Changing concepts concerning the management of vesicoureteral reflux

PURPOSE: Conservative estimates indicate that up to 54% of patients who present with vesicoureteral reflux have dysfunction voiding. Children with voiding dysfunction and vesicoureteral reflux historically have a high breakthrough infection rate of 34% to 43%. Breakthrough infection represents significant morbidity and it is the most common indication for surgical intervention for vesicoureteral reflux. Voiding dysfunction is present in 79% of patients who proceed to reflux surgery. We evaluated the impact of pelvic floor muscle retraining combined with a medical program in patients with voiding dysfunction and vesicoureteral reflux. MATERIALS AND METHODS: Children with a history consistent with voiding dysfunction and vesicoureteral reflux were screened by uroflowmetry/electromyography, bladder scan for post-void residual urine, renal ultrasound and voiding cystourethrography. Confirmed cases of voiding dysfunction and vesicoureteral reflux were prospectively enrolled in this study. Children participated in an interactive, computer assisted, pelvic floor muscle retraining program that involved a conservative medical regimen and pelvic floor muscle retraining. All patients received prophylactic antibiotics. We evaluated the rate of breakthrough urinary tract infection, reflux outcome and surgical intervention. A literature review with the key words vesicoureteral reflux, voiding dysfunction and urinary tract infection was performed to identify historical control cases for comparison. RESULTS: Study enrollment criteria were fulfilled by 49 girls and 4 boys 4 to 13 years old (average age 8.8), representing 72 units with low grades I to II (48) and high grades III to V (24) reflux. Mean followup was 24 months. Initial uroflowmetry/electromyography and bladder scan revealed a staccato flow pattern and normal post-void residual urine in 11% of cases, staccato flow pattern and elevated post-void residual urine in 10%, flattened flow pattern and normal post-void residual urine in 28%, and flattened flow pattern and elevated post-void residual urine in 51%. Breakthrough infection developed in 5 patients (10%), including 1 in whom reflux had resolved and 1 with grade I reflux who underwent observation. The parents of 2 patients elected to complete biofeedback without surgical intervention and these patients did not have a repeat infection. Reimplantation was performed in 1 case (2%). There was resolution in 18 low and 7 high grade refluxing units, including 2 older patients with a long history of high grade bilateral disease. Average time to resolution was 7.8 months. We noted elevated post-void residual urine in 88% of the patients with high grade reflux. Average age at resolution was 9.2 years. During a 24-month period one of us (P. H. M.) noted a greater than 90% decrease in surgical intervention. CONCLUSIONS: A combined conservative medical and computer game assisted pelvic floor muscle retraining program appears to have decreased the incidence of breakthrough urinary tract infections and facilitated reflux resolution in children with voiding dysfunction and vesicoureteral reflux. Patients with high grade reflux and voiding dysfunction commonly present with elevated post-void residual urine, contraindicating the indiscriminate administration of anticholinergics. Decreasing the rate of urinary tract infections may have a dramatic impact on the need for surgical intervention and enable the reflux resolution rate to approximate that in patients without voiding dysfunction. Prospective controlled trials are needed to determine whether pelvic floor muscle retraining combined with a conservative medical regimen alters the natural history of vesicoureteral reflux in patients with voiding dysfunction.     

The effect of biofeedback treatment on voiding and urodynamic parameters in children with voiding dysfunction

