Adaptação transcultural e validação do Constipation Scoring System para a população brasileira / Cross-cultural adaptation and validation of the constipation scoring system for the brazilian population

ABSTRACT Background Beyond Rome IV Criteria, the assessment of functional constipation in clinical practice can also be obtained by the Constipation Scoring System (CSS). By accessing the CSS, health professionals are able to measure this dysfunction, guiding initial therapeutic approach and post-treatment response. In addition, the CSS enables the standardization of results concerning functional constipation research. Objective To promote translation, cross-cultural adaptation and validation of the CSS for the Brazilian population. Methods To attain the score in Portuguese, the adaptation was accomplished in four steps (translation, back translation, application and adjustments). Afterward, the validation and adaptation to the Brazilian population was performed through test-retest. Results For adults, the convergent validity of the Brazilian version of the CSS showed a significant correlation to the Rome IV Criteria evinced by the positive Spearman correlation (r2) of 0.816 (P<0.001). Between the test-retest responses, the translated version of the score had a Cronbach's Alpha of 0.972. A high level of internal consistency was also obtained when each item of the questionnaire was assessed separately, revealing an adequate internal reliability Conclusion The CSS was well adapted and accepted by the Brazilian population, demonstrating the linguistic and psychometric validity of this Portuguese version of the score.

RESUMO Contexto Além dos Critérios de Roma IV, a avaliação da constipação funcional também pode ser obtida por meio do Constipation Scoring System (CSS). Ao acessar o CSS, o profissional de saúde consegue mensurar a constipação funcional, orientando a abordagem terapêutica inicial e a resposta pós-tratamento. Além disso, o CSS possibilita a padronização dos resultados das pesquisas sobre esta disfunção. Objetivo Promover a tradução, adaptação transcultural e validação do CSS para a população brasileira. Métodos Para obtenção da versão do CSS em português, a adaptação foi realizada em quatro etapas (tradução para o inglês, retrotradução para o português, aplicação e ajustes). Posteriormente, foi realizada a validação e adaptação para a população brasileira por meio de teste-reteste. Resultados Para adultos, a validade convergente da versão brasileira do CSS apresentou correlação significativa com os critérios de Roma IV evidenciada pela correlação de Spearman positiva (r) de 0,816 (P<0,001). Entre as respostas do teste-reteste, a versão traduzida do escore apresentou um Alpha de Cronbach de 0,972. Um alto nível de consistência interna também foi obtido quando cada item do questionário foi avaliado separadamente, revelando uma confiabilidade interna adequada. Conclusão O CSS foi bem adaptado e aceito pela população brasileira, demonstrando a validade linguística e psicométrica da versão em português do escore.

Uma Proposta Educativa para Abordar Objeção de Consciência em Saúde Reprodutiva durante o Ensino Médico / An Educational Proposal to Address Conscientious Objection in Reproductive Health during Medical Education

