Longitudinal follow-up of bladder function in children who participated in the Swedish Reflux Trial.

BACKGROUND: Several publications have reported the coexistence of vesicoureteral reflux (VUR) and bladder dysfunction in children. Whether this dysfunction remains in the longer term is not yet known. OBJECTIVE: This study revisited children who participated in the Swedish Reflux Trial (SRT) with the primary aim of evaluating whether bladder and bowel dysfunction (BBD) in these patients persisted until adolescence. The secondary aim was to evaluate two BBD subgroups, and relations to recurrent urinary tract infections (UTI). STUDY DESIGN: Of the 161 eligible children at SRT study-end, 73 children participated. Their bladder function was evaluated longitudinally using a validated BBD questionnaire with symptom score (cut-off ≥7) and uroflowmetry, at five (T2) and ten years (T3) after study-end. T1 was the SRT study-end. Besides BBD, the sub-diagnoses overactive bladder (OAB) and dysfunctional voiding symptoms (DVS) were calculated from symptom scores. RESULTS: BBD was diagnosed in 37% of children at mean age 3.7 years, which decreased with age to 23% of adolescents (mean age 15.7). DVS and OAB subgroups were equally common at T1, but only DVS was identified at the last follow-up (T3) (p = 0.0008). Recurrent UTIs were seen in 17% at T3 and were more common in patients with BBD (p = 0.038). The gender distribution of BBD also changed, from being equally common at the end of the SRT to affecting mainly adolescent girls at the last follow-up (p = 0.022). Information was available regarding VUR status after repeat VCUGs during follow-up in 22 patients, 12 of them after endoscopic treatment. An improvement in VUR grade was found in the 22, but during follow-up numbers with BBD or UTI did not differ between treated and non-treated groups. DISCUSSION: The prevalence of BBD decreased from 37% at 3-4 years of age to 23% in adolescence, when it was almost exclusively seen in girls. BBD and the subgroup DVS were associated with UTI. Even if epidemiological studies have established a predisposition to bladder symptoms and UTI in girls, little is known about bladder function in adolescents with a history of VUR during the first years of life. One limitation of the study was the number of patients participating. Also, the number of patients with kidney damage was more common in the cohort. CONCLUSION: In this longitudinal follow-up of BBD in children with VUR, the number of children with BBD decreased with age. In adolescence, both BBD and recurrent UTIs mainly affected girls.

Four-hour voiding observations detect neurogenic lower urinary tract dysfunction in neonates with anorectal malformation.

INTRODUCTION: Neurogenic lower urinary tract dysfunction (LUTD) has been reported in 20-50% of children with anorectal malformations (ARM). As neurogenic LUTD represents an inherent risk of renal deterioration and urinary tract infections, an early diagnosis is important. The gold standard for evaluating neurogenic LUTD involves invasive urodynamic testing but a useful addition should be an easy-to-perform, non-invasive method of screening. OBJECTIVE: In this study, we evaluate non-invasive 4 h voiding observations as a screening method for neurogenic LUTD in ARM children. STUDY DESIGN: Thirty-four patients with ARM, excluding those with perineal fistulas, were evaluated using both 4 h voiding observation and urodynamic testing before and after posterior sagittal anorectoplasty (PSARP) at median ages of 0.3 and 1.1 years. In the urodynamic assessment, the gold standard for neurogenic LUTD, nine children received the diagnosis, eight innate and one post-surgery. RESULTS: Five boys with a high urethral fistula and anomalies of the spinal cord had urodynamically diagnosed neurogenic LUTD, a dysfunction also identified in the 4 h voiding observations. The pattern was characterised both by an increase in the number of voiding and the number of interrupted voiding, urinary leakage and elevated residual urine (Figure). In three girls with a vestibular fistula and tethered cord, an urodynamic investigation identified suspected mild neurogenic LUTD. In the voiding observations, an abnormal voiding pattern was not as obvious in the girls as in the five males. One girl with cloaca showed signs of postsurgical denervation damage, which was easily identified in the 4 h voiding observations (high capacity and elevated residual urine). DISCUSSION: In the present study, gender differences in the severity of dysfunction reflected in the free voiding pattern in infants with ARM and neurogenic LUTD is probably the result of the different underlying causes of neurogenic LUTD in boys and girls. Boys with the condition have a congenital malformation of the caudal part of the spinal cord and girls a tethering of the cord. The most obvious limitation of the study was the low number of patients. Despite this, we consider the results worth reporting, since we found that results in the free voiding observations effectively confirmed what was established in the urodynamic investigations. CONCLUSION: In pre-PSARP patients, 4 h voiding observations can be used to screen for severe neurogenic LUTD requiring attention and treatment. When post-surgical denervation is suspected, the voiding observation is also a good method for indicating the diagnosis.