PURPOSE: We studied the effects of biofeedback treatment on voiding and urodynamic parameters in children with voiding dysfunction. MATERIALS AND METHODS: We prospectively studied 188 children between June 1998 and November 2003. Biofeedback was performed with a urodynamics processor that enables simultaneous recording of urine flow and electromyography, and visual display of flow/electromyography activity. At the beginning of the study this treatment was performed once weekly. After patients understood the concept and performed homework regularly sessions were scheduled at 3 to 4-week intervals and continued for 6 months. All children were evaluated at 6 months and again at 2 years after completing biofeedback training. RESULTS: The number of the children completing biofeedback was 168 (89.4%). Improvement was obtained in all parameters, ranging from 59.2% to 87.8% at 6 months. Maximum improvement was acquired with flattened voiding in 65 of 74 children (87.8%), whereas the least improvement was acquired with daytime wetting in 58 of 98 children (59.2%). These improvements continued at 2-year followup, and ranged from 53.1% to 87.3%. While the rate of improvement for nocturnal enuresis, staccato voiding, detrusor-sphincter dyssynergia, vesicoureteral reflux and urinary tract infection had increased, the remaining parameters had decreased at 2-year followup. CONCLUSIONS: Biofeedback training is a simple, effective and well tolerated treatment modality in children for various parameters resulting from bladder dysfunction. Motivation and willingness to participate in biofeedback treatment are important selection criteria.     

Interactive computer games for treatment of pelvic floor dysfunction

PURPOSE: We reviewed our experience with a conservative medical program and computer game assisted pelvic floor muscle retraining in patients with voiding dysfunction to substantiate our previous findings that demonstrated improvement and/or cure in a majority of patients, and identify factors that may be associated with unsuccessful treatment. MATERIALS AND METHODS: All patients presenting with symptoms of dysfunctional voiding enrolled in our pelvic floor muscle retraining were examined. Cases were subjectively evaluated for improvement of nocturnal enuresis, diurnal enuresis, constipation, encopresis and incidence of break through urinary tract infection. Patients in whom our initial conservative approach that included our biofeedback program failed were further treated with medication, and outcomes were reviewed as well. Fisher's exact test was used for statistical analysis to identify factors that may predict failure with our program. RESULTS: During the last 2 years 134 girls and 34 boys were enrolled in the pelvic floor muscle retraining program. Of the patients 160 (95%) were compliant with the program. Mean patient age was 7.6 years (range 4 to 18). The average number of hourly treatment sessions was 4.9 (range 2 to 13). Uroflowmetry and electromyography demonstrated a flattened flow pattern with increased post-void residual volume in 32% of patients, flattened flow pattern with normal post-void residual 47%, staccato flow pattern with increased post-void residual 11% and staccato flow pattern with normal post-void residual 10%. Subjective improvement was demonstrated in 87% (146) of patients, while 13% (22) had no improvement. Statistically significant predictors of failure included bladder capacity less than 60% of predicted volume (p <0.03) and patient noncompliance (p <0.04). Twelve patients who had no improvement with biofeedback were treated with medication and 10 (83%) improved. Multichannel urodynamics or spinal magnetic resonance imaging (MRI) was obtained in only 7 (4%) of our patients with no neurological lesion identified by spinal MRI. CONCLUSIONS: A conservative program combined with computer game assisted pelvic floor muscle retraining improves symptoms in most patients with voiding dysfunction. A majority of patients can be treated without medication. However, in a select population of patients with a small capacity bladder in whom biofeedback fails, anticholinergic medication appears to alleviate symptoms. In our experience almost all patients presenting with symptoms of voiding dysfunction can be treated without multichannel urodynamics, spinal MRI or medication.     

Biofeedback successfully cures detrusor-sphincter dyssynergia in pediatric patients

PURPOSE: We assessed the efficacy of voiding and bladder biofeedback for achieving perineal synergy and curing symptoms in children with detrusor-sphincter dyssynergia MATERIALS AND METHODS: A total of 16 boys and 27 girls 4 to 14 years old with detrusor-sphincter dyssynergia diagnosed by uroflowmetry and electromyography underwent biweekly voiding biofeedback therapy consisting of perineal floor electromyography during uroflowmetry. The 6 patients with enuresis and an unstable bladder also underwent bladder biofeedback training during cystometry. Biofeedback continued until detrusor-sphincter dyssynergia resolved. Followup consisted of electromyography and uroflowmetry 1 month after completing biofeedback training, and telephone interviews after 2 and 4 years. RESULTS: Biofeedback resolved detrusor-sphincter dyssynergia in all children, although the condition disappeared significantly sooner in girls (p <0.02). Secondary enuresis disappeared significantly earlier than primary enuresis (p <0.0001). The 2-year success rate of 87.18% for enuresis decreased to 80% at the 4-year followup. CONCLUSIONS: Voiding and bladder biofeedback achieves perineal synergy and cures symptoms in children with detrusor-sphincter dyssynergia     

