Jens Christian Djurhuus

The Standardization of Terminology of Lower Urinary Tract Function in Children and Adolescents: Report from the Standardisation Committee of the International Children’s Continence Society

PURPOSE The impact of the original International Childrens Continence Society terminology document on lower urinary tract function resulted in the global establishment of uniformity and clarity in the characterization of lower urinary tract function and dysfunction in children across multiple health care disciplines. The present document serves as a stand-alone terminology update reflecting refinement and current advancement of knowledge on pediatric lower urinary tract function. MATERIALS AND METHODS A variety of worldwide experts from multiple disciplines in the ICCS leadership who care for children with lower urinary tract dysfunction were assembled as part of the standardization committee. A critical review of the previous ICCS terminology document and the current literature was performed. In addition, contributions and feedback from the multidisciplinary ICCS membership were solicited. RESULTS Following a review of the literature during the last 7 years the ICCS experts assembled a new terminology document reflecting the current understanding of bladder function and lower urinary tract dysfunction in children using resources from the literature review, expert opinion and ICCS member feedback. CONCLUSIONS The present ICCS terminology document provides a current and consensus update to the evolving terminology and understanding of lower urinary tract function in children. For the complete document visit http://jurology.com/.

The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society.

PURPOSE We updated the terminology in the field of pediatric lower urinary tract function. MATERIALS AND METHODS Discussions were held of the board of the International Childrens Continence Society and an extensive reviewing process was done involving all members of the International Childrens Continence Society as well as other experts in the field. RESULTS AND CONCLUSIONS New definitions and a standardized terminology are provided, taking into account changes in the adult sphere and new research results.

Vagotomy and subsequent risk of Parkinson's disease

Parkinsons disease (PD) may be caused by an enteric neurotropic pathogen entering the brain through the vagal nerve, a process that may take over 20 years. We investigated the risk of PD in patients who underwent vagotomy and hypothesized that truncal vagotomy is associated with a protective effect, whereas superselective vagotomy has a minor effect.

Transabdominal Ultrasound of Rectum as a Diagnostic Tool in Childhood Constipation

PURPOSE We tested whether transverse rectal diameter measured by ultrasound could identify rectal impaction, investigated whether transverse diameter is enlarged in constipated children compared to healthy children and evaluated transverse diameter during treatment of constipation. MATERIALS AND METHODS A total of 51 children 4 to 12 years old were included in the study. Of the children 27 (mean age 7.0 +/- 1.8 years) had been diagnosed with chronic constipation by Rome III criteria and 24 (9.1 +/- 2.7 years) were healthy controls. All patients underwent a thorough medical history and physical examination, including digital rectal examination and measurement of rectal diameter by transabdominal ultrasound. Constipated children underwent repeat investigations after 4 weeks of laxative treatment. RESULTS Average rectal diameter of children with negative digital rectal examination was 21 +/- 4.2 mm (mean +/- SD), leading to the approximation that a value greater than 29.4 mm (mean +/- 2 SD) indicates rectal impaction. All children with rectal impaction identified by digital examination had a rectal diameter larger than 29.4 mm. Moreover, constipated children had a significantly larger rectal diameter (42.1 +/- 15.4 mm) than healthy children (21.4 +/- 6.0 mm, p <0.001). After 4 weeks of laxative treatment constipated children had a significant reduction in rectal diameter (mean 26.9 +/- 5.6 mm, p <0.001). CONCLUSIONS Transverse rectal diameter seems to be a valuable tool to identify rectal impaction and may replace digital rectal examination. Constipated children have a significantly larger rectal diameter compared to healthy children, and when constipation is treated the diameter is reduced significantly.

NO RELATIONSHIP BETWEEN SUBJECTIVE ASSESSMENT OF URINARY INCONTINENCE AND PAD TEST WEIGHT GAIN IN A RANDOM POPULATION SAMPLE OF MENOPAUSAL WOMEN

