Lower urinary tract dysfunction in childhood

Urofacial (ochoa) syndrome: A literature review

The Urofacial or Ochoa Syndrome (UFS or UFOS) is characterized by an inverted facial expression (those affected seem crying while smiling) associated with lower urinary tract dysfunction without evident obstructive or neurological cause. It is associated with autosomal recessive inheritance mutations in the HPSE2 gene, located at 10q23-q24, and the LRGI2 gene, located in 1p13.2; however, in up to 16% of patients, no associated mutations have been found. Recent evidence suggests that these genes are critical to an adequate neurological development to the lower urinary tract and that the origin of the disease seems to be due to peripheral neuropathy. There is clinical variability among patients with UFS and not all present the classic two components, and it has even been genetically confirmed in patients with a prior diagnosis of Hinman Syndrome or other bladder dysfunctions. Also, the presence of nocturnal lagophthalmos in these patients was recently described. Early recognition and timely diagnosis are critical to preventing complications such as urinary tract infections or chronic kidney disease. Next, the history of Urofacial Syndrome, the advances in its pathophysiology, and its clinical characteristics is reviewed.

Endoscopic Botulinum Toxin Injection for Refractory Enuresis Based on Urodynamic Assessment

Purpose

This study aimed to determine the urodynamic characteristics of refractory enuresis and explored whether those characteristics can be managed through differential endoscopic injections with botulinum toxin.

Methods

In total, 27 patients with nonmonosymptomatic enuresis who showed no response after conservative treatment for more than 12 months were included. The patients then underwent a videourodynamic study and received a differential endoscopic injection of botulinum toxin on the same day. Reduced capacity, detrusor overactivity, and bladder neck widening were the 3 major abnormal findings assessed during the filling phase, while sphincter hyperactivity was the only abnormality assessed during the emptying phase. An intravesical or intrasphincteric injection of botulinum toxin was attempted according to the videourodynamic study findings. Follow-up was conducted at 1, 3, 6, and 12 months after treatment.

Results

The median age was 10 years (range, 7–31 years). Although 19 and 8 patients had a preoperative diagnosis of overactive bladder or dysfunctional voiding, respectively, the urodynamic diagnosis was different in more than half of the patients. Those showing detrusor overactivity benefited from intravesical botulinum toxin injection, whereas those with only sphincter hyperactivity benefited from both intravesical and intrasphincteric injections. Treatment resistance to botulinum toxin seemed to be attributable to bladder neck widening. Time had no apparent effect on efficacy, which persisted 6 months after the injection. More than 80% of the patients maintained the benefits of the injection after 1 year.

Conclusions

Videourodynamic studies were useful for identifying the reasons underlying refractory nonmonosymptomatic enuresis and helpful for determining the appropriate site of botulinum toxin injection.

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.

Factors Associated with Urinary Incontinence in Pregnant Adolescents: A Case-Control Study

STUDY OBJECTIVE

To evaluate the factors associated with urinary incontinence (UI) in pregnant adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A case-control study was conducted in 3 Brazilian public hospitals. Adolescents between the ages of 10 and 19 years with gestational age of 27 weeks or more were included. The sample size was calculated using the Open-epi (http://www.openepi.com/Menu/OE_Menu.htm) 3.01 program considering gestational obesity as an associated factor. The resulting sample consisted of 658 volunteers, 329 in the case group (with UI) and 329 in the control group (without UI). The subjects responded to the evaluation form containing information about the outcome of interest and possible associated factors. Stata 14.0 software (StataCorp) was used to perform multivariate logistic analysis.

RESULTS

The variables age between 10 and 14 years (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.13-5.35; P = .023), previous UI (OR, 1.9; 95% CI, 1.36-2.75; P < .001), and constipation (OR, 1.7; 95% CI, 1.23-2.42; P = .002) were associated with UI in pregnant adolescents. Multigravida was not a factor associated (OR, 0.5; 95% CI, 0.31-0.66; P < .001) for UI in pregnant adolescents.

CONCLUSION

Attention must be given to primigravidae between the ages of 10 and 14 years who report previous UI and/or constipation to ensure referral to the appropriate health care professional for early prevention of UI.

Urinary Tract Infections in Infants and Children

Urinary tract infections (UTI) are one of the most common infections in children and symptoms may be nonspecific. The risk of renal scarring is highest in children under 1 year of age with febrile UTI and high-grade vesicoureteral reflux (VUR). Although treatment of UTI is usually straightforward, given increased rates of antimicrobial resistance worldwide, the choice of treatment for pediatric UTI should be guided by community resistance patterns whenever feasible. The benefit of antimicrobial prophylaxis after first UTI and/or in the presence of VUR remains controversial, but a recent meta-analysis supports continuous antimicrobial prophylaxis in children with VUR, indicating a need for more research in this area.

