Influence of Adrenergic Agonists and Antagonists on Urethral Pressure, Bladder Pressure and Detrusor Hyperactivity in Children with Myelodysplasia

ABSTRACT. In children with myelodysplasia and a low lumbar or sacral level of spinal cord lesions detrusor hyperactivity with pressure fluctuations is an almost constant phenomenon contributing to incontinence. In thirteen children with this type of dysfunction the effect of adrenergic agonists and antagonists on bladder and urethral pressures were studied by means of intravesical and urethral pressure recordings during the normal bladder-filling phase. Intravenous infusion of noradrenaline during the bladder-filling phase slightly reduced detrusor hyperactivity and the urethral pressure was increased. Following i.m. injection of the alpha-adrenergic antagonist pheatolamine both the intravesical and proximal urethral pressures were reduced to about the same extent and the detrusor hyperactivity decreased. It is concluded that noradrenaline mainly changed urethral pressure while alpha-adrenergic blockade caused decreased tone in both the detrusor and the urethra as well as decreased detrusor hyperactivity.     

Influence of adrenergic agonists and antagonists on urethral pressure, bladder pressure and detrusor hyperactivity in children with myelodysplasia

In children with myelodysplasia and a low lumbar or sacral level of spinal cord lesions detrusor hyperactivity with pressure fluctuations is an almost constant phenomenon contributing to incontinence. In thirteen children with this type of dysfunction the effect of adrenergic agonists and antagonists on bladder and urethral pressures were studied by means of intravesical and urethral pressure recordings during the normal bladder-filling phase. Intravenous infusion of noradrenaline during the bladder-filling phase slightly reduced detrusor hyperactivity and the urethral pressure was increased. Following i.m. injection of the alpha-adrenergic antagonist phentolamine both the intravesical and proximal urethral pressures were reduced to about the same extent and the detrusor hyperactivity decreased. It is concluded that noradrenaline mainly changed urethral pressure while alpha-adrenergic blockade caused decreased tone in both the detrusor and the urethra as well as decreased detrusor hyperactivity.     

Urodynamic dysfunction in infants with vesicoureteral reflux

Patients and Methods: Vesicoureteral reflux (VUR) may result from inadequate length of the intravesical ureteric tunnel and from urodynamic dysfunction. VUR and symptomatic urinary tract infection (UTI) are both more common in male infants and may be related to urodynamic dysfunction and functional intravesical obstruction. We therefore conducted urodynamic studies in 75 infants with primary VUR and retrospectively evaluated their voiding cystourethrogram (VCUG) for evidence of inadequate sphincteric relaxation. RESULTS: High voiding detrusor pressure (>70 cm H(2)O), increased postvoid residual (>2 mL/kg body weight), or detrusor-sphincter dyssynergy were observed in 79% of infants with primary VUR without significant differences between male and female infants or in infants with or without UTI. Infants with bilateral grade IV-V VUR showed a higher prevalence of detrusor hyper-reflexia and higher voiding detrusor pressure than infants with lower grades of VUR or unilateral grade IV-V VUR. On VCUG, inadequate external urethral sphincter relaxation during voiding was noted in 10 of 47 male infants. CONCLUSIONS: The findings suggest that high intravesical pressures contribute to the development and severity of VUR, and that high voiding detrusor pressure in some infants with primary VUR may be related to inadequate relaxation of the external urethral sphincter.     

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.     

Gastric tonometry after gastroschisis repair.

Gastric tonometry and intravesical pressure measurement were performed on eight babies born with gastroschisis for 72 hours after abdominal closure. Intravesical pressure was not high. The gastric mucosal pCO2 and gastric mucosal pH remained stable and closely matched arterial values. Tonometry may be a useful technique to monitor these babies.     

Gastric tonometry after gastroschisis repair

Gastric tonometry and intravesical pressure measurement were performed on eight babies born with gastroschisis for 72 hours after abdominal closure. Intravesical pressure was not high. The gastric mucosal pCO2 and gastric mucosal pH remained stable and closely matched arterial values. Tonometry may be a useful technique to monitor these babies.     