PURPOSE We studied the association between urinary incontinence and pad weight gain during a 24-hour pad test in healthy menopausal women. MATERIALS AND METHODS Menopausal women 45 to 58 years old were randomly sampled from the national register. Information on self-reported urinary incontinence was collected at patient interview using a structured questionnaire. A 24-hour home pad test was performed and episodes of urinary incontinence during the pad test were noted. RESULTS A total of 144 women 45 to 57 years old (mean age 50) were included in the study. At the interview 99 subjects (69%) reported urinary continence and 45 (31%) reported incontinence. Of the continence group 78 women (80%) performed the pad test and the mean weight gain was 3.1 gm. (range 0 to 9). Of the incontinence group 38 women (84%) performed the pad test and the mean weight gain was 3.3 gm. (range 0 to 8, not significant). Of the 38 women in the incontinence group 16 reported 1 or more episodes of urinary incontinence, whereas the remaining 22 reported no incontinence during the pad test. There was no difference in pad weight gain between these 2 groups (mean gain 3.3 gm., range 0 to 8). CONCLUSIONS The subjective assessment of urinary incontinence was frequent but it was not associated with the objective findings of the 24-hour pad test.

Transcutaneous Electrical Nerve Stimulation for Refractory Daytime Urinary Urge Incontinence

PURPOSE We studied the effect of transcutaneous electrical nerve stimulation in children with overactive bladder and treatment refractory daytime urinary incontinence. MATERIALS AND METHODS We recruited 27 children 5 to 14 years old with daytime urge incontinence refractory to timer assisted standard urotherapy and anticholinergics who had normal urinalysis, and unremarkable urinary tract ultrasound and physical examination. Study exclusion criteria were bladder underactivity, lower urinary tract obstruction, ongoing defecation disorders, lower urinary tract surgery and previous transcutaneous electrical nerve stimulation. After a 2-week run-in of standard urotherapy the children underwent natural fill ambulatory urodynamics to confirm detrusor overactivity. Subsequently they were randomly allocated to 4 weeks of 2 hours of daily active or placebo S2-S3 transcutaneous electrical nerve stimulation. The severity of incontinence and urgency, and 48-hour bladder diaries were recorded before randomization and during intervention week 4. Children withdrew from anticholinergics throughout the study period. RESULTS Two children were excluded from randomization due to urodynamic signs of lower urinary tract obstruction. After 4 weeks of intervention 8 children (61%) in the active group showed a significant decrease in incontinence severity but this occurred in only 2 (17%) in the sham treated group (p <0.05). The active group had a significantly greater decrease in daily incontinence episodes compared to the sham treated group (p <0.01). Transcutaneous electrical nerve stimulation did not alter maximal and average voided volumes. CONCLUSIONS Sacral transcutaneous electrical nerve stimulation seems superior to placebo for refractory daytime incontinence in children with overactive bladder. This effect does not seem to be a consequence of improved bladder reservoir function.

Single Dose Imipramine Reduces Nocturnal Urine Output in Patients With Nocturnal Enuresis and Nocturnal Polyuria

PURPOSE We investigated the effect of imipramine on nocturnal urine output in patients with nocturnal enuresis. MATERIALS AND METHODS There were 15 monosymptomatic enuretic patients 15 to 37 years and 8 control subjects 25 to 32 years old. We measured nocturnal urine output, urine osmolality, creatinine clearance, osmolal clearance, free water clearance, excretion of solutes, fractional excretion of sodium, fractional excretion of potassium and plasma vasopressin with and without a single oral dose of imipramine (1 mg./kg. of body weight) taken at 8 p.m. RESULTS Baseline studies showed significantly larger and less concentrated nocturnal urine among enuretics compared with controls. We observed a marked antidiuretic effect of imipramine in 6 enuretics with severe nocturnal polyuria. The imipramine induced decrease in urine output was accompanied by reduced osmolal clearance. Approximately a third of the observed decrease in solute excretion was attributed to lower excretion of sodium and potassium. The remaining two-thirds were most likely caused by an increased tubular reabsorption of urea, which may be secondary to a sympathomimetic effect of imipramine tubules, possibly because of altered adrenal medullary function with an increase in proximal tubular sodium and water reabsorption. The resultant lower tubular flow rate facilitates tubular reabsorption of urea in the distal part of the nephron. CONCLUSIONS Imipramine has a vasopressin independent antidiuretic effect if nocturnal polyuria is present. The antidiuretic effect of imipramine can be attributed primarily to increased alpha-adrenergic stimulation in the proximal tubules with a secondary increased urea and water reabsorption more distally in the nephron.

