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Aims: Dysfunctional voiding (DV) remains a poorly understood and a poorly managed problem, both in children and adults. The Think Tank (TT) discussed how to improve the management of DV in these two different age groups and in transitional care., Methods: During the 2018 International Consultation on Incontinence Research Society held in Bristol, a multidisciplinary TT on DV was created. The presentations and subsequent discussion, leading to research recommendations intended to improve the management of DV in children and adults are summarized., Results: To improve the management of DV in children and adults, the TT panel proposed: (1) to conduct reliable prevalence studies of DV; (2) to perform longitudinal studies to prospectively test the sequence hypothesis by answering the following questions: (a) Which, if any children show a progression from overactive bladder or voiding postponement to DV?; (b) Which children develop each disorder without precursors?; and (c) Is there a continuation of DV from childhood to adulthood, or are adult cases new-onset presentations?; (3) to obtain detailed information regarding psychopathology to understand which comorbid psychological disorders prevail and at which rate, in those suffering DV; (4) to develop and validate diagnostic tools specifically for DV; (5) to better establish urodynamic correlates of DV specific for different age groups; and (6) to generate prospective long-term data regarding the efficacy of different treatment options and management strategies., Conclusions: The future research recommendations of this TT may improve our management of DV in children and adults., (© 2019 Wiley Periodicals, Inc.)

Objective: To determine whether urinary incontinence (UI) and lower urinary tract symptoms (LUTS) persist over years, patients treated for UI and LUTS in childhood were re-evaluated in adulthood., Materials and Methods: Forty-seven women (cases) treated in childhood for daytime UI/LUTS (group A) and nocturnal enuresis (group B) self-completed (average age: 24.89 ± 3.5 years) the International Consultation on Incontinence Questionnaire for Female with LUTS (ICIQ-FLUTS). ICIQ-FLUTS was self-administered to 111 healthy women (average age: 23 ± 5.1 years) from a nursing school as a control group. Data obtained from ICIQ-FLUTS and quality of life (QoL) score (0-10) were compared (Fisher's exact test) between patients and controls, and between group A (n = 28) and group B (n = 19)., Results: Prevalence of LUTS was higher in patients than in controls. The difference between patients and controls was statistically significant (p = 0.0001) for UI (34% vs. 7%) and feeling of incomplete bladder emptying (49% vs. 28%). QoL score was >5 in 59% of patients and 1% of controls (p = 0.0001). No significant differences were found between groups A and B., Conclusions: UI and LUTS are confirmed in young women who suffered for the same condition in childhood. Longitudinal studies are needed to assess if these symptoms persist or are newly onset., (Copyright © 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: We studied whether noninvasive urodynamic evaluation can be as effective and safe as invasive urodynamics in detecting lower urinary tract dysfunction and in preventing late onset renal failure during long-term management of boys with posterior urethral valves., Materials and Methods: We evaluated 47 boys with posterior urethral valves using repeat urodynamics. A total of 28 patients with followup of at least 3 years and repeat evaluation of serum creatinine were included in the study. The first 14 boys in the series underwent cystometry and pressure-flow study at least every 3 years (group A), and the remaining 14 patients were monitored annually from age 5 with bladder diary, uroflowmetry, post-void residual urine on ultrasound and serum creatinine (group B). Lower urinary tract dysfunction and serum creatinine were compared (Fisher exact test and Mann-Whitney test) between groups A and B, and by stratifying patients into subgroups by age (5 to 6, 7 to 13 and older than 13 years). In all patients urodynamic diagnosis of lower urinary tract dysfunction was matched and confirmed with lower urinary tract symptoms., Results: During followup the prevalence of lower urinary tract dysfunction did not differ significantly between group A (71% in boys 5 to 6, 43% in boys 7 to 13 and 85% in boys older than 13 years) and group B (36%, 43% and 60%, respectively). Late onset renal failure was observed in 2 boys in group A and 2 in group B., Conclusions: Noninvasive urodynamic evaluation seems to be as safe and effective as invasive urodynamic study in the long-term management of boys with posterior urethral valves. Based on these findings, invasive urodynamics may be reserved for cases of progressive deterioration of lower urinary tract dysfunction or renal function., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Followup of total urogenital mobilization for persistent urogenital sinus is well established anatomically and functionally. Nevertheless, studies comparing bladder function in different subsets of patients with urogenital sinus, such as congenital adrenal hyperplasia and cloaca, are scant., Materials and Methods: We reviewed the records of patients with congenital adrenal hyperplasia and cloaca who underwent total urogenital mobilization and urodynamics in the last 10 years. Those with a short urogenital sinus (less than 2.5 cm) not requiring an abdominal approach and without spinal dysraphism were selected for study. Urodynamics were performed postoperatively before and after toilet training, and compared between patients with congenital adrenal hyperplasia and cloaca. Methods, definitions and units conformed to International Continence Society/International Children's Continence Society standards. For the emptying phase we defined bladder outlet obstruction as maximum detrusor pressure greater than 70 cm H(2)O and underactive detrusor as maximum detrusor pressure less than 20 cm H(2)O plus post-void residual urine greater than 25 ml., Results: Six patients with congenital adrenal hyperplasia and 6 with cloaca met study criteria. Three patients with congenital adrenal hyperplasia and 4 with cloaca underwent urodynamics before and after toilet training at a median age of 2 (range 2 to 4) and 5 years (range 3 to 8), respectively. Urodynamics were done in 1 patient with congenital adrenal hyperplasia before toilet training, and in 2 with congenital adrenal hyperplasia and 2 with cloaca after toilet training. All patients had normal urodynamics except 1 with congenital adrenal hyperplasia and detrusor overactivity, which normalized after toilet training. In all cloaca cases urodynamics were abnormal. Before toilet training bladder outlet obstruction was found in 2 patients, detrusor underactivity was found in 1 and detrusor overactivity was found in the remaining 1. After toilet training a detrusor underactivity pattern was found in 4 patients and bladder outlet obstruction was found in 2. All patients except 1 with cloaca had post-void residual urine before and after toilet training (median 100 ml, range 25 to 200). After toilet training all patients with congenital adrenal hyperplasia became spontaneously dry and all with cloaca were placed on clean intermittent catheterization., Conclusions: In the long term patients with cloaca show bladder outlet obstruction or underactive/acontractile detrusor patterns, which are not noted in patients with congenital adrenal hyperplasia. Therefore, in patients with cloaca urogenital sinus length may not be as good an indicator of functional results as it is in patients with congenital adrenal hyperplasia. Whether additional rectal dissection and repositioning surgical procedures in cloaca cases may have a role in explaining such a difference remains to be clarified.

