Marianne A.W. Vijverberg

Home uroflowmetry biofeedback in behavioral training for dysfunctional voiding in school-age children: a randomized controlled study.

PURPOSE We studied the added value of home uroflowmetry for biofeedback training compared to added attention and standard therapy in a multicomponent behavioral training program for voiding disorders in school-age children. Little is known about the role of biofeedback by home uroflowmetry for dysfunctional voiding due to NNBSD in children. MATERIALS AND METHODS A randomized controlled study was conducted at an outpatient pediatric incontinence university clinic from January 2000 to June 2003. A total of 192 children 6 to 16 years old who were suffering from recurrent urinary tract infections with or without urge incontinence were screened for NNBSD. Of 143 eligible patients 44 were randomly allocated to receive 8 weeks of standard therapy (outpatient behavioral therapy), 46 to receive 8 weeks of home video instructions together with standard therapy and 53 to receive 8 weeks of home uroflowmetry biofeedback together with standard therapy. After 8 weeks all treatment groups proceeded with standard therapy for 16 weeks, after which prophylaxis with antibiotics was stopped and patients were followed for another 6 months. Main outcome measurement was total relief of complaints, namely urinary tract infections and, if present, incontinence, at 12 months after randomization. RESULTS At baseline there was no reason to predict major incomparabilities between the groups. In an intent to treat analysis there was no difference in total relief between standard treatment (44%) and added video instruction (42%, RR 0.96, 95% CI 0.59 to 1.56). Total relief in the added home uroflowmetry group (55%) was higher than with standard therapy (RR 1.24, 95% CI 0.80 to 1.93), although the difference was not statistically significant. A per protocol analysis suggested that the groups with added home uroflowmetry showed better total relief than the pooled groups with standard therapy and those with added video (RR 1.40, 95% CI 0.98 to 2.00). CONCLUSIONS Home uroflowmetry appears to be a useful adjunctive treatment for the reduction of complaints in children with dysfunctional voiding due to nonneurogenic bladder-sphincter dyssynergia.

Colposuspension in girls: clinical and urodynamic aspects

OBJECTIVES To investigate the effect of colposuspension on bladder function and urinary incontinence in girls with structural stress incontinence. PATIENTS AND METHODS A Burch colposuspension was performed in 26 incontinent girls for congenital bladder neck insufficiency (10), incontinence after urethrotomy (seven), hypospadias (five) and ectopic ureterocele (four). The indication for surgery was failure of conservative therapy (consisting of cognitive and biofeedback bladder training, physical therapy and/or antimuscarinic drugs in 23 children) and a severe anatomical defect of the bladder outlet in three. Colposuspension was combined with reconstruction of the distal urethra in three patients and of the bladder neck in seven. All girls had urodynamic tests before and after colposuspension. RESULTS After surgery 14 of the 26 patients (54%) were completely dry, four (15%) had improved and eight (31%) still had incontinence requiring pads. In 17 patients (65%) additional conservative therapy was given and three (12%) had additional surgery. After a median follow-up of 62 months, 65% were completely dry, 19% had improved and 15% were incontinent. Of 25 patients who had recurrent urinary tract infections before colposuspension, 14 had none afterwards. Bladder overactivity in 10 patients before colposuspension resolved in five and de novo overactivity was detected in four. CONCLUSIONS In a selected group of girls with structural urinary incontinence, Burch colposuspension can be used when medical treatment, cognitive and biofeedback bladder training fail. It is reasonably effective for resolving incontinence and safe for bladder function.

