Lower Urinary Tract Abnormalities Research Articles

BLADDER TRANSPLANTATION: THE NEW FRONTIER IN ABDOMINAL ORGAN TRANSPLANTATION.

Lower urinary tract abnormalities are directly implicated in the etiology of renal dysfunction in 6 to 24% of dialytic patients. These patients require bladder capacity and compliance readjustment before being considered viable candidates for renal transplantation. Vesical augmentation surgeries often involve the use of intestinal segments. Although these procedures can effectively restore bladder capacity and compliance, they present various issues related to maintaining mucous absorption and secretion capacity. Acidosis, recurrent urinary tract infections, and stone formation are extremely common, leading to frequent hospitalizations and graft function loss. Urinary tissue is certainly ideal for these reconstructions; however, bladder augmentation using ureter and renal pelvis are feasible only in a minority of cases. Experimental studies have been conducted to establish the groundwork for vascularized bladder transplantation. Last year, for the first time, this procedure was performed on a brain-dead patient. During this intervention, cystectomy was performed with preservation the vascular pedicle, followed by organ reimplantation. The graft remained viable for a period of 12 hours post-transplant. However, this intervention utilized a robotic platform, making it less reproducible in a multi-organ procurement setting as well as for most transplant centers. Moreover, it is debatable whether the benefits of exclusive bladder transplantation outweigh the risks associated with immunosuppression. For patients needing renal transplantation and requiring lower urinary tract reconstruction, however, utilizing the donor's bladder may offer an attractive alternative, avoiding the inherent complications of enterocystoplasty without increasing immunological risk. Combined kidney and bladder transplantation has the potential to emerge as the next frontier in abdominal organ transplants.

Renal transplantation in children with abnormal lower urinary tract: Single center experience

Renal transplantation in children with abnormal lower urinary tract: Single center experience

Electromyography of the External Anal Sphincter during Micturition and Electrophysiological Bulbocavernosus Reflex in Healthy Spayed Female Canines.

This study aimed to find methods and interferences and illustrate the pattern of external anal sphincter (EAS) electromyography (EMG) during micturition and to determine reference intervals of electrophysiological bulbocavernosus reflex (EBCR) by using robust statistical methods in healthy spayed female canines. Ten healthy spayed female canines (no breed restriction) with a body weight of 11.3-18 kg were enrolled. EAS EMG during micturition and the EBCR test were performed under light general anesthesia. Altogether 25 out of 34 EAS EMG showed a similar pattern, including low-amplitude high-frequency bursting pattern before voiding, medium- or high-amplitude low-frequency bursting pattern at the beginning of voiding, oscillate medium- and/or high-amplitude low-frequency bursting with a low-amplitude high-frequency bursting pattern during voiding, and high-amplitude high-frequency bursting pattern at the end of voiding. An average of 100 consecutive stimulations of EBCR for one cycle were performed in each dog and another cycle was repeated to ensure reproducibility. The lower and upper limits of the reference interval of EBCR onset latency values and EBCR mean amplitude values were calculated using both standard and robust methods with untransformed and transformed Box-Cox data. The EBCR onset latency was between 13.85 and 27.44 milliseconds, whereas the EBCR mean baseline to peak amplitude was not transformed with Box-Cox transformation. All EBCR compound muscle action potentials started with a negative sharp wave, which tapers from the baseline in the upward direction, showing an upturned bell-shaped curve. In conclusion, this study was possibly the first to examine the method and provide the electrographic pattern of EAS EMG during micturition and reference intervals of EBCR onset latency in spayed female dogs, which may serve as baseline information to help veterinarians differentiate healthy from diseased dogs. Further studies should compare normal dogs and dogs with lower urinary tract abnormalities at different lesion locations.

INTO THE VOID: A CAREER IN INCONTINENCE… AND BEYOND

Abstract Long-believed inevitable with age, urinary incontinence (UI) --like dementia – has proved neither ineluctable nor untreatable. Moreover, older adults remain continent despite abnormal lower urinary tract (LUT) function! The key is that the LUT is just one risk factor, and incontinence results from contributors at every level: from drugs and diseases beyond the LUT, to problems of brain and physical function, to multiple issues within the LUT itself. Such insights have provided the rationale for a nontraditional diagnostic and therapeutic strategy, one that has not only improved outcomes but also enabled creation of previously-believed heretical approaches that address the LUT last and only if necessary. In addition, this approach enabled development of Medicare’s Minimum Data Set for frail elderly and, more importantly, may facilitate development of scalable ways to raise the floor of care for other geriatric syndromes as well.

