Urodynamics In Children Research Articles

Ongenital Medullary Malformations and Urinary Disorders: The Contribution of Urodynamic Assessment in the Diagnostic, Prognostic and Theurapeutic Approach in the Light of Recommendations and The Literature

Congenital medullary malformations or spinal dysraphisms are anomalies in the closure of the neural tube affecting the spinal column and the spinal cord. The cause is usually multifactorial. The main cause of morbidity and mortality in these children is renal deterioration. This is the main cause of neurological bladder in children. Urinary management must begin early, from the neonatal period, with the aim of preserving the urinary tract and renal function, as vesico-sphincter imbalance is the cause of renal deterioration and may therefore be life-threatening for these children. Urodynamic investigation is the key examination for analysing the functioning of the lower urinary tract and proposing a course of treatment based on the mechanisms of vesicosphincter dysfunction. There are still very few publications on urodynamics in children. Although urodynamic exploration techniques differ little from those used in adults, the pathophysiology of bladder and bowel function in infants is specific to this age group. This article reviews the literature to demonstrate the value of urodynamic testing in the diagnosis and treatment of urinary disorders in congenital medullary malformations.

Novel use of contrast enhanced ultrasonography with urodynamics in children: A comparison study to fluoroscopy.

Video urodynamics (UDS) has classically been performed using fluoroscopy (fluoro). Contrast enhanced voiding ultrasonography (ceVUS) has rarely been reported for use with UDS. This is the first study to compare the imaging characteristics of ceVUS versus fluoro UDS. Children were enrolled for ceVUS UDS who previously underwent fluoro UDS. Demographics, imaging data for ceVUS and fluoro UDS, time between studies, and clinical data between studies were recorded. Changes in clinical status included implantation/cessation of catheterization or anticholinergic medications, leakage between, urinary tract infections, hydronephrosis and neurologic changes. Comparison testing was performed using McNemar's Chi-Squared and Wilcoxon matched-pairs signed rank test. Seventy-five children were recruited. Median time between studies was 1.3 years (IQR 0.9-2.9). There were no differences for bladder shape (p = 0.59), vesicoureteral reflux (p = 0.10), bladder neck (p = 0.59) or urethra (p = 1.0) between studies. In 5 cases, the bladder neck could not be visualized adequately due to layering of the microbubble contrast against urine. Benefits to ceVUS included ability to visualize the exact moment the bladder neck opened. Following exclusion of patients with clinical changes that might affect imaging findings, an analysis of 28 patients demonstrated no differences between the two studies. CeVUS can be used adequately in conjunction with UDS. Limitations to ceVUS include more granular imaging for bladder shape versus fluoro and inability to visualize bladder neck if residual urine is in the bladder, mitigated by bladder emptying. Benefits include ability to visualize the dynamic activity of the bladder neck due to constant imaging with ceVUS.

Editorial commentary to clinical utility and interrater reliability of video urodynamics in children with isolated fibrolipoma of filum terminale

Retrospective reports are valuable, especially when they convey messages about what to do or not to do in the future. In the study by S.F Batie et al. ( 1 Batie S.F. Coco C.T. Braga B.P. Chan Y.Y. Stanasel I. Jacobs M.A. Baker L.A. Peters C.A. Schlomer B.J. Clinical utility and interrater reliability of video urodynamics in children with isolated fibrolipoma of filum terminale. J Pediatr Urol. 2023 May 5; (S1477-5131 Epub ahead of print. PMID: 37211501): 00203-00206https://doi.org/10.1016/j.jpurol.2023.05.002 Abstract Full Text Full Text PDF Scopus (0) Google Scholar ) the role of video urodynamics (VUDS) in case of isolated fibrolipoma of the filum terminale, is combined with an investigation of the interrater reliability of VUDS as obtained from post hoc assessment performed by 6 pediatric urologists. Their agreement was fair to very good. Most imaging parameters show very good agreement, whereas the agreement about the urodynamic parameters is less satisfactory with the exception of compliance. Clinical utility and interrater reliability of video urodynamics in children with isolated fibrolipoma of filum terminaleJournal of Pediatric UrologyPreviewChildren with an isolated fibrolipoma of filum terminale (IFFT) but otherwise normal spinal cord are often evaluated with video urodynamics (VUDS). VUDS interpretation is subjective and can be difficult in young children. These patients may undergo detethering surgery if there is concern for current or future symptomatic tethered cord. Full-Text PDF