The usefulness of a minimal urodynamic evaluation and pelvic floor biofeedback in children with chronic voiding dysfunction

OBJECTIVE: To report our experience of assessing children with chronic voiding dysfunction (>6 months' duration) using a minimal urodynamic evaluation, and the management of detrusor-sphincter dyscoordination (DSdc) using pelvic floor biofeedback. PATIENTS AND METHODS: From 1994 to 1997, 120 children (mean age 7.5 years) with three predominant and associated symptoms were referred to one urologist; they had nocturnal enuresis (28 children), urge incontinence (42) or urinary tract infection (50). All patients were assessed by urinary culture, renal ultrasonography and a minimal urodynamic evaluation, i.e. urinary flowmetry with sphincter electromyography (EMG) using perineal surface electrodes. If they had urinary tract infection and/or renal dilatation, they underwent voiding cysto-urethrography. In children with DSdc, urinary training with frequent voiding was instituted initially, with subsequent pelvic floor biofeedback exercises if the improvement was deemed unsatisfactory. RESULTS: DSdc was diagnosed in 33 children (28%), none of whom had isolated nocturnal enuresis. Pelvic floor biofeedback was undertaken by 15 children (12 girls and three boys); it was well accepted because it was administered as a computer game. In all affected patients the DSdc resolved on EMG and there was a significant clinical improvement. Vesico-ureteric reflux was detected in 24 patients, associated with DSdc in 10. The reflux resolved spontaneously on antibiotic prophylaxis in six children and after urinary re-education in four. CONCLUSION: A minimal urodynamic evaluation seems to be useful in the diagnosis of DSdc which caused urinary tract infection and/or bladder overactivity. The results with pelvic floor biofeedback were excellent in these children.     

Is it reasonable to treat refractory voiding dysfunction in children with botulinum-A toxin?

PURPOSE: We present our results with botulinum-A toxin transperineal pelvic floor/external sphincter injection combined with behavioral and biofeedback reeducation in children with voiding dysfunction who had been resistant to previously applied therapies. MATERIAL AND METHODS: Eight boys and 12 girls between 7 and 12 years old (mean age 9) with recurrent urinary tract infection, an interrupted or fractional voiding pattern and high post-void residual urine in whom behavioral, short biofeedback and alpha-blocker therapies had failed were included in the study. They were treated with botulinum-A toxin at a dose of 50 to 100 U. Botulinum-A toxin was injected transperineally into the pelvic floor and/or external sphincter in all patients. In boys the sphincter was localized endoscopically before injection (endoscopically assisted transperineal approach). Behavioral and biofeedback reeducation started 15 days after injection. RESULTS: Followup was between 9 and 14 months. All patients were without urinary tract infection and fever, while 5 were still on chemoprophylaxis. Six months after treatment residual urine decreased in 17 of 20 patients by 0 to 130 ml (mean +/- SD 45.75 +/- 32.17 ml, t = 6.360, p <0.001). Nine patients reestablished a normal voiding curve and 8 showed improvement. Three did not manifest any significant improvement. In 1 girl transitory incontinence resolved spontaneously within 48 hours. There were no other complications. CONCLUSIONS: The effect of botulinum is transitory. However, it can break the circle of detrusor-sphincter dyssynergia and the period when it is sustained can be used for retraining the patient in normal voiding. At this moment botulinum-A toxin is one of last options in refractory cases of voiding dysfunction.     