Renal Hypoplasia: Case Literature Review

Introduction: Congenital anomalies of kidney and urinary tract (CAKUT) presents a broad range of disorders including abnormal renal parenchymal development, disrupted parenchymal development, abnormalities of lower urinary tract, urinary collecting system. The knowledge of these anomalies will help the clinicians and surgeons during the procedures of kidney. The purpose of this article is to present one of the cases of renal hypoplasia and the review that highlights renal hypoplasia cases. Methodology: A vertical incision has been made in midline from xiphoid process to pubic symphysis encircling the umbilicus, another incision from pubic symphysis laterally up to the anterior superior iliac tubercle along the iliac crest to expose the abdominal cavity. Details of the position suprarenal gland and the upper poles of the kidneys and external appearance of kidneys in situ were noted. The arrangement of the attached structures such as the hilum with structures passing through, ureter, bladder, abdominal aorta and the inferior vena cava were also noted and recorded. Observation and Result: The size of the left kidney was found small in comparison to right kidney. Coronal section of left kidney also showed a smaller number of renal pyramids, major calyces and minor calyces. Conclusion: The knowledge of anatomical variations of urinary system has a significant role for clinicians and surgeons for diagnosing diseases including congenital anomalies, radiological interpretations, procedures, surgical interventions and management of clinical conditions. KEY WORDS: Renal Hypoplasia, Congenital Anomalies Of Kidney And Ureter, Cadavers, Dissection.

Currarino Syndrome: lower urinary tract function, treatment plan and outcomes

Currarino syndrome (CS) is a rare congenital disorder characterized by anorectal malformation, sacral agenesis and presacral mass. We performed video-urodynamics (VUDS) assessment of patients with CS to characterize the lower urinary tract function, individualize management plans and to follow outcomes. We conducted a cross-sectional study on 11 patients diagnosed with CS at the spina bifida multidisciplinary clinic. Lower urinary tract function was assessed by VUDS from three months to 12 months after neurosurgery. All patients had sacral agenesis; nine patients had anorectal malformation (9/11, 81.8%) and five patients had a presacral mass (5/11, 45.5%). The average age at neurosurgery was 7.9 months (range, 2–19). One patient had bilateral vesicoureteral reflux (VUR) with increasing detrusor pressure at the end of filling. In two patients, the detrusor activity showed weakening during urination, while no other lower urinary tract abnormality was identified on urodynamic evaluation. Six patients underwent VUDS before and after surgery; of these, two patients showed improved bladder function after surgery, while the remaining four patients showed no change in urodynamics. The average duration of follow-up was 27.5 months (range, 9–51). Renal function was normal in all patients. We can conclude that patients with CS often exhibit associated neurological abnormalities. VUDS assessment may help detect lower urinary tract dysfunction at an early stage and facilitate timely urological intervention to avoid kidney damage.

A Randomized Controlled Trial of a Modified Cystoscopy Technique using the Peak-End Rule in order to Improve Pain and Anxiety

To determine if a modified cystoscopy technique utilizing the peak-end rule cognitive bias decreases pain and anxiety during flexible cystoscopy in patients who undergo cystoscopy. A total of 85 participants undergoing their first diagnostic cystoscopy were enrolled in a blinded single-center, prospective, randomized controlled trial. Patients with lower urinary tract abnormalities, prior radiation and chronic pelvic pain were excluded. Participants were randomized to a standard cystoscopy (arm A) or a modified cystoscopy (arm B) where a two-minute period at the end of the procedure was completed during which the cystoscope was left in the bladder without being manipulated. Following the cystoscopy, participants completed a standard pain and anxiety questionnaire. Differences in mean pain and anxiety score between arms were evaluated using a Mann-Whitney test with a two-sided alpha of 0.05. Eighty-five patients were randomized and underwent flexible cystoscopy. Three participants were ineligible, one required secondary procedures, and two did not complete the questionnaires. Among the 82 eligible patients, 45 were randomized to standard cystoscopy (arm A) and 37 to the modified cystoscopy (arm B) with mean pain scores of 23.20 and 11.97, respectively (P=.039). Mean anxiety scores were 2.09 and 0.88 for arm A and B, respectively (P=.013). This study demonstrated a clinically meaningful decrease in pain and anxiety for patients undergoing flexible cystoscopy when employing the modified cystoscopy technique versus the standard practice. This free and straightforward method to improve patient comfort and decrease stress during first time flexible cystoscopy should be considered by clinicians.

