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To void at will: lnvestigation and treatment of children with bladder dysfunction
Linköping University, Department of Molecular and Clinical Medicine, Pediatrics. Linköping University, Faculty of Health Sciences.
2002 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Improvements in diagnostic and treatment procedures have made it possible to obtain a normal kidney function and continence for most children with bladder dysfunction. However, in the daily clinical work further diagnostic and treatments procedures may be required when traditional methods fail to help the child. The aims of the present studies were to evaluate such diagnostic and treatments alternatives.

A 4-hours observation test of voiding pattern was evaluated in 50 healthy newborns, as reference values were lacking for this age group. Normal values for voiding frequency, intervals, volume and residual urine were established. All parameters varied greatly both inter- and intraindividually. Residual urine occurred after some voidings in most newborns.

At our clinic, children are catheterised without anaesthesia or sedation, following a special concept of preparation. When evaluating this routine most children (93/99) tolerated the procedure well. Five girls and one boy (or their parents) reported the catheterisation to be "very painful", without requiring that the procedure was interrupted.

The diagnostic value of the bladder cooling tests (BCT) was evaluated in 108 children with neurogenic bladder dysfunction. The BCT could identify a functional sacral reflex arch in children without voiding contractions or confirm a suspected lower motor neurone lesion. A positive test in children older than 6 years verified the diagnosis neurogenic bladder dysfunction.

The effect of anogenital afferent stimulation (AGAS) was retrospectively evaluated in 48 children with therapy resistant urge incontinence. Thirty-eight percent were cured, another 15 % improved. AGAS is a useful, potentially curative treatment in children with severe urge incontinence.

Intravesical electrical stimulation (IVES) was offered as alternative treatment to 44 children with bladder emptying problems, 20 of neurogenic origin. Twenty-eight children, 8 with neurogenic problems, had long term normalisation of their voiding and 11/15 children could discontinue clean intermittent catheterisation. IVES seems to be a promising method for treatment of underactive detrusor in children.

Conclusions: Some investigative methods aimed at children with suspected bladder dysfunction were evaluated together with two new treatment modalities involving electrical stimulation of afferent nerve fibres. Anogenital or intravesical electrical stimulation represents alternative options for children with urge incontinence or underactive detrusor when standard treatments fail.

Abstract [sv]

Förbättrad diagnostik och utveckling av nya behandlingmetoder har gjort det möjligt att bevara en normal njurfunktion och kontinens för flertalet barn med blåsstörningar. l det dagliga kliniska arbetet uppkommer emellertid ofta krav utrednings- och behandlingsalternativ när traditionella metoder inte räcker till. Syftet med dessa studier var att utveckla och utvärdera nya diagnostiska och terapeutiska metoder för barn med blåsstörning.

Ett 4-timmars observationstest av miktiansmönstret har utvärderats hos 50 friska nyfödda barn, eftersom referensvärden fattades för denna åldersgrupp. Normalvärden för miktionsfrekvens, intervall, volym och resturin har har tagits fram och visar stora variationer i samtliga miktiansparametrar såväl inter- som intraindividuellt. Flertalet nyfödda barn hade resturin efter någon eller flera miktioner.

Vid PNUT-enheten vid Barn- och ungdomsmedicinska kliniken kateteriseras så gott som samtliga barn transuretra!t utan anestesi eller sedering men efter noggrann förberedelse enligt speciellt program. Vid utvärdering tyckte flertalet (95/99) att konceptet var bra/mycket bra. Fem flickor och en pojke (eller deras föräldrar) tyckte att kateteriseringen gjorde "mycket ont", men utan att kräva att proceduren skulle avbrytas.

Det diagnostiska värdet av köldtest har utvärderats på 108 barn med neurogen blåsrubbning. Köldtestet kunde påvisa en fungerande sakral reflexbåge även hos barn utan miktianskontraktion alternativt bekräfta en misstänkt nedre motorneuronskada. Ett positivt test hos barn äldre än 6 år verifierar diagnosen neurogen blåsrubbning

Effekten av anagenital afferent stimulering (AGAS) har utvärderats retrospektivt hos 48 barn med terapiresistent trängningsinkontinens. Trettiotvå procent blev botade och ytterligare 15 % blev förbättrade. AGAS är en användbar, potentiellt kurativ behandlingsmetod för barn med svår trängningsinkontinens.

lntravesikal elektrisk stimulering (IVES) erbjöds som alternativ behandling till 44 barn med blåstömningsproblem, hos 20 orsakat av neurogena skador. Tjugoåtta barn, 8 med neurogena problem, fick en bestående normalisering av miktionen och 11/15 barn kunde avsluta behandlingen med ren intermittent kateterisering. lVES tycks vara en lovande metod att behandla svag detrusarfunktion hos barn.

