients with constipation. However, in subgroups of mild to moderate NE and 0.4 mg desmopressin, constipation was not associated with treatment response of enuresis. Logistic regression analysis revealed that constipation was significantly related to the effectiveness of desmopressin.

DISCUSSION

This study confirmed the negative effects of constipation in response to desmopressin in patients with NE. To the best of authors knowledge, this work is the first study to evaluate the relationship of constipation in enuretic patients and the efficacy of desmopressin.

CONCLUSIONS

The presence of constipation negatively affects the response to desmopressin in patients with NE, especially in patients with severe enuresis and in patients prescribed with low dose of desmopressin.

Prospective evaluation of the management of bowel dysfunction in children with neuropathic lower urinary tract dysfunction and its effect on bladder dynamics

INTRODUCTION AND AIM

Children with neuropathic lower urinary tract dysfunction usually suffer from associated bowel dysfunction, urinary tract infection and vesicoureteral reflux. This work aimed to highlight the impact of bowel management on bladder dynamics.

PATIENTS AND METHODS

In the period from January 2011 to January 2013, 30 patients, 21 girls and 9 boys with neuropathic lower urinary tract dysfunction were studied. All suffered from urinary tract and bowel dysfunctions. All children were on urological treatment. They had their bowel managed by assurance and psychological support, dietary modification, retrograde or antegrade enemas and maintenance therapy. They were evaluated initially and on follow up by history, physical examination, ultrasound, urodynamics, Wexener score and bowel control chart.

RESULTS

Mean age was 8.3 ± 3.47 years (range from 4 to 18). There was a significant decrease in bowel dysfunction (Wexener score decreased from 12.67 ± 1.54 to 10.17 ± 1.76, p = 0.00), rectal diameter (decreased from 34.83 ± 5.91 to 27.90 ± 5.32 mm, p = 0.00), and frequency of UTI (p = 0.00). Detrusor leak point pressure decreased from 37.33 ± 24.95 to 30 ± 17.35 cmH2O, (p = 0.42). The cystometric capacity increased from 136.63 ± 45.69 to 155.17 ± 39.29 ml. (p = 0.001). Reflux and kidney function improved but was not statistically significant (p = 0.25 and p = 0.066 respectively).

CONCLUSION

Management of bowel dysfunction is of utmost importance in the treatment of children with neuropathic bladder dysfunction. It has a positive effect on lower urinary tract function and decreasing the incidence of complications. This is a LEVEL III prospective study.

'Frequently recurring' nocturnal polyuria is predictive of response to desmopressin in monosymptomatic nocturnal enuresis in childhood

INTRODUCTION

The nocturnal polyuria is considered a significant predictive value for response to desmopressin. The cutoff value useful to define nocturnal polyuria is still a matter of debate. Moreover, it is current notion that maximal voided volume (MVV) could be used as a predictor for desmopressin response.

OBJECTIVE

The objective of this study was to assess the impact of different definitions of nocturnal polyuria (and of its frequency) and MVV in predicting the response to desmopressin.

STUDY DESIGN

A total of 103 patients with frequent monosymptomatic nocturnal enuresis (≥4 wet nights/week) were enrolled. A bladder diary over a 4-day period was collected. The MVV was defined as the highest micturition volume detected at bladder diary. Nocturnal diuresis was measured in 5 wet nights. Then, patients were administered with 120 mcg of sublingual desmopressin. After 2 months, if there was no complete response, the dose was increased to 240 mcg. Nocturnal polyuria was defined as follows: 1.Definition 1: nocturnal urine production >130% of the expected bladder capacity (EBC). 2. Definition 2: >100% EBC. 3. Definition 3: > 20×(age + 9) mL. The primary outcome was 'response to desmopressin' after 3 months of treatment.

RESULTS

Fifty-three patients responded to desmopressin. Comparing the responses to desmopressin on the basis of the three definitions of nocturnal polyuria, no significant difference was found. There was no cutoff value of nocturnal polyuria expressed as %EBC useful in providing a significant receiver-operating characteristic (ROC) curve. The area under the ROC curve for MVV expressed as %EBC was 0.67 (95% confidence interval [CI], 0.54-0.80; p = 0.01). A MVV >103.1% of EBC had 78.8% (95% CI, 61.1-91.0) sensitivity and 47.5% (95% CI, 31.5-63.9) specificity for predicting response to desmopressin. Among the patients with nocturnal polyuria according to definition 1, a higher percentage of subjects with nocturnal polyuria in 4 out of 5 or 5 out of 5 nights responded to desmopressin, compared with other patients. Patients presenting with nocturnal polyuria according to definition 3 in 5 out of 5 nights showed a 100% of response to desmopressin. At multivariate analysis, the only significant odds ratio (OR) to respond to desmopressin was that of patients with nocturnal polyuria according to definition 1 in >3 nights (OR = 7.1, 95% CI, 1.3-40.3).

DISCUSSION AND CONCLUSIONS

The presence or absence of nocturnal polyuria-according to all three definitions-in at least one night was not effective in predicting the response to desmopressin. Predictors of desmopressin response were nocturnal polyuria in >3 out of 5 wet nights according to definition 1 and in 5 out of 5 wet nights according to definition 3.

Can we predict vesicoureteral reflux resolution in patients with non-neurogenic lower urinary tract dysfunction?

OBJECTIVE

To analyze factors influencing reflux resolution in patients with the coexistence of non-neurogenic lower urinary tract dysfunction and vesicoureteral reflux.

METHODS

The data of 153 children who were diagnosed with vesicoureteral reflux and accompanying non-neurogenic lower urinary tract dysfunction between 2010 and 2015 were retrospectively evaluated. Patients with neurogenic and anatomical malformations, monosymptomatic nocturnal enuresis, previous history of vesicoureteral reflux surgery, irregular and/or incomplete follow-up data were excluded. After exclusion of 55 patients, 98 patients were enrolled in this study. Patients were divided into two groups according to the presence of spontaneous vesicoureteral reflux resolution during the follow-up period. Group 1 consisted of 54 children with spontaneous vesicoureteral reflux resolution, whereas group 2 included 44 children without resolution. Medical history, physical examination, urinalysis, uroflowmetry combined with electromyography, ultrasonography, as well as the Dysfunctional Voiding and Incontinence Symptom Score questionnaire were also evaluated.

RESULTS

The mean age at presentation was 7.57 ± 0.23 years (range 5-13 years), and the mean follow-up period was 28.3 months. Significant differences were noted between the two groups in terms of dysfunctional voiding and incontinence symptom score, bladder wall thickness, and the post-void residual urine volumes. In addition, lower urinary tract symptoms, namely frequency, urgency and daytime incontinence, were found to be higher in group 2. In multivariate analysis, post-void residual urine volume and Dysfunctional Voiding and Incontinence Symptom Score were found to affect reflux resolution rates (P = 0.002, P = 0.002, respectively).

CONCLUSIONS

The absence of significant post-void residual urine volume, and a low Dysfunctional Voiding and Incontinence Symptom Score increase the likelihood of spontaneous resolution rates of vesicoureteral reflux in children with non-neurogenic lower urinary tract dysfunction.

Percutaneous electrical stimulation for overactive bladder in children: a pilot study

PURPOSE

The purpose of this was to evaluate the efficacy (tolerance and safety) of once-a-week parasacral percutaneous electrical nerve stimulation (PENS) to treat overactive bladder (OAB) in children.

