Evolution of the management of acquired neurogenic bladder in children using intradetrusor botulinum toxin type A injections: 5-year experience and perspectives

ObjectiveTo report the clinical and urodynamic results of repeated intradetrusor botulinum toxin type A injections in children with an acquired neurogenic bladder.Patients and methodWe reviewed the data of 8 patients presenting an acquired neurogenic bladder treated between 2005 and 2010. Their mean age was 12.4 years old (range: 5–18). They were all on clean intermittent catheterization. All patients presented detrusor overactivity resistant to oral anticholinergic treatment. They received between 2 and 6 injections at a dose of 12 botulinum toxin units (BU)/kg (maximum 300 BU). Cystometry was performed 4–8 weeks after treatment.ResultsFive patients became completely dry, 2 were only rarely wet, and data are lacking for 1 patient. Febrile urinary tract infections ceased after 1 or 2 injections. The mean maximal detrusor pressure decreased below 40 cmH₂O after 1, 2 and 3 injections. The normalized safe capacity rose significantly after 1, 2 and 3 injections. The normalized maximal bladder capacity rose similarly after 1, 2 and 3 injections although not always significantly.ConclusionIntradetrusor botulinum toxin-A injections significantly reduce detrusor pressure and can be repeated with efficacy. They have their place in between anticholinergic treatment and surgery. The procedure could be simplified and the dosage reduced.     

Treatment with modified intravesical oxybutynin chloride for neurogenic bladder in children

ObjectiveWe have previously reported that intravesical oxybutynin chloride with hydroxypropylcellulose (modified intravesical oxybutynin) is an effective therapeutic agent for patients with detrusor overactivity. In this study, we report on the efficacy, safety and side effects of modified intravesical oxybutynin administration in children with neurogenic bladder.PatientsModified intravesical oxybutynin (1.25 mg/5 mL, twice a day) was administered to four children (three males and one female) with neurogenic bladder (detrusor overactivity and/or low compliance bladder), who were previously unresponsive to or experienced intolerable side effects from oral medications. A cystometrogram was obtained before, 1 week after, and 1 year after the first intravesical instillation of modified oxybutynin. We also carefully observed anticholinergic side effects, occurrence of urinary tract infection and degree of incontinence during this treatment.ResultsAfter 1 week, both cystometric bladder capacity and compliance were improved in all patients, and detrusor overactivity was undetectable in three of four patients. At 1 year, there was further improvement in bladder compliance in three patients, and detrusor overactivity was not observed in two patients. Significant improvement in the degree of incontinence was achieved. No systemic anticholinergic side effects were observed in any of the patients. One patient with vesicoureteral reflux discontinued the therapy after 2 months due to upper urinary tract infections.ConclusionModified intravesical oxybutynin is an effective and relatively safe therapeutic option for children with neurogenic bladders.     

Botulinum toxin-A (Botox®) intradetrusor injections in children with neurogenic detrusor overactivity/neurogenic overactive bladder: A systematic literature review

ObjectivesDescribe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB).MethodsA MEDLINE and EMBASE search for clinical studies involving BTX-A injected into the detrusor of children with NDO or NOAB was performed, prior to data analysis.ResultsA total of six articles evaluating the efficacy and safety of Botox^® in patients with NDO and incontinence/NOAB were selected. The underlying neurological disease was myelomeningocele in 93% of patients. Most were over 2 years of age. The most common amount of Botox injected was 10–12 U/kg with a maximal dose of 300 U, usually as 30 injections of 10 U/ml in the bladder (excluding the trigone) under cystoscopic guidance and general anaesthesia. Most of the studies reported a significant improvement in clinical (65–87% became completely dry) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to <40 cm H₂O and compliance was increased >20 ml/cm H₂O) variables, without major adverse events.ConclusionsBotox injections into the detrusor provide a clinically significant improvement and seem to be very well tolerated in children with NDO and incontinence/NOAB refractory to antimuscarinics.     

Repeated injections of intradetrusor onabotulinumtoxinA as adjunctive treatment of children with neurogenic bladder

Aim

To evaluate the effects of repeated injections of onabotulinumtoxinA in children with neurogenic bladders refractory to conventional treatment.

Patients and methods

A total of 26 children with neurogenic bladder were prospectively studied. Some patients received up to four repeat injections. Patients were reinjected if they showed improvement in voiding diary, score of urinary incontinence and/or urodynamic studies; otherwise, augmentation cystoplasty was indicated.

