Comparative analysis of the symptomatology of children with lower urinary tract dysfunction in relation to objective data

OBJECTIVES: To assess the clinical presentation of children with lower urinary tract dysfunction (LUTD) relating to objective examination data. MATERIALS AND METHODS: Forty-four children (36 girls and 8 boys with mean age of 6.8 years) with LUTD were prospectively assessed through a specific questionnaire that analyzed clinical presentation of those patients. These data were then compared to objective data, such as micturition diary and uroflowmetry with electromyography. RESULTS: A urinary tract infection (UTI) antecedent was observed in 31 cases (70.5 percent), and of those, 24 cases of UTI were accompanied by fever. All children presented micturition urgency. Daily urinary incontinence was observed in 33 cases (75 percent) and nocturnal enuresis in 23 (52.3 percent). As for micturition frequency, 15 (34.1 percent) had normal frequency 19 (43.2 percent) presented more than 10 daily micturition episodes and 10 (22.7 percent) thought they urinated less than 5 times a day. In the uroflowmetry and electromyography examination, 14 (31.8 percent) experienced lack of coordination during micturition. Of 10 children with infrequent micturition, 5 confirmed this in their micturition diaries and 2 listed more than 5 micturition episodes per day in the diary. Of 19 patients presenting polaciuria, only 5 confirmed this in their micturition diaries, while 7 had less than 10 micturition episodes per day. CONCLUSION: Most children with LUTD presented a previous UTI, and daily incontinence was verified in around 75 percent of the patients. Complaints of polaciuria or infrequent micturition are not noted completely in the micturition diaries and there is no parameter in the clinical history that offers good sensitivity or specificity for the diagnosis of lack of perineal coordination.

Simplified upper pole nephrectomy: initial experience

OBJECTIVE: To assess the results of an upper pole nephrectomy technique on 5 children. MATERIALS AND METHODS: Upper pole nephrectomy was performed on 5 children, including 4 females and 1 male. Age ranged from 3 to 6 years old. The technique was performed without initial dissection of the renal pedicle. The upper pole is incised and removed. Upon its complete dissection, the segment that drains the upper pole is easily identified, clamped and sectioned. RESULTS: Three children with ureterocele and 2 with ectopic ureter underwent this procedure. There was no intra- or postoperative complication with this technique. DSMA scintigraphy showed no decrease in renal function in the remaining kidney following the procedure. CONCLUSION: The polar nephrectomy technique is simple, and has the advantage of not approaching the renal hilum, which makes surgery less laborious and prevents risk of renal damage, hemorrhage and decreased function in the remaining renal portion.

Findings in cystourethrography that suggest lower urinary tract dysfunction in children with vesicoureteral reflux

PURPOSE: Children with lower urinary tract dysfunction and vesicoureteral reflux, at cystography assessment, frequently present alterations in the lower urinary tract anatomy such as dilated posterior urethra, irregularity of the bladder wall and diverticula. However, the significance of these findings is unknown. The objective of this study is to evaluate the incidence of these findings, their time of disappearance and their correlation with the severity of the reflux. MATERIALS AND METHODS: 193 children with vesicoureteral reflux, considered simple, in the age group above 5 years at the moment of diagnosis, were analyzed. The recommendation for follow-up of these patients was one voiding cystoureterography (VCUG) each year. Only patients with a minimum of 2 VCUGs performed in a period of at least 6 months were considered. The VCUGs were classified as positive and negative in relation to findings that were characteristic of lower urinary tract dysfunction (LUTD). RESULTS: From the 193 children analyzed, 50 (26 percent) presented positive VCUG and 143 negative VCUG. From the patients without symptoms of lower urinary tract dysfunction (n = 135), 12 (9 percent) presented positive VCUG and 123 (91 percent) a negative VCUG. From the patients with negative VCUG, 68 (48 percent) presented unilateral reflux and 75 (52 percent) presented bilateral reflux. From those with positive VCUG, 26 (52 percent) had unilateral reflux and 24 bilateral reflux (48 percent). This difference was not statistically significant. A higher incidence of grade II reflux was more evident in patients with negative VCUG and degree III in patients with positive VCUG (p < 0.05). CONCLUSIONS: Our study demonstrated that 64 percent of the patients with LUTD and reflux presented findings in the VCUG that suggest dysfunction.

Comparative study between intravenous urography and renal scintigraphy with DMSA for the diagnosis of renal scars in children with vesicoureteral reflux

PURPOSE: To assess the value of intravenous urography (IVU) in detecting and grading the renal scar, comparing its results with those of scintigraphy with dimercaptosuccinic acid (DMSA). MATERIALS AND METHODS: The study included 43 children investigated by DMSA and IVU, who had vesicoureteral reflux diagnosed and classified through voiding cystourethrography. RESULTS: Among the kidneys with reflux, there was agreement between the results of DMSA and IVU concerning the presence and the absence of scars in 82.4 percent of the cases. Based on the results obtained, IVU would have a sensitivity of 66.6 percent, specificity of 94.4 percent; accuracy of 82.5 percent; positive predictive value (PPV) of 90 percent and negative predictive value (NPV) of 79 percent, when compared with DMSA results. Our data also confirm the close relation between the reflux grade and the presence of renal scar, since 75 percent of the kidneys with grade IV and V reflux presented scars. In relation to the grading of nephropathy, in 78 percent of patients the classification of the scar by both methods was identical. The highest disagreement was verified in the group with segmental scar on DMSA, where 41.6 percent of the kidneys were classified as normal on IVU. CONCLUSION: The data obtained confirm that the scintigraphy with DMSA is essential in the investigation of patients with renal scar, and cannot be replaced by IVU, due to its low sensitivity and lower ability of satisfactory grading.

Etiology of urinary tract infection in scholar children

OBJECTIVE: To prospectively assess the prevalence of vesicourethral dysfunction in children over 3 years old, comparing it with the occurrence rate for other potential factors that cause urinary infection in this age range. MATERIALS AND METHODS: 36 girls and 9 boys were assessed, with mean age of 6.4 years, ranging from 3 to 13.9 years. These children were prospectively assessed regarding the presence of symptoms of lower urinary tract dysfunction. These data were compared with the retrospective assessment of other potential risk factors for urinary infection. Ultrasonography was performed in 28 children and voiding cystourethrogram was performed in 26 patients. RESULTS: Vesicourethral dysfunction was diagnosed in 39 (87 percent) of the 45 children with urinary infection. Among these 39 patients, all had voiding urgency, 30 (77 percent) had urinary incontinence, 12 (31 percent) pollakiuria and 3 (8 percent) presented infrequent voiding. Vaginal discharge was evidenced in 8 (22 percent) girls and phimosis in 2 (22 percent) boys. Obstipation was diagnosed in 10 (22 percent) cases. Significant post-voiding residue was detected in 4 (13 percent) of the 28 cases assessed. Vesicoureteral reflux was evidenced in 5 (19 percent) of the 26 patients who underwent voiding cystourethrogram. In only 2 (4 percent) cases there was not an apparent cause for the infection. CONCLUSION: Vesicourethral dysfunction is a major cause of urinary infection in children with ages above 3 years old. In cases where voiding dysfunction in not present, other predisposing factors must be assessed. However, only 4 percent of the patients did not present an apparent urologic cause for the infection.