Congenital Malaria and Its Associated Factors at Issaka Gazobi Maternity of Niamey in Niger.

BACKGROUND: Congenital malaria is a serious and common infection in tropical Africa. It has multiple consequences on the newborn and the mother. OBJECTIVE: The objective of this study is to calculate the prevalence of congenital malaria, describe its clinical signs, and analyze its associated factors. Methodology. It is a cross-sectional and prospective study, conducted at Issaka Gazobi Maternity of Niamey, from June 1 to November 30, 2017. The diagnosis was made by microscopy of a thick and thin blood smear of mother, newborn, and umbilical cord. RESULTS: Two hundred and forty-nine (249) consecutive newborn/mother pairs were included. The prevalence of congenital malaria infection was 26.51% (66/249) with a parasite density of 101 P/µl (SD: 47.3; [80; 320]). The prevalence of congenital malaria disease was 14.06% (35/249) with a parasite density of 108 P/µl (SD: 32.6; [40; 200]. All patients were infected with Plasmodium falciparum. 43% (18/35) of neonates had hyperthermia and did not have a sucking reflex, 8.5% (3/35) were anaemic, 11.42% (4/35) had convulsed, 20% (7/35) had a coma, and 45.71% (16/35) had a low birth weight. No deaths were recorded, and only the nonuse of bed nets was significantly associated with congenital malaria (p = 0.04). CONCLUSION: In Niger, one out of four newborns is infected with Plasmodium. Infection can progress to congenital malaria disease. The use of mosquito nets and intermittent preventive treatment would reduce the incidence of congenital malaria.

Distribution and relative densities of Aedes aegypti in Niger.

Its climate and environmental conditions put Niger at particularly high risk of the spread of Aedes mosquitoes, which can transmit arboviruses. In September 2016, the Republic of Niger reported its first outbreak of Rift Valley Fever (RVF) in the northern region of Tahoua, near the Mali border, particularly in the departments of Tchintabaraden, Tassara, and Abalak. The history of RVF has showed that epidemics and epizootics have a considerable socioeconomic impact in affected countries, such as Niger, whose populations are particularly concerned by livestock farming. Cross-sectional studies were conducted to investigate the abundance of Aedes aegypti and the risk of arbovirus transmission in 54 villages between 2002 and 2017. Sampling took place in 27 villages, with three methods used in each village: (a) capture of aggressive female mosquitoes landing on human adult volunteers from three households, both indoors and outdoors, during two consecutive nights ; (b) insecticide spray collections of resting mosquitoes early in the morning in five selected dwellings, different from those chosen for landing catches, and (c) capture by four Centers for Disease Control (CDC) light traps, both indoors and outdoors, for two nights. The remaining 27 villages were sampled only by insecticide spray collection of resting mosquitoes. The inventory, distribution, and abundance of mosquito species found at the sampled localities were evaluated. The mosquitoes (Culicidae) caught belonged to four genera, namely: Anopheles spp., Aedes spp., Culex spp. and Mansonia spp. Besides these Culicidae, other biting Diptera (Phlebotomes) were found during the capture. À total of 130,424 adult mosquitoes was caught during the study, 2.6% (3,444/130,423) of them Aedes spp. Aedes aegypti accounted for 96.6% of the Aedes spp. captured. Ae. Aegypti was collected in 41.0% (22/54) of the villages and was abundant (accounting for more than 15% of all mosquitoes captured) in 5 localities. The presence, geographical distribution, and abundance of Ae. aegypti near and in human habitations suggest a high risk of arbovirus transmission in Niger. The high abundance of arbovirus vectors encountered in this study should be a source of concern. Our observations highlight the importance of quantifying and monitoring the risk of arbovirus transmission in Niger. These results are of great importance for public health.

[Prescription of antimalarial drugs in the pediatric ward of the National Hospital of Lamordé, in Niamey]. / Prescription d'antipaludiques dans le service de pédiatrie de l'Hôpital national de Lamordé, à Niamey.