The Relationship Between Children With Voiding Problems and Their Parents

PURPOSE We determined whether parents of children with overactive bladder and dysfunctional voiding had had similar symptoms in childhood. MATERIALS AND METHODS A case-control study was done in parents with and without children with overactive bladder or dysfunctional voiding. All were recruited from an outpatient clinic. Diagnoses in children were made according to the International Childrens Continence Society standardization report. Childhood symptoms in parents were assessed by a 19-item questionnaire and current urogenital symptoms were assessed by the Urogenital Distress Inventory. Comparisons between groups were made with categorical and interval statistics. RESULTS A total of 173 cases and 98 controls were entered in the study. Statistically significantly more mothers of children with overactive bladder or dysfunctional voiding reported having had similar symptoms in childhood than mothers of children without lower urinary tract symptoms. Overactive bladder symptoms of childhood persisted into adulthood. No association between childhood dysfunctional voiding symptoms and adult emptying disorders was noted. Fathers of children with overactive bladder reported to have stopped bed-wetting at a significantly later age than control fathers. CONCLUSIONS Results reveal an association between overactive bladder symptoms in children and their parents. To a lesser extent this finding also holds true for dysfunctional voiding symptoms.

A comparative analysis of pediatric uroflowmetry curves

This study was conducted to try to objectify assessment of pediatric uroflowmetry curves.

Long-term follow-up of incontinence and urge complaints after intensive urotherapy in childhood (75 patients followed up for 16.2-21.8 years)

OBJECTIVE To reassess the incontinence and urge complaints in adults who had undergone inpatient urotherapy during childhood and compare the results with the short-term outcomes. METHODS From 1987 to 1990, 95 children (13 boys and 82 girls; age 6-17 years) underwent hospitalized urotherapy to treat functional lower urinary tract symptoms. This group was traced and a questionnaire was administered by telephone. The long-term data on incontinence and urge complaints were compared with the results at 6 months after training. RESULTS Of the 95 patients, 92 were traced, and a cohort of 75 could be analyzed. At long-term follow-up (mean 17.9 years), of the 75 patients, 63 (84%) had a good, 8 (11%) a moderate, and 4 (5%) a poor outcome. At short-term follow-up, 56 of the current 75 patients had had a good outcome, and at long-term follow-up, 47 of these 56 patients still had a good score. However, during the intervening period, 3 of these 56 patients developed incontinence recurrence and scored a poor result, and 6 others scored a moderate result. Originally, after 6 months of follow-up, 7 patients had had a moderate outcome; 5 of these had improved to good, 1 still scored moderate, and 1 had deteriorated over time to poor. Twelve patients had originally had a poor outcome at short-term follow-up. Of these, 11 had spontaneously improved to good and 1 to moderate. CONCLUSION If the original outcomes of pediatric intensive inpatient urotherapy are good, they tend to remain so over time in most patients.

Urethral length in girls with lower urinary tract symptoms and forme fruste of female epispadias

PURPOSE To investigate systematically the length of the urethra in girls with lower urinary tract symptoms. MATERIALS AND METHODS In a group of 121 consecutive girls presented at a tertiary referral clinic for urinary incontinence or recurrent urinary tract infections, urethral length was measured by perineal ultrasound. The urethra was measured with the patient in supine position without anesthesia. Mean age of the patients was 7.8 (0-15) years. RESULTS Average urethral length was 26 mm. Minimum length was 12 mm, measured in a 5-year-old girl with dribbling incontinence. Maximum measured length was 40 mm in a 15-year-old girl. In four girls (3.3%), aged 1-10 years (mean 6.3), a short urethra was detected, with measured lengths of 12 and 14 mm. All four had normal genitalia, and were referred with therapy-resistant urinary incontinence or urinary tract infections. A gradual increase in average urethral length was measured from 23 mm at birth to 32 mm at 15 years. CONCLUSION Urethral length can be measured accurately by ultrasound. Although a short urethral length is rarely detected by ultrasound in girls with incontinence, it may be associated with therapy-resistant incontinence. In such cases, different treatment options are available.