Development and Validation of Symptom Score for Total Bladder-Bowel Dysfunction: Subscales for Overactive Bladder and Dysfunctional Voiding.

PURPOSE: Bladder-bowel questionnaires are an important tool in diagnosing nonneurogenic bladder-bowel dysfunction in children. We report the validity and reliability of a bladder-bowel questionnaire that has been in clinical use at our institution for decades. MATERIALS AND METHODS: The bladder-bowel questionnaire contains 13 questions, with answers ranging from never (score of 0) to daily (3). The questionnaire was answered by 139 healthy controls and 134 children 3 to 16 years old diagnosed with bladder-bowel dysfunction by a pediatric urologist/urotherapist. A subdiagnosis of overactive bladder or dysfunctional voiding was made in each patient. Bladder-bowel questionnaire scales were developed and evaluated against hypotheses of validity (known groups/convergent/discriminating) and reliability (internal consistency/retest reliability), sensitivity and specificity. Responsiveness was tested in 80 patients who answered the bladder-bowel questionnaire after treatment. RESULTS: A total bladder-bowel dysfunction score scale demonstrated the ability to discriminate between patients with bladder-bowel dysfunction and healthy subjects. It resulted in a ROC curve with AUC of 0.96. The maximized sensitivity was 94% and specificity was 89% for a cutoff score of 7. Two subscales were identified referring to 6 filling phase items and 3 voiding phase items. When tested in patients with overactive bladder and dysfunctional voiding, respectively, multivariable scales performed sufficiently to discriminate between those with and without overactive bladder, and those with and without dysfunctional voiding. All of these scales fulfilled the evaluated requirements for validity and reliability. At 1 year after treatment all scale scores corresponded to patient improvement (p <0.0001), suggesting the bladder-bowel questionnaire can detect clinical change over time. CONCLUSIONS: The bladder-bowel questionnaire is valid and reliable for diagnosing bladder-bowel dysfunction in pediatric patients, and overactive bladder and dysfunctional voiding in those with bladder-bowel dysfunction.

The Swedish Infant High-grade Reflux Trial - Bladder function.

INTRODUCTION: It has been suggested that infants with high-grade vesicoureteral reflux (VUR) have lower urinary tract dysfunction (LUTD) that is characterised by large bladder capacity (BC) and increased post-void residual (PVR). However, most of these infants have normal or small BC in early infancy and develop large capacity during the first year of life. OBJECTIVE: This study aimed to see whether LUTD development during the infant years in children with high-grade VUR could be prevented by early reflux resolution. MATERIALS AND METHODS: For early VUR intervention, endoscopic treatment (ET) was used in a randomised trial comprising 77 infants (55 boys) aged <8 months with VUR grade 4-5 (n = 30/n = 47); 39 were randomised to antibiotic prophylaxis and 38 to ET. Voiding cystourethrogram, free voiding observation (FVO) and renal scintigraphy were performed at baseline and after 1 year. Bladder capacity and PVR were obtained from FVO. LUTD was defined as a BC of ≥150% of expected and a PVR of ≥20 ml. RESULTS: There were no differences in bladder function variables seen between the treatment groups, despite significant differences in VUR resolution. Analysing bladder function related to VUR outcome (VUR grade ≤2 vs grade >2), independent of treatment, showed that VUR grade ≤2 was associated with a smaller BC at 1 year (P = 0.050) (a tendency already seen at baseline) and a lower PVR at baseline (P = 0.010). PVR increased from baseline to 1 year (P = 0.037) in children with grade ≤2 VUR (Summary Table). The group with persistent bilateral grade 5 VUR at 1 year had more abnormal bladder variables compared with other study subjects, with a tendency of larger BC (P = 0.057), higher PVR (P = 0.0073) and more LUTD (P = 0.029) at baseline and a larger BC at 1 year (P = 0.016). In explanatory analyses, using logistic regression, a high PVR at baseline was identified as a predictor of VUR grade >2 (P = 0.046), persistent bilateral grade 5 VUR (P = 0.022), recurrent urinary tract infection (P = 0.034), and only a tendency was seen regarding new renal damage (P = 0.053). CONCLUSION: There was no between-group difference seen in bladder function. In children with VUR resolution at follow-up, independent of treatment, BC decreased, whereas PVR increased. High PVR at baseline was a predictive factor for both non-resolution of high-grade VUR and recurrent urinary tract infection. The results suggest that LUTD cannot be prevented by early VUR resolution, but rather is an important prognostic factor for VUR outcome in both endoscopic and prophylactic treatment.