In Niger, malaria is a major public health problem, due to the high number of deaths that are attributable to it and because of its heavy weight and socioeconomic status. The objective of this study was to contribute to the inventory of medical practices to rationalize the use of medicines and minimize the resistance phenomenon. This is a prospective study, which took place from May 1 to July 31, 2009, in the pediatric ward of the National Hospital of Lamordé. It concerned children aged from 0 to 14 years hospitalized and having received one or more antimalarial drugs during at least 24 h. During the 3 months of the study, 1,248 children had been admitted in the department. Among them, 881 children received antimalarial treatment, i.e., 70.5% with prescriptions. Malaria was confirmed by microscopy in 410 children, i.e., 46.5% of the sick children received antimalarial treatment. Prescription control was deemed noncompliant in 258 patients, i.e., 29.3% of the total. Treatments based on microscopic diagnosis are one of the strategies that will help to streamline the use of antimalarial drugs to improve their effectiveness and efficiency and also to reduce the risk of emergence of resistance.

[Mortal poisoning by bee stings in a child: Study of a case observed in the regional hospital of Maradi (Niger)]. / Envenimation mortelle par piqûres d'abeilles chez l'enfant : à propos d'un cas observé au centre hospitalier régional de Maradi (Niger).

We report a fatal case due to a massive attack by a swarm of bees in a nine-year-old child. The accident was fatal because of two aggravating factors: the cephalic location and the large number of stings (about 300). Complications were coagulopathy, anemia, hemorrhage, coma, and oligoanuria. Support was symptomatic at a facility second level. The outcome was fatal within 14 days. In view of the encountered difficulties, we recommend to build written protocols for the management of envenomation in any health training reference.

[Tuberculosis in children: 29 cases in two hospitals of Niamey and at the national tuberculosis center]. / La tuberculose chez l'enfant: a propos de 29 cas colliges dans deux hopitaux de Niamey et au centre national antituberculeux.

In 2013, the WHO considered that worldwide, the annual incidence of the tuberculosis is of 9 million cases, and prevalence at 14 million. The diagnosis of tuberculosis in children is difficult and can be at the origin of a delay of care and an under estimation of the amount of cases. The purpose of this study was to analyze the epidemiological and diagnostic aspects of tuberculosis in children. It was a multicenter study taking place from October 1st, 2009 until June 1st, 2011. The average age of children was of 4.6 years, with a sex-ratio of 1.43. 65, 52% of patients were inoculated with BCG; 86, 21% arose from family from a low socio-economic level; 55% suffered from malnutrition. Extrapulmonary effects are more frequent than pulmonary (62.07% versus 37.93%). IDR was positive in 85.71% of the children; the sedimentation speed was high in 88.89% of them. The HIV serology tests were administered to 27.59% of the children, all were seronegative. The fight against tuberculosis has to intensify, through the combination of several strategies, such as vaccination, active screening, the adequate care of the cases, improvement of socioeconomic conditions of the populations and research for a new more effective vaccine, news methods of diagnostic and antituberculosis drugs successful.

INTRODUCTION: En 2013, l'OMS a estimé qu'à travers le monde, l'incidence annuelle de la tuberculose était de 9 millions de cas, et la prévalence de 14 millions. Le diagnostic chez l'enfant est difficile et cela est à l'origine de retard de prise en charge et d'une sous estimation des cas. MÉTHODE: Cette étude a été réalisée dans le but d'analyser les aspects épidémiologiques et diagnostiques de la tuberculose chez l'enfant. Il s'agit d'une étude multicentrique prospective qui s'est déroulée d'octobre 2009 à juin 2011, à Niamey dans les deux hôpitaux nationaux et au Centre National Antituberculeux. RÉSULTATS: L'âge moyen des enfants était de 4,6 ans, et le sex-ratio était de 1,4. Soixante cinq virgule cinq pourcent des patients étaient vaccinés au BCG; 86, 2% étaient issus de famille à bas niveau socio-économique; 55% d'entre eux souffraient de malnutrition. Les atteintes extra-pulmonaires étaient plus fréquentes que les formes pulmonaires (62,1% versus 37,9%). L'IDR était positive chez 85,7% des enfants; la vitesse de sédimentation était élevée chez 88,9% d'entre eux. Le test sérologique pour le VIH a été fait chez 27,6% des enfants; tous étaient séronégatifs. CONCLUSION: La lutte contre la tuberculose doit s'intensifier, à travers la combinaison de plusieurs stratégies, telles que la vaccination, le dépistage actif, la prise en charge adéquate des cas, l'amélioration des conditions socio-économiques des populations et la recherche d'un nouveau vaccin, ainsi que de nouvelles méthodes de diagnostic.

