Mark Horowitz

Biofeedback therapy for children with dysfunctional voiding

OBJECTIVESnBiofeedback therapy has been recognized as a treatment option for children with classic dysfunctional voiding (DV) where there is inadequate pelvic floor relaxation during voiding. However, there are few articles that discuss methodology and limited sites where it is available. In the hope of making biofeedback a more practical and accessible option, we report our indications, easy to duplicate methodology, and results.nnnMETHODSnTwenty-one consecutive children diagnosed with DV refractory to standard therapy were enrolled in our biofeedback program. Therapy consisted of extensive age-appropriate explanations of DV and demonstrations of normal and abnormal voiding patterns. Cyclic uroflow studies with pelvic floor electromyography are performed, which the child monitors on analog chart and audio recorders. The child returns weekly until consistent relaxation of the pelvic floor during voiding is demonstrated. Timing between sessions is then increased to monitor progress and retention of concepts previously taught.nnnRESULTSnAn excellent clinical response was one in which there was consistent relaxation of the pelvic floor throughout voiding, normal flow pattern, and no residual urine volume (urodynamic response), coupled with profound resolution of voiding symptoms. Seventeen of 21 (81%) had an excellent response, 3 (14%) had a fair response, and 1 (5%) was too inconsistent to rate. The average number of sessions to achieve a consistent urodynamic response was 3.7 (range 2 to 14) and full clinical response somewhat longer. Average follow-up since beginning therapy has been 34 months (range 14 to 51).nnnCONCLUSIONSnBiofeedback therapy is an effective method for treating DV with poor pelvic floor relaxation. Although initially labor intensive, it yields sustained positive results in most patients in a short time.

Circumcision : Successful glanular reconstruction and survival following traumatic amputation

PURPOSEnCircumcision remains the most common operation performed on male individuals in the United States. Unfortunately various complications may occur during circumcision ranging from trivial to tragic. We report 7 cases of traumatic amputation of the glans penis and/or urethra during circumcision. In addition, errors in circumcision technique as probable mechanisms of injury, principles of repair and limits of tissue viability are discussed.nnnMATERIALS AND METHODSnThe medical records of 7 patients who underwent traumatic circumcision amputation of the glans penis and/or urethra were reviewed. Glanular amputation occurred in 6, 8-day-old neonates during ritual circumcision and in 1, 5-month-old infant circumcised by a physician.nnnRESULTSnExcised glanular tissue remained viable up to 8 hours after injury. Followup ranged from 8.5 to 108 months. All patients had an acceptable cosmetic result. No long-term complications developed in the 8-day-old group but a distal urethral fistula formed in the 5-month-old patient.nnnCONCLUSIONSnCareful selection of technique and device as well as strict attention to detail at circumcision should eliminate most injuries. On the basis of our results we recommend reanastomosis of the glans and/or urethra following distal amputation even when there is a delay in surgical repair of up to 8 hours.

Comparative Urodynamic Findings After Primary Valve Ablation, Vesicostomy or Proximal Diversion

PURPOSEnThere is little known about the effect of urinary diversion on the bladder of children with posterior urethral valves. There is a fear that diversion may result in contracted noncompliant bladders. We wished to compare urodynamic parameters in patients who underwent primary ablation of posterior urethral valves and in those who underwent diversion in the form of vesicostomy or pyelostomy.nnnMATERIALS AND METHODSnUrodynamics were done in 32 boys with a history of posterior urethral valves divided into 3 groups based on initial treatment: 1) transurethral valve ablation; 2) cutaneous vesicostomy, subsequent closure and valve ablation, and 3) proximal cutaneous pyelostomy, subsequent reconstitution and valve ablation.nnnRESULTSnPatients who underwent initial diversion with vesicostomy or pyelostomy had bladders with larger functional capacity, better compliance and less instability. Chronic renal failure developed in 25% of the patients who underwent primary valve ablation and 33% of those who underwent diversion. Average period of diversion in vesicostomy and pyelostomy patients was 25 months.nnnCONCLUSIONSnBased on our findings temporary diversion does not seem to damage bladders. On the contrary, placing a damaged bladder at rest may help to improve bladder function. Bladder function following reconstitution correlated poorly with ultimate outcome and progression to renal failure. While we do not recommend temporary diversion as the treatment of choice for patients with posterior urethral valves, we believe that when chosen as treatment, it can be safely performed with little risk of further damage to the bladder.

