Non-neuropathic Bladder Sphincter Dysfunction Research Articles

The role of occult spinal malformation and upper urinary tract deterioration in children with intractable voiding dysfunction

Objectives: To evaluate the presence of upper urinary tract deterioration (UUTD) and accompanying pathologies in children treated with the diagnosis of non-neurogenic bladder-sphincter dysfunction (NNBSD). Patients and Methods: We retrospectively reviewed the medical records of 316 consecutive patients with NNBSD who were treated. All cohort were grouped into two: Group I (Treatment success; n=284), Group II (Treatment failure with any form of occult spinal pathology; n=32). Thirty-four children with treatment-failure and normal magnetic resonance imaging (MRI) findings were excluded. Groups were compared for pre- and posttreatment pediatric lower urinary tract symptom score (PLUTSS), presence of UUTD and urodynamic findings. Results: The mean PLUTSS was significantly less in Group I compared with Group II at pre-treatment and 3 months thereafter the initial treatment (12.20 ± 5.90 and 5.20 ± 4.90 vs 20.3 ± 2.14 and 18 ± 3.4, respectively p 20 cm H2O and presence of vesicoureteral reflux (VUR). Conclusion: UUTD in NNBSD is more common in children with occult spinal pathology, than in those without. Keywords: Non-neuropathic bladder sphincter dysfunction, Upper urinary tract deterioration, Symptom score

Feasibility and outcome of clean intermittent catheterization for children with sensate urethra

Clean intermittent catheterization (CIC) is an important asset in managing children with noncompliant bladders. We review the feasibility and late outcomes of patients with normal urethral sensation who began CIC. We reviewed all patients with posterior urethral valve (PUV) or non-neuropathic bladder sphincter dysfunction (NNBSD) who began on CIC, and had at least 2 years of follow-up. We considered their age, indication, acceptance and compliance with CIC. Additionally, we examined the late outcome of bladder function and the need for any surgical intervention at follow-up. Between 1999 and 2006, 52 patients with PUV (38 patients) or NNBSD (14 patients) were started on CIC. Of these 52 patients, 48% were under the age of 4. A total of 44 patients (85%) accepted the recommendation for CIC, and 34 patients (65%) were compliant with the protocol after at least 2 years of follow-up. The age of the patients was the only significant factor related to the success of the protocol (4 years old or younger, p = 0.03). After at least 2 years of follow-up, 28 patients (54%) remained on CIC and have not required urinary diversion or bladder reconstruction. The current study showed that CIC is a feasible option for patients with sensate urethra, which necessitates the introduction of treatment as early as possible. Further, those patients who are compliant with the CIC demonstrated a better chance of avoiding subsequent surgical intervention for the management of a non-compliant bladder.

Determining compliance in clean intermittent catheterization for children with sensate urethra

It is known that clean intermittent catheterization is more difficult for children and their parents; the normal genital sensation may cause pain and distress during catheterization attempts and afterwards. Neel presents evidence that clean intermittent catheterization is feasible in children with a sensate urethra.1 The quality of life in the children with a sensate urethra has been previously investigated in the literature, and was found to be comparable to those children without a sensate urethra.2 Neel highlights the feasibility of doing clean intermittent catheterization for those patients, but we are still lacking information on whether the frequencies of the catheterization, in addition to the age of the children, have any impact on compliance. Most of the time, the frequency of catheterization depends on the primary pathology. For instance, posterior urethral valve and non-neuropathic bladder sphincter dysfunction patients may be managed with double voiding. In these cases, catheterization can sometimes be used as an adjunct to double voiding, and some children may do well with double voiding and would not need catheterization; therefore, compliance may not accurately be determined. As for age, the authors reported that children under the age of 4 years are more compliant. This illustrates that the earlier catheterization is introduced to children, the better they are at being compliant with it. Finally, when we talk about compliance, outcome should be a variable measure; it is mandatory to correlate the frequency of the catheterization, the size of the catheter and the age of the patient to the final outcome (i.e., upper tract changes, urinary tract infections or incontinence episodes).

