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Bladder function development and its urodynamic evaluation in neonates and infants less than 2 years old

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Abstract

AimsTo understand the function development of bladder and its evaluation in neonates and infants less than 2 years old.Methods Literature on neonatal and infant bladder function development and urodynamic evaluation were collected and reviewed.ResultsNormal range of bladder volume, pressure during voiding and other parameters in neonates and infants less than 2 years old is far from set up, making interpretation of UDS findings difficult. This review provides insight into the bladder development process and problems of the lower urinary tract in this age group with special emphasis on the urodynamic evaluation.Conclusions Further animal and human studies will increase our understanding of bladder development leading toward mature function. UDS are still important in providing information for early bladder dysfunction in newborns and infants. Neurourol. Urodynam. © 2014 Wiley Periodicals, Inc.

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... The urinary bladder is responsible for collecting the urine produced by the kidneys and transported by the ureters. The bladder derives from the endoderm, for the epithelial lining (urothelium), and from the mesoderm for the muscles (smooth muscle cells and fibroblasts) [42]. Muscle cells are the first to appear (seven to 10 weeks of gestation). ...
... Muscle cells are the first to appear (seven to 10 weeks of gestation). At the end of the second trimester, the bladder loses its peristaltic conduit shape to become a container with small unordered movements; a circular musculature develops at the neck of the future bladder [42]. At the 15th week of gestation, the urethra presents involuntary striated muscles. ...
... The innervation of the bladder is very complex. Various structures intervene, such as the sacral parasympathetic nerves, the hypogastric sympathetic chain and the pudendal nerves [42]. ...
Article
According to current scientific standards, the fascia is a connective tissue derived from two separate germ layers, the mesoderm (trunk and limbs, part of the neck) and the ectoderm (cervical tract and skull). The fascia has the property of maintaining the shape and function of its anatomical district, but it also can adapt to mechanical-metabolic stimuli. Smooth muscle and non-voluntary striated musculature originated from the mesoderm have never been properly considered as a type of fascia. They are some of the viscera present in the mediastinum, in the abdomen and in the pelvic floor. This text represents the first article in the international scientific field that discusses the inclusion of some viscera in the context of what is considered fascia, thanks to the efforts of our committee for the definition and nomenclature of the fascial tissue of the Foundation of Osteopathic Research and Clinical Endorsement (FORCE).
... In these patients, the spinal cord is often tethered and the presence or not of neurological consequences of the tethering, i.e. motor deficits or bladder-sphincter dysfunction, is crucial in the decision on whether to perform detethering neurosurgery [4]. Early evaluation of bladder function is essential for the choice of treatment strategy as to start CIC or not in the neonatal period [11,12]. In spite of good knowledge of factors leading to renal damage in individuals with SD [13][14][15] there is a lack of consensus for optimal follow up [16,17]. ...
... Voiding observation with provocation test was easy to perform but sometimes adjustments were required due to individual factors such as restrictions of positioning after back surgery. Voiding with stream 12 (Table 2). Newborns with SD had lower voided volumes (max and median volumes p<0.001), greater range regarding the number of voids (p<0.001) and significantly higher minimal residual volumes than healthy newborns (p<0.01), ...
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Extended summary Introduction 4-hour voiding observation with provocation test (VOP) using a scale, a damp detector and ultrasound for determination of residuals, is an easily performed non-invasive method for the evaluation of bladder function in newborns. Neonatal bladder function evaluated with VOP has been described for healthy newborns (HN) but not for children with spinal dysraphism (SD), for whom early bladder evaluation is essential for decisions regarding Clean Intermittent Catheterization and follow-up. The aim of the present study was to describe voiding observation with provocation test in newborns with spinal dysraphism and compare with corresponding data for healthy newborns. Methods and materials At a tertiary hospital, a four-hour voiding observation with provocation (VOP) was performed in 50 neonates (22 girls, 28 boys) with spinal dysraphism (37 open SD, 13 closed SD) consecutively evaluated for possible neurogenic bladder-sphincter dysfunction (1998-2019). All newborns with open SD and 4/13 with closed SD had been through postnatal neurosurgery before the test. Mean age was 10 days. Voiding observation was performed during 4 hours with visual observation the fourth hour recording behavior and urinary flow (with stream, drops). Finally, bladder provocations (e.g. suprapubic compression) were performed, and any leakage was noted. Findings were compared to those of 50 healthy newborns (HN) earlier published (Gladh et al. 2002). There were no significant differences in background data such as gender, age or diuresis between newborns with SD and HN. Results and Discussion Results of VOP for newborns with spinal dysraphism and healthy newborns, volumes group median and range (ml). Data for visual observation of voiding and for provocation test missing for four and two children respectively. Voiding observation with provocation test of children with SD revealed significant differences compared to HN. Some children with SD had frequent small voids/leakages and low bladder volumes while three had no voiding and high volumes. Leakage during bladder provocation test and not voiding with a stream was not seen in HN but were common in newborns with SD (69% resp. 74%) (p<0.01). A child with these findings should thus be investigated further. Identifying children needing Clean Intermittent Catheterization is important as well as being able to postpone or refrain from invasive urodynamic studies if not strongly indicated. VOP may give valuable information for these judgements. Conclusion Newborns with spinal dysraphism differ from healthy newborns in many aspects of bladder function. Bladder function varies between newborns with closed and open spinal dysraphism. Many newborns with spinal dysraphism leak at bladder provocation and void without a stream but healthy newborns do not. Early determination of post-void residuals is mandatory in children with spinal dysraphism and non-invasive VOP gives this information in a standardized way, also adding information on frequency, voiding with a stream and leakage at provocation.
... In Korea, the prevalence of OAB in children between the ages of 5 and 13 years was 16.59% [5]. Franco reported the prevalence of OAB was 5-12% (5-10 years of age) and 0.5% in older adolescents (16)(17)(18) years of age) [6]. ...
... The arrows indicate a normal urodynamic tracing of pressure flow study with sphincter relaxation and detrusor contraction during voiding phase. Finally, it initiated urination cord (Onuf's nucleus), the micturition reflex center in the pontine mesencephalic center (PMC) and the cerebral cortex [17]. The PMC coordinates detrusor and urethral function, while the cerebral cortex facilitates or inhibits micturition. ...
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PurposeTo investigate the correlation between urethral instability (URI) and overactive bladder (OAB) in children. Methods We retrospectively investigated 126 children with OAB and 36 children without OAB using synchro-cystourethrometry. The prevalence of detrusor overactivity (DO) and URI, and the diagnostic sensitivity of DO alone and DO combined with URI, was compared. The OAB children with URI voluntarily received transcutaneous electrical pudendal nerve stimulation with anisodamine (stimulation group, SG) or anisodamine alone (non-stimulation group, NSG). The effectiveness of treatment was evaluated. Average voided volume (AVV), maximum voided volume (MVV), and number of voids per day (NV) were collected and analyzed. ResultsIn OAB children, the prevalence of DO and URI was 51.6 and 32.5%, respectively. The prevalence of URI was 5.6% in controls. The prevalence of URI was significantly higher in OAB children. The diagnostic sensitivity and Youden index of DO combined with URI were higher than DO alone. In SG, 45.7% of children were cured, with a ≥ 50% improvement rate of 82.9%, while no child was cured, with a ≥ 50% improvement rate of 36.8% in NSG. A significant increase in AVV and MVV together, with a decrease in NV, was seen in SG. There was a significant difference in visual analogue scale values between SG and NSG (P < 0.01). Conclusions Urethral instability plays an essential role in the pathogenesis and progression of OAB in children. Synchro-cystourethrometry is a useful urodynamic technology to precisely diagnose OAB, and transcutaneous electrical pudendal nerve stimulation may be an effective treatment for OAB children induced by URI.
... Neonatally, the bladder is often emptied incompletely, whereas most infants still empty their bladder completely at least once during a four-hour observation time (Holmdahl et al., 1996;Gladh et al., 2000). As the child grows, so does the bladder, and the frequency of interrupted voids and of incomplete bladder emptying declines (Van der Cruyssen et al., 2015;Wen et al., 2015). Usually during the second or third year of life, the child becomes gradually more aware of the bladder filling and starts to be able to control micturition. ...