MATERIALS AND METHODS

This is a prospective case series of children aged 4-14 years who underwent PENS for OAB. Acupuncture needles were used bilaterally and symmetrically at S3 for sacral nerve stimulation (Figure). Eighteen children with pure OAB underwent PENS weekly for 20 weeks. Frequency was 10 Hz. Intensity varied up to a maximum of 10 mA, as tolerated by the participant, but without reaching the motor threshold. Pulse width was 600 μs Patients' voiding history was assessed before treatment using a structured questionnaire. The dysfunctional voiding scoring system (DVSS) was used before and after treatment to quantify symptoms of lower urinary tract dysfunction. A visual analog scale (VAS) was used to evaluate treatment outcome.

RESULTS

Seven boys and eleven girls (mean age, 7.82 ± 2.45 years) were included. According to the VAS, symptoms were resolved in 66% of patients. Urinary urgency, present in all children at baseline, was resolved in 84% (P = 0.001). The proportion of patients with involuntary loss of urine without urgency decreased from 77% before treatment to 27% (P = 0.04). Urge incontinence resolved in 13 of 16 patients after treatment (P = 0.001). Only one of the 12 children with frequent urination at baseline reported this complaint after treatment (P = 0.04). All cases of recurrent urinary tract infection were resolved (P = 0.001). Regarding nocturnal enuresis, treatment was successful in 9 of 14 children (P = 0.004).

DISCUSSION

The theory behind this new method is that when skin impedance is overcome through the use of acupuncture needles and greater proximity is attained between the tip of the electrode and the sacral nerves, a more effective stimulus is achieved, with enough energy to provide the same benefits as parasacral transcutaneous electrical nerve stimulation with the advantage that treatment can be given only once a week.

CONCLUSIONS

Percutaneous electrical nerve stimulation seems to be an effective and safe treatment for OAB over the short term. Furthers studies with a control group are needed.

The amount of urine voided in bed by children with enuresis

INTRODUCTION

Enuretic children wet their beds either because of nocturnal polyuria or nocturnal detrusor overactivity. Polyuric children often respond to desmopressin, whereas children with nocturnal detrusor overactivity are often therapy resistant and may have low daytime voided volumes. It is logical to assume that the enuretic event in children with nocturnal polyuria occurs with a full bladder, i.e. with the enuretic voided volume (EVV) close to the child's expected bladder capacity (EBC) for his/her age. However, the EVV has only rarely been studied, and little is known about how it relates to case history, polyuria, or daytime bladder function. The aim of this study was to look at EVV and relate it to voiding chart data and treatment response.

METHODS

Anamnestic data and voiding charts, including measurement of nocturnal urine production and EVV, in enuretic children with or without concomitant daytime incontinence attending a tertiary center were retrospectively reviewed. The EVV was analyzed and compared to anamnestic data, voiding chart data, and response to therapy in accordance with the guidelines of the International Children's Continence Society.

RESULTS

Data were available for 220 children (age 5-24, median 9), 40 of whom were girls. The prevalence of previous or present daytime incontinence was 42.4%, and 50.5% sometimes experienced urgency. The average EVV was 54.9 ± 32.8% of EBC. EVV correlated highly significantly to nocturnal urine production (p < 0.001). Still, EVV ≥ EBC was observed in only 16 children. EVV was slightly larger in girls (p = 0.013) and in children with urgency (p = 0.034), but there were no significant EVV differences between children responding or not responding to antidiuretic, anticholinergic, or antidepressant therapy. Relevant data are summarized in the Table below.

DISCUSSION

Case history and daytime voiding chart data give very little information about nocturnal bladder function. The EVV is strongly influenced by nocturnal urine production but only rarely reaches up to a level close to or exceeding the EBC. The enuretic event only very rarely represents the emptying of a full bladder. Thus, a component of nocturnal detrusor overactivity can be assumed to be present in almost all enuretic children, even in children with nocturnal polyuria. The value of the EVV is limited in predicting response to therapy.

Pediatric sacral nerve stimulator explanation due to complications or cure: a survival analysis

INTRODUCTION

Historically, there have been few treatment options for children with severe refractory bladder and bowel dysfunction (BBD). Sacral neuromodulation (SNM) continues to show promising results in this challenging pediatric population with recalcitrant lower urinary tract symptoms. At the authors institution, they have begun offering explantation to those with persistent improvement after >6 months of having device turned off. The authors hypothesized that (1) SNM explantation for cure increases with extended follow-up and (2) those explanted for cure would have improved symptoms and quality of life when compared to those explanted for complication.

MATERIALS & METHODS

The authors retrospectively reviewed all consecutive patients aged <18 years who underwent SNM placements at their institution (2012-2017). They excluded those without the second stage procedure. Reasons for device explantation were categorized as cure (resolution of symptoms with the device turned off for at least 6 months) or a complication (e.g. infection, need for magnetic resonance imaging, or pain). Non-parametric tests and survival analysis were used for analysis to account for differential follow-up time. Of those explanted, surveys were electronically sent to assess BBD severity and overall quality of life.

RESULTS

Of 67 children who underwent a first stage procedure, 62 (92.5%) underwent a second stage procedure. 61 met inclusion criteria (68.9% female, 29.5% with previous filum section, median age at implantation 10.3 years). During follow-up (median 2.3 years), 12 patients (19.7%) had the SNM exchanged/revised because of lead fracture/breakage and return of urinary symptoms. To date, 50 patients remain with their SNM implanted, and 11 have been explanted. Adjusting for follow-up time, the risk of explantation was 6.5% at 2 years (2.2% for cure, 4.3% for complications) (Figure 1). Explantation increased to 24.5% at 3 years (16.5% for cure, 8.0% for complications) and 40.4% at 4 years (32.4% for cure, 8.0% for complications). Questionnaires were collected on patients after explant (median 2.2 years), with improvement in those explanted for cure compared to complication (Figure 2).

DISCUSSION

Sacral neuromodulation explantation for cure is a novel concept previously not described in the literature. Limitations of this study include the relatively small numbers and lack of objective data in the cohort that remains with SNM device implanted.

CONCLUSION

Sacral neuromodulation is a safe, viable option for the pediatric patient with refractory bladder dysfunction. Furthermore, SNM explantation for cure is an option with increasing likelihood after 2 years.

International Continence Society (ICS) report on the terminology for nocturia and nocturnal lower urinary tract function

INTRODUCTION

The terminology for nocturia and nocturnal lower urinary tract function is reviewed and updated in a clinically and practically-based consensus report.

METHODS

This report has been created by a Working Group under the auspices and guidelines of the International Continence Society (ICS) Standardisation Steering Committee (SSC). All relevant definitions were updated on the basis of research over the last 16 years since the publication of the first nocturia standardization document in 2002. An extensive process of 16 rounds of internal and external reviews was involved to examine each definition exhaustively, with decision-making by collective opinion (consensus).

RESULTS

A clinically-based terminology report for nocturia and nocturnal lower urinary tract function, encompassing five key definitions divided into signs and symptoms has been developed. Clarity and user-friendliness have been key aims to make it interpretable by healthcare professionals and allied healthcare practitioners involved in the care of individuals with nocturnal lower urinary tract function.

CONCLUSION

A consensus-based terminology report for nocturia and nocturnal lower urinary tract function has been produced to aid clinical practice and research.

The impact of bowel and bladder problems on children's quality of life and their parents: A scoping review

BACKGROUND

Functional bladder and bowel problems are common in children and have a serious psychological as well as physical impact. The objective of this scoping review was to synthesise evidence on the impact of such conditions both on children's quality of life (QOL) and their parents.

