The relationship between dysfunctional voiding and congenital vesicoureteral reflux

Risk Factors for the Development of Bladder and Bowel Dysfunction

BACKGROUND

Patients with vesicoureteral reflux and concomitant bladder and bowel dysfunction (BBD) are at high risk for febrile urinary tract infections. Risk factors for BBD have been identified in retrospective studies without validated measures.

METHODS

We conducted a secondary analysis of the Randomized Intervention for Children with Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation trials. The outcome of interest in the analysis of these children was the development of BBD, defined by using the dysfunctional voiding questionnaire, during any time point in the studies. We used multivariable logistic regression to determine the independent effects of sex, baseline percentile BMI, cohort status (Randomized Intervention for Children with Vesicoureteral Reflux versus Careful Urinary Tract Infection Evaluation), continuous antibiotic prophylaxis (yes or no), and reflux status (dilating versus nondilating) on the development of BBD.

RESULTS

Three hundred and eighteen patients met inclusion criteria. The majority of patients (244 patients, 77%) were not toilet trained at baseline visit. The median baseline age (interquartile range) was 21 months (11-35 months), and 299 (94%) patients were girls. During the study period, 111 (35%) developed BBD. Baseline BMI percentile was not associated with BBD development (adjusted odds ratio [aOR] = 1.0; 95% confidence interval [CI]: 0.9-1.1), whereas female sex was highly associated with BBD development (aOR = 12.7; 95% CI: 1.6-98). Patients with dilating reflux at baseline were 2.1 times more likely to develop BBD (95% CI: 1.2-3.7). Antibiotic prophylaxis was not associated with BBD development (aOR = 0.8; 95% CI: 0.4-1.4).

CONCLUSIONS

Dilating reflux and female sex were identified as risk factors for development of BBD, but neither BMI nor prophylactic antibiotics was associated with the development of BBD.

Urodynamics investigation on children with vesicoureteral reflux identifies overactive bladder and poor compliance in those with voiding dysfunction

BACKGROUND

Up to 50% of children with vesicoureteral reflux (VUR) may have associated voiding dysfunction. It is thought to be an important determinate of the severity and resolution of VUR; however, to date there has been no objective measurement defining the impact of voiding dysfunction in children with VUR. The purpose of this study is to compare the urodynamic parameters of children with VUR who have and do not have symptomatic voiding dysfunction.

METHODS

We performed a retrospective study of 138 children with a diagnosis of primary VUR who underwent urodynamic investigations. Information regarding patient demographics, grade and laterality of VUR and clinical history of bladder dysfunction were assessed. Urodynamic parameters recorded included detrusor overactivity, early and late compliance, voiding pressure, post-void residual volume and functional bladder capacity. Statistical analysis was performed using t Student analysis, Pearson's χ(2) test or Fischer's exact test, with a p < 0.05 as being significant.

RESULTS

The mean age of the patients at the time of urodynamic evaluation was 5.8 years (SD 4.4). 30% had symptomatic voiding dysfunction based on the clinical history. Children without a history of voiding dysfunction had higher grades of VUR as compared to those with it (p = 0.002). Bladder hypertone, detrusor overactivity, detrusor hypereflexia and poor late bladder compliance presented a statistically significant higher incidence the incidence of bladder overactivity and poor late bladder compliance was higher in children with bladder dysfunction than those without it.

CONCLUSION

Our findings suggest that voiding dysfunction does have objective and quantifiable effects on bladder dynamics. Urodynamic evaluation may play a role in the management of children with VUR by identifying those with bladder dysfunction secondary to abnormal voiding habits.

Antimicrobial mechanisms of the urinary tract

The urinary tract is a key system to maintain the homeostasis of the human body. It is relatively open to the outside environment, the perineum, a region highly colonized by bacteria. Bacteria can even be found in urine of healthy individuals. Still, urinary tract infections are far less frequent than it could be expected under these conditions. The high resistance against such infections has been observed already more than 100 years ago. Since then, many antimicrobial mechanisms of the urinary tract have been elucidated. Some questions, however, remain challenges for patients, scientists and health care professionals. In this review, we try to summarize the achieved knowledge about mechanisms, maintaining the urinary tract free of infection. In addition, we discuss their relevance and possible clinical application.

An electron microscopic examination of the intravesical ureter in children with primary vesico-ureteric reflux

OBJECTIVE

To determine the structure of the intravesical distal ureteric wall of patients with primary vesico-ureteric reflux (VUR), and to compare the findings with previous reports.

