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Objectives Functional gastrointestinal disorders (FGD) are common during early childhood. In severe defecation disorders, anorectal manometry (AM) is done to exclude aganglionosis. High-resolution anorectal manometry (HRAM) can probably improve diagnostics but normative data in infants are scarce. This study aims to provide HRAM data in healthy infants overall and in subgroups of infants with FGD, defined as functional constipation (FC), infant colic (IC) and infant dyschezia (ID) (ROME 3 criteria). Methods This prospective observational cohort study enrolled healthy term infants, having HRAM at 2 and 6 months, using a water-perfused pediatric anorectal silicone catheter. Data was provided for presence of anorectal waves and recto anal inhibitory reflex (RAIR), volume needed to elicit RAIR and anal resting pressure (ARP). Questionnaires at 2 and 6 months identified subjects with FC, IC and ID. Results A total of 187 HRAM investigations were done in 107 infants, without any complications. Normal RAIR was found in all, at least at one occasion. Mean ARP increased between 2- and 6-month investigations in infants without FGD. No other differences in HRAM data could be seen between infants with or without an FGD. At 2 months FC, IC and ID were seen (2%, 4% and 17%), whereas at 6-months only FC and ID were seen (7% and 1%). Conclusion We can provide data on HRAM in infants at 2 and 6 months of age. When performing repeated HRAM in healthy infants, RAIR was found in all subjects. HRAM is safe, easy tolerable and can be recommended in infants with or without FGD. An infographic is available for this article at:http://links.lww.com/MPG/C583.

BackgroundAn association between bladder-bowel dysfunction (BBD) and urinary tract infection (UTI) is well-known. However, a question less explored is whether children with UTI early in life also have increased prevalence of BBD after they are toilet-trained. In this study, consecutively selected children with pyelonephritis during their first year of life were assessed for BBD at pre-school age.MethodsNinety-two children (51 boys) hospitalized due to pyelonephritis during their first year of life were assessed for BBD at median age 5.4 years. A validated BBD questionnaire, along with urine flow and residual volume measurements, was used for diagnosing BBD. During follow-up, the group was well-characterized regarding renal status, vesicoureteral reflux (VUR), and recurrent UTI.ResultsBBD was diagnosed in 35/92 (38%), of which the majority was sub-diagnosed with dysfunctional voiding (DV). There was a strong association between BBD and recurrent UTI during follow-up (p p = 0.0008). BBD was also associated with kidney damage (p = 0.017).ConclusionIn children with pyelonephritis during the first year of life, 38% had BBD at pre-school age, regardless of whether they had VUR or not. The study shows an important association between BBD and recurrent UTI, so an assessment of BBD is therefore recommended for pre-school children with UTI, especially when they have history of pyelonephritis during infancy.

AIM Aim of the study was to provide a scoring system for predicting downgrading and resolution of infantile high-grade vesicoureteral reflux (VUR). METHODS Eighty-nine infants (65 boys) with high-grade VUR (grade 4-5) diagnosed at median age 2.5 months and followed to 39 months had repeated investigations of VUR grade, renal damage/function and bladder function. Recurrent urinary tract infections (UTIs) were registered. Risk variables collected at 1 year were analysed as independent factors for spontaneous resolution to grades ≤2 and 0, using univariable/multivariable logistic regression. RESULTS A scoring system was built with a total of 14 points from four independent risk factors (sex, breakthrough UTI, type of renal damage and subnormal glomerular filtration rate). Children with persistent VUR (grade 3-5) had higher scores compared with the group with spontaneous resolution (grade 0-2) (mean 7.9 vs. 4.5, P

Thank you for your commentary1 on the clinical usefulness of our scoring system2 . We do agree about the importance of patient selection and individualized risk-benefit approach for the management of high-grade vesicoureteral reflux (hVUR) in general and infant hVUR in particular.

The bladder exstrophy-epispadia complex (BEEC) includes malformations with midline closing defects of the lower abdomen and external genitalia. Long-term consequences with urinary incontinence and sexual dysfunction, in spite of multiple surgical interventions, are common and expected to affect the patient's health-related quality of life (HRQOL). The extent and the predictive factors are, however, not known. New patient-reported outcome research is emerging, but valid and reliable condition-specific HRQOL are still missing. The aim of this review is to summarize and discuss the latest published reports (2015–2019) on HRQOL in patients with the BEEC and its relationship to incontinence and sexual factors.