Clinical utility and interrater reliability of video urodynamics in children with isolated fibrolipoma of filum terminale

Children with an isolated fibrolipoma of filum terminale (IFFT) but otherwise normal spinal cord are often evaluated with video urodynamics (VUDS). VUDS interpretation is subjective and can be difficult in young children. These patients may undergo detethering surgery if there is concern for current or future symptomatic tethered cord. We hypothesized that VUDS in children with IFFT would have limited clinical utility regarding decision for or against detethering surgery and VUDS interpretation would have poor interrater reliability. Patients with IFFT who underwent VUDS for from 2009 to 2021 were retrospectively reviewed to evaluate clinical utility of VUDS. 6 pediatric urologists who were blinded to patient clinical characteristics reviewed the VUDS. Gwet's first order agreement coefficient (AC1) with 95% CI was used to assess interrater reliability. 47 patients (24F:23M) were identified. Median age at initial evaluation was 2.8yrs (IQR:1.5-6.8). 24 (51%) patients underwent detethering surgery (Table). VUDS at initial evaluation were interpreted by treating urologist as normal in 4 (8%), reassuring for normal in 39 (81%), or concerning for abnormal in 4 (9%). Based on neurosurgery clinic and operative notes for the 47 patients, VUDS made no change in management in 37 patients (79%), prompted detethering in 3 (6%), was given as reason for observation in 7 (15%), and was normal or reassuring for normal but not documented as a reason for observation in 16 (34%) (Table). Interrater reliability for VUDS interpretation had fair agreement (AC1=0.27) for overall categorization of VUDS and EMG interpretation (AC1=0.34). Moderate agreement was seen for detrusor overactivity interpretation (AC1=0.54) and bladder neck appearance (AC1=0.46). In our cohort, 90% of patients had a normal or reassuring for normal interpretation of VUDS. VUDS interpretation affected clinical course in a minority of patients. There was fair interrater reliability for overall VUDS interpretation and therefore clinical course regarding detethering surgery could vary depending upon interpreting urologist. This fair interrater variability appeared to be related to variability in EMG, bladder neck appearance, and detrusor overactivity interpretation. VUDS affected clinical management in about 20% of our cohort and supported the choice for observation in around 50% of patients. This suggests VUDS does have clinical utility in pediatric patients with IFFT. The overall VUDS interpretation had fair interrater reliability. This suggest VUDS interpretation has limitations in determining normal versus abnormal bladder function in children with IFFT. Neurosurgeons and urologists should be aware of VUDS limitations in this patient population.

Determination of tibial somatosensory evoked potentials predicts detrusor sphincter dyssynergia in children with neurogenic bladder dysfunction.

Tibial somatosensory evoked potentials (SEP) are used to identify the neurological status and tethered cord (TC) in patients with spina bifida (SB). Its significance in contributing to the interpretation of urodynamics to determine bladder status is unknown. This study aimed to determine the correlation between SEP and urodynamics in children with SB. SEP and urodynamic results, for differential diagnosis of TC, were evaluated. SEP scores were correlated with urodynamic findings. SEP results were scored from 1 to 6, with 1, denoting a favorable score and 6, an unfavorable score. Age, gender, detrusor, and sphincter activities in urodynamics were noted. Results were analyzed using the χ2 test and logistic regression analysis. Receiver operating characteristic (ROC) curve was formed to get a valid threshold for the SEP score to predict the urodynamic condition. There were 44 SB patients for whom SEP was done for differential diagnosis of TC. Fifteen patients who did not meet the inclusion criteria were excluded from the study. SB aperta was present in 17 patients and occulta in 12, respectively. The patients had a mean age of 6.6 ± 3.2 years. There were 13 boys and 16 girls. A strong correlation was found between high SEP scores and detrusor sphincter dyssynergia (p < 0.001). A SEP score over 3.5 was found to be 93% sensitive and 73% specific to predict this correlation. There was no relationship between detrusor activity and SEP scores (p = 0.18). Tibial SEP is an important noninvasive adjunct tool for the diagnosis of TC in patients with SB. Urodynamic studies are the gold standard in the evaluation of bladder status in neurogenic bladder dysfunction due to SB. Detrusor sphincter dyssynergia may be regarded as a sign of severe spinal cord injury in these patients. Our findings suggest that in children with neurogenic bladder, high SEP scores may predict the presence of detrusor sphincter dyssynergia but not the status of detrusor function while providing pathophysiological evidence for neural injury.

