Die überaktive Blase im Kindesalter

Enuresis is one of the most frequent urinary symptoms in children. 80% suffer from primary enuresis nocturna. 20% have urinary incontinence with additional symptoms of frequency, urgency and daytime incontinence, which is also defined in children as overactive bladder in absence of urinary tract infections, neurological, anatomical or further local pathology (OAB in childhood). The underlying pathophysiology is a maturation arrest of the bladder control resulting in detrusor hyperactivity. In most of the cases the differentiation between enuresis and OAB is easily possible with non-invasive primary diagnostic procedures.Invasive diagnostic tools like video urodynamic studies may become necessary when first-line therapy fails. The treatment options comprise bladder training with timed voiding and drink protocols (urotherapy) as well as pharmacologic relaxation of detrusor instability by anticholinergic drugs.     

Terodiline: a dose titrated, multicenter study of the treatment of idiopathic detrusor instability in women

Idiopathic detrusor instability is a common cause of lower urinary tract symptoms at all ages and in both sexes. Treatment initially is conservative and often includes drug therapy. Terodiline has the theoretical advantage of being a drug with anticholinergic and calcium channel blocking effects. Theoretically, by using a drug with dual action the beneficial effect of reduced detrusor overactivity might occur at a dosage below that likely to lead to the troublesome side effects experienced by patients who take pure anticholinergic agents. A total of 70 female patients completed a study characterized by extremely strict inclusion criteria and a tight protocol. Other novel elements to the study were the extensive use of urinary diaries for symptom evaluation, standardized urodynamic studies agreed upon by the participating centers and the dose titration design of the trial. Terodiline has been demonstrated to be a safe, well tolerated and effective drug in the treatment of idiopathic detrusor instability. Drug treatment led to significant decreases in urinary frequency and incontinence episodes. Pre-micturition symptoms, such as urgency, were markedly reduced and the voided volume was significantly increased. Although there were consistent trends towards greater improvement in the urodynamic measurements, when the terodiline and placebo groups were compared these did not reach statistical significance, partly due to a large improvement in the placebo group. Nevertheless, terodiline has been shown to be a useful drug for conservative management of patients with detrusor instability.     

Urodynamic studies in enuresis and the nonneurogenic neurogenic bladder

We studied urodynamically 55 patients with enuresis. The severity of urinary incontinence ranged from occasional nocturnal episodes to daytime and nighttime wetting associated with radiographic abnormalities of the bladder and upper urinary tract. Despite differences in symptoms, urodynamic findings of poor cerebral appreciation of the degree of bladder filling and sudden unanticipated detrusor contractility were common in 50 of the 55 patients. Volitional detrusor sphincter discoordination also was common and appeared to be related to uncontrolled bladder contractility rather than a primary problem.     

Biofeedback training for detrusor overactivity in children

PURPOSE: We evaluated biofeedback training for incontinence due to detrusor overactivity in children. MATERIALS AND METHODS: Included in our study were 22 boys and 17 girls with a mean age of 11.2 years. We noted nighttime incontinence in 3 patients, nighttime incontinence and daytime urinary symptoms in 26, and daytime incontinence in 10. All patients had detrusor overactivity and incontinence refractory to conventional treatment, including bladder training, tricyclic antidepressants, anticholinergics, desmopressin and/or conditioning therapy. Urodynamic study was performed using an 8Fr double lumen transurethral catheter for cystometry, a double balloon transrectal catheter for rectal pressure and external anal sphincter pressure measurement, and surface electrodes for sphincter electromyography. During biofeedback training patients were instructed to contract the anal sphincter without raising abdominal pressure to inhibit overactive bladder contractions. Biofeedback training was repeated monthly until cystometry revealed a stable bladder or lower urinary tract symptoms improved considerably. RESULTS: Four patients were lost to followup. Of the remaining 35 children urinary symptoms were cured in 23 and improved in 4. Urodynamic studies after 6 months of biofeedback training in 33 cases showed that bladder overactivity disappeared in 10 and improved in 18. Bladder capacity at the initial desire to void and maximum cystometric capacity increased significantly (p = 0.0115 and <0.0001, respectively). Detrusor-sphincter dyssynergia in 2 patients before biofeedback training resolved in each after therapy. CONCLUSIONS: Biofeedback training for detrusor overactivity is effective even in pediatric cases refractory to conventional treatment.     