Sammanfattning: Olika undersökningmetoder för barn med blåsdysfunktion har utvärderats liksom två nya behandlingsmodeller med elektrisk stimulering av afferenta nervfibrer. Anagenital och intravesikal elektrisk stimulering representerar alternativa möjligheter att behandla barn med trängningsinkontinens respektive svag detrusar när traditionella behandlingmetoder inte hjälper.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2002. , 60 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 713
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-26652Local ID: 11217ISBN: 91-7373-154-4 (print)OAI: oai:DiVA.org:liu-26652DiVA: diva2:247201
Public defence
2002-01-11, Administrationsbyggnadens aula, Universitetssjukhuset, Linköping, 13:00 (Swedish)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-09-10Bibliographically approved
List of papers
1. Voiding pattern in healthy newborns
Open this publication in new window or tab >>Voiding pattern in healthy newborns
2000 (English)In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 19, no 2, 177-184 p.Article in journal (Refereed) Published
Abstract [en]

A 4-hour observation period has been used in infants to investigate suspected bladder dysfunction. The aim of the present study was to extend the usefulness of this protocol by establishing reference values for voiding frequency, intervals, volumes, and residual urine in healthy newborns. The study included 51 healthy newborns, 26 girls and 25 boys, aged 3 to 14 days. During a 4-hour period, all micturitions and residuals were recorded as well as feeding, sleeping, crying, and defecations. The observation was completed with the child undressed to observe the urinary stream during one void. Different provocation tests were tried to induce urinary leakage. All newborns voided with a stream, about once per hour, with a median volume of 23 mL. For each voiding parameter, there was a large inter- and intra-individual variability. Double voidings were common as well as sizable residual volumes. The diuresis was about six times higher than in healthy school children. The healthy newborns did not leak during provocation tests such as manual compression of the bladder.

Keyword
children, newborns, voiding pattern
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25250 (URN)10.1002/(SICI)1520-6777(2000)19:2<177::AID-NAU8>3.0.CO;2-0 (DOI)9689 (Local ID)9689 (Archive number)9689 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
2. Effect of thoughtful preparation on the catheterization of children undergoing investigative studies
Open this publication in new window or tab >>Effect of thoughtful preparation on the catheterization of children undergoing investigative studies
2003 (English)In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 22, no 1, 58-61 p.Article in journal (Refereed) Published
Abstract [en]

Aims:

To evaluate an anesthetic sedation free method of transurethral catheterization in children.

Methods:

The child and his or her parents are thoroughly prepared for the procedure by means of written and oral child-adapted information and practical instructions. To evaluate this routine, a simple questionnaire was given to 115 consecutive children undergoing transurethral catheterization.

Results:

The questionnaire was returned by 99 children (86%). Most children and parents (95) found the preparation“good”or“very good”and tolerated the catheterization procedure well. Only six children reported the catheterization to be“very painful”(without requiring that the procedure was terminated). Complications, such as urgency, smarting pain during voidings, or both, after withdrawal of the catheter, occurred in 12 children and urinary tract infections in 3. Unexpectedly, girls were affected more often than boys.

Conclusions:

Careful preparation of children and their parents allows the great majority of diagnostic studies that require urethral catheterization to be accomplished without anesthesia. Neurourol. Urodynam. 22:58–61, 2003. © 2003 Wiley-Liss, Inc.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26471 (URN)10.1002/nau.10020 (DOI)11022 (Local ID)11022 (Archive number)11022 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
3. Outcome of the bladder cooling test in children with neurogenic bladder dysfunction
Open this publication in new window or tab >>Outcome of the bladder cooling test in children with neurogenic bladder dysfunction
1999 (English)In: Journal of Urology, ISSN 0022-5347, E-ISSN 1527-3792, Vol. 161, no 1, 254-258 p.Article in journal (Refereed) Published
Abstract [en]

Purpose

We evaluated the diagnostic use of the bladder cooling test in children with neurogenic bladder dysfunction.

Materials and Methods

We performed 201 bladder cooling tests in 65 female and 43 male patients 5 days to 17 years old, including 70 with myelomeningocele, 12 with high spinal lesions, 9 with sacral spinal lesions and 17 with encephalopathy of various types. At the end of routine cystometry we rapidly infused body temperature saline to approximately a third of cystometric capacity, followed by the same volume of saline at 4 to 8C. The test was considered positive when a detrusor contraction greater than 30 cm. water was evoked by the cold but not the warm infusion.

