Reed Nesbit and pediatric urology.

OBJECTIVES: To ascertain the pediatric urology experience and contributions of Reed Nesbit, a urologist known primarily as an educator, transurethral resectionist, and prostate expert. METHODS: The writings of Nesbit and appropriate background references were analyzed. RESULTS: Nesbit's contributions to pediatric urology, particularly the Cabot-Nesbit orchidopexy, the buttonhole preputial transposition, the dorsal tunical tuck for chordee, and the elliptical anastomosis were significant. CONCLUSIONS: Nesbit's contributions to pediatric urology were innovative and enduring.

Fate of patients started on clean intermittent self-catheterization therapy 10 years ago.

We evaluated 60 patients placed on a clean intermittent catheterization program more than 10 years ago to determine their outcome. To date 27 patients still are performing self-catheterization, 18 have discontinued the procedure and 15 have been lost to followup. No patient has had deterioration in renal function. Prior incontinence was alleviated completely in 10 of the 27 patients still on the program and 10 of the 18 patients no longer on catheterization have returned to normal voiding. Clean intermittent catheterization is an effective treatment modality in properly selected patients, with few complications and excellent long-term results.

The significance of bacilluria in children on long-term intermittent catheterization.

We reviewed the records of 255 children who have been managed by clean intermittent catheterization during the last 10 years to determine the incidence of bacilluria and upper tract changes. Bacteriuria was documented in 56 per cent of the children but febrile urinary tract infections occurred in only 11 per cent and fresh renal damage in 2.6 per cent. In the absence of vesicoureteral reflux bacilluria proved to be innocuous, since vesicoureteral reflux, progressive hydronephrosis or increasing parenchymal scarring did not develop. Bacteriuria in association with low grade reflux was rarely harmful and the reflux actually disappeared in up to 50 per cent of cases. However, bacteriuria in patients with high grade reflux was not an innocent phenomenon, since not only did the reflux tend to persist but pyelonephritis occurred in more than 60 per cent of the patients. In this latter group of patients reimplantation is an important therapeutic consideration if sterile urine cannot be achieved.

Further observations on the cystometric and uroflowmetric effects of bethanechol chloride on the human bladder.

We evaluated the cystometric and uroflowmetric effects of bethanechol chloride on non-neurogenic, non-decompensated human bladders. Statistically significant changes were measured using cystometric and uroflowmetric parameters. We discuss the indications and methods for therapy with bethanechol chloride.

Association of urinary tract infection and reflux with uninhibited bladder contractions and voluntary sphincteric obstruction.

We studied 53 neurologically normal children with recurrent urinary tract infection who were found to have bladder-sphincter incoordination characterized by voluntary sphincteric constriction during involuntary uninhibited bladder contraction. Increased intravesical pressure was documented during these events and was associated with vesicoureteral reflux in nearly 50 per cent of the children and with abnormalities of the ureteral orifice in 30 per cent of those without reflux. We hypothesize that increased intravesical pressure causes urinary infection in these children and produces a spectrum of intravesical anatomic distortion that predisposes to vesicoureteral reflux. In a prospective uncontrolled study treatment of the uninhibited bladder contractions allowed 58 per cent of the patients to maintain sterile urine without subsequent antimicrobial therapy after cure of the initial infection.

Mechanisms of urinary tract infection.

Most urinary tract infections begin as a cystitis secondary to decreased host resistance brought on by disruption of tissue integrity or a decrease in blood supply to the bladder. In the female, infrequent voiding and the uninhibited bladder are the most common causes of urinary tract infection and are best treated by healthy voiding regimens; while in the male, structural and functional obstructive uropathy are most often associated with urinary tract infection and are alleviated by lowering the high intravesical pressures via surgical or medical measures. The concept that host resistance is the determinant of infection rather than the organism has permitted the use of clean, intermittent self-catheterization; clean intermittent self-dilatation; and transurethral diverticulectomy in the therapy of a host of urologic disease syndromes.

Transurethral treatment of urethral diverticula in women.

Six women with urethral diverticulitis and a history of having had previous operations for diverticula were subjected to transurethral diverticulotomy with a knife electrode. Each patient had multiple diverticula, some compartmented, located in the mid or most proximal segments of the urethra. All patients have been relieved of the symptoms and infection during the postoperative period, varying from 1 1/2 to 7 years.