Results

Of the 26 patients, 12 were reinjected a second time, 6 patients were reinjected a third time and 2 patients received a repeat injection for the fourth time. Six months after the first, second and third injection, the urinary incontinence score 0 (dry) was 50, 77 and 75 %, respectively. After each injection, the mean bladder capacity in voiding diary and the mean maximum cystometric capacity increased. The mean detrusor pressure at the end of filling decreased. Only compliance after the first injection improved significantly. Detrusor overactivity (n: 4), improved during 3 months and reappeared in three children after the first injection, but at greater cystometric volumes. In the fourth case, it reappeared 11 months after the third injection. Five patients underwent cystoplasty.

Conclusion

After treatment with onabotulinumtoxinA, urinary continence achieved was 50–77 %. There were favorable changes in urodynamic variables, but they were insufficient. Detrusor overactivity was attenuated, but did not disappear completely.     

Urodynamic effects of propiverine in children and adolescents with neurogenic bladder: results of a prospective long-term study

ObjectiveTo evaluate prospectively the efficacy and tolerability of propiverine for long-term treatment of neurogenic detrusor overactivity (NDO) in children.Materials and methods17 children and adolescents with NDO (10 female, 7 male; average age at last consultation 13.0 years) were evaluated during long-term treatment with propiverine (0.8 mg/kg body weight/day). Outcome measurements included urodynamic parameters, continence, hydronephrosis and tolerability of propiverine.ResultsAverage follow-up was 3.6 years (range 2.0–5.9). The average maximum detrusor pressure was 33.2 ± 4.8 cmH₂O and bladder compliance was 20.0 ± 5.4 ml/cmH₂O at the last follow-up visit. Maximum cystometric bladder capacity (MCBC) within the normal range was attained in 11 patients; it was still reduced (average of 61% of expected MCBC) in the remaining 6. Incontinence occurred on average once per day. Hydronephrosis was classified for each renal unit separately: grade 0 was measured in 26 and 22 cases, grade 1 or 2 in 6 and 8 cases, grade 3 or 4 in 2 and 4 cases pre and post treatment, respectively. In 6/17 patients adjuvant intravesical oxybutynin was applied, in 4 out of these 6 patients more invasive procedures, such as untethering, augmentation cystoplasty or botulinum toxin injections, were necessitated. Propiverine monotherapy was well tolerated in 11/17 patients. No serious adverse events were encountered during the study period.ConclusionLong-term efficacy and tolerability of propiverine for NDO in children and adolescents is promising: clinically relevant improvements in key urodynamic outcomes were paralleled by improvements in incontinence score.     

托特罗定在小儿神经原性膀胱的应用评价

目的 评价托特罗定治疗小儿神经原性膀胱的有效性和安全性.方法 随访126例2002年1月至2009年9月收治的神经原性膀胱患儿,男71例,女55例,年龄(6.2±3.1)岁,全部病例行清洁间歇导尿,81例同时服用托特罗定(0.1 mg·kg-1·d-1,2次/d),45例未服用托特罗定.就诊时和治疗3个月后分别行尿动力学和临床评价.结果 导尿+药物组中8例因副作用终止治疗,其中3例出现口干,2例头晕,3例便秘加重,73例坚持服用托特罗定.就诊时导尿组膀胱容量、膀胱顺应性、逼尿肌压分别为(119.3±19.6)ml、(4.0±1.1)ml/cmH2O、(56.7±10.4)cmH2O.3个月后膀胱容量、膀胱顺应性、逼尿肌压压分别为(122.0±20.1)ml、(4.1±1.1)ml/cmH2O、(55.8±10.9)cmH2O,无明显变化.11例(24.4%)逼尿肌过度活动减轻,13例(28.9%)漏尿分数下降.药物+导尿组就诊时膀胱容量、膀胱顺应性、逼尿肌压分别为(119.8±17.6)ml、(4.4±1.3)ml/cmH2O、(55.1±11.7)cmH2O,3个月后膀胱容量、膀胱顺应性、逼尿肌压分别为(149.6±23.1)ml、(7.5±2.3)ml/cmH2O、(38.4±11.6)cmH2O,膀胱容量、膀胱顺应性明显增加,膀胱内压降低.58例(79.5%)逼尿肌过度活动减轻,53例(73%)漏尿分数下降及家长表示满意.结论 托特罗定可抑制逼尿肌过度活动,降低膀胱内压,增加膀胱顺应性和膀胱容量,较少有副作用,有利于保护上尿路功能,并可减轻尿失禁的程度,对于反射亢进型小儿神经原性膀胱的治疗是安全、有效的.