Summary Introduction Ureteropelvic junction obstruction (UPJO) is one of the most common causes of hydronephrosis in pediatric populations. Many need surgical intervention. The aim of surgery is preserving renal function and reducing symptoms such as urinary tract infections and pain. Objectives The objectives were to evaluate differential renal function (DRF) in infants and children after surgery for UPJO and to identify factors predicting postoperative improvement. The difference in outcomes between patients with antenatal hydronephrosis and those diagnosed later was evaluated. Study design A total of 85 children (63 boys and 22 girls) aged 0–16 years, treated for UPJO with dismembered pyeloplasty, were followed up as per a structured protocol including ultrasounds and renal scans (MAG-3) pre-operatively and three and 18 months postoperatively. Five children with bilateral or single kidney UPJO were excluded. Patient records were retrospectively reviewed, and the patients were grouped as per prenatal (group 1, n = 23) or postnatal (group 2, n = 57) diagnosis. Univariable and multivariable logistic regression analyses searching for factors predicting >5% postoperative improvement in DRF on the obstructed side were performed. Factors included in analyses were age at diagnosis and surgery, sex, type of presentation, cause of obstruction, estimated glomerular filtration rate, pre-operative DRF, anteroposterior diameter (APD), APD/renal parenchymal thickness, and grade of hydronephrosis as per the Onen alternative grading system (grade 1–4). Results Pre-operative DRF on the obstructed side was a mean of 42% (standard deviation, 12), with no difference between the groups. The median age at surgery was 0.9 (0.2–10) and 8.1 (0.6–16) years in groups 1 and 2, respectively (P 5%, and one deteriorated. The proportion of patients with improved DRF was higher in group 1 (n = 10; 45%, P = 0.026). Anteroposterior diameter, APD/parenchymal thickness, pre-operative DRF, and antenatal diagnosis were predictors in the univariable analyses, and high APD (odds ratio [OR] = 1.1, P = 0.0023), antenatal diagnosis (OR = 0.23, P = 0.048), and low pre-operative DRF (OR = 0.90, P = 0.0045) built the best model of independent factors predicting improvement in DRF in multivariable analyses (Summary Figure). Discussion The limitation of the study is that it is retrospective, but it has the advantage of a uniform follow-up protocol, including patients from a five-year period, with few lost to follow-up. The results can be of interest in evaluating factors of importance for predicting recovery of function in obstructive uropathies in children. Conclusion The majority of children had preserved or improved function after surgery for UPJO. Those with an antenatal diagnosis displayed a greater ability to catch up in DRF, and high APD, antenatal diagnosis, and low pre-operative DRF were independent predictive factors of an improvement in renal function after pyeloplasty. Download : Download high-res image (177KB) Download : Download full-size image

Introduction High-grade vesicoureteral reflux (VUR) in children is associated with recurrent urinary tract infection (UTI) and renal damage. Breakthrough UTI despite continuous antibiotic prophylaxis (CAP) during the first years of life is a matter of concern and evokes early intervention. We investigated whether early endoscopic treatment (ET) of VUR grade 4–5 can reduce the risk of UTI recurrence and renal scarring. Materials and methods This prospective, randomized, controlled, multicentre, 1-year follow-up trial comprised 77 infants

AIM In approximately one third of cases, congenital high-grade vesicoureteral reflux (VUR) diagnosed during infancy is seen together with lower urinary tract dysfunction (LUTD), characterised by a high-capacity bladder and incomplete emptying. In an earlier study, 20 of these infants were treated with clean intermittent catheterisation during a 3-year period and with surgical treatment of the VUR before catheterisation was ended. In the present study, bladder function was evaluated in these children at school age. METHODS Bladder function was evaluated in the 20 children at a mean age of 7.3 years using a validated voiding-bowel questionnaire with scores (cut-off score 7) and a urine flow/residual study. RESULTS Four children (20%) had a normal voiding function at follow-up, whereas 11 (55%) had a clear bladder/bowel dysfunction (scores 7-19) and five (25%) had a mild dysfunction (score 6). Ten (63%) of the children with any dysfunction were recognised as dysfunctional voiding. Recurrent febrile urinary tract infections were correlated with the scores of faecal questions (P = .041), but for total scores P = .058. CONCLUSION The follow-up of bladder function in children at 7.3 years, diagnosed with high-grade VUR and LUTD in infancy, revealed bladder/bowel dysfunction of varying severity in the majority of cases.