Effects of diabetes on female voiding behavior

PURPOSE: We studied voiding behavior in women with type 2 diabetes vs nondiabetic female controls and examined factors associated with voiding dysfunction in patients with diabetes. MATERIALS AND METHODS: After eliminating coexisting medical factors that could affect voiding function we evaluated voiding behaviors in 194 female patients with diabetes treated regularly at a diabetic clinic and 162 control women using a lower urinary tract symptom questionnaire based mainly on the American Urological Association Symptom Index questionnaire and free flow analyses with post-void residual urine estimates. Emptying efficiency was defined as 100% x volume voided/(volume voided + post-void residual urine). RESULTS: Compared with controls patients with diabetes had significantly higher nocturia scores (p = 0.003), weaker urinary streams (p = 0.02), less voided volumes (220 +/- 97 vs 280 +/- 104 ml, p = 0.04) and lower maximal flow rates (19.4 +/- 8.4 vs 25.9 +/- 8.5 ml per second, p <0.001). Remarkable residual urine (100 ml or greater) was detected in 1.8% of controls vs 13.9% of patients. After controlling for age and voided volume diabetes was significantly associated with a decrease in baseline maximum flow of 4.5 ml per second (95% CI 2.9 to 6.2). In patients with diabetes peripheral neuropathy was an independent factor associated with the decrease in emptying efficiency (p = 0.03). CONCLUSIONS: Diabetes significantly altered voiding patterns in a significant proportion of women treated at the diabetic clinic. Peripheral neuropathy is an important factor associated with diabetic voiding dysfunction.     

Bladder reservoir function in children with monosymptomatic nocturnal enuresis and healthy controls

PURPOSE: We investigated bladder reservoir function in children with monosymptomatic nocturnal enuresis and in healthy controls. MATERIALS AND METHODS: A total of 18 children with monosymptomatic nocturnal enuresis and 119 controls who were 7 to 13 years old were recruited. Children completed frequency volume charts and measurements of nocturnal urine production. Mean diuresis in the period preceding each voiding was calculated. Those with enuresis were grouped according to bladder capacity and hospitalized for 4 nights, including a baseline night and 3 with an oral water load. Enuresis volumes and post-void residual volume were estimated, allowing the calculation of bladder volume at the time of enuresis. RESULTS: Nine children with monosymptomatic nocturnal enuresis were characterized as having normal bladder capacity and 9 had decreased bladder capacity. We found large intra-individual variability in daytime voided volume in all 3 groups of participants. Children with enuresis and small bladder capacity generally voided with volumes close to maximal voided volume. A total of 93 enuresis episodes were recorded. Large intra-individual variability was seen in bladder volume at enuresis and it was lower than maximal voided volume in more than 50% of episodes. Variability in bladder volume at enuresis was greatest in the patient group with decreased bladder capacity. We found a significant correlation between diuresis and bladder capacity in all groups during the day and night. CONCLUSIONS: There is a great intra-individual diurnal variability in voided volume in children with enuresis and in healthy children. Enuresis seems to occur at bladder volumes that are smaller and larger than the maximal voided volume obtained from voiding charts.     

The role of video-urodynamic studies in managing non-neurogenic voiding dysfunction in children