Abstract：

Objective To evaluate the efficacy and safety of tolteroding to treat neurogenic bladder in children. Methods 126 patients (71 boys and 55 girls of 6. 2 ± 3. 1 years old) with hyperreflexia neurogenic bladder who were treated during January 2002 to September 2009 were followed up. All patients were performed clean intermittent catheterization. 81 patients took tolterodine(0. 1mg· kg-1 ·d-1 ,2 times/d) and 45 patients did not use tolterodine. Urodynamic and leakage score were evaluated before the treatment and 3 months later. Results 8 patients stopped tolterodine due to side effect,such as dry mouth in 3, dizziness in 2, sever constipation in 3. 73 patients took tolterodine all the time. Before treatment, the bladder volume, compliance and detrusor pressure in catheterization group were 119. 3 ± 19. 6 ml、4. 0 ± 1. 1ml/cmH2O 、56. 7 ± 10. 4 cmH2O, respectively. Three months after the treatment, bladder volume, compliance and detrusor pressure were 122. 0 ± 20. 1 ml、4. 1 ± 1. 1ml/cmH2O 、 55. 8 ± 10. 9 cmH2O, respectively. There was no significant difference. Detrusor overactivity in 11 patients(24. 4％)and leakage score in 13 patients (28. 9％)decreased. Bladder volume, compliance and detrusor pressure in catheterization + tolterodine group in the beginning were 119. 8 ± 17. 6ml、4. 4 ± 1.3ml/cmH2O 、 55. 1 ± 11.7 cmH2O, respectively. 3 months later, bladder volume, compliance and detrusor pressure were 149. 6 ± 23. 1 ml、7. 5 ± 2. 3ml/cmH2O 、38. 4 ± 11.6 cmH2O, respectively. Bladder volume and compliance increased and detrusor pressure decreased significantly. Detrusor overactivity in 58 patients(79. 5％)and leakage score in 53 patients(73％)decreased. The parents satisfied with this result. Conclusions Tolterodine could inhibit the detrusor overactivity, so it could decrease detrusor pressure and increase bladder volume and compliance and protect kidney. It was effective to the children with hyperreflexia nerurogenic bladder.     

The use of an intra vesical silicon inflatable baloon device improves results of bladder autoaugmentation technique. Long term follow up

PurposeTo present the long-term RESULTS of bladder autoaugmentation in children with low compliant neurogenic bladders comparing the usual technique with a modified technique using an intra vesical silicon inflatable balloon device.Material and MethodsTwenty-two patients with low-compliant neurogenic bladders and incontinence confirmed urodynamically were divided in two groups. Group I (12 patients) underwent autoaugmentation using the classical detrusorectomy approach. Group II (10 patients) underwent autoaugmentation associated to an intra vesical silicon inflatable device filled with saline solution customized to allow urine elimination and sustain partial bladder distention.ResultsFollow up ranged from 2 to 11 years (mean 4 years). Patients in Group I showed unsatisfactory RESULTS, with only one patient achieving continence using clean intermittent catheterization (CIC). Four patients showed mild improve on urodynamic parameters. Patients in group II showed encouraging RESULTS. Six patients achieved continence with CIC. Two patients achieved continence using CIC and anticholinergic agents. Bladder capacity had a mean increase of approximately 71% and bladder compliance mean increased from 15.6 ± 16.8 ml/cmH2O to 34.3 ± 22.8 ml/cmH2O (p = 0.02). Two patients with previously dilated upper urinary tract showed a decrease in the grade of dilatation.ConclusionsBladder autoaugmentation using an intra vesical silicon inflatable balloon device showed better RESULTS compared to the usual autoaugmentation technique. The presented device didn't add morbidity to the surgical procedure. This technique can be used in selected patients in order to improve urodynamic parameters and continence without the potential disadvantages of using bowel segments for bladder augmentation.     