Can ultrasound measurement of bladder wall thickness be a useful adjunct for regular urodynamics in children with spina bifida?

Spina bifida is a major cause of neurologic bladder dysfunction among children. The goal of neurogenic bladder treatment is to preserve renal function. Close follow-up is essential, as lower urinary tract functions can change with patient growth. Presently, invasive urodynamics is the gold standard for precisely assessing lower urinary tract function. Ultrasound is a low-cost, non-invasive, uncomplicated examination that can be easily repeated. Bladder wall thickness (BWT) measurement by ultrasound has been proposed as a non-invasive alternative for identifying lower urinary tract dysfunctions. Currently there are few reports on BWT in children with spina bifida, and BWT assessment methodology has yet to be defined. The present study aim was to investigate whether BWT could be a useful adjunct for regular urodynamics in children with spina bifida. We especially focused on the precise bladder volume during BWT measurements that were simultaneously performed with urodynamics. This prospective observational study investigated 33 patients with spina bifida who underwent video urodynamics. We assessed BWT measurements using ultrasound simultaneously performed with video urodynamics. BWT was calculated for the ventral and dorsal walls at 0%, 20%, 40%, 60%, 80%, and 100% of the expected bladder capacity. Median of bladder capacity was 240mL, and bladder compliance was 19.2 mL/cmH2O. Detrusor overactivity was present in 66.7% and vesicoureteral reflux was present in 27.3% of the patients. BWT of the ventral wall was significantly lower than the dorsal wall. During increases in the bladder volume, both the ventral and dorsal walls exhibited proportional thinning (p<0.05). There were no significant differences for BWT between males and females. Although there was a higher statistical tendency for detrusor overactivity versus without detrusor overactivity (p=0.085), there were no significant differences found between patients with and without detrusor overactivity. This is the first report where multiple BWT measurements points with video urodynamics were simultaneously performed. Selection of bladder volumes for BWT measurements is critical. Our current study measured six points for each patient during urodynamics. However, available data was not sufficient for detecting bladder function. Until now, there has been no valid standard condition defined for measuring BWT and thus, lack of a standardized method has resulted in discrepancies among studies. Our measurement conditions showed BWT may not correlate with the degree of bladder detrusor dysfunction. As BWT ultrasound cannot identify bladder dysfunction of children with spina bifida, this cannot be used as a substitute for invasive urodynamics.

Utility of Urodynamics in Children with Dysfunctional Voiding

This review will allow the reader to understand the rationale for urodynamic testing in a child who is neurologically intact and is suspected of having dysfunctional voiding. We will look to define criteria that will prevent the overuse and unnecessary use of this invasive test in children. The literature does not support the routine use of invasive urodynamics for children with urge syndrome but does support its use for elucidation of dysfunctional voiding abnormalities in neurologically intact children. The child with functional voiding issues presents itself with factors that are different from the child with neurogenic causes of incontinence. The role of the brain cannot be taken out of the equation in the normal sensate child and its impact can be quite significant leading to results that may not be what is actually occurring in day to day life. It is also critical that the person ordering VUD understand that there is limited value in ordering these tests for urge incontinence and frequency since the diagnosis of DO can be made for the most part from the history. Judicious use of the VUD study can be quiet valuable in allowing the user to pinpoint in complex cases the cause of the incontinence or poor voiding dynamics that are present. VUD should be a final choice in the workup of the sensate child with functional voiding problems and rarely used as a first line evaluation.