METHODS

The scoping review followed Arksey and O'Malley's framework. Relevant studies were identified by a comprehensive search of scientific databases. Inclusion criteria focused on children with bladder and bowel dysfunction, their QOL, and impact on parents. Studies were analysed for aims, study populations, measures, and results.

RESULTS

A total of 783 records were retrieved with 30 meeting the criteria. Most studies found that QOL was reduced in children with nocturnal enuresis, day bladder dysfunction, bowel dysfunction, and combined bladder and bowel dysfunction. Parents' QOL and social-emotional functioning were also negatively affected.

CONCLUSIONS

Functional bladder and bowel problems should be identified and treated as early as possible to minimise negative impacts on QOL of children and their carers. Future research should focus on how to best provide early and effective intervention in the most accessible manner.

Medical Comorbidity of Nocturnal Enuresis in Children

Introduction:

The purpose of this study was to evaluate the characteristics of patients with nocturnal enuresis (NE).

Methods:

We enrolled 403 children with NE referred to the Services of Pediatrics, Campus Bio-Medico University Hospital of Rome between June 2013 and July 2018. We excluded 2 children, respectively, with renal agenesis and chromosomopathy.

Results:

Of the 401 patients, 101 girls (25.2%) and 300 boys (74.8%), aged 5–16 years; mean age at first visit 8.8 ± 2.44 years. During the physical examination, we asked the patients and their parents specific questions to identify signs and symptoms of voiding disorders and comorbid conditions. In addition, we evaluated family history and behavioral characteristics of patients. In this study, NE was heredity in the 31.2% of cases. We found urogenital abnormalities in 15.7% of cases, constipation in 14.5% of cases, innocence heart murmur in 21.4% of cases and parasomnias in a good percentage of cases, especially snoring (13.7%), restless sleep (5.7%), somniloquy (23.7%) and bruxism (14.7%).

Conclusions:

Our experience demonstrates that there are a lot of comorbidities that are associated with NE and can influence the prognosis and the response to the therapy in these children.

Effectiveness of Intra-anal Biofeedback and Electrical Stimulation in the Treatment of Children With Refractory Monosymptomatic Nocturnal Enuresis: A Comparative Randomized Controlled Trial

Purpose

To compare the effects of intra-anal biofeedback (BF) and intra-anal electrical stimulation (ES) on pelvic floor muscles (PFMs) activity, nocturnal bladder capacity, and frequency of wet night episodes in children with refractory primary monosymptomatic nocturnal enuresis (PMNE).

Methods

Ninety children of both sexes aged 8–12 years with refractory PMNE participated in this study. They were randomly assigned to 3 groups of equal number: control group (CON) that underwent behavioral therapy and PFM training, and 2 study groups (BF and ES) that underwent the same program in addition to intra-anal BF training and intra-anal ES, respectively. PFMs activity was assessed using electromyography, nocturnal bladder capacity was evaluated by measuring the first morning voided volume, and a nocturnal enuresis diary was used for documenting wet night episodes before treatment and after 3 months of treatment.

Results

After training, all groups showed statistically significant improvements in all measured outcomes compared to their pretreatment findings. The ES group showed significantly greater improvements in all measured outcomes than the CON and BF groups.

Conclusions

Both intra-anal BF training and ES combined with behavioral therapy and PFMs training were effective in the treatment of PMNE, with intra-anal ES being superior to BF training.

International Consultation on Incontinence 2016; Executive summary: Urodynamic testing

AIMS

The International Consultation on Incontinence has published an update of the recommendations for the diagnosis and management of urine incontinence (ICI2016). This manuscript summarizes the consultations committee-recommendations with regard to urodynamic assessment.

METHODS

Expert consensus on the basis of structured evidence assessment has been the basis of the consultations publication and has been summarized by the committee for this manuscript.

RESULTS

Patients that are not satisfied with their initial management on the basis of their reported signs and symptoms of urinary incontinence, as well as all patients with neurological abnormalities that are potentially relevant for the function of the lower urinary tract, may very likely profit from objective diagnosis and staging and grading of their dysfunction, with urodynamic testing, regardless their age, vulnerability and/or comorbidities. The principles and technical innovations as well as the principal recommendations for the utilization of (invasive) urodynamic assessment for women, men, children, and vulnerable elderly, with or without neurogenic lower urinary tract dysfunction with urinary incontinence are provided in this abbreviated ICI recommendations-document.

CONCLUSIONS

The ICI2016 committee on urodynamics presents an executive summary of the most important reasons and recommendations for the use of urodynamic investigations for patients with urinary incontinence.

Uroflowmetry Before and After Meatotomy in Boys with Symptomatic Meatal Stenosis Following Neonatal Circumcision - A Long-term Prospective Study

OBJECTIVE

To assess uroflowmetry in the long-term follow-up of symptomatic meatal stenosis patients prior to and following meatotomy. Severity of symptoms and treatment success has been defined by patient history, physical examination, and witnessed voiding. Uroflowmetry might add objective parameters for the assessment, however long-term data are lacking.

METHODS

A prospective study following 25 symptomatic toilet-trained boys before and after meatotomy was performed with short and long-term follow-up after surgery. Patient history, physical examination, and uroflowmetry variables were recorded.

RESULTS

Fifteen patients were fully evaluable. Mean age at operation was 6.4 years (2.5-10.5) with an average follow-up of 43 months. All patients were symptomatic before surgery; complete symptomatic resolution was achieved in all patients at short-term follow-up, and in 12 at long-term follow-up. A stenotic meatus was seen in all patients before surgery, at long-term follow-up 12 of 15 (80%) had an open appearing meatus (P = .0001). Abnormal uroflowmetry pattern was present in 8 of 15 (53%) prior to surgery and 2 of 15 (13%) at long-term follow-up (P = .02). Normal maximal flow rate as defined by ICCS were seen in 5, 11, and 12 patients before, 1 month after and at long-term follow-up (P = .06 and 0.02, respectively). PVR improved significantly at long-term follow-up (P = .0012).

CONCLUSION

Symptom evaluation and physical examination should be the hallmark assessing children with meatal stenosis. Clinical assessment one month after surgery suffices and long-term follow-up is unnecessary. Uroflowmetry provides objective assessment as well as surgical success; however, it is unnecessary since it does not change the management.

Behavioral disorders and impairment of quality of life in children and adolescents with lower urinary tract dysfunction

BACKGROUND

Lower urinary tract dysfunction (LUTD) is a broad term describing the full spectrum of disorders in any of the stages of bladder function-storage or voiding LUTD is a clinical condition associated with emotional and behavioral disorders in children. This cross-sectional study aimed to investigate the association of emotional and behavioral symptoms and their impact on the quality of life (QoL) in children and adolescents with LUTD.

METHODS

Eighty-eight patients and their parents enrolled in an interdisciplinary program for children and adolescents with LUTD were included in the analysis. Child Behavior Checklist (CBCL) was used to estimate the prevalence of behavioral and emotional problems through the assessment of 14 items. Pediatric Quality of Life Inventory (versions for parents and children) was applied in the versions for parents and children to evaluate the QoL. The Pediatric Quality of Life Inventory-PedsQL, version 4.0-was applied separately for parents and patients. The association of clinical variables and aspects related to QoL of patients were evaluated through non-parametric correlations (Spearman) and multiple linear regression analysis.

