Pediatric Lower Urinary Tract Dysfunction Research Articles

Can Videourodynamics shape management in refractory pediatric lower urinary tract dysfunction?

Can Videourodynamics shape management in refractory pediatric lower urinary tract dysfunction?

Pediatric Lower Urinary Tract Dysfunction: A Comprehensive Exploration of Clinical Implications and Diagnostic Strategies.

Lower urinary tract dysfunction is clinically important because it may cause urinary tract infections, mainly due to accumulation of residual urine, and adversely affect renal function. In addition, it may cause urinary incontinence, strongly affecting the child's quality of life. The function of the lower urinary tract is closely associated with function of the bowel because constipation is commonly present with bladder dysfunction. The interplay between the lower urinary tract and bowel function, coupled with common conditions such as detrusor overactivity and voiding dysfunction, requires a nuanced diagnostic approach. Detrusor overactivity, a benign but socially harmful condition, is the principal cause of daytime urinary incontinence in childhood. It needs to be differentiated from more serious conditions such as neurogenic bladder dysfunction or urethral obstruction. Voiding dysfunction, a habitual sphincter contraction during voiding, is common in children with detrusor overactivity and may be self limiting but may also result in residual urine and urinary tract infections. It may resemble, in severe cases, neurogenic bladder dysfunction, most often caused by spinal dysraphism, which very often leads to recurrent urinary tract infections and high intravesical pressures, jeopardizing renal function. A voiding diary is crucial in the initial evaluation of lower urinary tract function in children.

Brazilian Portuguese translation, cross-cultural adaptation, and content validation of the pediatric lower urinary tract symptom score

BackgroundEarly screening instruments for professionals are important to reduce the cost and time of diagnosing pediatric lower urinary tract dysfunction. This study aimed to translate, cross-culturally adapt, and validate pediatric lower urinary tract symptom scores. MethodsThis methodological study was conducted in 2019 in two phases: translation and cross-cultural adaptation, and content validation. In the first phase, we used translators, specialists, and 30 parents of children with voiding dysfunction. In the second phase, validation was performed by 11 pediatric urology specialists. FindingsThe instrument was translated and adapted to Brazilian Portuguese and presented an excellent level of verbal comprehension. Further, the instrument presented a good content validity index >0.8 for all items, except for the nomenclature and clarity of two items, as indicated by the Cronbach's alpha value of 0.75 for internal consistency. DiscussionThe final version showed semantic, idiomatic, experiential, and conceptual equivalence with the original instrument, indicating that it is adequate for other assessments of psychometric qualities. Practice implicationsThe translation and adaptation of an important instrument for diagnosing lower urinary tract dysfunction in children to other countries helps nurses identify the disease early and monitor the treatment.

Delineating the Diagnostic Concordance Between Pediatric Lower Urinary Symptoms Scoring and Voiding Diary in Pediatric Lower Urinary Tract Dysfunction.

This retrospective research endeavored to conduct a comparative evaluation of the Pediatric Lower Urinary Tract Symptoms Scoring (PLUTSS) system and the Voiding Diary (VD). The correlation between these diagnostic tools, their prognostic value for treatment outcomes in pediatric Lower Urinary Tract Dysfunction (LUTD), and their relationship with patients' sociodemographic characteristics were also explored. The study data for the cohort established between December 2005 and September 2006 were obtained from a specialized thesis, while the subsequent expansion from 2022 to 2023 involved a prospective approach, including an additional 73 patients, resulting in a total of 113 pediatric patients (79 females and 34 males). Comprehensive diagnostic evaluations, such as urinalysis, urine culture, renal function tests, urinary tract ultrasound, uroflowmetry-electromyography (EMG), and post-voiding residual urine measurement (PVR), were conducted. The patient's symptoms were assessed using the Pediatric Lower Urinary Tract Symptom Score (PLUTSS) and a two-day-three-night voiding diary. The correlation between the PLUTSS and VD was not absolute but substantial concerning daytime frequency and incontinence. Notably, PLUTSS emerged as the primary predictor of treatment outcomes. No significant association was discerned between sociodemographic characteristics, such as socioeconomic status, sibling count, toilet training, school performance, patientpersonality, and LUTD diagnosis or prognosis. The findings underscore the prognostic value of PLUTSS for treatment outcomes in pediatric LUTD. Although a significant correlation was observed between PLUTSS and VD, they are not interchangeable. As a result, concurrent utilization of both tools is endorsed for comprehensive diagnosis, follow-up, and treatment planning in pediatric LUTD.