Purpose: Adrenoleukodystrophy is an x-linked genetic disorder characterized by the breakdown of the myelin sheath surrounding nerve cells in the brain and progressive dysfunction of the adrenal gland with 6 possible phenotypes. Lower urinary tract symptoms affect the quality of life of these patients but only sporadic cases have been previously studied by urodynamics. We report to our knowledge the first series in the literature looking at the prevalent pattern., Materials and Methods: A total of 14 children and adults 8 to 53 years old (average age 30) with different phenotypes were referred for evaluation. Of the patients 6 had adrenomyeloneuropathy without cerebral involvement (C-) 3 had the adult cerebral form, 3 had the childhood cerebral form, 1 had cerebral involvement (C+) and 1 was asymptomatic. All patients were submitted to a screening protocol, consisting of the self-administered short form questionnaire International Conference on Incontinence Questionnaire-Short Form (ICIQ-SF) and a 3-day voiding diary. Patients were divided in group 1-no urinary symptoms, ICIQ-SF score 0 and no further investigation (3); group 2-frequency/urgency, ICIQ-SF score 1 to 5, uroflowmetry and post-voiding residual urine (4); and group 3-voiding symptoms and incontinence, ICIQ-SF score greater than 5, standard urodynamic examination (7)., Results: A neurogenic overactive bladder was the prevalent urodynamic finding (6 of 7 patients), while hypocontractility was found in 1 case., Conclusions: Vesicosphincteric dysfunction can be explained by spinal and/or cerebral involvement in the different neurological forms of adrenoleukodystrophy. Attempts at treatment with anticholinergics and neuromodulation in 4 of our patients provided temporary benefit with clear subjective amelioration of symptoms and improved quality of life.

Purpose: Neurovesical dysfunction (NVD) is common in children with anorectal malformation (ARM). NVD is mainly related to tethered cord or iatrogenic injury but how to investigate it is still debated. We evaluate the usefulness of routine magnetic resonance imaging (MRI) and urodynamics (UDS) for ARM., Materials and Methods: A total of 89 children were screened for sacral, spinal or urological anomalies using sacrum x-ray, MRI, renal and spinal ultrasound, uroflowmetry and/or 4-hour voiding observation. UDS was performed in 60 patients with suspected NVD. Mean +/- SD followup was 9.8 +/- 5.2 years., Results: Of the 89 patients 29 presented with urinary tract anomalies. The prevalence of sacral (53 cases) and spinal cord (54) anomalies was no different between patients with low, intermediate and high ARM. Spinal cord tethering was present in 13 patients with a normal sacrum x-ray. NVD was found in 31 of the 89 patients (hyperreflexia 21 and hypo-areflexia 10), and was associated with sacral and spinal anomalies in 23, occult spinal dysraphism without bone lesion in 3 and sacral anomalies in 5. The incidence of NVD was 40% of cases with low and 51% with high ARM., Conclusions: Because tethered cord occurs in children without sacral anomalies as well as in those with low ARM, we recommend evaluation of all patients using MRI. When MRI is positive UDS should be performed. We agree with a previous suggestion to evaluate all males with rectourethral fistula and females with cloaca malformations. Finally we recommend a noninvasive evaluation for all other children and UDS when neurogenic dysfunction is suspected.