Bladder exstrophy–epispadias complex (BEEC) is a rare spectrum of genitourinary malformations. Children risk long-term urinary and genital dysfunctions. To achieve a comprehensive understanding, this study aimed to review the literature on generic and disease-specific health-related quality of life (HRQOL) in BEEC patients, and methodologies used. A literature search was conducted in Pubmed/CINAHL/Embase/PsycINFO/Cochrane, from inception to May 2018. A meta-analysis of HRQOL in BEEC patients compared to healthy references was performed. Twenty-one articles (published 1994–2018), describing HRQOL of children and adolescents (n = 5) and adults only (n = 5), or integrated age populations (n = 11), were identified (median sample size 24, loss to follow-up 43%, response rate 84%). Overall HRQOL was reduced in BEEC patients compared to healthy references in 4/4 studies. Impaired physical or general health in BEEC patients has been described in 9 articles, diminished mental health in 11, restricted social health in 10, and sexual health/functioning or body perception impairments in 13 articles. Urinary incontinence was the most common factor related to worse HRQOL (12 studies). In six studies, HRQOL was better than healthy norms. In eligible studies (n = 5), the pooled estimate of the effect of BEEC indicated worse HRQOL for children and adults (0 > effect sizes

Summary Introduction Neurogenic lower urinary tract dysfunction (LUTD) has been reported in 20–50% of children with anorectal malformations (ARM). As neurogenic LUTD represents an inherent risk of renal deterioration and urinary tract infections, an early diagnosis is important. The gold standard for evaluating neurogenic LUTD involves invasive urodynamic testing but a useful addition should be an easy-to-perform, non-invasive method of screening. Objective In this study, we evaluate non-invasive 4 h voiding observations as a screening method for neurogenic LUTD in ARM children. Study design Thirty-four patients with ARM, excluding those with perineal fistulas, were evaluated using both 4 h voiding observation and urodynamic testing before and after posterior sagittal anorectoplasty (PSARP) at median ages of 0.3 and 1.1 years. In the urodynamic assessment, the gold standard for neurogenic LUTD, nine children received the diagnosis, eight innate and one post-surgery. Results Five boys with a high urethral fistula and anomalies of the spinal cord had urodynamically diagnosed neurogenic LUTD, a dysfunction also identified in the 4 h voiding observations. The pattern was characterised both by an increase in the number of voiding and the number of interrupted voiding, urinary leakage and elevated residual urine (Figure). In three girls with a vestibular fistula and tethered cord, an urodynamic investigation identified suspected mild neurogenic LUTD. In the voiding observations, an abnormal voiding pattern was not as obvious in the girls as in the five males. One girl with cloaca showed signs of postsurgical denervation damage, which was easily identified in the 4 h voiding observations (high capacity and elevated residual urine). Discussion In the present study, gender differences in the severity of dysfunction reflected in the free voiding pattern in infants with ARM and neurogenic LUTD is probably the result of the different underlying causes of neurogenic LUTD in boys and girls. Boys with the condition have a congenital malformation of the caudal part of the spinal cord and girls a tethering of the cord. The most obvious limitation of the study was the low number of patients. Despite this, we consider the results worth reporting, since we found that results in the free voiding observations effectively confirmed what was established in the urodynamic investigations. Conclusion In pre-PSARP patients, 4 h voiding observations can be used to screen for severe neurogenic LUTD requiring attention and treatment. When post-surgical denervation is suspected, the voiding observation is also a good method for indicating the diagnosis. Download : Download high-res image (240KB) Download : Download full-size image Summary Figure . Four-hour voiding observation studies in A: a three-month-old boy with anorectal malformation and neurogenic lower urinary tract dysfunction diagnosed by urodynamic tests, and B: a healthy infant of the same age.

We evaluated psychosocial outcomes, psychosexual development and sexual function in adolescents who had undergone surgery for proximal hypospadias. We hypothesized that these outcomes would be impaired compared to peers.We identified 55 males age 14 years or older who underwent surgery for penoscrotal to perineal (intraoperatively defined) hypospadias between 1996 and 2005. A total of 33 patients with a median age of 17.5 years (range 14 to 25) answered a Web based questionnaire with self-constructed questions, completed the validated Psychological General Well-Being Index, Body-Esteem Scale for Adolescents and Adults and Penile Perception Score, and underwent clinical evaluation. A total of 31 patients with distal hypospadias (median age 19 years, range 14 to 35) and 25 age matched healthy men (17.5 years, range 14 to 25) served as controls.Interest in sex, age at sexarche and satisfaction with sexual experiences were comparable between patients and controls. Three patients with proximal hypospadias (10%) and 1 control (4%) reported occasional erectile problems. Three patients with proximal hypospadias (11%), 1 patient with distal hypospadias (3%) and 1 control (4%) affirmed anejaculation. There were no differences in results between validated questionnaires. Patients with proximal hypospadias were more dissatisfied with penile length (39%) compared to controls (12%, p = 0.049). Concerning physical contact, 10 patients (38%) expressed uncertainty. Extra support in school was more frequent among patients with proximal hypospadias (p = 0.024 vs distal hypospadias, p = 0.068 vs control group).Despite concerns regarding penile length, sexual experiences were comparable to those of other adolescents, although more than a third of patients with proximal hypospadias demonstrated uncertainty on questions relating to desire for physical contact. Specialized tutoring in school was more common in patients with proximal hypospadias. Continuous followup throughout childhood allowing extra time for age adequate information and support is warranted.