NIRS: Past, Present, and Future in Functional Urology.

Purpose of ReviewNear infrared spectroscopy (NIRS) is a non-invasive optical technique that uses near infrared light to detect the oxygenation status and hemodynamics of various organs. This article reviews the use of NIRS for the non-invasive assessment of lower urinary tract dysfunction (LUTD). Applications include assessment of bladder outlet obstruction, overactive and underactive bladder, neurogenic LUTD, pediatric LUTD, interstitial cystitis/bladder pain syndrome, and pelvic floor dysfunction. In addition, the article describes how NIRS is elucidating more about the brain-bladder connection. Technological advancements enabling these applications are also discussed.Recent FindingsWhile evidence exists for the application of NIRS throughout a wide range of LUTD, most of these studies are limited by small sample sizes without matched controls. Investigators have experienced problems with reproducibility and motion artifacts contaminating the data. The literature is also becoming dated with use of older technology.SummaryNIRS holds potential for the non-invasive acquisition of urodynamic information over time scales and activities not previously accessible, but it is not yet ready for use in routine clinical practice. Advances in wearable technology will address some of the current limitations of NIRS, but to realize its full potential, larger scale validation studies will be required. Moreover, multidisciplinary collaboration between clinicians, scientists, engineers, and patient advocates will be critical to further optimize these systems.

Delayed in toilet training association with pediatric lower urinary tract dysfunction: A systematic review and meta-analysis

Globally, attitudes and practices towards toilet training have changed several decades ago and children are completing toilet training at a later age compared to previous generations. Concurrently, there has been an increase in the incidence of pediatric bladder bowel dysfunction (BBD), including lower urinary tract dysfunction (LUTD). Whether the fact of delayed toilet training may negatively impact the ability of children to obtain bladder and bowel control and cause LUT dysfunction remains controversial. To investigate the association between age at initiation of toilet training or approach to toilet training and the risks of lower urinary tract (LUT) dysfunction. A comprehensive search of the CENTRAL, EMBASE and MEDLINE via Ovid SP, and CINAHL via EBSCO databases was conducted to identify RCTs, cohort or case-control studies investigating the association between age at initiation of toilet training, approach used for toilet training, and pediatric LUT dysfunction. A total of 10 studies with 24,121 participants (aged 5-17) were included for pooled analysis. Overall, the odds ratio (OR) with 95% confidence interval (95%CI) of LUT dysfunction in children who initiated toilet training at a younger age when compared to those who initiated toilet training at an older age, was 0.71 (0.63-0.81), P<0.001), irrespective of the approach used for toilet training (Table). Subgroup analysis for day-time incontinence (persistent daytime wetting) was 0.77 (0.62-0.95), P=0.014; although the outcomes for enuresis fluctuated, favorable results were still observed in the earlier training group (OR:0.63, 95%CI:0.43-0.94, P=0.023). Subgroup analysis for age at initiating toilet training vs LUT dysfunction also showed favorable results in children who were trained earlier, i.e., before 24 months (OR:0.77, 95% CI 0.63-0.94, P=0.009). Sensitivity analysis confirmed that the results were robust. Although the definition about the age of initial toilet training varied greatly in studies, findings from the current study suggested that the optimal time for initiating toilet training may be prior to the age of 24 months; if toilet training was initiated after 24 months or later, it may result in increased prevalence of LUT dysfunction. Since no RCTs studies were included in the current meta-analysis, well-designed longitudinal studies with larger sample size and from different cultural background are needed to confirm these results. This meta-analysis presents preliminary findings that show the incidence of LUTD may be decreased by initiating toilet training in children at a younger age.

Complementary and Integrative Management of Pediatric Lower Urinary Tract Dysfunction Implemented within an Interprofessional Clinic.