... Wen et al. consider UDS important in providing information on early bladder dysfunction in newborns and infants [28]. Also the ICSS (International Children's Continence Society), in their recommendations for diagnosis and treatment of occult spinal dysraphisms, indicates UDS as an important component for treatment decision, although admitting the challenge in interpreting the results of infants and pretoilet-trained children [25]. ...
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PurposeEarly de-tethering procedures are performed on spinal dysraphisms to prevent neuro-urological deterioration caused by growth. Partial lipoma removal may cause delayed deterioration by re-tethering, while complete removal may increase the risk of postoperative worsening. The present study evaluates the risk of postoperative deterioration and the protective potential of intraoperative neurophysiological monitoring (IOM), with a special reference to the conus lipomas treated with the radical approach.Methods Forty toddlers (< 24 months) underwent complete perioperative neurological and urological assessment, including urodynamic study (UDS). The dysraphisms were subgrouped according to Pang’s classification. IOM was applied in all patients: transcranial motor evoked potentials (tMep) combined with mapping were recorded in all cases while bulbocavernosus reflex (BCR) was evaluable just in 7 cases.ResultsAt preoperative evaluation, 11 children already had UDS impairment and 2 had motor disturbances before neurosurgery. At 1-month follow-up, preoperative motor disturbances were stable, 7/11 UDS alterations normalized, and the remaining 4 were stable. At 6-month follow-up, all motor deficits and 8/11 preoperative UDS alterations had improved. Unfortunately, 7 children with previously normal UDS experienced a new impairment after surgery: 2/7 normalized while 5/7 did not recover. This postoperative permanent urodynamic impairment occurred in 4 chaotic lipoma (CLchaos) and in one terminal myelocystocele (TMC) that means a surgical deterioration rate of 22% for the high risk cases.Conclusions This small highly selected series confirms that early de-tethering may stop or revert the spontaneous neuro-urological deterioration: in fact, preoperative UDS impairment was frequent (27.5%) and improved in all the low surgical risk cases (limited dorsal myeloschisis, filar, transitional and dorsal lipomas). On the contrary, in CLchaos and TMC, early de-tethering was unable to revert preoperative UDS impairment, and radical surgery carried a high risk of new neuro-urological deterioration directly caused by the operation. In our experience, IOM had a protective role for motor functions, while it was less effective for the neuro-urological ones, probably due to the anesthesiology regimens applied. In conclusion, among the dysraphisms, CLchoas proved to be the worst enemy that often camouflages at MRI. Affording it without all possible IOM weapons carries a high risk to harm the patient.
... 14 Additionally, many studies have shown that the newborn's brain has joint or partially joint control of voiding. 11,15 The connections between brain and bladder are already established in newborns. Babies are aware of their elimination needs from birth and communicate those needs through various vocal and bodily signals, the relationship between voiding patterns and brain activity in healthy preterm neonates using video-electroencephalo-graph (video-EEG) has been established. ...
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Background: Child self-administration of urination is one of the most challenging stages of development in early childhood, and it is also an important manifestation of family development in parenting. But a pilot survey shows that urination control has decreased significantly during the past decade in Mainland China.Whether it is related to delay of elimination communication (EC) is unclear. Methods A cross-sectional study in children (aged 3-10 years) was performed by distributing 10 010 anonymous self-administered questionnaires to parents in Mainland China from March to September 2017. T The questionnaires included sociodemographic data,caregivers’ information,and details about the disposable diapers (DD) usage,EC commencement date. Results A total of 8 629 ( 86.22% ) children were qualified to enter the final statistical analysis.The urinary control rates at 2 years old in children with EC starting before 12 months of age was significantly higher than those who start after 12 months of age ( 70.72 %vs 59.02 %,p<0.001),and significantly higher than those no EC ( 70.72 %vs 42.48 %,p<0.001). In addition,there was no significant difference in the rate of urinary control at 2 years old between the subgroups at different EC start times within 12 months. After 12 months, the urinary control rate at 2 years old of different subgroups decreased with the start time of EC, which were: 59.97% and 54.10%. The results of urinary control rates at several other ages (ie, 0.5 years,1 year,and 1.5 years) are similar to those at 2 years of age. There was no difference between groups of different genders. The later the beginning of EC, the lower the urination control was found . EC helps infants move quite easily into traditional toilet training when they are old enough. Conclusions Infants and young children start EC as soon as possible at the age of 3 to 12 months is conducive to the development of daytime urination control. A later onset of EC may be risk factors for urination control.
... Although the male membranous urethra and female middistal urethra are very similar in terms of anatomy, tissue structure, embryonic development, and innervation, the morphology of the male urethral sphincter is different from that of females due to the presence of the male prostate. [24][25][26] This morphological difference between males and females forms the anatomical basis for the functional difference in the urinary sphincter between genders. As a result of the position and existence of the prostate in males, as well as the morphological and functional differences in the urethral sphincter between genders, the response to DBS treatment with respect to urinary functions of PD patients appeared to be more genderspecific, with broader improvements in females. ...
Article
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Purpose: To evaluate the effect of deep brain stimulation (DBS) on urinary dysfunctions in Parkinson's patients. Patients and methods: A total of 416 patients, diagnosed with Parkinson's disease (PD) based on the UK Parkinson's Disease Society Brain Bank Diagnostic Criteria, were enrolled in the study, including 307 males and 109 females. The effects of DBS treatment on urinary functions during urination and bladder storage of these patients were evaluated using testing and assessment scales, such as the American Urological Association Symptom Index (AUA-SI), Overactive Bladder Symptom Scores (OAB-SS), Quality Of Life Scale (QOL), and urodynamic tests. The data were statistically analyzed with the chi-square test and both independent-samples t-test and paired-samples t-test were used in this study. Results: Symptoms of urinary dysfunctions, such as urinary frequency, urgency, and incontinence, in the patients with PD were notably relieved by DBS treatment (P<0.05), and the OAB-SS and bladder storage problems were greatly improved as well (P<0.05). Compared with those in male patients, DBS surgery significantly improved the AUA-SI, urinary symptom scores, and QOL in female PD patients (P<0.05), as well as other functional indicators related to the urinary tract, including the maximum urinary flow rate, detrusor pressure at peak flow, and residual urine volume in female PD patients (P<0.05). Conclusion: DBS surgery is effective in improving urinary functions in PD patients, as primarily reflected by the alleviation of urinary symptoms such as urinary frequency, urgency, and incontinence. Female PD patients displayed better urinary function outcomes from DBS treatment than did male patients.
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Introduction There is no general agreement among paediatric urologists on how infants with spina bifida (SB) should be investigated after birth. Recently the EUA/ESPU guidelines have been published recommending a baseline DMSA scan in the first year of life and a Voiding Cystourethrogram (VCUG) or Videourodynamic (VUD) between the second and third month of life. Objective The aim of this study was to evaluate the outcome of renal investigations in the first year of life in infants with SB to verify if an early DMSA scan is indicated in the management of this group of patients. Methods All renal imaging, Renal and Bladder Ultrasound (RBUS), VCUGs, VUDs and DMSA were reviewed by two independent assessors to evaluate outcome. Results Seventy patients with spina bifida (40 girls) were enrolled between June 2015 and February 2020. An early VUD detected vesico-ureteral reflux (VUR) in 8/49 (16%) of patients. An early VUD also gave additional information on detrusor under or over activity, bladder trabeculation, end filling detrusor pressure (EFDP) and sphincteric incompetence. DMSA scan detected renal scarring in 4/68 (6%) patients. Three of these 4 patients had significant history of febrile UTIs while the fourth patient had grade 2 left sided VUR. Conclusions The initial assessment of a newborn with myelodysplasia includes a Renal and Bladder Ultrasound during birth hospitalization. This study confirms the recently published EUA/ESPU guidelines on the management of neurogenic bladder in children and adolescents, which recommend a VUD or VCUG & Cystomanometry with Electromyogram (CMG) (if VUD not available) in the first 6-12 weeks of life. A selective approach to DMSA scan only in infants with SB who either had a febrile UTI or vesico-ureteric reflux would not have missed any scarring or dysplasia and would have saved 60 unnecessary nuclear scans.