OBJECTIVE: To retrospectively evaluate the role of video-urodynamics (VUD) in the diagnosis and management of voiding dysfunction in children. PATIENTS AND METHODS: The records of the 128 children with dysfunctional voiding symptoms were retrospectively evaluated. All patients had a noninvasive screening assessment consisting of a detailed voiding history, ultrasonography and uroflowmetry, and measurement of residual urine. All the patients had also undergone VUD with no selection criteria. The results of VUD were compared retrospectively with the noninvasive screening assessment results. RESULTS: In 84 patients with urge syndrome VUD showed detrusor overactivity in 72 (86%); the bladder configuration and voiding-phase results were normal. Three (3.5%) patients had low-grade reflux. In 38 patients with voiding dysfunction VUD showed an intermittent flow pattern and/or increased electromyographic activity with a "spinning top" deformity of the bladder neck and increased detrusor pressure during voiding. Five (13%) of these children had low-grade reflux. In six infrequent voiders VUD revealed increased bladder capacity with fractionated flow patterns, with concomitantly increased abdominal pressures. There was decreased detrusor pressure during voiding with significant residual urine volume in only two patients; there was no reflux in any of the patients in this group. CONCLUSION: We do not recommend routine VUD in children with non-neurogenic voiding dysfunction, as it does not generally change the management and treatment. A detailed voiding history and physical examination is usually sufficient for a correct diagnosis.     

Rehabilitation of the dysfunctional bladder in children: method and 3-year followup

A rehabilitation program has been developed for children with functional, nonneurogenic bladder disturbance. The basis for the program is a bladder regimen supplemented by biofeedback training if needed. Results in the first 70 children (64 girls and 6 boys) are presented. After 1 and 3 years 36 and 53 children, respectively, had completely normalized voiding patterns, that is they were continent, had no urgency, voided 3 to 6 times a day and emptied the bladder completely in 1 portion with a normal flow rate. The training program is applicable in children with varying urodynamic diagnoses and it has been used in children as young as 4 years old.     

Perinephric urinoma secondary to neurogenic bladder with vesicoureteral reflux: Report of an adult case

We report a case of infectious perinephric urinoma in a 73-year-old woman who had a neurogenic bladder with vesico-ureteral reflux. The patient was admitted to our emergency room with right lumbago and high fever. Ultrasounds and computed tomography demonstrated a right large perinephric cystic mass, bilateral hydronephrosis and much residual urine. Percutaneous drainage of the cystic mass was performed with an indwelling urethral catheter. The content of the mass was urine infected with Escherichia coli. Antibiotic therapy was performed successfully and we then examined the cause of the urinoma. A urodynamic study demonstrated a low-compliance small bladder and detrusor-sphincter dyssynergia. A voiding cystourethrogram revealed right grade III vesicoureteral reflux. The patient was unable to be cleared with intermittent catheterization and had an indwelling urethral catheter inserted. In 1 year, the voiding cystourethrogram showed no vesicoureteral reflux and the patient was well with no evidence of recurrent urinoma without the urethral catheter. There have been only two reported cases of urinoma caused by neurogenic bladder with vesico-ureteral reflux in children and this is the first case reported in an adult.     

The urodynamic profile of myelodysplasia in childhood with spinal closure during gestation

PURPOSE: Spinal dysraphism is the most common cause of neurogenic bladder dysfunction in newborns. Urodynamic findings in these patients include uninhibited bladder contractions, bladder areflexia, decreased compliance and detrusor-sphincter dyssynergia. Early urodynamic studies are recommended for spina bifida to help identify bladder characteristics that may cause a risk of upper tract deterioration. We recently evaluated a new early type of intervention involving closure of the neural tube defect during gestation in 25 patients at our institution. We hypothesize that this procedure results in decreased exposure of the spinal cord to amniotic fluid, which may improve neurological function. To date we have evaluated 16 of the 25 patients with video urodynamics. We compared the results to those in the literature on patients with myelomeningocele and without prenatal intervention. MATERIALS AND METHODS: We performed urodynamic testing in 16 patients with a mean age of 6.5 months, including cystometrography, fluoroscopic evaluation of filling and voiding, pelvic floor electromyography and post-void residual urine measurement. In addition, we retrospectively reviewed renal ultrasound, voiding cystourethrography, catheterization need, number of urinary tract infections and medication in these cases. RESULTS: Uninhibited detrusor contractions and an areflexic bladder were identified in 6% and 43% of patients, respectively, while 19% had decreased compliance and 75% had leak point pressure greater than 40 cm. water. Mean bladder capacity was 40 cc and 31% of patients had much lower capacity than expected for age. Previous renal ultrasound and voiding cystourethrography showed evidence of upper tract dilatation and reflux in 2 cases, respectively. Intermittent catheterization and anticholinergic therapy were required by 1 patient each and 1 had a significant urinary tract infection. CONCLUSIONS: Urodynamic findings in this population are comparable to those previously reported in the literature in patients with spina bifida without prenatal closure of the spinal defect. The lower incidence of urinary tract infection and reflux in our study probably represents more aggressive early urological management rather than neurological improvement. These urodynamic studies were performed early in life and future evaluation may ultimately reveal improved bladder function compared with that in others with myelodysplasia. However, at this time we recommend that patients who undergo spinal cord defect closure during gestation be evaluated and treated in the same manner as those with myelomeningocele but without fetal intervention.     

