Non-neurogenic Lower Urinary Tract Dysfunction Research Articles

Chinese expert consensus on clinical diagnosis and treatment of non-neurogenic lower urinary tract dysfunction in children

Non-neurogenic lower urinary tract dysfunction (NNLUTD) is a common clinical problem in children, which is an important cause of lower urinary tract symptoms, urinary tract infection and vesicoureteral reflux in children, often accompanied by behavioral and psychological problems. At present, there is no consistent evaluation method and treatment for NNLUTD in children. Experts of Pediatric Urodynamics and Pelvic Floor Group of Pediatric Surgery Branch of Chinese Medical Association formulated this consensus according to the NNLUTD related diagnosis and treatment guidelines designated by International Children's Continence Society (ICCS) and International Continence Society (ICS), and combined with the latest relevant literatures at home and abroad, to provide reference for the clinical standard diagnosis and treatment of NNLUTD in children.

Comparison of maximum voided volume and maximum bladder capacity in voiding diary, uroflowmetry and cystometrography in children with non-neurogenic lower urinary tract dysfunction

BackgroundMaximum voided volumes (MVV) and maximum bladder capacities (MBC) are important parameters in the evaluation of lower urinary tract functions in children. However, consistency of MVV and MBC measurements between voiding diary (VD), uroflowmetry (UF) and cystometrography (CMG) in children with non-neurogenic lower urinary tract dysfunction (LUTD) has not been addressed specifically. ObjectiveWe aimed to compare the MVV in VD and UF and MBC in CMG in children with non-neurogenic LUT dysfunction and investigate for possible factors for discrepancies. Materials and MethodsChildren with non-neurogenic LUTD were retrospectively evaluated with a focus on VD, UF, and CMG. VD applied for 2 days and MVV recorded except for first urine in morning. UF repeated in children with < 50% of expected bladder capacity (EBC) for age. Highest value and post voiding residual urine (PVR) was recorded. CMG was performed if these conditions were present: High PVR or LUT dysfunction resistant to standard urotherapy (conservative management with biofeedback) and medical therapy (oral anticholinergics) or LUT dysfunction accompanied by VUR or recurrent UTI. MBC in CMG was recorded according to International Children Continence Society (ICCS) standards. MVV and MBC in VD, UF, CMG were compared and possible factors for discrepancy were investigated. Results54 children (median age: 10 (4-17) years) were included in the study. 39 (72.2%) were girls, 15 (27.8%) were boys. Median MVV was 232.50 (20-600) ml in VD, 257.50 (69-683) ml in UF and MBC was 184 (31-666) ml in CMG (p= 0.012) (Summary Table). In the subgroup analysis, it was shown that the bladder capacities obtained from all three tests were not compatible with each other in children younger than 10 years of age, in girls, in those with recurrent urinary tract infection, detrusor overactivity, high PVR and normal flow pattern (p=0.003, p=0.016, p=0.029, p<0.001, p=0.045, p=0.03, respectively). DiscussionThere is a discrepancy between bladder capacities obtained from VD, UF and CMG In children with non-neurogenic LUT dysfunction. In particular, the lower capacity obtained from invasive urodynamic tests may be related to the poor compliance of children during the procedure. Therefore, when invasive urodynamics is required in these cases, we recommend that maximum cystometric capacity to be evaluated by comparing with voided volumes at UF, VD and other clinical signs and symptoms, and urodynamic parameters in more detail. ConclusionMVV in VD and UF are comparable, but MBC in CMG is lower in children with non-neurogenic LUTD selected for invasive urodynamic studies. More attention should be paid to bladder capacity obtained from urodynamic studies in children exhibiting the characteristics identified in the subgroup analysis. We believe that evaluating bladder capacity values, especially obtained from invasive studies, in conjunction with clinical findings can prevent misdiagnosis, over investigation and overtreatment in children with non-neurogenic LUTD.

Urinary biomarkers in children with neurogenic and non-neurogenic lower urinary tract dysfunction: A systematic review and meta-analysis.