保留膀胱黏膜肠浆肌层膀胱扩大术的尿流动力学评价

目的评价神经性膀胱行保留膀胱黏膜双层小肠浆肌层膀胱扩大术后的尿流动力学变化。方法45例逼尿肌反射亢进型神经性膀胱行保留膀胱黏膜的小肠浆肌层膀胱扩大术，男26例，女19例，年龄4～14岁。36例随访2年，手术前后行尿流动力学检查。结果手术后膀胱容量、膀胱顺应性、尿流率较术前增加，逼尿肌压降低，残余尿量／膀胱容量较术前减小，无抑制收缩减轻。逼尿肌括约肌不协调和尿道闭合压无改变。30例临床症状改善。结论保留膀胱黏膜的双层肠浆肌层膀胱扩大术可增加膀胱容量及顺应性，降低逼尿肌压，减轻逼尿肌反射亢进的程度，逼尿肌括约肌不协调以及尿道闭合压无明显变化。     

小儿神经原性膀胱手术前后尿流动力学检查评价

目的　基于手术前后尿流动力学检查结果的分析,对小儿神经原性膀胱逼尿肌和括约肌不协调的成因进行讨论,并对外科治疗进行评价。方法　55例行盆底肌加强及膀胱颈悬吊的神经原性膀胱患儿于术前和术后4～10个月行尿流动力学对照检查,然后分析其结果并行统计学处理。结果　34例逼尿肌反射亢进型中,30例术后逼尿肌和括约肌不协调减轻或较协调,4例无变化。最大膀胱容量增加（89.0±17.2）ml,最大尿道压力下降（2.7±0.37）kPa,最大尿道闭合压下降（3.1±0.6）kPa;21例术后逼尿肌无反射或反射低下型,逼尿肌反射明显改善11例,改善10例,最大膀胱容量增加（55.6±10.3）ml,最大尿道压力增加（2.9±0.7）kPa,最大尿道闭合压增加（2.6±0.7）kPa。结论　盆底肌加强和膀胱颈悬吊手术是治疗小儿神经原性膀胱的良好术式。因腰骶部脊膜膨出所致的小儿神经原性膀胱逼尿肌与外括约肌协同失调本质上可能是尿道外括约肌对漏斗状膀胱颈代偿性收缩的一个表现。     

Long-term efficacy and safety of tolterodine in children with neurogenic detrusor overactivity

ObjectiveWe evaluated long-term (≥12 months) efficacy and safety of tolterodine in children with neurogenic detrusor overactivity.Subjects and methodsSubjects successfully completed one of three 12-week, open-label studies and had stable neurologic disease and urodynamic evidence of neurogenic detrusor overactivity requiring intermittent catheterization. Drug formulation and dosing were based on age (4 months–4 years, tolterodine oral solution 0.2–2 mg twice daily; 5–10 years, tolterodine oral solution 0.5–4 mg twice daily; 11–16 years, tolterodine extended-release capsules 2, 4, or 6 mg once daily). Daily doses were individualized for each subject. Efficacy was evaluated urodynamically and using parent-completed 3-day bladder diaries.ResultsThirty subjects were enrolled. Functional bladder capacity (volume at first leakage, first sensation of bladder fullness or 40 cm H₂O pressure) increased by month 12 in the younger age groups but not in the oldest subjects. Volume to first detrusor contraction >10 cm H₂O pressure and detrusor leak point pressure did not change in any age group. The number of incontinence episodes per 24 h decreased in all subjects, as did the number of catheterizations per 24 h. Mean volume per catheterization increased in all subjects. Seven treatment-related adverse events were reported.ConclusionsBoth tolterodine formulations were effective and well tolerated in children with neurogenic detrusor overactivity.     

Bladder perforation in augmentation cystoplasty during urodynamic investigation: A case report and review of the literature

BackgroundSpontaneous bladder rupture is a known complication of augmentation cystoplasty. We report the second case of bladder rupture during filling cystometry many years after bladder augmentation and the first case occurring in a patient with an autoaugmentation cystoplasty. In addition, the management and outcome for a bladder perforation in an autoaugmentation cystoplasty will be discussed.CaseA 20-year-old male with a history of an L4 myelomeningocele underwent an autoaugmentation cystoplasty for neurogenic bladder dysfunction and decreased bladder wall compliance five years previously. He self catheterized four times daily. During filling cystometry, detrusor pressure increased to 60 cm H₂O with 300 mL filling. Detrusor pressure then rapidly decreased to 20 cm H₂O without evidence of external leakage. The infusion was immediately stopped and X-ray showed intraperitoneal leakage of contrast material. Serial abdominal examination demonstrated worsening abdominal distension. Exploratory laparotomy revealed a 2 cm perforation within the autoaugment portion of the bladder.ConclusionAn autoaugmentation cystoplasty improves bladder compliance and capacity with the use of native urothelial tissue. Although perforation after autoaugmentation has not been previously reported, caution must be used during urodynamic evaluation in patients with decreased bladder wall compliance and augmentation cystoplasty.     

