J. Vande Walle

TRANSCUTANEOUS NEUROMODULATION FOR THE URGE SYNDROME IN CHILDREN: A PILOT STUDY

PURPOSE Neuromodulation has been used to treat voiding dysfunction in adults. Due to its invasiveness it has rarely been used in children until now with the availability of transcutaneous neurostimulation. We evaluated clinical effects of transcutaneous neuromodulation on detrusor overactivity in children with the urge syndrome. MATERIALS AND METHODS Between May 1, 1998 and February 28, 1999, 15 girls (mean age 10.2 years) and 26 boys (mean age 10.7 years) with proved detrusor hyperactivity on videourodynamic study underwent neuromodulation. All children had been given anticholinergic therapy previously. Neurostimulation only was used in children in whom anticholinergics had no effect and those who had significant side effects. Anticholinergics were continued in children in whom they had a partial effect. Stimulation of 2 Hz. was applied for 2 hours every day. Surface electrodes were placed at the level of sacral root S3. After 1 month of trial stimulation those children who responded continued the treatment for 6 months, and were evaluated every 2 months. RESULTS Of the 41 children 15 boys and 13 girls responded after 1 month of trial therapy with an increase in bladder capacity, decrease in urgency, decrease in incontinence and/or better sensitivity. Of the 13 children who did not respond 9 lacked motivation and 4 had no clinical effect despite motivation. After 6 months of therapy a significant increase in bladder capacity, decrease in voiding frequency and decrease in incontinence periods were noted. Adverse effects were not observed. One year after therapy relapse was noted in 7 patients, leaving 21 of 41 children definitively cured. CONCLUSIONS Although preliminary, our results indicate that transcutaneous neuromodulation can improve symptoms of detrusor overactivity, as response to stimulation was noted in 76% of our patients and 56% were cured after 1 year. This therapeutic option is attractive for children because of its noninvasiveness and absence of adverse effects.

Pelvic‐floor therapy and toilet training in young children with dysfunctional voiding and obstipation

Objective To analyse experience in treating young children (4–5 years old) with urodynamically confirmed voiding dysfunction, using a noninvasive training programme.

The effect of botulinum-A toxin in incontinent children with therapy resistant overactive detrusor.

PURPOSE We determined the effect of detrusor injection of botulinum-A toxin in a cohort of children with therapy resistant non-neurogenic detrusor overactivity. This prospective study included therapy resistant children with overactive bladder. MATERIAL AND METHODS During the study period of 19 months 10 boys and 11 girls were included. All patients showed decreased bladder capacity for age, urge and urge incontinence. Main treatment duration before inclusion was 45 months. A dose of 100 U botulinum-A toxin (Botox) was injected in the detrusor. RESULTS Side effects were evaluated in all 21 included patients. The side effects reported were 10-day temporary urinary retention in 1 girl and signs of vesicoureteral reflux with flank pain during voiding in 1 boy, which disappeared spontaneously after 2 weeks. No further examinations were done since the boy refused. Two girls experienced 1 episode each of symptomatic lower urinary tract infection. Eight girls and 7 boys with a minimum followup of 6 months represent the study group for long-term evaluation. In this study group after 1 injection 9 patients showed full response (no more urge and dry during the day) with a mean increase in bladder capacity from 167 to 271 ml (p <0.001). Three patients showed a partial response (50% decrease in urge and incontinence) and 3 remained unchanged. Eight of the 9 full responders were still cured after 12 months, while 1 of the initially successfully treated patients had relapse after 8 months. The 3 partial responders and the patient with relapse underwent a second injection with a full response in the former full responder and in 1 partial responder. CONCLUSIONS Botulinum-A toxin injection in children with non-neurogenic overactive detrusor is an excellent treatment adjunct, leading to long-term results in 70% after 1 injection.