Objective: To determine whether bladder dysfunction in boys with posterior urethral valves (PUV) changes from a uniform pattern of hypercontractility during infancy to the hypocontractility found in adolescence, by reviewing serial urodynamic studies., Patients and Methods: Thirty boys with PUV and no voiding symptoms underwent a total of 86 urodynamic tests (mean 2.8 each). The first urodynamic study was undertaken at 1-4 years of age in 15 boys and at 5-13 years in 15. They were re-evaluated at least 3 years later; 15 patients underwent the first and last urodynamic study, respectively, at a mean age of 2.8 and 7.7 years (group A), 10 boys at 6.2 and 8. 8 years (group B) and five at 9.4 and 15.2 years (group C). In 10 boys aged > 5 years the first and last pressure-flow studies (PFS) were analysed using an advanced analysis (PFA) to better identify hypocontractility., Results: Bladder dysfunction was found in 21 of 30 (70%) boys at the first evaluation and in 18 (60%) at the last. In 25 boys the urodynamic pattern changed. Of the 15 boys in group A, 10 of 12 who had hypercontractility changed to normal (seven), low compliance (one) or hypocontractility (two), and two remained stable; two of the remaining three with normal urodynamic studies changed to hypocontractility, while one was unchanged. Among the 10 boys in group B, six with hypercontractility changed to normal (three) or hypocontractility (three); two with normal urodynamic findings and one with low compliance changed to hypocontractility. Of the five boys in group C who showed severe hypocontractility after puberty, three had a normal pattern, one low compliance and one hypercontractility before puberty. The PFA showed a 'weak' detrusor in four of the seven boys who were considered normal on standard PFS. At the urodynamic follow-up, the PFA pattern changed to a 'weak' detrusor in four boys who had a normal (two) or strong (two) detrusor at the first evaluation., Conclusions: Bladder dysfunction in boys with PUV changes during childhood and through adolescence. The urodynamic pattern of hypercontractility generally found soon after valve ablation gradually changes to hypocontractility in many boys and this pattern seems to be the rule after puberty. The evidence from this series supports the hypothesis that long-term detrusor hyperactivity in boys with PUV leads to detrusor failure, but a longitudinal 15-year follow-up from birth to puberty is needed to validate this concept.

From 1976 to 1994, we followed 55 children with occult spinal dysraphism (OSD). The average age at diagnosis was 4.5 years (range: 24 days - 21 years). In 13 cases the OSD was associated with anorectal anomalies. Urologic symptoms were present at diagnosis in 24 children (43%), but urinary incontinence affected all patients in the evolution of the OSD. At diagnosis, all children underwent complete neurourologic and urodynamic evaluation. Nine required early neurosurgical correction, before 3 years of age. During follow-up, intermittent clean catheterization was started in all patients. Vesicoureteral reflux was present or developed in 17 patients: 15 underwent endoscopic procedures and 2 required bladder augmentation because of upper-tract and renal-function deterioration. Endoscopic treatment for urinary incontinence was performed in 3 children. At long-term follow-up (6 to 18 years), socially acceptable continence was achieved in 78% of the children; renal failure occurred in 8. The long-term results were analyzed in order to compare the evolution of urinary continence and renal function in children with OSD with or without neurosurgery.

In adults the development of modern equipment for ambulatory monitoring permits long-term evaluation of the lower urinary tract which is more accurate than standard urodynamics (SUD). In children continuous urodynamic monitoring (CUM) has been used infrequently and therefore standardisation of the method has not been previously achieved, nor have the techniques and difficulties of performing 24-hour monitoring been solved. The aim of this study was to identify a technical method of CUM in children which was feasible and to verify its usefulness. For this purpose, we reviewed our preliminary experiences of CUM in children with neuropathic bladder. From March to November 1995 we made an outpatient study of the neuropathic bladders of 11 myelodysplastic children aged 1 to 18 years (average age 10.2 years). 7 of them were males and 4 females. All underwent SUD. With the children resting in bed, a 6-hour CUM (Lectromed MPR-2) was performed using a 4 Fr. microtip intravesical catheter (suprapubic in 3 infants and transurethral in 8 children) and an intrarectal catheter. The parents and/or a nurse monitored the fluid intake and micturition events and recorded the data in a diary. Based on the CUM experience in infants with non-neurogenic bladder dysfunction, the 3 suprapubic studies were done after 12 hours of urethral drainage in order to prevent leakage of urine. In all of the patients we were able to study 2 to 4 bladder fillings during a period of 6 to 8 hours (average 6.5 hours) observation. In 9 of the 11 children the CUM pattern was comparable to the SUD one but in the 2 remaining patients CUM showed uninhibited contractions. Higher uninhibited voiding contraction pressures were recorded in hyper-reflexic bladders. Our preliminary results show that it is feasible to perform CUM in children and that it has advantages over standard cystometry in the investigation of children with neuropathic bladder even if it is carried out for short term (6 hours).