Lower urinary tract dysfunction in children is a common multifactorial functional problem that often correlates with bowel dysfunction and behavioral disorders. Ideal management combines integrative therapies that optimize bladder and bowel habits, address behavioral issues, foster mind–body connection, and improve pelvic floor muscle dysfunction. Movement therapies that teach diaphragmatic breathing and relaxation, mind–body awareness, and healthy pelvic floor muscle function are vital for long-term symptom improvement in children. This paper outlines recommendations for integrative management of these patients and discusses a recently developed interprofessional clinic that aims to better meet these patients’ complex needs and to provide patients with an integrated holistic plan of care. Additional work is needed to scientifically assess these treatment models and educate providers across the various disciplines that evaluate and treat these patients.

Primary and Secondary Tethered Cord and Association with Pediatric Lower Urinary Tract Dysfunction

Tethered cord syndrome (TCS) due to adhesion defect of the spinal cord is one of the major causes of lower urinary tract dysfunction (LUTD) in children. The aim of this article is to evaluate the association, diagnosis, and treatment of TCS with LUT disorders in children. TCS is divided into two groups as primary and secondary depending on whether it is congenital or acquired. TCS can manifest with gait disturbance, pain, orthopedic deformities, and LUT symptoms. LUT symptoms may be the only symptom in some cases. TCS may cause neurogenic LUTD characterized by detrusor sphincter dyssynergia, urinary incontinence, and upper urinary tract damage in children. Primary urologic goal of surgical repair of TCS is prevention of upper urinary tract deterioration and improving LUT symptoms. Urodynamic studies revealing functional deterioration of the LUT are objective tests for surgical indication. Treatment should be planned by a multidisciplinary approach.

Application of Mitrofanoff procedure in pediatric lower urinary tract dysfunction

Objective To discuss the treatment effect with Mitrofanoff procedure in lower urinary tract of pediatric patients. Methods 9 patients conducted Mitrofanoff procedure from January 2014 to January 2018 in our center were analyzed retrospectively. There were 2 boys and 7 girls, age from 4 to 14 years old (7.3 years old in average).1 child was diagnosed as bladder exstrophy, 4 children were neurogenic bladder, 2 children were bladder tumor and the other 2 were urethral trauma. All patients were conducted Mitrofanoff procedure under general anesthesia, used appendix as the conduit, 3 patients used their original bladder as reservoir, bladder augmentation was employed in 4 patients and ileal neobladder was employed in 2 patients to construct reservoir. The distal of appendix was inserted into submucosal of reservoior and the proximal end was connected to the umbilical or lower abdominal wall. Results The operations were all successfully completed without sever complications, the time spent was 176-210 min, 190 min in average, hemorrhage amount 20-35 ml. Patients were followed up 15 to 50 months, the bladder capacity is 80 to 120 ml. Hydronephrosis was improved compared with pre-operative condition. 4 children diagnosed with neurogenic bladder still suffered vesical ureteral reflux. All patients can conduct clean intermittent catheterization without difficulty. There was no leakage of urine from the stoma, while 2 patients showed leakage of urine from urethra when exercising, so we closed the bladder neck 6 month later. Conclusion Mitrofanoff procedure can be implied in children with end-staged lower urinary tract dysfunction due to nerogenic bladder, bladder tumor, bladder exstrophy, which makes intermittent catheterization become more convenient. Key words: Lower urinary tract dysfunction; Appendix conduit; Urinary diversion; Reservoir

The Role of Non-invasive Testing in Evaluation and Diagnosis of Pediatric Lower Urinary Tract Dysfunction.

The symptoms of lower urinary tract dysfunction (LUTD) including urinary incontinence, frequency, and urgency are among the most common reasons children are referred to pediatric urologists. Despite this, the workup for LUTD is often time consuming and a source of frustration for patients, parents, and clinicians alike. In the current review, we summarize the important role non-invasive testing plays in the diagnosis and management of children with LUTD and to show how use of these tests can help avoid the need for more invasive testing in the majority of children. Non-invasive tests such urine studies, uroflowmetry ± simultaneous electromyography, assessment of post-void residual, renal/bladder ultrasound, and pelvic ultrasound when used appropriately can provide valuable information to facilitate decision making during the evaluation of children with LUTD. While these tests should be employed prior to more invasive testing such as urodynamic studies, they can often act as a surrogate for the more invasive tests. Non-invasive tests can help us in our goal of improving diagnostic ability to better classify the child's LUTD into an actual condition which allows targeted treatment in the hope of better outcomes and more satisfied patients and families.