Excess diuresis and natriuresis during acute sleep deprivation in healthy adults

The transition from wakefulness to sleep is associated with a pronounced decline in diuresis, a necessary physiological process that allows uninterrupted sleep. The aim of this study was to assess the effect of acute sleep deprivation (SD) on urine output and renal water, sodium, and solute handling in healthy young volunteers. Twenty young adults (10 male) were recruited for two 24-h studies under standardized dietary conditions. During one of the two admissions, subjects were deprived of sleep. Urine output, electrolyte excretions, and osmolar excretions were calculated. Activated renin, angiotensin II, aldosterone, arginine vasopressin, and atrial natriuretic peptide were measured in plasma, whereas prostaglandin E(2) and melatonin were measured in urine. SD markedly increased the diuresis and led to excess renal sodium excretion. The effect was more pronounced in men who shared significantly higher diuresis levels during SD compared with women. Renal water handling and arginine vasopressin levels remained unaltered during SD, but the circadian rhythm of the hormones of the renin-angiotensin-aldosterone system was significantly affected. Urinary melatonin and prostaglandin E(2) excretion levels were comparable between SD and baseline night. Hemodynamic changes were characterized by the attenuation of nocturnal blood pressure dipping and an increase in creatinine clearance. Acute deprivation of sleep induces natriuresis and osmotic diuresis, leading to excess nocturnal urine production, especially in men. Hemodynamic changes during SD may, through renal and hormonal processes, be responsible for these observations. Sleep architecture disturbances should be considered in clinical settings with nocturnal polyuria such as enuresis in children and nocturia in adults.

INTRA-INDIVIDUAL VARIABILITY IN NIGHTTIME URINE PRODUCTION AND FUNCTIONAL BLADDER CAPACITY ESTIMATED BY HOME RECORDINGS IN PATIENTS WITH NOCTURNAL ENURESIS

PURPOSE We evaluated the intra-individual variability and reproducibility of nighttime urine production on wet nights and functional bladder capacity estimated by long-term home recordings of monosymptomatic nocturnal enuresis. In particular, the intention was to evaluate the validity of 1 versus 2 weeks of recording when estimating urine volume on wet nights and 1 versus 2 weekends of recording when estimating functional bladder capacity. MATERIALS AND METHODS We analyzed 120, 2-week home recordings of nighttime urine volume from patients with monosymptomatic nocturnal enuresis 6 to 16 years old (mean age 9.1) with at least 3 wet nights per week. Most patients were nonresponders or partial responders to desmopressin. Nighttime urine volume was estimated by weighing diapers before and after sleep, and measuring morning urine volume. Of the home recordings 62 included frequency volume charts for 2 weekends, which were evaluated for functional bladder capacity defined as the largest voided volume observed. RESULTS No significant overall week-to-week differences were observed in average urine volume on wet nights and functional bladder capacity. There was a large intra-individual variability in all measured variables, which was most pronounced for functional bladder capacity and least pronounced for urine volume on wet nights. With regard to repeatability, the limits of agreement of urine volume on wet nights were -32% and 36% (95% confidence interval) as opposed to -54% and 48% for functional bladder capacity. CONCLUSIONS In this study intra-individual week-to-week estimates of average urine volume on wet nights demonstrated acceptable variability and repeatability in contrast to functional bladder capacity. A reliable estimate of urine volume on wet nights could be obtained by 7 nights of home recording, whereas 4 days of daytime recording were necessary when estimating functional bladder capacity. Similar studies of patients who respond to desmopressin are needed.

Pad testing in incontinent women: a review.

Abstract: This article reviews the literature on pad-weighing tests used for objectifying and quantifying incontinence in urinary incontinent women. The patients wear pads weighed before and after the test period. A weight gain is taken as a measure of the amount of urine loss. The tests are in principle of two different types: short-term office tests and long-term home tests, and measure different aspects of urinary control and dysfunction. Both have an inherent large intra- and interindividual variability. Pad weight gains obtained from patients referred for incontinence and those from self-reported continent controls overlap to a certain degree, and it is not possible to identify distinct numerical cut-off values separating continence from incontinence. This suggests that incontinence is a complex condition in which the amount of leakage, other sources of weight gain, and differences in the individual patients’ personal characteristics influence the identification and quantification of the problem. In spite of the shortcomings the pad tests remain a valuable tool for both the clinician and the researcher. The home pad tests are superior to the office tests in terms of authenticity, and should be performed with a concomitant systematic registration of the participant’s voidings, fluid intake and episodes of incontinence.