Spinal dysraphism (SD) has been found associated with functional abnormalities of anorectal anomalies (ARA). The incidence of SD in these children is probably underestimated and a complete neuroradiological investigation of the lower urinary tract function has not been carried out routinely. In a 2 years time frame we performed urodynamic (UDS) evaluations on 14 patients (8 males and 6 females) with ARA who showed SD at Magnetic Resonance Imaging (MRI) studies. We divided them into 2 groups by age: group A (5 to 18 months) and group B (3 to 12 years). The UDS findings were classified as upper (UMN) and lower motor neuron (LMN) lesion. Out of the 9 children included in group A, 5 showed normal urodynamic pattern, while 4 had pathological UDS findings suggesting UMN lesion. Among the older (group B) children only one had normal and 4 had pathological findings: 2 hyperreflexia suggesting UMN lesion and 2 external sphincter denervation suggesting LMN lesion. These data support the hypothesis that the neurovesical dysfunction found in children with anorectal anomalies results from a possible association with spinal dysraphism. An early morphological evaluation of the spinal cord is mandatory in all children with ARA prior to definitive surgical correction of the malformation. The low incidence of pathological UDS findings in small children if compared to older ones suggest that SD, although present, may be asymptomatic.

Urinary incontinence following Posterior Urethral Valves (PUV) ablation has been attributed in the past to sphincter injury, but it is nowadays accepted that bladder dysfunction (BD) plays a determinant role. In order to assess BD evolution, we have evaluated, from 1982 to 1994, 48 boys with PUV by urodynamics (UD) studies. Age of the patients ranged from 10 months to 15 years. A total of 65 examinations were performed. We considered four groups: 0-3 years; 4-7 years; 8-12 years and > 12 years. Uninhibited detrusor contractions (instability), end filling pressure (EFP), bladder capacity and voiding detrusor pressure were evaluated in order to assess the presence of BD distinguishing it in: hypercontractility, hypocontractility and low-compliant bladder. The results collected confirm a high percentage of BD in PUV boys (71%) and the evolution of hypercontractility versus hypocontractility in 60% of patients considered.

OBJECTIVE To evaluate 10 years of experience, and thus define the occurrence and causes, of neurogenic lower urinary tract dysfunction in children with pelvic neoplasms treated by surgery. PATIENTS AND METHODS From 1991 to 2000, 33 children were operated by the same surgeons for pelvic neoplasms; 11 were analysed, comprising four each with sacrococcygeal teratoma (ST) and ganglioneuroma, and one each with yolk sac tumour (YST), neuroblastoma and myofibroblastic bladder sarcoma (MBS). The other patients were not assessed because eight had died or were in severe progression, three were treated by bladder substitution and the others were lost to follow-up or refused a urological evaluation. All 11 children were evaluated at ≥ 6 months after surgery with a questionnaire about bowel and voiding habits, a neurological and orthopaedic assessment, a noninvasive urodynamic study, renal ultrasonography and spinal and pelvic magnetic resonance imaging (MRI). All patients with signs of bladder dysfunction were evaluated by a pressure-flow study. The results were analysed for surgical approach and anatomical involvement, i.e. group A, extensive surgery for complete tumour excision in the sacral area (ST and YST); group B, surgery for tumour resection in the paraspinal ganglia area (neuroblastoma and ganglioneuroma); and group C, bladder tumour with partial bladder resection (MBS). RESULTS Eight patients had signs or symptoms related to bladder sphincter dysfunction. One child refused the invasive urodynamic evaluation, leaving seven for analysis (two each ST and ganglioneuroma, one each YST, neuroblastoma and MBS). The urodynamic findings were normal in three children. On spinal and pelvic MRI a presacral lipoma with syringomyelia was discovered in one child with ST. Eight children had bladder dysfunction and two had no neurogenic damage (which was only in sacral tumours); in one child it was related to an upper motor neurone lesion from spinal dysraphism and in the... [ABSTRACT FROM AUTHOR]