Article
Aims: To investigate the prevalence of overactive bladder (OAB) and assess its risk factors in 5- to 14-year-old Chinese children. Methods: A cross-sectional study of OAB prevalence was performed by distributing 11 800 anonymous self-administered questionnaires to parents in five provinces of mainland China from July to October 2018. The questionnaires included questions on sociodemographics, history of urinary tract infection (UTI), lower urinary tract symptoms (LUTS), family history of LUTS, bowel symptoms, and details about the elimination communication (EC) start time. OAB was defined as urgency and increased the daytime frequency with or without urinary incontinence. Results: A total of 10 133 questionnaires qualified for statistical analysis. The overall prevalence of OAB was 9.01% and decreased with age, from 12.40% at 5 years to 4.55% at 14 years (χ2 trend = 88.899; P < .001). The proportion of dry OAB increased with age, whereas the proportion of wet OAB decreased. A late-onset of EC was associated with a high OAB prevalence (χ2 trend = 39.802; P < .001). Children with obesity, a history of UTI, nocturnal enuresis (NE), a family history of LUTS, constipation, and fecal incontinence had a higher prevalence of OAB than did normal children (P < .05). Conclusion: Obesity, a history of UTI, NE, a family history of LUTS, and bowel symptoms are risk factors associated with OAB. Starting EC before 12 months of age might help reduce the prevalence of OAB in children.
Chapter
Urologic manifestation, evaluation, and management of a child with a tethered cord secondary to occult spinal dysraphism are not clearly understood. There are no strong evidence-based studies that help guide the pediatric urologist. This chapter reviews the basic understanding of occult spinal dysraphism and its potential impact on urinary bladder dynamics and symptomatic voiding dysfunction. The foundation of management often centers on urodynamic testing which provides objective assessment of urinary bladder function. The urodynamic study helps define current status directing active management and provides a baseline that can be utilized to place in perspective changes that might be occurring because of the progression of cord tethering. The potential need for operative intervention of the tethered cord due to occult spinal dysraphism based on urologic symptoms or urodynamic parameters will be discussed along with the expected outcome.
Article
Aims To introduce the standard procedure of cystometry and interpretation of the results in children. Methods The literature on cystometry in children in PubMed for the last 20 years was reviewed. The updated knowledge regarding indication, preparation, technique, and interpretation of cystometry in children were summarized. Results Filling cystometry is the core content of a paediatric urodynamic study. In this section, the technique for performing cystometry is introduced in details. Emphasis is placed on correctly setting up the equipment according to ICS and ICCS guidelines, using appropriate terminology, providing indications for its performance with specific considerations for children, and proper interpretation of results. Conclusions Cystometry can be used in children including newborn to evaluate lower urinary tract dysfunction.
Chapter
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The second edition of Doppler Ultrasound in Obstetrics & Gynecology has been expanded and comprehensively updated to present the current standards of practice in Doppler ultrasound and the most recent developments in the technology. Doppler Ultrasound in Obstetrics Gynecology encompasses the full spectrum of clinical applications of Doppler ultrasound for the practicing obstetrician-gynecologist, including the latest advances in 3D and color Doppler and the newest techniques in 4D fetal echocardiography. Written by preeminent experts in the field, the book covers the basic and physical principles of Doppler ultrasound; the use of Doppler for fetal examination, including fetal cerebral circulation; Doppler echocardiography of the fetal heart; and the use of Doppler for postdated pregnancy and in cases of multiple gestation. Chapters on the use of Doppler for gynecologic investigation include ultrasound in ectopic pregnancy, for infertility, for benign disorders and for gynecologic malignancies. With more than 500 illustrations, including over 150 in color, this book is a must-have reference for all practicing obstetrician- gynecologists, radiologists and sonographers who are interested in maternal-fetal Doppler sonography.
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There is an agreement to use simple formulae (expected bladder capacity and other age based linear formulae) as bladder capacity benchmark. But real normal child's bladder capacity is unknown. To offer a systematic review of children's normal bladder capacity, to measure children's normal maximum voided volumes (MVVs), to construct models of MVVs and to compare them with the usual formulae. Computerized, manual and grey literature were reviewed until February 2013. Epidemiological, observational, transversal, multicenter study. A consecutive sample of healthy children aged 5-14 years, attending Primary Care centres with no urologic abnormality were selected. Participants filled-in a 3-day frequency-volume chart. Variables were MVVs: maximum of 24 hr, nocturnal, and daytime maximum voided volumes. Factors: diuresis and its daytime and nighttime fractions; body-measure data; and gender. The consecutive steps method was used in a multivariate regression model. Twelve articles accomplished systematic review's criteria. Five hundred and fourteen cases were analysed. Three models, one for each of the MVVs, were built. All of them were better adjusted to exponential equations. Diuresis (not age) was the most significant factor. There was poor agreement between MVVs and usual formulae. Nocturnal and daytime maximum voided volumes depend on several factors and are different. Nocturnal and daytime maximum voided volumes should be used with different meanings in clinical setting. Diuresis is the main factor for bladder capacity. This is the first model for benchmarking normal MVVs with diuresis as its main factor. Current formulae are not suitable for clinical use. Neurourol. Urodynam. © 2013 Wiley Periodicals, Inc.
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Traditionally, sensory signaling in the urinary bladder has been largely attributed to direct activation of bladder afferents. There is substantive evidence that sensory systems can be influenced by non-neuronal cells, such as the urothelium, which are able to respond to various types of stimuli that can include physiological, psychological and disease-related factors. The corresponding release of chemical mediators (through activation of a number of receptors/ion channels) can initiate signaling mechanisms between and within urothelial cells, as well as other cell types within the bladder wall including bladder nerves. However, the mechanisms underlying how various cell types in the bladder wall respond to normal filling and emptying, and are challenged by a variety of stressors (physical and chemical) are still not well understood. Alterations or defects in signaling mechanisms are likely to contribute to the pathophysiology of bladder disease with symptoms including urinary urgency, increased voiding frequency and pain. This review will discuss some of the components involved in control of lower urinary tract function, with an emphasis on the sensor and transducer roles of the urothelium.
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Purpose: The development of micturition in mice has been poorly studied because of the minute urine volume voided per micturition. We characterized development of the micturition pattern in young mice. Materials and methods: Micturition in young and adult C57BL/6 strain mice, including 5 males and 4 females at age 3 weeks immediately after weaning, and 5 of each gender at ages 9 to 10 weeks, respectively, was recorded by the automated voided stain on paper method. Micturition data were obtained under 12-hour light/dark cycles in young mice for 16 days and in adult mice for 4 days. Diurnal variations were assessed during 8 hours until the first void after lights off and those until lights on. The 24-hour rhythmicity of urinary frequency was calculated for 4-day data at the beginning and at the end on young mice, and for 4-day data on adult mice using a chi-square periodogram and relative power spectral density. Results: Mean frequency was 20 to 30 times per day. Total daily urine volume and mean daily urine volume voided per micturition increased with age. The diurnal rhythm of frequency matured to adult levels with development, which was primarily achieved by maturation of the diurnal variation of urine volume in male mice, followed by female mice. Diurnal variation of urine volume voided per micturition was indistinct at the initial stage and gradually matured toward adult levels. Conclusions: The automated voided stain on paper method was used to record micturition development in young mice. This generated data corresponding to frequency-volume charts in humans. Our findings could lead to the establishment of a mouse model of developmental micturition disorders, such as nocturnal enuresis.
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Functional lower urinary tract problems, bladder and bowel problems, or dysfunctional elimination syndrome are all terms that describe the common array of symptoms that include overactive bladder syndrome, voiding postponement, stress incontinence, giggle incontinence, and dysfunctional voiding in children. This article discusses the nomenclature and looks at the pathophysiology of functional bladder disorders from a different perspective than has been the norm in the past. Some standard medical treatments as well as some newer forms of treatment are outlined. Treatment algorithms for urinary frequency and urinary incontinence have been created to help the practitioner manage the patient.
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PurposeWe updated the terminology in the field of pediatric lower urinary tract function.Materials and Methods Discussions were held in the board of the International Children's Continence Society and an extensive reviewing process was done involving all members of the International Children's Continence Society, the urology section of the American Academy of Pediatrics, the European Society of Pediatric Urology, as well as other experts in the field.Results and Conclusions New definitions and a standardized terminology are provided, taking into account changes in the adult sphere and new research results. Neurourol. Urodynam. 26:90–102, 2007. © 2006 Wiley-Liss, Inc.