Fate of Dysfunctional Bladder after Pediatric Renal Transplantation

Introduction: Graft function on long term into patients with LUTD is still a myth, So, we aimed know the natural history of LUTD and graft function into patient with abnormal lower urinary tract. Patient and Method: The study was conducted by retrospective review of 129 files of pediatric live renal transplant patients;Patients in either group had clinical evaluation of lower urinary tract function and assessment of graft functions at least one year after RT. Results: On evaluation the magnitude of change of cystometric variables we found 57% improvement of incidence of urodynamic detrusor overactivity and 48% improvement in patient categorized as poor/ decreased compliance. There was 90% increase in the number of patients with adequate capacity. Patients showed 55.5% decrease in the number of patient with high PVR. Conclusion: Live donor renal transplant into pediatric patients with LUTD due to organic or neurogenic lower urinary tract pathology showed high serum creatinine on long term follow up.

UTI in kidney transplant.

Urinary tract infection (UTI) remains the most common type of infection contracted by kidney transplant patients. UTI reduces both patient and graft survival. Understanding and managing UTI in transplant patients requires an appreciation of their unique anatomy and physiology. Both the transplant and native urinary systems can be affected by upper and/or lower urinary tract infections. Factors that contribute to UTI in kidney transplant patients are numerous and interact with each other. Factors can include excessive immunosuppression by medications and/or chronic disease, foreign material in the urinary system, transplant kidneys affected by ischaemia-reperfusion injury, non-functioning native kidneys, and abnormal lower urinary tracts. Research is ongoing to highlight the roles each of these contributing factors play and how they may be mitigated to reduce the incidence of UTI. Antimicrobials remain the mainstays of treatment and prophylaxis and this has promoted the development of multi-drug resistant organisms. This challenge necessitates awareness of UTI and methods to reduce rates by all healthcare professionals involved in kidney transplantation.

Time to resolution of isolated antenatal hydronephrosis with anteroposterior diameter ≤ 20 mm.

Data regarding spontaneous resolution of mild hydronephrosis consist of different etiologies, and hence, it is heterogeneous. The aim of this study is to evaluate spontaneous resolution rates and the time to complete resolution of antenatally detected isolated hydronephrosis in patients with renal pelvis antero-posterior diameter (RPAPD) ≤ 20mm. Retrospective chart review of patients who were admitted to our pediatric nephrology clinic for the evaluation of antenatal hydronephrosis between 2011 and 2017 was conducted. Patients that had hydronephrosis with RPAPD ≤ 20mm, < SFU (Society for Fetal Urology) grade IV on initial postnatal evaluation, and ≥ 3months of follow-up with at least two renal ultrasounds (US) were included. Complete resolution of hydronephrosis was regarded as SFU grade 0 with a RPAPD of < 7mm. Patients with ureteric and lower urinary tract abnormalities were excluded. There were a total of 276 patients who met the inclusion criteria. Median follow-up was 16months (range 3-96months). Hydronephrosis completely resolved in 198 patients (71.7%). Surgery was not required in any of the patients; however, nine patients (3.3%) showed progression to higher grades of hydronephrosis or increase in AP diameter. Median time to complete resolution of hydronephrosis was 6months (range 2-35months) in our study. Those with AP diameter < 10mm became normal in median of 5months, while it took median 11months for patients with AP diameter 10-20mm to become normalized (p < 0.001).Conclusion: Isolated antenatal hydronephrosis with RPAPD ≤ 20mm would spontaneously resolve in 71.7% of the cases. Resolution may be expected to happen in 3years, while the majority will take place in the first year of life. What is Known: • Antenatal hydronephrosis comprises an important amount of clinical visits. • Spontaneous resolution rates differ for various etiologies. What is New: • Isolated antenatal hydronephrosis with RPAPD ≤ 20mm completely resolves within 3years in approximately 72% of the cases. • Resolution can be observed within the first year of life in most of the cases.

Renal transplantation into optimized abnormal lower urinary tract - Impact on graft outcomes, patient survival, and complications.