RESUMO OBJETIVO Este estudo procurou avaliar a técnica do role-playing na abordagem da objeção de consciência no currículo médico, estimulando o raciocínio ético e a habilidade de comunicação, competências necessárias a um maior conforto na alegação de recusa por parte do profissional. MÉTODOS Estudo de intervenção que envolveu 120 acadêmicos de Medicina no momento em que encerravam o internato em Perinatologia. Os estudantes responderam a um questionário autoaplicável, antes e depois da intervenção, contendo variáveis demográficas e questões sobre a anuência de conduzir ou não situações em saúde reprodutiva, como abortamento legal, orientação contraceptiva a jovens adolescentes e prescrição da pílula do dia seguinte. O grau de conforto dos estudantes ao conduzirem estes casos e os conhecimentos éticos sobre o tema também foram questionados. Recolhidos os questionários, os alunos assistiram a três filmes de curta-metragem, um tratando da recusa de um médico a realizar um abortamento previsto em lei; outro sobre orientação contraceptiva a uma jovem de 13 anos e sem o consentimento dos pais; e um terceiro, acerca da prescrição da pílula do dia seguinte a uma jovem que teve uma relação desprotegida no 14º dia do ciclo. Encerrada esta etapa, se estimulou uma discussão sobre os seguintes tópicos: aspectos legais sobre o tema, direito à objeção de consciência do médico, violação da autonomia da paciente e prejuízo à saúde do solicitante decorrente da recusa por parte do médico. Encerrada esta fase preparatória, formaram-se subgrupos de três alunos que simularam os três casos clínicos, havendo um revezamento entre os papéis de médico, paciente e observador. Após a dramatização, os estudantes foram estimulados a discutir as inter-relações nos papéis de médico e paciente, a objeção de consciência do médico, o efeito da recusa ao tratamento no paciente e a capacidade de comunicação do médico. Ao final, foi reaplicado o mesmo questionário, com as mesmas questões sobre a anuência ou não da condução dos casos clínicos, o conforto ou não ao conduzi-los, como também as perguntas referentes aos conhecimentos éticos sobre objeção de consciência. Os dados foram analisados pelo teste do X2, teste t e teste de McNemar, com nível de significância de 5%. RESULTADOS A alteração do conforto do estudante na condução do abortamento previsto em lei, após a intervenção, foi significativa (p < 0,001). O mesmo foi observado na orientação contraceptiva a jovens adolescentes (p < 0,001) e na prescrição da contracepção de emergência (p = 0,002). A mudança de opinião quanto à objeção ao abortamento legal foi significativa (p = 0,003) e também quanto à orientação contraceptiva a jovens adolescentes (p = 0,012). Não se observaram diferenças na prescrição da pílula do dia seguinte (p = 0,500). CONCLUSÕES A aplicação dessa metodologia no grupo participante tornou mais confortável a condução dos casos discutidos e forneceu um conteúdo técnico, legal e ético para melhor embasamento de suas opiniões.

ABSTRACT OBJECTIVES To evaluate the effectiveness of role-playing in addressing the issue of conscientious objection in the medical curriculum. METHODS This is an intervention study involving 120 medical students on completion of their internship in Perinatology.The project consisted of eight modules with 15 students in each. Initially a questionnaire was applied to obtain the students' demographic information, religion, ethical knowledge of conscientious objection in medical practice, whether or not the students agreed with it, and the level of comfort in addressing situations such as legal abortion, the prescription of emergency contraceptives, and giving advice on contraception to young adolescents. Subsequently, three short films, created exclusively for the project, were shown. The first addressed a doctor's refusal to perform an abortion on a 15-year-old girl who had been the victim of sexual violence. The second simulatedes a doctor's objection to providing advice on contraception to a 13-year-old adolescent without parental consent, and the third portrayed the doctor's refusal to prescribe emergency contraception to a young woman after having unprotected intercourse on the 14th day of her cycle. A discussion was then instigated on the following topics: the existing legislation on the subject, the doctor's right to conscientious objection, violation of the patient's autonomy, and the potential for discrimination and harm to the patient's health due to the doctor's refusal. Subgroups of three students were then formed, to simulate clinical cases, with the students taking turns to play the roles of the physician, patient and observer. At the end, the questionnaire was reapplied. The data were analyzed by the χ2 test, t-test and McNemar's test, with a level of significance of 5%. RESULTS Abortion was rejected by 35.8% of the students, contraception for adolescents by 17.5%, and emergency contraception by 5.8%. The predictors identified with legal abortion were stronger religious belief (p < 0.001) and more frequent attendance of religious services (p = 0.034). The refusal to provide contraception to adolescents was significantly higher among women (p = 0.037).Of the sample, 25% did not explain the reason for their refusal, 15% did not describe all procedures, and 25% said they would not forward patients. The change in comfort in conducting legal abortion after the intervention was significant (p < 0.001). The same was observed in the attitude to providing contraceptives to young adolescents (p < 0.001) and in the prescription of emergency contraception (p = 0.002). The change of opinion regarding objection to legal abortion was significant (p = 0.003), as was the attitude to providing and also regarding the contraceptives to young adolescents (p = 0.012). No differences were observed in the prescription of emergency contraception (p = 0.500). CONCLUSIONS The application of this methodology in the participant group made the students more comfortable about conducting cases like those discussed, and provided technical, legal and ethical content for a better grounding of their opinions.