Voiding function study with ultrasound in male and female neonates

BACKGROUND: The neonatal period has been characterized as a time when males have a much higher incidence of urinary infection and severe ureteral reflux than females. However, little information about the voiding function in the neonatal period is available. METHODS: The bladder urine volumes, before and after voiding, and urinary flow rates were determined with the use of noninvasive voiding-provocation maneuvers and ultrasound in the apparently normal neonates. RESULTS: There was no significant difference in the prevoid bladder urine volume between the two sexes. After they were stimulated to enhance the tension of their abdominal wall musculature, 65 of 118 females (55.1%) and 64 of 115 males (55.7%) voided. The voiding was observed in 94 (81.0%) of the 116 neonates who had had a prevoid volume above 12 ml. The residual urine expressed as a percentage of the prevoid volume was significantly higher in the males (median, 12.0% in males vs. 3.0% in females, P < 0.01), with the values being above 20% in 26 (41%) of the 64 males compared with 10 (15%) of the 65 females (P < 0.01). Urinary flow rates, determined in 52 neonates, were significantly smaller in males than in females (mean +/- SD, 2.6 +/- 0.9 g/second vs. 3.8 +/- 1.3 g/second, respectively, P < 0.001). CONCLUSION: This voiding function study with ultrasound using noninvasive voiding-provocation maneuvers successfully revealed that male neonates have a larger residual urine volume and smaller urinary flow rates than female neonates. This study should be useful for the diagnosis of voiding dysfunction in children with abnormal urinary symptoms.     

Voiding pattern in healthy children 0 to 3 years old: a longitudinal study

PURPOSE: We describe the development of voiding patterns and bladder control in healthy children during the first 3 years of life. MATERIALS AND METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.     

Diagnosis of female bladder outlet obstruction and relevance of the parameter area under the curve of detrusor pressure during voiding: preliminary results

PURPOSE: The diagnosis of bladder outlet obstruction in women by pressure flow study may be difficult because there are several definitions of bladder outlet obstruction, several parameters and no standard cutoffs. We evaluated the ability of pressure flow studies to separate women into unobstructed, equivocal and obstructed groups. MATERIALS AND METHODS: In a prospective study 85 women with lower urinary tract symptoms underwent clinical evaluation, including physical examination, voiding cystourethrography, endoscopy, flow rate and post-void residual volume measurement. A pressure flow study was performed 15 days later. The pressure flow study parameters were maximum flow, post-void residual volume, detrusor pressure at maximum flow, vesical pressure at maximum flow, area under the curve of detrusor pressure during voiding and area under the curve of detrusor pressure during voiding adjusted for voided volume. After considering the clinical evaluation 2 urologists classified the patients into 3 groups, namely unobstructed, equivocal and obstructed, as the traditional classification. Linear discriminant analysis was then performed using the traditional classification and pressure flow study data. RESULTS: Mean patient age was 55 years (range 18 to 83). According to the traditional classification there were 36 unobstructed, 28 equivocal and 21 obstructed cases. Significant differences were noted in all pressure flow study parameters (analysis of variance p <0.05). Linear discriminant analysis showed that area under the curve of detrusor pressure during voiding adjusted for voided volume was the most statistically discriminating parameter. Of the cases 86%, 36% and 57% were identically categorized by the traditional and area under the curve of detrusor pressure during voiding adjusted for voided volume parameter classifications in the unobstructed, equivocal and obstructed groups, respectively. The other pressure flow study parameters showed less satisfactory results. CONCLUSIONS: Area under the curve of detrusor pressure during voiding adjusted for voided volume appears to be the most discriminating urodynamic parameter of female bladder outlet obstruction. Other studies are needed to test the reliability and validity of this new parameter.     

