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Purpose: In the setting of the European Bladder Dysfunction Study, a multi-center, randomized, controlled trial of treatment options for functional incontinence in children, we assessed the concordance between reported and reviewed urodynamic scores. Materials and Methods: A total of 97 children with clinically diagnosed urge syndrome and 105 with clinically diagnosed dysfunctional voiding enrolled in the European Bladder Dysfunction Study and underwent full urodynamic studies before and immediately after treatment for urinary incontinence. Photocopies of 72% of the original urodynamic recordings were available for blinded review. Results: The concordance for detrusor overactivity throughout the filling phase was 37% in urge syndrome cases and for increased pelvic floor activity during voiding it was 81% in dysfunctional voiding cases. Differences in original and reviewed scores were equally distributed among participating centers. Conclusions: Concordance between original and reviewed urodynamic scores was low for detrusor overactivity. Concordance was acceptable for increased pelvic floor activity during voiding but was not specific for dysfunctional voiding. Since interpreting urodynamic studies is based on pattern recognition, investigator bias can only be compensated for by blinded review of the actual recordings.

Purpose We prospectively assessed response and cure rates of alarm treatment, following pretreatment with antimuscarinics and/or holding exercises aimed at increasing maximum volume voided in 149 children with monosymptomatic nocturnal enuresis. Materials and Methods In a prior trial the same 149 children had been randomized into 5 groups to assess interventions for increasing maximum volume voided, namely placebo or antimuscarinics with (groups A and B, respectively) and without (C and D, respectively) holding exercises, and a control group (E) receiving just alarm treatment. Following pretreatment groups A to D received alarm treatment. Full response and cure rates were assessed, as well as the influence on these rates of baseline maximum volume voided, increase in maximum volume voided after pretreatment, gender, age and previous treatment. Results Neither full response nor cure was influenced significantly by the increase in maximum volume voided achieved in groups A and B with holding exercises. Overall full response ranged from 50% to 73%, and overall cure ranged from 50% to 67%. Possible predictors for full response and cure were prior treatment (p

The treatment of ectopic ureterocele is controversial. In addition to debate on optimal therapy, discussion exists on whether there is further risk of deteriorating bladder function after extensive bladder surgery during the first year of life, which is a reason to postpone surgery. In a prospective nonrandomized trial we treated 40 patients regardless of age who had ectopic ureterocele with complete surgical reconstruction of the lower urinary tract and upper pole resection of poorly functioning upper pole moieties at referral. Excluded from study were 3 patients with only 1 affected renal moiety initially. We treated 31 female and 9 male patients 0 to 8.8 years old (mean age 2.17) at surgery for ectopic ureterocele extending into the bladder neck and urethra, including 19 younger than 1 year. Primary ureterocele excision was performed in 37 cases with reconstruction of the urethra, bladder neck and trigone, and ureteral reimplantation. Because of small ureterocele size, the ureterocele was left in situ in 3 patients, leading to secondary ureterocele removal due to obstructive voiding and urinary incontinence in 1 each. A staged procedure in 5 neonates involved primary lower urinary tract reconstruction with upper pole cutaneous ureterostomies followed by upper pole resection or ureteral reimplantation a few months later. After bladder neck reconstruction in 16 cases colposuspension was also done to create a normal vesicourethral angle. All patients underwent clinical and urodynamic evaluation at least 1.25 years after surgery (mean followup 5.59). Patients who were too young for the clinical assessment of continence by January 1999 were excluded from study. All patients are continent. A secondary endoscopic procedure was required in 13 cases, including cystoscopy only in 2, scar incision near the ureteral orifice in 3, endoscopic reflux treatment in 4, ureterocele remnant resection in 2 and bladder neck incision for obstructive voiding in 2. Secondary open bladder reconstruction was performed in another case due to a diverticulum. Postoperatively only 1 or 2 uncomplicated episodes of urinary tract infection developed in 11 patients, while there were recurrent urinary tract infections in 4. In a patient with a preexisting loss of renal function a severe infection led to renal scarring. The voiding pattern was normal in 29 patients but 11 had dysfunctional voiding, including 5 with recurrent urinary tract infection. Urodynamic followup confirmed these clinical findings. Bladder capacity in these patients was relatively high at an average of 124% of expected capacity for age. We noted no statistically significant difference in followup parameters in patients who underwent surgery before and after age 1 year. Additional colposuspension in 16 patients did not result in any significant change in outcome compared with that in patients without this procedure. When compared with results in the literature, complete primary lower urinary tract reconstruction in patients with ectopic ureterocele appears to have better results than a staged approach with initial endoscopic treatment. Moreover, our study provides no proof that extensive reconstructive bladder surgery in neonates and infants leads to bladder function deterioration at a later age