Constipação funcional e bexiga hiperativa em mulheres: um estudo de base populacional / Functional constipation and overactive bladder in women: a population-based study

ABSTRACT BACKGROUND: An association between urinary disorders and functional constipation has been registered in children and adults, with functional constipation being a common complaint in individuals with overactive bladder. OBJECTIVE: To evaluate the prevalence of functional constipation, overactive bladder and its dry/wet subtypes in women and to determine which bowel symptoms predict overactive bladder. METHODS: A cross-sectional study of women randomly approached in public spaces. Exclusion criteria: neurological/anatomical abnormalities of the bowel or urinary tract. Constipation was defined as ≥2 positive symptoms of those listed in the Rome criteria. Urinary abnormalities (frequent urination, urgency, incontinence, nocturia) were defined by a score ≥2 in the respective item of the International Consultation on Incontinence Questionnaire - Overactive Bladder. Dry overactive bladder was defined as urgency without incontinence, while wet overactive bladder included incontinence. RESULTS: A total of 516 women with a mean age of 35.8±6 years were interviewed. Rates of functional constipation, overactive bladder, dry overactive bladder and wet overactive bladder were 34.1%, 15.3%, 8.9% and 6.4%, respectively. Functional constipation was associated with overactive bladder and dry overactive bladder, with functional constipation predicting dry overactive bladder (OR=2.47). Quality of life was poorer in constipated women compared to non-constipated and even worse in constipated women with wet overactive bladder (median 22.5; 95%CI: 17.25-35.25). Manual maneuvers were significantly associated with both overactive bladder subtypes. Independent predictive factors for overactive bladder were manual maneuvers (OR=2.21) and <3 defecations/week (OR=2.18), with the latter being the only predictive factor for dry overactive bladder (OR=3.0). CONCLUSION: Functional constipation is associated with overactive bladder and its dry subtype, particularly in the younger population. In addition, this association is responsible for lower quality of life scores, especially when urinary incontinence is present. The presence of manual maneuvers and less than three defecations per week should direct us to look for overactive bladder.

RESUMO CONTEXTO: A associação entre distúrbios urinários e constipação funcional vem sendo observada em crianças e adultos, sendo a constipação funcional uma queixa comum em indivíduos com bexiga hiperativa. OBJETIVO: Avaliar a prevalência de constipação funcional, bexiga hiperativa e seus subtipos seco/úmido em mulheres e determinar quais os sintomas intestinais estão mais associados e são preditores de bexiga hiperativa. MÉTODOS: Estudo de corte transversal com mulheres abordadas aleatoriamente em locais públicos. Os critérios de exclusão foram: anormalidades neurológicas/anatômicas do intestino ou do trato urinário documentadas. A constipação foi definida como ≥2 sintomas positivos daqueles listados nos critérios de Roma. Alterações urinárias (frequência urinária aumentada, urgência, incontinência e noctúria) foram definidas por um escore ≥2 no respectivos itens do Questionário Internacional de Consulta sobre Incontinência - Bexiga Hiperativa. Foi denominada de bexiga hiperativa seca a presença de sintomas de urgência sem incontinência urinária e bexiga hiperativa úmida quando a urgência estava associada a incontinência urinária. RESULTADOS: Foram entrevistadas 516 mulheres com idade média de 35,8±6 anos. As taxas de constipação funcional, bexiga hiperativa, bexiga hiperativa seca e bexiga hiperativa úmida na amostra estudada foram de 34,1%, 15,3%, 8,9% e 6,4%, respectivamente. Foi observada associação entre constipação funcional e bexiga hiperativa / bexiga hiperativa seca, sendo a constipação funcional fator preditor para esse subtipo de bexiga hiperativa (OR=2,47). O escore de qualidade de vida foi pior nas mulheres com constipação funcional em comparação com as não constipadas e ainda pior nas mulheres com constipação funcional associada a bexiga hiperativa úmida (mediana 22,5; IC 95%: 17,25-35,25). A presença de manobras manuais estava significativamente associada aos dois subtipos de bexiga hiperativa. Os fatores preditivos independentes para bexiga hiperativa foram manobras manuais (OR=2,21) e <3 defecações/semana (OR=2,18), sendo este último o único fator preditivo para bexiga hiperativa seca (OR=3,0). CONCLUSÃO: Em mulheres, a constipação funcional está associada a bexiga hiperativa e seu subtipo seco, particularmente na população mais jovem. Além disso, essa associação é responsável por piores escores de qualidade de vida, principalmente quando a incontinência urinária está presente. A presença de manobras manuais e menos de três defecações por semana em mulheres devem nos direcionar a procurar por bexiga hiperativa.