MATERIALS AND METHODS

Specimens of the distal intravesical ureteric segments were taken surgically from children undergoing ureteric reimplantation surgery for primary VUR. There were 24 distal intravesical ureteric specimens from 15 children (nine female and six male). Ultra-thin sections were cut from the specimens and examined with a transmission electron microscope.

RESULTS

The appearance of the muscular layers of the specimens of different grades differed markedly. There were intercellular oedematous areas in the muscular layer in specimens from patients with grade 2 and 3 VUR. In specimens from grade 4 VUR there were also intracytoplasmic vacuoles in the smooth muscle cells. The most marked and striking changes were in the specimens from children with grade 5 VUR, in which there were large intercellular oedematous areas and prominent large intracytoplasmic vacuoles.

CONCLUSION

Refluxing ureters differ from normal ureters in having disorganized smooth muscle fibres and altered smooth muscle cell structure, leading to incompetence of the valve mechanism. Although we cannot confirm that these pathological changes in the smooth muscle layer of the intravesical ureteric wall are caused by VUR we conclude that, with increasing degrees of reflux, the degree of smooth muscle damage increases, and that the rate of spontaneous resolution decreases.

Medical management of vesicoureteral reflux--quiz within the article. Don't overlook placebos

Vesicoureteral reflux (VUR) in children is associated with increased risk of urinary tract infection (UTI). Recurrent UTI in the presence of the VUR is believed to cause renal scarring, which carries a risk of subsequent hypertension, toxemia of pregnancy, and significant renal damage, including end-stage renal disease. The natural history of VUR is to improve or resolve completely with time in most of the patients. The traditional management consists of prompt treatment of UTI, long-term anti-microbial prophylaxis until the VUR resolves, or surgical intervention in those with persistent high grade VUR, recurrent UTI in spite of prophylaxis with anti-microbial agent, allergy to anti-microbial agents, and patient/parent non-compliance with the medical management. Voiding dysfunction and constipation play an important role, and their diagnosis and appropriate management helps reduce the frequency of UTI and promote the resolution of the VUR. Patients with renal scarring need to be monitored for potential complications such as hypertension, proteinuria, and progression of the renal damage. In patients with hypertension and/or proteinuria, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are the drugs of choice, because of their reno-protective properties. Recent studies have revealed that there is no convincing evidence that UTI in the presence of VUR predicts renal injury or that the use of long-term anti-microbial prophylaxis or surgical intervention prevents renal scarring or its progression. However, until proven otherwise by a prospective, placebo-controlled, randomized study, it is advisable to err on the side of caution and consider VUR and UTI risk factors for renal scarring and treat each patient on individual basis.

Investigation of Dysfunctional Voiding in Children with Urgency Frequency Syndrome and Urinary Incontinence

PURPOSES

Dysfunctional voiding may result in lower urinary tract symptoms (LUTS) in children and is associated with urinary tract infection and vesicoureteral reflux (VUR). This study analyzed the videourodynamic investigations in children with urgency frequency syndrome and/or urinary incontinence.

METHODS

Forty children, 1-13 years old, with urgency frequency syndrome and/or incontinence were investigated to determine their LUTS or for the assessment of VUR. Videourodynamic study was performed in all patients and the results were analyzed with clinical characteristics and underlying pathophysiology.

RESULTS

Dysfunctional voiding was present in 75.7% of the children with detrusor overactivity, in 73.3% of the children with VUR, in 63% of the children with urinary incontinence, in 77% of the children with episodic urinary tract infection, and in all of the children with diurnal enuresis. Compared to children without dysfunctional voiding, the voiding pressure was significantly higher in children with dysfunctional voiding (with VUR, 61.1 +/- 29.8 vs. 24.8 +/- 15.8 cm H(2)O, p = 0.004; without VUR, 53.4 +/- 24.1 vs. 24.8 +/- 15.8 cm H(2)O, p = 0.010). Biofeedback pelvic floor muscle training and treatment with antimuscarinic agent effectively decreased detrusor pressure, increased bladder capacity and maximum flow rate, and reduced the grade of VUR in 5 children who had post-treatment urodynamic studies.

CONCLUSIONS

This study has shown that dysfunctional voiding is highly prevalent in children with symptoms of urgency frequency and incontinence. Biofeedback pelvic floor muscle training is effective in treatment of dysfunctional voiding in children.

Voiding dysfunction: outcome in infants with congenital vesicoureteral reflux

OBJECTIVES

To assess the rate of development of voiding dysfunction as an outcome in patients with congenital vesicoureteral reflux.