Radiological bladder characteristics in VCU for young children with high-grade VUR.

OBJECTIVES: It has been suggested that infants with dilating vesicoureteral reflux (VUR) often have lower urinary tract (LUT) dysfunction. Signs such as high voiding pressure levels, low bladder capacity and dyscoordination at voiding have previously been thought to be indicative of dysfunction. However, these findings have also been recognised in healthy infants and are, thus, not specific to dysfunction in this age group. The urodynamic findings of interest for LUT dysfunction in children with high-grade VUR have been shown to be high bladder capacity with incomplete emptying, and often with overactivity during filling. Because the bladders in children with VUR are often only investigated with voiding cystourethrography (VCUG) and not urodynamics, the question has arisen as to whether some of the urodynamic findings indicating dysfunction can be recognised as radiological signs. The aim of the present study was to evaluate whether cystometric signs of LUT dysfunction in infants with high-grade VUR could be recognised in VCUG. MATERIALS AND METHODS: One hundred and fifteen infants (80 boys) with Grades III-V VUR were included and investigated repeatedly with videocystometry (VCM) at a median age 6, 21 and 39 months. The sign looked for in the VCUG was bladder size (large, normal or small), according to the chosen levels in the bony pelvis. To validate the chosen levels for the different bladder sizes, bladder capacity data from a longitudinal study in healthy children were used. In addition, abnormalities in bladder wall/form and filling of the posterior urethra without voiding, as signs of bladder overactivity and detrusor-sphincter dyscoordination, were evaluated. RESULTS: Bladder size was estimated on VCUG as large, normal or small, according to pelvic landmarks. Large bladder size was mainly seen at the second and third evaluations (64% and 46%), whereas small capacity was mainly seen during the first year (33%). Corresponding cystometric capacities (ml) showed a significant difference between the groups of small, normal and large bladder size. The cystometric capacities of large and small bladder size were also compared with bladder capacity in healthy controls, where large had significantly higher bladder capacity versus age (P = 0.0001) and small had significantly lower (P = 0.011) bladder capacity versus age than in the healthy controls. Bladder shape/wall pathology was mainly seen during the first year (42%), combined with small capacity, and correlated to overactive contractions during filling. Moreover, filling of the posterior urethra without voiding, indicating detrusor/sphincter dyscoordination at voiding, was quite common during the first year (33%), and then successively decreased. CONCLUSIONS: The clinical implication from this study of small children with high-grade VUR was that a large bladder on VCUG was synonymous with a high-capacity bladder. According to earlier studies, this is a sign of LUT dysfunction in this age group and should therefore be an indicator for additional studies of bladder function. Overactive contractions could also be recognised in VCUG, but only at the infant evaluation, which should also be regarded as an indicator of LUT dysfunction. All other bladder VCUG signs mainly seen during early infancy were signs of immature bladder function and not a result of VUR dysfunction.

Effects of transcutaneous neuromodulation (TENS) on overactive bladder symptoms in children: a randomized controlled trial.

BACKGROUND: The aim of the present study was to investigate whether addition of transcutaneous electrical nerve stimulation (TENS) treatment improves the results of standard urotherapy in children with overactive bladder (OAB) symptoms. MATERIAL AND METHODS: Sixty-two children with symptoms of OAB and incontinence were included. The children were randomized either to standard urotherapy treatment alone or a combination of standard urotherapy and TENS. The effect variables were taken from a voiding-drinking diary: number of voiding, number of incontinence episodes, and maximum voided volume. RESULTS: Both treatment groups had good treatment results, with no significant difference between the groups. In the standard treatment group 13/28 (46%) were completely dry and 11/28 (40%) had a decrease in incontinence episodes, compared to 16/24 (67%) and 3/24 (13%), respectively, in the standard+TENS group (p=0.303). The number of voiding decreased in two-thirds of the patients in both groups. However, maximal voided volume only increased in the standard treatment group. Subjectively 72% and 80% considered themselves significantly improved or free of symptoms. Previous treatment was registered in 15/55 (27%). All efficacy variables decreased in those with previous treatment, but with no difference between the standard and standard+TENS treatment groups. The only difference noted was when comparing the children without previous treatment in the groups: a significantly higher proportion were completely dry in the TENS group (12/18 [71%] versus 10/22 [48%], p=0.05). CONCLUSION: Our results showed no significant difference overall in treatment response to OAB symptoms between urotherapy only and urotherapy+TENS, whereas a tendency to difference was found in children without previous treatment. Thus with good urotherapy support, TENS only seems to have marginal additional effects on OAB symptoms.