The aim of this systematic review is to assess urinary biomarkers studied in children with neurogenic and non-neurogenic lower urinary tract dysfunction (LUTD). The systematic review was conducted in accordance with the PRISMA guidelines. The screening was performed on PUBMED without any publication date limitation. Only original articles were included. Parameters related to the following topics were obtained: study design, characteristics of participants, number of participants, age, control group, types of biomarkers, measurement technique in urine, subgroup analysis, urodynamic findings, and outcome. Dutch Cochrane Checklist (DCC) and level of evidence by EBRO platform were used for quality assessment. Meta-analysis was performed with the Comprehensive Meta-Analysis Version 4 program. A total of 494 studies were screened and 16 studies were included. 11 (68.75%) were conducted in children with non-neurogenic LUTD and 5 (31.25%) neurogenic LUTD. Nerve growth factor (NGF) was evaluated in 12 studies, brain-derived neurotrophic factor (BDNF) in 5, Tissue Inhibitor of Metalloproteinase-2 (TIMP-2) in 2, transforming growth factor beta-1 (TGF Beta-1) in 2, neutrophil gelatinase-associated lipocalin (NGAL) in 1, and Aquaporin-2 in 1. According to DCC, 10 (62.5%) articles were evaluated on 4 (37.5%) items and 4 articles on 5 items. The average score was 3.91+/-0.56. The level of evidence was found as B for 13 (81.25%) articles and C for 3 (18.75%). In meta-analysis, urinary NGF levels in children with non-neurogenic LUTS were significantly higher than in the healthy control group (Hedges's g = 1.867, standard error = 0.344, variance = 0.119, p = 0.0001). Urinary biomarkers are promising for the future with their noninvasive features. However, prospective studies with larger sample sizes are needed to better understand the potential of urinary biomarkers to reflect urodynamic and clinical findings in children with LUTD.

Outcomes of a newly established transitional urology outpatient clinic: a real-world experience.

To evaluate the demographic and clinical characteristics of patients who visited our transitional urology (TU) outpatient clinic formed by pediatric urologists with urology background within the first year upon its establishment. Files of 130 consecutive patients who visited our TU outpatient clinic, which was established in 01 March 2021, between 01 March 2021 and 01 March 2022 were retrospectively collected. Patients were divided into two groups: those with a previous follow-up in our pediatric urology department (Group I, n: 81, 62.3%) and those who were followed up in other clinics during childhood (Group II, n: 49, 37.7%) afterwards. Demographic characteristics, complaints at admission, previous medical history, and management plans at the recent clinical visit were noted. We defined a successful and smooth transition from childhood to adult care as not being without follow-up within the first year after the age of 18years and not requiring extraordinary medical assistance (e.g., emergency room visits, hospitalization, intensive care unit admissions) from the last urological control to the TU outpatient clinic visits. The most common diagnoses were vesicoureteral reflux (n: 32, 24.6%), neuropathic bladder accompanied by spina bifida (n: 31, 23.8%), obstructive uropathy (n: 25, 19.2%), hypospadias (n: 20, 15.3%), non-neurogenic lower urinary tract dysfunction (n: 19, 14.6%), and bladder exstrophy (n: 8, 6.1%). The distribution of primary diagnosis in the two patient groups was similar. The median time from the last pediatric urology visit to the current TU clinical visit was significantly longer in Group II (12 vs. 60months, p < 0.001),consequently, the median patient age at admission was significantly higher in Group II (21 vs. 23years, p = 0.020). The rate of a successful and smooth transition was 86.4% in Group I, whereas Group II had a completely unsuccessful transition period. Upon admission to TU outpatient clinic, the requirement of a surgical intervention was lower in Group I (21% vs. 38.8%, p = 0.028).Also,the need for medical treatment changes was higher in Group II (9.9% vs. 53.1%, p < 0.001). Our findings emphasize the importance of patient referral to a TU clinic that deal with lifelong problems of congenital genitourinary diseases. Delays in receiving medical or surgical treatments during transition from childhood to adulthood may be associated with higher need for subsequent surgical interventions in this vulnerable patient population.