Outpatient biofeedback relaxation of the pelvic floor in treating pediatric dysfunctional voiding: a short-course program is effective

INTRODUCTION: We report the treatment results of a short course of biofeedback relaxation of the pelvic floor (BRPF) in treating children with dysfunctional voiding. MATERIALS AND METHODS: Fourteen girls and 6 boys with videourodynamically proved dysfunctional voiding were enrolled. To increase the awareness of the abnormal voiding pattern, the anatomy of the pelvis and the results of a voiding diary and videourodynamics were extensively explained to the patients/parents. Surface electromyography and uroflowmetry were used as biofeedback tools to teach the adequate relaxation of the pelvic floor during voiding. The child was asked to practice the relaxation technique at home at least twice a day. BRPF was performed once a week until the child had 2 consecutive normal bell-shaped uroflow recordings. Patients were reevaluated at 4, 8, 12 and 24 weeks after BRPF training. RESULTS: The mean patient age was 8.3 +/- 3.8 years. The mean number of BRPF training sessions was 2.2 +/- 0.9. The mean follow-up period was 18.9 months. Normalization of abnormal uroflowmetry was achieved in 18 patients (90%). The mean maximal uroflow rate and voided volume increased from 13.3 +/- 4.3 to 18.0 +/- 3.4 ml/s (p < 0.01) and from 138 +/- 56 to 193 +/- 65 ml (p < 0.01), respectively. The postvoiding residual urine decreased from 54.5 +/- 47.6 to 21.3 +/- 10.6 ml (p < 0.01). Complete and partial resolution of voiding symptoms was achieved in 14 (70%) and 6 patients (30%), respectively. Recurrence was noted in 2 of the 10 patients who had complete resolution of symptoms and who had been followed up for more than 6 months. CONCLUSIONS: Short-course outpatient BRPF is an effective treatment of pediatric dysfunctional voiding.     

Uroflowmetry: its current clinical utility for women

Uroflowmetry, the simple, non-invasive measurement of urine flow over time during micturition, has a long and interesting history, clear definitions, a clear purpose in screening for voiding difficulty and, most importantly, technical accuracy. Data interpretation is currently limiting its clinical utility, despite appropriate analysis being available in long-standing existing research. The main clinically important numerical parameters are the maximum and average urine flow rates and the voided volume. Urine flow rates are strongly dependent on voided volume. Reference to established (Liverpool) nomograms will most accurately correct for this dependency. Nomograms will also optimise the validation of uroflowmetry data and the accurate assessment of its normality, compared with fixed urine flow rates and "cutoffs" for voided volume. Abnormally slow urine flow (under the 10th centile Liverpool Nomograms) is the most clinically significant abnormality. Repeat uroflowmetry, concomitant post-void residual measurement and voiding cystometry studies are appropriate options for evaluating any abnormal uroflowmetry.     

