Kelm Hjälmås

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.

Historical Clues to the Complex of Dysfunctional Voiding, Urinary Tract Infection and Vesicoureteral Reflux

The prevalence of nonneuropathic bladder/sphincter dysfunction was assessed with a questionnaire in 310 of the 386 children enrolled in the European branch of the International Reflux Study in Children. Despite the exclusion criteria (neuropathic bladder, anatomical malformations other than vesicoureteral reflux and overt dysfunctional voiding or urge incontinence), the prevalence of bladder/sphincter dysfunction was as high as 18%. Four patterns of dysfunction emerged: urge syndrome, staccato voiding, fractionated and incomplete voiding, and voiding postponement. The questionnaire proved helpful in detecting low profile cases of bladder/sphincter dysfunction, as well as indicating the need for further urodynamic studies. A strong correlation was established between recurrences of urinary tract infections, as well as disappearance of vesicoureteral reflux (negative correlation) and nonneuropathic bladder/sphincter dysfunction. This finding implies that detection and treatment of bladder/sphincter dysfunction are essential in every child with the complex of recurrent urinary tract infection and vesicoureteral reflux.

Enuresis - Background and Treatment

Nocturnal urinary continence is dependent on 3 factors: 1) nocturnal urine production, 2) nocturnal bladder function and 3) sleep and arousal mechanisms. Any child will suffer from nocturnal enuresis if more urine is produced than can be contained in the bladder or if the detrusor is hyperactive, provided that he or she is not awakened by the imminent bladder contraction. Urine production is regulated by fluid intake and several interrelated renal, hormonal and neural factors, foremost of which are vasopressin, renin, angiotensin and the sympathetic nervous system. Detrusor function is governed by the autonomic nervous system which under ideal conditions is under central nervous control. Arousal from sleep is dependent on the reticular activating system, a diffuse neural network that translates sensory input into arousal stimuli via brain stem noradrenergic neurons. Disturbances in nocturnal urine production, bladder function and arousal mechanisms have all been firmly implicated as pathogenetic factors in nocturnal enuresis. The group of enuretic children are, however, pathogenetically heterogeneous, and two main types can be discerned: 1) Diuresis-dependent enuresis - these children void because of excessive nocturnal urine production and impaired arousal mechanisms. 2) Detrusor-dependent enuresis - these children void because of nocturnal detrusor hyperactivity and impaired arousal mechanisms. The main clinical difference between the two groups is that desmopressin is usually effective in the former but not in the latter. There are two first-line therapies in nocturnal enuresis: the enuresis alarm and desmopressin medication. Promising second-line treatments include anticholinergic drugs, urotherapy and treatment of occult constipation.

Rehabilitation of the Dysfunctional Bladder in Children: Method and 3-Year Followup

A rehabilitation program has been developed for children with functional, nonneurogenic bladder disturbance. The basis for the program is a bladder regimen supplemented by biofeedback training if needed. Results in the first 70 children (64 girls and 6 boys) are presented. After 1 and 3 years 36 and 53 children, respectively, had completely normalized voiding patterns, that is they were continent, had no urgency, voided 3 to 6 times a day and emptied the bladder completely in 1 portion with a normal flow rate. The training program is applicable in children with varying urodynamic diagnoses and it has been used in children as young as 4 years old.

The genetics of primary nocturnal enuresis: inheritance and suggestion of a second major gene on chromosome 12q.