Who needs an ultrasound? Using patient symptom questionnaire & UTI history to determine when to obtain an RBUS in children with non-neurogenic lower urinary tract dysfunction

Non-neurogenic lower urinary tract dysfunction (LUTD) is one of the most common reasons for presentation to a pediatric urologist, affecting up to 20% of children. Predicting who will benefit from RBUS as part of their work-up is challenging as the majority will have normal imaging. Our objective was to assess the utility of using the Dysfunctional Voiding and Incontinence Scoring System (DVISS) and urinary tract infection (UTI) history to predict which LUTD patients were most likely to have an abnormal RBUS as well as determine a DVISS cutoff to aid in making this prediction. We hypothesized that higher DVISS scores and a positive urinary tract infection (UTI) history would be associated with increased likelihood of RBUS abnormality. We retrospectively reviewed outpatients seen for LUTD from 5/2014-1/2016 who received an RBUS. Association between prior UTI, DVISS score, gender, and race and RBUS abnormality were evaluated using logistic regression analysis. Receiver operating characteristic (ROC) curves were created to evaluate the predictive model and a Youden index calculated to determine the optimal cutoff for DVISS score to predict abnormal RBUS. 15 of 333 patients (4.5%) had a clinically significant RBUS abnormality. Significantly more patients with abnormal RBUS had a positive UTI history and median DVISS was higher. UTI history and DVISS score were associated with RBUS abnormality whereas neither gender nor race were. A DVISS score cutoff of 12 was determined to be ideal for predicting abnormal imaging. Using DVISS≥12 and positive UTI history, patients with both risk factors were significantly more likely to have an abnormal RBUS than those with zero or one risk factor (Figure). To the best of our knowledge this is the first study to try to identify risk factors associated with RBUS abnormality in pediatric LUTD patients and create an evidence-based approach to imaging these patients. We found both DVISS cutoff ≥12 and positive UTI history to be useful to risk stratify LUTD patients' likelihood of abnormal RBUS. Limitations include the study's retrospective nature as well as the fact the population was drawn from a tertiary care pediatric hospital with a large referral population and the fact that the decision to order an RBUS was based on individual clinician preference and decision making. We found that DVISS score≥12 and UTI history are useful in guiding the decision to obtain RBUS in pediatric LUTD patients.

Children with Non-Neurogenic Lower Urinary Tract Dysfunction Require Less Frequent and Number of Botulinum Toxin Injections Than Neurogenic Ones

Children with Non-Neurogenic Lower Urinary Tract Dysfunction Require Less Frequent and Number of Botulinum Toxin Injections Than Neurogenic Ones

Percutaneous Tibial Nerve Stimulation Improves Lower Urinary Tract Dysfunction and Infection Rate in a Kidney Transplant Recipient With Augmentation Cystoplasty: A Case Report and Literature Review

Almost 20% of patients with congenital posterior urethral valves (PUV) reach end-stage kidney disease requiring kidney transplantation (KT). An augmentation cystoplasty (AC) is performed to treat significant lower urinary tract dysfunction (LUTD) which can persist afterwards due to residual valve bladder and lead to recurrent urinary tract infections (UTIs) and a worse graft survival. Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive second-line neuromodulation therapy approved for the treatment of non-neurogenic LUTD performed in the outpatient setting. Herein, we reported the case of significant improvement of bladder voiding pattern and yearly UTI rates through PTNS in a 32-year-old male KT recipient with a history of congenital PUV and AC. The patient was referred to our institution at the beginning of 2019 for urgency, high post-void residual volume (PVR) and recurrent clinically significant UTIs (3 to 4/y). After assessment, the patient attended once-weekly 30-minute sessions of PTNS for 12 consecutive weeks. A significant improvement of urodynamic and infectious outcomes was observed through 3-day bladder diaries, questionnaires, and laboratory exams during the subsequent 3 years of regular follow-up. The present results might be significant for the prevention of antibiotic resistance and for better graft survival in KT recipients. We successfully treated a patient with AC, implying that the technique may be appliable also in this case. Neuromodulation in KT is still an unexplored field of research, we advocate for prospective assessment of the efficacy of PTNS in these patients, as reproducible results might lead to life-changing improvements.