Assessing children's blood pressure--considerations of age and body size: the Muscatine Study

Blood pressure was assessed in 4,207 children, aged 5 to 18 years, examined in the schools of Muscatine, Iowa during 1981. Overall, 69.9% of the age-sex-specific quintiles and height-sex-specific quintiles of systolic blood pressure were identical. In only 1.0% of children did these quintiles differ by more than one. Children whose blood pressure was in the highest quintile for both age and height were more obese than their peers. Those whose blood pressure was high for age but not for height were proportionately taller and heavier than their age peers. Children whose blood pressure was high for height but not for age were older, shorter, and lighter. Thus, having precocious levels of blood pressure for age during childhood is associated with excessive body weight or precocious height, whereas having high blood pressure for height but not for age is associated with being short for age. The latter suggests that age may be a factor independent of height and weight affecting blood pressure level in childhood. These relationships of body size and age to blood pressure must be considered when evaluating children's blood pressure levels in the clinical setting, and a technique for doing so is presented.     

Cloacal exstrophy variant with intravesical phallus: further description of anatomy and implications for gender reassignment

Variant presentations of cloacal exstrophy are exceedingly rare. Historically, genetic males with cloacal extrophy were re-assigned to the female gender due to phallic inadequacy. Early recognition of intravesical phallic structures in cloacal exstrophy cases may impact gender reassignment discussions and long-term gender outcomes. We report the case of a male infant with cloacal exstrophy presenting with an intravesical phallus, review and compare the presenting anatomical features of the three previously reported cases, and discuss the potential impact of these findings on gender reassignment in these complex children.     

Relationship between height and blood pressure in Japanese schoolchildren

Background: Blood pressure examinations for health education use have been conducted at several schools in Japan. It has been reported that blood pressure is closely associated with bodyweight and height in US children. The aim of the present paper was to evaluate the association between height and blood pressure in Japanese schoolchildren. Methods: In Iwata city in Japan, blood pressure screening was conducted by the school administration. A total of 98.9% (10 152/10 270 children) of all fifth (10‐year‐olds) and ninth graders (14‐year‐olds) residing in the Old Iwata area from 2002 to 2007 were analyzed. Results: In 10‐year‐old and 14‐year‐old boys, regression analysis indicated that a positive correlation between weight and blood pressure was the strongest among the three body size indices (height, weight, and body mass index), but the association between height and blood pressure was also significant. For girls from both the 10 and 14 year age groups, the correlation of weight and blood pressure was stronger than those for the other body size indices, but there were also significant associations between height and blood pressure, except for height and diastolic blood pressure in the 14‐year‐olds. Conclusions: There is a significant positive relationship between height and blood pressure. Further study is necessary to provide a blood pressure reference based on height in the Japanese program to prevent children from developing lifestyle‐related risk factors.     

Arterial pressure and puberty: relation to height-weight characteristics

The study of 315 boys and 497 girls, aged 10 to 18 years, showed that blood pressure rises during puberty. Growth in height seems to explain this increase better than sexual maturation, at least in boys. These results confirm the significance of associating blood pressure and height in adolescence. The correlation coefficients between blood pressure, weight indices (weight for height, Quetelet's index, skinfold thickness), weight components (lean body mass, fat body mass) indicate that blood pressure is to a large extent determined by lean body mass (mainly in boys), according to the marked development of the osteomuscular system. We are of the opinion that this should be considered when interpreting blood pressure level in adolescents.     

Management of post-operative bladder spasm

OBJECTIVE: Pain management following bladder surgery in children is often complicated by bladder spasm. The overall severity of spasm can be reduced with opioids, anticholinergic medication and sedatives, although breakthrough spasms often occur. At the Royal Children's Hospital, Melbourne, intravesical bupivacaine has been used to manage postoperative bladder spasm to good effect. The administration of intravesical bupivacaine is analysed in this prospective audit of locally applied intravesical anaesthetic and compared with other methods. METHOD: From February to August 2003, histories of 58 patients who had intravesical bupivacaine were studied and compared with six other methods of management of postoperative bladder spasm. CONCLUSION: Data showed that epidural anaesthesia was the most effective treatment of pain, with a pain score reduction of 6.6, compared with a reduction of 6.1 with intravesical bupivacaine, and 4.5 using intravenous morphine. However, intravesical bupivacaine was the most effective method for the relief of bladder spasm.     

Intrarenal reflux: diagnosis with contrast-enhanced harmonic US

The objective of this case report is to demonstrate the possibility of visualizing intrarenal reflux (IRR) in children using contrast-enhanced harmonic voiding urosonography (VUS). A 10-month-old girl underwent VUS as part of the work-up of acute pyelonephritis of the right kidney. Before and after intravesical administration of US contrast medium (Levovist) the urinary tract was scanned in harmonic imaging mode. Bilateral vesicoureteric reflux was detected (right grade IV, left grade III). Moreover, at the height of the reflux the right kidney parenchyma turned markedly echogenic, corresponding to massive IRR. The voiding cystourethrography that followed confirmed the results of the VUS.     