[Intestinal parasitosis in children less than five years of age in Niamey, Niger]. / Les parasitoses intestinales chez les enfants de moins de cinq ans a Niamey au Niger.

According to the WHO, in 2002, 3.5 billion of people worldwide were infected with intestinal parasites. Every year, roundworms, hookworms and amoebae are the cause of 195,000 deaths around the world. Despite this high prevalence, these infections are said to be neglected and attract little interest. And yet, they are sometimes very grave especially when contracted by children where they can lead to malnutrition. This prospective study aims to clarify the overall prevalence of intestinal parasites in children. METHODS: The study took place in the pediatric service of the Lamorde national Hospital and the two pediatric services of the Niamey national hospital. This descriptive and analytical study, took place from April to June 2011. Included were children aged 1 month to 59 months, having had a stool examination. RESULTS: The search for parasites was positive in 66 children (33%). The prevalence is statistically higher (p = 0.02) among children 25-59 months (43.84%) than among those whose age is between 1-24 months (26.77%). Male children were more infected than female with respectively 38.7% and 28.04% infection rates. CONCLUSION: Intestinal parasites are frequent in Niamey, despite numerous deworming campaigns. There's been more parasitic protozoa caused by a proportion of 81, 81%, against a proportion of 18, 18 % for metazoans. Conducting a study on the national scale is necessary to understand the general prevalence of intestinal parasites. This would enable a more adapted strategy to the fight against these illnesses.

INTRODUCTION: Selon l'OMS, en 2002, on a évalué à 3,5 milliards le nombre de sujets infectés par des parasites digestifs, à travers le monde. Chaque année, les ascaris, les ankylostomes et les amibes occasionneraient 195000 décès dans le monde. Malgré cette forte prévalence, ces maladies dites négligées, suscitent peu d'intérêt. Et pourtant, elles sont parfois graves surtout chez l'enfant où elles peuvent entraîner la malnutrition. Cette étude vise à évaluer la prévalence globale des parasitoses intestinales chez les enfants. MÉTHODE: L'étude s'est déroulée dans le service de pédiatrie de l'Hôpital National Lamordé et les deux services de pédiatrie de l'Hôpital National Niamey. C'est une étude descriptive visée analytique, qui a été réalisée d'avril à juin 2011. Ont été inclus dans l'étude tous les enfants âgés de 1 à 59 mois, ayant bénéficié d'un examen coprologique. RÉSULTATS: La recherche des parasites était positive chez 66 enfants (33%). La prévalence était statistiquement plus élevée (p=0,02) chez les enfants âgés de 25 à 59 mois (43,8%), que chez ceux dont l'âge est compris entre 1 et 24mois (26,8%). Les protozoaires étaient les parasites les plus fréquents (81,8%) et les métazoaires représentaient 18,2%. CONCLUSION: Les parasitoses intestinales sont fréquentes au Niamey, malgré les campagnes de déparasitage. La réalisation d'une étude national, nous parait nécessaire afin de connaitre la prévalence générale des parasitoses intestinales. Cela permettra d'adapter les stratégies de lutte contre ces maladies.

Prévalence et sensibilité aux antibiotiques de Neisseria gonorrhoeae chez les professionnelles du sexe et les patients IST au Niger

Le but de l'etude etait d'estimer la prevalence des infections a Neisseria gonorrhoeae et d'evaluer la sensibilite aux antibiotiques des souches; en vue d'une revision eventuelle du traitement par approche syndromique des ecoulements genitaux au Niger. De juillet a decembre 2007; un depistage systematique a ete effectue chez des professionnelles du sexe (PS) dans 5 localites; et des patients consultant pour IST a Niamey. Parallelement a l'examen microscopique apres coloration de Gram; les prelevements endocervicaux ou uretraux ont ete mis en culture sur gelose chocolat Polyvitex (bioMerieux); avec/sans inhibiteurs VCN; en atmosphere humide; sous 5-10CO2; pendant 1 a 2 jours. Les colonies suspectes sont identifiees sur galerie API NH (bioMerieux) et les antibiogrammes realises. Le gonocoque n'a ete isole que chez 0;68(5/739) des PS. Aucune souche n'a ete obtenue chez les 20 patientes IST; contre 2 chez les 9 cas d'uretrite masculine. Chacune des souches est resistante a au moins un des antibiotiques recommande par l'OMS dans l'approche syndromique. Cinq produisent une penicillinase et 2 une beta-lactamase a spectre elargi. Avec cette relative rarete des isolats et l'existence de resistance a au moins un des antibiotiques preconises; seule une surveillance microbiologique de routine permettra une collecte suffisante de souches pour avoir des donnees fiables necessaires a une revision de protocole

[Carcinosarcoma of the prostate. Case report]. / Le carcinosarcome de la prostate. A propos d'un cas.