Role of Posterior Tibial Nerve Stimulation in the Treatment of Refractory Monosymptomatic Nocturnal Enuresis: A Pilot Study

We evaluated the early clinical and urodynamic results of posterior tibial nerve stimulation in patients with refractory monosymptomatic nocturnal enuresis. We randomly assigned 28 patients with refractory monosymptomatic nocturnal enuresis to 2 equal groups. Group 1 received a weekly session of posterior tibial nerve stimulation for 12 weeks and group 2 was the placebo group. Evaluation was performed in each group at baseline and after posterior tibial nerve stimulation to compare clinical and urodynamic findings. Another clinical assessment was done 3 months after the first followup. The 2 groups were comparable in baseline clinical and urodynamic data. Overall, 13 patients (46.4%) had detrusor overactivity and 14 (50%) had decreased bladder capacity. After treatment 11 group 1 patients (78.6%) had a partial or full response to posterior tibial nerve stimulation but only 2 (14.3%) in group 2 had a partial response (p = 0.002). Also, the average number of wet nights in group 1 was significantly lower than at baseline (p = 0.002). All urodynamic parameters significantly improved in group 1. In contrast, the number of wet nights and urodynamic parameters did not change significantly in group 2. At 3-month followup the number of patients with a partial or full response in group 1 had decreased from 11 (78.6%) to 6 (42.9%). No change was evident in group 2. Posterior tibial nerve stimulation can be a viable treatment option in some patients with refractory monosymptomatic nocturnal enuresis. However, deterioration in some responders with time suggests the need for maintenance protocols.

Editorial Comment

Non-neurogenic neurogenic bladder is a term used to describe a form of bladder-sphincteric dysfunction in children. It is typically characterized by a combination of urinary incontinence, impaired and inefficient emptying, and recurrent urinary tract infections. Bowel dysfunction, including constipation and encopresis, are also common. The clinical and urodynamic sequelae are often identical to those in children with neurogenic bladder, except that no neurologic pathologic features can be demonstrated on physical examination or radiographic imaging. The urodynamic evaluation will reveal detrusor-external sphincter dyssynergia, and the urinary tract decompensation can range from diurnal incontinence to elevated postvoid residual urine volumes to upper tract deterioration from vesicoureteral reflux, elevated filling pressures, and impaired bladder compliance. The treatment of this condition has been aimed at restoring low-pressure urinary storage and efficient, timely bladder emptying. Urofacial Syndrome: A Subset of Neurogenic Bladder Dysfunction Syndromes?UrologyVol. 78Issue 4PreviewThe urofacial syndrome (Ochoa syndrome) is considered to represent a subgroup of the non-neurogenic bladder dysfunction, characterized by non-neuropathic bladder-sphincter dysfunction, along with a characteristic inversion of the facial expression with laughing. Recent research suggests that it is probably a genetic inherited disease transmitted in an autosomal recessive fashion and might represent a distinct entity. We report a case of this syndrome in a 14-year-old boy who presented with left pyelonephritis, hydronephrosis, and bladder dilation. Full-Text PDF ReplyUrologyVol. 78Issue 4PreviewNon-neurogenic neurogenic bladder (NNNB) lies at the most severe end of the spectrum of the non-neurogenic elimination disorders in children.1 When Ochoa and Gorlin2 reported their results in 1987, 33% of the 66 patients had renal functional impairment, 26% had hypertension, and 24% had end-stage renal failure. Full-Text PDF

Urofacial Syndrome: A Subset of Neurogenic Bladder Dysfunction Syndromes?

The urofacial syndrome (Ochoa syndrome) is considered to represent a subgroup of the non-neurogenic bladder dysfunction, characterized by non-neuropathic bladder-sphincter dysfunction, along with a characteristic inversion of the facial expression with laughing. Recent research suggests that it is probably a genetic inherited disease transmitted in an autosomal recessive fashion and might represent a distinct entity. We report a case of this syndrome in a 14-year-old boy who presented with left pyelonephritis, hydronephrosis, and bladder dilation.

The Relevance of Urodynamic Studies for Urge Syndrome and Dysfunctional Voiding: A Multicenter Controlled Trial in Children

The objective of this study was to compare prospectively, in urge syndrome and dysfunctional voiding, clinical patterns with urodynamic patterns, to assess changes in urodynamic patterns after treatment, and to correlate urodynamic patterns and parameters with treatment outcome. In the European Bladder Dysfunction Study 97 children with clinically diagnosed urge syndrome received standard treatment, to which was randomly added placebo, oxybutynin or bladder training with online feedback. In a separate branch 105 children with clinically diagnosed dysfunctional voiding were randomly allocated to standard treatment or standard treatment plus pelvic floor training with online feedback. In all children urodynamic studies were performed before and immediately after treatment. In urge syndrome detrusor overactivity was present in 33% of cases before and 27% after treatment (of which 65% were de novo). Detrusor overactivity did not correlate with treatment outcome. In dysfunctional voiding increased pelvic floor activity during voiding, which was present in 67% of cases before and 56% after treatment (of which 45% were de novo), did not correlate with treatment outcome. In urge syndrome as well as in dysfunctional voiding neither maximum detrusor pressure during voiding, cystometric bladder capacity, bladder compliance nor free flow patterns correlated with treatment outcome. Neither detrusor overactivity nor increased pelvic floor activity during voiding correlated with treatment outcome. Standard treatment could be the first choice in urge syndrome as well as in dysfunctional voiding, reserving urodynamic studies for patients in whom this first approach fails.