Purpose: We studied the inheritance pattern, clinical features and outcome in children with vesicoureteral reflux (VUR). Characteristics of known familial VUR cases were also compared with those of sporadic VUR. Material and Methods: 726 patients were treated for VUR between 1990-2004. The families were contacted by letter inquiring if other members of the family were affected. The phenotype of all cases (familial and non-familial) was characterized in terms of presenting symptoms, reflux grade, recurrent urinary tract infections, kidney damage, and the natural course of reflux. Results: The response rate was 79%. A total of 99 individuals (22%) reported relatives with VUR. Since some of the 99 index cases belonged to the same family, the total number of families was ultimately 66. The distribution of relatives with VUR was: 38 siblings, 20 parents (15 mothers), 19 cousins, 15 aunts/uncles and 12 grandparents. The phenotype of VUR did not differ between familial and non-familial cases. However, VUR among relatives was of milder grade than index and sporadic cases. Conclusions: The proportion of hereditary reflux in our material was lower than in other studies (22%). We found a strong overrepresentation of maternal transmission of reflux. Severity of the disease did not differ between familial and non-familial VUR.

Background The aim of the present study was to investigate whether addition of transcutaneous electrical nerve stimulation (TENS) treatment improves the results of standard urotherapy in children with overactive bladder (OAB) symptoms. Material and methods Sixty-two children with symptoms of OAB and incontinence were included. The children were randomized either to standard urotherapy treatment alone or a combination of standard urotherapy and TENS. The effect variables were taken from a voiding–drinking diary: number of voiding, number of incontinence episodes, and maximum voided volume. Results Both treatment groups had good treatment results, with no significant difference between the groups. In the standard treatment group 13/28 (46%) were completely dry and 11/28 (40%) had a decrease in incontinence episodes, compared to 16/24 (67%) and 3/24 (13%), respectively, in the standard + TENS group ( p = 0.303). The number of voiding decreased in two-thirds of the patients in both groups. However, maximal voided volume only increased in the standard treatment group. Subjectively 72% and 80% considered themselves significantly improved or free of symptoms. Previous treatment was registered in 15/55 (27%). All efficacy variables decreased in those with previous treatment, but with no difference between the standard and standard + TENS treatment groups. The only difference noted was when comparing the children without previous treatment in the groups: a significantly higher proportion were completely dry in the TENS group (12/18 [71%] versus 10/22 [48%], p = 0.05). Conclusion Our results showed no significant difference overall in treatment response to OAB symptoms between urotherapy only and urotherapy + TENS, whereas a tendency to difference was found in children without previous treatment. Thus with good urotherapy support, TENS only seems to have marginal additional effects on OAB symptoms.

Summary Introduction It has been suggested that infants with high-grade vesicoureteral reflux (VUR) have lower urinary tract dysfunction (LUTD) that is characterised by large bladder capacity (BC) and increased post-void residual (PVR). However, most of these infants have normal or small BC in early infancy and develop large capacity during the first year of life. Objective This study aimed to see whether LUTD development during the infant years in children with high-grade VUR could be prevented by early reflux resolution. Materials and methods For early VUR intervention, endoscopic treatment (ET) was used in a randomised trial comprising 77 infants (55 boys) aged Results There were no differences in bladder function variables seen between the treatment groups, despite significant differences in VUR resolution. Analysing bladder function related to VUR outcome (VUR grade ≤2 vs grade >2), independent of treatment, showed that VUR grade ≤2 was associated with a smaller BC at 1 year ( P = 0.050) (a tendency already seen at baseline) and a lower PVR at baseline ( P = 0.010). PVR increased from baseline to 1 year ( P = 0.037) in children with grade ≤2 VUR (Summary Table). The group with persistent bilateral grade 5 VUR at 1 year had more abnormal bladder variables compared with other study subjects, with a tendency of larger BC ( P = 0.057), higher PVR ( P = 0.0073) and more LUTD ( P = 0.029) at baseline and a larger BC at 1 year ( P = 0.016). In explanatory analyses, using logistic regression, a high PVR at baseline was identified as a predictor of VUR grade >2 ( P = 0.046), persistent bilateral grade 5 VUR ( P = 0.022), recurrent urinary tract infection ( P = 0.034), and only a tendency was seen regarding new renal damage ( P = 0.053). Conclusion There was no between-group difference seen in bladder function. In children with VUR resolution at follow-up, independent of treatment, BC decreased, whereas PVR increased. High PVR at baseline was a predictive factor for both non-resolution of high-grade VUR and recurrent urinary tract infection. The results suggest that LUTD cannot be prevented by early VUR resolution, but rather is an important prognostic factor for VUR outcome in both endoscopic and prophylactic treatment. Summary Table . Bladder variables by grade ≤2 vs grade >2 VUR at 1-year follow-up. Variable Total (n = 74) Within-group P -value Grade ≤2 VUR at 1 year (n = 29) Grade >2 VUR at 1 year (n = 45) Between-group P -value Bladder capacity (%) • Baseline 126 (49–466) 120 (49–283) 138 (65–466) 0.14 • 1 year 113 (3–296) 0.075 90 (31–194) 121 (30–296) 0.050 • Large (≥150%) baseline 28 (41%) 7 (27%) 21 (49%) 0.12 • Large (≥150%) 1 year 22 (33%) 7 (26%) 15 (39%) 0.43 Residual urine (ml) • Baseline 9 (0–83) 6 (0–55) 11 (1–83) 0.010 • 1 year 14 (0–108) 0.025 9 (0–84) 16 (0–108) 0.41 Lower urinary tract dysfunction • Baseline 17 (24%) 3 (12%) 14 (33%) 0.087 • 1-year follow-up 18 (27%) 6 (22%) 12 (31%) 0.63 Continuous variables: median (minimum−maximum), categorical variables: n (%).