RESULTS

According to CBCL's clinical scores, 56% of the patients showed total behavioral problems, 55% internalizing, and 38% externalizing. When comparing the conditions of LUTD and the CBCL scores, patients with voiding postponement had the lowest rates of total problems (P = 0.036). Children and adolescents with LUTD who also had enuresis showed a higher frequency of externalizing problems (P = 0.001), especially aggressive behavior (P = 0.013). Scores of patients with LUTD were significantly lower in all domains of QoL than normative data. Presence of behavioral problems was associated with worse QoL in all evaluated aspects. The total QoL was most influenced by the CBCL school competence scale according to the regression model analysis.

CONCLUSIONS

The study findings suggest the relevance of evaluation of behavioral and social repercussions of LUTD to improve the multidisciplinary approach for this condition in pediatric population.

Systematic Review and Meta-analysis of Alarm versus Desmopressin Therapy for Pediatric Monosymptomatic Enuresis

This study is to compare the efficacy of enuresis alarm and desmopressin therapy in managing pediatric monosymptomatic enuresis. We performed systematic literature searches on different databases from inception until April 2017 without language restriction. All randomized control trials comparing an enuresis alarm and desmopressin in managing children with monosymptomatic enuresis were included. A total of 15 studies with 1502 participants (aged 5 to 16 years) were included for pooled analysis. Overall, an enuresis alarm outperformed desmopressin in achieving at least a partial response (>50% reduction in wet nights) in per-protocol analysis (OR: 1.53, 95% CI 1.05 to 2.23) but not in intention-to-treat analysis (OR: 0.97, 95% CI 0.73 to 1.30) as the alarm was hampered by a high dropout rate (OR: 2.20, 95% CI 3.41 to 4.29). However, alarm therapy yielded a better sustained response (OR: 2.89, 95% CI 1.38 to 6.04) and lower relapse rate (OR: 0.25, 95% CI 0.12 to 0.50). In the intention to treat analysis, the results revealed that alarm and desmopressin therapy are comparable in efficacy with regards to achieving >50% reduction in baseline wet nights in enuretic children. However, enuresis alarms offer a superior treatment response and a lower relapse rate in well-motivated children.

Lower Urinary Tract Symptoms in Older Children With and Without Diabetes Mellitus

Lower urinary tract symptoms (LUTS) are an underrecognized complication of diabetes mellitus (DM) in adults and have undergone limited investigation in children. We estimated the prevalence of LUTS in 120 older children (11-17 years) with and without DM and identified patient factors associated with LUTS in logistic regression. Older children (11-17 years) completed a validated LUTS measure and questions about age, ethnicity, gender, body mass index, and degree of bother secondary to LUTS. The unadjusted prevalence of LUTS was 20.87% in the overall cohort, and LUTS was twice as prevalent in children with DM (33.3% vs 16.7%) than children without DM. In logistic regression, Hispanic/Latino ethnicity was positively associated with LUTS (odds ratio = 8.45, P = .011). LUTS may be a prevalent but underrecognized condition, which is more prevalent in Hispanic/Latino and diabetic children.

Pelvic floor biofeedback therapy in children: Assessment of symptom scores in responders and non-responders

INTRODUCTION

Pelvic Floor Biofeedback Therapy (PFBT) can be an effective treatment for pediatric lower urinary tract symptoms (LUTS). Due to differing perceptions of efficacy and practice patterns, we sought to further evaluate PFBT in our practice. We hypothesized that PFBT results in quiescence of EMG activity during voiding and improves questionnaire scores in patients with LUTS.

METHODS

We retrospectively reviewed all patients undergoing PFBT and refined the analysis to females ≥6 years old with ≥2 sessions with completed voiding questionnaires pre- and post-treatment, active EMG during voiding, with non-neurogenic urinary tract complaints refractory to standard urotherapy. Validated Bladder Bowel Dysfunction (BBD) questionnaires were collected at each visit. Quiescence of EMG activity and changes in BBD score were the primary outcomes.

RESULTS

229 patients underwent ≥1 PFBT session, of which 64 females ≥6 years of age with ≥2 PFBT sessions and completed pre and post PFBT voiding questionnaires were identified. In this group, mean age at PFBT start was 10.1 (6.2-17.0). Patients completed 3.1 sessions (2-6). No difference was seen in post-void residual (PVR) between first and last session (23.8 vs 22.6 mL, P = 0.55). Median questionnaire score decreased from 18 (4-42) before to 13 (2-28) following PFBT (P < 0.0001). Responders, characterized by silencing of the EMG after PFBT, occurred in 31% (20/64). Non-responders were younger (P = 0.007) with higher pre-PFBT questionnaire scores.

CONCLUSION

The use of PFBT appears to result in a significant reduction in symptom scores, though quiescence of EMG was observed following therapy in less than 1/3 of patients.

Chronic Urinary Retention due to Fowler's Syndrome

Fowler's syndrome (FS) is a rare cause of chronic urinary retention in teenage girls and young women. We present a case of a 14-year-old girl who presented at our hospital 2 weeks after uncomplicated laparoscopic appendectomy. The girl complained of reduced urinary frequency and prolonged micturition time. Following an acute cystitis 2 months later, she completely lost her ability to void. A comprehensive set of investigations to assess the cause of her urinary retention including a cerebral and spinal magnetic resonance imaging (MRI), and videourodynamics were performed. The diagnostic workup revealed polycystic ovaries and an asensitive and hypotonic bladder with capacity up to 1200 mL and high maximum urethral pressure of 120 cm of water. She did not tolerate clean intermittent catheterization; therefore, a suprapubic catheter was placed. Under this treatment, she suffered recurrent urinary tract infections. Two years later, she was diagnosed with FS on the basis of the medical history, clinical symptoms, and urodynamic findings. Finally, the implantation of a S3 neurostimulator restored her ability to void.

An interprofessional approach to managing children with treatment-resistant enuresis: an educational review

Enuresis (intermittent urinary incontinence during sleep in a child aged ≥ 5 years) is commonly seen in paediatric practice. Despite the availability of effective interventions, treatment resistance is encountered in up to 50% of children. In this educational review we attempt to provide insight into the causes of treatment resistance, and offer practical suggestions for addressing this condition using an interprofessional approach. We explore the pathophysiology of and standard treatments for enuresis and discuss why standard treatments may fail. An interprofessional approach to treatment resistance is proposed which utilises the expertise of professionals from different disciplines to address the problems and barriers to treatment. The two interprofessional approaches include a multidisciplinary approach that involves the patient being sent to experts in different disciplines at different times to address their treatment resistance utilising the skills of the respective experts, and an interdisciplinary approach that involves a patient being managed by members of interdisciplinary team who integrate their separate discipline perspectives into a single treatment plan. Although an interdisciplinary approach is ideal, interdisciplinary teams may not be available in all circumstances. Understanding the roles of other disciplines and engaging clinicians from other disciplines when appropriate can still be helpful when treatment resistance is encountered.

Tips for managing treatment-resistant enuresis

Enuresis (bedwetting) is common in school-aged children and can impact health, psychosocial well-being and quality of life. Although effective treatment is available, treatment resistance is encountered in about 50%. This paper discusses the management of treatment-resistant enuresis from a multidisciplinary perspective. Causes of treatment resistance include lower urinary tract problems, constipation, incorrect alarm training techniques, sleep disorders including sleep apnoea and psychological comorbidities. Practical suggestions to address treatment resistance are offered utilising expertise from clinicians from different disciplines.

