Early treatment improves urodynamic prognosis in neurogenic voiding dysfunction: 20 years of experience / Tratamento precoce melhora o prognóstico urodinâmico na disfunção miccional de origem neurogênica: 20 anos de experiência

Abstract Objective: To evaluate the association between early treatment and urodynamic improvement in pediatric and adolescent patients with neurogenic bladder. Methodology: Retrospective longitudinal and observational study (between 1990 and 2013) including patients with neurogenic bladder and myelomeningocele treated based on urodynamic results. The authors evaluated the urodynamic follow-up (bladder compliance and maximum bladder capacity and pressure) considering the first urodynamic improvement in two years as the outcome variable and early referral as the exposure variable, using a descriptive and multivariate analysis with logistic regression model. Results: Among 230 patients included, 52% had an early referral. The majority were diagnosed as overactive bladder with high bladder pressure (≥40 cm H2O) and low bladder compliance (3 mL/cmH2O) and were treated with oxybutynin and intermittent catheterization. Urodynamic follow-up results showed 68% of improvement at the second urodynamic examination decreasing bladder pressure and increasing bladder capacity and compliance. The percentage of incontinence and urinary tract infections decreased over treatment. Early referral (one-year old or less) increased by 3.5 the probability of urodynamic improvement in two years (95% CI: 1.81-6.77). Conclusion: Treatment onset within the first year of life improves urodynamic prognosis in patients with neurogenic bladder and triplicates the probability of urodynamic improvement in two years. The role of neonatologists and pediatricians in early referral is extremely important.

Resumo Objetivo: Avaliar a associação entre tratamento precoce e melhoria urodinâmica em pacientes pediátricos e adolescentes portadores de bexiga neurogênica. Metodologia: Estudo observacional longitudinal retrospectivo (entre 1990-2013) em pacientes com bexiga neurogênica e mielomeningocele tratados com base no diagnóstico urodinâmico. Avaliamos a evolução urodinâmica (complacência, capacidade e pressão vesical) e consideramos primeira melhoria urodinâmica em até dois anos como variável desfecho e encaminhamento precoce (primeira urodinâmica até um ano de vida) como exposição. Foi feita análise descritiva e multivariada com modelo de regressão logística. Resultados: Entre 230 pacientes incluídos 52% foram encaminhados precocemente. A maioria tinha bexiga hiperativa com pressão maior do que 40 cmH2O, complacência abaixo de 3 ml/cmH2O e foi tratada com oxibutinina e cateterismo intermitente. Na evolução urodinâmica, 68% apresentou melhoria já no segundo exame com redução da pressão e aumento da capacidade e da complacência vesical. O percentual de incontinência e infecção urinária diminuiu ao longo do tratamento. O encaminhamento precoce aumentou 3,5 vezes a probabilidade de melhoria urodinâmica até dois anos em relação aos encaminhados após o primeiro ano de idade (CI95% 1,81-6,77). Conclusão: Tratar no primeiro ano de vida melhora o prognóstico urodinâmico de pacientes com bexiga neurogênica, triplica a probabilidade de melhoria urodinâmica em até dois anos. A atuação do neonatologista e do pediatra, ao reconhecer e encaminhar o paciente precocemente para o diagnóstico, é extremamente importante.

Application of data mining techniques to explore predictors of upper urinary tract damage in patients with neurogenic bladder

This study proposed a decision tree model to screen upper urinary tract damage (UUTD) for patients with neurogenic bladder (NGB). Thirty-four NGB patients with UUTD were recruited in the case group, while 78 without UUTD were included in the control group. A decision tree method, classification and regression tree (CART), was then applied to develop the model in which UUTD was used as a dependent variable and history of urinary tract infections, bladder management, conservative treatment, and urodynamic findings were used as independent variables. The urethra function factor was found to be the primary screening information of patients and treated as the root node of the tree; Pabd max (maximum abdominal pressure, >14 cmH2O), Pves max (maximum intravesical pressure, ≤89 cmH2O), and gender (female) were also variables associated with UUTD. The accuracy of the proposed model was 84.8%, and the area under curve was 0.901 (95%CI=0.844-0.958), suggesting that the decision tree model might provide a new and convenient way to screen UUTD for NGB patients in both undeveloped and developing areas.