Studies of enuresis VIII. Detrusor and sphincter instability caused by overactivity of integral voiding reflexes

Ninety-one children with nocturnal enuresis or enuresis plus daytime urgency incontinence were studied by cystometry. Seventy-two per cent of the girls and 62 per cent of the boys had evidence of bladder instability. Sixty-eight children in whom abnormalities were found on preliminary voiding urodynamics or voiding cystourethrography also underwent calibration and endoscopic examination under anesthesia. An atropine-suppression test was also performed preoperatively in some children with a markedly unstable bladder demonstrated on preoperative cystometry. In the majority of children tested suppression of bladder instability with atropine was demonstrable. Voluntary detrusor sphincter dyssynergia was demonstrated in a majority of the children with daytime urgency incontinence. Sixty-five per cent of the boys and 81 per cent of the girls were treated for urethral obstructive lesions suspected to be of functional urodynamic significance. Postoperative cystometry showed marked improvement in bladder stability in 57 per cent of the girls and 63 per cent of the boys treated for suspected urethral obstructive pathology. The anticholinergic suppression test was found to have no significant predictive value relative to the cause or surgical curability of bladder instability. The pathophysiologic significance of overactivity of integral voiding reflexes 6 through 11 is described.     

Sex distribution of adult idiopathic detrusor instability in relation to childhood bedwetting.

The urodynamic case records of 1000 consecutive men and women were reviewed to study the link between idiopathic detrusor instability (DI) and childhood nocturnal enuresis and to determine whether a sex difference in this relationship may exist. Idiopathic DI was found in 10% of the men, 63% of whom had suffered from childhood bedwetting; 29% of the women had idiopathic instability, of whom 38% had been nocturnal enuretics. Thus the link between adult idiopathic DI and childhood bedwetting appeared to be stronger for men than for women. The sex distribution of subjects is not always reported in urodynamic studies of bedwetters and adults with an unstable bladder. We suggest that this should become routine practice as it may help to shed light on the aetiology of idiopathic detrusor instability.     

尿动力学检查在小儿排尿功能障碍中的质量控制及应用

【摘　要】　目的 评价尿动力学检查(UDS)在小儿排尿功能障碍诊治中的作用。方法 对79例小儿排尿功能障碍行UDS。结果 79例中遗尿症：DI:57.1%、功能性膀胱容量减少:42.8%、逼尿肌-括约肌协同失调（DSD）：39.2%。尿频尿急：DI：71.4%、DSD：61.9%、尿道闭合压增高：52.3%。尿失禁：DI：70.6%、DSD：64.7%、膀胱容量减少：52.9%。脊柱裂：逼尿肌反射亢进：71.4%、DSD：57.1%、膀胱顺应性降低：57.1%。结论 应根据患儿的不同情况制定相应的治疗方案治疗小儿排尿功能障碍,才能取得满意效果。部分病例比较特殊,治疗中需区别对待。尿动力学检查在诊断和指导治疗方面起着重要的作用。     

Video cystometry in young infants with renal dilation or a history of urinary tract infection

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 (105+/-44 cmH2O vs 69+/-22 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.     