METHODS

A computerized database was used to review the medical records of all patients with congenital reflux diagnosed before 6 months of age from 1988 to 2002. Only those infants with reflux who were followed up for at least 6 months past the age of toilet training were included. The parameters tabulated in this group included the presence of frequency, daytime wetting, urge incontinence, and infrequent voiding. The variables were summarized using contingency tables, and associations were evaluated using chi-square analysis and Fisher's exact test.

RESULTS

Of 342 patients (145 boys and 197 girls) with reflux, 67 (19.6%) developed voiding dysfunction (17.9% boys and 20.8% girls). No statistically significant difference was found between high grade (IV and V) and low grade (I and II) or grade III reflux, or between unilateral and bilateral reflux for the development of voiding dysfunction. Of the patients with reflux who had renal damage on dimercaptosuccinic acid scan, 24.3% of girls and 30.4% of boys developed voiding dysfunction, which was not significantly different from those without renal damage.

CONCLUSIONS

Approximately 20% of patients with vesicoureteral reflux diagnosed before 6 months of age demonstrated dysfunctional voiding after the age of toilet training. Voiding dysfunction occurred independent of sex, laterality, or severity of vesicoureteral reflux. Infants with renal damage on dimercaptosuccinic acid scan developed dysfunctional voiding only at a slightly greater, but not significantly different, rate than those with normal kidneys.

[Complex vesicoureteral reflux. Our experience]

OBJECTIVE

To analize the proportion of complex reflux in the whole amount of patients treated endoscopically of vesicoureteral reflux in our hospital. To determine the endoscopic treatment success in complex reflux, and the influence of reflux grade in it.

MATERIAL AND METHODS

We present our experience between 1992 and 2003 with three kinds of substances (polytetrafluoroethylene, polydimethylsiloxane and dextranomer-hyaluronic acid copolymer). We treated complex reflux in 74 patients with endoscopic injection. All patients were scheduled to have voiding cystourethrogram 3 and 9 moths after injection. A positive response was defined as grade 0 or I reflux.

RESULTS

Reflux was solved using the endoscopic procedure in 86.25% after first injection, 93.75% after second and 96.25% after third. The corresponding results for reflux grade II, III and IV were 88.9%, 83.3% and 100%.

CONCLUSIONS

We conclude that subureteral injection of different sustances (Teflon, Macroplastique or Deflux) is a useful treatment for most cases of vesicoureteral reflux. We propose it as first step of treatment.

Vesicoureteral reflux: who benefits from surgery?

Increased recognition of the association between urinary tract infections and reflux, sibling screening, and the evaluation of antenatal hydronephrosis have resulted in an increase in the diagnosis of reflux early in life. Although many children would sustain no untoward affects of their condition if reflux were left untreated, the disease can be severe and even life threatening. Although antireflux operations have been refined and improved, it remains difficult to determine which individuals truly benefit from these operations. A large prospective randomized placebo-antibiotic-operation study with long-term follow-up is needed, as is the development of nomograms, to assess the individual child's risk of adverse outcomes.

A multivariate analysis of dysfunctional elimination syndrome, and its relationships with gender, urinary tract infection and vesicoureteral reflux in children

PURPOSE

We explored and quantified the relationships between dysfunctional elimination syndrome (DES), and gender, urinary tract infection (UTI) and vesicoureteral reflux (VUR) in children.

MATERIALS AND METHODS

Data on 2,759 pediatric patients treated at a referral practice who underwent renal sonography and voiding cystourethrography were summarized. The patients were children with VUR or normal genitourinary anatomy who presented with UTI or dysfunctional voiding and children screened for genitourinary problems such as hematuria, sibling reflux or bedwetting. A multivariate logistic regression approach was used to model and quantify the associations between DES and other pediatric urology factors.

RESULTS

Of the girls 36.0% with unilateral VUR had DES, while 36.1% with bilateral VUR had DES. The corresponding rates for boys were 20.5% and 21.2%. The higher rate of DES in girls was independent of UTI and VUR status. While UTI was not associated with DES in boys or girls without VUR, in patients with VUR and UTI the risk of DES almost doubled (OR 1.97). Reflux alone without UTI was negatively associated with DES in boys (OR 0.50, 95% CI 0.34, 0.73) and girls (OR 0.26, 95% CI 0.19, 0.36).

CONCLUSIONS

Girls had a significantly higher rate of DES than boys in all UTI and VUR subgroups in the current data. UTI significantly impacts the DES occurrence in patients with VUR. No statistically significant difference was detected in the DES rate between the unilateral and bilateral VUR groups, and the reflux group as a whole did not seem to have a higher rate of DES in boys or girls.