Concised Form for Lower Urinary Tract Dysfunction Symptom Scale in Children

INTRODUCTION

Symptom Scales (SS) are questionnaires for evaluating and following up of special illnesses. SS used for the diagnosis and follow-up of Lower Urinary Tract Dysfunction (LUTD) in children is called LUTD Symptom Scale (LUTDSS).

AIM

Aim of the present study was to identify the questions which are more important for the diagnosis of LUTD in children and create a simpler SS.

MATERIALS AND METHODS

From January 2005 to March 2015, 631 children between the age 5 and 15 were enrolled in this study. Eleven children with active urinary tract infections were excluded from the study. Two hundred sixty three children from the nursery and secondary school saying that they have no urinary complaints and having LUTDSS <9 were designed as control group. Three hundred fifty seven children with LUTDSS score ≥9 were thought as having LUTD and diagnoses were verified with 3-day bladder diaries and 2-time Uroflow-EMG-PVR tests. The answered questions of LUTDSS in patient and control group were compared.

RESULTS

Children with daytime incontinence (first question of questionnaire) were 47.7 (4.8-510) times (p=0.01), children with enuresis (third question) were 59.53 (6.2-961) times (p=0.001), children with pause while urinating (eighth question) were 28.7 (4.4-2090) times (p=0.001), children with urgency (tenth question) were 54.7 (29.3-604) times (p=0.039) more likely to have LUTD than the children not having these complaints. The area under ROC curve created by using 1,3,8, and 10 questions was calculated 86.4%.

CONCLUSION

The diagnosis and control of LUTD can be made by using only 1., 3., 8. and 10. questions, and these 4 questions could form simpler SS for LUTD in children.

The role of urinary nerve growth factor for the diagnosis and assessment of the biofeedback success in children with dysfunctional voiding

INTRODUCTION

Dysfunctional voiding (DV) occurs in neurologically normal children who are not able to establish brain control on detrusor muscle contractions (DMCs). It is also reported to be the result of incorrect voiding habits during toilet training. Children contract pelvic floor muscles (PFMs) to suppress DMC and DV begins. Urinary nerve growth factor (uNGF) is necessary for the synthesis and regulation of neurotransmitters, development of dorsal root ganglia (sensory neurons), and development of sympathetic cells during embryonic and post-natal life. uNGF has also a role in the intracellular signal transduction in nerve cells towards the target organ. To our knowledge, no study has investigated the association between uNGF, biofeedback treatment and DV in children.

OBJECTIVES

The aim was to examine the potential effect of uNGF in the assessment of the effectiveness of biofeedback success in children with lower urinary tract disorders.

STUDY DESIGN

Fifty-two children with the suspicion of DV and 48 children from a primary school reporting no urinary complaints were enrolled in this study from October 2010 to April 2013 in the Urology Department. uNGF levels were compared.

RESULTS

The mean uNGF/creatinine (Cr) level was 0.23 ± 0.26 in the control group and 0.96 ± 0.88 in the DV group (p < 0.001). The mean uNGF/Cr levels in the DV group at baseline and at the end of biofeedback therapy at 6 and 12 months were 0.90 ± 0.78, 0.26 ± 0.32, and 0.40 ± 0.50, respectively (p < 0.001) (Figure).

DISCUSSION

To our knowledge this study is the first to show the correlations between uNGF levels and biofeedback therapy in children with DV. Tissue NGF in 12 patients with overactive bladder (OAB)/detrusor overactivity and 15 healthy women was previously compared and it was suggested that there was no correlation between bladder tissue NGF and OAB. uNGF levels in the bladder in patients with interstitial cystitis and idiopathic sensorial urgency were evaluated previously, and uNGF levels reported. Similar to these reports, most of the previous studies handled uNGF in patients with diseases such as interstitial cystitis, OAB, urinary tract infections, urolithiasis, spinal cord injury, and prostate cancer, and found significantly higher uNGF levels. These studies were generally in adults. A previous study about uNGF comprised 40 children with OAB, in contrast to other studies. According to this study, 40 children diagnosed with OAB were administered anti-muscarinic therapy (oxybutynin 0.3-0.5 mg/kg/day). It was reported that uNGF/Cr levels of the OAB group were higher than control group. In the current study, we evaluated the uNGF difference in DV and the effect of biofeedback treatment on uNGF levels.

CONCLUSIONS

uNGF levels were higher in children with DV and decreased after biofeedback therapy. uNGF levels could be used for the diagnosis and the assessment of biofeedback success in these children.

[Acute urinary retention in a pre-school girl with constipation]

OBJECTIVE

To report a case of a preschool girl who developed acute urinary retention associated with constipation.