Rectal diameter assessment in enuretic children-exploring the association between constipation and bladder function

OBJECTIVES

Detrusor overactivity and constipation often co-exist in children with enuresis. Constipation is known to be linked to detrusor overactivity. The voiding chart is the best non-invasive way to investigate bladder function, whereas the ultrasonographical detection of rectal dilatation is the best way to objectify constipation. We wanted to investigate a possible relationship between the rectal diameter and voiding chart data in enuretic children.

METHODS

Children with therapy-resistant enuresis were retrospectively evaluated. All had completed a voiding chart for at least 48 h. The rectal diameter was assessed ultrasonographically. The cutoff for rectal dilatation was set at 30 mm.

RESULTS

We evaluated 74 patients (12 girls) aged 10.2 ± 2.8 years, 35 of whom had rectal dilatation. No significant differences in voiding chart parameters were found between children with normal versus dilated rectum. Neither did urgency or a history of daytime incontinence differ between the groups. Boys were more likely to have rectal dilatation than girls (p = 0.02).

CONCLUSIONS

The absence of differences regarding voiding chart data may be explained as two mechanisms neutralizing each other: behavioral factors may make the constipated children void seldom and with large volumes, whereas detrusor overactivity caused by rectal compression of the bladder may have the opposite effect. Another option may be that the voiding chart is too blunt an instrument to detect detrusor overactivity. Constipation, and thus presumably bladder dysfunction, seems to be more important in enuretic boys than girls.

Enuresis in children and adolescents with sickle cell anaemia is more frequent and substantially different from the general population

Background

No large studies have examined the prevalence of enuresis, its various forms and risk factors in children with sickle cell anaemia (SCA) in Sub-Saharan Africa using standardised definitions. We determined age and gender-specific prevalence of enuresis and compared the nature of enuresis in children with and without SCA. We also identified predictors of enuresis in children with SCA.

Methods

Caregivers of children with SCA attending a tertiary centre haematology clinic in Nigeria were interviewed using a questionnaire. In addition, a separate questionnaire was completed for every sibling aged 5–17 years whose haemoglobin genotype was known. Enuresis and its various forms were defined using the definitions of the International Children’s Continence Society.

Results

The study involved 243 children with SCA and 243 controls matched for age and sex. The mean age of the study cohort was 9.9 (3.4). Females made up 45.7% of the cohorts. The prevalence of enuresis was 49.4% and 29.6% in children with and without SCA, respectively (p = 0.009). In both groups, the prevalence of enuresis declined with age but remained five times higher at 25% in children with SCA aged 14–17 years compared with controls. Also, children with SCA and enuresis were older, more likely to have non-monosymptomatic enuresis and wet at least three nights per week than controls. Independent predictors of enuresis in children with SCA were a family history of enuresis and young age.

Conclusion

Children with SCA had more frequent and more severe enuresis which persisted to late adolescence than age and sex-matched controls. These features indicate a subset of enuresis that is difficult to treat in the general population. Young age and enuresis in a family member define a subset of children with SCA more likely to have enuresis. Healthcare workers need to discuss enuresis with parents of children with SCA and offer referral to continence services.

The Relationship Between Nocturnal Enuresis and Spina Bifida Occulta: A Prospective Controlled Trial

OBJECTIVE

To compare the frequency of spina bifida occulta (SBO) detected in patients with nocturnal enuresis (NE) and to investigate its clinical significance.

METHODS

Patients aged 6 to 15 years who were admitted to the urology clinic with NE were included in this prospective study. The control group consisted of patients who were admitted with a complaint of abdominal or lateral pain. The patients who had lower urinary tract symptoms (LUTS) were classified as nonmonosymptomatic NE (NMNE). Those with monosymptomatic NE were treated with desmopressine. In patients with NMNE, treatment with oxybutynin was added if an overactive bladder or uninhibited contraction was detected by urodynamics.

RESULTS

A total of 184 NE and 180 control patients were included in the study. SBO was detected in 71 (19.5%) patients and LUTS in 100 (27.4%). When the groups with and without NE were compared, the number of patients with SBO (26% vs 17%, P = .044) and those with LUTS (36% vs 17.5%, P < .001) were significantly higher in the NE group. The overall rate of dryness (67.4% vs 83.6%, P = .024) and response to LUTS treatment (65% vs 97%, P < .01) were significantly lower in those with SBO than in those without SBO.

CONCLUSION

SBO is more common in NE patients than in non-NE patients. Response to NE treatment is lower in SBO patients with severe LUTS; for this population, advanced treatment options may be considered earlier.

Standard urotherapy as first-line intervention for daytime incontinence: a meta-analysis

According to the International Children's Continence Society (ICCS) guidelines for the treatment of daytime urinary incontinence (DUI) in children and adolescents, the first-line intervention for all types of DUI is standard urotherapy (SU). Despite this recommendation there is still no meta-analysis available on the effectiveness of SU. The aim of this study is to provide a meta-analytic evaluation of the intervention. This meta-analysis is based on Odds Ratios (OR) and consists of 26 patient samples out of 19 studies (N = 1609), collected from well-established medical databases. Remission rates after SU are compared to spontaneous remission rates, which are matched to the individual follow-up period. The meta-analysis shows that SU is an effective treatment of DUI. Compared to a spontaneous remission rate of 15.40% per year, urotherapy increases the probability to recover by a factor of 7.27 (6.57 if corrected for publication bias). After exclusion of three outlying samples this effect can be generalized for all types of SU and all patient populations. Moderator analyses cannot identify variables which significantly influence the variance of effect sizes. However, RCTs seem to be associated with lower effects, even when the control group is not considered for effect size calculation. Based on the present meta-analysis, SU is an effective intervention for treating DUI in children and adolescents. Of 100 patients in 1 year, approximately 56 patients (54 if corrected for publication bias) remit after being treated with SU, while only 15 out of 100 remit spontaneously. However, to further quantify the effect size of SU in comparison to spontaneous remission rates and other treatments, additional RCTs are still needed.

Time Course of Treatment for Primary Enuresis With Overactive Bladder

PURPOSE

To characterize the course of treatment for nonmonosymptomatic enuresis with overactive bladder (OAB) in a real clinical setting.

METHODS

Data from 111 OAB patients with moderate to severe enuresis were analyzed. The baseline analysis included a questionnaire, voiding diary, uroflowmetry with postvoid residual urine measurement, and plain abdominal radiography of the kidneys, ureters, and bladder (KUB). Following standard urotherapy for 1 month, anticholinergic medication was administered with or without laxatives. Desmopressin was added if there was a partial response to OAB. Patients were followed every 3 months to evaluate the status of OAB and enuresis. Multivariate analysis was performed to identify predictors associated with the lack of complete response (CR) in enuresis at 12 months.

RESULTS

Following 12 months of treatment, 64% and 88% of patients experienced at least partial response in enuresis and OAB, respectively. Urgency improved more quickly than enuresis, supporting the need to address daytime symptoms before enuresis. Seventy-nine patients (71%) had fecal impaction on KUB and/or subjective constipation. The combination of anticholinergics with either laxatives or desmopressin fared better than anticholinergics alone. Daytime incontinence and anticholinergics- only treatment were associated with a lack of CR during 12 months of treatment.

Conclusions

The data confirmed the validity of addressing OAB before treating enuresis. The results of this study also highlight the need to address fecal impaction. Patients should be counseled about the need for a prolonged course of treatment before starting treatment. Anticholinergics should be accompanied with either desmopressin or laxatives for better control of enuresis.