Optimal bladder diary duration for patients with suprapontine neurogenic lower urinary tract dysfunction

ABSTRACT Purpose: To identify the minimum bladder diary's length required to furnish reliable documentation of LUTS in a specific cohort of patients suffering from neurogenic urinary dysfunction secondary to suprapontine pathology. Materials and Methods: From January 2008 to January 2014, patients suffering from suprapontine pathology and LUTS were requested to prospectively complete a bladder diary form for 7 consecutive days. Micturitions per day, excreta per micturition, urgency and incontinence episodes and voided volume per day were evaluated from the completed diaries. We compared the averaged records of consecutive days (2-6 days) to the total 7 days records for each patient's diary, seeking the minimum diary's length that could provide records comparable to the 7 days average, the reference point in terms of reliability. Results: From 285 subjects, 94 male and 69 female patients enrolled in the study. The records of day 1 were significantly different from the average of the 7 days records in every parameter, showing relatively small correlation and providing insufficient documentation. Correlations gradually increased along the increase in diary's duration. According to our results a 3-day duration bladder diary is efficient and can provide results comparable to a 7 day length for four of our evaluated parameters. Regarding incontinence episodes, 3 days seems inadequate to furnish comparable results, showing a borderline difference. Conclusions: A 3-day diary can be used, as its reliability is efficient regarding number of micturition per day, excreta per micturition, episodes of urgency and voided volume per day.

Epididymitis in Patients with Anorectal Malformations: A Cause for Urologic Concern

Introduction Epididymitis in patients with anorectal malformation (ARM) represents a unique problem because unlike the general population, an underlying urinary tract problem is frequently identified. We review our experience with epididymitis in ARM population with an emphasis on examining urologic outcomes. Materials and Methods We performed a retrospective review of male patients with ARM cared for from 1980 to 2010. Clinical and pathologic variables recorded included age at presentation, recurrence, associated urologic anomalies, incidence of ureteral fusion with mesonephric ductal structures, glomerular filtration rate and urodynamic parameters. Results Twenty-six patients were identified with documented episodes of epididymitis. Renal injury was noted in five patients (19%), all of whom were diagnosed with neurogenic bladder (NGB) several years after anorectoplasty. NGB was found in ten patients (38%) in our series. Ectopic insertion of ureter into a mesonephric ductal structure was discovered in five patients (19%). Twelve patients (46%) had recurrent episodes of epididymitis, with seven of these patients (58%) being diagnosed with NGB. Two patients in the pubertal group presented with a history of epididymitis and complained of ejaculatory pain. Conclusion Epididymitis in a patient with ARM warrants a comprehensive urologic investigation, particularly in recurrent episodes. Attempts at surgical intervention (e.g. vasectomy) should be avoided until functional assessment of the urinary tract has occurred. Failure to recognize this association may lead to potentially avoidable complications and morbidity. Long term urological follow up of these patients is warranted to identify at risk patients and minimize renal deterioration .

Idiopathic and neurogenic detrusor overactivity: do the different patterns have urodynamic characteristics related to gender or neurological condition?

Objectives To evaluate the urodynamic characteristics of the two patterns (phasic, P and terminal, T) of detrusor overactivity (DO) according to gender and neurological condition. Materials and Methods: Urodynamic characteristics of DO were analysed in a population with proven urodynamic DO (127 women and 76 men, respectively with 48 and 43 neurological diseases (encephalic, incomplete medullar lesion or peripheral)). Phasic DO is characterized by phasic waves with or without leakage while terminal DO is defined by a single non-inhibited contraction resulting in incontinence. Parameters analysed for both patterns of DO (among other parameters) included: volume and amplitude of the first non-inhibited detrusor contraction (NIDC#1), and for phasic DO: duration of pressure rise during NIDC#1 and number of NIDC. Results Phasic DO was observed in younger patients in the whole population whatever the gender (women: 55.9 years vs. 64.7 years, p = 0.0052; men: 57.4 years vs. 67.8 years, p = 0.0038). Volume at NIDC#1 was greater for neurological PDO (significant in women: 185 vs. 125 mL, p = 0.0223). Other parameters were not significantly different whatever the gender. Amplitude of NIDC#1 during PDO was significantly lower than that of NIDC during terminal DO (TDO) in both genders whatever the neurological condition (p < 0.0001). Volume at NIDC#1 in both patterns was dependent on the level of neurological lesion. Conclusion The main difference between the patterns of DO is that PDO occurs in younger individuals. There is no significant difference between urodynamic characteristics of each pattern whatever gender or neurological status. Further studies will provide additional information on the impact of the level of neurological lesion on the pattern of DO. .