THE TREATMENT OF POST-URETHROTOMY INCONTINENCE IN PEDIATRIC AND ADOLESCENT FEMALES

PURPOSE Until 1986 many urologists performed currently outdated, redundant internal urethrotomy as standard therapy for recurrent urinary tract infection in girls. We describe the results of therapy in patients who became incontinent due to previous internal urethrotomy. MATERIALS AND METHODS Between 1986 and 1995, 21 female patients with post-Otis urethrotomy incontinence have presented at our department with combined dysfunctional voiding, recurrent urinary tract infection and various types of urinary incontinence partially based on bladder instability and often provoked by abdominal straining. All cases were diagnosed by repeat video urodynamics and ultrasound of the open bladder neck. Endoscopy provided proof of scarring in the bladder neck and urethra. All patients except 1 underwent conservative treatment for at least 2 years, consisting of pharmacological therapy, physical therapy and biofeedback training. Surgical therapy to cure incontinence was performed in 14 cases, including a conventional Burch-type colposuspension in 5, modified needle colposuspension in 4 and complete endoscopic excision of the urethral scars followed by open reconstruction of the bladder neck and urethra in an abdominoperineal procedure in 5. RESULTS Conservative treatment has been completely successful in 7 patients. Primary open or needle colposuspension was unsuccessful in 6 of 9 cases, including several requiring further surgery to achieve dryness. The results of excising urethral scars with bladder neck and urethral reconstruction were good in 4 of 5 patients at a followup of at least 4 years. CONCLUSIONS When previous internal urethrotomy appears to be an important factor in the evaluation of incontinence, conservative therapy is the treatment of choice. Conservative therapy should consist of biofeedback reeducation of the voiding pattern and physical therapy. When surgery is needed, excision of the urethral scars with reconstruction of the bladder neck and urethra plus colposuspension is superior to colposuspension only.

Cognitive Behavioral Therapy on the Basis of Urotherapy

Urotherapy is described as a therapy that is intended for children with lower urinary tract syndrome (LUTS) in order to improve the dysfunction of the bladder. It is a combination of cognitive, behavioral, and physical training. The purpose of the urotherapy is to normalize voiding pattern and prevent functional damage of the kidneys. Therefore, as a basic guidance it always started with explanation of the bladder function and dysfunction. Understanding of the problem helps for further motivation for treatment. Account shall be taken of the total process of clean fill to be emptying the bladder. The program is divided into standard therapy and specific interventions, such as pelvic floor training, behavior training, and biofeedback training. Explanation and instruction, in combination with drug treatment of constipation and urinary tract infection, physical therapy, and feedback can be part of the treatment.

Disorders of Elimination: Voiding Dysfunction

Between 7% and 10% of school age children are seen by a specialist for recurrent urinary tract infections and/or urinary incontinence based on non-neurogenic lower urinary tract dysfunction.

Prevalence of incontinence, Soiling and Urinary Tract infections in healthy dutch schoolchildren

Abstract Purpose To evaluate the prevalence of lower urinary tract complaints and soiling in a cohort of healthy Dutch children, between 5 and 9 years of age. Material and Methods A group of 203 boys and 177 girls was investigated by questionnaire. The questionnaire was based on the validated list of the International Reflux Study Group, expanded with questions on defaecation and soiling. The questionnaire was intended to be filled in by the parents. Results The total group of 380 children represents a response rate of 60%. Of the boys, 14.3% complain of day-time incontinence, 13.8% have less than three wet episodes a week, and 6.9% have more than three weekly wet episodes; 19.7% of boys has soiling, 3.4% have been treated with laxatives and 6.9% have been treated at least once with antibiotics for urinary tract infection. Of the girls, 12.4% experience day-time incontinence, 11.8 have less than three wet episodes a week, 6.2% have more than three wet episodes weekly; 19.7% show soiling, 2.3% have been on laxatives and 16.9% have been treated for UTIs. Conclusions With growing proof of a direct connection between LUTS at an older age and LUTS at pediatric age, these RESULTS are of utmost importance. In the near future, they will be needed to convince health care authorities of the necessity to invest money in the treatment of LUTS in children to prevent morbidity at an older age. Pediatric urologists are now faced with the important task of proving that treatment of pediatric LUTS actually prevents LUTS at an older age.