Treating functional urinary incontinence can improve problem behavior in children

In children, non-neuropathic bladder-sphincter dysfunction is associated with behavioral problems, but whether a cause and effect relationship exists is unclear.

Sacral Neuromodulation for the Dysfunctional Elimination Syndrome: A Single Center Experience With 20 Children

Recent advances in neuromodulation have demonstrated promise in treating children with the dysfunctional elimination syndrome refractory to medical management. Sacral nerve stimulation with the InterStim implantable device has been used in adults for management of chronic urinary complaints. However, there are few data regarding the usefulness of sacral nerve stimulation in children. We report our experience with sacral nerve stimulation for severe dysfunctional elimination syndrome. A total of 20 patients 8 to 17 years old with the dysfunctional elimination syndrome refractory to maximum medical treatment underwent sacral nerve stimulation at our institution. Patients were followed prospectively for a median of 27 months after the procedure. Urinary incontinence, urgency and frequency, nocturnal enuresis and constipation were improved or resolved in 88% (14 of 16), 69% (9 of 13), 89% (8 of 9), 69% (11 of 16) and 71% (12 of 17) of the patients, respectively. Urinary retention requiring intermittent catheterization persisted in 75% of the patients (3 of 4) despite sacral nerve stimulation. Complications requiring operative treatment occurred in 20% of the patients (4 of 20). Following marked symptomatic improvement 2 devices were explanted at 20 and 19 months following placement, and both patients have remained symptom-free. Sacral nerve stimulation is effective in the majority of our patients, and should be considered in children with severe dysfunctional elimination syndrome refractory to maximum medical treatment.

Functional urinary and fecal incontinence in neurologically normal children: symptoms of one ‘functional elimination disorder’?

To clarify the relationship between disordered defecation and non-neuropathic bladder-sphincter dysfunction (NNBSD) by comparing the prevalence of symptoms of disordered defecation in children with NNBSD before and after treatment for urinary incontinence (UI), and assessing the effect of such symptoms on the cure rate for UI. In the European Bladder Dysfunction Study, a prospective multicentre study comparing treatment plans for children with NNBSD, 202 children completed questionnaires on voiding and on defecation, at entry and after treatment for UI. Four symptoms of disordered defecation were evaluated; low defecation frequency, painful defecation, fecal soiling, and encopresis. At entry, 17 of the 179 children with complete data sets had low defecation frequency and/or painful defecation (9%), classified as functional constipation (FC). Of the 179 children, 57 had either isolated fecal soiling or soiling with encopresis (32%), classified as functional fecal incontinence (FFI). After treatment for UI, FFI decreased to 38/179 (21%) (statistically significant, P = 0.035); for FC there were too few children for analysis. After treatment for UI, 19 of the 179 children (11%) reported de novo FFI. Symptoms of disordered defecation did not influence the cure rate of treatment for UI. FFI improved significantly after treatment for UI only, but not in relation to the outcome of such treatment. FFI did not influence the cure rate for UI. There was little to support a causal relation between disordered defecation and NNBDS ('functional elimination syndrome').

Is it Reasonable to Treat Refractory Voiding Dysfunction in Children With Botulinum-A Toxin?