Clinical management of nocturnal enuresis

Nocturnal enuresis (NE) is a common health problem. Approximately 10% of 7-year-old children wet the bed regularly during sleep. Enuresis can be categorized into monosymptomatic (MEN) and nonmonosymptomatic (NMEN) forms. MEN occurs without any other symptoms of bladder dysfunction. NMEN is associated with dysfunction of the lower urinary tract with or without daytime incontinence. The rate of comorbid gastrointestinal, behavioral, and emotional disorders is elevated depending upon the subtype of NE. A careful clinical history is fundamental to the evaluation of enuresis. Diagnostic procedures include medical history and psychological screening with questionnaires, bladder and bowel diary, physical examination, urinalysis, ultrasound, and examination of residual urine. The mainstay of treatment is urotherapy with information and psychoeducation about normal lower urinary tract function, the underlying cause of MEN, disturbed bladder dysfunction in the child with NMEN and instructions about therapeutic strategies. Alarm therapy and the use of desmopressin have been shown to be effective in randomized trials. Children with NMEN first need treatment of the underlying daytime functional bladder problem before treatment of nocturnal enuresis. In patients with findings of overactive bladder, besides urotherapy, anticholinergic drugs may be useful.

Urine flow rate curve shapes and their descriptors

AIMS

To review the descriptors and definitions of urine flow rate curve shape with a view to promoting greater clarity and to propose standard terms METHODS: A search was made in the PubMed and ICS standardization documents on urine flow rate curve shape.

RESULTS

The flow shape descriptors and their definitions are summarized and presented. "Normal" was widely used for describing a bell-shaped flow curve, and "plateau" was mostly used where the ICS describe "constrictive" flow shape. The use of shape descriptors "fluctuating," "compressive," "tower-shaped," and "intermittent" varied in the literature.

CONCLUSION

This survey provides an overview of flow shape descriptors and their definitions. We suggest it is clearer to use only descriptors that describe shape alone, that is, normal, fluctuating, intermittent, and plateau, with comments on symmetry and Q_max .

Age-related changes in urinary flow following dorsal inlay graft urethroplasty for hypospadias in early childhood: Potential improvement over 11 years of age

INTRODUCTION

One of the goals of hypospadias repair is to create a neourethra with normal urinary stream and normal growth. Several studies have reported that dorsal inlay graft urethroplasty (DIG) has wide indications for various clinical phenotypes of hypospadias, with good short-term outcomes and few complications. However, there have been no reports that evaluated both short-term and long-term functional outcomes using uroflowmetry in patients with DIG.

OBJECTIVE

The aim was to investigate whether uroflowmetry parameters change with time following DIG for hypospadias in early childhood.

MATERIALS AND METHODS

Uroflowmetry parameters after DIG for hypospadias in childhood were retrospectively evaluated and compared between two defined ages at follow-up: 4-6 years and 11-13 years. Maximum urinary flow (Q_max) under the 25th percentile on the Miskolc nomogram was defined as obstruction. To evaluate the shapes of uroflow quantitatively, the flow index (FI) was used. The FI cut-offs for the flow shapes were defined as tower >1.253, plateaus <0.659; bells were between these two values.

RESULTS

Thirty-four patients met the inclusion criteria. The median operative age was 1.8 years (range 1.0-4.9 years). The median follow-up time was 10.3 years (range 7.2-12.3 years). The mean ± SD Q_max at the two follow-up times increased with time, from 9.2 ± 3.7 to 18.8 ± 7.8. The mean ± SD FI changed from 0.53 ± 0.19 to 0.85 ± 0.31. Both Q_max and the FI were significantly improved (p < 0.001, p < 0.001, respectively). There were significantly fewer patients with obstruction evaluated by the Miskolc nomogram at 11-13 years of age (n = 11, 32.4%) than at 4-6 years (n = 31, 91.2%) (p < 0.001). Plateau shapes assessed by the FI were seen in 24 (70.6%) patients at 4-6 years and 10 (29.4%) patients at 11-13 years (Table). The number of patients with plateau shapes was significantly decreased (p = 0.001).

DISCUSSION

Only one report noted long-term outcomes and spontaneous uroflowmetry resolution after tubularized incised plate urethroplasty. The current report is the first to present the short-term and long-term uroflowmetry outcomes after DIG. In addition, the FI was used for the first time to evaluate uroflowmetry after hypospadias repair. It was found that the uroflowmetry parameters improved spontaneously over 11 years of age following DIG for hypospadias in early childhood.

CONCLUSION

Uroflowmetry parameters improved spontaneously over 11 years of age following DIG for hypospadias in early childhood.

Clinical features of, and association of bladder ultrasound and uroflowmetry with, overactive bladder recovery period in children

BACKGROUND

Overactive bladder (OAB) is a symptomatic syndrome defined by urinary urgency, usually accompanied by increased urination frequency and nocturia, with or without urinary incontinence. The prevalence of pediatric OAB in 5-13 year olds is as high as 16.6%, but the pathophysiology and epidemiology have not been sufficiently elucidated.

METHODS

We retrospectively reviewed medical records in 117 children with OAB aged between 5 and 15 years during the years 2012-2016. At initial presentation, abdominal ultrasound and uroflowmetry were performed, and behavioral modifications, such as timed voiding, and constipation therapy were initiated. If there was no response after 4 weeks, antimuscarinic treatment was added. We evaluated the clinical features of OAB and factors related to the recovery period, which was defined as the period from the start of behavioral modifications to cure.

RESULTS

The average recovery period was 11.9 ± 9.73 months. There was no significant difference in the recovery period according to age, gender, percentage of urination frequency, nocturnal enuresis, or constipation. The recovery period was significantly shorter in the group with bladder wall thickness ≥5 mm than with bladder wall thickness <5 mm. Children with a tower-shaped curve on uroflowmetry had a significantly shorter recovery period than those with a bell-shaped curve.

CONCLUSIONS

Bladder wall thickness and uroflow curve shape are related to the recovery period of pediatric OAB.

Symptoms of Obstructive Sleep Apnea, Nasal Obstruction, and Enuresis in Children With Nonsyndromic Cleft Lip and Palate: A Prevalence Study

OBJECTIVE

To estimate the prevalence of symptoms of obstructive sleep apnea (OSA), nasal obstruction, and enuresis in children with nonsyndromic unilateral cleft lip and palate.

DESIGN

Prospective cross-sectional study.

SETTING

Referral care center.

PARTICIPANTS

One hundred seventy-four children aged 6 to 12 years of both genders.

INTERVENTIONS

Symptoms of OSA and nasal obstruction were investigated by analysis of scores obtained by the Sleep Disturbance Scale for Children (SDSC) and Congestion Quantifier (CQ-5). Enuresis was considered as present when urinary loss was reported during sleep (at least 1 episode/month, last 3 months). To characterize the enuresis as mono- or polysymptomatic, symptoms of dysfunction of the lower urinary tract (DLUT) were investigated by the Dysfunctional Voiding Scoring System (DVSS). Statistical analysis was performed at a 5% level of significance.

RESULTS

Positive SDSC scores for OSA were observed in 60 (34%) children; positive CQ-5 scores for nasal obstruction in 45 (26%), positive DVSS scores for DLUT in 30 (17%), and enuresis was reported by 29 (17%), being categorized as primary in 66% and polysymptomatic in 72% of the children. Compared to the pediatric population, OSA, nasal obstruction, and enuresis prevalence ratios were up to 7 (95% confidence interval [CI] 5-9), 2 (95% CI 2-3), and 3 times (95% CI 2-5) higher, respectively. There was a positive/moderate correlation between symptoms of OSA and nasal obstruction ( P = .0001). No correlation was seen between symptoms of OSA and enuresis.