Summary Introduction High-grade vesicoureteral reflux (VUR) in infants is associated with congenital renal abnormalities, recurrent UTI, and bladder dysfunction. Endoscopic treatment (ET) is a well-established method in children with low to moderate reflux grades, but there is a lack of randomised controlled trials regarding the use of ET versus continuous antibiotic prophylaxis in infants with high-grade VUR. Objective This study aimed to determine whether high-grade VUR in infants can be treated with endoscopic injection and whether ET is superior to antibiotic prophylaxis in the treatment of VUR. Materials and methods This prospective, randomised, controlled, multicentre, 1-year follow-up trial comprised 77 infants (55 boys, 22 girls) n = 30/ n = 47). Of the infants, 52 (68%) had bilateral VUR. Thirty-nine were randomised to antibiotic prophylaxis and 38 to ET (with prophylaxis until resolution). Voiding cystourethrogram, ultrasound, renal scintigraphy, and free voiding observation were performed at study entry and after 1 year to evaluate VUR grade, and renal and bladder function. Results VUR grade ≤2 was seen in 22 (59%) infants in the endoscopy group and eight (21%) in the prophylaxis group at follow-up ( p = 0.0014). The success rate in the endoscopy group was 100% in unilateral grade 4, falling to 31% in bilateral grade 5 ( p = 0.0094). Correspondingly, the results in the prophylaxis group were 40% in grade 4 down to 0% in bilateral grade 5 ( p = 0.037) ( Table ). Logistic regression analyses identified ET, VUR grade 4, unilaterality, and low residual urine at baseline as positive predictors of VUR down-grading to ≤2 (area under ROC curve 0.88). In four patients with reflux resolution after one injection, dilating reflux recurred at the 1-year follow-up. One patient had a UTI possibly related to ET. In our material four patients required re-implantation, of whom one was obstructive after injection. Discussion The opportunity to offer even small infants with high-grade VUR an alternative, minimally invasive treatment option is a great advance in paediatric urology. In this high-risk group, bilateral VUR grade 5 stands out with its poor bladder function and low chance of resolution. The recurrence rate of dilating VUR after successful ET is consistent with previous studies. The limitations are the relatively small number of patients and the short follow-up. Conclusion High-grade VUR in infants can be treated with injection therapy and the resolution rate is higher than that of prophylaxis treatment. The complication rate is low and VUR grade 4, unilaterality, and low residual urine are favourable for the resolution and down-grading of VUR. Table . VUR-grade at 1-year follow-up and VUR ≤2 divided by VUR-grade and uni- or bilaterality at baseline trial. Variable Endoscopy group ( n = 38) Prophylaxis group ( n = 39) p -value Grade of VUR at 1-year follow-up VUR = 0 17 (46%) 6 (16%) VUR = 1 2 (5%) 0 (0%) VUR = 2 3 (8%) 2 (5%) VUR = 3 6 (16%) 7 (18%) VUR = 4 4 (11%) 13 (34%) VUR = 5 5 (14%) 10 (26%) 0.0007 VUR grade ≤2 vs >2 at 1-year follow-up VUR grade 0–2 22 (59%) 8 (21%) VUR grade 3–5 15 (41%) 30 (79%) 0.0014 Variable Endoscopy group Prophylaxis group VUR grade ≤2 at 1-year follow-up ( n = 22) VUR grade >2 at 1-year follow-up ( n = 15) p -value VUR grade ≤2 at 1-year follow-up ( n = 8) VUR grade >2 at 1-year follow-up ( n = 30) p -value VUR grade at Baseline Unilateral 4 7 (100%) 0 (0%) 2 (40%) 3 (60%) Bilateral 4 6 (75%) 2 (25%) 4 (40%) 6 (60%) Unilateral 5 4 (67%) 2 (33%) 2 (29%) 5 (71%) Bilateral 5 5 (31%) 11 (69%) 0.0094 0 (0%) 16 (100%) 0.037

