Journal Archives - Volume 5
Editorial: It is hardly possible to understand bladder dysfunction in children with its clinical management without knowing something about development and maturation of the bladder function from infancy onwards. The reason is that in most cases bladder dysfunction of the central nervous control of the lower urinary tract (LUT) which comprises the bladder, the urethra, and the sphincters. Since the bladder is a unique organ in that it receives innervations from all three major neurosystems (sympaticus, parasympaticus), and the somatic system). Fine-tuning of the central nervous system during childhood is a mandatory prerequisite for normal LUT function. Albeit scientific evidence in this area is still scarce, it seems evident that this fine-tuning is governed by genetic mechanisms with delayed expression in about 5–10% of the general population and it is among this subgroup that we find children with dysfunctional bladders. It should be stressed that the term "dysfunction" in this context excludes organic aetiology such as congenital anomalies of the spinal cord or of the LUT.
Editorial: Relation between dysfunctional voiding syndromes and vesicoureteral reflux (VUR) has been suspected for more than three decades. Furthermore, children with VUR are often found to have associated voiding problems. Management of vesicoureteral reflux has evoked with improved understand of the natural history of reflux. Treatment of VUR has shifted from immediate surgical management to "watchful waiting". This shift in the management of VUR has also been accompanied by better appreciation of bladder function in children with reflux. The association of dysfunctional voiding with VUR has been proposed for quite some time. Despite several early reports, the attention directed towards dysfunctional voiding in children with VUR has not been widely embraced until the last decade. In this chapter, we will discuss the role dysfunctional voiding plays in VUR and also examine the significance of the evaluation and treatment of voiding dysfunctions with VUR.
Bladder function during infancy has previously been regarded as automatic, with voiding induced by a constant volume in the bladder and without cerebral influence. Development of bladder control was supposed to begin at one year of age and often fully developed by age 4–5 years. It was described by Muellner as ‘`a maturation, which could not be influenced by training’’. Another factor which was considered important was the doubling of bladder capacity between 2 and 4–5 years of age. These statements about maturation combined with the improvement in the quality of disposable napkins has contributed to a more liberal view about what age potty-training should be started.
Abstract: The nonneurogenic neurogenic bladder (NNNB) syndrome, starting from the term itself, describes a contradictory and apparently nebulous identity. In spite off urodynamics techniques refinements and reports on terminology availability there is no clear definition of the syndrome. In term of etiology, there is not a cut-off distinction with the dysfunctional voiding on one site and with isolated (or occult) neurogenic disorders on the other site, the latter being just a matter of exclusion. Furthermore, although today there is a huge attention, at different patients' age and by various specialists, to functional disorders of the bladder and the pelvic region overall, no establish relationship has been drawn out between Nonneurogenic Bladder syndrome and dysfunctional voiding disorders with comparable urodynamic characteristics, commonly seen in adults.
Abstract:A child who is wetting after 5 years of age should be considered incontinent, Urinary incontinence in children is a common problem with far reaching medical, social and psychological implications. Though numerous causes have been attributed for paediatric urinary incontinence yet, by far, spinal dysraphism (aperta and occulta) is the most common cause of neurovesical dysfunction in the paediatric age group. Various modalities of management have been proposed for the treatment of neurogenic bladder. Way back in 1972, clean intermittent catheterization (CIC) was popularized by Lapides as the cornerstone of treatment off neuropathic bladder. With advances in technology, newer modalities of treatment like neuromodulation and biofeedback have been proposed to be quite effective in the treatment of urinary incontinence of neurogenic origin. The present article aims to review the non surgical management options in the treatment of neurogenic urinary incontinence. For the better understanding of these treatment options, especially their mechanism of action, a short review off neuroanatomy and neurophysiology of micturition is also given.
Abstract: Neurogenic sphincter incompetence in children is mostly congenital (spinal dysraphism, sacral agenesis, diastematomyelia and tethering of the spinal cord) and occasionally acquired (tumors, traumas, iatrogenic injuries and neural degenerative diseases). In such situations, the complex dynamic mechanism allowing the bladder to store urine without leakage and to empty completely is impaired. The impact of voiding dysfunction on continence and, ultimately, upper urinary tract function warrants our attention to its management. When conservative medical management does not achieve dryness and/or protect the urinary tract, surgical procedures need to be considered. There are two possible approaches of the sacral nerve roots; or by using urological procedures. In this chapter, we will focus only on the latter procedures, as very few centers have experienced with neurostimulation. The two major aims of the urological management of neurogenic sphincter deficiency in children are the preservation of the upper urinary tract and the achievement of dryness. These two requirements necessitate finding the appropriate balance between intravesical pressure (related to the reservoir) and sufficient bladder outlet resistance. None of the current urological procedures available can restore dynamic, normally functioning sphincteric mechanisms. All procedures tend to either create a passive controllable outlet obstruction (bladder neck reconstruction or injection, urethral suspension and artificial urinary sphincter) or bypass the defective lower urinary tract (diversion). Although our discussions will be limited to the surgical management aspect of sphincteric incompetence, effort must first be made to ensure a large-capacity and compliant reservoir.
Abstract: The functions of the bladder are to receive urine from the kidneys, to store urine at appropriate pressure without leaking, and to empty fully at a socially acceptable time and place. A neuropathic bladder is one that contracts inadequately, empties poorly and often involuntarily. In addition, such a bladder is frequently of low volume, poorly compliant and stores urine at high pressure, the consequences of which include incontinence, frequent infection and renal impairment.
Abstract: Urinary incontinence in children can mainly be divided into three etiological categories; neuropathic bladder sphincter dysfunctions, uropathic dysfunctions and non neuropathic bladder sphincter dysfunctions.
Abstract: This chapter reviews the epidemiology, genetics, psychological impact, pathophysiological factors and specific identifiable causes, investigation, management and prognosis of primary (PNE) and secondary nocturnal enuresis (SNE).
Abstract: Children with urinary incontinence and enuresis carry a higher risk both for subclinical emotional and behavioral symptoms, as well as for clinical disturbances. In epidemiological, as well as clinical studies, the rate of comorbid behavioral disorders lies between 20-30% (max, 40%), i. e. 2-4 times higher than in non-wetting children. Secondary nocturnal enuresis and voiding post ponement have a higher comorbidity, while urge incontinence and primary nocturnal enuresis, especially the monosymptomatic forms, have a risk for comorbid behavioral disorders. The association between enuresis/urinary incontinence and behavioral disorders are complex. While subclinical symptoms will often improve upon attaining dryness, manifest disorders require additional counseling and treatment. This substantial group of nearly a third of all wetting children require professional attention.
Abstract: Nocturnal enuresis has for thousands of years and in all parts of the world been one of the most common and distressing disorders of childhood. During history there has been no end to the speculations about causes and treatments and these have been heavily influenced by culture, religion and history. Some of the earliest descriptions of enuresis dates back to 1550 B. C. in Papyrus Ebers. Since then a long list of remedies have been claimed to be effective ranging from extracts of animals, organs or plants, e. g. boiled comb of a hen in tepid water, testicles from a hare in a glass of wine, and flowers of chrysanthemums. More painful remedies such as induced blisters on the back, ivory cone in the rectum; whipping and surgical procedures have been employed as well as public humiliation of the child. Even in the modern time a multiple of treatment modalities are available ranging from well documented treatments such as desmopressin and the enuresis alarm to treatments that differ only little to ancient remedies in terms of lack of physiological background.