Effect of dominant hemispheric stroke on detrusor function in patients with lower urinary tract symptoms

Objectives: To determine the effect of unilateral hemispheric lesion on voiding dysfunction by comparing urodynamic parameters in dominant, non‐dominant and bilateral hemispheric stroke patients. Methods: We retrospectively reviewed the medical records of patients from a magnetic resonance imaging and urodynamic study. We identified 69 cases among 192 stroke patients who had undergone urodynamic study due to lower urinary tract symptoms from June 2003 to December 2008. Results: Among the analyzed variables in the urodynamic study, total bladder capacity, voided volume, postvoid residual urine volume, maximum flow rate, average flow rate, detrusor pressure at the maximum flow rate, and bladder compliance did not show statistically significant differences among dominant, non‐dominant and bilateral hemispheric stroke patients groups (P > 0.05). The dominant hemispheric stroke group had detrusor overactivity in 64.2% of cases and detrusor underactivity in 35.8%; the non‐dominant hemispheric stroke group had detrusor overactivity in 66.7% of cases and detrusor underactivity in 33.3%; and the bilateral stroke group had detrusor overactivity in 60.0% of cases and detrusor underactivity in 40.0% (P = 0.946). Conclusion: Urodynamic findings cannot be characterized by the laterality of the unilateral hemispheric ischemic lesion. There are no significant differences in lower urinary tract symptoms between dominant, non‐dominant and bilateral hemispheric ischemic stroke patients.     

Intramedullary epidermoid cyst presenting with abnormal urological manifestations

STUDY DESIGN: Report of an epidermoid cyst with intramedullary localization. OBJECTIVE: To describe an atypical presentation of intramedullary epidermoid cyst. SUMMARY OF BACKGROUND DATA: Intramedullary epidermoid cysts are rare entities with a marked variability in the clinical presentation, essentially of neurological pertinence. METHODS: Case report of a spinal epidermoid cyst in a 13-year-old girl presenting with urological symptoms: she had a 12-month history of recurrent low urinary tract infections, urinary frequency and nocturnal enuresis. A urodynamic evaluation was performed and showed the presence of involuntary bladder contractions with detrusor instability and low bladder compliance. Magnetic resonance imaging of the spine demonstrated an intramedullary lesion of the dorsal spinal cord. RESULTS: The mass was excised and 6 months after surgical excision, urological manifestations improved with decreased detrusor hyper-reflexia, increased bladder capacity and compliance and no later report of urinary tract infections. CONCLUSIONS: In our patient, unusual clinical manifestations of the tumor have delayed the diagnosis, but its complete removal has led to remission of symptoms. Detailed neurological examination and investigations are indicated in patients with clinical and urodynamic features, suggestive of neuropathic bladder.     

The open bladder neck: a significant finding?

Women with lower urinary tract symptoms were retrospectively studied. They were all investigated using a urinary symptoms questionnaire, a frequency-volume chart and videocystourethrography. An open bladder neck was recorded at maximum cystometric capacity with the patient standing in the left lateral position, if contrast medium entered the proximal urethra at rest in the absence of a detrusor contraction or an increase in intra-abdominal pressure. Women with neurological disorders were excluded. Of 4500 women, 2,593 (57.6%) had a single urodynamics diagnosis and were included in the study: 1207 (46.5%) had urodynamics diagnosis of urodynamic stress incontinence, 558 (21.5%) had detrusor overactivity, 118 (4.6%) had sensory urgency, and 710 (27.4%) had a normal urodynamic study. Out of the 2,593 women included, 776 women (29.9%) had an open bladder neck at rest while 1817 (70.1%) had a closed bladder neck at rest. Only 45% (542/1207) of women with urodynamic stress incontinence had an open bladder neck at rest. Seventy percent (542/776) of women with an open bladder neck had a diagnosis of urodynamic stress incontinence whilst 73% of women with detrusor overactivity and 93% of those with sensory urgency had a closed bladder neck. An open bladder neck at rest is not diagnostic of urethral sphincter incompetence but is associated with urodynamic stress incontinence. It is not associated with urgency as few women with sensory urgency and detrusor overactivity were found to have an open bladder neck. Imaging the bladder neck at rest has questionable value.Editorial Comment: The authors report on a very large series of women who had video urodynamic studies. They concluded that an open bladder neck was not conclusive of Intrinsic Sphincter Deficiency. They also noted that most women with detrusor overactivity or sensory urgency did not have an open bladder neck, which contradicts previous theories regarding bladder neck funnelling have a high association with detrusor overactivity.     