Urinary bladder control during the first 3 years of life in healthy children in Vietnam--a comparison study with Swedish children.

OBJECTIVES: To study outcomes of early potty training in a population of healthy children with a tradition of early potty training and to compare these findings with a group of children to whom potty training was applied later. SUBJECTS AND METHODS: Mothers and their 47 healthy children in Vietnam participated in this longitudinal study. The voiding pattern and emptying ability were followed by the 4-h voiding observation method from 3 months to 3 years of age. A comparison is made with a group of 57 Swedish children investigated in a similar manner. RESULTS: In the group of Vietnamese children, 89% were on daily potty training at the age of 6 months. At the age of 24 months, potty training was complete for 98%. In the Swedish group, just a few (5%) had started daily potty training by the age of 24 months (p < 0.001). The Vietnamese group had fewer voidings and lower voided volumes than the Swedish group. In the Vietnamese children, bladder emptying could be regarded as having been completed, with no residual urine at 9 months, compared with the Swedish group, which first showed complete emptying at the age of 36 months. CONCLUSION: Potty training performed daily affects the emptying ability positively. In the Vietnamese group, no residual urine was found at the age of 9 months. These results differ significantly from those of the group of Swedish children.

Lower urinary tract function in childhood; normal development and common functional disturbances.

This review aims to provide researchers and clinicians involved with the adult lower urinary tract with background knowledge regarding the early development of bladder function and its most common disturbances in childhood. Bladder development begins in weeks 4-6 and the detrusor muscle is formed during weeks 9-12 of gestation. Higher CNS centres are involved in micturition at birth, and the infant usually wakes up, at least briefly, to void. Voiding during the first years of life is often incomplete, owing to detrusor-sphincter dyscoordination, but this disappears when bladder control is attained. Approximately 5-10% of 7-year-old children suffer from daytime incontinence and/or nocturnal enuresis, and a few per cent of them will not outgrow it. Daytime incontinence in childhood is usually attributable to detrusor overactivity, although it is unclear to what extent it is the detrusor or the micturition reflex per se that is overactive. Enuresis - nocturnal incontinence - is caused by either nocturnal polyuria and/or nocturnal detrusor overactivity, in both cases combined with high arousal thresholds. Bladder problems in childhood constitute a risk factor for the development or persistence of bladder problems in adulthood.

Dysphagia in adults operated on for esophageal atresia--use of a symptom score to evaluate correlated factors.

INTRODUCTION: Dysphagia is not unusual following repair of esophageal atresia (EA). The lack of a uniform definition has led to a variance when it comes to reporting the prevalence of dysphagia among patients operated on for EA. Our aim is to estimate the occurrence and degree of dysphagia, using a numerical score with its statistical versatility independent of a specific definition. The results are used to find early risk factors of dysphagia within this patient group. The results are also used to see whether we can find a correlation between dysphagia and symptoms of gastroesophageal reflux (GER) and quality of life (QoL). METHODS: 79 consecutive survivors operated on for EA in Gothenburg between 1968 and 1983 were located. Hospital charts were reviewed and patients received questionnaires on dysphagia, symptoms of GER and QoL. Dysphagia was measured by a numerical score, symptoms of GER were extracted using a predetermined questionnaire (GerdQ), and QoL was determined using the generic questionnaire SF-36. RESULTS: 73 patients (92.4%) returned the questionnaires. In order to make the study group as homogeneous as possible with regard to the malformation we choose to study the 63 patients representing the vast majority: those with Gross type C. 36 patients (57%) had symptoms of dysphagia to varying degrees. We did not find any aggravating factors in their hospital charts nor did we find any correlation to the most recent demographics. There was a significant difference in dysphagia scores when we compared Gross type C to the often more complex type A (p<0.05). We did not find any correlation to heartburn but a strong correlation to regurgitation with an OR of 2.8 (95% CI: 1.2-6.6). The QoL was good for this patient group, and we did not find any correlation between QoL and the dysphagia score. CONCLUSIONS: The dysphagia score provides easy-to-use results when it comes to evaluating the potential influence of dysphagia. Dysphagia is common within this patient group. Patients operated on for EA Gross type A seem to do worse when it comes to dysphagia. Regurgitation is associated with dysphagia, which could imply that GER is an aggravating factor. Further studies to support this finding will show whether there is a correlation between the dysphagia score and the results of 24-h pH-monitoring. If so, this could mean that treating GER might decrease dysphagia, at least in this patient group.