CASE DESCRIPTION

A girl aged six years old presented a 24 hour history of inability to urinate. She was went twice to the emergency room during this period. In the first admission, 12 hours after the onset of the symptoms, she presented abdominal pain and acute urinary retention. After the drainage by urinary catheterization of 300 mL of clear urine, she presented relief of the symptoms and, as urinalysis had no change, the patient was discharged home. Twelve hours after the first visit, she returned to the emergency room complaining about the same symptoms. At physical examination, there was only a palpable and distended bladder up to the umbilicus with no other abnormalities. Again, a urinary catheterization was performed, which drained 450 mL of clear urine, with immediate relief of the symptoms. Urinalysis and urine culture had no abnormalities. During the anamnesis, the diagnosis of constipation was considered and a plain abdominal radiography was performed, which identified large amount of feces throughout the colon (fecal retention). An enema with a 12% glycerin solution was prescribed for three days. During follow-up, the child used laxatives and dietary modifications, this contributed to the resolution of the constipation. There were no other episodes of urinary retention after 6 months of follow-up.

COMMENTS

Acute urinary retention in children is a rare phenomenon and constipation should be considered as a cause.

Evaluation and management of recurrent urinary tract infections in children: state of the art

Urinary tract infections (UTIs) represent an important cause of febrile illness in young children and can lead to renal scarring and kidney failure. However, diagnosis and treatment of recurrent UTI in children is an area of some controversy. Guidelines from the American Academy of Pediatrics, National Institute for Health and Clinical Excellence and European Society of Paediatric Radiology differ from each other in terms of the diagnostic algorithm to be followed. Treatment of vesicoureteral reflux and antibiotic prophylaxis for prevention of recurrent UTI are also areas of considerable debate. In this review, we collate and appraise recently published literature in order to formulate evidence-based guidance for the diagnosis and treatment of recurrent UTI in children.

Constipation in children with isolated overactive bladders

OBJECTIVE

To evaluate the prevalence of constipation in children with isolated overactive bladder (IOAB) and no micturition complaints.

MATERIALS AND METHODS

A questionnaire was used to evaluate constipation in 51 children with IOAB, as well as in a control group of 74 children between the ages of 4 and 14 years. The Rome III criteria for children were used to assess constipation. IOAB was defined as the presence of symptoms such as urgency with or without daytime incontinence or frequency, a bell-shaped uroflow, and no post-residual urine.

RESULTS

Mean patient ages were 7.94 (±2.8) and 8.28 (±3.4) years in the OAB and control group, respectively (p = 0.54). Twenty-eight (54.9%) of the OAB group were girls, and 34 (45.9%) were girls in the control group (p = 0.32). More of the children with IOAB had constipation than those without urinary symptoms (54.9% vs. 29.7%, p = 0.005; or 2.87, 95% CI: 1.3-6.0). The results were statistically significant regarding the following Rome III criteria: "history of stool retention", "presence of painful or hard bowel movements", "the presence of a large fecal mass in the rectum" and "large diameter stools which may obstruct the toilet". Within the group with OAB, constipation was more common among males (p = 0.05). There was no association between the type of OAB symptoms and constipation. The average dysfunctional voiding symptom score was 9.76 (±4.1). Eleven children (21.6%) presented alterations on ultrasound. Girls with OAB presented more frequently with UTI than boys (18 vs. 10, p = 0.13).

CONCLUSION

This was the first comparative study with respect to constipation in children with IOAB and without urinary symptoms. Children with IOAB have a greater risk of having constipation compared to those with no urinary symptoms.

Comparison of low-dose ketamine to midazolam for sedation during pediatric urodynamic study

INTRODUCTION

Aim of sedation during pediatric urodynamic studies (UDS) is a calm and cooperative child while not affecting measurements. We compared the effectiveness of midazolam to low-dose ketamine infusion for sedation and their impact on urodynamics.

MATERIALS AND METHODS

ASA-I children undergoing UDS were randomly assigned to group K (ketamine) loading dose (0.25 mg·kg(-1)) followed by infusion of 10-20 μg·kg(-1) ·min(-1) or group M (midazolam) loading dose of (0.02 mg·kg(-1)) followed by 1-2 μg·kg(-1) ·min(-1). The sedation scores and reactivity to catheterization were monitored by Children Hospital of Wisconsin Sedation Scale and Frankl Behavior Rating Scale, respectively. The UDS included two-channel filling cystometry in supine position followed by a free uroflowmetry in sitting position. The UDS was performed and interpreted in accordance with good urodynamic practice guidelines of International Continence Society (2002).

RESULTS

A total of 34 children were enrolled. Group K children (n = 17) attained sedation earlier 6.80 (±3.36) min vs. 9.40 (±2.82) min; (P = 0.03) than group M (n = 17) and also recovered earlier 11.60 (±3.13) min vs. 19.67 (±5.49) min (P = 0.01). Reactivity scores during urinary and rectal catheterization were lower in group K (P = 0.03 and 0.01), respectively. Historical UDS data of 21 participants were available for comparison with effect of medication. None of the study drugs affected UDS parameters significantly.