清洁间歇导尿在小儿神经源性膀胱治疗中的价值

目的 评价清洁间歇导尿在小儿神经源性膀胱治疗巾的临床意义.方法 脊髓栓系综合征患儿64例.男49例,女15例,年龄3～13岁.均已行脊髓栓系松解手术.临床表现为尿失禁,611例合并大便失禁.52例合并足畸形.就诊时和就诊后1年分别行尿动力学和排泄件膀胱尿道造影以及超声检查,治疗期间36例坚持间歇导尿.28例未能坚持间歇导尿.结果 导尿组开始有9例合并Ⅲ°以下输尿管反流.4例为单纯肾积水.膀胱容量、顺应性、逼尿肌压分别为(176±34.5)ml、(3.5±0.6)ml/cmH2O、(54.6±13.2)cmH2O.1年后3例输尿管反流消失,2例肾积水减轻,膀胱容量、顺应性、逼尿肌压分别为(188±30.3)ml、(3.7±0.9)ml/cmH2O、(50.6±11.8)cmH2O,4例发生尿路感染(11.1%).未导尿组开始有7例合并Ⅲ°以下输尿管反流,5例为单纯肾积水,膀胱容量、顺应性、逼尿肌压分别为(168±37.2)ml,(3.2±0.7)ml/cmH2O,(59.6±15.6)cmH2O.1年后13例合并输尿管反流.9例合并肾积水.膀胱容量、顺应性、逼尿肌压分别为(142±23.6)ml,(1.6±0.7)ml/cmH2O,(72.4±9.3)cmH2O.3例发生尿路感染(10.7%).结论清洁间歇导尿可保护膀胱功能.避免或减轻上尿路功能的损害,并不增加尿路感染的发生率.对于神经源性膀胱治疗有重要的应用价值.     

膀胱自体扩大术在神经性膀胱患儿中的应用评价

目的评价逼尿肌部分切除、膀胱自体扩大术的临床疗效。方法选择脊髓脊膜膨出患儿6例,其中男性3例,女性3例,年龄18个月至9岁。患儿均口服索利那新和行清洁间歇导尿3个月后无好转而行逼尿肌部分切除、膀胱自体扩大术,术后予清洁间歇导尿,手术前及术后1年行泌尿系超声、排泄性膀胱尿道造影,并行尿动力评价,评价指标为膀胱容量、膀胱顺应性和充盈末逼尿肌压。结果术前尿动力学检查显示6例患儿膀胱容量减小、膀胱顺应性下降及逼尿肌压升高,其中5例膀胱容量低于预期容量的50%。排泄性膀胱造影4例合并膀胱输尿管反流,其中左、右侧Ⅳ°反流各1例,双侧Ⅳ°反流2例。6例患儿手术后恢复顺利,无穿孔、感染发生。术后1年尿动力学检查显示6例患儿膀胱容量略有增加,但膀胱容量与预期膀胱容量(年龄×30+30)、膀胱顺应性及逼尿肌压力无明显变化,VCUG显示4例输尿管反流无减轻。结论对于膀胱容量明显变小的神经性膀胱患儿,逼尿肌部分切除、膀胱扩大术不能有效增加膀胱容量和顺应性,降低逼尿肌压,临床不能取得满意的效果。     

Can urodynamic studies be dispensed with in the initial urologic management of children with meningomyelocele? A study of 30 cases and review of the literature