CONCLUSIONS

Children with nonsyndromic cleft lip and palate have high prevalence of nasal obstruction and enuresis and are at risk of OSA.

Do uroflowmetry and post - void residual urine tests necessary in children with primary nocturnal enuresis?

Objectives:

To examine the benefits of repetitive uroflowmetry and post void residual urine (PVR) tests in children with primary nocturnal enuresis (PNE).

Material and methods:

Children aged ≥6 years with PNE who visited our clinics for management of enuresis were included for study. Patients were requested to complete a questionnaire including baseline characteristics and Dysfunctional Voiding Symptom Score (DVSS), 2-day bladder diary, and Rome III criteria for constipation. Two uroflowmetry and PVR tests were requested. Children with congenital or neurogenic genitourinary tract disorders were excluded. All children underwent urotherapy and desmopressin combined with anticholinergics or laxatives if indicated. The definition of abnormal flow patterns (≥1 abnormal), elevated PVR (≥1 abnormal), small maximal voided volume (MVV), nocturnal polyuria (NP) and response to treatment complied with the ICCS standardization document. Kaplan-Meier survival analysis and Cox proportional-hazards regression tests were used to evaluate the predictors of response.

Results:

In total, 100 children aged 8.5±2.3 years were enrolled for study (M: F=66:34) with 7.3±7.4 months of follow-up. Poor correlation was observed between DVSS/small MVV and PVR (p>0.05). Univariate analysis revealed that elevated PVR is associated with significantly less hazard of complete response to medical treatment (HR: 0.52, p=0.03), while not significantly associated with abnormal flow patterns, NP, constipation or small MVV. Multivariate analysis revealed that only elevated PVR (HR 0.30, 95% CI 0.12-0.80) and NP (HR 2.8, 95% CI 1.10-7.28) were significant predictors for complete response.

Conclusions:

In managing pediatric enuresis, elevated PVR is a significant predictor for lower chance of complete response to treatment whether they had high DVSS or not.

Dysfunctional voiding: Challenges of disease transition from childhood to adulthood

N/A

The Role of Non-invasive Testing in Evaluation and Diagnosis of Pediatric Lower Urinary Tract Dysfunction

PURPOSE OF REVIEW

The symptoms of lower urinary tract dysfunction (LUTD) including urinary incontinence, frequency, and urgency are among the most common reasons children are referred to pediatric urologists. Despite this, the workup for LUTD is often time consuming and a source of frustration for patients, parents, and clinicians alike. In the current review, we summarize the important role non-invasive testing plays in the diagnosis and management of children with LUTD and to show how use of these tests can help avoid the need for more invasive testing in the majority of children.

RECENT FINDINGS

Non-invasive tests such urine studies, uroflowmetry ± simultaneous electromyography, assessment of post-void residual, renal/bladder ultrasound, and pelvic ultrasound when used appropriately can provide valuable information to facilitate decision making during the evaluation of children with LUTD. While these tests should be employed prior to more invasive testing such as urodynamic studies, they can often act as a surrogate for the more invasive tests. Non-invasive tests can help us in our goal of improving diagnostic ability to better classify the child's LUTD into an actual condition which allows targeted treatment in the hope of better outcomes and more satisfied patients and families.

Diagnostic scores, questionnaires, quality of life, and outcome measures in pediatric continence: A review of available tools from the International Children's Continence Society

PURPOSE

We reviewed and collated information concerning the available tools for the measurement of symptoms and outcomes in pediatric continence.

MATERIALS AND METHODS

MEDLINE, EMBASE, and CINHAL databases were searched for relevant articles published prior to December 2016 and independently screened by two researchers. Expert opinion was also widely sought through consultation with the ICCS Board membership and their professional networks and the multidisciplinary authorship group. The most relevant materials were then selected for analysis and inclusion and resulted in a document available on the ICCS website for all members to review. Insights and feedback were considered with consensus and agreement reached to modify the document.

RESULTS AND CONCLUSIONS

A variety of useful tools for the assessment and measurement of bladder and bowel dysfunction and quality of life and behavioral comorbidities are presented together with their indications and potential pitfalls. ICCS cannot recommend one over another as the most useful for each clinician will vary depending on the clinical setting, available time, and patient population. We provide a framework for choosing those that are most appropriate based on our findings.

Animated versus non-animated biofeedback therapy for dysfunctional voiding treatment: Does it change the outcome?

PURPOSE

The aim of this study is to evaluate and compare the effectiveness of animated vs. non-animated biofeedback therapy in the treatment of dysfunctional voiding (DV) in the pediatric age group.

METHODS

In this study, children with DV were randomly assigned for animated and non-animated biofeedback therapy. Age, voiding dysfunction symptom scores (VDSS), urinary ultrasound and uroflowmetry parameters such as electromyography (EMG) activity, voided volumes, post voiding residual urine volume (PVR) and maximum flow rate (Qmax) were evaluated. At the end of treatment, clinical success was regarded as the cessation of EMG activity during voiding, resolution of symptoms (reduction in VDSS, frequency, intermittency, urgency and incontinence), and improvements in uroflowmetry parameters.

RESULTS

A total of 40 children were included in the study. There were 20 children in the non-animated group (16 girls, 4 boys; mean age: 10.5±3.2years) and 20 children in the animated group (15 girls, 5 boys; mean age: 9.5±3.63years). Patients received a mean of 5.2±1.9 sessions in both groups. Cessation of pelvic muscle activity on EMG was 75% in the non-animated group and 90% in the animated group (p=0.407). Reduction in VDSS was clinically significant in both groups (p=0.001 for both). There was no significant difference between the clinical success rates of the nonanimated and animated groups (80% vs. 70% respectively, p=0.125). PVR decreased by 68% in the non-animated group (p=0.015) while a 60% decrease was observed in the animated group (p=0.001).

CONCLUSION

In our study, there was no difference between animated and non-animated biofeedback therapy in terms of clinical success rates.

TYPE OF STUDY

Prospective comparative study LEVEL OF EVIDENCE: Level II.

Extraordinary daytime only urinary frequency in childhood: Prevalence, diagnosis, and management

INTRODUCTION

Since standardization of the ICCS terminology, only two small case series of children with extraordinary daytime only urinary frequency (EDOUF) have been published. The aims of the present study were i) to describe a large cohort of children affected by EDOUF, to evaluate its rate among the main micturition pediatric disturbances, and to determine if there is different EDOUF onset among seasons; ii) to investigate possible associations with urodynamic abnormalities by non-invasive techniques; iii) to evaluate whether postponing micturition exercise (PME) can objectively verify the anamnestic data hinting at the EDOUF diagnosis; and iv) to determine the effect of postponing micturition at home.

MATERIAL AND METHODS

We reviewed the records of all patients with EDOUF, nocturnal enuresis, and/or overactive bladder firstly examined from March 2012 to February 2016. We evaluated post-void residual and bladder wall thickness by urinary ultrasound and uroflowmetry and recorded the season in which the EDOUF started. Through the PME, the EDOUF diagnosis was confirmed if patients were able to postpone micturition reaching at least 80% of the expected bladder capacity without showing urinary incontinence. At home, we recommended postponing micturition for a maximum of 3 h if EDOUF affected the normal daily activities of both children and parents. We set a telephone interview for 3 months later.