Airway resistance measured by the interrupter technique: normative data for 2-10 year olds of three ethnicities.

BACKGROUND AND AIMS: The measurement of airway resistance using the interrupter technique (R(int)) is feasible in preschool children and other subjects unable to undertake spirometry. This makes it potentially useful for the measurement of lung function in these groups. Commercial devices use different algorithms to measure pressure and flow from which R(int) is derived. This study provides normative values for British children using devices from a single manufacturer. METHODS: R(int) was measured in 236 healthy children of three ethnic groups (Afro-Caribbean and black African, Bangladeshi, and white British) aged 2-10 years using Micro Medical devices. Software in the devices calculated R(int) from pressure measured by the two point, back extrapolation method from the pressure transient during valve closure, with flow measured just before valve closure. RESULTS: R(int) is related to both age and height, but when age is allowed for there is not a significant relation with height. Neither gender nor any of the ethnicities studied was significantly related to R(int). DISCUSSION: These measurements in healthy children using this technique may be used as reference data for similar populations.     

“The intraureteric diverticulum”, a manifestation of ureterocoele intussusception

An ectopic ureterocoele may present as a diverticular-like structure at the bladder base appearing during voiding cystography. The radiological appearances are described and the mechanism of formation as seen in serial 70 mm film is discussed. The conventional intravesical filling defect of an ureterocoele may not be recognised when the bladder is filled by contrast medium. This sign of extra-vesical intra-ureteric invagination is only seen during voiding.     

Endoscopic and minimal open surgical incision of ureteroceles

Ureterocele decompression by endoscopic or open incision was the primary treatment in 59 children with 63 ureteroceles. Of these, 18 were intravesical and 45 were ectopic. The endoscopic or open incision adequately decompressed all intravesical ureteroceles and 37 of 45 ectopic ureteroceles (82%). After incision, the secondary operation rate was 17% for intravesical and 62% for ectopic ureteroceles. In our opinion, endoscopic or open incision must be considered a definitive treatment in the large majority of intravesical ureteroceles and is also valid in ectopic ureteroceles. In these cases, the early decompression obtained by this approach produced significant functional recovery, fewer urinary tract infections, and facilitated subsequent surgery in those patients requiring complete surgical reconstruction. Accepted: 11 June 1997     

Sonographic evaluation of the normal ureteral submucosal tunnel in infancy and childhood

Sonography was used to evaluate in vivo the length of the submucosal segment of the intravesical ureter in 35 normal infants, children and adults. Age varied between 3 and 30 years. Sonographic measurements were plotted against, age, height and weight. Analysis of the statistical data shows an almost linear growth profile in this age group. The dimensions obtained in vivo by ultrasound technique are comparable to the published dimensions obtained in vivo by endoscopic calibration or in vitro on fresh specimens. Although promising, ultrasound of the vesico-ureteral junction is because of technical limitations not yet applicable in neonates and infants in which measurement of the submucosal tunnel could be of clinical importance.     

Childhood risk factors for high adult blood pressure: the Muscatine Study

In adult populations, elevated blood pressure is related to the development of occlusive atherosclerosis, stroke, and renal disease. The significance of blood pressure levels in childhood, unless extremely elevated, has not been related to disease outcomes. In this study, the risk of high blood pressure in young adult life is evaluated based on the observations of blood pressure and other factors made during the school-aged years. Subjects, 2445 in number, were first observed at ages 7 through 18 years and again between 20 and 30 years. During childhood, measurements of blood pressure, height, and weight were made in alternate years. At adult ages, the same measurements were again made and a health questionnaire was administered. According to the data, adult blood pressure is correlated with childhood blood pressure, body size, and change in ponderosity from childhood to adult life. Adult ponderosity is related to childhood ponderosity, and those who are most obese as adults show the greatest increase in weight for height from their childhood years. These observations suggest that strategies to prevent the acquisition of excess ponderosity during adolescence may be useful in preventing adult hypertension.     

Dysfunction of the lower urinary and distal gastrointestinal tracts in pediatric patients with known spinal cord problems.