Neurogenic bladder dysfunction.

The combined use of cystometry and perineal electromyography permits the physician to detect abnormalities in the synchronization of bladder contraction and urinary sphincter relaxation. With each pattern of neurogenic bladder disease, the coordination between bladder and sphincter determines whether urinary tract problems will develop. Treatment is tailored to specific bladder and sphincter defects.

The anticholinergic effects of dicyclomine hydrochloride in uninhibited neurogenic bladder dysfunction.

A preliminary study to assess objectively the effects of dicyclomine upon uncontrolled detrusor contractions and bladder capacity was undertaken in 14 patients with a cystometric diagnosis of uninhibited neurogenic bladder. Response was measured by cystometry performed 1, 2 and 4 hours after a 20 mg. oral dose. Of the 14 patients 11 had significant blockade of uninhibited contractions and a concomitant increase in bladder capacity. Similar but less dramatic changes were noted in the remaining 3 patients. Dicyclomine seems to have effective anticholinergic properties. No remarkable side effects were observed.

Followup of abdominal neourethra.

Abdominal neuroethrostomy is a highly satisfactory form of urinary diversion for patients with irreparable urethral stricture or destruction. Normal renal function, structure and urinary continence have been observed in 7 patients for as long as 17 years.

Transurethral treatment of urethral diverticula in women.

Six women with urethral diverticulitis and a history of having had previous operations for diverticula were subjected to transurethral diverticulotomy with a knife electrode. Each patient had multiple diverticula, some compartmented, located in the mid or most proximal segments of the urethra. All patients have been releived of the symptoms and infection during the postoperative period, varying from 1 1/2 to 7 years.

Action of oral and parenteral bethanechol on decompensated bladder.

A double blind balanced Latin-square study was conducted on 20 adult patients with decompensated bladders to determine the relative effectiveness of oral and parenteral bethanechol chloride (Urecholine) on the stretch response of bladder muscle. Detrusor reaction was measured by modified cystometry. Five mg. of subcutaneous bethanechol chloride produced a significant increase in intravesical pressure which was more rapid in onset, of larger magnitude, and of shorter duration than oral doses of 100 and 200 mg.

Altered bladder function in staghorn calculus disease.

Disorders of the lower urinary tract that predispose to urinary infection were identified in 69 per cent of 62 patients with branched renal calculi. Within an average followup of 6.3 years control of these disorders was observed to reduce the rate of reinfection and the frequency of complications after operative stone removal.

Followup of abdominal neourethra.

Abdominal neourethrostomy is a highly satisfactory form of urinary diversion for patients with irreparable urethral stricture or destruction. Normal renal function, structure and urinary continence have been observed in 7 patients for as long as 17 years.

New approach to myelodysplasia.

Data from 60 patients with myelodysplasia are presented. Electromyography of the periurethral striated muscle in conjunction with simultaneous cystometry allows prediction of those patients at risk from urinary tract infection in 100 per cent of the cases. Intermittent self-catheterization is an effective form of therapy for bladder dysfunction in patients with myelodysplasia. An orderly approach to the evaluation and management of bladder dysfunction is outlined.

Comparison of rapid versus slow decompression of the distended urinary bladder.

Experiments are described showing that urinary retention with its associated increased intravesical pressure and overstretching of the bladder wall can lead to loss of capillary and tissue integrity. Our findings indicate that the severity of damage to the bladder wall prior to catheterization determines the degree of hemorrhage after bladder decompression and not the rate of emptying.

Further observations on self-catheterization.

A non-sterile technique of intermittent self-catheterization was used for 218 patients with an inability to void in a normal fashion because of obstructive uropathy, decompensated detrusor or neurogenic bladder. Marked improvement was noted in urinary continence, urinary infection, renal function, bladder emptying and, perhaps most important, the mental and emotional status of the patient and/or parents. The extremely low incidence of complications and its therapeutic efficacy clearly make clean, intermittent self-catheterization an outstanding weapon in the urological armamentarium and a most persuasive reminder that host resistance is still the primary factor in the occurrence of infection.