Introduction:Literature regarding the outcomes of renal transplant in patients with abnormal lower urinary tracts (LUTs) is conflicting. The study aimed to determine the graft outcomes and complications of renal transplantation in an optimized abnormal LUT as compared to those with a normal LUT.Materials and Methods:In this single-center retrospective-matched cohort study, we identified 31 patients with an optimized abnormal LUT in our transplant database between 2006 and 2016 (Group A) and selected an equal number of matched controls (Group B). The primary outcome was graft survival, and secondary outcomes were overall survival and complications.Results:The median age was 24 years (range: 12–45), and the median duration of follow-up was 36 months in both groups. On Kaplan–Meier analysis, the estimated mean graft survival was 106 months (confidence interval [CI]: 91-120) in Group A versus 128 months (CI:117-139) in Group B (P = 0.47, log-rank analysis). On subgroup analysis of Group A, augmented bladders had the poorest mean survival (81 months, CI: 56–106), P = 0.09). The mean estimated patient survival was comparable between Group A and B (109 months, CI: 96–122 versus 139 months, CI: 134–144), P = 0.13). Infective complications (27 episodes vs. 1) and re-admissions (77 vs. 30) were significantly higher in Group A (P = 0.04 and P < 0.01). Clean intermittent catheterization was a risk factor for infections (63% vs. 37%, P = 0.033, odds ratio: 5).Conclusions:The graft and overall survival was comparable at 3 years in both groups. Infective complications were higher in Group A.

Favorable Outcomes of Renal Transplant in Children With Abnormal Lower Urinary Tract.

Chronic kidney disease caused by lower urinary tract abnormalities is a significant complication in pediatric care. Although there are conflicting reports about clinical outcomes in the past, favorable outcomes have been reported in recent years. Despite this, many centers still refrain from performing renal transplant in these patients. Here, we compared clinical outcomes of renal transplant recipients with and without lower urinary tract abnormalities. Our study included 71 renal transplant recipients who were divided into 3 groups: 17 patients with abnormal lower urinary tracts having vesicoureteral reflux (group 1), 7 patients with abnormal lower urinary tracts having bladder dysfunction (group 2), and 47 patients with anatomically and functionally normal lower urinary tracts (group 3). We retrospectively compared demographic features, clinical course, graft survival, pre- and posttransplant incidence of urinary tract infections, and final graft function among the groups. There were no statistically significant differences among groups regarding median age at time of transplant, graft survival, median creatinine level, and median glomerular filtration rate (P > .05). Significant differences were shown in incidence of urinary tract infections between patients in groups 1 and 2 (abnormal lower urinary tracts) and group 3 (normal lower urinary tracts) before transplant (P < .05). Although frequency of urinary tract infections in groups 1 and 2 were moderately higher than shown in group 3 after transplant, this difference was not statistically significant. Although the children with abnormal lower urinary tracts had slightly higher incidence of urinary tract infections, there were no differences between patients with abnormal and normal lower urinary tracts regarding allograft survival and function. In addition, proper follow-up of patients before and after transplant, based on our experience, should include educating patients and their parents about potential complications after transplant for the best outcome of renal transplant.

The Impact of Insertion of Double J Uretral Stent On Urological Complications in Renal Transplant Recipients: A Single Centre Experience.

Objectives This study aimed to analyze retrospectively the impact of routine Double J stent placement on early urological complications in live related renal transplantation and compared the results with those transplanted without a stent at SIUT. Material and Methods A retrospective study was conducted on 158 patients who underwent live related renal transplantation between December 2007 and May 2008 at SIUT. Based on exclusion criteria 103 patients were selected for the study. These patients were categorized into two groups. Group A comprised of patients who received a Double J stent while group B consisted of patients who were stents free. Early urological complications were recorded. Inclusion criteria were the recipients between 18-50 years, single renal transplants, with normal lower urinary tract and all patients underwent uretrovesical anastomosis by Lich Gregoir technique. The patients with pathological lower urinary tract, having minimum follow-up period of 3 months and those who lost their grafts within this period were excluded. Results: Group A comprised of 54 (52.4%) patients of which 39 were males and 15 females whereas group B had 49 patients (47.6%) of which 41 were males and 8 females. None of the patients in either group developed a urinary leak. In group B, 3 patients developed urinary obstruction while no obstruction was recorded in the Group A (p=0.06). Although 7 patients in group A (12.96%) had a positive urine culture, only 3 patients in Group B developed UTI (p=0.242). Conclusion: This study suggests that routine placement of DJ stent is unnecessary in renal transplant recipients and its use should be limited to patients with an abnormal lower urinary tract.