Investigation of dysfunctional voiding in children with urgency frequency syndrome and urinary incontinence

PURPOSES: Dysfunctional voiding may result in lower urinary tract symptoms (LUTS) in children and is associated with urinary tract infection and vesicoureteral reflux (VUR). This study analyzed the videourodynamic investigations in children with urgency frequency syndrome and/or urinary incontinence. METHODS: Forty children, 1-13 years old, with urgency frequency syndrome and/or incontinence were investigated to determine their LUTS or for the assessment of VUR. Videourodynamic study was performed in all patients and the results were analyzed with clinical characteristics and underlying pathophysiology. RESULTS: Dysfunctional voiding was present in 75.7% of the children with detrusor overactivity, in 73.3% of the children with VUR, in 63% of the children with urinary incontinence, in 77% of the children with episodic urinary tract infection, and in all of the children with diurnal enuresis. Compared to children without dysfunctional voiding, the voiding pressure was significantly higher in children with dysfunctional voiding (with VUR, 61.1 +/- 29.8 vs. 24.8 +/- 15.8 cm H(2)O, p = 0.004; without VUR, 53.4 +/- 24.1 vs. 24.8 +/- 15.8 cm H(2)O, p = 0.010). Biofeedback pelvic floor muscle training and treatment with antimuscarinic agent effectively decreased detrusor pressure, increased bladder capacity and maximum flow rate, and reduced the grade of VUR in 5 children who had post-treatment urodynamic studies. CONCLUSIONS: This study has shown that dysfunctional voiding is highly prevalent in children with symptoms of urgency frequency and incontinence. Biofeedback pelvic floor muscle training is effective in treatment of dysfunctional voiding in children.     

Enuresis--causes, diagnosis and therapy

672 children aged between 4 and 16 years were treated for primary or secondary enuresis between 1980 and 1986. The group included more girls than boys. A systematic diagnostic investigation, consisting of a detailed medical history, physical examination, urinalysis and sonography of the kidneys and bladder, was carried out in all cases. This investigation was followed by urodynamic tests to detect any functional disorders of the lower urinary tract. Finally, a voiding cystogram, urethral calibration and urethrocystoscopy were conducted to screen for morphological changes. Three major groups of causes of enuresis were identified. Functional miction disorders were found in 312 (46.4%) children. In these cases there was an inability to voluntarily control the detrusor, detrusor-sphincter dyssynergia and hyperactivity of the detrusor. 223 (33.2%) of the children had pathological anatomical changes of the urinary tract, such as malformations leading to vesicoureteral reflux, vesicular diverticula, duplication of the upper urinary tract, megaureter, urethral stenosis or urethral valves, with associated infection. Psychogenic disorders were diagnosed in 137 (20.4%) cases. The first group received drug treatment and biofeedback training for reestablishment of conscious control over the vegetative functions of the lower urinary tract. The second group underwent surgery for correction of the pathological anatomical changes. The third group was referred for psychotherapy.     

梨状腹综合征的尿动力学表现(附二例报道)

目的 探讨梨状腹综合征(PBS)患儿尿动力学表现及临床意义。方法 报告2例男性PBS患儿(年龄分别为12岁和8岁)尿动力学检查结果及其指导临床治疗的意义。结果 2例患儿均表现为下尿路梗阻，剩余尿增多，膀胱容量增大，尿道高压，其中1例表现不稳定膀胱。1例行膀胱颈口电切，尿路梗阻症状缓解。结论 PBS患儿尿动力学主要表现为下尿路梗阻，剩余尿增多。对于梨状腹综合征患儿需及时行尿动力学检查，了解下尿路功能状况，采取相应的治疗措施如膀胱颈口电切等方法解除梗阻，防止上尿路损害发展。     