No immediate effect on urodynamic parameters during transcutaneous electrical nerve stimulation (TENS) in children with overactive bladder and daytime incontinence-A randomized, double-blind, placebo-controlled study.

To evaluate the immediate effect on natural fill urodynamic parameters and bladder function during transcutaneous electrical nerve stimulation (TENS) in children with overactive bladder (OAB) and daytime urinary incontinence (DUI). In this double-blind, placebo-controlled study, 24 children with severe OAB and DUI (mean age 8.5 ± 1.2 years) underwent 48-h natural fill urodynamics. After 24 h of baseline investigation, the children were randomized to either active continuous TENS (n = 12) or placebo TENS (n = 12) over the sacral S2-S3 outflow. The urodynamic recordings were analyzed manually for three different bladder contraction patterns resulting in a void. The number of bladder contractions not leading to a void was also calculated. Maximum voided volume (MVV) and average voided volume (AVV) were identified for both the baseline and the intervention day. We found that TENS had no immediate objective effect on bladder capacity. The difference (before minus after treatment) in MVV/EBC in the active TENS group = 0.03 ± 0.23 versus placebo TENS group = -0.01 ± 0.10 (P = 0.61). Also, there was no significant difference in the proportion of different bladder contraction types between the two groups. TENS did not significantly influence the number of bladder contractions not leading to a void. Results are presented as mean ± SD. There is no immediate objective effect of TENS on bladder activity assessed by natural fill urodynamics in children with OAB and DUI.

Autonomic dysreflexia during urodynamics in children and adolescents with spinal cord injury or severe neurologic disease

Autonomic dysreflexia (AD) is a well-established association of high spinal cord injury (SCI), particularly in those occurring above T6. When a noxious stimulus is encountered, the body responds by stimulating an increase in blood pressure, which is then countered by vasodilation. In patients with autonomic dysreflexia, the patient is unable to vasodilate below the level of spinal injury due to interruption of the autonomic innervation below the injury. This then leads to persistently elevated blood pressure causing uncoordinated autonomic responses such as headache, flushing, sweating, and even hypertensive crisis. The noxious stimulus most commonly reported is bladder or bowel distention [1]. This potential trigger is especially important since many patients with SCI require catheterization and repeated urodynamic testing, both of which predispose them to bladder distention. In response to an incident during which a patient developed severe hypertension during UDS, institutional concern was raised about the potential risk of AD in other patients with SCI ≥ T8 and other severe neurological disease undergoing urodynamic testing, and a protocol was initiated in 2007 for monitoring for AD during UDS. Although no long-term complication was encountered in this incident, the need for improvement in our understanding of the detection and treatment of AD during urodynamic testing was highlighted. However, due to the potential of UDS to trigger AD and possible subsequent severe cardiovascular crisis, a protocol was established at our institution. Because of reports documenting episodes of AD for patients with severe, non-SCI neurologic disease and the unknown risk, these patients also were historically monitored at our institution as well. Autonomic dysreflexia (AD) is an uncoordinated autonomic response seen in patients with spinal cord injury (SCI). AD is often triggered by bladder distention, which may occur during urodynamic studies (UDS), and has potentially life-threatening consequences. Our purpose is to determine the prevalence and associated factors of AD in children undergoing UDS with either SCI or other neurological disease. We identified 13 pediatric patients with SCI at the eighth thoracic vertebrae or above (SCI ≥ T8) or other severe neurological disorder with urodynamic evaluations between 2007 and 2011 at our institution. We retrospectively reviewed these patients for age, gender, bladder volume, bladder compliance, detrusor instability, symptoms of AD, blood pressure, and urinary infection. There were a total of 13 patients with SCI ≥ T8 (9), transverse myelitis (2), and encephalomyelitis (2). There were a total of 41 urodynamic studies with an average of 3.2 studies per patient. One adolescent with C1/2 injury and a prepubertal child with T2/3 injury developed AD. AD was not observed in non-SCI patients. The patients who developed AD had multiple subsequent episodes with follow up UDS. No statistical associations were found for the variables evaluated. No major complications occurred, and AD was successfully managed conservatively. With appropriate monitoring and education, AD is easily recognized and managed conservatively. We found an increased risk of patients developing subsequent AD episodes after an initial episode. Patients who did not have autonomic dysreflexia during initial UDS did not experience autonomic dysreflexia on subsequent UDS. We did not observe autonomic dysreflexia occurring in children with transverse myelitis or encephalomyelitis.