Prevalence, attitudes, and factors motivating conscientious objection toward reproductive health among medical students / Prevalência, atitudes e fatores motivadores à objeção consciente com relação à saúde reprodutiva entre estudantes de medicina

Abstract Objective We have evaluated the prevalence of and the motivating factors behind the refusal to provide reproductive health services and the ethical knowledge of the subject among medical students from the Escola Bahiana de Medicina e Saúde Pública, in the state of Bahia, Brazil. Methods The present cross-sectional study involved 120 medical students. A questionnaire was utilized. The dependent variables were students' objections (or not) regarding three clinical reproductive health cases: abortion provided by law, contraceptive guidance to an adolescent without parental consent, and prescription of emergency contraception. The independent variables were age, gender, religion, ethical value, degree of religiosity, and attendance at worship services. Ethical knowledge comprised an obligation to state the reasons for the objection, report possible alternatives, and referral to another professional. Data were analyzed with χ2 tests and t-tests with a significance level of 5%. Results Abortion, contraception to adolescents, and emergency contraception were refused by 35.8%, 17.5%, and 5.8% of the students, respectively. High religiosity (p < 0.001) and higher attendance at worship services (p = 0.034) were predictors of refusing abortion. Refusal to provide contraception to adolescents was significantly higher among women than men (p = 0.037). Furthermore, 25% would not explain the reason for the refusal, 15% would not describe all the procedures used, and 25% would not refer the patient to another professional. Conclusion Abortion provided by law was the most objectionable situation. The motivating factors for this refusal were high commitment and religiosity. A reasonable portion of the students did not demonstrate ethical knowledge about the subject.

Resumo Objetivo Avaliar a prevalência e os fatoresmotivadores da recusa emprestar serviços de saúde reprodutiva, bem como o conhecimento ético do tema, entre estudantes de medicina. Métodos Estudo transversal, envolvendo 120 estudantes demedicina. Aplicou-se um questionário cujas variáveis dependentes forama existência ou não de objeções quanto à condução de três casos clínicos sobre saúde reprodutiva: o abortamento previsto em lei, a orientação contraceptiva a uma adolescente sem consentimento dos pais, e a prescrição de contracepção de emergência. As varáveis independentes foram: idade, gênero, religião, valor ético, grau de religiosidade e frequência a cultos religiosos. Os conhecimentos éticos pesquisados foram a obrigação de expor os motivos da objeção, relatar as alternativas possíveis e encaminhar a paciente a outro profissional. Os dados foram analisados pelo teste do χ2 e pelo teste-t, com nível de significância de 5%. Resultados O abortamento foi recusado por 35,8% dos estudantes, a contracepção aos adolescentes por 17,5%, e a contracepção de emergência por 5,8%. A alta religiosidade (p < 0,001) e uma maior frequência a cultos (p = 0,034) foram os preditores identificados no caso do abortamento previsto em lei. A recusa da contracepção aos adolescentes foi significativamente maior entre as mulheres (p = 0,037). Entre os estudantes, 25% não explicariam o motivo da recusa, 15% não descreveriam todos os procedimentos e 25% não fariam o encaminhamento da paciente para outro profissional. Conclusão O abortamento previsto em lei, foi a situação mais objetada. Os fatores motivadores a esta recusa foram o alto comprometimento e maior religiosidade. Uma parcela razoável dos alunos não demonstrou ter conhecimentos éticos sobre o tema.

Factors associated with child sexual abuse confirmation at forensic examinations / Fatores associados à confirmação por exame médico legal de abuso sexual infantil

Abstract The aim of this study is identify potential factors associated with child sexual abuse confirmation at forensic examinations. The forensic files of children under 12 years of age reporting sexual abuse at the Nina Rodrigues Institute of Forensic Medicine in Salvador, Bahia, Brazil between January 2008 and December 2009 were reviewed. A multivariate analysis was conducted to identify factors associated with finding evidence of sexual abuse in forensic examinations. The proportion of cases confirmed by the forensic physician based on material evidence was 10.4%. Adjusted analysis showed that the variables place of birth, type of abuse reported, family relationship between the child and the perpetrator, and the interval between the reported abuse and the forensic examination were not independently associated with finding forensic evidence of sexual abuse. A report of penetration was associated with a five-fold greater likelihood of confirmation, while the victim being 10-11 years of age was associated with a two-fold of abuse confirmation than younger children. These findings should be taken into consideration when drawing up guidelines for the multidisciplinary evaluation of children suspected of being victims of sexual abuse and in deciding whether to refer the child for forensic examination.