Does monosymptomatic enuresis exist? A molecular genetic exploration of 32 families with enuresis/incontinence

Objectives  To confirm linkage to microsatellite markers on chromosome 8q, 12q, 13q and 22q in families with nocturnal enuresis/incontinence segregating with an autosomal dominant pattern, and to determine if there is an association between the clinical subtype and these linked loci.

The Role of Pelvic-Floor Therapy in the Treatment of Lower Urinary Tract Dysfunctions in Children

The pelvic-floor is under voluntary control and plays an important role in the pathophysiology of lower urinary tract (LUT) dysfunctions in children, especially of non-neuropathic bladder sphincter dysfunction. The following therapeutic measures can be applied to try to influence the activity of the pelvic-floor during voiding: proprioceptive exercises of the pelvic-floor (manual testing), visualization of the electromyographic registration of relaxation and contraction of the pelvic-floor by a curve on a display (relaxation biofeedback), observation of the flow curve during voiding (uroflow biofeedback), learning of an adequate toilet posture in order to reach an optimal relaxation of the pelvic-floor, an individually adapted voiding and drinking schedule to teach the child to deal consciously with the bladder and its function and a number of simple rules for application at home to increase the involvement and motivation of the child. In children however with persisting idiopathic detrusor instability additional therapeutic measures may be necessary to improve present urologic symptoms (incontinence problems, frequency, urge) and to increase bladder capacity. Intravesical biofeedback has been used to stretch the bladder and seems to be useful in case of sensory urge. Recently a less invasive technique, called transcutaneous electrical nerve stimulation (TENS), has been applied on level of S3 with promising results in children with urodynamicaly proven detrusor instability, in which previous therapies have failed.

Oral lyophylizate formulation of desmopressin: superior pharmacodynamics compared to tablet due to low food interaction.

PURPOSE Desmopressin is a standard treatment for monosymptomatic nocturnal enuresis. Different formulations are promoted as bioequivalent, although these claims are not supported by comparative pharmacodynamic data in children. Food interaction is known to influence the bioavailability of desmopressin. We compared the pharmacodynamics of the 2 most frequently used desmopressin formulations, tablet and lyophilizate, with a standardized meal, allowing extrapolation to clinical reality, where the interval between evening meal and medication intake is limited for school-age children. We hypothesized there would be a faster pharmacodynamic response, and greater concentrating and antidiuretic activity for the fast dissolving (melt) formulation compared to the tablet with simultaneous food intake. MATERIALS AND METHODS Two tests were performed on separate days in identical standardized conditions, starting with a 15 ml/kg water load. After achieving maximal diluting capacity a standardized meal was administered, followed by desmopressin tablet (t test) or melt (M-test). Diuresis rate and urinary osmolality were measured hourly. Paired data from 4 girls and 15 boys with a mean age of 12.1 years were obtained. RESULTS In the early response phase more than 25% of patients had a higher diuresis rate with tablet vs melt formulation, reaching statistical significance in the plateau phase (urine collected at hours 3 to 5, p <0.02) and in duration of action (urine collected at hours 5 to 8, p <0.005). For desmopressin melt smaller standard deviations in diuresis rate were remarkable. Concentrating capacity demonstrated no significant differences between formulations in the early response phase, in contrast to the plateau phase (p <0.036) and duration of action (p <0.001). CONCLUSIONS With meal combination desmopressin melt formulation has a superior pharmacodynamic profile to tablet, making it more suitable for the younger age group with a limited interval between meal and drug administration.

Sleep fragmentation and increased periodic limb movements are more common in children with nocturnal enuresis.

To determine sleep fragmentation in children with nocturnal enuresis (NE).