Obesity is associated with an increased risk of pain in weight-bearing joints. Although pain often decreases after obesity surgery, this is the reverse for some patients. Hypermobility is described as an excessive range of motion in joints and has been suggested to be a possible cause of joint pain. It is not known whether there is an association between increased joint pain after weight loss and hypermobility.The objective of this study was to investigate whether there is an association between hypermobility and increased joint pain after massive weight loss.University hospital, Sweden.A survey including a screening questionnaire about hypermobility and questions about joint pain was sent to 149 people who had previously undergone bariatric surgery. Ninety-three people (72 women and 21 men) completed the questionnaire.Nineteen of the respondents fulfilled the criteria for hypermobility. There were no significant differences between the groups with and without hypermobility regarding pain in weight-bearing joints before or after surgery. There was a significant difference between the groups with increased or novel pain in the ankles, shoulders, hands, and feet (P.05) after the weight loss. Furthermore, the patients with hypermobility had increased or novel pain in a significantly higher number of weight-bearing joints, other joints, and joints in total (P.05).Even with a small sample size, a tendency can be seen for people with hypermobility to experience increased joint pain after weight loss compared with those without hypermobility.

We studied variables with impact on cessation of congenital high grade vesicoureteral reflux in univariate analyses and provide a multivariate model for prediction of reflux resolution.A total of 80 male and 35 female infants (median age 2.7 months) were included in this prospective observational study. Of the cases 71% were diagnosed after urinary tract infection and 26% after prenatal ultrasound. Reflux was bilateral in 70% of the patients and maximum grade was III in 16%, IV in 45% and V in 39%. The study protocol included repeat videocystometries, renal scintigrams, chromium edetic acid clearances and free voiding observations. Median followup was 36 months.Overall spontaneous reflux resolution, including cases downgraded to grade I to II, was 38%. Variables significantly negatively correlated to resolution were breakthrough febrile urinary tract infection, bladder dysfunction, higher grade of reflux at inclusion, renal abnormality, subnormal renal function, increased bladder capacity, residual urine and passive occurrence of reflux. Multivariate Cox proportional hazard model with stepwise selection identified 3 independent predictors--renal abnormality (hazard ratio 0.45, 95% CI 0.31-0.64, p0.0001), bladder dysfunction (hazard ratio 0.43, 95% CI 0.29-0.64, p0.0001) and breakthrough urinary tract infection (hazard ratio 0.38, 95% CI 0.18-0.78, p = 0.009). Performance of the model was evaluated by the receiver operating characteristic curve, with a calculated area under the curve of 83%.Overall resolution rate in congenital high grade vesicoureteral reflux is high during the first years of life. By multivariate analyses renal abnormality, bladder dysfunction and breakthrough febrile urinary tract infection were identified as strong independent negative predictive factors for reflux resolution.

Purpose To investigate whether mode of occurrence of vesicoureteral reflux (VUR), during micturition (M), during filling without increase in pressure (passive, P) or in response to an overactive contraction (OA), can be explained by differences in bladder function. Also, to study if the mode of occurrence of VUR can predict spontaneous resolution. Materials and methods There were 93 infants (68 boys and 25 girls) with VUR (grade III–V) included. Videocystometry was performed at median ages 5, 22 and 32 months registering grade and mode of reflux and bladder function characteristics. Results Mode of occurrence of reflux changed with age. During infancy P, OA and M reflux comprised almost equal parts. At follow up, P reflux had increased and both OA and M reflux had decreased. This was partly due to a significantly higher probability of spontaneous resolution for M than P reflux, at 40 months (42 vs 18%). P and M reflux were significantly correlated to bladder function characteristics. P reflux was seen in children with high bladder capacity and occurred early in filling. Other predictors were higher age within the respective group and female sex. M reflux was correlated to lack of residual urine, low bladder capacity and absence of overactivity. Other indicators were male sex and low-grade reflux. Conclusions P and M reflux correlate to different bladder patterns: P with high bladder capacity and M with low bladder capacity and without signs of bladder dysfunction. M seems to be benign with a higher resolution rate.