Impact of Race, Gender, and Socioeconomic Status on Symptom Severity at Time of Urologic Referral.

The Dysfunctional Voiding and Incontinence Scoring System (DVISS) is a validated tool to evaluate lower urinary tract dysfunction (LUTD) severity in children. DVISS provides a quantitative score (0-35) including a quality-of-life measure, with higher values indicating more/worse symptoms. Clinically, variability exists in symptom severity when patients present to pediatric urology with LUTD. We hypothesized that symptom severity at consultation varied based on race, gender, and/or socioeconomic status. All urology encounters at a single institution with completed modified DVISS scores 6/2015-3/2018 were reviewed. Initial visits for patients 5-21years old with non-neurogenic LUTD were included. Patients with neurologic disorders or genitourinary tract anomalies were excluded. Wilcoxon rank sum tests compared scores between White and Black patients and between male and female patients. Multiple regression models examined relationships among race, gender, estimated median household income, and insurance payor type. All statistics were performed using Stata 15. In total, 4086 initial patient visits for non-neurogenic LUTD were identified. Median DVISS scores were higher in Black (10) versus White (8) patients (p < 0.001). Symptom severity was higher in females (9) versus males (8) (p < 0.001). When estimated median income and insurance payer types were introduced into a multiple regression model, race, gender, and insurance payer type were significantly associated with symptom severity at presentation. Race, gender, and socioeconomic status significantly impact LUTS severity at the time of urologic consultation. Future studies are needed to clarify the etiologies of these disparities and to determine their clinical significance.

2 - Feasibility and efficacy of Functional Electrical Stimulation (FES) in children with non-neurogenic lower urinary tract dysfunction

2 - Feasibility and efficacy of Functional Electrical Stimulation (FES) in children with non-neurogenic lower urinary tract dysfunction

The results of three times repeated filling cystometry and pressure flow studies in children with non-neurogenic lower urinary tract dysfunction.

We previously reported that some urodynamic parameters change with repetitive filling in children with neurogenic lower urinary tract dysfunction (LUTD). In this study, we aimed to search if three-times repeated filling cystometries (FC) and pressure-flow studies (PFS) would change the urodynamics parameters in children with non-neurogenic LUTD. All children with three repeated FC and PFS between June 2017 and December 2018 were included in the study. Urodynamic reports and charts were evaluated retrospectively. The first sensation of bladder filling (FSBF), maximum cystometric capacity (MCC), detrusor pressure at the FSBF (Pdet.first.sens ), maximum detrusor pressure during filling (Pdet.fill.max ), presence of detrusor over activity, compliance, maximum urine flow (Qmax), detrusor pressure at the maximum urine flow (PdetQmax), residual urine and presence of detrusor sphincter dyssynergy (DSD) were compared among three-times repeated urodynamic studies. Forty children were included in the study. 27 (67.5%) were girls and 13 (32.5%) were boys. Median age was 9 (3.4-17) years. Indications were LUTD with low grade vesicoureteral reflux in 19 (47.5%), LUTD refractory to conservative management in 13 (32.5%), urinary tract infection with LUTD in 6 (15%) and secondary enuresis in 2 (5%). Pdet.first.sens , presence of DO, MCC, Qmax, PdetQmax, residual urine, flow pattern, and presence of DSD were comparable in all three repeated tests. The third FC may show decreased filling detrusor pressures and increased compliance with no change on capacity. In children with non-neurogenic LUTD, three-times repeated FC and PFS present comparable results except FSBF, Pdet.fill.max, and compliance at the third test.

The Burden of Urinary Incontinence on Caregivers and Evaluation of Its Impact on Their Emotional Status.