Estimation of renal function in children and adolescents with spinal dysraphism.

PURPOSE: In children with spinal dysraphism such as myelomeningocele the relation between muscle mass and body composition varies considerably. Therefore, it is difficult to evaluate the relevance of renal function assessments done with serum creatinine. Since serum cystatin C has been suggested to be independent of body size and composition, this evaluation was compared to chromium(51) edetic acid clearance. MATERIALS AND METHODS: Simultaneous measurements of cystatin C and chromium(51) edetic acid clearance were performed prospectively in 65 patients 2 to 19 years old with spinal dysraphism. RESULTS: Cystatin C values were within the normal range in all patients, while chromium(51) edetic acid clearance was reduced in 10. A significant relation was seen. CONCLUSIONS: Using chromium(51) edetic acid clearance as a gold standard, children with spinal dysraphism and slightly to moderately reduced renal function may remain undiagnosed if cystatin C is used for evaluation.

Complications of clean intermittent catheterization in young females with myelomeningocele: 10 to 19 years of followup.

PURPOSE: We evaluated the rate of complications associated with catheterization and the risk of urethral lesions in girls with myelomeningocele treated with clean intermittent catheterization for a minimum of 10 years. MATERIALS AND METHODS: We examined the medical records of 31 females with myelomeningocele followed from the start of clean intermittent catheterization until age 11 to 20 years. Catheterization had been performed for a median of 15 years (range 10 to 19). Altogether, catheterization was used for a total of 459 patient-years. Noncoated polyvinyl chloride catheters were used in all cases. Anticholinergic treatment was given during 176 of the patient-years. RESULTS: Complications of catheterization were recorded in 13 patients on 20 occasions. Macroscopic hematuria was seen in 4 individuals. In 2 patients the hematuria was caused by urethral polyps that were cured by resection. Difficulties with catheterization occurred in 12 patients. The problems were solved by temporary use of lubrication or by other minor changes in management. There were no difficulties recorded after puberty. The risk of difficulties at catheterization doubled with the use of a Ch8 to Ch10 catheter compared to a Ch12 or larger catheter, and doubled during assisted clean intermittent catheterization compared to clean intermittent self-catheterization. CONCLUSIONS: There were remarkably few problems associated with clean intermittent catheterization in these females with myelomeningocele, despite long treatment periods and use of noncoated polyvinyl chloride catheters. Clean intermittent self-catheterization and large size catheters were associated with few complications.

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.

Ultrasound assessment of detrusor thickness in children and young adults with myelomeningocele.

PURPOSE: We determine by ultrasonography the range of dT in carefully treated and followed children with myelomeningocele, and evaluate the role of such measurements for the understanding of bladder abnormalities in these patients. MATERIALS AND METHODS: We studied 66 children and young adults with MMC (34 males and 32 females, median age 8.1 years, range 1.1 to 20.1). Detrusor thickness was measured with a previously established ultrasonographic technique and the results were compared to those in normal children. The variation in detrusor thickness with degree of bladder dysfunction as well as with bladder wall trabeculation, kidney function and anticholinergic treatment was studied. RESULTS: The detrusor of the ventral wall was slightly thinner in children with MMC compared to normal. No significant variation in dT was found for different degrees of bladder dysfunction, bladder wall trabeculation, kidney function or anticholinergic treatment. Boys had thicker detrusor of the ventral wall than girls. CONCLUSIONS: Children with MMC, followed closely and treated according to international standards, do not acquire detrusor thickening as measured by ultrasonography. The detrusor thickness did not correlate with the degree of bladder dysfunction or renal function, or with anticholinergic treatment. Bladder wall trabeculation at VCU was not associated with bladder wall thickening on ultrasonography. We postulate that in a closely monitored and actively treated population of patients with MMC muscular hypertrophy and the development of connective tissue in the bladder wall is kept to a minimum.

