Treatment of bladder dysfunction and high grade vesicoureteral reflux does not influence the spontaneous resolution rate.

PURPOSE: We investigated whether the treatment of bladder dysfunction in infants with congenital high grade vesicoureteral reflux could influence the spontaneous resolution rate of the reflux and the number of recurrent urinary tract infections. MATERIALS AND METHODS: A total of 115 infants with high grade vesicoureteral reflux were included in a followup study of bladder function and reflux resolution between 1993 and 1999. The present study deals with 20 of these infants with mainly grade V reflux, most of whom had recurrent urinary tract infections in combination with high post-void residual and high bladder capacity. Treatment with clean intermittent catheterization was instituted during infancy in these 20 patients and continued until a median age of 4 years. RESULTS: Bladder capacity was high at presentation and at all followup investigations in the clean intermittent catheterization treated group. Moreover, residual urine was high at presentation and especially between ages 1 and 2 years. However, after bladder control was achieved this residual decreased and consisted mainly of reflux urine. In only 1 girl did reflux resolve spontaneously during the 4-year followup period. A total of 18 patients were treated surgically at the end of this period, and clean intermittent catheterization could be stopped a few months later in all but 2. Urinary tract infection recurrences were uncommon after the institution of treatment. CONCLUSIONS: The treatment of bladder dysfunction characterized by a high capacity bladder with poor emptying in infants with congenital high grade reflux does not influence the rate of spontaneous resolution. On the other hand, the tendency toward recurrent urinary tract infections appears to decrease with treatment.

Does treatment with clean intermittent catheterization in boys with posterior urethral valves affect bladder and renal function?

PURPOSE: In boys with resected posterior urethral valves (PUV) deterioration of renal function is seen during childhood and adolescence, which may partly be caused by bladder dysfunction. We present data on renal and bladder function initially and at followup of boys with PUV in whom the bladder dysfunction has been treated since infancy. MATERIALS AND METHODS: The study included 35 boys with PUV. Bladder regimen, including early toilet training from the age of 1.5 years and detrusor relaxant drugs for the treatment of incontinence from ages 4 to 6 years, was introduced to all patients. A total of 19 boys were started on clean intermittent catheterization (CIC) at a median age of 8 months due to pronounced bladder dysfunction with poor emptying, unsafe pressure levels, high grade reflux and renal impairment. RESULTS: No serious complications of CIC have been seen during followup. Of the 19 boys 2 stopped performing CIC due to noncompliance of the parents at 1 and 3 years, respectively. Initial renal function, measured as median glomerular filtration rate (GFR) in percent of expected for age, was 60% in the CIC group and 90% in the nonCIC group. At followup at a median age of 8 years the CIC group (n = 14, 3 transplanted boys excluded) had an increase in median differential GFR (difference between followup and initial GFR) of 7% (p <0.01), which was similar increase to that of the nonCIC group. In the 2 boys who stopped performing CIC renal function deteriorated with a median differential GFR of -24%. In the CIC group detrusor instability decreased. Poor compliance was seen in 6 of the 19 boys initially and only one remained poorly compliant. In 1 of the boys who stopped performing catheterization a low compliant bladder developed. In all of the other cases bladder capacity increased more than expected for age. CONCLUSIONS: The results suggest that treatment of bladder dysfunction in boys with PUV can counteract the deterioration in renal function seen during childhood but the number of patients in our study is limited.

The voiding pattern of healthy preterm neonates.

PURPOSE: To elucidate further the maturation of voiding habits from gestation to infancy we investigated the free voiding pattern of healthy preterm neonates. MATERIALS AND METHODS: We evaluated 11 male and 8 female healthy preterm newborns at a mean of 32 weeks after cessation of menstrual flow (postmenstrual age). Assessment was done in the neonatal ward using 4-hour voiding observation, a method described previously in studies of free voiding pattern of full-term newborns. RESULTS: The voiding pattern of male and female preterm neonates was characterized by 1 void per hour and a mean voided volume of 53% of bladder capacity with 58% frequency of interrupted voiding. Residual urine was increased but varied during observation (mean 11% bladder capacity) and was 0 after at least 1 void during 4 hours in 14 of the 19 subjects. Two-thirds of all voiding occurred during sleep, whereas a third of the newborns showed signs of arousal with a mean awake time of only 17 minutes. CONCLUSIONS: The voiding pattern of preterm versus full-term subjects is characterized by an increased number of interrupted voidings, further indicating that these voidings represent immature behavior of detrusor-sphincter coordination. Also, the high number of voidings during sleep suggest a more immature pattern for preterm newborns.

The voiding pattern in infants with dilating reflux.

OBJECTIVE: To determine whether the voiding pattern in infants with dilating vesico-ureteric reflux (VUR) differs from that in healthy infants, thus supporting the existence of bladder dysfunction in infants with VUR. PATIENTS AND METHODS: Forty-one infants (33 boys and eight girls) with dilating VUR (grades 3-5) were studied using a noninvasive 4-hourly voiding record described previously in studies of the voiding pattern of healthy infants, and the results compared with those obtained from healthy infants of similar age. RESULTS: The voiding pattern in the boys with VUR was characterized by small frequent voids and interrupted voids in more patients (36%) than in healthy boys (15%). Conversely, the girls with VUR were infrequent voiders of relatively high volumes. Residual urine was significantly increased in both boys and girls, as was bladder capacity, although not significantly. CONCLUSIONS: The free voiding pattern in infants with dilating reflux differs from that seen in healthy infants of comparable age. The characteristics for boys and girls differed but was in accordance with that seen in invasive urodynamic studies, suggesting refluxing infants to have a bladder dysfunction.

Four-hour voiding observation in young boys with posterior urethral valves.

PURPOSE: We evaluated 4-hour voiding observation as a method of basic assessment of bladder dysfunction in young boys with posterior urethral valves. MATERIALS AND METHODS: Voiding pattern, including number of voids, voided and residual urine volume, and bladder capacity, was determined noninvasively in 24 boys younger than 4 years with posterior urethral valves and compared to that of healthy age matched controls. Results were then compared to those of standard cystometry. RESULTS: The number of voids was higher, voided volume was smaller and residual urine volume was higher in the posterior urethral valve group. There was no difference in voiding pattern before and after removal of the anatomical obstruction. Voided and residual urine volume, and bladder capacity were higher on standard cystometry than on voiding observation. CONCLUSIONS: Four-hour voiding observation is an easy noninvasive method that focuses on emptying difficulties and clearly detects differences in voiding patterns between boys with posterior urethral valves and healthy, nontoilet trained children. We recommend the method as a complement to standard cystometry for the diagnosis and followup of bladder dysfunction in young boys with posterior urethral valves to identify the need for treatment.