This study aimed to evaluate caregivers of children with urinary incontinence in terms of the caregiving burden and its associated manifestations. Caregivers of children who are being treated for urinary incontinence secondary to neurogenic and non-neurogenic lower urinary tract dysfunction (LUTD) were evaluated for caregiver burden (Zarit score), depression (Beck Depression Inventory [BDI]), and anxiety (Beck Anxiety Inventory [BAI]). Additionally, children were evaluated for dysfunctional voiding score. All scores were statistically analyzed for correlation with and relation to the caregiver's emotional status. Zarit score was equal in caregivers of children with neurogenic and non-neurogenic LUTD. BDI score was higher in caregivers of patients with neurogenic LUTD, whereas BAI score was higher in caregivers of patients with non-neurogenic LUTD. In the evaluation performed, considering the etiological difference, Zarit score in the group with non-neurogenic LUTD correlated positively with BAI and BDI scores. In the neurogenic bladder group, Zarit score correlated with BDI score. It is important not only in psychiatric patients, but also in those with other chronic disease processes, to evaluate the mental status of caregivers and to support them in dealing with the problem.

Clinical application of intravesical botulinum toxin type A for overactive bladder and interstitial cystitis.

After decades of clinical and basic science research, the clinical application of botulinum toxin A (Botox) in urology has been extended to neurogenic detrusor overactivity (NDO), idiopathic detrusor overactivity, refractory overactive bladder (OAB), interstitial cystitis/bladder pain syndrome (IC/BPS), lower urinary tract symptoms, benign prostatic hyperplasia, and neurogenic or non-neurogenic lower urinary tract dysfunction in children. Botox selectively disrupts and modulates neurotransmission, suppresses detrusor overactivity, and modulates sensory function, inflammation, and glandular function. In addition to motor effects, Botox has been found to have sensory inhibitory effects and anti-inflammatory effects; therefore, it has been used to treat IC/BPS and OAB. Currently, Botox has been approved for the treatment of NDO and OAB. Recent clinical trials on Botox for the treatment of IC/BPS have reported promising therapeutic effects, including reduced bladder pain. Additionally, the therapeutic duration was found to be longer with repeated Botox injections than with a single injection. However, the use of Botox for IC/BPS has not been approved. This paper reviews the recent advances in intravesical Botox treatment for OAB and IC/BPS.

A randomised, double-blind, placebo-controlled clinical trial assessing the efficacy of bedtime buddy\xae for the treatment of nocturnal enuresis in children

BackgroundNocturnal enuresis (NE), or ‘bedwetting’, is a form of night-time urinary incontinence occurring in younger children. A diagnosis of NE can be socially disruptive and psychologically stressful for a child. The most common strategies used by parents to manage NE are waking the child during the night to use the bathroom and limiting the child’s water intake before going to bed. Behavioural or educational therapies for NE such as urotherapy or bladder retraining are widely accepted and considered as a mainstream treatment option for non-neurogenic lower urinary tract dysfunction in children. Pharmacotherapy also plays an ancillary role. However, there is no gold standard therapy or intervention to effectively manage NE.MethodsThis study aims to determine the efficacy of a herbal combination in the treatment of NE in children. The target population for this study is 80 children aged between 6 and 14 years old (males and females) who have primary nocturnal enuresis ≥3 per week (wet nights). The active group will receive one or two capsules per day containing 420 mg of a proprietary blend of Urox® (Seipel Group, Brisbane, Australia) containing Cratevox™ (Crataeva nurvala L; Capparidaceae; Varuna) stem bark extract standardised for 1.5% lupeol: non-standardised Equisetum arvense L. (Equisetaceae; Horsetail) stem extract; and, non-standardised Lindera aggregata Sims. The primary outcome for this study is the frequency of nocturia. Secondary outcomes include safety, quality of life, and daytime incontinence. Each participation will be involved in the trial for 32 weeks including contact with the research team every 2 weeks for the first 8 weeks and then every 8 weeks until trial completion.DiscussionThis study examines a novel treatment for an under-researched health condition affecting many children. Despite the availability of several therapies for NE, there is insufficient evidence to support the use of any one intervention and as such this randomised placebo-controlled phase II trial will be an important contribution to understanding potential new treatments for this condition.Trial registrationAustralian and New Zealand Clinical Trials Registration Number: 12618000288224.Protocol: 23 February 2018, version 1.1.