Progress of application of urodynamics in children with voiding dysfunction

Voiding dysfunction is common in children, urodynamic study is necessary to evaluate voiding dysfunction.Recently, urodynamic studies in children with voiding dysfunction have been performed with increasing frequency as the techniques have been applied in most hospitals widely.New technologies, such as ultrasound urine flow in newborns and ambulatory urodynamics monitoring in children, have been used.Urodynamic has been used routinely in children with neurogenic bladder in China.This review summarized the application of urodynamics in children with voiding dysfunction and the relevant terminologies in pediatric urodynamics, in order to provide a reference for clinical applications and researches. Key words: Urodynamic; Voiding dysfunction; Child; Diagnosis

C22 Urodynamics in children – a 10 years experience

C22 Urodynamics in children – a 10 years experience

Uroflowmetry Nomograms for Healthy Children 5 to 15 Years Old

We determined flow rates and generated flow rate-voided volume nomograms based on healthy children 5 to 15 years old voiding spontaneously in their natural environment. A total of 824 healthy school children of both genders were enrolled. A single uroflow record from each child was evaluated. A total of 103 children with a voided volume of less than 50 ml and/or a staccato/interrupted uroflow pattern were excluded, and 721 records were analyzed. Data were evaluated using several mathematical formulas and goodness of fit was determined. Linear regression analysis was used to generate nomograms. Flow rates and voided volumes increased with increasing age, with the effect being more pronounced in girls. No significant difference was noted in uroflow rates from 5 to 10 years, but significant differences (p <0.001) started appearing at 11 to 15 years. Also no significant difference was noted in uroflow rates among children 11 to 15 years. Therefore, 2 age groups were designated, with group 1 consisting of patients 5 to 10 years old and group 2 consisting of patients 11 to 15 years old. There were 222 boys and 122 girls in group 1 and 240 boys and 137 girls in group 2. In group 1 the maximum and average ± SD flow rates were 15.26 ± 4.54 ml per second and 7.68 ± 3.26 ml per second, respectively, for boys and 17.98 ± 6.06 ml per second and 9.19 ± 4.23 ml per second, respectively, for girls. In group 2 these rates were 22.50 ± 7.24 ml per second and 10.78 ± 4.03 ml per second, respectively, for boys and 27.16 ± 9.37 ml per second and 13.48 ± 5.21 ml per second, respectively, for girls. This large study, which expands the scant existing literature on uroflow parameters in healthy children, will hopefully promote wider application of uroflowmetry testing in the pediatric population.

Practical urodynamics in children, part 2: Normal uroflowmetry curve is not a guarantee of normal voiding function

Since uroflowmetry and postvoiding residual (PVR) urine tests are noninvasive and relatively inexpensive, they are regarded as first-line screening tools for evaluating pediatric voiding function.1 The International Children’s Continence Society states that bellshaped uroflowmetry curves usually imply normal voiding function in children.2 Herein, we present a girl with voiding dysfunction who had a normal bell-shaped uroflowmetry curve because of abdominal straining.

Non Invasive Urodynamic Assessment in Children—Are They Reliable? Validation of Non-Invasive Urodynamics in Children with Functional Voiding Disorders