We sought to study renal abnormality and renal function through time in infants with high grade vesicoureteral reflux.This prospective observational study included 115 infants (80 boys and 35 girls) younger than 1 year with grade III to V vesicoureteral reflux. The diagnosis was made after prenatal ultrasound in 26% of the patients and after urinary tract infection in 71%. Patients were followed by renal scintigraphy, 51chromium edetic acid clearance and video cystometry. Median followup was 62 months.Renal abnormality, which was found in 90% of the children at followup, was generalized in 71% and focal in 29%. The abnormality was bilateral in 28% of the affected patients. Total glomerular filtration rate was less than 80% of expected in 30% of the patients. Single kidney function was less than 40% of expected total glomerular filtration rate in 71% of the patients. Renal status (parenchymal abnormality and function) remained unchanged through time in 84 of 108 available cases (78%), improved in 5 (5%) and deteriorated in 19 (18%). Predictive factors for deterioration were recurrent febrile urinary tract infection, bilateral abnormality and reduced total glomerular filtration rate. Deteriorated renal status was more common in cases diagnosed prenatally than in those detected after urinary tract infection.Among these infants with high grade vesicoureteral reflux renal abnormality was frequent and was associated with subnormal filtration of one of the kidneys. Decreased total glomerular filtration rate was seen in about a third of the patients. Overall deterioration of renal status was seen in only a fifth of the patients. Infection control seems to be an important factor to minimize the risk.

We investigated whether the treatment of bladder dysfunction in infants with congenital high grade vesicoureteral reflux could influence the spontaneous resolution rate of the reflux and the number of recurrent urinary tract infections.A total of 115 infants with high grade vesicoureteral reflux were included in a followup study of bladder function and reflux resolution between 1993 and 1999. The present study deals with 20 of these infants with mainly grade V reflux, most of whom had recurrent urinary tract infections in combination with high post-void residual and high bladder capacity. Treatment with clean intermittent catheterization was instituted during infancy in these 20 patients and continued until a median age of 4 years.Bladder capacity was high at presentation and at all followup investigations in the clean intermittent catheterization treated group. Moreover, residual urine was high at presentation and especially between ages 1 and 2 years. However, after bladder control was achieved this residual decreased and consisted mainly of reflux urine. In only 1 girl did reflux resolve spontaneously during the 4-year followup period. A total of 18 patients were treated surgically at the end of this period, and clean intermittent catheterization could be stopped a few months later in all but 2. Urinary tract infection recurrences were uncommon after the institution of treatment.The treatment of bladder dysfunction characterized by a high capacity bladder with poor emptying in infants with congenital high grade reflux does not influence the rate of spontaneous resolution. On the other hand, the tendency toward recurrent urinary tract infections appears to decrease with treatment.

Reports concerning bladder dysfunction patterns in infants with high grade vesicoureteral reflux during the first year of life vs older children with reflux are contradictory. To describe the development of bladder function characteristics in children with congenital dilating reflux, we evaluated such infants urodynamically and followed them regularly for a 3-year period.A total of 89 males and 25 females with grade III to V dilating reflux were evaluated 3 times using videocystometry at mean ages of 6, 20 and 40 months.Characteristics of the urodynamic pattern at 6 months could not be differentiated from normal patterns for that age, including low and normal bladder capacity, high voiding pressure levels, dyscoordination at voiding (80%) and overactivity during filling (60%). However, at 20 months the overall pattern was different, including increased bladder capacity and residual volume, normal voiding pressure, persistent overactivity during filling and dyscoordination at voiding. Bladder dysfunction was seen in 48 children (42%) at 20 months, of whom 34 primarily had high bladder capacity with incomplete emptying (dilated bladder dysfunction) and 14 had overactive bladder. Predictors for development of dilated bladder dysfunction at followup were high residual urine at 6-month examination and recurrent urinary tract infections. Recurrent infections were significantly correlated to high residual urine at all investigations and to detrusor overactivity at the 20-month examination.Urodynamic patterns changed between the first and second year of life in patients with dilating reflux, from an immature pattern with high pressure levels to high capacity bladder with incomplete voiding. Therefore, bladder dysfunction, which was seen in 42% of patients, was only possible to diagnose after the first year of life and was mainly seen as high capacity bladder with incomplete voiding.