Resumo O Objetivo deste estudo é identificar potenciais fatores associados à confirmação de abuso sexual infantil no exame médico legal. Foram revisados os laudos de sexologia forense realizados em crianças menores que 12 anos que relataram abuso sexual no Instituto Médico Legal de Salvador, Brasil, no período de janeiro de 2008 a dezembro de 2009. Análise multivariada foi utilizada para identificar fatores relacionados à confirmação de abuso sexual pelo exame médico forense. A proporção de casos confirmados pelo médico legista com base em evidencia material foi de 10,4%. A análise ajustada demostrou que as variáveis naturalidade, tipo do relato de abuso, parentesco com o agressor, e intervalo entre o abuso relatado e a perícia não estão independentemente relacionadas à confirmação de abuso sexual em exame de corpo de delito. A presença de relato de penetração estava associada a uma chance cinco vezes maior de confirmação, e a faixa etária de 10 a 11 anos apresentou uma chance duas vezes maior de ter casos confirmados do que crianças menores. Estes dados devem ser levados em conta no planejamento de diretrizes para a avaliação multidisciplinar de crianças com suspeita de serem vítimas de abusos sexual e na decisão de encaminhamento para exame de corpo de delito.

Enuresis and overactive bladder in children: what is the relationship between these two conditions?

ABSTRACT Objective: Evaluate clinical aspects associated with the presence of nocturnal enuresis (NE) in children with a diagnosis of overactive bladder (OAB). Material and Methods: A data base of 200 children who were evaluated by a structured questionnaire was analysed retrospectively . OAB was defined as the presence of urinary urgency (n=183 cases) and/or daytime urinary incontinence associated with holding maneuvers (n=168 cases). Inclusion criteria were a confirmed diagnosis of OAB, age 5-16 years, and no anatomical or neurological alterations of the urinary tract. Patients were divided into enuretics and non-enuretics. The two groups were compared with respect to sex, age, skin color, presence urinary infection, urgency, urge incontinence, non-urge incontinence, pollakiuria, urinary dysfunction, nocturia, holding maneuvers, number of episodes of enuresis and bowel alterations. In a univariate analysis, the chi-square test was used to compare proportions, with p-values <0.05 being considered significant. A multivariate analysis was conducted to identify independent predictive factors. Results: Enuresis was diagnosed in 141/200 children. The two groups were similar with respect to sex, age and skin color. No difference was found in relation to urinary infection, non-urge incontinence, urinary dysfunction, nocturia, encopresis or constipation. The two groups were significantly different with regard to some symptoms related to OAB such as urgency (p=0.001), urge incontinency (p=0.001) and holding maneuvers (p=0.033). Following multivariate analysis, only holding maneuvers (p=0.022) remained as an independent predictive factor. Conclusion: The only independent predictive factor for resolution of enuresis in children with OAB, as detected in the multivariate analysis, was holding maneuvers.

Doenças e variações anatômicas confundidas com abuso sexual em crianças - Estudo descritivo / Disorders and anatomical variations confused with sexual abuse in children - A descriptive study

Objetivo: Descrever as doenças e variações anatômicas confundidas com abuso sexual em crianças. Método: Estudo descritivo com dados secundários. Foram revisados os laudos de crianças menores de 12 anos periciadas no Instituto Médico Legal Nina Rodrigues, entre 2005 e 2010, por suspeita de abuso sexual baseada em queixa ou alteração anogenital, sem relato de abuso sexual no histórico da perícia. O critério utilizado para identificar os casos foi a conclusão do médico legista no laudo. Resultados: Foram encontrados 410 casos sem relato ou testemunho de abuso sexual. Neste grupo, em 31 casos (7,6%) a conclusão do laudo identificou uma doença ou variação anatômica, baseado na queixa ou alteração anogenital que gerou a suspeita de abuso sexual. Foram encontrados 16 casos de prolapso uretral (52%). As outras condições médicas identificadas incluíram sinéquia de ninfas, neoplasia vaginal, dermatites, variação anatômica, doença de Crohn, enterobíase, corpo estranho vaginal, fenda perineal e infecção urinária. Conclusão: Foram encontrados casos de doença ou variação anatômica confundidos com abuso sexual em 7,6% das crianças em que a origem da suspeita foi uma queixa ou alteração anogenital, sem relato de abuso no histórico. Prolapso uretral representou 52% dos casos de equivoco...