Detrusor overactivity is missed by stopping urodynamic investigation at a bladder volume of 500mL.

To investigate whether detrusor overactivity (DO) is missed in a relevant percentage of patients if the urodynamic investigation (UDI) is stopped at a filling volume of 500mL due to the fear of bladder overdistention, in patients with lower urinary tract symptoms and high bladder capacity. A consecutive series of 1598 patients with a bladder capacity of >500mL in the bladder diary undergoing UDI due to lower urinary tract dysfunction (LUTD) was prospectively investigated. UDI was performed according to Good Urodynamic Practices recommended by the International Continence Society. UDI was stopped at strong desire to void or in case of autonomic dysreflexia, vesico-uretero-renal reflux, bladder pain or discomfort. Of the 1598 patients (594 women, 1004 men), 1282 (80%) and 316 (20%) had neurogenic and non-neurogenic LUTD, respectively. Overall, DO was detected in 66% (1048/1598), in 71% (910/1282) with neurogenic and in 44% (138/316) with non-neurogenic LUTD. DO occurred in 16% (263/1598, 95% confidence interval [CI] 14.7-18.4%) only at a bladder volume >500mL. This phenomenon was significantly (P<0.001) more frequent in patients with neurogenic (18% [236/1282], 95% CI 16.4-20.6%) compared with non-neurogenic (9% [27/316], 95% CI 5.9-12.1%) LUTD. In both neurological and non-neurological patients with high bladder capacity, we strongly recommend not to stop UDI at a bladder volume of 500mL, as DO might be missed in a relevant percentage leading to inappropriate patient treatment.

Can we predict vesicoureteral reflux resolution in patients with non-neurogenic lower urinary tract dysfunction?

To analyze factors influencing reflux resolution in patients with the coexistence of non-neurogenic lower urinary tract dysfunction and vesicoureteral reflux. The data of 153 children who were diagnosed with vesicoureteral reflux and accompanying non-neurogenic lower urinary tract dysfunction between 2010 and 2015 were retrospectively evaluated. Patients with neurogenic and anatomical malformations, monosymptomatic nocturnal enuresis, previous history of vesicoureteral reflux surgery, irregular and/or incomplete follow-up data were excluded. After exclusion of 55 patients, 98 patients were enrolled in this study. Patients were divided into two groups according to the presence of spontaneous vesicoureteral reflux resolution during the follow-up period. Group1 consisted of 54 children with spontaneous vesicoureteral reflux resolution, whereas group2 included 44 children without resolution. Medical history, physical examination, urinalysis, uroflowmetry combined with electromyography, ultrasonography, as well as the Dysfunctional Voiding and Incontinence Symptom Score questionnaire were also evaluated. The mean age at presentation was 7.57±0.23years (range 5-13years), and the mean follow-up period was 28.3months. Significant differences were noted between the two groups in terms of dysfunctional voiding and incontinence symptom score, bladder wall thickness, and the post-void residual urine volumes. In addition, lower urinary tract symptoms, namely frequency, urgency and daytime incontinence, were found to be higher in group2. In multivariate analysis, post-void residual urine volume and Dysfunctional Voiding and Incontinence Symptom Score were found to affect reflux resolution rates (P=0.002, P=0.002, respectively). The absence of significant post-void residual urine volume, and a low Dysfunctional Voiding and Incontinence Symptom Score increase the likelihood of spontaneous resolution rates of vesicoureteral reflux in children with non-neurogenic lower urinary tract dysfunction.

Non-invasive Testing and Its Role in Diagnosis and Management of Children With Voiding Dysfunction

Purpose of Review The symptoms of non-neurogenic lower urinary tract dysfunction (LUTD) including urinary incontinence, frequency, and urgency are among the most common reasons for which children are referred to pediatric urologists. The workup for LUTD is often time consuming and a source of frustration for patients, parents, and clinicians alike. In this review, we describe the non-invasive tests that are available and discuss their utility in the evaluation and management of children with LUTD.