Voiding pattern and acquisition of bladder control from birth to age 6 years--a longitudinal study.

PURPOSE: We describe the voiding pattern and acquisition of bladder control in healthy children up to age 6 years. MATERIALS AND METHODS: We determined age for daytime and nighttime dryness, voiding patterns, voiding volumes and post-void residual volume per 4 hours individually and noninvasively every 3 months up to age 3 years and every 6 months up to age 6 years in 36 female and 23 male patients using 4-hour voiding observation and uroflowmetry/ultrasound. RESULTS: Median age for attaining daytime and nighttime dryness was 3.5 and 4 years, respectively. No significant difference was found between girls and boys. All but 1 child attained daytime dryness an average of 10 months before attaining nighttime dryness. Bladder sensation was reported in 31%, 79% and 100% of patients at ages 2, 3 and 4 years, respectively. Median bladder capacity was 67 ml, 123 ml and 140 ml at years 1, 3 and 6, respectively. Median post-void residual volume was 5.5 ml, 0 ml and 2 ml at ages 1, 3 and 6 years, respectively. CONCLUSIONS: Today bladder control is acquired at a later stage despite earlier awareness of bladder function. The occurrence of bladder sensation from age 1.5 years motivates an earlier start with toilet training. Infants with small post-void residual volume at age 6 months or large bladder capacity will probably attain daytime dryness earlier than those with large post-void residual volume at age 6 months or small bladder capacity.

Complications of clean intermittent catheterization in boys and young males with neurogenic bladder dysfunction.

PURPOSE: We evaluate the risk for urethral lesions and epididymitis in boys with neurogenic bladder dysfunction treated by clean intermittent catheterization (CIC) for a minimum of 10 years. MATERIALS AND METHODS: The medical records of 28 males with neurogenic bladder dysfunction followed from the start of CIC until the age of 15 to 20 years were reviewed. RESULTS: CIC had been performed for a median of 16 years (range 10 to 21). Overall CIC was used for 438 years (265 before and 173 after puberty). During 76% of the years a noncoated polyvinyl chloride catheter with lubrication was used and in 24% of years a hydrophilic coated polyvinyl chloride catheter was used. The catheter size was 12C or greater in 43% of the cases. Independence from self-catheterization occurred during 37% of the CIC years. Of the patients 19 experienced at least 1 episode of difficulty inserting the catheter and/or had macroscopic hematuria on a total of 42 occasions. Major urethral lesions were seen on cystoscopy in 7 patients on 9 occasions (5 false passages, 1 superficial recess, 2 meatal stenoses, 1 urethral stricture). Major urethral lesions were not associated with puberty and did not occur during self-catheterization or with use of catheters 12C or greater. Epididymitis was seen in only a 12 year-old boy. CONCLUSIONS: The overall rate of complications was low. The incidence of major urethral lesions did not increase during puberty. Self-catheterization and 12C catheter or greater seemed to be protective against major lesions.

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.

Enuresis, sleep and desmopressin treatment.

AIM: To detect effects of desmopressin on sleep in enuretic children and to look for polysomnographical differences between responders and non-responders to desmopressin treatment. METHODS: Twenty-one children with primary nocturnal enuresis were examined polysomnographically before treatment. All but one of the children then received treatment with desmopressin in standard dosage, and the response was documented. Seven of the children underwent a second polysomnographic registration while on treatment. RESULTS: The time interval (+/- 1 SD) between sleep onset and the enuretic episode was 92 +/- 67 min without medication and 372 +/- 157 min when desmopressin was given (p = 0.003). Standard polysomnographic variables were not affected by the drug. Ten children were desmopressin responders and 10 were non-responders. The total sleep time was 455 +/- 56 min in the former and 408 +/- 31 min in the latter group (p = 0.04). The responders spent 27.4 +/- 5.5% of their total sleep time in rapid eye movement sleep, compared with 18.2 +/- 6.5% in the non-responder group (p = 0.004). CONCLUSION: Desmopressin has no major effects on sleep as such but does delay bladder emptying. Enuretic children responding to desmopressin treatment have more rapid eye movement sleep than therapy-resistant children.

Bladder function in healthy neonates and its development during infancy.