To validate the non-invasive tests that can predict the type of bladder dysfunction normally diagnosed by invasive urodynamics. Children below 12 yrs of age were evaluated prospectively. Non-invasive urodynamic evaluation included history, clinical examination, frequency volume charting, ultrasonographic scan, urine analysis and renal function tests. Micturating cystourethrogram was carried out in children with recurrent urinary tract infections. All children underwent invasive urodynamic studies and the significance of association of the parameters of noninvasive assessment with invasive urodynamics was determined. Chi square test using Epi 6 software was used for statistical analysis of data. 41 children underwent invasive urodynamic studies. The commonest disorder was detrusor instability in 28 (68.2%). Dysynergic voiding was noted in 8 (19.5%). The study was normal in 5 (12.1%). Nocturnal enuresis with day time symptoms, holding maneuvers, small frequent voiding pattern (p<0.05) and a small capacity bladder with insignificant residue (p=0.0003) predicts detrusor instability. Straining (p=0.0006), large capacity bladder with significant post void residue in the absence of vesicouretric reflux (p<0.05) predicts dysyneric voiding. On combining the various non-invasive tests and validating them against invasive urodynamics in diagnosing detrusor instability and dysnergic voiding, they have a sensitivity of 88.4% and 87.5%, specificity of 72.7% and 69.2%, positive predictive value of 0.88 and 0.63 and positive likelihood ratio of 3.1 & 2.2 respectively. Functional voiding disorders can be diagnosed with reasonable accuracy by minimally invasive methods.

Home Urodynamics In Children With Mmc

PURPOSE Progressive loss of bladder function in children with MMC is an ongoing concern. Urodynamic studies can monitor bladder function changes and the effect of treatment but are available at (half)-yearly intervals at best. We present the pilot data of a non-invasive method to measure bladder pressure at home. MATERIAL AND METHODS During catheterization an extra tube is connected to the catheter. By placing this tube along a vertical ruler the bladder pressure at that time point is measured in cm water and bladder volume (ml) is noted. During regular videourodynamic investigations this method was compared to the standard methodology in 22 patients. For a pilot clinical study we included 5 children with MMC, aged 0-3 years, who were on CIC. Bladder pressure was measured at home during the first morning catheterization by the parents, daily for the first two weeks and twice weekly thereafter. RESULTS The home bladder pressures deviated CONCLUSIONS The home bladder pressure equipment allows reliable measurement of the bladder pressure by the parents. The high frequency allows feedback to the physician on the response of bladder pressure to (changes in) treatment and thereby facilitates fine-tuning of the treatment (medication dose or CIC frequency). In addition, weekly feedback to the parents about the effects of bladder therapy on the bladder pressures of their child increases compliance to therapy.

Home urodynamics in children with mmc

Purpose Progressive loss of bladder function in children with MMC is an ongoing concern. Urodynamic studies can monitor bladder function changes and the effect of treatment but are available at (half)-yearly intervals at best. We present the pilot data of a non-invasive method to measure bladder pressure at home. Material and methods During catheterization an extra tube is connected to the catheter. By placing this tube along a vertical ruler the bladder pressure at that time point is measured in cm water and bladder volume (ml) is noted. During regular videourodynamic investigations this method was compared to the standard methodology in 22 patients. For a pilot clinical study we included 5 children with MMC, aged 0-3 years, who were on CIC. Bladder pressure was measured at home during the first morning catheterization by the parents, daily for the first two weeks and twice weekly thereafter. Results The home bladder pressures deviated <10% from the videourodynamic pressures. In the home situation bladder pressure was easily measured by the parents. The home-measured bladder pressure showed the expected day-to day variation related to bladder filling. Because of the fixed time of measurement variation over a longer period was small. Conclusions The home bladder pressure equipment allows reliable measurement of the bladder pressure by the parents. The high frequency allows feedback to the physician on the response of bladder pressure to (changes in) treatment and thereby facilitates fine-tuning of the treatment (medication dose or CIC frequency). In addition, weekly feedback to the parents about the effects of bladder therapy on the bladder pressures of their child increases compliance to therapy. Progressive loss of bladder function in children with MMC is an ongoing concern. Urodynamic studies can monitor bladder function changes and the effect of treatment but are available at (half)-yearly intervals at best. We present the pilot data of a non-invasive method to measure bladder pressure at home. During catheterization an extra tube is connected to the catheter. By placing this tube along a vertical ruler the bladder pressure at that time point is measured in cm water and bladder volume (ml) is noted. During regular videourodynamic investigations this method was compared to the standard methodology in 22 patients. For a pilot clinical study we included 5 children with MMC, aged 0-3 years, who were on CIC. Bladder pressure was measured at home during the first morning catheterization by the parents, daily for the first two weeks and twice weekly thereafter. The home bladder pressures deviated <10% from the videourodynamic pressures. In the home situation bladder pressure was easily measured by the parents. The home-measured bladder pressure showed the expected day-to day variation related to bladder filling. Because of the fixed time of measurement variation over a longer period was small. The home bladder pressure equipment allows reliable measurement of the bladder pressure by the parents. The high frequency allows feedback to the physician on the response of bladder pressure to (changes in) treatment and thereby facilitates fine-tuning of the treatment (medication dose or CIC frequency). In addition, weekly feedback to the parents about the effects of bladder therapy on the bladder pressures of their child increases compliance to therapy.