Single scrotal incision orchiopexy - a systematic review

Objective To conduct a systematic review on single scrotal incision orchiopexy. Materials and Methods: A search was performed using Pubmed, through which 16 articles were selected out of a total of 133. The following conditions were considered exclusion criteria: other surgical methods such as an inguinal procedure or a laparoscopic approach, retractile testes, or patients with previous testicular or inguinal surgery. Results A total of 1558 orchiopexy surgeries initiated with a transcrotal incision were analyzed. Patients' ages ranged between 5 months and 21 years. Thirteen studies used high scrotal incisions, and low scrotal incisions were performed in the remainder of the studies. In 55 cases (3.53%), there was a need for inguinal incision. Recurrence was observed in 9 cases, testicular atrophy in 3, testicular hypotrophy in 2, and surgical site infections in 13 cases. High efficacy rates were observed, varying between 88% and 100%. Conclusions Single scrotal incision orchiopexy proved to be an effective technique and is associated with low rates of complications. .

Bacteriúria assintomática em mulheres diabéticas: revisão sistemática / Asymptomatic bacteriuria in diabetic women: systematic review

JUSTIFICATIVA E OBJETIVOS: A infecção do trato urinário (ITU) é uma doença frequente e na ausência de sintomas denomina-se bacteriúria assintomática (BA). O manuseio da BA em pacientes diabéticas é controverso, por esta razão o objetivo deste estudo foi discutir os achados na literatura que discorrem sobre BA em mulheres diabéticas e o manuseio desta condição clínica.CONTEÚDO: Revisão sistemática da literatura no Medline,LILACS e Scielo, no período de 1997 a 2012, utilizando-se como descritores: "asymptomatic bacteriuria and diabetes". A prevalência de BA é três vezes maior em mulheres diabéticas do que em não diabéticas. Vários fatores de risco para BA em mulheres com diabetes têm sido sugeridos, incluindo idade, intercurso sexual e duração da doença. A bactéria mais frequentemente encontrada é a Escherichia coli. Quanto à questão de a BA poder levar a perda de função renal ou hipertensão arterial sistêmica, os estudos com maior follow-up concluem que não houve diferença significativa após análise multivariada entre os grupos de mulheres diabéticas com e sem BA. Quanto à taxa de incidência de ITU quando comparados os grupos com BA tratados com antibióticos versus controle,também não houve diferença significativa com o agravante de ocorrência de bactérias mais resistentes como causa de novas ITU.CONCLUSÃO: Em vista do tratamento da BA, em longo prazo,não diminuir a quantidade de episódios de ITU sintomática, pielonefrites agudas e internações em mulheres diabéticas, o screening e o tratamento da BA não devem ser recomendados.

BACKGROUND AND OBJECTIVES: Urinary tract infection (UTI) is a common disease and, in the absence of symptoms, is called asymptomatic bacteriuria (AB). The management of BA in diabetic female patients is controversial. The aim of this study was to discuss findings in literature that are related to AB in diabetic women and to management of this condition.CONTENTS: A systematic review of the literature in Medline, LILACS and Scielo in the period from 1997 to 2012, using descriptors such as "asymptomatic bacterinuria and diabetes" was performed. The prevalence of AB is three times greater in diabetic than in non-diabetic women. Several risk factors for AB in women with diabetes have been suggested, such as age; sexual intercourse and disease duration. The most often found bacteria in AB is Escherichia coli. Cohort studies with longer follow-up did not show that AB could lead to loss of renal function and/or hypertension when they compared groups of diabetic women with and without AB. Regarding the incidence of new UTI episodes, clinical trials showed no differences when compared AB group treated with antibiotics versus AB group treated with placebo. Also, there was no significant difference with the occurrence of more resistant bacteria as a cause of new UTI. CONCLUSION: The treatment of AB does not decrease the number of episodes of symptomatic UTI, acute pyelonephritis, and hospitalization in diabetic women in the long run. For this reason, screening and treatment of AB in diabetic women should not be recommended.