Results

The bladder cooling test was positive in 37 children younger than 4 years, at which age it is normally positive. The test was negative in only 2 patients, indicating a complete lower motor neuron lesion. It was positive in 34 of the 57 children older than 6 years, at which age it should be negative. Thus, the positive bladder cooling test confirmed neurogenic bladder dysfunction. Four of the 20 children with a negative test voided normally, while the remainder had no voiding contractions, suggesting a nonfunctional spinal sacral reflex arch to the bladder.

Conclusions

The bladder cooling test is a simple, reliable assessment that may serve to demonstrate a functional sacral reflex arch in young patients without voiding contractions or confirm a suspected lower motor neuron lesion. It may be used longitudinally to demonstrate changes in bladder function with growth.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25255 (URN)10.1016/S0022-5347(01)62125-6 (DOI)9694 (Local ID)9694 (Archive number)9694 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
4. Anogenital electrical stimulation as treatment of urge incontinence in children
Open this publication in new window or tab >>Anogenital electrical stimulation as treatment of urge incontinence in children
2001 (English)In: BJU International, ISSN 1464-4096, E-ISSN 1464-410X, Vol. 87, no 4, 366-371 p.Article in journal (Refereed) Published
Abstract [en]

Objectives To evaluate retrospectively the result of anogenital afferent stimulation (AGAS) in neurological healthy children with therapy-resistant urge incontinence.

Patients and method The study included 48 children (24 girls and 24 boys, 5–14 years old) with a diagnosis of bladder instability verified by cystometry in all. Anogenital afferent stimulations were applied using a battery-powered dual constant-current stimulator. The children were stimulated continuously at 10 Hz for 20 min once or twice daily and if required the children and/or the parents continued to apply the treatment at home. For home stimulation a single (anal) channel stimulator was used. The patients were instructed to stimulate for 20 min at maximum intensity two to three times a week until the effects were optimal. The outcome was evaluated retrospectively by comparing voiding/incontinence diaries obtained before and at the follow-up 6–12 months after the end of treatment.

Results AGAS was applied at the clinic for a median (range) of 9 (4–20) times. Thirty-one children continued with home stimulation for another 25 (5–96) sessions. At the follow-up, 18 children were cured and another seven improved, with a leakage score of less than half that before treatment. The treatment was well tolerated by most children.

Conclusions Anogenital afferent stimulation is an effective, potentially curative treatment in children with severe urge incontinence. Home stimulation is a well accepted adjuvant to treatment at the clinic and improves the outcome.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25251 (URN)10.1046/j.1464-410X.2001.00109.x (DOI)9690 (Local ID)9690 (Archive number)9690 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
5. Intravesical electrical stimulation in the treatment of micturition dysfunction in children
Open this publication in new window or tab >>Intravesical electrical stimulation in the treatment of micturition dysfunction in children
2003 (English)In: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 22, no 3, 233-242 p.Article in journal (Refereed) Published
Abstract [en]

Aims To evaluate the results of intravesical electrical stimulation (IVES) in an open prospective study to treat underactive detrusor in children. The treatment was offered as an alternative to clean intermittent catheterization (CIC).

Methods Forty-four children were included, 21 girls and 3 boys (6–16 years, md 10) with idiopathic, 9 girls and 11 boys (4–18 years; md 13) with neurogenic underactive detrusor. IVES was given by a catheter electrode in the bladder (cathode) with the anode attached to the suprapubic abdominal skin. Continuous stimulation at 20 or 25 Hz was delivered by battery powered stimulators giving unipolar square-wave pulses (0,2 or 0,7 ms). Stimulation intensity was adjusted individually according to the acceptance of the child (12–64 mA). IVES was initially given at the clinic but 18 children had additional treatment at home. Effect of treatment was monitored by micturiton/incontinence diary, reports of bladder sensation, recordings of urinary flow, residual volume and frequency of urinary tract infections.

Results The IVES-treatment was completed by 39/44 children. Long term normalization of the voiding (md 2,5 years follow up) was obtained for 20/24 children with idiopathic problems (83%) and 8/20 with neurogenic problems (40%). Another four had much improved bladder function. The neurogenic group required more stimulation sessions than the idiopathic group. Of those on CIC, 11/15 who completed IVES could discontinue the catheterization. The frequency of urinary tract infections and incontinence decreased significantly (P < 0.01).

Conclusions It is concluded that IVES is a promising method to treat the underactive detrusor in children.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25252 (URN)10.1002/nau.10078 (DOI)9691 (Local ID)9691 (Archive number)9691 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved

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