The prevalence of nonneuropathic bladder/sphincter dysfunction was assessed with a questionnaire in 310 of the 386 children enrolled in the European branch of the International Reflux Study in Children. Despite the exclusion criteria (neuropathic bladder, anatomical malformations other than vesicoureteral reflux and overt dysfunctional voiding or urge incontinence), the prevalence of bladder/sphincter dysfunction was as high as 18%. Four patterns of dysfunction emerged: urge syndrome, staccato voiding, fractionated and incomplete voiding, and voiding postponement. The questionnaire proved helpful in detecting low profile cases of bladder/sphincter dysfunction, as well as indicating the need for further urodynamic studies. A strong correlation was established between recurrences of urinary tract infections, as well as disappearance of vesicoureteral reflux (negative correlation) and nonneuropathic bladder/sphincter dysfunction. This finding implies that detection and treatment of bladder/sphincter dysfunction are essential in every child with the complex of recurrent urinary tract infection and vesicoureteral reflux.

The effect of posterior sagittal anorectoplasty (PSARP) and its variants on lower urinary tract function was investigated urodynamically in 32 patients with anorectal malformations. In 27 patients urodynamic evaluation was performed before and after surgery and in 4 it was done postoperatively only. One child was clinically assessed with no postoperative urodynamic study. Minor postoperative changes in the specific preoperative urodynamic pattern were observed in 4 cases but the changes did not seem to be related to surgery. In 3 boys with rectourethral fistulas detrusor failure consistent with autonomic denervation was noted postoperatively. Standard posterior sagittal anorectoplasty was performed in 1 of the 3 boys and posterior sagittal anorectoplasty combined with additional transabdominal procedures was done in the other 2. In general our findings suggest that posterior sagittal anorectoplasty and its variants do not affect lower urinary tract function unless these surgical techniques are combined with major transabdominal procedures and extensive retrovesical dissection.

A total of 50 children with the caudal regression syndrome (caudal dysplasia sequence) underwent urodynamic evaluation of lower urinary tract function. Of the patients 15 had isolated sacral agenesis, 13 had sacral agenesis in combination with an anorectal malformation and 22 had an anorectal malformation without sacral anomaly. Neurogenic bladder-sphincter dysfunction was observed in 11 of the 15 children with isolated sacral agenesis (73%) and in 10 of the 13 children with combined sacral agenesis and anorectal malformation (77%). The pattern of neurogenic bladder-sphincter dysfunction in both groups did not differ significantly. In the group of 22 children with isolated anorectal malformation only 1 had signs of neurogenic bladder-sphincter dysfunction. These results indicate that anorectal malformation per se does not influence lower urinary tract function and that the sacral anomaly is the determining factor for neurogenic bladder-sphincter dysfunction in children with anorectal malformation.

Objective To evaluate whether colonic enema irrigation influences the urodynamic characteristics of patients with spina bifida, an overactive bladder and detrusor sphincter dyssynergia (DSD). Patients and methods Since 1991, 83 patients with spina bifida at our institution have treated their bowel dysfunction by colonic irrigation every 24–48 h. In 12 patients (seven boys and five girls, mean age 7.7 years, range 0.7–13.8) with an overactive bladder and DSD, urodynamic studies of the bladder before and after enema treatment were available with no intercurrent changes in urological therapy. Results There were no significant changes overall in bladder capacity, leak-point pressure, bladder compliance and bladder instability in the selected group of children. Conclusion Although enema therapy for bowel treatment in patients with spina bifida gave good results for faecal incontinence, with good patient compliance, no favourable effect on bladder function should be expected in most patients with a high-risk urinary tract dysfunction. Further study is needed to determine factors in patients who will benefit urologically from enema treatment.