Family history and behavioral abnormalities in girls with recurrent urinary tract infections: a controlled study

PURPOSE

We evaluated the role of family history, infrequent voiding, poor fluid intake, functional stool retention and inadequate anogenital hygiene or toilet habits in girls with recurrent urinary tract infections.

MATERIALS AND METHODS

The possible occurrence of these risk factors was assessed in 90 Swiss girls with recurrent urinary tract infections and in a control group of 45 girls.

RESULTS

Family history was positive in 42% of patients and in 11% of controls (p <0.001). Behavioral abnormalities were also more frequently noted in girls with recurrent urinary tract infections than in the control group (81% vs 56%, p <0.01). There were 137 abnormalities in 73 girls with recurrent urinary tract infections and 30 abnormalities in 25 controls. Two or more abnormalities each, that is 2 in 32 girls and 3 in 16, were noted in 48 girls with recurrent urinary tract infections and in 5 control girls. No controls presented with more than 2 abnormalities. Infrequent voiding (54% vs 24%, p <0.001), poor fluid intake (53% vs 16%, p <0.001) and functional stool retention (30% vs 13%, p <0.05) were more frequently disclosed in girls with recurrent urinary tract infections than in control girls. In contrast, the frequency of inadequate stool hygiene or toilet habits was similar in patients and controls (14% and 13%, respectively).

CONCLUSIONS

The evaluation of girls with recurrent urinary tract infections should focus on identifying behavioral aspects, including infrequent voiding, poor fluid intake and functional stool retention.

The Intravesical Ureter in Children With Vesicoureteral Reflux: A Morphological and Immunohistochemical Characterization

PURPOSE

We investigated intravesical ureteral endings using immunohistochemical methods to study general morphology, smooth muscle architecture and collagen composition in children with vesicoureteral reflux.

MATERIALS AND METHODS

Samples were obtained from 29 ureterorenal units in children with a mean age of 52.3 months undergoing reflux surgery. Routine histological paraffin embedded sections were stained with hematoxylin and eosin, and Masson trichrome to assess general morphology. Staining for actin, myosin and desmin was performed to evaluate the presence, allocation and architecture of the ureteral smooth muscle wrap. In addition, indirect immunohistochemical methods were used to study the collagen composition of the ureteral wall and CD68 was used for macrophage labeling as a marker of tissue remnant scavenging. All investigations were done using high power field magnification for quantification. In addition, age matched, nonrefluxing ureteral specimens served as controls.

RESULTS

Smooth muscle alpha-actin, myosin and desmin expression were extensively decreased in all specimens pertaining to the ureteral ending. This distal part showed a high degree of muscle atrophy and degeneration as well as a disordered fiber arrangement associated with increased extracellular matrix collagen accumulation. In addition, CD68 positive macrophages were significantly increased. In contrast to these observations, the proximal intravesical portion of the ureter showed intact morphology and arrangement of the muscular coat.

CONCLUSIONS

Refluxing intravesical ureteral endings showed dysplasia, atrophy and architectural derangement of smooth muscle fibers. Consequently symmetrical contraction of the distal ureteral smooth muscle coat creating the active valve mechanism to protect reflux is not achievable.

Dysfunctional elimination syndrome: is it related to urinary tract infection or vesicoureteral reflux diagnosed early in life?

OBJECTIVE

It has been suggested that urinary tract infections (UTIs) early in life predispose to dysfunctional elimination syndrome (DES). This study evaluated the relationship between early UTI, vesicoureteral reflux (VUR), and DES by comparing two cohorts of school-aged children.

METHODS

The UTI cohort (n = 123) included children previously enrolled in a prospective treatment trial conducted between 1992 and 1997. All were diagnosed with a febrile UTI before 2 years of age. The comparison cohort (n = 125) included children who were evaluated for fever in the emergency department between 1992 and 1997, whose urine culture was negative. Dysfunctional elimination symptoms were compared in the two cohorts by having families complete a revised version of the Dysfunctional Voiding Scoring System.

RESULTS

Completed questionnaires were received from 248 children. There were no significant differences in selected demographic or clinical characteristics between the two cohorts. DES was present in 22% and 21% of children with and without a history of early UTI, respectively. Among children with UTIs, 18% of those with VUR and 25% of those without VUR had DES.

CONCLUSIONS

Dysfunctional elimination is common in a general pediatric population. Neither UTI nor VUR diagnosed before 2 years of age was associated with DES in school-aged children.

The long-term outcome of bilateral Cohen ureteric reimplantation under a common submucosal tunnel

OBJECTIVE

To analyse the results of bilateral Cohen reimplantation under a common submucosal tunnel, over an 18-year period.