PURPOSE: Bladder function in healthy neonates and its development during infancy are described. MATERIALS AND METHODS: Results of free voiding studies of healthy neonates and infants using 4-hour voiding observation and urodynamics studies were reviewed. RESULTS: According to these studies, voiding in the healthy neonate is characterized by small, frequent voids of varying volume in the individual case and interrupted voiding in 30% of the cases. Interrupted voiding is clearly an immature phenomenon since it is seen in 60% of preterm neonates and disappears completely before the age of toilet training. These voidings are considered to be due to a dyscoordination between the sphincter and detrusor, which has also been observed on urodynamic studies and which probably also explains incomplete emptying seen in this age group. Emptying remains incomplete to the age of toilet training when residual urine is median 0 ml. during 4 hours of observation. Voiding rarely occurs during quiet sleep even in the neonatal period, when signs of arousal are often noted before voiding. However, voiding during sleep in 60% occurs of preterm infants, indicating that it may be due to maturation of the central nervous system. Bladder instability is rarely seen in healthy neonates and infants according to urodynamic studies but hyperactivity is suggested in the neonatal bladder with premature voiding contractions after only a few milliliters of filling and with leakage of urine. This latter phenomenon probably explains the low cystometric bladder capacity in this age group. High voiding pressure levels also accompany this low bladder capacity. CONCLUSIONS: Thus, it can be suggested that the neonatal bladder is regulated by neuronal pathways with connections to the cerebral cortex in the neonatal period, which is contrary to the earlier concept of voiding as an automatic event in response to a constant volume in the bladder. This theory does not mean that voiding is conscious or voluntary in this age group, but only that the voiding reflex disturbs the neonate. New characteristics include the concept of physiological dyscoordination, such as hyperactivity of the detrusor seen as low bladder capacity, and high voiding pressures in the neonatal period.

Recognition of bladder instability on voiding cystourethrography in infants with urinary tract infection.

PURPOSE: We evaluate voiding cystourethrography as a method for identifying bladder instability in infants. MATERIALS AND METHODS: Cystometry was combined with voiding cystourethrography in 79 male and 64 female infants with first time urinary tract infection. Bladder wall irregularity, elongation of bladder shape, and filling of the posterior urethra were transient radiological signs occurring during bladder filling and were considered to reflect bladder instability. A pediatric radiologist looked for these signs on all 480 films exposed during bladder filling. The results were correlated to simultaneous detrusor pressure recordings. The analysis was repeated independently by a urologist to evaluate the reliability of the radiological signs used. RESULTS: The sensitivity and specificity were both 90% in the evaluation of radiological signs of bladder instability. Filling of the posterior urethra was the least frequently reported radiological sign, which was seen at 53% of unstable contractions. However, when this sign was reported, instability was usually correctly detected (85%). Evaluation accuracy had improved with increasing numbers of noted signs per film. This accuracy had included 29%, 67% and 91% of unstable contractions that were correctly diagnosed when 1, 2 or 3 signs were noted, respectively. The number of noted signs was positively related to the strength of the unstable detrusor contraction. Urologist evaluations had similar results to the radiologist, although the sensitivity was somewhat lower (79% and 90%, respectively). CONCLUSIONS: Unstable detrusor contractions could be identified in infants by evaluation of radiological signs on voiding cystourethrography. Findings of bladder wall irregularity, elongation of bladder shape and filling of the posterior urethra indicated unstable detrusor contraction. The more such findings are observed, the stronger the indication.

Treatment of primary monosymptomatic nocturnal enuresis with desmopressin: predictive factors.

OBJECTIVE: To investigate predictive factors for the outcome of treatment of primary monosymptomatic nocturnal enuresis (PMNE) with desmopressin. PATIENTS AND METHODS: Data from a large open multicentre study were analysed. The study comprised 399 children with PMNE who were recruited for long-term desmopressin treatment. Before treatment a history was taken and the children observed for 4 weeks. After a 6-week dose-titration period with desmopressin, the children were classified into four groups depending on the response rate. RESULTS: The children who improved during desmopressin treatment were older, had fewer wet nights during the observation period and had only one wet episode during the night, mostly after midnight. Many of them did not require the maximum dose of desmopressin to become dry. No hereditary factor for the response to desmopressin was found. CONCLUSION: Those most likely to be permanently dry with desmopressin treatment are older children who respond to 20 microg desmopressin and who do not wet frequently.