Destruction of the urinary tract in children with elimination, storage, and holding dysfunction of the lower urinary and the distal GI tracts is caused primarily by high intravesical pressure. UTI accelerates this process. The LPP and the status of the urethral control mechanism and its relationship to the detrusor are the primary determinants of intravesical pressure. Intravesical pressures of more than 40 cm H2O are dangerous because they cause a pressure gradient that is transmitted proximally to the renal papillae, which results in the cessation of renal blood flow and a loss of renal function over time. Hydroureteronephrosis, VUR, UTI, urinary incontinence, and calculi formation also may occur. If these dangerously high intravesical pressures remain untreated, renal failure is likely to occur over time. These children then require dialysis or renal transplantation to survive, which is tragic and represents an enormous economic cost to society. Renal failure and upper urinary tract damage is nearly 100% preventable with early and appropriate evaluation and treatment. CIC is a crucial part of the management of these children and has been shown to be safe and effective, even in newborn boys. The use of the Credé maneuver (i.e., manual compression) to empty the bladder is obsolete and should be abandoned. The distal GI tract is inseparable from the lower urinary tract and must be treated simultaneously. Failure to treat the distal GI tract yields poor clinical results and much patient dissatisfaction and makes it difficult or impossible to treat the child's urinary tract problem successfully. Bowel-management programs must include daily high water and fiber intake, together with digital perianal stimulation or fecal extraction. Neuropathic bladder and bowel problems that are intractable to conservative medical and mechanical (i.e., CIC and digital perianal stimulation or fecal extraction, respectively) management almost always can be corrected surgically with high success rates in cooperative patients. Finally, neuropathic bladder and bowel problems can be extremely isolating and debilitating problems. Psychologic counseling and emotional support must be provided as needed. The care that these patients receive must be organized, comprehensive, and correlated with these patients' lifestyles. If these children are evaluated and treated early, they have the potential to live long, healthy, and productive lives.     

Arterial distensibility in children and teenagers: normal evolution and the effect of childhood vasculitis.

BACKGROUND: Polyarteritis nodosa is a necrotising vasculitis of the medium sized and small muscular arteries. The inflammatory and subsequent reparative processes may alter the arterial mechanical properties. The effect of vasculitic damage on arterial distensibility has never been explored however. AIM: To determine the normal values and the effect of childhood vasculitis on arterial distensibility in children and teenagers. METHODS: Distensibility of the brachioradial arterial segment was studied using pulse wave velocity (PWV proportional, variant 1/ radical distensibility), in 13 children with polyarteritis nodosa at a median age of 11.8 (range 4.9-16) years. As a control group, 155 healthy schoolchildren (6-18 years, 81 boys) were studied. PWV was assessed using a photoplethysmographic technique; blood pressure was measured by an automatic sphygmomanometer (Dinamap). Data from patients were expressed as z scores adjusted for age and compared to a population mean of 0 by a single sample t test. Determinants of PWV in normal children were assessed by univariate and multivariate linear regression analyses. RESULTS: Age, height, weight, and systolic blood pressure correlated individually with the brachioradial PWV. Multivariate analysis identified age as the only independent determinant. Ten of the patients were in clinical remission, while three had evidence of disease activity at the time of study. The PWV in the patient group as a whole was significantly greater than those in healthy children (mean z score +0.99). Raised C reactive protein concentration (>2 mg/dl) in the three patients with active disease was associated with a higher PWV when compared to those in remission (z score +2.78 v +0.45). The diastolic blood pressure of the patients was higher than those of the controls (z score +1.04) while the systolic pressure was similar (z score -0.36). CONCLUSIONS: PWV in the brachioradial arterial segment increases gradually during childhood independent of body weight, height, mass, and blood pressure. Increased PWV, and hence decreased distensibility, in this peripheral arterial segment occurs in polyarteritis nodosa and is amplified during acute inflammatory exacerbation.     

Airway resistance measured by the interrupter technique: normative data for 2-10 year olds of three ethnicities

Background and Aims: The measurement of airway resistance using the interrupter technique (R_int) is feasible in preschool children and other subjects unable to undertake spirometry. This makes it potentially useful for the measurement of lung function in these groups. Commercial devices use different algorithms to measure pressure and flow from which R_int is derived. This study provides normative values for British children using devices from a single manufacturer. Methods: R_int was measured in 236 healthy children of three ethnic groups (Afro-Caribbean and black African, Bangladeshi, and white British) aged 2–10 years using Micro Medical devices. Software in the devices calculated R_int from pressure measured by the two point, back extrapolation method from the pressure transient during valve closure, with flow measured just before valve closure. Results: R_int is related to both age and height, but when age is allowed for there is not a significant relation with height. Neither gender nor any of the ethnicities studied was significantly related to R_int. Discussion: These measurements in healthy children using this technique may be used as reference data for similar populations.