Article
Cystometry is increasingly being used in infants to diagnose bladder dysfunction. However, infantile urodynamic patterns have not been fully established. In this study we investigated the urodynamic patterns in young infants with renal dilation or a history of urinary tract infection, but with no apparent lower urinary tract symptoms. We use video cystometry with simultaneous perineal EMG recording. Thirty-five infants (27 male and 8 female) with congenital renal dilatation or a history of urinary tract infection at age 2 days to 24 months old were involved. We found that detrusor instability occurred in 8.6% of these subjects. Bladder capacity increased with age but less than would nomally be expected. An intermittent voiding pattern was observed in 57% (20/35) of subjects and was characterized by a single or recurring increase in sphincter activity with a simultaneous rise in the voiding detrusor pressure curve. The maximum voiding detrusor pressure with pelvic floor overactivity was significantly higher than that with no pelvic floor overactivity (105ᇀ cmH2O vs 69ᆪ cmH2O, P<0.001). The median post-voiding residual volume was 2 (range 0 to 65) ml. We conclud that in infants with no apparent lower urinary tract symptoms, bladder instability is uncommon, and the capacity is lower than the normally expected range; an intermittent voiding pattern is common and the residual urine volume showed great variation. This probably represents an immature detrusor-sphincter function.
Chapter
Three-dimensional (3D) reconstruction of ultrasound images was first demonstrated nearly 15 years ago but only now is becoming a clinical reality. In the meantime, methods for 3D reconstruction of computed tomography (CT) and magnetic resonance imaging (MRI) have achieved an advanced state of development, and 3D imaging with these modalities has been applied widely in clinical practice. Three-dimensional applications in ultrasound have lagged behind CT and MRI, because ultrasound data is much more difficult to render in 3D, for a variety of technical reasons, than either CT or MRI data. Only in the past few years has the computing power of ultrasound equipment reached a level adequate enough for the complex signal processing tasks needed to render ultrasound data in three dimensions. Within the past years several new ultrasound techniques have appeared. Three-dimensional ultrasound scanning, in which there has been great interest, is one of them [1]. Especially within obstetrics and gynecology several papers on that topic describe promising results. Gynecologic diagnostics relying on morphologic signs and accurate distance and volume measurements is one of the areas believed to benefit from 3D ultrasound; however, until now only few prospective works have been published, most of them counted as preliminary. One of the main reasons might be the huge technologic challenge. It is proposed that technologic progress over the next few years will allow feasible real-time 3D scanning. Gynecologic ultrasound scanning will thereby undoubtedly take another giant leap forward.
Article
To investigate the difference of voiding pattern between newborns with and those without hypoxic ischemic encephalopathy (HIE). Forty hospitalized newborns aged 4-21 days were included in this study. Twenty-one were preterm newborns with HIE, and the remaining 19 preterm newborns were without HIE. The voided volume, postvoid residual (PVR) volume, consciousness at voiding, voiding time, voiding frequency, and quantity of intake milk and liquid within 4 hours from 8 am-12 pm were recorded. The liquid intake was the same in both groups according to standard protocol. The diaper weight difference before and after voiding was defined as voided volume. The PVR volume was determined by ultrasound. The state of consciousness at voiding was monitored by electroencephalography. Voided volume and rate of consciousness at voiding was significant lower in newborns with HIE compared with the control group ([10.8 ± 6.5 mL, 16.3 ± 17.1%] vs [14.1 ± 7.1 mL, 57.1 ± 21.0%], P <.05, respectively), whereas PVR volume and voiding frequency were significant higher ([1.6 ± 1.0 mL, 4.0 ± 1.1 times] vs [1.2 ± 0.9 mL, 3.2 ± 0.9 times] per 4 hours, P <.05, respectively). The differences in voiding pattern supported the concept that the higher centers of the central nervous system were involved in the control of voiding. HIE had a significant effect on voiding pattern of preterm newborn.
Article
The objective of this ICCS standardization document is to report the initial diagnostic evaluation and subsequent work-up of children with neuropathic bladder dysfunction. Due to a paucity of level I or level II, "levels of evidence" publications, these recommendations are actually a compilation of best practices because they seem to be effective and reliable, although not with any control. Throughout the document, the emphasis is on promoting early, comprehensive evaluation of lower urinary tract function that is thorough but with a minimum of unnecessary testing. This includes what tests to order, when to order them and what to do with the results. Some of the recommendations may not be practical in various worldwide locations but the suggested testing should be considered the ideal approach to completely diagnosing and then promulgating treatments based on the full knowledge of the condition and its effect on urinary tract function. Once the findings are delineated, those lower urinary tract patterns of dysfunction that put the kidneys at risk for deterioration, that are barriers to attaining eventual continence, and that have long-term consequence to the lower urinary track can be obviated by specific management recommendations. The indications and timing of investigations to achieve these objectives are clearly defined in each diagnostic category and during follow-up. This document should be used as a basis for appropriate evaluation and timely surveillance of the various neuro-urologic conditions that affect children.
Article
To investigate the voiding pattern in <4-week-old newborns by 12-h daytime observation periods. Twenty-one healthy 1- to 28-day-old newborns were included (10 full term, 11 preterm). The 12-h free voiding parameters, including voiding frequency (VF), voiding volume (VV), post-voiding residual volumes (PRV) and status at voiding (awake/sleep), were recorded at day 1, 4, 7, 14 and 28 after birth. Voiding was recorded 778 times. VF increased in the full-term and preterm newborns between day 4 and 7, decreased in preterms between day 14 and 28, but remained higher than in the full terms. VV increased twice in full terms and once in preterms during 28 days and PRV fluctuated. In contrast, VV was higher in the full term than in the preterms at days 4, 7, 14 and 28. PRV was higher at days 4 and 28. Interrupted voiding was less frequent in the full term than in the preterms. Voiding pattern in the preterms differed in many ways from that of the full-term newborns. Frequent interrupted and incomplete voiding pattern in the preterm newborns indicates a disrupted coordination of the detrusor-sphincter and a delayed maturation of the neural micturition centre.
Article
In the last decade interest has arisen in the use of ultrasound derived measurements of bladder wall thickness, detrusor wall thickness and ultrasound estimated bladder weight as potential diagnostic tools for conditions known to induce detrusor hypertrophy. However, to date such measurements have not been adopted into clinical practice. We performed a comprehensive review of the literature to assess the potential clinical usefulness of these measurements. A MEDLINE® search was conducted to identify all published literature up to June 2009, investigating measurements of bladder wall thickness, detrusor wall thickness and ultrasound estimated bladder weight. Measurements of bladder and detrusor wall thickness, and ultrasound estimated bladder weight have been studied in men, women and children. A convincing trend has been shown in the ability of these measurements to differentiate men with from those without bladder outlet obstruction. In addition, measurements of bladder wall thickness have revealed a considerable difference between detrusor overactivity and urodynamic stress incontinence. A number of confounding variables and a lack of standardized methodology has resulted in discrepancies among studies. Therefore, reproducible diagnostic ranges or cutoff values have not been established. Ultrasound derived measurements of bladder and detrusor wall thickness, and ultrasound estimated bladder weight are potential noninvasive clinical tools for assessing the lower urinary tract.
Article
To investigate preoperative urinary flow patterns in hypospadic infants and compare them to those from normal infant boys. Twenty-one boys (median age 14.0, range 12.8-21.6 months) referred for distal hypospadias surgery were compared to 19 healthy boys (median age 12.0, 9.2-19.8 months). In both groups a 14-mm transit-time ultrasound flow probe mounted around the base of the penis continuously registered uroflow. Median maximum flow rate (Q(max)) was significantly lower in hypospadics (2.4 vs 4.4 ml/s, P < 0.01) while there was no difference in the voided volume per micturition (19.0 vs 21.0 ml, P 0.33). Flow curve pattern analysis revealed plateau-shaped curves in 31% of hypospadics compared to none in normal infant boys. Interestingly, dyscoordinated flow curves (interrupted, staccato, spike-dome) were less common in the hypospadics (36% vs 64%, P < 0.01). Meatal size did not correlate to Q(max) (rho = 0.26, P = 0.26). Infants with hypospadias void with a lower Q(max) and a lesser degree of dyscoordination as compared to normal infant boys. It can be speculated that decreased urethral compliance may contribute to the lower Q(max) and may act as a silencer for dyscoordination.