Transurethral incision of bladder neck for voiding dysfunction after radical hysterectomy: A report of 24 cases

Twenty-four women who had radical abdominal hysterectomy, and subsequently developed persistent high post-void residual urine underwent transurethral bladder neck incision. Persistent high post-void residual urine is defined as a residual urine volume 20% greater than the amount just voided. This was determined during a 24-hour period, 3 months or more after the radical hysterectomy. Our results indicated that the bladder outlet resistance before and after the procedure was 0.96±1.01 and 0.19±0.07 respectively (P<0.05). The mean ratios between residual urine and total bladder volume in 24 cases were reduced from 93.45±42.93% to 33.47±22.79% after the procedure (P<0.001). In addition, there was a significant decrease of functional urethral length, maximal urethral closure pressure and bladder outlet resistance. Based on the ratios of residual urine and total bladder volume, 7 patients were markedly improved, 10 were partially improved, 7 remained unchanged and none worsened. The overall improvement rate was 71% (17/24). Urinary incontinence was a rare complication which occurred in only one woman (4%).     

Preoperative urodynamic evaluation may predict voiding dysfunction in women undergoing pubovaginal sling

PURPOSE: We determine which urodynamic parameters can best predict postoperative voiding dysfunction following pubovaginal sling surgery. MATERIALS AND METHODS: The records of 98 consecutive women who had undergone pubovaginal sling surgery with allograft fascia lata between July 1998 and July 2000 were reviewed. Urodynamic and followup data were sufficient for evaluation for 73 patients. Urodynamic and clinical parameters were correlated with urinary retention, time to return of efficient voiding and development of postoperative urgency symptoms. RESULTS: Average time to return of efficient voiding was 3.92 days (median 3). Of 21 women who voided without a detrusor contraction urinary retention developed in 4 (23%) versus 0 of 48 who voided with detrusor contraction (p = 0.007). Urinary retention was defined as the need to perform even occasional self-catheterization. All 4 women with urinary retention had a detrusor pressure of less than 12 cm. H(2)O (0 in 3, 4 in 1). None of the women with a detrusor pressure of greater than 12 cm. H(2)O had urinary retention (p = 0.047). The presence of Valsalva voiding in women without a detrusor contraction did not affect the incidence of urinary retention (11.1%) compared to those who did not demonstrate Valsalva voiding (5.1%) (p = 0.603). Peak flow rate, detrusor instability on preoperative urodynamics and post-void residual urine volume were not associated with postoperative urinary retention. Finally, post-void residual urine volume predicted delayed return to normal voiding (p = 0.001). There were no other urodynamic parameters that were significantly associated with urinary retention, delayed return to normal voiding or postoperative urgency symptoms including peak flow rate, capacity or compliance. CONCLUSIONS: Women who void without or with a weak detrusor contraction are most likely to have urinary retention postoperatively. Therefore, we conclude that preoperative urodynamic evaluation may be used to counsel women regarding the risk of urinary retention following the pubovaginal sling procedure.     

Tubularized incised plate repair: functional outcome after intermediate followup

PURPOSE: We describe the functional outcome following tubularized incised plate repair of hypospadias in toilet trained children after an intermediate followup. MATERIALS AND METHODS: Children were included in this study only if they were toilet trained and had flow rate data not less than 6 months after primary tubularized incised plate hypospadias repair or 2 months after any secondary procedure to correct complications. Uroflow data (peak flow, voided volume and post-void residuals) were analyzed and plotted on previously determined age-volume dependent nomograms. RESULTS: Of the 48 boys 39 required no secondary procedures, while 9 secondary fistula closures were performed in 2, meatotomy in 2 and dilation in 5. After either primary (26) or secondary (7) procedures 33 of the 48 patients (68.7%) had normal peak flow rate and 15 (31.3%) had low peak flow rate. Of the 48 patients 46 had post-void residual urine less than 10% of voided volume. CONCLUSIONS: Most children will void efficiently with no straining and no post-void residual (1/2) to 4 years after tubularized incised plate hypospadias repair. Of our patients 68.7% have normal peak flow rate. Intermediate followup of larger series and followup at puberty are recommended to resolve the debate concerning the long-term functional outcome of tubularized incised plate hypospadias repair.