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

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

Musculoskeletal Dysfunction and Pain in Adults with Asthma

Background. The mechanical alterations related to the overload of respiratory muscles observed in adults with persistent asthma might lead to the development of chronic alterations in posture, musculoskeletal dysfunction and pain; however, these changes remain poorly understood. Objective. This study aimed to assess postural alignment, muscle shortening and chronic pain in adults with persistent asthma. Methods. This cross-sectional and controlled study enrolled 30 patients with mild (n = 17) and severe (n = 13) persistent asthma. Fifteen non-asthmatic volunteers were also assessed. Asthma was classified by the Global Initiative for Asthma (GINA) guidelines. Postural alignment and muscle shortening were evaluated by head and shoulder positions, chest wall mobility, and posterior (trunk and lower limb) muscle flexibility. In addition, the measures used were previously tested for their reproducibility. Pain complaints were also assessed. Results. In comparison with non-asthmatic subjects, patients with mild or severe persistent asthma held their head and shoulders more forward and had lower chest wall expansion, decreased shoulder internal rotation, and decreased thoracic spine flexibility. Chronic lower thoracic, cervical, and shoulder pain was significantly increased in patients with mild or severe asthma compared with non-asthmatic subjects (p < 0.05). Conclusion. Adults with persistent asthma have musculoskeletal dysfunction and chronic pain that is independent of the severity of their disease but that might be related to their age at the onset of disease symptoms.     

Stress Urinary Incontinence in Women with Neurogenic Lower Urinary Tract Dysfunction

Purpose of Review

The purpose of this review is to discuss the pathophysiology of neurogenic SUI in the female patient, examine the evidence supporting surgical and non-surgical treatment options, and outline our recommendations for the care of this population.

Recent Findings

AFPVS appears to be more efficacious than MUS for this group; however, almost all patients will require self-catheterization after surgery. MUS have a higher probability of maintaining spontaneous voiding but also care the risk mesh complications and higher failure rates. Bladder neck AUS placement may also be considered, but most studies show high reoperation rates and have only a few female subjects. In severe refractory cases of SUI or in the setting of urethral erosion, bladder neck closure has been shown to have good continence outcomes.

Summary

SUI in the setting of neurogenic lower urinary tract dysfunction is often more severe and harder to address than non-neurogenic SUI, due in part to the high rates of ISD in this population. Patients should be screened for other causes of urinary incontinence with UDS prior to any invasive interventions. AFPVS is an appropriate first-line therapy for these patients, particularly in individuals who already perform self-catheterization. Finally, in the setting of moderate to severe urethral erosion, bladder neck closure or urinary diversion should be strongly considered.

     

Urinary Dysfunction in the Rectal Cancer Survivor

Improvements in diagnosis and treatment have resulted in significant improvement in survival rates for rectal cancer. This has led to increasing focus on post-treatment quality of life. One common sequela of treatment for rectal cancer is urinary dysfunction, defined as either difficulty voiding or incontinence. This consists of multiple clinical syndromes of distinct etiologies, most commonly dysfunction of the pelvic autonomic nerves or pelvic floor instability. This can vary in both duration and severity, with some patients experiencing transient and mild symptoms, while others experience prolonged functional impairment. A number of treatment options exist, including behavioral, pharmacologic, and surgical interventions. Because of the multifaceted nature of this process, optimal symptom relief requires careful evaluation of the severity and etiology of a patient’s complaints. Ultimately post-treatment urinary dysfunction can have a significant impact on quality of life, and it is important for clinicians to understand both the causes and management of this process.     

Lower Urinary Tract Dysfunction in Multiple Sclerosis

Multiple sclerosis is commonly associated with bladder dysfunction, which is frequently reported to be the worst aspect of the disease. Patients may experience bothersome bladder symptoms early in the course, and this should be explored. If necessary, a formal evaluation of the lower urinary tract should be offered. The type of bladder dysfunction may also change with time, which highlights the need for continual follow-up assessments. Anticipated problems are incomplete bladder emptying and disorders with urine storage, which may occur simultaneously. This may lead to symptoms of overactive bladder and recurrent urinary tract infections. Conservative measures for management should be used initially while other sinister pathology is excluded. Newer treatments such as botulinum toxin A and neural stimulation techniques are replacing more invasive surgical procedures. Treatment approaches have been described and should be offered by teams who are familiar with patients having uro-neurological complaints.     