RESULTS

The clinical characteristics of the EDOUF population are shown in the Table. The EDOUF rate was 12.1%. The rate of EDOUF onset was significantly lower during the summer than in other seasons (p = 0.02) and the OR for onset of EDOUF in the summer - compared with the other seasons - was 0.37 (95% CI 0.18-0.74; p = 0.005). Eighty-five (80.2%) patients reported an intermittent trend of the EDOUF with variable periods of improvement and worsening. All the EDOUF patients had normal uroflowmetry, 1/106 had post-micturition bladder wall thickness >5 mm and one post-void residual. At the PME, 106 out of 106 (100%) patients with EDOUF were able to reach at least 80% of the EBC without showing urinary incontinence or urgency incontinence. After 3 months, in 98.1% of the patients the symptoms had disappeared or improved.

DISCUSSION AND CONCLUSIONS

Childhood EDOUF is rather common and is generally associated with normal non-invasive urodynamic patterns. The PME allows verification of anamnestic data of EDOUF. The sole recommendation to postpone micturition for a maximum of 3 h or until the micturition postponement became stressful could be considered as a possible approach.

Oral Desmopressin Lyophilisate Formulation (MELT): Efficacy and Safety in Children and Adults

Nocturnal enuresis (NE) is a common disorder in childhood and desmopressin is one of the most widely and well-tolerated medications for NE. The recent oral lyophilisate formulation of desmopressin (MELT) is effective in the treatment of NE in children and nocturia in adults. A MEDLINE literature search MEDLINE (2000-July 2017) was performed using the search terms MELT enuresis, MELT desmopressin, sublingual desmopressin, lyophilisate desmopressin. Twenty articles were analyzed with a number of patients of 3448. In 12 articles were reported 1275 pediatric patients (<18 years old), and in 8 articles 2213 adult patients. In pediatric population the indication was enuresis in 1269 patients and central diabetes insipidus in 6 patients. In adult population the indication was nocturia in 1941 patients, renal colic in 259 patients, healthy volunteers 13 patients. In 17 studies desmopressin was administered alone while in 3 studies in association respectively with Tolterodina, Ketorolac and Tamsulosin. In 7 studies were reported side effects in only 81 patients, 60 in pediatric population and 21 in adult population. The reported side effects in pediatric population were nausea, lethargy, lower limb weakness, headache, diarrhea, viral gastroenteritis. The reported side effects in adult population were asymptomatic hyponatriemia, nausea, diarrhea, dizziness, symptomatic hyponatriemia. Our review confirm that the MELT formulation of desmopressin guarantee the same response of other formulations with a lower doses and a lowest number of side effects. We believe according with the literature that this formulation is actually the first line and safety treatment for nocturnal enuresis and nocturia.

An adolescent boy progressing insidiously to end-stage renal disease: Answers

Hinman syndrome was a non-neurogenic neurogenic bladder and the most severe form of dysfunctional voiding disorder. The bladder-sphincter discoordination causes damage to the bladder and upper urinary tract if it is not diagnosed early and treated adequately. This case emphasizes the following important message: nighttime wetting is not a benign condition in every child. Parental awareness should be raised about voiding disorders, as it may be possible to prevent important renal diseases such as Hinman syndrome.

Risk Factors of Nocturnal Enuresis in Children with Attention Deficit Hyperactivity Disorder

BACKGROUND

Presence of attention deficit hyperactivity disorder (ADHD) has a negative effect on the resolution of incontinence; however, there are few studies which investigated the risk factors of nocturnal enuresis (NE) in patients with ADHD.

AIMS

This study was conducted to investigate the prevalence of NE and its risk factors in children with ADHD.

METHODS

331 children, aged 6 to 10 years, diagnosed as having ADHD were enrolled in this study. The diagnosis of ADHD was confirmed by an experienced child and adolescent psychiatrist according to DSM-IV-TR. NE was defined as nighttime wetting with or without daytime incontinence, at least twice a week over a period of 3 months or longer in children 5 years old and older without anatomical abnormalities. Details on demographic data, perinatal history, medical history and developmental history were collected from parents or medical records.

RESULTS

Most of the ADHD patients with inattentional subtype (77.5%) had NE, compared to 31.7% in the hyperactive/Impulsive subtype and 22.5% in the combined subtype (p<0.001, t=42.71). Among children with enuresis, there were significantly higher rates of history of familial enuresis (26% vs. 18 %, p<0.001, t=16.9), cesarean delivery (47% vs. 33%, p=0.019, t=5.84) and history of neonatal sepsis (16% vs. 7%, p=0.018, t=5.62) than non-NE children. Moreover, patients with NE had lower birth weight than non-NE patients (2.93(0.65) vs. 3.09 (0.46), p=0.026, t=2.51). Also, low parental education was associated with increase in the rate of NE.

CONCLUSION

Children with ADHD have a high prevalence of NE. Male sex, low education level of parents, history of neonatal sepsis, positive family history of NE, low birth weight and caesarian delivery may be risk factors for NE in ADHD children. Most ADHD patients with inattentional subtype had NE.

Imipramine for refractory daytime incontinence in the pediatric population

INTRODUCTION AND OBJECTIVE

Lower urinary tract (LUT) and voiding dysfunction constitute a large percentage of pediatric urology referrals. Children with urinary incontinence unresponsive to behavioral modifications and traditional pharmacotherapy including anticholinergics and alpha blockers remain a challenge. We evaluated the impact of imipramine on treatment outcomes in children with refractory incontinence.

STUDY DESIGN

Children ≤18 years of age with refractory non-neurogenic daytime incontinence prescribed imipramine were identified. Patient demographics and baseline testing were assessed, as well as medication dosing and side effects of all patients. The Vancouver Symptom Score (VSS) was completed at the initial consultation and each subsequent clinic visit. The questionnaire was self-administered and completed by patients and/or parents. Treatment success was defined as per the International Children's Continence Society (ICCS).

RESULTS

One hundred and three patients (55 males and 48 females) met the inclusion criteria. The intention-to-treat response rate was 65% (complete 44, partial response 23). Sixteen (15.6%) patients were non-responders and 20 (19.4%) were lost to follow-up. There was no statistical difference between all groups with regards to age, baseline VSS, and dose. Of those children with complete follow-up (n = 83), 44 (53%) experienced complete treatment response. Pre- and post-VSS were statistically different in both complete and partial response groups (complete 19.5-9.5; p < 0.0001; partial 19.7-13; p = 0.0002) (Table). Side effects were reported by 11 out of 83 (13.3%) patients; partial responders experienced a higher likelihood of side effects (26.1%; p = 0.03).

DISCUSSION

The mainstay of LUT dysfunction management in children is implementation of a bowel program and timed voiding regimen, with additional treatment modalities and pharmacotherapy added depending upon prevailing symptomatology. Daytime incontinence refractory urotherapy, anticholinergics, and/or non-selective alpha blockers can be difficult to treat, and can be unresponsive to parasacral transcutaneous electrical nerve stimulation (TENS) and percutaneous tibial nerve stimulation (PTNS). We observed that over half of children with refractory daytime incontinence reported complete resolution of daytime accidents with imipramine. Limitations of the study include the retrospective nature, relatively small sample size and lack of control group.

CONCLUSIONS

Two-thirds of children with refractory daytime incontinence experienced treatment response to imipramine, adding a valuable tool to the pediatric urologist's armamentarium in managing select, challenging patients.