Alexandra Vermandel

THE ROLE OF BLADDER BIOFEEDBACK IN THE TREATMENT OF CHILDREN WITH REFRACTORY NOCTURNAL ENURESIS ASSOCIATED WITH IDIOPATHIC DETRUSOR INSTABILITY AND SMALL BLADDER CAPACITY

PURPOSE Not all children with primary nocturnal enuresis, an unstable detrusor and small bladder capacity can be treated successfully with anticholinergics and bladder drill. We report our use of bladder biofeedback in patients who did not respond to 3 months of such treatment. MATERIALS AND METHODS A total of 24 patients (median age 10.4 years) were studied. For bladder biofeedback a transurethral catheter was placed and connected with a 3-way connector. The bladder was slowly filled through this catheter and the intravesical pressure could be seen on a vertical tube, which was also connected to the transurethral catheter. The perineal bulbar detrusor inhibiting reflex was used in cases of involuntary bladder contraction. During the day patients retained urine as long as possible and completed a micturition chart. RESULTS Of the 24 patients bed-wetting stopped completely in 17 and decreased in 6, and treatment failed in 1. All patients were followed for at least 6 months after treatment. There were 2 cases of recurrence in the group that was cured. CONCLUSIONS Intravesical biofeedback can successfully treat patients with refractory primary enuresis associated with unstable detrusor and small bladder capacity.

Clinimetric properties of illness perception questionnaire revised (IPQ-R) and brief illness perception questionnaire (Brief IPQ) in patients with musculoskeletal disorders: A systematic review

Several questionnaires are available to evaluate illness perceptions in patients, such as the illness perception questionnaire revised (IPQ-R) and the brief version (Brief IPQ). This study aims to systematically review the literature concerning the clinimetric properties of the IPQ-R and the Brief IPQ in patients with musculoskeletal pain. The electronic databases Web of Sciences and PubMed were searched. Studies were included when the clinimetric properties of the IPQ-R or Brief IPQ were assessed in adults with musculoskeletal pain. Methodological quality was determined using the COSMIN checklist. Eight articles were included and evaluated. The methodological quality was good for 3 COSMIN boxes, fair for 11 and poor for 3 boxes. None of the articles obtained an excellent methodological score. The results of this review suggest that the IPQ-R is a reliable questionnaire, except for illness coherence. Internal consistency is good, except for the causal domain. The IPQ-R has good construct validity, but the factor structure is unstable. Hence, the IPQ-R appears to be a useful instrument for assessing illness perceptions, but care must be taken when generalizing the results of adapted versions of the questionnaires. The Brief IPQ shows moderate overall test-retest reliability. No articles examining the validity of the Brief IPQ were found. Further research should therefore focus on the content and criterion validity of the IPQ-R and the clinimetric properties of the Brief IPQ.

Readiness signs used to define the proper moment to start toilet training: A review of the literature†‡

Confusion exists about when to start toilet training, which causes stress and anxiety. Another consequence can be the actual postponement of the toilet training process, which has created extra social problems. Therefore, in this review we will focus on the proper moment to start toilet training, more specific on readiness signs. This will clarify on which topics further research is necessary. We searched databases for publications on toilet training. Next, we gathered information about the normal development of healthy children and at which age skills needed for each readiness sign are acquired. Twenty‐one readiness signs were found. Our results show that there is no consensus on which or how many readiness signs to use. Depending on the readiness sign, the moment to start toilet training can vary a lot. More studies are needed to define which readiness signs are most important and how to detect them easily. Neurourol. Urodynam. 31:437–440, 2012.

Value of increase in bladder capacity in treatment of refractory monosymptomatic nocturnal enuresis in children

OBJECTIVES To evaluate children with refractory monosymptomatic nocturnal enuresis to determine whether detrusor overactivity (DOA) plays a role in 4 weeks of unsuccessful treatment with retention control training (RCT); whether an increase in bladder capacity can eventually be obtained by RCT plus oxybutynin; and whether the increase in capacity is the primary key to success. METHODS Sixty-eight children with refractory monosymptomatic nocturnal enuresis were included. They all had a maximal cystometric capacity less than the age-expected value. RCT was done by water loading and retention to the point of urgency once daily. During training, changes in bladder capacity were evaluated by voiding charts. If after 4 weeks of RCT, less than a 10% increase in bladder capacity was noted, oral oxybutynin was added. RESULTS The incidence of DOA was 66%. After 4 weeks of RCT, the bladder capacity increased in 20.6%. Combining RCT with oxybutynin led in the end to normalization of the bladder capacity in 79.4%. Older age and high-pressure DOA negatively influenced the ability to increase the bladder capacity. Fifteen children became completely dry, mainly by converting enuresis to nocturia. CONCLUSIONS Unsuccessful RCT is often caused by DOA, especially if a bladder capacity rise of at least 10% cannot be achieved within 4 weeks. If oxybutynin is added to the treatment, normalization of bladder capacity can be obtained in most. This increased bladder capacity cures enuresis only in a minority by sharpening their arousal and provoking nocturia.