Article
We sought to assess urinary flow patterns in premature males using ultrasound flow probes. Specifically customized ultrasound flow probes connected to a flowmeter were mounted on the penis of 29 premature males (median gestational age 31.3 weeks). Flow data were sampled to a personal computer and flow curves were assessed with regard to configuration, maximum flow rate and voided volume. Examinations were performed at the neonatal unit within the ambient environment of the incubators and under the surveillance of a study nurse for a period of 4 hours. Data from 25 boys (98 voids) were applicable for analysis. Flow curve configuration was bell shaped in 48% of patients, interrupted in 44%, staccato in 6% and plateau in 2%. Overall 59% of flows were dyscoordinated, and no patient with more than 1 assessable void had exclusively coordinated flows. Median voided volume was 3.9 ml (range 0.6 to 25.2), median maximum flow rate was 1.0 ml per second (0.3 to 10.0) and median number of voids per hour was 1.0 (0.2 to 3.6). No correlation was found between flow curve configuration and maximum flow rate (p = 0.32). However, plateau shaped curves were associated with larger voided volumes (p = 0.05). Urinary flow pattern assessment in preterm males is possible and reveals a high degree of dyscoordination. There is a tendency toward a mixture of coordinated and dyscoordinated flow patterns in the same individual.
Article
Much current research on lower urinary tract physiology focuses on afferent mechanisms. The main goals are to define and control the signaling pathways by which afferent information is generated and conveyed to the central nervous system. We summarize recent research on bladder afferent mechanisms. We systematically reviewed the literature by searching PubMed up to June 2009 with focus on the last 5 years. At least 2 signaling pathways can be identified, including the urothelial and the myogenic pathway. The urothelial pathway is a functional unit consisting of the urothelium, interstitial cells and afferent nerves in the lamina propria. Signaling occurs via muscle-mucosal mechanoreceptors, mucosal mechanoreceptors and chemoreceptors. The myogenic pathway is activated via in-series mechanoreceptors responding to distention and via spontaneous contractile activity in units of myocytes generating afferent noise. To control dysfunctional micturition we must know more about all components involved in normal micturition control, including how afferent information is handled by the central nervous system.
Article
A totally non-invasive transperineal urodynamic technique using Doppler ultrasonography has been developed. Normal urine doesn't have blood cells so urine was thought not to produce Doppler effects. However, basic studies confirmed that the decrease of pressure at high velocity (Bernoulli effects) caused dissolved gas to form microbubbles, which are detected by Doppler ultrasonography. Subjects sat and a probe was advanced via remote control to achieve gentle contact with the perineal skin. The digital uroflow data signals and the color Doppler ultrasound video images were processed on a personal computer. This method was viable to diagnose the degree of bladder outlet obstruction. The advantage of being rapid, effective, and equipped with no special attachments allows it to surpass any other non-invasive urodynamic methods. The difference between the echocardiogram and the ultrasound urodynamic system is only the frequency of obtaining velocity information: more than 50 times per minute vs once every several hours, respectively. Although the ultrasound urodynamic system is more difficult to develop than the echocardiogram, one principle is shared by both methods. The patient can void freely without interruptions, there is no contact between the penis and the equipment and it is specifically directed toward non-invasive diagnosis. The development of non-invasive Doppler ultrasound videourodynamics will dramatically expand understanding of voiding function.
Article
To discuss (1) mechanisms involved in the generation and control of myocyte contractions and consequent afferent nerve activity and (2) these mechanisms as targets for drugs aimed for treatment of overactive bladder (OAB) symptoms and detrusor overactivity (DO). Literature review of myocyte activation, bladder afferent nerves, mediators in the bladder, and translational aspects of the findings. During bladder filling, there is normally no parasympathetic outflow from the spinal cord. Despite this, the bladder develops tone during filling and also exhibits non-synchronized local contractions and relaxations that are caused by a basal myogenic mechanical activity that may be reinforced by release of, for example, acetylcholine from non-neuronal and/or neuronal sources or local mediators, such as prostaglandins and endothelins. It is suggested that these spontaneous contractions are able to generate activity in afferent nerves ("afferent noise") that may contribute to DO and OAB. Spontaneous bladder myocyte contractions and factors that are able to modulate them, as well as the consequent afferent nerve activity, may be targets for drugs meant for treatment of OAB/DO.
Article
We studied the natural development of urinary flow and lower urinary tract function in healthy male infants. Custom-made ultrasound flow probes connected to a flowmeter were mounted on the penis in 20 infants who previously had been assessed in the immediate postnatal period. Median subject age was 10.7 months (range 9.2 to 19.8). Flow data were sampled to a personal computer and flow curves were assessed regarding configuration, maximum flow rate and voided volume. Results were analyzed statistically and were compared to those obtained in the neonatal period. Comparison of uroflow parameters was assessed by using analysis of variance, while contingency coefficients and Wilcoxon test were used for comparisons involving nominal and paired data, respectively. A p value of less than 0.05 was considered statistically significant. A total of 19 infants had evaluable data, of whom 15 also had evaluable data from the original neonatal study. Flow curve pattern was bell shaped in 32% of patients, interrupted in 46%, staccato in 15%, tower in 3% and spike-dome in 3%. Dyscoordinated patterns accounted for 46% of all flows, a significant increase compared to the neonatal period, in which only 34% of flows were considered dyscoordinated (p <0.01). While voided volume increased significantly with age, maximum flow rate remained more or less stable. Contrary to conventional wisdom, infants continue to exhibit urinary flow dyscoordination to an even greater extent than in the neonatal period. Therefore, the anticipated normalization of urinary flow is most likely to occur after the first year of life.
Article
The afferent innervation of the urinary bladder consists primarily of small myelinated (Adelta) and unmyelinated (C-fiber) axons that respond to chemical and mechanical stimuli. Immunochemical studies indicate that bladder afferent neurons synthesize several putative neurotransmitters, including neuropeptides, glutamic acid, aspartic acid, and nitric oxide. The afferent neurons also express various types of receptors and ion channels, including transient receptor potential channels, purinergic, muscarinic, endothelin, neurotrophic factor, and estrogen receptors. Patch-clamp recordings in dissociated bladder afferent neurons and recordings of bladder afferent nerve activity have revealed that activation of many of these receptors enhances neuronal excitability. Afferent nerves can respond to chemicals present in urine as well as chemicals released in the bladder wall from nerves, smooth muscle, inflammatory cells, and epithelial cells lining the bladder lumen. Pathological conditions alter the chemical and electrical properties of bladder afferent pathways, leading to urinary urgency, increased voiding frequency, nocturia, urinary incontinence, and pain. Neurotrophic factors have been implicated in the pathophysiological mechanisms underlying the sensitization of bladder afferent nerves. Neurotoxins such as capsaicin, resiniferatoxin, and botulinum neurotoxin that target sensory nerves are useful in treating disorders of the lower urinary tract.
Article
To investigate the effect of voiding position on uroflowmetric variables and postvoid residual urine (PVR) volume in healthy adult men without lower urinary tract symptoms (LUTS). Men without LUTS were enrolled. Participants were asked to report to the urodynamic suite with comfortably full bladder for uroflowmetry. Each participant performed six voids into digital uroflowmeter (Solar Silver, Medical Measurement System, The Netherlands), all on separate occasions, twice in each of the standing, sitting, and squatting down positions. PVR was measured using transabdominal ultrasound (Siemens). Total 72 participants were enrolled and 61 completed the study; their mean (+/-SD) age was 26.6 +/- 6.9 years. All of them but one was accustomed to void in standing and squatting positions. The mean maximal flow rates (Q(max)) and average flow rates (Q(ave)) were significantly lower in sitting position, than standing and squatting positions (Q(max): 19.8 +/- 7.4 vs. 23.8 +/- 7.7 and 24.4 +/- 8.1 ml/sec, respectively; P = 0.0001. Q(ave): 11.2 +/- 4.5 vs. 13.9 +/- 4.5, and 13.8 +/- 5.1 ml/sec, respectively; P = 0.0001). The corresponding values of voiding time were significantly higher (t(vv): 38.6 +/- 20.7 sec vs. 28.3 +/- 15.3 and 30.6 +/- 18.1 sec, respectively; P = 0.0001). The latter two positions were statistically similar in voiding characteristics. Voided volumes and PVR were statistically similar among all the three positions. Uroflow parameters were higher in standing and squatting positions compared to sitting in individuals not accustomed to void in sitting position. Therefore, uroflowmetry should not be performed in a position the individual is not familiar with.