Renal function in children with congenital neurogenic bladder

AIMS: Preservation of renal function in children with congenital neurogenic bladder is an important goal of treatment for the disease. This study analyzed the evolution of renal function in patients with congenital neurogenic bladder. METHODS: We reviewed the records of 58 pediatric patients with respect to the following attributes: gender, age, etiology of neurogenic bladder, reason for referral, medical/surgical management, episodes of treated urinary tract infections, urodynamics, DMSA scintigraphy, weight, height, blood pressure, glomerular filtration rate, microalbuminuria and metabolic acidosis. Statistical analysis was performed, adopting the 5 percent significance level. RESULTS: The mean age at presentation was 4.2 ± 3.5 years. Myelomeningocele was the most frequent etiology (71.4 percent). Recurrent urinary tract infection was the reason for referral in 82.8 percent of the patients. Recurrent urinary tract infections were diagnosed in 84.5 percent of the patients initially; 83.7 percent of those patients experienced improvement during follow-up. The initial mean glomerular filtration rate was 146.7 ± 70.1 mL/1.73 m²/min, and the final mean was 193.6 ± 93.6 mL/1.73 m²/min, p = 0.0004. Microalbuminuria was diagnosed in 54.1 percent of the patients initially and in 69 percent in the final evaluation. Metabolic acidosis was present in 19 percent of the patients initially and in 32.8 percent in the final assessment. CONCLUSIONS: Patient referral to a pediatric nephrologist was late. A reduction in the number of urinary tract infections was observed with adequate treatment, but microalbuminuria and metabolic acidosis occurred frequently despite adequate management.

The use and rationale of selective alpha blockade in children with non-neurogenic neurogenic bladder dysfunction

INTRODUCTION: We present here a long-term observation of 2 children with a rare syndrome with a non-neurogenic neurogenic bladder dysfunction (Hinman's syndrome), and we investigated the safety and efficacy of long-term use of terazosine in association with prophylactic antibiotics, timed voiding and a bowel regimen. MATERIALS AND METHODS: Two children, 7 years-old (22 kg) and 11 years-old (36 kg) presented in 1997 to our pediatric urology clinic with symptoms of urgency, frequency, urge incontinence and nocturnal enuresis. Both children were placed in a regimen of terazosine (starting with 0.5 mg increasing until 2 mg). RESULTS: There were no significant side effects throughout the entire treatment. The first 7-year old boy however developed some dizziness when the dose of terazosine was increased to 2 mg (after 4 weeks of administrating 1 mg), and this disappeared immediately when the dosage was reduced back to 1 mg daily. The urgency symptoms improved in both boys after 3 weeks of 1 mg terazosine. The secondary enuresis in the 11 year-old boy resolved after 2 months of 2 mg terazosine. CONCLUSION: It is possible to say that the alpha-blocker medication, terazosine can be administered safely to children with a non-neurogenic bladder dysfunction, also known as the Hinman's syndrome. These results have shown that dysfunctional voiding, postvoiding residual and upper tract involvement can disappear over time when long term terazosine is given in combination with timed voiding, prophylactic antibiotic therapy and treatment of the associated constipation. Our observations also suggest a permanent effect after discontinuing the medication.

Apendicocecostomia y Mitrofanoff apendicular / Appendicocecostomy and appendicular Mitrofanoff

Presentamos un caso clínico de incontinencia urinaria parcial en un paciente de sexo masculino de 17 años y diagnótico de meningomielocele, vejiga neurogénica de baja capacidad y disminución del tono uretral, el cual fue sometido anteriormente a gastrocistoplastia, técnica de Kropp, colocación de un esfínter uretral artificial estático de Lima

Recomendaciones para pacientes con vejiga neurógena / Recomentations for patients with neurogenic bladder

La difusión de medidas que permitan prevenir mayores complicaciones cuando ya está presente una patología, y la necesidad de facilitar una vida más adecuada a aquellos individuos afectados por una enfermedad, como es la vejiga neurogéna, es el objetivo que persigue este artículo dirigido a médicos y enfermeras, al entregar algunas indicaciones prácticas para que sean dadas a conocer al paciente y a sus familiares

Vejiga neurogénica secundaria a mielodisplasia: experiencia con 121 casos / Neurogenic bladder secondary to myelodysplasia: experience with 121 cases

Se presenta la experiencia obtenida entre 1989 y 1992 con 121 pacientes perteneciente a la clínica de espina bífida que experimentaban vejiga neurogénica. De esta serie, 43 pacientes pertenecían al grupo de bajo riesgo y 78 al de alto riesgo. Se encontraron diferencias estadísticamente significativas entre ambos grupos en lo que respecta a valores de creatinina, resultados de urocultivos y repercusión sobre la parte alta del aparato urinario. Se analizó especificamente en el grupo de alto riesgo el tratamiento en cada uno de ellos, y se encontró que 59 se conservaban bajo tratamiento conservador a base de cateterismo intemitente y anticolinérgicos, en seis se había efectuado vesicostomía y en 12 había ocurrido fracaso del tratamiento conservador, con una capacidad vesical menor de 50 por ciento, presiones vesicales superiores a 50 ml de agua y ureterohidonefrosis con reflujo o sin éste. Se revisaron los aspectos epidemiológicos en cada uno de los miembros del grupo, y se encontró que ocho de estos 12 pacientes presentaban reflujo vesicoureteral, cinco en forma bilateral y tres unilateral que requirieron una operación contra el reflujo. La enterocistoplastia efectuada en tres pacientes con íleon, y en los nuevos restantes con colon sigmoideo, transformó las vejigas de alta presión en órganos de baja presión; el vaciamiento se efectuó mediante cateterismo limpio intermitente. Diez de los 12 pacientes no experimentaron repercuciones en las vías urinarias superiores y se conservaban secos durante más de tres horas después del cateterismo. Solamente en sos pacientes persistió la incontinencia, por lo que requerirán instalación de esfínter artificial u otro procedimiento de continencia. En este estudio se pone de manifiesto la necesidad de establecer diagnóstico temprano y tratamiento oportuno que permita a estos pacientes tener una calidad de vida aceptable, a la vez que disminuye la morbimortalidad que ocasiona este trastorno

