Urodynamic assessment of children treated with botulinum toxin A injections for urge incontinence: a pilot study.

OBJECTIVE: This study aimed to investigate changes in urodynamic findings and symptoms after detrusor injections of botulinum toxin A (BTX-A) in children with idiopathic detrusor overactivity (IDO) and urge incontinence. MATERIAL AND METHODS: Eight girls and five boys, aged 7-19 years, who had urge incontinence refractory to scheduled voiding and anticholinergics, were included this prospective study. Urodynamic studies showed postoperative IDO in 12 patients. A dose of 50-100 IU (1.3 -- 4.8 IU/kg) BTX-A was primarily administered at 15-20 detrusor sites. A control urodynamic study was performed within 3 months after the injections. Seven patients had a repeated procedure 16 (range 6-24) months on the average after the first one. RESULTS: Eleven of the 13 patients had daily incontinence and two had incontinence a couple of times a week in association with urge symptoms. Postoperatively, no patient had urinary retention, but one girl had a urinary tract infection 4 months after the therapy. Five patients had a full response, seven partial responses and one no response 1-3 months after the first treatment. After 1 year, three of nine patients still have full response. Maximum cystometric capacity increased after the first treatment from a median of 227 ml to 379 ml (p = 0.005) and the number of patients with uninhibited detrusor contractions more than 30 cmH2O during the filling phase decreased from eight to two out of 13 (p = 0.041). CONCLUSIONS: Intradetrusor BTX-A injections effectively reduce day-time wetting, significantly increase bladder volume and decrease detrusor overactivity in children with urge incontinence refractory to scheduled voidings and anticholinergics.

Urodynamic findings in men operated on for an undescended testicle.

OBJECTIVE: To test the hypothesis that men with a history of undescended testicle have voiding problems similar to those in rodents exposed to excessive amounts of oestrogens during development, although the role of oestrogen in the failure of the human testicle to descend remains controversial. PATIENTS AND METHODS: Thirteen men (mean age 45 years) previously operated on for an undescended testicle (testis-retention, TR group) and 12 age-matched men operated on for inguinal hernia or appendicitis (control group) participated in a urodynamic examination, transrectal ultrasonography (TRUS) of the prostate, and blood tests for hormones and prostate-specific protein. They also completed a questionnaire on urinary symptoms. RESULTS: The free maximum flow rate was significantly lower and the detrusor pressure at maximum flow (P(det)Q(max)) slightly higher in the TR than the control group. Three men in the TR group (and none of the controls) had bladder outlet obstruction (BOO), whereas voiding was not obstructed among 11 control men (and five men in the TR group). The hormone concentrations of the groups did not differ significantly but the prostates were significantly smaller in the TR group. The testosterone concentrations and the ratio between 17beta-oestradiol (E2) and free testosterone (E2/fT) influenced prostate size significantly. An exploratory analysis suggested that E2/fT may influence the maximum detrusor pressure and P(det)Q(max). CONCLUSION: Men born with an undescended testicle had smaller prostates but more often had BOO than did the controls. The results suggest that an imbalance between the actions of oestrogen and testosterone may influence the initiation and continuance of BOO among cryptorchid men.

Estimation of glomerular filtration rate and bladder capacity: the effect of maturation, ageing, gender and size.

OBJECTIVE: To show that glomerular filtration rate (GFR) and bladder capacity (BC) develop isometrically, and to provide graphs for estimating GFR and BC for specific individuals of any age, sex, height and weight, for cystometric purposes. MATERIALS AND METHODS: GFR and BC data were collected from published reports; graphs relating GFR and BC to age, sex, height and weight were obtained by using a computerized curve-fitting technique that minimizes the 1.1 power of the absolute error. RESULTS: The plots show the GFR and BC for individuals of 10th, 50th and 90th percentile height and weight as a function of age and sex for different physiological conditions. GFR increases up to age 20 years and thereafter declines, whereas GFR per unit body surface area reaches a maximum at 3.25 years old and declines thereafter. CONCLUSIONS: The clinical management strategy to preserve or enhance renal function in paediatric and adult nephrological disease should incorporate the present data on development, growth, ageing and deterioration of function. These data should be used when interpreting cystometrograms and evaluating compliance. The graphs are useful for clinically estimating GFR and BC, especially when estimating infusion rate and BC for individual patients. BC and GFR develop isometrically with a proportionality constant of 4.56 min, except from birth to 1.5 years of age. Accordingly, individuals with healthy urinary systems, irrespective of age, sex and size, in the same physiological conditions have, on average, the same time to reach BC, ranging from 7 h at a normal 1% GFR to 41 min at the maximum diuresis of 10% GFR.

Prototype system for enhancing cystometric analysis with special emphasis on the pediatric population.

BACKGROUND AND PURPOSE: A urodynamic test system of improved accuracy and reliability was developed and implemented for enhancing cystometry. This system integrates known medical information, including the specialized problems of pediatric urodynamics, with the cystometric and imaging data. METHODS: After the requirements for the ideal cystometrogram test unit were established, a system was constructed, calibrated, and implemented in clinical practice. The patient's age, size, and sex are used to produce a patient-specific pressure-volume template for the cystometrogram test. RESULTS: This template showed the minimal and normal bladder capacities and the physiologically safe, equivocal, and dangerous pressure fields coded with symbolic colors. Different time averages of the pressure data were used to show bladder factors such as compliance and instability. The templates with data were presented automatically (therefore objectively) without operator intervention on monitors during testing and as printed copies on completion. CONCLUSIONS: The presentation of data in an easily understood format facilitates effective communication between the urologist, referring physician, and patient. Some of the physiological and statistical problems in pediatric urodynamic testing are efficiently and accurately resolved by this system, resulting in better analysis and diagnostic capabilities.