Article
Urodynamic evaluations were done on 37 children to diagnose voiding pattern abnormalities and/or recurrent urinary infections. Each of 25 children had 2 sets of testing to judge a practical method of urodynamic evaluation. Bipolar anal skin electrodes were compared to bipolar perianal muscle needle electrodes as a means of monitoring the urethral sphincter/pelvic floow electromyographic activity. In addition, the urethral catheter was compared to the suprapubic catheter as a means of monitoring intravesical pressure. The results were similar and statistically significant (p less than 0.001). The remaining 12 children were evaluated based only on the results of bipolar anal skin electrodes and uroflowmetry. The results of both groups clearly demonstrated that surface perianal electrodes are practical, accurate and reliable for the diagnosis and treatment of children with voiding pattern abnormalities. We recommend the use of surface electrodes and a urethral catheter as techniques for the urodynamic evaluation of voiding pattern abnormalities of children without overt neuropathology or extensive urethral operation. Preoperative surface electromyography of the urinary sphincters may prove to be a useful screening test to detect occult dyssynergia in patients who have had failed ureteral reimplants.
Urodynamic examination yields invaluable information about lower urinary tract function in infants and children in the following clinical situations: Daytime urinary incontinence, suspected infravesical obstruction, overt or suspected neurogenic bladder dysfunction, vesico-ureteral reflux with upper tract dilatation and chronic or recurrent bacteriuria. A normal development of lower urinary tract function during the first 5 years of life means that detrusor contractility will be successively more inhibited; furthermore, the child will become aware of bladder filling and will be able to postpone or initiate micturition. A disturbed or delayed development may well be the most important cause of dysfunctional states in the lower urinary tract later in life. Most urodynamic variables are age-dependent. Normal bladder capacity can be fairly well assessed by: Bladder capacity in ml = 30 + (age in years x 30). Normal maximum urinary flow during micturition (in ml/s) should approximately equal the square root of voided volume (in ml). The normal range (+/- 2SD) is given by the value thus obtained +/- 7 ml/s. Intravesical pressure is lower in girls than in boys, and lower in infants than in older children, but otherwise it does not vary with age. A tense and apprehensive child will not produce reliable urodynamic data. This is, no doubt, the most important source of error when examining children. It is strongly emphasized, therefore, that the examination has to be performed in a kind, understanding and relaxed atmosphere.
Article
There are three superimposed centres of micturition: the sacral spinal centre, which is the oldest centre controlled by the pontine centre situated in the brain stem, which in turn is under the control of multiple subconscious structures: cerebellum, striate nucleus, hypothalamus and conscious structures: limbic cortex, frontal ascending and parietal ascending circumduction. The nervous pathways consist of the classical spinal pathways as far as their point of emergence. The innervation involves 2 systems:--a supra-levator system consisting of the essentially sympathetic superior hypogastric plexus and the essentially parasympathetic inferior hypogastric plexus which innervates the seminal tract, the bladder and the prostatic urethra;--a infra-levator system consisting of the internal pudendal nerve which innervates the striated sphincter.
Article
This chapter discusses the functional and the morphological properties of the spinal visceral afferent neurons, supplying the abdominal and pelvic organs. These neurons are involved in the regulation of the visceral functions, in sensations and in various spinal and supraspinal reflexes. Special emphasis has been placed on the visceral nociception and pain. The spatial resolution of the sensations that can be elicited from the viscera is relatively vague and can be fully explained, by the segmental width of the afferent inflow from each viscus. Most spinal visceral afferent units have various common functional properties: they are silent or display a low rate of ongoing activity; their axons are unmyelinated or thinly myelinated (conduction velocity below 2 m/second and mostly below 20 m/second, respectively); their receptive fields consist of from 1-9 mechanosensitive sites located in the mesenteries on the serosal surface or on the walls of the organs; local pressure in their receptive fields elicits slowly adapting responses; they respond to distensions and contractions of the viscera and to stretching of their mechanosensitive endings; they respond to various chemical stimuli applied in their receptive fields.
Article
This chapter discusses the neuroanatomical experiments that examine the segmental distribution and the central projections of the afferent neurons innervating the urogenital system, large intestine, heart, and upper abdominal organs and the identity of the peptide neurotransmitters in visceral afferent pathways. Recently, developed neuroanatomical tracing methods have yielded important advances in the knowledge of the organization of visceral afferent pathways at various levels of the spinal cord. Horseradish peroxidase tracing experiments have shown that afferent projections from a number of visceral organs exhibit a similar pattern of termination in the spinal cord, and that this pattern is markedly different from that of the somatic afferent neurons that innervate the skin. In addition, neurochemical studies, in which the axonal tracing techniques were combined with immunocytochemistry, revealed that a large percentage of the visceral afferent neurons exhibit neuropeptide immunoreactivity. These findings raised the possibility that neuropeptides may be important transmitters or neuromodulators in the visceral afferent systems.
Article
The series comprised 41 children aged 6 to 14 years consecutively referred with recurrent urinary tract infection and/or enuresis. Carbon dioxide cystometry was carried out in the supine and the erect position and combined with simultaneous electromyography (EMG). The external urethral sphincter was examined with a ring electrode mounted on a urethral catheter, while recordings from the striated anal sphincter were based on an anal plug electrode and perianal electrocardiographic (ECG) skin electrodes: 211 EMG and cystometric examinations were performed and all three methods gave satisfactory results. Correlation between them was good, as was reproducibility. Perianal surface ECG electrodes are recommended for the evaluation of functional disturbances of the external sphincter. They are painless, easy to use, and are well tolerated by the patient.
Article
A series of human fetal and neonatal specimens ranging in age from the second month of intrauterine development to 4 1/2 years after birth has been examined using histological and histochemical techniques. In both sexes histologically differentiated smooth muscle cells were evident in the bladder wall from the 52 mm crown-rump length stage onwards--urethral smooth muscle was not distinguishable until 119 mm crown-rump length. In addition to relatively late differentiation, urethral smooth muscle was histochemically distinct from the urinary bladder detrusor muscle. Sex differences in the arrangement and innervation of smooth muscle in the proximal urethra have also been observed, and these findings lend support to the presence of a pre-prostatic urethra sphincter. It seems likely that this sphincter acts principally to prevent reflux of ejaculate into the bladder during seminal emission.
Article
Striated muscle associated with the female urethra and vagina constitute a continuous mass which appropriately may be called the urogenital sphincter. Though continuous, the muscle may be separated into two parts--one that surrounds the urethra, and the other surrounding the urethra and vagina. The individual muscle fibers are small and are embedded in connective tissue and infiltrated with smooth muscle which obscures the visibility of the muscle to gross dissection. Developmentally the muscle primordium is laid down around the urogenital sinus and urethra early, and foreshadows the anatomical arrangement that is maintained in the adult with little change. The urogenital sphincter muscle extends from the base of the bladder where it lies within the pelvic cavity and continues through the urogenital hiatus of the pelvic diaphragm to expand around the vagina in the perineum. Additional fibers attach to the ischiopubic rami and constitute a compressor of the urethra. As a result there is no superior fascia of the so-called "urogenital diaphragm" which closes off a deep perineal compartment or forms a floor of the urogenital hiatus.
Article
To evaluate normal bladder function and micturition patterns in infants. Twenty-one infants (16 boys, five girls; mean age 5.9 months) with no lower urinary tract pathology underwent natural filling cystometry. Micturition patterns were also observed simultaneously with polysomnography in 26 healthy neonates (16 boys, 10 girls; mean age 7.4 days). In infants, cystometry showed (95% CI) a capacity of 42-53 mL, a maximum rise in detrusor pressure during voiding of 95-120 cmH2O and a voiding efficiency (voided volume/capacity) of 0.86-0.91. On micturition, urinary flow was discoordinated from peak detrusor pressures in 10 infants. Detrusor instability occurred in one of 21 infants. Micturition was observed only during wakefulness or on arousal from sleep. In neonates, 17 of 61 recorded voids (28%) were during full wakefulness and 44 (72%) during arousal from sleep. Notably, none of the recorded voids occurred during quiet sleep. The normal infant's bladder was stable and emptied almost completely. Voiding with incomplete co-ordination between detrusor contraction and urinary sphincter relaxation could be normal. Micturition never occurred during quiet sleep. There was cortical arousal in response to a full bladder even in new-born infants. This contradicts the traditional concept of a totally uninhibited bladder in infancy. There are potential implications for the management of children with nocturnal enuresis.