Urodynamic evaluation in pediatric neurogenic bladder

Urodynamic evaluation in pediatric neurogenic bladder is prerequisite for accurate prediction of prognosis and selection of appropriate treatment modality. We classified normal, hyperreflexic and areflexic bladders by cystometry. Hyperreflexic bladder was subdivided into two groups with or without detrusor sphincter dyssynergia and areflexic bladder into low pressure and high pressure. Among 36 patients with myelodysplasia on whom we performed a videourodynamic study vesicoureteral reflux was found in three of 7 patients with hyperreflexia with detrusor sphincter dyssynergia, two of 6 patients with hyperreflexia without detrusor sphincter dyssynergia and five of 10 patients with areflexia with high pressure. Low pressure areflexic bladder didn't show vesicoureteral reflux. When we evaluated 39 pediatric neurogenic bladder patients with a mean 25.5 follow-up months period, upper tract deterioration was improved and normal findings persisted in all the compliant patients to treatment. In the noncompliant group initial abnormal upper tract findings persisted or aggravated, especially in hyperreflexic bladder with dyssynergia and high pressure areflexic bladder. One of the three hyperreflexic bladders with dyssynergia and two of six high pressure areflexic bladders received augmented cystoplasty. These data show that urodynamic evaluation in pediatric neurogenic bladder provides excellent criteria for selecting high risk groups in pediatric neurogenic bladder.

Experiencia en el uso de segmentos intestinales detubulizados en urología / Experience in use of detubation intestinal segments in urology

Se presentan 60 pacientes que son sometidos a una intervención quirúrgica utilizando un segmento intestinal detubulizado, ya sea para un agrandamiento de vejiga con o sin ostomía cutánea continente o para fabricar un reservorio intestinal de orina con ostomía continente, que puede ser natural con el recto y ano o artificial que en nuestros casos han sido todos al ombligo. Se analizan tanto la etiologías que obligaron al uso del intestino como los diferentes segmentos intestinales usados. La etiología corresponde en 24 casos (40 por ciento) a vejigas neurogénicas, 9 casos (15 por ciento) a cistopatías intersticiales, 9 casos (15 por ciento) a cáncer de vejiga y el resto a una variada gama de patología. En la mayoría de los pacientes se efectuaron estudios urodinámicos y radiológicos preparatorios y postoperatorios, especialmente en los casos de vejigas neurogénicas, los cuales serán analizados en otra publicación

Disautonomia da bexiga urinária e seu tratamento em pacientes diabéticos / Disautonomy of the urinary bladder and its treatment in diabetic patients

Os pacientes diabéticos podem sofrer lesöes no sistema nervoso autonômico e periférico. Nesses indivíduos têm-se verificado por meio de exames especializados como a urodinâmica e testes eletrofisológicos uma alta incidência do envolvimento da funçäo vésico-uretral com uma reduçäo do tonus da bexiga, perda de sensaçäo de repleçäo vesical e do desejo de urinar, falta de sustentaçäo da contraçäo do detrusor durante a micçäo, originando um volume de urina residual e distensäo persistente da musculatura vesical. As suas características säo de uma bexiga neurogênica hipotônica com condiçöes favoráveis à infecçäo urinária. A alta morbidez e a mortalidade do pacientes com diabetes mellitus pode ser reduzida quando se faz o diagnóstico precoce do comprometimento do trato urinário e é iniciado um tratamento adequado

Disfunçöes uretro-vesicais na menopausa / Climacteric uretrovesical dysfunction

Revisaram-se os conceitos atuais sobre as principais disfunçöes uretro-vesicais femininas, dando ênfase ao diagnóstico diferencial das diversas síndromes que prevalecem na menopausa. Salienta-se a intençäo de destacar a incontinência urinária de esforço de outras disfunçöes uma vez que a orientaçäo terapêutica correta depende do diagnóstico preciso