Is There Any Difference Between Questionnaires on Pediatric Lower Urinary Tract Dysfunction?

To investigate the diagnostic properties of 3 different scoring systems (Dysfunctional Voiding Symptom Score [DVSS], Dysfunctional Voiding and Incontinence Symptoms Score [DVISS], Incontinence Symptom Index-Pediatric [ISI-P, for children older than 11 years]) that are used to evaluate lower urinary tract symptoms in pediatric population. Eighty-four participants were evaluated by detailed history, physical examination, 3 different scoring systems (DVSS, DVISS, ISI-P), ultrasonography, and uroflowmetry. Depending on the tests, cases were stratified as healthy or lower urinary tract symptoms (LUTS) by 2 urologists who were blinded to the questionnaires. Patients were reevaluated by the same tests and questionnaires 3 months after treatment. Diagnostic properties of questionnaires were calculated. Additionally, parents were asked to scale the improvement of symptoms subjectively from 0% to 100% to correlate to each of the three scoring systems. The mean ages of the normal and the LUTS groups were 9.1 ± 2.6 years and 10.1 ± 2.8 years, respectively (P = .301). Gender (male:female) distribution was 21:21 in the LUTS group and 25:17 in the control group (P = .381). In terms of diagnosis, DVISS has the highest accuracy (sensitivity: 81%, specificity: 97.6%, accuracy: 89%) followed by ISI-P (sensitivity: 55.6%, specificity: 100%, accuracy: 82%) and DVSS (sensitivity: 54.8%, specificity: 97.6%, accuracy: 76%). The similar order was valid for the 23 patients older than 11 years (accuracy for DVISS: 87%, for ISI-P: 82%, and for DVSS: 78%). In terms of response to treatment, all 3 tests showed good correlation with parents' ratings (DVSS: P < .001, DVISS: P = .005, ISI-P: P = .042). Although DVISS had the highest accuracy in distinguishing the patients from healthy controls, all 3 questionnaires seem to be equivalent for the evaluation of response to treatment.

Sacral Nerve Stimulation for Pediatric Lower Urinary Tract Dysfunction: Development of a Standardized Pathway with Objective Urodynamic Outcomes

We propose that sacral nerve stimulation is a valid adjunctive therapy for refractory pediatric lower urinary tract dysfunction, and that prospective collection of preoperative and postoperative validated questionnaires and urodynamic data in a standardized fashion is beneficial in characterizing patient response. Patients were candidates for sacral nerve stimulation if they had refractory voiding dysfunction and standard treatments had failed. Preoperative evaluation included urodynamic studies, spinal magnetic resonance imaging, and validated bladder and bowel related questionnaires. Children were stratified into 2 groups, ie overactive bladder with or without incontinence (group 1) and detrusor underactivity/urinary retention requiring clean intermittent catheterization (group 2). A staged procedure was used with initial test lead placement, followed by permanent device insertion 2 weeks later if patients demonstrated symptom improvement with test lead. Postoperatively children were followed with questionnaires and at least 1 urodynamic study. A total of 26 children underwent sacral nerve stimulation. Mean patient age was 10.8 years and median followup was 1.2 years. There were 23 patients in group 1 and 4 in group 2 (1 patient was included in both groups). In group 1voiding dysfunction scores improved significantly, and urodynamic studies revealed a significant decrease in mean number of uninhibited contractions andmaximum detrusor pressure during the filling phase. In group 2 there was significant improvement in mean post-void residual. Sacral nerve stimulation is a treatment option that may produce significant improvement in objective and subjective measures of bladder function in children with refractory lower urinary tract dysfunction.