We present our results with botulinum-A toxin transperineal pelvic floor/external sphincter injection combined with behavioral and biofeedback reeducation in children with voiding dysfunction who had been resistant to previously applied therapies. Eight boys and 12 girls between 7 and 12 years old (mean age 9) with recurrent urinary tract infection, an interrupted or fractional voiding pattern and high post-void residual urine in whom behavioral, short biofeedback and alpha-blocker therapies had failed were included in the study. They were treated with botulinum-A toxin at a dose of 50 to 100 U. Botulinum-A toxin was injected transperineally into the pelvic floor and/or external sphincter in all patients. In boys the sphincter was localized endoscopically before injection (endoscopically assisted transperineal approach). Behavioral and biofeedback reeducation started 15 days after injection. Followup was between 9 and 14 months. All patients were without urinary tract infection and fever, while 5 were still on chemoprophylaxis. Six months after treatment residual urine decreased in 17 of 20 patients by 0 to 130 ml (mean +/- SD 45.75 +/- 32.17 ml, t = 6.360, p <0.001). Nine patients reestablished a normal voiding curve and 8 showed improvement. Three did not manifest any significant improvement. In 1 girl transitory incontinence resolved spontaneously within 48 hours. There were no other complications. The effect of botulinum is transitory. However, it can break the circle of detrusor-sphincter dyssynergia and the period when it is sustained can be used for retraining the patient in normal voiding. At this moment botulinum-A toxin is one of last options in refractory cases of voiding dysfunction.

DOUBLE-BLIND PLACEBO CONTROLLED STUDY OF α-ADRENERGIC RECEPTOR ANTAGONISTS (DOXAZOSIN) FOR TREATMENT OF VOIDING DYSFUNCTION IN THE PEDIATRIC POPULATION

We sought to determine whether the alpha-adrenergic antagonist doxazosin could be used as primary therapy in children with voiding dysfunction. Children were assigned to maintain a voiding diary and then randomly divided into a double-blind placebo controlled protocol (0.5 mg doxazosin or placebo). Duplicate uroflow studies with post-void residual evaluations and assessment of dysfunctional voiding scores were performed on initiation and completion of the study. At the conclusion parents were asked to rank the perceived improvement of the urinary incontinence (ie parental subjective perception of improvement). No significant differences between doxazosin (18) and placebo (20) treated patients were found in the number of incontinent days per week, severity of incontinent episodes or alterations in uroflow patterns. Although not significant, 2 findings suggested a beneficial effect of doxazosin over placebo. Specifically, doxazosin decreased the number of incontinent episodes weekly from a median of 18 to 4, while the number of incontinent episodes weekly in the placebo group remained essentially unchanged, decreasing from 15 to 14 (p = 0.13). Doxazosin also improved the dysfunctional voiding scores over placebo, for an improvement of -3 vs 0 points. Further substantiating a doxazosin effect over placebo was the subjective perception of the parents that doxazosin significantly improved urinary continence (p <0.02). Compared to placebo, doxazosin did not demonstrate a significant objective benefit, but produced a significant subjective benefit in the treatment of urinary incontinence secondary to voiding dysfunction.

Percutaneous Electrical Nerve Stimulation in Children With Therapy Resistant Nonneuropathic Bladder Sphincter Dysfunction: A Pilot Study

We evaluated the effect of percutaneous electrical nerve stimulation on voiding dysfunction in a group of children with therapy resistant, nonneuropathic bladder sphincter dysfunction. In a prospective study 17 boys and 15 girls with mean age of 11.7 years underwent percutaneous electrical nerve stimulation after the failure of more than 2 years of urological and/or pharmacotherapy. The device for percutaneous electrical nerve stimulation consists of an interface cable, a surface electrode, a percutaneous needle and a portable stimulator. The needle is inserted at the tibial nerve level and a portable stimulator provided pulsations at a frequency of 20 Hz. for 30 minutes once weekly. Every 6 weeks the children were evaluated. Evaluation parameters were urgency, daytime incontinence, voiding frequency, the uroflowmetry curve and bladder capacity. When favorable results were observed after 6 sessions, therapy was continued for another 12 sessions. In 24 children anticholinergics started before stimulation that had only a partial effect were continued during stimulation. In 7 of the 28 children with urgency before therapy it disappeared after therapy and in 10 it improved. Of the 23 children with daytime incontinence before treatment 4 became dry after stimulation and in 12 incontinence decreased. Of the 19 patients who reported disturbed voiding frequency of less than 4 or more than 8 voids daily 16 achieved a normal frequency of 4 to 6 voids daily. In 21 children an abnormal uroflowmetry curve was observed before stimulation, while in 9 the flow curve was normal after therapy. Mean bladder capacity increased significantly from 185.16 to 279.19 ml. Percutaneous electrical nerve stimulation has a significant effect on voiding frequency, the uroflowmetry curve and bladder capacity in children with nonneurogenic bladder sphincter dysfunction

Percutaneous Electrical Nerve Stimulation in Children With Therapy Resistant Nonneuropathic Bladder Sphincter Dysfunction: A Pilot Study

Percutaneous Electrical Nerve Stimulation in Children With Therapy Resistant Nonneuropathic Bladder Sphincter Dysfunction: A Pilot Study

Enuresis and incontinence in children.