Combined Use of Urinary α1-Microglobulin and 99mTc DMSA Scintigraphy in the Diagnosis and Follow-Up of Acute Pyelonephritis and Cystitis in Children

Objectives: In the absence of specific symptomatology in children and neurogenic bladder disease patients, the early diagnosis of acute pyelonephritis is a challenge. The aim of the present study was to determine if dimercaptosuccinic acid (DMSA) lesion-positive (acute pyelonephritis) patients have elevated urinary α1-microglobulin (α1-MG) excretion (no false negatives) and if DMSA lesion-negative (cystitis) patients have normal urinary α1-MG excretion (no false positives). Methods: A selected population of 62 children above 3 months of age with a proven urinary tract infection were administered a DMSA scan. A control scan was performed after the acute phase of the illness, and the diagnosis of pyelonephritis (n = 44) was made retrospectively. The urinary α1-MG was determined by immunonephelometry. Results: The urinary α1-MG-creatinine ratio was highly sensitive (98%) and specific (100%) and correlated with the DMSA scintigraphy images. Only 1 of the 44 patients with pyelonephritis and all of the cystitis patients (n = 18) had a normal urinary α1-MG (<10 mg/g). The drop in absolute DMSA uptake correlated significantly (r = 0.758, p < 0.001) with the urinary α1-MG-creatinine ratio. The urinary α1-MG-creatinine ratio was significantly higher (p < 0.02) in bilateral than in unilateral pyelonephritis. Conclusion: DMSA lesion-positive (acute pyelonephritis) patients have elevated urinary α1-MG excretion and DMSA lesion-negative (cystitis) patients have normal urinary α1-MG excretion.

VOIDING DISORDERS IN SEVERELY MENTALLY AND MOTOR DISABLED CHILDREN

PURPOSE We evaluated the voiding and continence patterns in severely mentally and motor disabled children. MATERIALS AND METHODS The hetero-anamnestic, uroflometer and morning urine concentration profile results of 17 girls and 21 boys with severe mental and motor disability were evaluated in a prospective study. RESULTS Of the children 20 (52.7%) suffered daytime and/or nighttime wetting and 18 (47.4%) were continent. Daytime and nighttime wetting occurred in 85.7% of children with tetraparesis and in 66.6% of those with an IQ between 46 and 55, representing the highest incidence rates. Bladder capacity was too small for age (mean deficit 145 ml.) in 92% of the children. Uroflowmetry demonstrated a dysfunctional pattern in 60.7% of patients. Dysfunctional voiding occurred in 100% of children with coordination disorders and in 87.5% of those with an IQ between 46 and 55, representing the highest incidence rates. The morning urine concentration profiles showed an osmolality of at least 1,021 mOsm./kg. in all cases. CONCLUSIONS Although we found a remarkably high incidence of dysfunctional voiding, no correlation between the uroflow and continence patterns could be found. Restricted fluid intake, due to swallowing problems and insufficient hydration, causes an important bladder capacity deficit in most patients. Becoming continent is determined by motor disability, especially the degree of mobility, rather than by mental development.

Prospective evaluation of clinical voiding reeducation or voiding school for lower urinary tract conditions in children

PURPOSE We conducted a prospective controlled study evaluating the results of a clinical voiding reeducation program (voiding school) for treatment of lower urinary tract conditions in children compared to no treatment. MATERIALS AND METHODS A total of 38 children with nonneurogenic lower urinary tract conditions were included in the study. Controls, consisting of 15 children on the waiting list for the same program, received no treatment. The clinical voiding reeducation program consisted of instruction on voiding and drinking, individualized voiding diaries, pelvic floor biofeedback training, uroflowmetry, alarm therapy, cognitive therapy and psychological support. Data on voiding, drinking, pelvic floor control, voided volume, uroflow, incontinence and stool habits were gathered before the program, during the program and 6 months after the program. In the control group the same data were gathered. RESULTS In the study group a positive effect of voiding school was observed in 92% of children, with 42% becoming completely dry, 24% improving from incontinence during the day and night to incontinence during the day or night only, and 26% remaining incontinent. In all patients the number and amount of incontinence episodes decreased. In the control group no differences were observed between the start of study and 6 months later. The study group did significantly better on voided volume and incontinence compared to controls. CONCLUSIONS In this prospective controlled study a positive effect was noted on voided volume and incontinence with a clinical voiding reeducation program (voiding school).