Uroflowmetry with pelvic floor electromyography: inter-rater agreement on diagnosis of pediatric non-neurogenic voiding disorders

Uroflowmetry with electromyography (uroflow-EMG) is commonly used for evaluation of lower urinary tract (LUT) function in children. Diagnostic criteria based largely on uroflow-EMG findings have previously been proposed for several conditions collectively termed non-neurogenic voiding disorders (NNVDs). These include dysfunctional voiding (DV), idiopathic detrusor overactivity disorder (IDOD), detrusor underutilization disorder (DUD), and primary bladder neck dysfunction (PBND). It is unknown whether practitioners with varying levels of training and experience can apply the diagnostic criteria for these conditions with a high level of consistency. To assess inter-rater agreement on diagnosis of NNVDs using uroflow-EMG studies. Six raters performed post hoc evaluation of 84 uroflow-EMG studies and associated clinical data from children with symptoms of LUT dysfunction and no evidence of neurologic or anatomic abnormalities. Each rater was asked to categorize the uroflow-EMG studies as being consistent with DV, IDOD, DUD, PBND, or normal/unclassifiable. A consensus diagnosis was noted for studies on which at least four raters agreed. Inter-rater agreement was assessed via calculation of unweighted Fleiss' kappa statistics. Overall inter-rater agreement on NNVD diagnoses was moderate (kappa 0.46, 95% CI 0.38-0.54). Agreement between individual raters ranged from 0.33 (fair) to 0.74 (substantial) (Figure). There was no consensus on diagnosis for 20 patients (24%). Several factors may contribute to inter-rater disagreement on diagnosis of NNVDs. These include instances where patients satisfy one criterion for a particular diagnosis while missing others - or have findings consistent with more than one diagnosis. Strategies to address this may involve simplifying the diagnostic criteria, developing a clear algorithm that prioritizes certain criteria, and/or allowing assignment of multiple diagnoses. Practitioners could also benefit from standardized education regarding the diagnostic criteria for NNVDs. Potential limitations of this analysis included the use of just one uroflow-EMG study per patient in almost all cases. Also, the raters had variable levels of previous experience using the diagnostic criteria for NNVDs, and it is possible that they were not always applied as originally intended. If this were the case, it would support development of a standardized education tool to facilitate practitioner understanding and application of the criteria. Uroflow-EMG has shown promise for improving clinical management of NNVDs associated with pediatric LUT dysfunction. However, inter-rater agreement on NNVD diagnoses using current criteria is suboptimal. Various mechanisms should be explored to improve consistency in practitioners' diagnosis of NNVDs.

Botulinum Toxin A’s Expanding Role in the Management of Pediatric Lower Urinary Tract Dysfunction

Botulinum toxin A's (Onabotulinum toxin A - OnabotA) utility in the pediatric population is evolving, and is currently being used in the treatment of lower urinary tract dysfunction, both in children with neuropathic compromise, and non-neuropathic overactive bladders. The results of having OnabotA injected directly into the bladder wall cystoscopically are: a more compliant bladder with reduced bladder pressure, avoiding renal compromise and upper urinary tract deterioration; increased bladder capacity; and the ability for children to reach an improved degree of urinary continence through a minimally invasive approach. A growing body of research in patients with either neuropathic bladders or overactive bladders (OAB), have shown excellent results when looking at urodynamic parameters, patient satisfaction and improvement in symptomatology. One of the main indications for the use of OnabotA in children with neuropathic bladders is to delay or avoid the need for augmentation cystoplasty. By achieving the aforementioned results, some children can delay or avoid this more invasive and permanent procedure. Prospective studies are needed to answer questions regarding optimal dosage and frequency, ideal patient selection criteria and assessment of long-term outcomes and complications.