Physiology and evaluation of overactive bladder

Detrusor overactivity is a urodynamic observation characterized by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked. There are certain patterns of detrusor overactivity. Phasic detrusor overactivity is defined by a characteristic wave form and may or may not lead to urinary incontinence. Terminal detrusor overactivity is defined as a single involuntary detrusor contraction occurring at cystometric capacity, which cannot be suppressed. Neurogenic detrusor overactivity is qualified as neurogenic when it is a relevant neurological condition (old term is "detrusor hyperreflexia"), idiopathic detrusor overactivity when there is no defined cause (this term replaces "detrusor instability"). In neurogenic patients, detrusor overactivity is secondary to various pathophysiologic factors: interruption of inhibitor pathways issued from cerebral regions, activation de novo of vesical C reflex mediated by unmyelinated capsaicin fibers, and ultrastructural modifications of bladder urothelium. Bladder overactivity treatment is necessary to avoid renal complications and improve quality of life of neurogenic patients.     

Voiding dysfunction after radical retropubic prostatectomy: more than external urethral sphincter deficiency

OBJECTIVES: To analyse the relationship between RRP and urodynamic bladder dysfunction, and compare preoperative and postoperative functional status over long-term follow-up. Hypothesis on the pathophysiologic mechanism underlying urodynamic dysfunction has been reported. METHODS: PubMed databank search for original articles followed by review of urodynamic parameters: bladder filling sensation, detrusor overactivity, bladder compliance, cystometric bladder capacity, impaired detrusor contractility, bladder outlet obstruction, urinary incontinence. RESULTS: Detrusor dysfunction was rarely present as the sole diagnosis and was usually coupled with intrinsic sphincter deficiency. Data on bladder filling sensation, cystometric capacity, detrusor overactivity, impaired detrusor contractility, and bladder outlet obstruction were limited and contradictory. Detrusor overactivity was a de novo dysfunction in 2%-77% of patients. Impaired bladder compliance was present in 8%-39% of patients and was de novo in about 50%. Impaired detrusor contractility was found in 29%-61% of patients, was de novo in 47%, and recovered in about 50% of patients. The role of these dysfunctions as etiologic agents of urinary incontinence or voiding symptoms was unevenly assessed. CONCLUSIONS: Postoperative decentralization of the bladder, inflammation and/or infection, and geometric bladder wall alteration associated with preexisting hypoxemia with/without neuroplasticity have been posited as causes of detrusor dysfunction. Nevertheless, the lack of consistent preoperative urodynamic investigation makes it difficult to assess the operation's exact role in causing these dysfunctions. Thus, urodynamics performed, at least in selected cases, preoperatively and during follow-up could help arrive at a precise diagnosis of the underlying dysfunction, indicate the appropriate treatment, and prevent the incidence and onset of postoperative urinary incontinence.     

Urodynamics in Female Urology

Urodynamics in female urology are often indicated when empiric or conservative treatment does not improve lower urinary tract symptoms. Based on the expected underlying lower urinary tract dysfunction, the urodynamic evaluation is designed by the clinician to reproduce a patient's symptoms and to identify underlying pathophysiological mechanisms, as well as to analyse other functions of the lower urinary tract which may be relevant for planning further (invasive) treatment. In this review, we describe the available urodynamic tests, the normal findings, and the evidence for the role of urodynamics, and on the specific measurements and parameters used to evaluate female lower urinary tract symptoms.In women with a suspected storage dysfunction, filling cystometry allows identification of detrusor overactivity or reduced bladder compliance as possible underlying causation of overactive bladder. Most women with stress incontinence have other storage and/or voiding symptoms and urodynamics should always be performed prior to invasive treatment. In the minority with pure stress urinary incontinence, urodynamic observations can guide the type of surgery chosen, but this has not yet been shown to change treatment outcome.Voiding dysfunction in women has recently received more research attention and various urodynamic parameters are being evaluated on their ability to distinguish detrusor underactivity from bladder outlet obstruction in pressure-flow studies. Video-urodynamics can provide a useful addition when anatomical information is needed in complex patients (eg, prior surgery or neurogenic patients).Finally, ambulatory urodynamics can be used when symptoms cannot be reproduced or explained by conventional urodynamics.     