The efficacy of a wetting alarm diaper for toilet training of young healthy children in a day‐care center: A randomized control trial

To evaluate, in a randomized controlled way, the use of a daytime wetting alarm in a day‐care center during three consecutive weeks in healthy children.

Functional bladder capacity after bladder biofeedback predicts long-term outcome in children with nocturnal enuresis.

Objective: We previously reported a 70% cure rate for bladder biofeedback in children with primary nocturnal enuresis associated with small bladder capacity and detrusor instability. In this paper we report on bladder capacity and incidence of enuresis after 60 months of follow-up and discuss the role of decreased bladder capacity in nocturnal enuresis. Material and Methods: We prospectively evaluated 21 boys and 3 girls (mean age 10.4 years) treated with bladder biofeedback between October 1993 and July 1995. Baseline bladder capacity and capacity at the end of treatment and at 60 months follow-up were determined from a micturition chart. Results: At the end of primary treatment 17/24 patients had stopped bedwetting. In 4/17 responders and 4/7 non-responders the bladder capacity was <90% of normal for age. At 60 months, 4 patients had been lost to follow-up, 15 were dry at night and 4 continued bedwetting. One patient underwent surgery and was excluded from the study. Only 2/15 dry patients but 3/4 patients with persistent nocturnal enuresis had a bladder capacity of <90% of normal. Conclusions: Bladder biofeedback can be successfully used to treat children with refractory nocturnal enuresis associated with small bladder capacity and unstable detrusor. Normalization of bladder capacity and continuous growth of the bladder in order to keep the capacity normal would seem to be crucial to the long-term resolution of bedwetting in this select patient population.

Knowledge of the pelvic floor in nulliparous women

[Purpose] Proper pelvic floor function is important to avoid serious dysfunctions including incontinence, prolapse, and sexual problems. The current study evaluated the knowledge of young nulliparous women about their pelvic floor and identified what additional information they wanted. [Subjects and Methods] In this cross-sectional survey, a validated, 36 item questionnaire was distributed to 212 nulliparous women. The questionnaire addressed demography, pelvic floor muscles, pelvic floor dysfunction, and possible information sources. Descriptive statistics were generated for all variables. Stability and validity testing were performed using Kappa statistics and intra class correlation coefficients to define agreement for each question. The study was approved by the ethics Committee (B300201318334). [Results] Using a VAS scale (0 to 10), the women rated their knowledge about the pelvic floor as a mean of 2.4 (SD 2.01). A total of 93% of the women were insufficiently informed and requested more information; 25% had concerns about developing urinary incontinence, and 14% about fecal incontinence. Many of the women were unaware what pelvic floor training meant. [Conclusion] There was a significant lack of knowledge about pelvic floor function among nulliparous women. The majority of nulliparous women expressed a need for education, which might offer a way to reduce dysfunction.

Parents’ views on toilet training (TT) A quantitative study to identify the beliefs and attitudes of parents concerning TT

Background: In recent years, the age at which parents start and finish toilet training (TT) their children has increased. To cope with the problems caused by this later completion, it is essential to identify the beliefs and attitudes of the parents. Methods: Two thousand questionnaires were distributed to parents of children aged 30 to 36 months, attending 50 randomly selected schools in Antwerp, Belgium. Results: Too many children are toilet trained after the minimum school age of 30 months. Most parents are not aware of the possible negative consequences this can entail. Mothers with a paid occupation think more often that children should be toilet trained before the age of 30 months, and the higher the mother’s educational level, the more likely she will send her child to school toilet trained. More of single parents think that children who are not yet toilet trained should be allowed to go to school and more often send their not fully toilet-trained children to school. Conclusion: Parents should be better informed about the possible negative consequences of a later completion of TT. Single parents, more than other parents, should be assisted in the TT process and offered more support.

Toilet training in healthy children: Results of a questionnaire study involving parents who make use of day‐care at least once a week

To investigate how toilet training (TT) is dealt with and what the associated feelings are in Flemish families using day‐care at least once a week.

Refractory monosymptomatic nocturnal enuresis: a combined stepwise approach in childhood and follow-up into adolescence, with attention to the clinical value of normalizing bladder capacity

There are two papers in the paediatric urology section this month. The first, from Belgium, assessed the importance of normalising bladder capacity to the age‐expected capacity in children with refractory nocturnal enuresis, and evaluated the long‐term results when the children reached adolescence. The second paper from the USA assessed the role of apoptosis and proliferation in children with undescended testes.