Psychosocial Comorbidities and Obesity are Associated with Lower Urinary Tract Symptoms in Children with Voiding Dysfunction

There is emerging awareness of comorbid psychosocial characteristics in children with lower urinary tract dysfunction. To explore the prevalence of these comorbidities and their relationship to lower urinary tract symptoms, we examined the psychosocial comorbidities and body mass index of children with lower urinary tract dysfunction. We prospectively collected data on all new patients 6 to 17 years old with nonneurogenic lower urinary tract dysfunction who presented to a single nurse practitioner in 2011. Parents completed a 21-question lower urinary tract symptom score based on a validated questionnaire and a psychosocial questionnaire that screened for stressful life events and psychological diagnoses. We examined the correlation of body mass index percentile and psychosocial comorbidities with lower urinary tract symptom score. Of the 358 patients 28.5% were obese, 31.8% had a recent life stressor and 22.9% had a comorbid psychiatric disorder. Younger age correlated with a higher lower urinary tract symptom score (r = -0.34, p <0.0001). Children with a recent life stressor (p = 0.049), psychiatric disorder (p = 0.0026) or the 2 comorbidities (p = 0.039) had a significantly higher lower urinary tract symptom score than children without comorbidities. Underweight and obese children had a significantly higher lower urinary tract symptom score than healthy weight and overweight children (p = 0.009). Almost a third of the patients in our study were obese. More than 40% of the children had a psychiatric disorder and/or recent life stressor. Younger age, an underweight or obese body mass index and a recent stressful life event or psychiatric disorder correlated with a higher lower urinary tract symptom score. This study supports previous recommendations to screen for psychosocial comorbidities and obesity during the evaluation of pediatric lower urinary tract dysfunction.

Sacral Nerve Stimulator Revision Due to Somatic Growth

Sacral nerve modulation is a Food and Drug Administration approved treatment for refractory urgency, frequency, urge incontinence and nonobstructive urinary retention in adults. The sparse literature on sacral nerve modulation in children focuses on its initial efficacy in patients with neurogenic bladder and dysfunctional elimination. We describe our initial experience with sacral nerve modulation and the phenomenon of growth spurts associated with lead malfunction that necessitates revision. After receiving institutional review board approval we retrospectively reviewed the charts of pediatric patients who underwent sacral nerve modulation surgery at our institution. Charts were examined for patient demographics, subjective success, the need for further surgery and success after revision. Four patients underwent sacral nerve modulation at an average age of 12.1 years. All patients reported initial success, defined as greater than 50% symptom improvement. Subsequently 3 patients required a total of 5 revisions due to lead malfunction with an average of 1.5 years between surgeries. In those requiring revision the average somatic growth between revisions was 8.1 cm. Return of efficacy was reported after each revision. All patients had functioning nerve stimulators in place and continued to have a positive subjective response. The sparse data on sacral nerve modulation in children shows efficacy and safety similar to those in adults. Somatic growth may be associated with lead malfunction and require surgical revision. We report a small series showing that revision can be done successfully and safely. Informed consent for sacral nerve modulation in pediatric patients should include a discussion of somatic growth as a possible cause of lead malfunction necessitating revision.

Sacral Neuromodulation in Children With Urinary and Fecal Incontinence: A Multicenter, Open Label, Randomized, Crossover Study

The clinical benefit of sacral neuromodulation is unclear due to the paucity of randomized trial data. The purpose of this study was to evaluate sacral neuromodulation for management of urinary and fecal incontinence in a pediatric population. This multicenter, open label, randomized, crossover study included children older than 5 years. After trial stimulation of the S3 root a neuromodulator (InterStim) was implanted on the S3 foramen. Clinical examinations, voiding and bowel diaries, and urodynamic and manometric evaluations were performed at the beginning (t1) and end (t2) of the first period, and at the beginning (t3) and end (t4) of the second period. A total of 33 patients (24 boys) with a mean +/- SD age of 12.22 +/- 5.09 years were randomized. Etiologies were mainly of neurological origin. Incontinence was mixed urinary and fecal in 19 cases, urinary only in 9 and fecal only in 5. Cystometric bladder capacity increased during sacral neuromodulation (delta +24.27 ml vs -37.45 ml, p = 0.01). There was no significant change in other urodynamic or manometric parameters. Overall positive response rate was more than 75% for urinary (81%) and bowel (78%) function. Crossover analysis indicated that sacral neuromodulation is more effective than conservative treatment for both types of incontinence (p = 0.001). In a pediatric population sacral neuromodulation is effective for bladder and bowel dysfunction and should be considered before irreversible surgery.

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.