THE USE OF RADIOGRAPHY, URODYNAMIC STUDIES AND CYSTOSCOPY IN THE EVALUATION OF VOIDING DYSFUNCTION

Children with dysfunctional voiding disorder often undergo radiological, cystoscopic or urodynamic evaluation to identify an anatomical or organic cause. We determined the role of these studies in the evaluation, management and ultimate outcome of a large patient population with voiding dysfunction at a single institution. We retrospectively evaluated the records of 1, 153 children with dysfunctional voiding disorder treated from 1990 to 1999. A thorough history and physical examination with specific emphasis on voiding patterns were done and urinalysis was performed in all cases. Ultrasound of the urinary system and excretory urography were done in 1,050 (91%) and 24 (2%) patients, respectively, while voiding cystourethrography was performed in 672 (58%), including 564 with a history of nonfebrile urinary tract infection. Cystoscopy and a formal urodynamic study were performed in 61 (5%) and 40 (3.5%) cases, respectively. Mean patient age at referral was 6 years (range 3 to 14). Of the children 74% were girls and 26% were boys. Physical examination of the abdomen, back, genitalia and neurological system was unremarkable in all cases. Ultrasound of the upper urinary system was normal in 1,018 patients (97%) and showed insignificant pyelectasis in 32 (3%). All 24 excretory urography studies were normal and voiding cystourethrography was normal in 470 of 672 cases (70%). Unilateral and bilateral low grade, and unilateral high grade reflux was present in 108, 19 and 3 patients, respectively. Urodynamic studies were performed in 40 children who did not respond to standard treatment. We noted detrusor instability in 16 patients, detrusor-sphincter dyssynergia in 6 and sensory abnormality in 3, while the study was completely normal in 10. Cystoscopy revealed normal findings in 17 cases, trabeculations in 21, inflammation in 20 and type 1 posterior urethral valves in 2. The incidence of upper tract changes and positive anatomical findings in children with voiding dysfunction is too low to justify routine radiological evaluation and cystoscopy. However, in those who present with a nonfebrile urinary tract infection there remains an important role for voiding cystourethrography. We do not recommend routine urodynamics in children with voiding disorder because this study does not change therapy or influence the final outcome. Thorough history and physical examination lead to the correct diagnosis and treatment in the majority of children. A focus on correcting faulty voiding behavior with the judicious administration of antibiotics and anticholinergic therapy leads to a favorable outcome in most cases.

Lower Urinary Tract Dysfunction and Urodynamics in Children

Lower Urinary Tract Dysfunction and Urodynamics in Children

Urodynamics in Children. Part I. Methodology

We evaluated 237 children for various urologic disorders in the urodynamic laboratory. A total of 334 studies was done, using a 6-channel recorder† combined with a portable fluoroscopic unit. Simultaneous recordings of intravesical pressure, intra-abdominal pressure, urine flow rate, external urethral electromyography and cystourethrography were obtained during bladder filling and voiding. These objective tests have provided us with an insight into the nature of a variety of voiding dysfunctions in children. Details of the methods used for urodynamic testing in these children are outlined and compared to other methods that have been proposed.

Review of fundamental urodynamics in children

During the past three years, 190 children were seen with varied and mostly complicated urodynamic problems. Over 300 studies were performed. This experience prompted a reappraisal of fundamental urodynamic concepts pertinent to pediatric bladder disorders.