Panurethral Stricture After Photovaporization of the Prostate for Benign Prostatic Hyperplasia

To report the development of panurethral stricture disease and other lower urinary tract abnormalities as a complication of photovaporization of the prostate (PVP). We evaluated three patients who were referred for the treatment of urethral stricture disease after PVP. Evaluation included antegrade cystoscopy, urethroscopy, retrograde urethrography, and cystourethrography. All three patients had panurethral stricture disease, and a low capacity bladder with bilateral vesicoureteral reflux had developed in one patient as a complication of PVP. Although not previously reported, a potential complication of PVP is devastating panurethral stricture disease.

Urinary tract infection following kidney transplantation: frequency, risk factors and graft function

The aim of this study was to determine the proportion of children who develop urinary tract infection (UTI) after kidney transplantation (KTx) and to identify the factors associated with UTI and its impact on graft function. To this end, we undertook a chart review of children who underwent KTx at Red Cross Children's Hospital between January 2003 and December 2009 and were followed-up for at least 6 months after transplantation. Sixty-two children (53.2% males) were followed-up for a mean (standard deviation) period of 36.9 (19.7) months. Mean age at transplantation was 10.0 (4.6) years. Twenty-five (40.3%) children had 89 UTI episodes during the study period, equivalent to 0.94 UTI episodes per one patient-year of follow-up. Acute pyelonephritis occurred in 17 (27.4%) children; another 17 (27.4%) had multiple post-KTx UTI. Klebsiella (40.0%) and Escherichia (28.0%) were the commonest organisms. Those with post-KTx UTI were, at transplantation, younger (8.3 vs. 11.2 years; p = 0.017), had lower urinary tract abnormality (LUTA) (13 vs. 1; p = 0.000) and had pre-KTx UTI (13 vs. 5; p = 0.001). Multivariate analysis revealed that only age <5 years at transplantation and LUTA remained significant and that UTI KTx was not associated with worsening graft function. UTI is common after post-KTx. Among our patient cohort, younger age and LUTA were risk factors, but UTI did not affect graft function.

Posterior Urethral Valve Treatments and Outcomes in Children Receiving Kidney Transplants

We evaluated the impact of surgical approaches to posterior urethral valves on renal transplant survival and compared transplant survival in children with vs without posterior urethral valves. We reviewed the records of all children who underwent renal transplantation from January 1984 to March 2008 and performed univariate subgroup analysis in those with posterior urethral valves. We evaluated the ureteroneocystotomy method, immunosuppression and valve treatment. In patients with posterior urethral valves we regarded nocturnal and/or daytime incontinence, severe urgency and the need for intermittent catheterization or double voiding for increased post-void residual urine as signs of bladder dysfunction. The initial renal transplant was received by 418 children at a mean age of 5.6 years. The 59 boys with posterior urethral valves received a total of 69 kidneys. By 8-year followup the kidney had failed in 24 of 59 boys with and 143 of 359 without posterior urethral valves (OR 0.9665, 95% CI 0.5462-1.692, p = 0.9105). Immunosuppression was consistent in the 2 groups. Outcomes were similar across all ureteroneocystotomy techniques. Initial management for posterior urethral valves was valve ablation alone in 12 boys, vesicostomy in 7 and supravesical diversion in 11. There was no difference in transplant survival or bladder dysfunction based on valve intervention. In 18 boys (55%) we noted overlapping signs of bladder dysfunction, of whom 11 performed intermittent catheterization or had increased post-void residual urine, 4 had severe urgency, 4 had daytime incontinence and 7 had nocturnal incontinence. Bladder dysfunction did not predict increased graft loss (OR 3.306, 95% CI 0.7615-16.27, p = 0.1134). Of children who undergo renal transplantation boys with posterior urethral valves do not have a higher graft failure rate. Treatment for posterior urethral valves did not significantly impact transplant survival or bladder dysfunction.

Febrile urinary tract infection, vesicoureteral reflux, and renal scarring: current controversies in approach to evaluation

The ideal approach to the radiological evaluation of children with urinary tract infection (UTI) is in a state of confusion. The conventional bottom-up approach, with its focus on the detection of upper and lower urinary tract abnormalities, including vesicoureteral reflux, has been challenged by the top-down approach, which focuses on confirming the diagnosis of acute pyelonephritis before more invasive imaging is considered. Controversies abound regarding which approach may best assess the ultimate risk for reflux-related renal scarring. Evolving practices motivated by the emerging evidence, the desire to minimize unnecessary interventions, as well as improve compliance with recommended testing, have added to the current controversies. Recent guideline updates and ongoing clinical trials hopefully will help in addressing some of these concerns.