Dietary Nutrients and Urinary Incontinence in Japanese Adults

Objectives: To investigate the association between dietary nutrients and urinary incontinence (UI) among Japanese adults. Methods: A total of 1017 adults (710 men and 307 women) were recruited from the community in central and southern Japan. A structured questionnaire, incorporating the International Consultation on Incontinence Questionnaire‐Short Form (ICIQ‐SF) and a validated food frequency questionnaire, was administered to participants by face‐to‐face interview. Information on dietary nutrients intake from each food item was obtained using the Japanese food composition tables. Logistic regression analyses were performed to determine the association between nutrients intake and the prevalence of UI. Results: The observed prevalence of UI was 8.7% (n = 62) for men (mean age 62.5 years) and 29% (n = 89) for women (mean age 62.0 years) based on the ICIQ‐SF criterion. Of the 50 dietary nutrients and micronutrients considered, soluble fiber (P = 0.03) and omega‐6 polyunsaturated fatty acids (P = 0.01) were found to be inversely associated with the UI prevalence for men, whereas increasing the intake of lutein/zeaxanthin appeared to be marginally associated (P = 0.04) with a reduced risk of UI for women. Conclusion: Three dietary nutrients have been identified to be associated with UI in middle‐aged and older Japanese adults. Further research and clinical trials are needed to ascertain the effects of dietary nutrients on UI.     

Efficacy of Clean Intermittent Catheterization for Urinary Incontinence in Children with Neurogenic Bladder Dysfunction Secondary to Myelodysplasia

Objectives: To evaluate the efficacy of clean intermittent catheterization for urinary incontinence in myelodysplastic children. Methods: The cohort comprised of 38 children (19 boys and 19 girls, aged between 10 months to 16 years) with neurogenic bladder secondary to myelodysplasia. Group A included 16 children who had dilated upper urinary tract or vesicoureteral reflux when clean intermittent catheterization was introduced. The remaining 22 children with normal upper urinary tract were enrolled to group B. In the present study, we defined socially acceptable continence as having completely dry or slight stress incontinence that patients can manage with several small pads. Results: Of the 16 group A patients, 9 obtained socially acceptable continence by conservative management. Of the 22 group B patients, 11 reported socially acceptable continence by conservative management. Vesical compliance was significantly higher in cases who reported socially acceptable continence than in those with incontinence persistent regarding all participants (10 ± 7.2 vs 6.8 ± 6.2 mL/cmH₂O, P = 0.0347) and group A (9.1 ± 6.7 vs 3.7 ± 1.4 mL/cmH₂O, P = 0.0350). Leak point pressure was significantly higher in patients who obtained socially acceptable continence than in those having persistent incontinence regarding all participants (50 ± 17.2 vs 25 ± 6.6 mL/cmH₂O, P = 0.0003), group A (51 ± 21.4 vs 26 ± 7.2 mL/cmH₂O, P = 0.0348) and also, group B (49 ± 12.8 vs 23.7 ± 6.3 mL/cmH₂O, P = 0.0043). Conclusion: In our series, socially acceptable continence was obtained in only 20 patients (52%) by conservative management. The present study suggests that the limitation of conservative treatment seems to be apparent when they have urethral closure deficiency and/or intractable poor vesical compliance.     

