Going Dutch in nocturnal enuresis.

Based on several intervention programmes, a strategy for the treatment of nocturnal enuresis has recently been developed by an expert committee in the Netherlands. It consists of three parts. First, two structured interviews are given: one to differentiate between enuresis and incontinence and one to detect associated problems such as diurnal enuresis, constipation or behavioural problems. Secondly, a medical examination is made, confined to the inspection of the external genitalia and lower back, palpation of the abdomen and urine examination. Thirdly, the following guidelines for treatment at different age levels are applied: up to the age of 6 years no intervention is needed; between the ages of 6 and 8 years, lifting out of bed and/or the calendar method; between the ages of 8 and 12 years, enuresis alarm (if not successful, medication with desmopressin is prescribed for a restricted period of time), and ambulatory dry-bed training in a group setting may follow; over 13 years of age, clinical dry-bed training according to the Messer/Azrin method is advised. According to the expert committee, these guidelines offer sufficient possibilities to deal with the problem of nocturnal enuresis.

Vesicoureteric reflux and videourodynamic studies: results of a prospective study after three years of follow-up.

OBJECTIVE: To study prospectively the influence of videourodynamic studies on the management of children with vesicoureteric reflux. METHODS: One hundred one children with reflux were investigated routinely with videourodynamic studies, as well as renal scans, ultrasound studies, and/or intravenous urograms. The studies were repeated at one, three, and five years. If bladder instability was demonstrated, the primary treatment consisted of anticholinergic drugs and antibiotics, regardless of the grade of reflux. In reflux Grades IV and V with instability and renal scars, surgery was performed. In case of a stable bladder, reflux Grades I-III received antibacterial treatment, while surgical correction was used for reflux Grades IV and V. RESULTS: The results of three years of follow-up of 101 children are reported. Bladder instability was found in 39 children. Thirty of them with reflux Grades I-IV and instability could be managed with anticholinergic and antibacterial drugs, while 9 needed surgical correction. CONCLUSIONS: A voiding cystourethrogram is only sufficient for the detection of reflux but for correct management of these children a (video)urodynamic study is mandatory. After treatment of frequently found bladder dysfunction, the reflux will disappear in the majority of cases.

Effect of parenteral testosterone therapy on penile development in boys with hypospadias.

Forty boys with hypospadias received 2 mg/kg testosterone esters intramuscularly 5 and 2 weeks before surgical correction of the hypospadias. The effects on penile development were determined 3 and 5 weeks after the first injection and 3 and 12 months post-operatively. A significant effect on penile development was shown. This effect disappeared during the first year following treatment. There was no effect on bone maturation, children's height and the ultimate testosterone level. All adverse effects disappeared after cessation of therapy. Androgen receptor deficiency as a possible cause of hypospadias is not supported by our observations.

[Routine urodynamic studies is not indicated in children with enuresis]. / Routinematig urodynamisch onderzoek bij kinderen met enuresis niet geïndiceerd.

From January 1980 to January 1992, urodynamic examinations were performed in 339 enuretic children without constipation or anatomical or neurogenic causes of incontinence. Nocturnal enuresis was seen in 178 patients, 130 children suffered from nocturnal and diurnal enuresis, and 31 had only diurnal enuresis. M. detrusor instability was found in 44% of the children and 73% showed more than 15% reduction in functional bladder capacity. In 5% an infravesical obstruction was suspected on pressure-flowmetry and in 12% dysfunctional voiding was seen. Routine urodynamic studies are not indicated in children with enuresis.

Treatment of vesicoureteric reflux. Results of a prospective study.

Between 1982 and 1986, 96 children with non-obstructive vesicoureteric reflux were included in a prospective study. Three patients withdrew from the study and results are therefore presented on 93 children with 135 refluxing ureters who were followed up for at least 5 years. Initially, all children with reflux grade III or less received antibiotic treatment only. Those with reflux grade IV were randomised to antibiotic treatment alone versus surgery plus antibiotic treatment; the primary treatment of reflux grade V was reimplantation. In 85 ureters treated by antibiotics only, reflux disappeared in 64 cases and was reduced in 12. In 50 ureters treated by reimplantation, reflux was cured in 46 cases and no severe ureteric obstruction was seen. Conservative management of reflux grade IV was less successful than surgery. The results of conservative, non-surgical treatment of reflux grades I-III were satisfactory, but for grades IV and V surgery should be the treatment of choice if detrusor instability has been excluded.