Cross-cultural adaptation of the dysfunctional voiding score symptom (DVSS) questionnaire for Brazilian children

PURPOSE: To translate and culturally adapt the Dysfunctional Voiding Symptom Score (DVSS), questionnaire into Brazilian Portuguese. MATERIALS AND METHODS: The 10-item Dysfunctional Voiding Symptom Score (DVSS) was translated into Brazilian Portuguese according to a standard methodology: translation, synthesis, back-translation, Expert Committee, and pre-testing. After the translation process the final version was pre-tested and patient responses were analyzed to identify necessary modifications. Reliability was evaluated using the test-retest method, and internal consistency was assessed using Cronbach’s alpha. RESULTS: The Cronbach’s alpha coefficient was calculated in the test and retest phases. Internal consistency was found to be satisfactory, as confirmed by a Cronbach’s alpha coefficient of 0.76 for the test and 0.77 for the retest. A high degree of stability was found in the test/retest, with an intraclass correlation coefficient (ICC) of 0.960 (p < 0.001; 95 percent CI: 0.943-0.972). CONCLUSION: The cross-cultural adaptation process of the Dysfunctional Voiding Symptom Score questionnaire to be used on Brazilian children was successfully completed following internationally accepted methodologies.

Is continent urinary diversion feasible in children under five years of age?

Purpose: To review our clinical experience with urinary continent catheterizable reservoir in children under five years of age. Materials and Methods: A total of 23 patients (16 males, 7 females) with a median age of 3.64 years were evaluated. Among these, 6 (26.08 percent) had a posterior urethral valve, 9 (39.13 percent) myelomeningocele, 4 (17.39 percent) bladder exstrophy, 2 (8.69 percent) genitourinary rabdomyosarcoma, 1 (4.34 percent) had spinal tumor and 1 (4.34 percent) an ano-rectal anomaly. Results: Perioperative complications were observed in four patients consisting of one febrile urinary tract infection, one partial operative wound dehiscence, one partial stomal dehiscence and one vesico-cutaneous fistula after a secondary exstrophy repair. The overall long-term complications rate was 40.90 percent and consisted of two stomal stenoses (9.09 percent), one neobladder mucosal extrusion (4.54 percent), three neobladder calculi (13.63 percent) and persistence of urinary incontinence in three patients (13.63 percent). The overall surgical revision was 36.36 percent and final continence rate was 95.45 percent with mean follow-up of 39.95 months Conclusion: Continent urinary diversion is technically feasible even in small children, with acceptable rates of complications.

Lower urinary tract dysfunction in children: what do pre-school teachers know about it?

OBJECTIVE: To evaluate the basic knowledge of pre-school teachers who deal with children between the ages of 4 and 7 years, who present signs of lower urinary tract dysfunction (LUTD). MATERIALS AND METHODS: We performed a survey with 50 teachers from 9 private schools working with pre-school children. The criteria for selection were if teachers were certified or non-certified elementary school teachers - NCEST and the amount of professional experience. RESULTS: Thirty-three teachers considered that the normal daily urinary frequency should be from 4 to 7 times. Two of the 50 teachers considered it normal to urinate less than 4 times per day and 15 teachers considered more than 7 times per day as normal. There was no difference between the 2 categories of certified or NCEST nor between those with more or less than five years of professional experience. Thirty-three percent believed that to urinate more than 4 times during a class period (4-5 hours) could indicate a urinary problem. There was a statistically significant difference among the certified and NCEST but not in terms of time of professional experience. If during this period the child would not ask to urinate, only 18 percent considered that as an indication of urinary problem. When asked about the symptoms that would indicate urinary urgency and urge incontinence, only 24 percent of the teachers connected it with urinary problem. There was no difference in terms of professional background or professional experience in these 2 last analyses. CONCLUSION: Our data shows evidences that private pre-schools teachers are not well informed of the clinical manifestation of LUTD.