ObjectiveTo identify whether a relationship exists between information gathered from voiding patterns, neurological status and radiological findings, and the actual dysfunction seen on cystometry in children with spina bifida.Patients and methodsThirty consecutive children with spina bifida underwent clinical evaluation, urinary tract imaging and cystometry. The clinical and radiological data were correlated with actual bladder dysfunction.ResultsCystometry was abnormal in 87% with overactive detrusor in 77%. Seventeen patients (57%) had significant residual urine of whom all had neurological or voiding abnormalities. Irrespective of radiological findings (abnormal in 53%), 90% of these patients had detrusor overactivity and 10% an underactive detrusor. In the group with insignificant residual urine (n = 13), upper tract was abnormal in six (46%) of which four had neurological/voiding abnormalities and detrusor overactivity. The other two patients with normal neurologic status and voiding pattern had normal cystometry, but their upper tract damage was inexplicable. Of the patients with insignificant residual urine and normal upper tracts (n = 7), four had neurologic/voiding abnormalities, three with an overactive detrusor and one underactive detrusor, and of the other three, one had an overactive detrusor.ConclusionsPatients with significant residual urine can be presumed to have detrusor overactivity and may be initially managed with clean intermittent catheterization and bladder relaxants. Cystometry is indicated if upper tract shows deterioration. In patients with insignificant residual urine and abnormal clinical evaluation or radiology, detrusor overactivity can be presumed and urodynamic studies deferred. Patients with insignificant residual urine, normal radiology but abnormal clinical findings must undergo initial cystometry.     

Neurogenic bladder in children: urodynamic studies and results with medical conservative treatment

We present the urodynamic findings and therapeutic results in 25 children with neurogenic bladder, ranging in age from 2 months to 14 years. We observed a significant reduction of urinary infections and vesicoureteral refluxes following medical treatment based on the urodynamic findings. Furthermore, we observed a worse evolution in patients with pre-voiding bladder pressure in excess of 50 cm H2O, incontinence being more difficult to treat in children with urethral closure pressure profile below 47 cm H2O. In our series, anticholinergic treatment improved hypertonia and hyperreflexia which disappeared in 66.6% of cases. Total continence was achieved in 37.5% and improved in 29.1% of children.     

Dose-escalating study of the pharmacokinetics and tolerability of fesoterodine in children with overactive bladder

ObjectiveTo determine the pharmacokinetics, safety and tolerability of fesoterodine, and assess the utility of 3-day bladder diaries (exploratory objective) in pediatric subjects with neurogenic detrusor overactivity or idiopathic overactive bladder (OAB).MethodsIn this 8-week open-label study, subjects (8–17 years, >25 kg) received fesoterodine 4 mg for 4 weeks, then 8 mg for 4 weeks. Blood samples were obtained at weeks 4 and 8.ResultsOf 21 subjects enrolled, 11 had neurogenic detrusor overactivity and 10 had idiopathic OAB; 1 discontinued (personal reasons). Mean age and weight were 13.2 years and 54.0 kg for boys (n = 12) and 13.1 years and 49.2 kg for girls (n = 9). 5-Hydroxy-methyltolterodine plasma concentrations did not differ by diagnosis and were consistent with predictions based on adult data. Treatment-related adverse events (all mild or moderate) included 1 event each of dry mouth, constipation, dry eyes and blurred vision, and 2 events each of nausea and increased post-void residual volume. Three-day bladder diaries proved feasible.ConclusionsOral administration of fesoterodine in pediatric subjects (>25 kg) with idiopathic OAB or neurogenic detrusor overactivity produced steady-state plasma 5-hydroxy-methyltolterodine exposures similar to those in adults. The doses given were well tolerated.     

Effect of phenylpropanolamine on incontinence in children with neurogenic bladders. A double-blind crossover study

In children with myelodysplasia and a low-level spinal cord lesion (low lumbar-sacral), detrusor hyperactivity together with dyssynergic urethral function forms the main pathophysiological basis for incontinence. Pharmacological treatment of incontinence due to neurogenic bladder dysfunction has been tried, mainly with anticholinergics and alpha-adrenoceptor antagonists. In this study, the effects of the alpha-adrenoceptor agonist phenylpropanolamine on urodynamic parameters and incontinence were investigated in 10 patients. Effects on incontinence were evaluated in a double-blind crossover trial. Plasma concentrations of phenylpropanolamine were measured by means of gas chromatography-mass spectrometry. Phenylpropanolamine reduced detrusor hyperactivity and improved continence, but the effect was not so pronounced as to make the patients continent.     