Management of Posterior Urethral Valves on the Basis of Urodynamic Findings

PURPOSEnAbnormal urodynamic findings are common in boys with a history of posterior urethral valves. However, to our knowledge there are few reports on the results of treating these abnormal findings. We analyzed the treatment of abnormal urodynamic parameters and its outcome in 21 boys who underwent valve ablation.nnnMATERIALS AND METHODSnAfter valve ablation multichannel urodynamic studies were performed in 31 boys, including 21 in whom studies were done before and after therapy was started for abnormal parameters. Detrusor instability and impaired bladder compliance were treated with anticholinergics or augmentation cystoplasty, and impaired detrusor contractility was managed with clean intermittent catheterization.nnnRESULTSnBefore therapy 17 of 21 boys had impaired compliance and detrusor instability, 2 had impaired compliance without instability and 2 had instability alone. After treatment 8 boys had impaired compliance and 4 had detrusor instability. After anticholinergics were initiated new onset myogenic failure in 2 boys necessitated clean intermittent catheterization. Of the 13 patients who presented with urinary incontinence 10 became dry and 3 had improvement with therapy. Vesicoureteral reflux in 10 boys at the time of the initial urodynamic study resolved in 7 with anticholinergic medication and in 1 after clean intermittent catheterization was begun for severely impaired compliance. All 21 boys were treated with anticholinergics and 2 were ultimately treated with augmentation cystoplasty. Clean intermittent catheterization was also instituted in 5 patients, including the 2 who required clean intermittent catheterization after myogenic failure developed. Five boys with high voiding pressures were found to have outlet obstruction due to residual valve tissue in 2, bladder neck obstruction in 2 and urethral stricture in 1 despite normal flow rates in 2.nnnCONCLUSIONSnUrodynamic studies are helpful in guiding therapy in boys after valve ablation. Anticholinergic therapy can improve compliance, decrease detrusor instability, improve continence and eliminate vesicoureteral reflux in the majority of boys, although there is an associated risk of myogenic failure. Flow rates and fluoroscopic voiding studies are often unable to detect outlet obstruction and must be obtained in conjunction with voiding pressure measurements to make this diagnosis.

TRANSURETHRAL RESECTION OF THE PROSTATE VERSUS OPEN PROSTATECTOMY: LONG-TERM MORTALITY COMPARISON

To determine whether transurethral prostatectomy results in higher long-term mortality rates than open prostatectomy, we reviewed retrospectively 1,125 patients treated by transurethral and 190 treated by nonperineal open prostatectomy for benign disease at 1 institution from 1978 through 1987. Patients in whom prostatic cancer was found were excluded. We identified age, preoperative medical illnesses and urinary retention, American Society of Anesthesiologists category, type of anesthesia, length of followup, health status and cause of death. For statistical analysis the study cohort consisted of 527 patients in whom the charts were complete and followup was adequate (421 in the transurethral prostatectomy and 106 in the open prostatectomy groups). Mean age for the 2 groups was 66.3 and 67.5 years, respectively. With an average followup of 70.7 months 77% of the transurethral prostatectomy group were alive, compared to 78% of the open prostatectomy group at an average followup of 71.4 months. We found no supportive evidence that transurethral prostatectomy results in higher long-term mortality rates than does an open operation (log-rank test p = 0.74). Also, there was no significant survival difference in patients who required a preoperative Foley catheter. We also examined a subset of patients with adequate followup who had no significant medical history (for example hypertension, diabetes, heart disease and so forth) and compared them to patients with medical illnesses at prostatectomy. There was a significant survival difference between those with and without preoperative medical conditions (Wilcoxon test p = 0.047) in the transurethral prostatectomy group but not in the open group (p = 0.58). However, there was no significant survival difference between procedures among the healthiest subset of patients (p = 0.16).

Vesicoureteral reflux in infants with prenatal hydronephrosis confirmed at birth: racial differences.

PURPOSEnWe compared the incidence of vesicoureteral reflux in black and nonblack patients in whom prenatal hydronephrosis was confirmed postnatally.nnnMATERIALS AND METHODSnWe reviewed the records of 58 black and 51 nonblack patients with confirmed hydronephrosis who underwent voiding cystourethrography.nnnRESULTSnReflux was present in 9 cases (8.3%). The prevalence of reflux in black and nonblack patients was 0 and 17.6%, respectively.nnnCONCLUSIONSnThe absence of vesicoureteral reflux in black infants with prenatal hydronephrosis and the 17.6% incidence in nonblack infants suggest that voiding cystourethrography should not be routinely performed in the black population, although it should continue to be done on a routine basis in the nonblack population.

Periurethral collagen injection for the treatment of urinary incontinence in children.

PURPOSEnWe assessed the efficacy and safety of periurethral collagen injection for urinary incontinence in children with neurogenic bladder dysfunction.nnnMATERIALS AND METHODSnWe treated 11 children (mean age 10.6 years) who had incontinence and neurogenic bladder dysfunction with periurethral injections of glutaraldehyde cross-linked collagen. All patients were on anticholinergics and all but 1 were on clean intermittent catheterization preoperatively. Four patients had previously undergone augmentation cystoplasty. All patients were assessed before and after injection with a subjective continence scale and multichannel urodynamics. Followup ranged from 4 to 20 months from the last injection.nnnRESULTSnMean group Valsalva leak point pressure was 34.5 cm. water. Four of the 11 patients had an identifiable detrusor leak point pressure. Overall success rate was 55% with 4 patients dry and 2 improved. Success correlated with a minimum increase in Valsalva leak point pressure of 20 to 25 cm. water to greater than 60 cm. water. Three patients had no demonstrable Valsalva leak point pressure after injection. All 5 patients in whom treatment failed had no change in Valsalva leak point pressure, including 2 with small capacity, poorly compliant bladders preoperatively. Because they had a component of sphincteric insufficiency, they underwent injection in the hope of increasing capacity with increased continence. In 3 patients Valsalva leak point pressure was greater than 50 cm. water. Detrusor leak point pressure developed in 3 patients postoperatively, including 1 with significantly increased Valsalva leak point pressure. One patient with significantly increased Valsalva leak point pressure had urethral hypermobility postoperatively. Of the 3 patients who subsequently underwent augmentation cystoplasty 1 is now dry, 1 is wet and 1 died of complications unrelated to urological disease. Patients underwent 1 to 4 procedures (mean 2.5).nnnCONCLUSIONSnPeriurethral collagen injection may be effective for urinary incontinence in patients who have adequate capacity with good compliance and low Valsalva leak point pressure. When there is no response to repeat injections or a transient response, one should consider the possibility of bladder decompensation.