We report one case of carcinosarcoma of the prostate in a patient of 43 years old. The clinical symptomatology was dominated by pollakiurie, dysuria digestive disorders, oedema of the lower limbs and the alteration of the general status. Digital rectal examination showed a big prostate, hard and irregular. The rate of PSA increased. Echography revealed a pelvic echogenic mass corresponding to a bulky prostate. CT scan of the abdomen and the pelvis showed a tissular, heterogeneous mass of 11 cm occupying the vesicoprostatic space and invading the basis of the bladder and the adjacent muscles (muscles obturateurs internes). Histology of a biopsy fragment of the mass revealed an adenocarcinoma and a mesenchymatous component calling up a prostatic carcinosarcoma. The treatment consisted in chemotherapy VAC. The evolution was deadly after 2 months.

[Inguinal hernia of the bladder. Report of 6 cases]. / Les hernies inguinales de la vessie. A propos de 6 cas.

The authors report 6 cases of inguinal hernia of the bladder seen between 1976 and 1996. All patients were males with a mean age of 67 years (range: 53 to 80 years). The hernia was situated in the right groin in all patients. No patients presented any suggestive clinical features. In 5 patients, the diagnosis was established by IVU, indicated for another disease associated with the hernia and, in one patient, the hernia was discovered after an operative wound to the bladder. Treatment consisted of elimination of bladder neck obstruction in 3 patients and reintegration of the bladder and abdominal wall repair in 4 patients. The postoperative course was uneventful.

[Traumatic rupture of the bladder. Report of 12 cases]. / Les ruptures traumatiques de la vessie. A propos de 12 cas.

Over the previous 8 years, the authors have treated 12 patients (11 males and 1 female with a mean age of 32 years (26 to 54 years)) with traumatic rupture of the bladder. Rupture was secondary to direct trauma to the full bladder in one case and pelvic trauma in 11 cases. Associated lesions were pelvic trauma (11 cases), head injury (4 cases), chest trauma (2 cases), rupture of the spleen (1 case) and small bowel perforation (1 case). The clinical features were dominated by suprapubic pain (11 cases), haematuria (10 cases), haemorrhagic shock (4 cases) and peritoneal syndrome (3 cases). IVU confirmed the diagnosis in 6 out of 8 cases. Retrograde cystourethrography was conclusive whenever it was performed. The retroperitoneal rupture was treated by indwelling catheter for 15 days. Intraperitoneal ruptures were treated surgically. The breach was situated in the dôme in 10 cases and on the posterior surface in 1 case. The size of the wound ranged from 2 to 8 cm. Treatment consisted of suture of the rupture and indwelling catheter for an average of 12 days. Cure was always obtained without sequelae.

[Vesico-uterine fistulas. Report of 30 cases]. / Les fistules vésico-utérines. A propos de 30 cas.

The authors report a series of 30 vesico-uterine fistulas (VUF) observed over a 25-year period. The mean age of the patients was 28 years (range: 18 to 40 years). VUF were secondary to caesarean section (23 cases), abnormal delivery (5 cases) and rupture of the bladder and uterus (2 cases). The presenting complaint was a permanent total and isolated urinary incontinence (22 cases), partial urinary incontinence associated with menstrual haematuria (4 cases), vesical menstrual bleeding associated with a oligomenorrhoea (3 cases) and menouria (1 case). The diagnosis was established on clinical findings in 14 patients. IVU, performed in 30 patients, visualized the uterine cavity in only 12 patients. Retrograde cystography, performed in 4 cases, demonstrated opacification of the uterine cavity. Hysterosalpingography, performed in 6 cases, confirmed the diagnosis of VUF in all 6 patients. Treatment was surgical, via a transperitoneovesical incision (22 cases) or a transvesical incision (8 cases) and consisted of isolation of the bladder and uterus and uterine and vesical suture. Urine drainage was performed by urethral catheter (28 cases) or cystostomy (2 cases). Urinary continence was perfectly restored in 24 patients, 6 patients presented residual fistulas another patient had a reduction of her bladder capacity. The objective of this study is to analyse the aetiological, diagnostic and therapeutic aspects of this disease.