PATIENTS AND METHODS

We retrospectively examined 102 children (35 boys and 67 girls, median age 5.5 years, range 0.5-13.5) who underwent bilateral antireflux ureteric reimplantation from 1983 to 2000 with a modified Cohen technique, re-implanting both ureters under a common submucosal tunnel in the mid-trigonal area, to treat primary vesico-ureteric reflux (VUR, 99 patients) or obstructive megaureter (three). The mean (range) follow-up was 10.6 (2-18) years.

RESULTS

The operation was successful in 198 of 204 (97%) ureters. One patient had vesico-ureteric stenosis in one ureter and was re-operated successfully. In two ureters in two different patients there was transient stasis after surgery caused by oedema within the tunnel, which gradually resolved. Two ureters in two other patients had reflux after surgery, which resolved spontaneously after 12 and 24 months, respectively. A 6-month old baby had anuria after surgery because of acute compression of both ureters within a narrow tunnel; this patient was re-operated, the tunnel widened and the obstruction resolved. None of 82 patients who had reached school age by the time of their last follow-up showed signs of voiding dysfunction.

CONCLUSIONS

The modified bilateral Cohen reimplantation with both ureters under a common submucosal tunnel offers very good long-term results in curing VUR or obstructive megaureter. Crossing one ureter upon the other within the tunnel does not predispose to long-term obstruction. From these results we recommend it as a reliable technique for surgically treating bilateral VUR or obstructive megaureter.

Radionuclide voiding patterns in children with vesicoureteral reflux

The purpose of this study was to evaluate bladder function in children with vesicoureteral reflux (VUR) by means of indirect radionuclide cystography (IRNC), and to investigate whether IRNC can identify those children with voiding dysfunction. The study enrolled 74 neurologically intact children, 14 boys and 60 girls aged 2-14 years, with VUR documented using contrast micturating cystourethrography as the initial method. In all patients, IRNC was performed using technetium-99m diethylene triamine penta-acetate (DTPA). Based on the urodynamic findings, three groups were distinguished: a group with VUR and normal urodynamic findings ( n=27), a group with VUR and detrusor hyper-reflexia ( n=43) and a group with VUR and detrusor-sphincter dyssynergia ( n=4). A control group comprised 64 healthy children, aged 2-13 years, without any symptoms of lower urinary tract dysfunction. The dynamics of bladder emptying were studied in the posterior view after intravenous injection of 37 MBq/10 kg b.w. DTPA, with acquisition of 90 2-s frames during voiding. The parameters evaluated were: voided urine volume (VV), bladder capacity, functional bladder capacity (FBC), residual urine, voiding time, average flow rate, peak flow rate (PFR) and ejection fraction (EF). With regard to the final urodynamic diagnosis, FBC, PFR and EF were found to be significant IRNC predictor variables using the logistic regression method. If abnormality on at least two of the three significant predictor variables was taken as the criterion of voiding dysfunction, the overall sensitivity, specificity and accuracy of IRNC in the detection of voiding dysfunction were 81%, 78% and 80%, respectively. Three radionuclide voiding patterns were detected in children with VUR: (1) a normal voiding pattern characterised by normal FBC with near-normal PFR and EF values, (2) a markedly reduced FBC with significantly reduced VV, PFR and EF values (in children with bladder instability), and (3) a higher bladder volume with a near-normal value for PFR and a slightly reduced or near-normal EF (in children with detrusor-sphincter dyssynergia). This study confirmed the association between lower urinary tract dysfunction and congenital VUR. IRNC was found to be a simple, non-invasive method which allows reliable differentiation of voiding patterns in patients with VUR. IRNC can be used as a first-line method for screening in children with VUR to identify those with abnormal voiding patterns.

Urinary incontinence in girls

Girls with incontinence may have minor irritative conditions or undiagnosed anatomic abnormalities that may require surgery. These abnormalities can be identified during a comprehensive history and physical examination that focuses on voiding signs and symptoms. Urinary tract infection and constipation if present should be identified. Most girls with daytime wetting will respond to conservative therapy using timed voiding, dietary changes, and anticholinergic medication. Uroflowmetry with a postvoid residual urine measurement can identify girls who may benefit from biofeedback to treat pelvic floor dysfunction. Formal urodynamics and spinal magnetic resonance imaging should be done in girls refractory to treatment. Instruments and tools to quantify dysfunctional voiding symptoms are being developed. Because most dysfunctional voiding will be treated clinically, these validated tools will be useful in documenting severity of symptoms and clinical outcomes.