Role of body mass index in school-aged children with lower urinary tract dysfunction: Does weight classification predict treatment outcome?

Lower urinary tract (LUT) dysfunction comprises a large percentage of pediatric urology referrals. Childhood obesity is a major health concern, and has been associated with voiding symptoms. We assessed the impact of body mass index (BMI) on treatment outcomes of children presenting with LUT or bladder-bowel dysfunction (BBD). Children aged 5-17 years diagnosed with non-neurogenic LUT dysfunction and no prior urologic diagnoses were identified. Patient demographics including BMI, lower urinary tract symptoms, constipation, medical and psychologic comorbidities, imaging, and treatment outcomes were evaluated. BMI was normalized by age and gender according to percentiles: underweight<5th, healthy 5th to <85th, overweight 85th to <95th, and obese>95th percentile. Uni- and multivariate analyses were performed to identify predictors of treatment response. During an 18-month period, 100 children (54 girls, 46 boys) met the inclusion criteria. The mean age at diagnosis was 7.7±2.4 years, and mean length of follow-up 15.3±13.1 months. Sixty-nine patients were a normal weight, 22 were overweight, and nine were obese. Fifteen percent of the children had complete treatment response, 63% partial response, and 22% non-response. On univariate analysis, children with elevated BMI (p=0.04) or history of urinary tract infection (p=0.01) were statistically more likely to not respond to treatment. Controlling for all other variables, children with BMI>85th percentile had 3.1 times (95% CI 1.11-8.64; p=0.03) increased odds of treatment failure (Table). BBD management includes implementation of a bowel program and timed voiding regimen, with additional treatment modalities tailored on the basis of the prevailing symptoms. We observed that school-aged children with a BMI≥85th percentile were over three times more likely to experience treatment failure when controlling for all other patient characteristics including constipation and a history of urinary tract infection. Limitations of the study include the relatively small sample size, lack of uroflow with electromyography to confirm the presence or the absence of detrusor sphincter dyssynergia, and inconsistent anticholinergic dosing. Nearly one-third of school-aged children presenting to our institution with LUT or BBD were overweight or obese when normalized for age and gender. Children with LUT dysfunction and elevated BMI are significantly less likely to experience treatment response.

Postvoidal residual urine is the most significant non-invasive diagnostic test to predict the treatment outcome in children with non-neurogenic lower urinary tract dysfunction

Uroflowmetry (UF) alone is often inadequate or unreliable to diagnose lower urinary tract dysfunction (LUTD). Therefore, other non-invasive tests, such as ultrasound (US), post-voiding residual volume (PVR) assessment and symptom scales, are used as well for objective definition of the problem. The aim of this study was to investigate the possible predictive function of the non-invasive diagnostic tests for the response to treatment. The prospective registry data of 240 patients with LUTD, from November 2006 to September 2013, were retrospectively analyzed. All patients were aged 5-14 years old. Patients with a previous diagnosis of vesicoureteral reflux (VUR), neurogenic bladder, monosymptomatic nocturnal enuresis (NE) were excluded from the study. Uroflowmetry, US, PVR and the Dysfunctional Voiding and Incontinence Symptom Scale (DVISS) were performed on every patient at their first visit and follow-ups. A DVISS <9 was considered as the DVISS response; parental opinion was based on International Continence Society criteria of clinical response. Time passed until clinical response was the last outcome parameter. Mean age was 8.2 years. Median follow-up was 60.5 months. A total of 62% of patients had complete response, 28.1% had partial response, and 9.7% had no response. Demographic variables were not associated with clinical outcome. Co-existing enuresis nocturna, multiple pharmacotherapy, and increased DVISS were associated with longer time until clinical response. Post-voiding residual volume assessment was the only test to have a prognostic value. Resolution rates of LUTD ranged from 40 to 90%. High resolution rate could be attributed to the long follow-up period, and the chance of spontaneous resolution. Treatment modalities and co-existing NE were associated with longer time until clinical response. Only PVR was associated with prognosis. This was the first study in literature to report such findings. It was seen that the normalization of pathologic patterns was a good sign for treatment success. The DVISS results showed significantly higher rates of incontinence compared to initial symptoms defined by the patients and/or their parents. This showed the importance of using scoring systems to better define the severity of symptoms. It was hard to establish a standardized cut-off value for bladder wall thickness on US. However, US was a good test for diagnosing additional pathologies. Increased PVR was the single tool that was associated with prognosis and, therefore, should always be performed after UF. In addition, DVISS can help parents be counseled about their treatment expectations.