Vagal Dysfunction and Impaired Urinary Sodium and Water Excretion in Cirrhosis

Objective: To evaluate the possible role of vagal impairment in the disturbances of urinary sodium and water excretion observed in cirrhosis. Methods: Standard cardiovascular reflex tests were used to assess Autonomic function in 11 cirrhotic patients, and the response to an acute intravenous water load was determined. Changes in plasma noradrenaline, antidiuretic hormone, renin., and atrial natriuretic peptide also were evaluated. Results: Patients with vagal dysfunction were shown to have significantly impaired urinary sodium and water excretion, compared with those whose cardiovascular tests were normal (5-h urinary sodium excretion, 32.3 ± 9.0 vs . 69.4 ± 12.7 mmol, p < 0.05; % water load excreted at 5 h, 67.8 ± 10.5 vs . 109.2 ± 3.67%, p < 0.008). This was associated with higher circulating noradrenaline, renin, and antidiuretic hormone levels after the water load in the vagal dysfunction group. Urinary sodium excretion correlated with the heart rate variation on deep breathing (r = 0.74, p < 0.013) and the heart rate response to atropine ( r = 0.75, p < 0.020); the % water load excreted correlated with the number of abnormal cardiovascular tests in each patient ( rS = 0.67, p < 0.02). Although patients with vagal abnormalities had worse liver function, urinary sodium and water excretion correlated better with parasympathetic tests than with standard parameters of hepatic function. Conclusions: The presence of vagal impairment in cirrhosis appears to be associated with impaired urinary sodium and water excretion, as well as disturbances in circulating vasoactive hormones. These findings could be due to an afferent defect resulting in diminished inhibitory input from intrathoracic volume and arterial baroreceptors, although a confounding effect of worse hepatic function in patients with vagal impairment cannot be excluded.     

Stress Urinary Incontinence in Women with Neurogenic Voiding Dysfunction

Female neurogenic sphincteric incontinence is a complex and debilitating condition. Stress urinary incontinence in this population is complicated by mixed urinary incontinence caused by functional and structural anomalies, which impacts upon management options. Patients require a full incontinence work-up, including a comprehensive history and physical examination, renal imaging, and videourodynamics. Understanding personal and physical limitations in addition to patient goals of treatment is tantamount in choosing the appropriate course of care. Options range from conservative therapy (behavioral modification) and clean intermittent catheterization with pharmacotherapy to invasive surgical options (bladder neck closure and urinary diversion). Before increasing sphincteric resistance, it is imperative to confirm that the bladder reservoir is well-balanced and filling under safe pressures. The risk of chronic urinary retention following treatment of the sphincter is high in this population. Much of the literature on this topic is anecdotal. Prospective studies comparing treatment options for neurogenic sphincteric incontinence within this population are needed.     

Bolus Consistency and Swallowing in Children and Adults

Research has shown that swallowing in adults is affected by bolus consistency. Little is known, however, regarding the effect of bolus consistency on swallowing in children. Electromyographic (EMG) data from typically developing five- and eight-year-old-children and adults were obtained from the following muscles as they swallowed boluses of different consistencies: (1) right upper lip, (2) right lower lip, (3) submental, and (4) laryngeal strap. Signal analyses included calculating EMG onset and offset and average EMG amplitude of muscle activity during swallowing. Findings revealed that by five years of age, children employ adultlike control strategies during swallowing: significant differences in duration and magnitude of muscle activity resulted as a function of bolus consistency. General observations revealed, however, that swallowing in children is characterized by muscle activity that is shorter in duration. Similarities and differences in the biomechanics of swallowing between children and adults are important to consider during clinical evaluations and treatment of children with dysphagia.     

Autonomic Dysfunction in Children with Hirschsprung's Disease

During embryogenesis, two differenttransmembrane receptors, Ret and Ednrb, together withtheir ligands, respective, GDNF and endothelin-3, areinvolved in the migration and differentiation of entericganglion cells, sympathetic neurons and melanocytes fromthe neural crest. Mutations in these genes have beenfound in a number of human and murineneurocristopathies, including Hirschsprung's disease.RET and GDNF knockouts suggest that they are involved in acorrect autonomic nervous system formation. The aim ofthis study is the evaluation of the autonomic nervoussystem in patients with Hirschsprung's disease. Seventeen children (mean age: 8.6 years) withHirschsprung's disease and 19 age- and sex-matchedcontrol children (mean age: 9.9 years) underwentpupillary and cardiovascular testing of sympatheticadrenergic and cholinergic function and cardiovagalcholinergic function. Seven of 17 patients withHirschsprung's disease were affected by autonomicdysfunction. Three of seven patients had evidence ofsympathetic denervation, two showed a parasympatheticdysfunction, whereas the remaining two had dysfunctionof both sympathetic and parasympathetic tests. Our datain a small number of patients with Hirschsprung's disease show that a subset of these patientsexhibits measurable autonomic dysfunction. A RETmutation has been found in one of them. As for theabsence of the enteric ganglion cells, autonomicdysfunction in these subjects seems to bepolygenic.