Spontaneous resolution rates of vesicoureteral reflux in Brazilian children: a 30-year experience

OBJECTIVE: We evaluated clinical characteristics of primary vesicoureteral reflux (VUR) in infants in a 30-year period in Brazil with special reference to the relation of renal parenchymal damage to urinary tract infection and gender. MATERIALS AND METHODS: From 1975 through 2005, 417 girls (81.6 percent) and 94 boys (18.4 percent) with all grades of reflux were retrospectively reviewed. Patients were categorized by the worst grade of reflux, maintained on antibiotic prophylaxis and underwent yearly voiding cystourethrography until the reflux was resolved. VUR was considered resolved when a follow-up cystogram demonstrated no reflux. Surgical correction was recommended for those who fail medical therapy, severe renal scarring or persistent VUR. RESULTS: Grades I to V VUR resolved in 87.5 percent, 77.6 percent, 52.8 percent, 12.2 percent and 4.3 percent, respectively. Renal scars were present at presentation in 98 patients (19.2 percent). Neither gender nor bilaterality versus unilaterality was a helpful predictor of resolution. The significant difference was found among the curves using the log rank (p < 0.001) or Wilcoxon (p < 0.001) test. CONCLUSION: Despite the current use of screening prenatal ultrasound, many infants are still diagnosed as having vesicoureteral reflux only after the occurrence of urinary tract infection in our country. Scarring may be associated to any reflux grade and it may be initially diagnosed at any age but half of the scars are noted with higher grades of reflux (IV and V). The incidence of reflux related morbidity in children has significantly diminished over the last three decades.

Elective appendicovesicostomy in association with monfort abdominoplasty in the treatment of prune belly syndrome

OBJECTIVE: To evaluate the role of elective appendicovesicostomy in association with Monfort abdominoplasty to avoid urinary tract infection (UTI) and renal damage in the post-operative follow-up of patients with prune belly syndrome. MATERIALS AND METHODS: We followed 4 patients operated in our institution (UNIFESP) (Monfort, orchidopexy and Mitrofanoff) and compared them to 2 patients treated similarly, but without an appendicovesicostomy, in a second institution (UFBA). We evaluated postoperative clinical complications, UTI and preservation of renal parenchyma. Patients were followed as outpatients with urinalysis, ultrasonography (US) and occasionally with renal scintigraphy. RESULTS: Mean follow-up was 23.5 months. Immediate post-operative course was uneventful. We observed that only one patient with the Mitrofanoff channel persisted with UTI, while the 2 patients used as controls persisted with recurrent pyelonephritis (> 2 UTI year). CONCLUSION: Our data suggest that no morbidity was added by the appendicovesicostomy to immediate postoperative surgical recovery and that this procedure may have a beneficial effect in reducing postoperative UTI events and their consequences by reducing the postvoid residuals in the early abdominoplasty follow-up. However, we recognize that the series is small and only a longer follow-up with a larger number of patients will allow us to confirm our suppositions. We could not make any statistically significant assumptions regarding differences in renal preservation due to the same limitations.

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.

Kidney transplantation in children: a 50-case experience

OBJECTIVES: The aim of this article was to report our experience with kidney transplantation in children. MATERIALS AND METHODS: From June 1980 to December 2003, 690 kidney transplants were performed in our institution, among which 50 were in patients with less than 18 years old. Technical aspects as well as clinical and surgical evolution were reviewed in this study. RESULTS: Patient's mean age was 12 years (2-17 years). Twenty-nine patients were male and 21 female. Live related donors were responsible for 75 percent of the cases (38 patients) and 25 percent (12 patients) came from cadaver donors. The main complications were ureteral fistula in 6 patients (12 percent), arterial stenosis in 2 (4 percent), wall infection and dehiscence in 1 case (2 percent). The overall rate of surgical complication was 20 percent. No case of hyperacute rejection was reported. During the follow-up 20 grafts were lost due to chronic rejection and 2 patients died. No loss of graft due to surgical complications was reported. The graft survival rate was 71 percent in 1 year, 64 percent in 3 years and 57 percent in 5-year follow-up. CONCLUSIONS: Kidney transplantation in children is a viable treatment option for terminal kidney disease presenting success and surgical complication rate similar to kidney transplantation in adults.

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.