Primary nocturnal enuresis (PNE), or bedwetting at night, affects approximately 10% of 6 year old children. Genetic components contribute to the pathogenesis and recently one locus was assigned to chromosome 13q. We evaluated the genetic factors and the pattern of inheritance for PNE in 392 families. Dominant transmission was observed in 43% and an apparent recessive mode of inheritance was observed in 9% of the families. Among the 392 probands the ratio of males to females was 3:1 indicating sex linked or sex influenced factors. Linkage to candidate regions was tested in 16 larger families segregating for autosomal dominant PNE. A gene for PNE was excluded from chromosome 13q in 11 families, whereas linkage to the interval D13S263-D13S291 was suggested (Zmax = 2.1) in three families. Further linkage analyses excluded about 1/3 of the genome at a 10 cM resolution except the region around D12S80 on chromosome 12q that showed a positive two point lod score in six of the families (Zmax = 4.2). This locus remains suggestive because the material was not sufficiently large to give evidence for heterogeneity. Our pedigree analysis indicates that major genes are involved in a large proportion of PNE families and the linkage results suggest that such a gene is located on chromosome 12q.

Pronounced detrusor hypercontractility in infants with gross bilateral reflux.

In this study the prevalence of bladder dysfunction in 18 children with gross bilateral reflux was investigated via cystometric recordings. In all except 1 infant maximal voiding detrusor pressure was 100 cm. or greater water (range 86 to 244). Pronounced instability during filling (overt instability) with pressure waves above baseline (mean 65 cm. water, range 42 to 194) was found in 9 infants. Another 5 children had evidence to suggest an uninhibited bladder, not manifested as unstable contractions during filling but as covert instability, meaning that the first unstable contraction was transformed into a premature and forceful voiding contraction. The high detrusor pressures found in 18 children with gross bilateral reflux during the voiding phase but also during the filling phase in half of the children suggest that a hypercontractile detrusor may be a contributory factor for the development of reflux even in this age group.

Four-Hour Voiding Observation in Healthy Infants

PURPOSE We present the 4-hour voiding observation as a method for basic assessment of bladder function in infants and nontoilet trained children. MATERIALS AND METHODS Voiding pattern, including number of voidings, voided volume, bladder capacity and residual urine for 4 hours, was determined noninvasively in 43 healthy infants. RESULTS The infants voided an average of 1 time per hour but with great variability. Bladder capacity increased with age according to the formula, 38 + 2.5 x age (months). Mean residual urine plus or minus standard deviation was 4.6 +/- 3.0 ml. In all infants residual volume was less than 5 ml. at least once during observation. CONCLUSIONS The 4-hour voiding observation is an easy noninvasive method of characterizing the voiding pattern, focusing especially on emptying difficulties, in infants and nontoilet trained children.

Bladder Dysfunction in Boys with Posterior Urethral Valves before and after Puberty

PURPOSE We characterized bladder dysfunction in boys with posterior urethral valves during childhood and adolescence. MATERIALS AND METHODS A total of 12 prepubertal boys with posterior urethral valves presenting before age 1 year was followed from ages 4 to 14 years and compared to 6 postpubertal boys with posterior urethral valves. Urodynamic evaluations and renal function studies were performed repeatedly. RESULTS Patients had a changing urodynamic pattern with instability decreasing with time, increasing bladder capacity and commonly an unsustained voiding contraction causing emptying difficulties. Postpubertal boys had high capacity bladders with low contractility. CONCLUSIONS We suggest that previously described urodynamic patterns of the valve bladder (unstable, poorly compliant and over distended bladders) are variations of the same basic pattern that changes with time toward decompensation.

The Changing Urodynamic Pattern in Valve Bladders During Infancy

Bladder dysfunction in boys with posterior urethral valves is well documented in studies of long-term followup. These reports suggest that dysfunctional bladders can be divided into 3 main types, including unstable, low compliant and over distended. To our knowledge urodynamic findings at presentation during infancy have not been described previously. We report on 16 male patients born between 1989 and 1993 who presented with symptoms of posterior urethral valves between birth and age 5 months, and who were followed with repeated urodynamic evaluations for a mean of 19 months. At presentation the bladder was hypercontractile with low capacity. During the first 3 years of life, the urodynamic pattern changed with vanishing hypercontractility and increasing bladder capacity, although instability remained unchanged with emptying difficulties. Thus, the 3 patterns of bladder dysfunction reported in older boys after resection of posterior urethral valves could not be found in infants and small children.