Functional bladder capacity after bladder biofeedback predicts long-term outcome in children with nocturnal enuresis

OBJECTIVE: We previously reported a 70% cure rate for bladder biofeedback in children with primary nocturnal enuresis associated with small bladder capacity and detrusor instability. In this paper we report on bladder capacity and incidence of enuresis after 60 months of follow-up and discuss the role of decreased bladder capacity in nocturnal enuresis. MATERIAL AND METHODS: We prospectively evaluated 21 boys and 3 girls (mean age 10.4 years) treated with bladder biofeedback between October 1993 and July 1995. Baseline bladder capacity and capacity at the end of treatment and at 60 months follow-up were determined from a micturition chart. RESULTS: At the end of primary treatment 17/24 patients had stopped bedwetting. In 4/17 responders and 4/7 non-responders the bladder capacity was <90% of normal for age. At 60 months, 4 patients had been lost to follow-up, 15 were dry at night and 4 continued bedwetting. One patient underwent surgery and was excluded from the study. Only 2/15 dry patients but 3/4 patients with persistent nocturnal enuresis had a bladder capacity of <90% of normal. CONCLUSIONS: Bladder biofeedback can be successfully used to treat children with refractory nocturnal enuresis associated with small bladder capacity and unstable detrusor. Normalization of bladder capacity and continuous growth of the bladder in order to keep the capacity normal would seem to be crucial to the long-term resolution of bedwetting in this select patient population.     

Evaluierung und Management der Enuresis

Enuresis is defined as nocturnal bed wetting for at least 2 nights per month in children older than 5 years. At this age the prevalence of enuresis is about 15–20%. More than 50% of these children show day time symptoms, such as frequency, urgency and incontinence (non-monosymptomatic enuresis). The other children are asymptomatic during day time and wet the bed during the night time (monosymptomatic enuresis). The main pathogenetic factors are nycturia, detrusor overactivity and reduced arousability. Psychological and psychiatric aspects, genetics and obstipation play an additional role in the etiology. Basic diagnostic investigations are mandatory before treatment. Clinical history, physical examination, sonography of the urinary tract, urinalysis and bladder diary are prerequisites before any therapeutic steps are taken. The cornerstones of primary enuresis therapy are general lifestyle advice, pharmacotherapy and alarm devices. Therapy-resistant children deserve further evaluation and a multidisciplinary therapy approach. After careful evaluation specific therapy is efficient in approximately 80% of patients.     

Botulinum toxin treatment for bladder dysfunction

Botulinum toxin A is available under three different protein complexes that are not interchangeable until appropriate comparative studies are undertaken. The best studied for the treatment of urinary incontinence as a result of neurogenic detrusor overactivity and overactive bladder/idiopathic detrusor overactivity is onabotulinum toxin A. This brand is only approved for the treatment of urinary incontinence as a result of neurogenic detrusor overactivity at a dose of 200 U and idiopathic detrusor overactivity at a dose of 100 U. In patients with detrusor overactivity as a result of spinal cord injury or multiple sclerosis, 200 U of onabotulinum toxin A should be injected in 30 different sites above the trigone. It was shown to be highly effective in curing or decreasing urinary symptoms of incontinence, increasing quality of life, increasing bladder capacity and decreasing maximal detrusor pressure. This effect was independent of the concomitant use of oral anticholinergic drugs. Adverse events were mild, mainly urinary tract infections and high postvoid residual requiring clean intermittent catheterization. In patients with overactive bladder/idiopathic detrusor overactivity, 100 U of onabotulinum toxin A should be injected in 20 sites above the trigone. It markedly decreases urinary incontinence and improves quality of life. Frequency and urgency episodes are also decreased. Adverse events are mild, mainly urinary tract infections and urinary retention. The latter occurred in just 5% of the patients. Candidates for onabotulinum toxin A treatment should be warned that the effect of the toxin is transient and that repeated injections will be required to maintain the effect in the long term. There is no evidence that repeated injections will have a decreased efficacy.