Renal Transplant in Children with Lower Urinary Tract Dysfunction: A Developing Country Experience

Purpose Paediatric transplantation is challenging in many ways, especially so when it is performed in patients with history of lower urinary tract dysfunction. We report our experience of Paediatric renal transplants with and without lower urinary tract dysfunction. Material and Methods 300 Paediatric (2-18 years) living related renal transplants (LRRTX) were performed between 1986 and 2008. Among them twenty had (significant) lower urinary tract dysfunction, majority including posterior urethral valves and non neurogenic neuropathic bladders. Of the twenty, 16 had undergone augmentation cystoplasty using various bowel segments and mitrofanoff continent catheterizable channel and were trained for CISC prior to LRRTX. Pre transplant native kidney nephrectomies were performed in four patients for optimization. Results Average age of the patient was 14 years. One year and five year graft survival in both groups were similar, 92% and 80% respectively. Acute rejection episodes were 23%. Chronic rejection (63%) and infections were the main causes of graft losses. Recurrent urinary tract infection was the major complication encountered in patient with augmented bladders performing CISC. One patient needed redo ureteroneocystostomy. All graft ureters were reimplanted in native bladder. Post transplant, native kidney nephrectomy was needed in one patient because of pyonephrosis. Conclusions Renal transplantation provides equally good graft and patient survival even in patients with history of lower urinary tract abnormalities, at least in short term. However, frequent urinary tract infection carries a high risk for the graft.

Ultrasonography and clinical findings in children with epididymitis, with and without associated lower urinary tract abnormalities

Ultrasonography and clinical findings in children with epididymitis, with and without associated lower urinary tract abnormalities

Pediatric Urinary Incontinence—Shouldn't We Speak the Same Language?

THE 2 reports in this issue of The Journal by Neveus (page 441) and Hoebeke (page 699) et al from the International Children’s Continence Society (ICCS) follow on the heels of the standardization of terminology for lower urinary tract function document that the ICCS promulgated 3 years ago. 1 To comprehend and compare what different clinicians and investigators are attempting to communicate it is imperative that everyone speak the same language and address conditions uniformly. The International Continence Society recognized this problem more than 30 years ago and, as a result, came up with a series of definitions that gradually became the vernacular and currently form the framework for the discussion of various pathological conditions involving the urinary tract in adults. 2– 4 Now it is possible for researchers and clinician scientists to make meaningful comparisons of protocols and perform evidence-based analyses to confirm or abrogate conclusions regarding specific diseases affecting lower urinary tract function in adults. 4 A group of forward thinking individuals believed that it was time for pediatric oriented physicians to advance the field of lower urinary tract dysfunction in children along lines similar to what the International Continence Society had proposed for adults. 5 Hence, the idea was born in the ICCS to further this process in children. The ICCS developed a list of vexing topics that needed standardization statements from an authoritative body to minimize confusion, address underlying issues, promote investigational studies and issue efficacious management based on scientific evidence. The result of this effort is the publication of these first 2 of an eventual sequence of 10 reports on lower urinary tract conditions and their ramifications. A group of renowned international experts constitute the authorship of these reports. The importance of these manifestos cannot be overstated. Although not perfect, they represent the latest knowledge about monosymptomatic nocturnal enuresis (MNE) and the evaluation of daytime urinary incontinence (without nighttime wetting). These documents are not meant to function as guidelines but rather as the minimum standard for understanding the causes of these conditions and the rationale for potential treatment options. MNE without daytime symptoms has a multifactorial etiology. Thus, understanding and differentiating its causes help the clinician (the primary care physician as well as the specialist) promote a systematic, safe and efficacious treatment approach to MNE. A similar argument can be raised for the document concerning children with only daytime incontinence. Defining the problem, excluding specific anatomical and neurological causes, assessing severity, promoting a stepwise investigational format using noninvasive tools and uncomplicated radiological assessment followed by more intensive maneuvers are approaches designed to provide physicians and pediatric health care providers with the most up-to-date facts to determine the cause(s) of daytime incontinence. The logical outcome of this systematic analysis will ultimately be efficient and effective treatments for daytime incontinence (the subject of a future standardization report). In these 2 published reports and in the 8 more that are expected to follow the aim of the ICCS is to promulgate a common language between researchers and health care providers. At the least they should serve as the clarion for future communication about assessment and management. These efforts make it easier to promote evidence-based approaches that will enhance the effective management of abnormal lower urinary tract conditions in children.