[The Martius flap in the treatment of vesicovaginal fistulas. Report of 20 cases]. / Le lambeau de Martius dans le traitement des fistules vésico-vaginales. A propos de 20 cas.

The authors report a series of 20 cases of vesicovaginal fistula (VVF) treated according to the Martius procedure. The mean age of the patients was 30 years (range: 20 to 37 years). All fistulas were secondary to obstetric trauma. The mean diameter of the fistula orifice was 4 cm. Fourteen fistulas were cervico-trigonal and 6 were urethro-cervico-trigonal. A rectovaginal fistula was associated with VVF in 2 patients. Five of the 20 patients had never been previously operated, while 15 patients had already been operated without success. Fifteen patients were cured immediately, while a second Martius procedure was necessary in 3 cases. Failure was considered to be definitive in 2 cases.

[Urethrorectal fistula. Report of 11 cases]. / Les fistules uréthro-rectales. A propos de 11 cas.

The authors report a series of 11 urethrorectal fistulas observed over a 25-year period. The mean age of the patients was 37 years (range: 15 to 70 years). The aetiologies were surgical trauma (5 cases), fracture of the pelvis (2 cases), inflammatory lesions (3 cases), and one fistula was congenital. The clinical features were dominated by urine discharge from the anus (11 cases), urinary tract infection (8 cases), spurious diarrhoea (6 cases), faecaluria (4 cases), pneumaturia (2 cases). Digital rectal examination was normal in 7 patients. IVU demonstrated opacification of the rectum in 5 out of 8 cases. Cystourethrography, performed in 9 patients, demonstrated the communication in each case. Urethrocystoscopy visualized the fistula in each case in which it was performed. Treatment consisted of bladder drainage by urethral catheter in all patients, allowing closure of the fistula in 2 patients. Colostomy was performed in 2 patients, internal urethrotomy and urethral catheter was performed in 2 cases. Surgical closure of the fistula was performed in 7 patients, via an abdominoperineal (3 cases), perineal (2 cases), transperitoneal (1 case) or transanosphincteric incision (1 case).

[Adrenal gland pheochromocytoma. Report of 26 cases]. / Phéochromocytomes surrénalines. A propos de 26 cas.

The authors analyse of a series of 26 patients (17 females and 9 males) with a mean age of 32 years (range: 18 to 55 years) operated for adrenal phaeochromocytoma. All patients were hypertensive. The laboratory assessment (assay of blood catecholamines and urinary catecholamine metabolites) performed in more than 2/3 of cases confirmed the diagnosis in more than 80% of cases. The topographic diagnosis was facilitated by computed tomography. Fifteen patients received preoperative treatment with alpha-blockers or calcium channel blockers. Various incisions were used, but a lumbar incision was the most frequent. Blood pressure was controlled postoperatively in 24 patients. Two patients died 1 and 2 postoperatively. New diagnostic modalities (CT, MRI) have facilitated the diagnosis and the site of localization of phaeochromocytomas, thereby improving the choice of incision. Patient-specific preoperative preparation and appropriate anaesthesia facilitate successful adrenal gland surgery.

[Hydatid cyst of the kidney. Report of 45 cases]. / Le kyste hydatique du rein. A propos de 45 cas.

The kidney is a rare site of hydatid disease. It remains clinically silent for a long time and only presents at the stage of complications. The diagnosis is essentially radiological. Renal hydatid cyst (RHC) raises therapeutic problems due to its complications, which sometimes make kidney-preserving cyst resection surgery difficult. The authors report a series of 45 cases of RHC treated in their department during a 20-year period. This series consisted of 27 men and 18 women with a mean age of 47 years (26-80 years). The clinical features were dominated by pain (80%), flank mass (42%), hydaturia (22%), haematuria (13%), urinary tract infection (6%), hypertension (3%). IVU, performed in all patients, showed calcifications in 35% of cases, renal tumour syndrome in 71% of cases and silent kidney in 22% of cases. Surgery was usually performed via a lumbar incision (75%) or a BARAYA incision (15%). Treatment consisted of 18 cyst roof resections (40%), 6 pericystectomies (13%), partial nephrectomy in 2 cases (4%) and total nephrectomy in 18 cases (40%). The postoperative course was marked by urinary fistula in two patients and one death at the 2nd postoperative month related to associated renal sarcoma. The objective of this study is to analyse the epidemiological, pathological and therapeutic features of this disease, which still constitutes a public health problem in Morocco.