Effect of onabotulinumtoxinA treatment on symptoms and urodynamic findings in pediatric neurogenic bladder

ObjectiveTo evaluate clinical and urodynamic efficiency of onabotulinumtoxinA (Botox) treatment in pediatric patients with urinary incontinence due to neurogenic overactive bladder.Patients and methodsSeventeen patients aged from 6 to 17 years (median 11 years) were treated with Botox injections. Clinical response to incontinence, duration of the response, and urodynamic results before and 1–3 months after treatment were evaluated.ResultsMean incontinence frequency decreased significantly (p = 0.036); six of 17 patients had >90% reduction, and a further three patients had a 50–90% reduction in incontinence episodes. Median duration of the response was 15 months (range 3–42 months). Mean bladder volume changed from 380 ± 148 ml to 453 ± 147 (p = 0.078), maximal detrusor pressure decreased from 45 ± 31 cmH₂O to 32 ± 21 cmH₂O (p = 0.030), and the number of patients with detrusor contractions during filling decreased from 12 to three (p = 0.005) after the treatment. The patients with poor bladder compliance had either no response or a short duration of response. At follow-up eight patients had undergone bladder augmentation because of persistent incontinence.ConclusionsAbout one third of pediatric patients with neurogenic bladder had a good response to Botox treatment. In many patients, the clinical response was longer than expected. The patients who initially had poor bladder compliance had a poor response to the treatment.     

神经源性膀胱伴输尿管反流的尿动力学研究

目的 探讨有输尿管反流的神经源性膀胱(NB)患儿有或没有逼尿肌过度活动(DO)时的尿动力学差异,为临床治疗此类患儿提供理论参考依据.方法 选取2013～2015年就诊并经影像尿动力学检查发现膀胱输尿管反流的NB患儿68例,男30例,女38例,年龄4～12岁,平均7.5岁.按照充盈期有DO,将其分为DO组(n=20)与无DO组(n=48).观察记录两组发生膀胱输尿管反流时的膀胱灌注量、逼尿肌压并计算发生反流时的膀胱顺应性;记录两组充盈结束时最大膀胱测压容量、最大逼尿肌压、并计算充盈期膀胱顺应性.结果 DO组发生膀胱输尿管反流时的膀胱容量与顺应性分别为(98.7±16.1)ml和(5.2±1.9) ml/cmH2O,无DO组发生膀胱输尿管反流时的膀胱容量与顺应性分别为(127.3±36.3)ml,(7.1±2.1)ml/cmH2O,差异均有统计学意义(P＜0.05);两组的逼尿肌压分别为(21.6±9.2)cmH2O、(19.2±7.4)cmH2O,差异没有统计学意义;DO组充盈结束时的膀胱容量与顺应性分别为(182.7±31.2)ml、(5.4±1.7) ml/cmH2O,与无DO组充盈结束时的膀胱容量(230.6±34.6)ml与顺应性(6.5±1.1)ml/cmH2O相比,差异有统计学意义;两组尿动力学检查结束时逼尿肌压分别为(33.8±7.8)cmH2O、(36.4±8.1)cmH2O,差异没有统计学意义.结论 膀胱容量小,膀胱顺应性差是有输尿管反流的NB患儿伴发DO时的尿动力学特征.     

Short pelvic floor EMG lag time II: Use in management and follow-up of children treated for detrusor overactivity

ObjectiveTo determine utility of short pelvic floor electromyography (EMG) lag time in monitoring therapeutic response in children with idiopathic detrusor overactivity (DO) and quiet EMG during voiding (idiopathic detrusor overactivity disorder, IDOD).Patients and methods162 consecutive normal children (77M, 85F) diagnosed with IDOD and short EMG lag time were reviewed. All were treated with combined standard urotherapy and anticholinergics. Pre-treatment uroflow/EMG parameters were compared with on-treatment parameters.ResultsMedian age at evaluation was 6.8 years and median EMG lag time was 0 s; 110 children had repeat uroflow/EMG studies while on anticholinergic therapy. With a median follow-up of 18.7 months, mean EMG lag time increased from 0.7 to 2.2 s and % expected bladder capacity for age (EBC) increased from 0.68 to 0.98 (both p < 0.01). EMG lag time increased in all patients while on therapy and normalized in 83 patients (75%).ConclusionA short EMG lag time on noninvasive uroflow/EMG in a patient with urgency can be a surrogate for urodynamics study (UDS) in diagnosing DO and objectively monitoring response to therapy. When effectively treated, children with DO have amelioration of their lower urinary tract symptoms (LUTS) and normalization of both EMG lag time and bladder capacity.