The effect of oxyphenonium bromide and oxybutynin hydrochloride on detrusor contractility and reflux in children with vesicoureteral reflux and detrusor instability.

In a prospective study the effects of the anticholinergic drugs oxyphenonium bromide and oxybutynin hydrochloride on detrusor contractility and reflux were studied. Although anticholinergic properties are claimed of both drugs, only oxybutynin hydrochloride proved to decrease detrusor contractility and the degree of reflux, probably due to a direct spasmolytic effect on the detrusor. Therefore, in cases of reflux and detrusor instability treatment with oxybutynin hydrochloride is recommended.

Complications of transurethral electro-incision of posterior urethral valves.

The development of dense urethral strictures following transurethral resection of posterior urethral valves is a well known complication, especially in the neonate. In 85 boys with posterior urethral valves no strictures were found during follow-up. Urinary incontinence associated with transurethral incision occurred in 3 patients and a small urethral diverticulum was found in 1. The complication rate associated with the transurethral incision itself was 5%. Our technique for transurethral incision of posterior urethral valves is described.

[The treatment of urinary incontinence in children using the AMS sphincter prosthesis]. / Behandeling van urine-incontinentie bij kinderen met behulp van de AMS-sfincterprothese.

In the Netherlands implantation of the AMS-sphincter prosthesis in childhood is still a rare mode of treatment. Since 1984 we have implanted only 12 artificial sphincters in children, aged 9-15 years. Finally in all children a good continence was achieved and only in one boy several technical problems were seen, which could be remedied successful.

Treatment of vesicoureteric reflux: results after 3 years in a prospective study.

Between 1982 and 1986, 96 children with nonobstructive vesicoureteric reflux were treated in a prospective study. There were 134 refluxing ureters. Results are reported after a follow-up period of 3 years in 94 children with 130 refluxing ureters. Initially all children with reflux grade III or less had antibiotic treatment only. Those with reflux grade IV were randomized for antibiotic treatment alone versus surgery plus antibiotic treatment, while the primary treatment of reflux grade V was reimplantation. In 84 ureters treated by antibiotics alone, reflux disappeared in 52 cases and in 18 ureters the reflux was reduced. In 49 ureters treated by reimplantation, reflux was cured in 39 cases and no severe ureteric obstruction was seen. Conservative management of reflux grade IV was less successful than surgery. The results of conservative, nonsurgical treatment of reflux grade I to III are satisfactory, but for grades IV and V reflux surgery should be the treatment of choice, provided that detrusor instability can be excluded.

Pitfalls in the treatment of congenital urologic anomalies.

Specific diagnostic and therapeutic considerations regarding urologic problems in the very young have encouraged the awareness that the treatment of congenital malformations requires special qualifications. In this paper 3 cases are presented to illustrate and stress our opinion that the treatment of congenital urologic anomalies in young children should be left to urologists who have been trained and work in the field of paediatric urology.

The role of videourodynamic studies in diagnosis and treatment of vesicoureteral reflux.

From January 1986 to January 1988, 63 children with 95 refluxing ureters have been studied in a prospective study with videourodynamic examination. All children with reflux grades I, II, and III received antibacterial treatment. Surgical treatment was adopted for reflux grades IV and V, provided detrusor instability had been excluded. However, if there was detrusor instability, anticholinergic drugs and antibacterial treatment were given in all grades of reflux and videourodynamic examination was repeated after 3 to 6 months and after 12 months of therapy. Bilateral reflux was found in 22 of 38 patients with a stable bladder, and reimplantation was performed in 11 patients with 18 refluxing ureters. In 25 children with 35 refluxing ureters of various grades of reflux, detrusor instability was found and unilateral reflux was noted more frequently than bilateral reflux. Surgery was necessary for only five children, because in the majority of the patients detrusor instability and reflux could be treated by anticholinergic drugs and antibacterial treatment. For the decision as to which treatment should be given in vesicoureteral reflux, a videourodynamic study is mandatory.

Results of surgical treatment of severe vesicoureteric reflux. Retrospective study of reflux grades 4 and 5.

A series of 80 children underwent surgery in the Sophia Children's Hospital for gross reflux grades 4 and 5. In this retrospective study the success rate for ureteric reimplantation was 90%. Analysis of growth showed that after surgery the children tended to fall within the normal ranges for height and weight. Deterioration in renal function was progressive in 3 children. New renal scars developed in 13% of renal units. Initially non-refluxing kidneys showed no further deterioration. Moderate hypertension was found in only 4 patients.