[Thyroid cancer metastasizing to the kidney. Report of a case]. / Métastase rénale d'un cancer de la thyroïde. A propos d'un cas.

The authors report a case of renal metastasis from a thyroid adenocarcinoma in a 56-year-old man, occurring 3 years after isthmolobectomy for papillary thyroid carcinoma. He predominant clinical symptoms were low back pain, haematuria and deterioration of the general state. Ultrasonography showed a hypoechoic left renal mass, 56 mm in diameter, with a thickened wall. Renal CT showed a homogeneous low-density formation with a thickened wall in the left kidney. Iodine 131 whole body scan showed increased uptake in the left kidney. The patient wes treated surgically via a subcostal incision. The surgical procedure consisted of radical nephrectomy. Macroscopic examination of the lesion showed a cystic mass. Histological examination of the mass revealed a renal metastasis from moderately differentiated thyroid adenocarcinoma.

[Bilateral adrenal pheochromocytoma. A case report]. / Le phéochromocytome surrénalien bilatéral. A propos d'un cas.

The authors report a case of apparently isolated bilateral adrenal phaeochromocytoma in a 25-year-old man presenting with abdominal pain and neurosensory signs of HT, but ignored and complicated by heart failure. Ultrasonography and abdominal CT revealed a bilateral adrenal tumour. The hormonal assessment, particularly metanephrines and normetanephrines, was normal. The diagnosis of phaeochromocytoma was proposed despite the negative hormonal assessment and was supported by positive MIBG scintigraphy, compatible with bilateral adrenal phaeochromocytoma with no other sites. Treatment consisted of right adrenalectomy and left tumour excision. The postoperative course was uneventful, and 3-year follow-up showed regression of the functional symptoms and control of blood pressure without any other treatment.

[Pathological horseshoe kidney. 30 case reports]. / Le rein en fer à cheval pathologique. A propos de 30 cas.

The authors report a series of 30 horseshoe kidneys observed over a 20-year period. This series consisted of 20 men (66.6%) and 10 women (33.4%) with a mean age of 35 years (20-65 years). The clinical features were dominated by abdominolumbar pain (22 cases), haematuria (12 cases) and pyuria (2 cases). Horseshoe kidney was associated with renal stones (20 cases), ureteropelvic junction syndrome (8 cases), upper urinary tract tumour (1 case). Treatment was surgical depending on the aetiology. The objective of this study was to analyse the epidemiological and diagnostic features of this disease, as well as the therapeutic features specific to each uropathy associated with horseshoe kidney.

[Augmentation enterocystoplasty. 35 cases]. / L'entérocystoplastie d'agrandissement. A propos de 35 cas.

The authors report their experience of augmentation enterocystoplasty, performed in 35 patients over a 16-year period. This series consisted of 20 men (57%) and 15 women (23%) with a mean age of 45 years (18 to 69 years). The aetiologies of small bladder were urogenital tuberculosis (17 cases), vesicovaginal fistula (8 cases), urogenital schistosomiasis (4 cases), interstitial cystitis (4 cases), neurogenic bladder (2 cases). Augmentation enterocystoplasty used the ileum (26 cases), sigmoid colon (5 cases) and caecum-ileum (4 cases). Augmentation enterocystoplasty was associated with supratrigonal cystectomy (20 cases), hydraulic antireflux valve (1 case), ileoureteroplasty (2 cases) and ureterovesical reimplantation (3 cases). Three patients developed a urinary fistula. The marked mucus production was responsible for urinary retention in one patient. Three patients developed metabolic acidosis requiring alkalinization. Two patients developed ureterohydronephrosis secondary to stenosis of the ureteroneovesical junction and another two patients developed bladder stones. The objective of this study was to evaluate the results of augmentation enterocystoplasty in patients with a small bladder or neurogenic bladder.