Multi-center randomized controlled trial of cognitive treatment, placebo, oxybutynin, bladder training, and pelvic floor training in children with functional urinary incontinence.

OBJECTIVE: Functional urinary incontinence causes considerable morbidity in 8.4% of school-age children, mainly girls. To compare oxybutynin, placebo, and bladder training in overactive bladder (OAB), and cognitive treatment and pelvic floor training in dysfunctional voiding (DV), a multi-center controlled trial was designed, the European Bladder Dysfunction Study. METHODS: Seventy girls and 27 boys with clinically diagnosed OAB and urge incontinence were randomly allocated to placebo, oxybutynin, or bladder training (branch I), and 89 girls and 16 boys with clinically diagnosed DV to either cognitive treatment or pelvic floor training (branch II). All children received standardized cognitive treatment, to which these interventions were added. The main outcome variable was daytime incontinence with/without urinary tract infections. Urodynamic studies were performed before and after treatment. RESULTS: In branch I, the 15% full response evolved to cure rates of 39% for placebo, 43% for oxybutynin, and 44% for bladder training. In branch II, the 25% full response evolved to cure rates of 52% for controls and 49% for pelvic floor training. Before treatment, detrusor overactivity (OAB) or pelvic floor overactivity (DV) did not correlate with the clinical diagnosis. After treatment these urodynamic patterns occurred de novo in at least 20%. CONCLUSION: The mismatch between urodynamic patterns and clinical symptoms explains why cognitive treatment was the key to success, not the added interventions. Unpredictable changes in urodynamic patterns over time, the response to cognitive treatment, and the gender-specific prevalence suggest social stress might be a cause for the symptoms, mediated by corticotropin-releasing factor signaling pathways.

Psychosocial factors in teenagers and young adults with myelomeningocele and clean intermittent catheterization.

OBJECTIVE: The aim was to analyse the psychosocial factors of teenagers and young adults with myelomeningocele with at least 5 years' experience of clean intermittent catheterization (CIC). MATERIAL AND METHODS: A qualitative interview technique with semi-structured questions was used in 22 participants aged 13-26 years (median 17) and issues addressed were information given to others, integrity, attitudes to other disabilities, friendship, partnership and sexuality. RESULTS: The participants wanted to inform their peers about the disability but often did not have the courage. Ignorance of the principle of self-CIC among medical staff was confusing. Urinary incontinence after the introduction of the self-CIC regimen was not seen as a problem in comparison with other major disabilities. Half of the participants had peers that they could call a best friend. The subjects wanted more specific information regarding their own sexual function. Finding a partner and becoming a parent were strongly desired but considered problematic. CONCLUSIONS: The participants wished to acquire more knowledge about CIC as a bladder-emptying method from the medical staff and also to have the respect to perform self-CIC at examinations. This study did not find any negative psychosocial factors associated with CIC.

The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society.

PURPOSE: We updated the terminology in the field of pediatric lower urinary tract function. MATERIALS AND METHODS: Discussions were held of the board of the International Children's Continence Society and an extensive reviewing process was done involving all members of the International Children's Continence Society as well as other experts in the field. RESULTS AND CONCLUSIONS: New definitions and a standardized terminology are provided, taking into account changes in the adult sphere and new research results.

Bladder function in preterm and full-term infants--free voidings during four-hour voiding observation.

The purpose with the present review was to characterise bladder function in healthy preterm and full-term infants from findings in studies using the four-hour voiding observation. Characteristics of the free voiding pattern were very similar in preterm and full-term infants. The frequency of voidings was once an hour, bladder volume inducing voiding varied, infants often woke up before voiding and the bladder was not completely emptied at every voiding. Furthermore, interrupted voidings interpreted as a detrusor-sphincter dyscoordination, were seen and were clearly an immature phenomenon since the frequency was high in the preterm infants and then decreased. Concluding these findings the voiding pattern seems to be immature early in life and there is distinct evidence for a connection to the CNS already in the preterm infant.

Epidemiology and natural history of urinary incontinence in women.

Understanding the epidemiology (distribution and determinants) of urinary incontinence (UI), as well as its natural history is a very important issue. In this article, we discuss prevalence, incidence, natural history, and the variations that may be related to race and ethnicity. We focus on epidemiologic population comprising community-dwelling women who are not institutionalized. Our review clearly shows that there is a lack of advanced epidemiologic analyses. Variables that better characterize UI include frequency measure, quantity of urine loss, duration, type, and severity. These factors should be incorporated into basic study design so that more advanced and informative analyses may be conducted.

The value of cystometry for the evaluation of neurogenic bladder in infants and children: an evidence based analysis.

The question whether cystometry is an accurate and reliable method for assessment and prognostication of neurogenic bladder dysfunction in infants and children has been discussed for many years. To elucidate this question, a search of the relevant literature has been made and the identified studies subjected to evidence based analysis. It was found that the great majority of authors recommend regular cystometry on the basis of non-controlled case series which carry a rather low level of scientific evidence (level of evidence 4, grade of recommendation C). There were two notable exceptions. One, the value of the bladder cooling test (BCT) has been validated in prospective studies comparing neurologically intact children and children with neurogenic bladder (Level of Evidence 2, Grade of recommendation B). Two, studies on natural fill (ambulatory) cystometry display Level 2 Evidence (good quality prospective matched cohort studies). Natural fill cystometry thus qualifies for a Grade B recommendation as the "golden standard" for urodynamics in infants and children.

Enuresis in children / Enurese na criança

Estudos demográficos recentes revelam que a prevalência da enurese noturna é de pelo menos 5-10 porcento nas crianças de seis à sete anos de idade, geralmente meninos, e de 0,5 porcento da população adulta. A enurese é o problema crônico mais comum da infância seguido das doenças alérgicas. A enurese noturna é ainda considerada uma vergonha e é mantida em segredo. Mas não há nada vergonhoso na enurese. Ela é causada por um atraso na maturação dos mecanismos somáticos responsáveis por dormir sem urinar a noite toda. Normalmente, este atraso é hereditário. Com poucas exceções, pode-se dizer que a enurese noturna não é causada por fatores psicossociais, embora gere problemas psicológicos para a criança, especialmente evidentes na deteriorização da auto-estima. A enurese noturna resulta da poliúria noturna e/ou da capacidade reduzida da bexiga e, além disso, da inabilidade da criança de acordar em resposta ao enchimento total da bexiga. Com este conhecimento, o tratamento da enurese noturna é baseado no alarme da enurese, cujo objetivo é induzir o despertar, e/ou desmopressina (DDAVP) que reduz a quantidade de urina produzida. O alarme pode ser a primeira escolha, mas precisa ser o apoio de ambos médico e pais. A desmopressina é utilizada quando o alarme falha ou não é aceito pela família, e progressivamente vem se tornando a primeira escolha. A desmopressina pode, a longo prazo, como o alarme, proporcionar uma cura sustentada para a enurese noturna, particularmente se a medicação for precedida de algumas semanas de treino da bexiga (uroterapia). Dessa forma, o conselho para o profissional médico é identificar a enurese noturna e prescrever o tratamento quando o paciente quer passar a noite sem urinar na cama.