Summary Objectives It has been suggested that infants with dilating vesicoureteral reflux (VUR) often have lower urinary tract (LUT) dysfunction. Signs such as high voiding pressure levels, low bladder capacity and dyscoordination at voiding have previously been thought to be indicative of dysfunction. However, these findings have also been recognised in healthy infants and are, thus, not specific to dysfunction in this age group. The urodynamic findings of interest for LUT dysfunction in children with high-grade VUR have been shown to be high bladder capacity with incomplete emptying, and often with overactivity during filling. Because the bladders in children with VUR are often only investigated with voiding cystourethrography (VCUG) and not urodynamics, the question has arisen as to whether some of the urodynamic findings indicating dysfunction can be recognised as radiological signs. The aim of the present study was to evaluate whether cystometric signs of LUT dysfunction in infants with high-grade VUR could be recognised in VCUG. Materials and methods One hundred and fifteen infants (80 boys) with Grades III–V VUR were included and investigated repeatedly with videocystometry (VCM) at a median age 6, 21 and 39 months. The sign looked for in the VCUG was bladder size (large, normal or small), according to the chosen levels in the bony pelvis. To validate the chosen levels for the different bladder sizes, bladder capacity data from a longitudinal study in healthy children were used. In addition, abnormalities in bladder wall/form and filling of the posterior urethra without voiding, as signs of bladder overactivity and detrusor–sphincter dyscoordination, were evaluated. Results Bladder size was estimated on VCUG as large, normal or small, according to pelvic landmarks. Large bladder size was mainly seen at the second and third evaluations (64% and 46%), whereas small capacity was mainly seen during the first year (33%). Corresponding cystometric capacities (ml) showed a significant difference between the groups of small, normal and large bladder size. The cystometric capacities of large and small bladder size were also compared with bladder capacity in healthy controls, where large had significantly higher bladder capacity versus age (P = 0.0001) and small had significantly lower (P = 0.011) bladder capacity versus age than in the healthy controls. Bladder shape/wall pathology was mainly seen during the first year (42%), combined with small capacity, and correlated to overactive contractions during filling. Moreover, filling of the posterior urethra without voiding, indicating detrusor/sphincter dyscoordination at voiding, was quite common during the first year (33%), and then successively decreased. Conclusions The clinical implication from this study of small children with high-grade VUR was that a large bladder on VCUG was synonymous with a high-capacity bladder. According to earlier studies, this is a sign of LUT dysfunction in this age group and should therefore be an indicator for additional studies of bladder function. Overactive contractions could also be recognised in VCUG, but only at the infant evaluation, which should also be regarded as an indicator of LUT dysfunction. All other bladder VCUG signs mainly seen during early infancy were signs of immature bladder function and not a result of VUR dysfunction.

Purpose The aim of the study was to investigate if bladder function variables could be recognized as radiological signs in the VCUG in children with vesicoureteral reflux (VUR). Material and Methods 116 patients with high-grade VUR had videocystometry at median age 6, 21 and 39 months. X-ray films of the bladder was reviewed for size (big = above the line between the iliac crests, small = below the line between the lower ends of sacroiliac junctions), pathology of the bladder wall (irregular, trabeculated, diverticula) and pathology of the bladder neck / proximal urethra (urethral sphincter closed with filling of the posterior urethra - PUF). Results Bladder volume estimated from the X-ray films (big, normal, small), correlated well to bladder volumes obtained from the urodynamic investigations, with significant difference between the groups (p Low age ( Conclusions Our observations indicate that bladder capacity could roughly be estimated from x-ray films by using the landmarks suggested in this study. The typical urodynamic pattern for small infants: low bladder capacity, overactivity, high voiding pressure and dyscoordination at voiding was recognised in X-ray films from VCUG.

Purpose The aim was to identify prognostic factors for spontaneous resolution of congenital high-grade vesicoureteral reflux (VUR). Material and Methods 115 infants (85 boys and 35 girls) were included at median age 2.7 months. 74% were diagnosed after urinary tract infection (UTI) and 26% after prenatal ultrasound. VUR was bilateral in 70% and of maximum grade III in 15%, grade IV in 45% and grade V in 40%. All have been followed with repeated video-VUCG, renal scintigrams (MAG-3 and DMSA) and 51Cr-EDTA-Clearances. Median follow-up time was 36 months. Results The overall spontaneous resolution rate (to grade II or less) was 39%. Significantly lower resolution was found in univariate Cox analysis, illustrated in Kaplan Meier survival curves, in those with renal damage, breakthrough UTI, bladder dysfunction, high bladder capacity, impaired renal function (lowered GFR), and reflux occurring without increase in pressure early during filling. Voiding reflux was connected to a high rate of spontaneous resolution. The resolution rate was also directly related to grade of VUR. There was no significant difference in resolution rate between boys and girls, pre or postnatal diagnosis, uni or bilateral VUR at start. Conclusions The overall resolution rate in congenital high-grade vesicoureteral reflux was high during the first years of life. A number of factors have been identified as important in the prediction of the long-time outcome of VUR in this study. Of these factors renal damage, bladder dysfunction and recurrent UTI have been shown to be the strongest independent predictors in a stepwise multivariate Cox analysis.