Pathophysiological and Therapeutic Considerations for Non-Neurogenic Lower Urinary Tract Dysfunction in Children.

Non-neurogenic lower urinary tract dysfunction (LUTD) in children is very common in clinical practice and is important as an underlying cause of lower urinary tract symptoms, urinary tract infection and vesicoureteral reflux in affected children. LUTD in children is caused by multiple factors and might be related with a delay in functional maturation of the lower urinary tract. Behavioral and psychological problems often co-exist in children with LUTD and bowel dysfunction. Recent findings in functional brain imaging suggest that bladder bowel dysfunction and behavioral and psychiatric disorders in children might share common pathophysiological factors in the brain. Children with suspected LUTD should be evaluated properly by detailed history taking, validated questionnaire on voiding and defecation, voiding and bowel diary, urinalysis, screening ultrasound, uroflowmetry and post-void residual measurement. Invasive urodynamic study such as videourodynamics should be reserved for children in whom standard treatment fails. Initial treatment of non-neurogenic LUTD is standard urotherapy comprising education of the child and family, regular optimal voiding regimens and bowel programs. Pelvic floor muscle awareness, biofeedback and neuromodulation can be used as a supplementary purpose. Antimuscarinics and α-blockers are safely used for overactive bladder and dysfunctional voiding, respectively. For refractory cases, botulinum toxin A injection is a viable treatment option. Prudent use of urotherapy and pharmacotherapy for non-neurogenic LUTD should have a better chance to cure various problems and improve self-esteem and quality of life in affected children.

Sacral neuromodulation for the treatment of neurogenic lower urinary tract dysfunction caused by multiple sclerosis: a single-centre prospective series.

BackgroundSacral neuromodulation is well established in the treatment of refractory, non-neurogenic lower urinary tract dysfunction, but its efficacy and safety in patients with lower urinary tract dysfunction of neurological origin is unclear. Only few case series have been reported for multiple sclerosis. We prospectively evaluated the efficacy and safety of sacral neuromodulation in patients with multiple sclerosis.MethodsSeventeen patients (13 women, 4 men) treated with sacral neuromodulation for refractory neurogenic lower urinary tract dysfunction caused by multiple sclerosis were prospectively enrolled (2007–2011). Patients had to have stable disease and confirmed neurogenic lower urinary tract dysfunction. Voiding variables, adverse events, and subjective satisfaction were assessed.ResultsSixteen (94 %) patients had a positive test phase with a >70 % improvement. After implantation of the pulse generator (InterStim II), the improvement in voiding variables persisted. At 3 years, the median voided volume had improved significantly from 125 (range 0 to 350) to 265 ml (range 200 to 350) (p < 0.001), the post void residual from 170 (range 0 to 730) to 25 ml (range 0 to 300) (p = 0.01), micturition frequency from 12 (range 6 to 20) to 7 (range 4 to 12) (p = 0.003), and number of incontinence episodes from 3 (range 0 to 10) to 0 (range 0 to 1) (p = 0.006). The median subjective degree of satisfaction was 80 %. Only two patients developed lack of benefit. No major complications occurred.ConclusionsChronic sacral neuromodulation promises to be an effective and safe treatment of refractory neurogenic lower urinary tract dysfunction in selected patients with multiple sclerosis.