Article
To evaluate natural filling cystometry in infants and young children. The study group comprised 37 infants and young children (mean age, 4.1 years) with various urological conditions. Suprapubic catheters were used in all patients with urethral sensation. Natural filling urodynamic (NFU) studies were performed using an ambulatory recorder and with an observer present throughout. For comparison, 17 of the 37 patients also had slow filling conventional cystometry (CMG). All NFU studies were successfully completed and the great majority of patients were unaffected by the investigation procedures. In comparison with conventional cystometry there were significant differences. For NFU, there was a lower bladder capacity (means, NFU 122 mL vs CMG 188 mL, P < 0.03); lower pressure rise on filling (means, NFU 5.7 cmH2O vs CMG 16.1 cmH2O, P < 0.001) and higher maximum detrusor pressures during micturition (means, NFU 130 cmH2O vs CMG 78 cmH2O, P < 0.01). Voiding efficiency was also slightly greater with NFU compared with CMG. Detrusor instability was recorded in five patients only during NFU and in two other patients only during CMG. A natural filling cystometry method which incorporates an unobtrusive recording system is likely to be superior to conventional CMG for assessing bladder function in infants and children. This is because (i) bladder function is investigated in near to natural conditions, (ii) the patients are mostly unaffected by the investigation procedures, (iii) there are significant differences between NFU and CMG in the measurements obtained, indicating that CMG may give false indices of bladder function.
Article
Fetal lower urinary tract function is under continuous maturation throughout gestation and is an integrated neurophysiologic event by late gestation. Preliminary in vivo study suggests that peripheral and central nervous system regulation of micturition occurs in utero, and that these events can be modulated pharmacologically and through external stimulation. Normal bladder function in utero is essential to normal development of the entire fetus, and in utero modulation of bladder dysfunction may be feasible as our understanding and diagnostic acumen increase.
Article
To evaluate bladder function in infants and children with no apparent voiding symptoms. The study included 83 infants and children (51 boys and 32 girls, aged 3 days to 12 years) with no neurological and lower urinary tract pathology but who had undergone or were about to undergo surgery for upper urinary tract or other pathology. They were evaluated using slow-filling cystometry, with simultaneous electromyography recorded using surface electrodes on the perineum. The voiding variables were compared among groups categorized by age, sex and body weight. In boys and girls, respectively, the mean (SD) post-void residual urine volume (PVR) was 6.3 (3.9) and 5.4 (4.8) mL, the maximum detrusor pressure during voiding was 66.1 (13.1) and 56.6 (14.7) cmH2O and the maximum voiding pressure was 73.9 (16.6) and 62.7 (16.2) cmH2O. There was no significant difference in these variables between the sexes or between infants and children (P > 0.05). Detrusor instability (DI) was apparent in nine of 83 (10.8%) infants and children and occurred in the late filling phase. Bladder capacity increased with age and body weight (from 30 mL in neonates to 350 mL in 12-year-old children), and mean (SD) bladder compliance increased with age, from 3.6 (0.5) mL/cmH2O in infants to 13.3 (3.0) mL/cmH2O in older children, at a filling rate of 5-7 mL/min. In these infants and children with no apparent voiding symptoms, most bladders were stable, DI could occur in the late filling phase of cystometry, voiding was nearly complete, the PVR being usually < 10 mL, and bladder capacity increased with age and body weight.
Article
To compare bladder function in infants with primary vesico-ureteric reflux (VUR) and those with normal lower urinary tracts. The study comprised 42 patients (36 males) with VUR (grades III to V) and 21 (16 males) without VUR (mean age in both groups, 6 months). Intravesical catheters were placed suprapubically under general anaesthesia and, after at least 24 h, natural-tilling urodynamics were monitored for three or more filling and voiding cycles. Various urodynamics patterns were defined: for infants without VUR these were either normal or normal-immature (discoordinated micturition) and none showed features indicating abnormal bladder function. By comparison, 24 of 42 infants with VUR showed abnormal urodynamic patterns (57%, 95% confidence interval 41% to 72%, P < 0.001). Seven (17%) were defined as unstable with small voided volumes, five (12%) had inadequate voiding dynamics, 10 (24%) showed a markedly dyssynergic pattern and two (5%) had obstructive patterns. The unstable, inadequate and obstructive patterns occurred only in boys. Detrusor activity during the filling phase occurred in 14 infants (13 boys) with VUR and in only one without VUR, when it was trivial. Post-void residual volumes of > 30% capacity were seen only in the VUR group (in 24 patients). There were 18 infants with VUR that showed the normal or immature urodynamics patterns, but for the 14 males the voiding pressures were higher than for those without VUR (mean maximum detrusor pressure, 161 and 117 cmH2O, respectively: P < 0.02). There is an association between abnormal urodynamic variables and a diagnosis of primary VUR in young infants (notably males) that may have important implications for concepts about the genesis and persistence of VUR.
Article
We studied the urodynamic pattern in asymptomatic infants who are siblings of children with vesicoureteral reflux. Cystometry and perineal electromyography were performed with voiding cystourethrography in 16 male and 21 female infant siblings screened for reflux at age 0.2 to 7.3 months (median 1.1). Vesicoureteral reflux was present in 25% of the male and 10% of the female infants. In those without vesicoureteral reflux unstable bladder contractions were noted in 8% of the male and 16% of the female subjects. In these infants median maximum voiding detrusor pressure was 127 (range 84 to 211) and 72 cm. water (range 42 to 240), respectively, and median bladder capacity was 20 ml. (range 10 to 49 and 10 to 120, respectively). Maximum voiding detrusor pressure was significantly higher in male than in female infants (p <0.01). Perineal electromyography was interpretable in 13 of the 16 male and 16 of the 21 female infants overall. All but 1 female subject had increased activity during voiding, which was also present intermittently in all subjects. Our study of asymptomatic siblings of children with vesicoureteral reflux has provided results that may be used as reference data for normal urodynamics in early infancy. Instability was rare. Bladder capacity was lower than expected with a predicted capacity at birth of approximately 20 ml. Maximum voiding pressure was high, especially in male subjects. The urodynamic voiding pattern suggests physiological dyscoordination, probably due to immature detrusor-sphincter function.
Article
To elucidate further the maturation of voiding habits from gestation to infancy we investigated the free voiding pattern of healthy preterm neonates. We evaluated 11 male and 8 female healthy preterm newborns at a mean of 32 weeks after cessation of menstrual flow (postmenstrual age). Assessment was done in the neonatal ward using 4-hour voiding observation, a method described previously in studies of free voiding pattern of full-term newborns. The voiding pattern of male and female preterm neonates was characterized by 1 void per hour and a mean voided volume of 53% of bladder capacity with 58% frequency of interrupted voiding. Residual urine was increased but varied during observation (mean 11% bladder capacity) and was 0 after at least 1 void during 4 hours in 14 of the 19 subjects. Two-thirds of all voiding occurred during sleep, whereas a third of the newborns showed signs of arousal with a mean awake time of only 17 minutes. The voiding pattern of preterm versus full-term subjects is characterized by an increased number of interrupted voidings, further indicating that these voidings represent immature behavior of detrusor-sphincter coordination. Also, the high number of voidings during sleep suggest a more immature pattern for preterm newborns.
Article
Interest in the potential diagnostic or prognostic implications of nephromegaly as evidence for compensatory renal hypertrophy has recently been emphasized in a variety of clinical settings. This project was designed to compare the results of linear and nonlinear sonographic models in the interpretation of renal size and growth during the first year of life. We identified all renal and abdominal ultrasound examinations that were performed between March 1994 and October 1997 in full-term infants under age 1 year during which (1) both renal lengths were measured and (2) both kidneys appeared anatomically normal. Using three different computerized algorithms based on published standards for sonographic renal length in relation to age, we calculated z-scores for the renal lengths and compared the results of the three methods: in method A the standards at birth, 1 week, 4 months, 8 months, and 1 year were all used; in method B the 1-week standard was omitted; in method C the standards at 1 week, 4 months, and 8 months were omitted. We evaluated 1,234 renal measurements in 617 patients (293 boys, 324 girls; mean age 0.24 year). Compared with method A, z-scores were significantly increased when either method B or C was used (P < 0. 0001). The mean increment in z-score was + 0.433 for method B and + 1.135 for method C. The prevalence of "nephromegaly" (z > + 2) was significantly increased when subannual standards were omitted (P < 0. 0001): using method A, 20 (1.6 %) kidneys were large for age compared with 74 (6.0 %) using method B, and 214 (17.3 %) using method C. All kidneys that were large for age based on method A were also large for age using both methods B and C. The rate of false-positive diagnosis of nephromegaly was 73 % (54/74 kidneys) with method B and 91 % (194/214 kidneys) with method C. Although the use of multiple subannual standards for renal length in infants less than 1 year of age is time consuming and mathematically more complicated, omission of these standards results in a statistically significant increase in the frequency of "spurious" nephromegaly. Precise application of published standards is important in the interpretation of sonographic measurements of renal length. Omission of the subannual standards for renal length in children who are less than 1 year of age can result in an incorrect impression of nephromegaly.