The terminology used to describe wetting children is defined. The etiologies of monosymptomatic nocturnal enuresis and nonneuropathic bladder-sphincter dysfunction are described. Treatment strategies and the results of recent large scale studies are presented.

The role of pelvic-floor therapy in the treatment of lower urinary tract dysfunctions in children.

The pelvic-floor is under voluntary control and plays an important role in the pathophysiology of lower urinary tract (LUT) dysfunctions in children, especially of non-neuropathic bladder sphincter dysfunction. The following therapeutic measures can be applied to try to influence the activity of the pelvic-floor during voiding: proprioceptive exercises of the pelvic-floor (manual testing), visualization of the electromyographic registration of relaxation and contraction of the pelvic-floor by a curve on a display (relaxation biofeedback), observation of the flow curve during voiding (uroflow biofeedback), learning of an adequate toilet posture in order to reach an optimal relaxation of the pelvic-floor, an individually adapted voiding and drinking schedule to teach the child to deal consciously with the bladder and its function and a number of simple rules for application at home to increase the involvement and motivation of the child. In children however with persisting idiopathic detrusor instability additional therapeutic measures may be necessary to improve present urologic symptoms (incontinence problems, frequency, urge) and to increase bladder capacity. Intravesical biofeedback has been used to stretch the bladder and seems to be useful in case of sensory urge. Recently a less invasive technique, called transcutaneous electrical nerve stimulation (TENS), has been applied on level of S3 with promising results in children with urodynamicaly proven detrusor instability, in which previous therapies have failed.

Assessment of lower urinary tract dysfunction in children with non-neuropathic bladder sphincter dysfunction

Correspondence to Mr Christopher R. Chapple, Urology Research Department, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK. Tel: +44 114 271 2791; fax: +44 114 279 8318 Univèrsitá degli Studi, L'Aquila, Italy

Anomalies of the external urethral meatus in girls with non-neurogenic bladder sphincter dysfunction.

To investigate in a prospective study the clinical and urodynamic characteristics associated with the correlation previously reported between non-neuropathic bladder sphincter dysfunction and minimal meatal deformities in girls. From January 1995 to June 1996 all girls referred for urodynamics to investigate non-neuropathic bladder sphincter dysfunction were examined for meatal anomalies. Two types of meatal anomalies were recognized, i.e. hypospadias, in which the urethral meatus is displaced dorsally and meatal web or covered hypospadias, in which there is a mucosal web on the dorsal side of the urethral meatus that deflects the urinary stream anteriorly. The girls presenting with minimal meatal deformities were compared with those presenting a normal meatal configuration for their history and video-urodynamic features. During the study, 288 girls were referred for video-urodynamics; 88 presented with meatal anomalies (24 hypospadias and 64 covered hypospadias) and comprised the study group; all other girls were considered as the control group. Incontinence during the day was more frequent in the study group (56%) than in the control group (34%) (P=0.003). Nocturnal enuresis was more frequent in the control group (87%) than in the study group (68%, P=0.006). Urge was more frequent in the study group (80%) than in the control group (65%, P=0.02), as was anterior deflection of the urinary stream (voiding over the toilet rim), in 48% and 4.5%, respectively (P<0.001). On video-urodynamics, dysfunctional voiding (detrusor sphincter dyscoordination during voiding) was more frequent in the study group (59%) than in the control group (38%, P=0.009), and vaginal voiding was more frequent in the study group (40%) than in the control group (11.5%, P<0.001). Girls presenting with meatal anomalies have more severe dysfunction, as estimated by urodynamics. Although the natural history of these anomalies and the incidence in the normal population is not known, it is thought that there is an aetiological correlation between the functional voiding disorders and the meatal anomaly. Surgical treatment to correct the anomalies is proposed.

Assessment of Lower Urinary Tract Dysfunction in Children with Non-Neuropathic Bladder Sphincter Dysfunction

Although nonneuropathic bladder sphincter dysfunction in children is frequently encountered, there is no consensus on the assessment of children presenting with this problem. An example is given of how these children can be assessed. After a noninvasive screening consisting of history, voiding diary, clinical examination, urinalysis, ultrasound and uroflowmetry, those children that will benefit from further videourodynamic studies are selected. Videourodynamics help to describe accurately the filling phase dysfunction and the voiding phase dysfunction, which helps to outline therapy. By using the described methods we are able to select those patients who will benefit from pharmacotherapy and those who will benefit from urotherapy.