CONCLUSIONS

Midazolam or low-dose ketamine provide satisfactory sedation during pediatric UDS without impacting urodynamic values.

Consolidation therapy is necessary following successful biofeedback treatment for pubertal chronic prostatitis patients: a 3-year follow-up study

OBJECTIVE

To assess long-term effects of biofeedback training on pubertal chronic prostatitis (CP).

METHODS

Pubertal CP patients received 12-week intensive biofeedback training and were divided into two groups: group 1 received further monthly training ≥ 24 (26-36) months; group 2 received further monthly training <24 (13-23) months. National Institutes of Health-CP Symptom Index (NIH-CPSI) scores, maximum urinary flow rate (Qmax) and postvoid residual urine volume (PVR) were recorded monthly.

RESULTS

Total NIH-CPSI scores decreased significantly in group 1 (n = 10; mean age ± SD 16.5 ± 1.1 years) together with all subdomain scores (pain, urination, life impact). Total NIH-CPSI scores increased significantly in group 2 (n = 12; mean age ± SD 16.3 ± 1.2 years) at 30 and 36 months, and were significantly different from group 1 at these time points. Urination and life-impact scores increased significantly and Qmax decreased significantly in group 2 at 30 and 36 months. PVR was unchanged in either group.

CONCLUSIONS

Twelve-week intensive biofeedback training requires lengthy consolidation sessions to achieve long-term success. Further investigation should assess longer intervals between consolidation sessions, for improving patient compliance and outcome.

Bladder control training in girls with lower urinary tract dysfunction

PURPOSE

To evaluate the efficacy of standard and biofeedback bladder control training (BCT) on the resolution of dysfunctional elimination syndrome (primary outcome), and on the reduction of urinary tract infections (UTI) and the use of medications such as antibacterial prophylaxis and/or anticholinergic/alpha-blockers (secondary outcome) in girls older than aged least 5 years.

MATERIALS AND METHODS

72 girls, median age of 8 years (interquartile range, IQR 7-10) were subjected to standard BCT (cognitive, behavioural and constipation treatment) and 12 one-hour sessions of animated biofeedback using interactive computer games within 8 weeks. Fifty patients were reevaluated after median 11 (IQR, 6-17) months. Effectiveness of BCT was determined by reduction of dysfunctional voiding score (DVS), daytime urinary incontinence (DUI), constipation, UTI, nocturnal enuresis (NE), post void residual (PVR), and improvements in bladder capacity and uroflow/EMG patterns.

RESULTS

BCT resulted in significant normalization of DUI, NE, constipation, bladder capacity, uroflow/EMG, while decrease of PVR didn't reach statistical significance. In addition, the incidence of UTI, antibacterial prophylaxis and medical urotherapy significantly decreased. There were no significant differences in DVS, DVI, NE, bladder capacity and voiding pattern at the end of the BCT and at the time of reevaluation. The success on BCT was supported by parenteral perception of the treatment response in 63.9% and full response in additional 15.3% of the patients.

CONCLUSION

Combination of standard and biofeedback BCT improved dysfunctional elimination syndrome and decreased UTI with discontinuation of antibacterial prophylaxis and/or anticholinergic/alpha-blockers in the majority of the patients. Better training results are expected in patients with higher bladder wall thickness as well as in those with vesicoureteral reflux, while presence of nocturnal enuresis may be a negative predictor of the training effect.

Prevalence of lower urinary tract symptoms in school-age children

Epidemiological studies have demonstrated rates of incontinence and enuresis as high as 20% in school-age children. This cross-sectional study aimed to investigate the prevalence of lower urinary tract (LUT) symptoms in 739 children aged 6-12 years enrolled in three government schools with different socioeconomic levels in Minas Gerais, Brazil. Symptoms of LUT were evaluated using a modified version of the Dysfunction Voiding Scoring System in which the cutoff point considered as an indicator of LUT dysfunction is >6 for girls and >9 for boys. Children with a score indicative of symptoms received an educational booklet on the functioning of the LUT and were sent for clinical evaluation. LUT dysfunction symptoms were detected in 161 (21.8%) children. Symptoms were most frequent in girls (p < 0.001), children aged 6-8 (p < 0.028), and attended the school with the lowest social level (p < 0.001). Intestinal constipation was the most prevalent finding (30.7%), independent of LUT score. The most common urinary symptoms in children with an elevated score were diurnal urinary incontinence (30.7%), holding maneuvers (19.1%), and urinary urgency (13.7%). Stress factors were associated in 28.4% of children. Our findings suggest that LUT symptoms must be investigated carefully at routine pediatric visits.