The management of unilateral poorly functioning kidneys in patients with posterior urethral valves

PURPOSEnThere is no uniform agreement on how to manage the unilateral nonfunctioning or poorly functioning kidney associated with posterior urethral valves. We studied the results of treatment of our patients to make recommendations regarding management of these kidneys.nnnMATERIALS AND METHODSnWe reviewed the records of 13 boys with a history of posterior urethral valves and a unilateral nonfunctioning or poorly functioning kidney, defined as less than 10% of total renal function on 99mtechnetium dimercapto-succinic acid renal scans. Variables investigated included pyelonephritis, hypertension, vesicoureteral reflux, nephroureterectomy, ureteral reimplantation and spontaneous cessation of reflux. We also evaluated how the management of abnormal urodynamic parameters influenced the results of reimplantation or medically induced cessation of reflux.nnnRESULTSnThree of the 6 boys with grade 5 reflux ipsilateral to the poorly functioning kidney required nephroureterectomy at a mean age of 21 months because of recurrent urinary tract infections. Another 4 boys underwent successful ureteral reimplantation, including 2 who had bilateral grade 5 reflux, and 2 who had ipsilateral grade 4 reflux, and grade 3 (1) and grade 2 (1) contralateral reflux. Of 4 boys ipsilateral grade 3 reflux in 3 and bilateral grade 5 reflux in 1 disappeared without surgery after treatment of urodynamic abnormalities. Two patients with poorly functioning kidneys and no reflux did not undergo surgery. Overall 10 of the 13 poorly functioning renal units were not removed, and these patients were free of pyelonephritis and hypertension. Ureteral reimplantation (4 ipsilateral and 3 contralateral) was performed only after urodynamic abnormalities were addressed. All reimplantations were successful.nnnCONCLUSIONSnBased on our results we believed that unilateral poorly functioning kidneys in patients with posterior urethral valves can be safely preserved in select patients without hypertension and pyelonephritis. Reimplantation to correct reflux may be preferable to nephroureterectomy in specific situations, such as when contralateral function is suboptimal and the contralateral ureter needs reimplantation. When indicated, reimplantation can be performed successfully if abnormal urodynamic parameters are addressed preoperatively. In fact, treating abnormal urodynamic findings may lead to spontaneous reflux resolution.

DESMOPRESSIN FOR NOCTURNAL INCONTINENCE IN THE SPINA BIFIDA POPULATION

PURPOSEnWe report our experience with the use of desmopressin in the spina bifida population that is dry during the day but wet at night.nnnMATERIALS AND METHODSnFrom 1994 to 1996, 18 patients with myelodysplasia were treated with desmopressin for persistent nocturnal enuresis. Initial dose was 40 mcg. before bedtime, decreased by intervals of 10 mcg. every 3 weeks. Patients were kept on the minimum dose required to keep them dry. We reviewed morning catheterized volumes, side effects and dosages needed to stay dry, and compared augmented patients with nonaugmented patients.nnnRESULTSnOf 18 patients 14 (78%) reported marked improvement in nocturnal enuresis. Of 6 augmented patients 5 (83%) are dry compared to 9 of 12 nonaugmented patients (75%). There were no adverse side effects from the use of desmopressin. Average dose to stay dry was 20 mcg. for augmented and 30 mcg. for nonaugmented patients. Of the 4 patients who had persistent nocturnal incontinence despite desmopressin 3 (75%) became dry with a single catheterization in the middle of the night.nnnCONCLUSIONSnDesmopressin is successful in treating nocturnal enuresis in the spina bifida patient with diurnal continence.

Ambiguous genitalia: Diagnosis, evaluation, and treatment

The pediatric radiologist plays a significant role in the evaluation and the treatment of infants with ambiguous genitalia. On the first day of life, an investigation should be initiated that includes studies, in particular a sonogram, to demonstrate the presence or absence of a uterus, and a genitogram to define the presence of a vagina. Once gender assignment has been made, information regarding the size of the vagina and its position in regard to the urogenital sinus becomes essential to the pediatric urologist when planning a course for reconstruction. Herein we break down intersex states into four major categories: female pseudohermaphroditism, male pseudohermaphroditism without müllerian structures, and male hermaphroditism with müllerian structures and true hermaphroditism. The role of the radiologist in each of these states is discussed.