Article
A 4-hour observation period has been used in infants to investigate suspected bladder dysfunction. The aim of the present study was to extend the usefulness of this protocol by establishing reference values for voiding frequency, intervals, volumes, and residual urine in healthy newborns. The study included 51 healthy newborns, 26 girls and 25 boys, aged 3 to 14 days. During a 4-hour period, all micturitions and residuals were recorded as well as feeding, sleeping, crying, and defecations. The observation was completed with the child undressed to observe the urinary stream during one void. Different provocation tests were tried to induce urinary leakage. All newborns voided with a stream, about once per hour, with a median volume of 23 mL. For each voiding parameter, there was a large inter- and intra-individual variability. Double voidings were common as well as sizable residual volumes. The diuresis was about six times higher than in healthy school children. The healthy newborns did not leak during provocation tests such as manual compression of the bladder. Neurourol. Urodynam. 19:177-184, 2000.
Article
Cystometry is increasingly used in children, being an important diagnostic tool for congenital and acquired malformations such as neurogenic bladder, vesicoureteric reflux, urinary tract infection, urge syndrome, nocturnal enuresis, urinary incontinence and anorectal malformations. During cystometry bladder storage and voiding function can be evaluated. Carefully conducted urodynamic studies provide an insight into the pathophysiologic mechanisms involved in voiding dysfunctions that cannot be obtained by any other diagnostic technique. A variety of methods are available, the most sophisticated being filling and voiding cystometry with flowmetry and electromyography (EMG) under fluoroscopy, i.e. videocystometry. A detailed home recording of the frequency and volume of micturition can provide important clues as to the underlying bladder dysfunction, and can significantly aid in the choice of appropriate investigative techniques, as well as in the interpretation of subsequent urodynamic findings. It must be realized that urodynamic studies are invasive procedures and that artifacts may occur and influence the correct interpretation of the results. Infants and children have a different spectrum of bladder dysfunctions from adults and are generally much less cooperative during a urodynamic study. Therefore, cystometric techniques must be significantly modified. This article reviews cystometry techniques and their application in female infants and children. Cystometry/flow/EMG studies with or without fluoroscopy, ambulatory urodynamics and telemetric urodynamic measurement and their application are outlined.
Article
We describe the development of voiding patterns and bladder control in healthy children during the first 3 years of life. We determined voiding patterns, bladder capacity and post-void residual urine volume per 4 hours individually and noninvasively every 3 months in 36 female and 23 male healthy infants using the 4-hour voiding observation. Voiding frequency decreased slowly from 5 to 2 voiding episodes per 4 hours from ages 3 months to 3 years. We noted interrupted voiding in 33% of subjects at age 3 months but this condition was rare after age 2 years. Voiding during sleep occurred mainly during the first 7 months of life and did not continue after age 18 months. Bladder capacity increased from a median of 52 to 67, 68 and 123 ml. during years 1 to 3, respectively. As measured by post-void residual urine volume, bladder emptying was unchanged during years 1 and 2 but it decreased during year 3 (median 6 versus 0 and mean 4 versus 3 ml. per 4 hours). During the first 3 years of life the number of voiding episodes, including interrupted voiding, post-void residual urine and voiding during sleep, decreased while bladder capacity increased.
Article
To assess the hypothesis that during fetal development, the external urethral sphincter changes from a concentric sphincter of undifferentiated muscle fibres to a transient ring of striated muscle which regresses caudo-cranially in the posterior urethra during the first year of life, when the sphincter assumes its omega-shaped configuration. The anatomy and development of the external urinary sphincter was assessed in human males and females during fetal life. Plastic-embedded sections (transverse, sagittal and frontal planes; 300-700 microm) of the pelvis of 31 females and 31 males (9 weeks of gestation to newborn) were stained with azure II/methylene blue/basic fuchsin and viewed at x 4-80. The sections of interest were taken from the bladder neck to the perineum. The sections of the membranous urethra were reconstructed three-dimensionally using a computer program. In both male and female an omega-shaped external sphincter was apparent in all specimens at > 10 weeks of gestation. In the early fetal period (ninth week), there was undifferentiated mesenchyme; in this period the mesenchyme was more dense in the anterior part and loose in the posterior part of the urethra. In females, there was a close connection between the urethra and the anterior wall of the vagina. The omega-shaped configuration of the external urethral sphincter was recognisable from 10 weeks of gestation in both sexes. There was no suggestion of a change from a cylindrical to an omega-shaped sphincter in the fetal period to birth. Also, a transient 'tail' posterior to the sphincter was not apparent. The rectovesical septum was well developed in neonates. There is no reason to assume that the development of the septum leads to an apoptosis of muscle cells in the posterior part of the external sphincter in males after birth. The anatomical development of the external sphincter does not explain transient outlet obstruction during fetal life. The function of the muscle may change during development because of neuronal maturation.
Article
Bladder function in healthy neonates and its development during infancy are described. Results of free voiding studies of healthy neonates and infants using 4-hour voiding observation and urodynamics studies were reviewed. According to these studies, voiding in the healthy neonate is characterized by small, frequent voids of varying volume in the individual case and interrupted voiding in 30% of the cases. Interrupted voiding is clearly an immature phenomenon since it is seen in 60% of preterm neonates and disappears completely before the age of toilet training. These voidings are considered to be due to a dyscoordination between the sphincter and detrusor, which has also been observed on urodynamic studies and which probably also explains incomplete emptying seen in this age group. Emptying remains incomplete to the age of toilet training when residual urine is median 0 ml. during 4 hours of observation. Voiding rarely occurs during quiet sleep even in the neonatal period, when signs of arousal are often noted before voiding. However, voiding during sleep in 60% occurs of preterm infants, indicating that it may be due to maturation of the central nervous system. Bladder instability is rarely seen in healthy neonates and infants according to urodynamic studies but hyperactivity is suggested in the neonatal bladder with premature voiding contractions after only a few milliliters of filling and with leakage of urine. This latter phenomenon probably explains the low cystometric bladder capacity in this age group. High voiding pressure levels also accompany this low bladder capacity. Thus, it can be suggested that the neonatal bladder is regulated by neuronal pathways with connections to the cerebral cortex in the neonatal period, which is contrary to the earlier concept of voiding as an automatic event in response to a constant volume in the bladder. This theory does not mean that voiding is conscious or voluntary in this age group, but only that the voiding reflex disturbs the neonate. New characteristics include the concept of physiological dyscoordination, such as hyperactivity of the detrusor seen as low bladder capacity, and high voiding pressures in the neonatal period.
Article
We determine the ultrasonographic detrusor thickness in healthy infants and children. We studied 150 healthy children, 79 boys and 71 girls, from newborns to 13 years old. The detrusor of the ventral and dorsal wall was measured with a previously established ultrasonographic technique, and the variation with age and bladder fullness was assessed. Detrusor thickness varied significantly with the degree of bladder fullness (thinner at higher volumes). It also increased slightly with age. At bladder fullness of 10% or greater of expected bladder capacity (EBC), calculated using the formula EBC (ml.) = age (years) x 30 + 30, a practical upper limit for the detrusor thickness of the ventral wall at all ages was 2.0 mm. at a bladder fullness up to 50% of expected bladder capacity or 1.5 mm. at a higher degree of fullness. The detrusor of the ventral wall was slightly thicker in boys than in girls and also somewhat thicker than the detrusor of the dorsal wall. The results indicate that ultrasonographic measurements of detrusor thickness in children may serve as a diagnostic tool and its usefulness in clinical as well as research work should be explored.