Outcome of Perthes' disease in unselected patients after femoral varus osteotomy and splintage.

We evaluated 56 hips (48 patients) with Perthes' disease to compare the radiographic results of two unselected groups: one treated with femoral varus osteotomy (22 hips) and another with Thomas splint (34 hips). The patients with less than 50% femoral head involvement (Salter Group A hips) seemed to have no advantage from the operation. The angle of the femoral neck was 10 degrees less in the operative group than in the nonoperative group. In hips with more than 50% head involvement (Salter Group B), the operative method resulted in slightly better coverage and sphericity of the femoral head than the conservative method. On average, the acetabular direction was similar in both groups. The authors conclude that femoral varus osteotomy may lead to residual coxa vara and does not necessarily improve the radiographic results in limited epiphyseal involvement. Neither does the operation have an effect on the acetabular direction in severe Perthes' disease.

Psychosocial development and premorbid skeletal growth in Legg-Calvé-Perthes disease: a study of nineteen patients.

We studied psychosocial development and skeletal growth in 19 newly diagnosed patients with Legg-Calvé-Perthes disease (LCPD). Eleven patients had problems in visuospatial skills and five of 12 school-aged children had learning difficulties. The growth velocity of the patients was evaluated from 4 years before until 2 years after the diagnosis was made. Eight patients had a catch-up growth with +1.2 (0.9-1.7) delta SDS score (SDS: mean and ranges) before the diagnosis. Four patients with short stature and retarded bone age slightly diminished their growth velocity. Overnight serum growth hormone (GH) concentration and insulin-like growth factor I (IGF-I) levels were examined in the first nine consecutive patients. One patient had a high and another had a low mean GH concentration level, whereas all patients had IGF-I levels within normal limits. These results suggest that different kinds of growth disturbances may be associated with LCPD.

MRI in late sequelae of Perthes' disease: imaging findings and symptomatology in ten hips.

Five painful (group A) and five symptomless (group B) hips in nine patients with late sequelae of Perthes' disease were studied with plain radiography and magnetic resonance imaging (MRI) in order to correlate MRI findings with symptomatology. The unaffected hips were also studied. In group A hips, poor congruence of the articular cartilage surfaces was present in three of five cases, whereas good congruence was found in all group B hips. In one spherical but painful hip (group A), MRI revealed a protuberance in the anterolateral cartilage of the femoral head. The joint cartilage in group A and B hips was, on average, 0.5 and 1.5 mm thicker, respectively, than the cartilage in the unaffected hips. The lateral joint capsule was, on average, 3.0 mm thicker in group A hips than in the unaffected hips (P < 0.05), which possibly reflects reactive changes due to chronic irritation in the painful hips. The mean joint capsule thickness differed by only 0.5 mm between the unaffected and group B hips. Mean anterior acetabular coverage by MRI was 97 % in group A and 98 % in group B, while in the unaffected hips mean anterior coverage was 102 %. In an aspherical painful hip, MRI revealed a juxta-articular cyst not visible by radiography. A symptomless intra-articular fragment, due to osteochondritis dissecans, was well visualized with MRI. MRI is recommended for evaluation of pain in hips with late sequelae of Perthes' disease. It may show abnormalities in bony structures, as well as in joint capsule and cartilage.

[Growth plate in primary osteochondritis dissecans of the hip: a prospective study with MRI]. / Le cartilage de croissance dans l'ostéochondrite primitive de hanche: étude prospective en IRM.

INTRODUCTION: In Perthes' disease, epiphyseal necrosis impairs the function of the growth plate and may result in growth disturbances of the femoral neck. The physeal changes during active disease were prospectively evaluated with magnetic resonance imaging (MRI). MATERIALS AND METHODS: MRI was performed and radiographs were obtained with six-month intervals from the time of diagnosis up to two years in nine hips (eight patients). RESULTS: Normal growth plate was seen in MRI as a stripe of low signal intensity between areas of high signal intensity from the epiphysis and the metaphysis. Distortion, widening and partial disappearance of the growth plate were noted in the hips classified into Catterall groups 3 and 4. The physeal distortion was seen as anterior curling, and, in some hips, as a W-shaped abnormality projecting down into the metaphysis. Delayed growth of the femoral neck, due to premature physeal closure, was noted in hips where the physeal deformation involved more than half of the growth plate. All pathological changes appeared on the MRI scans three to fifteen months after the first symptoms. The extent of the MRI changes did not correlate directly with Catterall's plain film staging. DISCUSSION: The distortion and widening of the growth plate seen in MRI probably reflect histological disarrangement of the physis due to an extensive epiphyseal necrosis. The physeal W-formation in MRI may represent a radiographic "metaphyseal cyst". Disappearance of the growth plate in MRI seems to indicate premature closure of the physis. CONCLUSION: It seems possible to predict premature closure with MRI even within fifteen months after the onset of Perthes' disease.