voiding dysfunction in children by dr.turky k. al-mouhissen urology chief resident - wr king...
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Voiding Dysfunction
in ChildrenByBy
Dr.TurkyDr.Turky K. Al-MouhissenK. Al-MouhissenUrology Chief Resident - WRUrology Chief Resident - WR
King Abdulaziz Medical Center - WRKing Abdulaziz Medical Center - WR
Normal Bladder Function in Infants & Children:Normal Bladder Function in Infants & Children:
The bladder is an abdominal organ The bladder is an abdominal organ
Detrusor consists of meshwork of smooth m. which has the Detrusor consists of meshwork of smooth m. which has the ability to elicit maximal active tension over a wide range of ability to elicit maximal active tension over a wide range of lengthlength
This allows the bladder to be filled at low pressure This allows the bladder to be filled at low pressure (compliance)(compliance)
Reservoir function determined by activity of detrusor m. and Reservoir function determined by activity of detrusor m. and bladder outletbladder outlet
Bladder sphincter plays a major role in urinary continence by Bladder sphincter plays a major role in urinary continence by closure of bladder neck & proximal urethraclosure of bladder neck & proximal urethra
Literature suggests thatLiterature suggests that Immature detrusor-sphincter coordinationImmature detrusor-sphincter coordination, manifested as detrusor , manifested as detrusor
hypercontractility and interrupted hypercontractility and interrupted voiding, commonly occurs in 1, commonly occurs in 1stst 1-2 1-2 yearsyears causing a degree of functional bladder outflow obstruction causing a degree of functional bladder outflow obstruction
(Sillen et al,1992;Yeung et al,1998)(Sillen et al,1992;Yeung et al,1998)
Some found significant age related differences in the histologic structure of the sphincter compared to adults
Activation, coordination, and integration of various parts of the bladder-sphincter complex involves central, somatic & autonomic nervous system through Sacral parasympathatic (pelvic n.) Thoracolumbar symp. (hypogastric & sympathatic chain) Sacral somatic n. (pudendal n.)
Parasymp. N. fibers run in pelvic n. Parasymp. N. fibers run in pelvic n. (S2-S4)(S2-S4) to supply the to supply the pelvic pelvic and vesical plexuses before entering the bladderand vesical plexuses before entering the bladder
Symp. n. arises from Symp. n. arises from (T10-L2)(T10-L2) to inferior mesenteric to inferior mesenteric ganglion ganglion hypogastric n.hypogastric n. to the pelvic plexus & to the pelvic plexus & bladder bladder There is also symp. innervation from T10-L2 supplying the There is also symp. innervation from T10-L2 supplying the
detrusor and urethral sphincter detrusor and urethral sphincter
The somatic nervous system The somatic nervous system (pudendal n.)(pudendal n.) supplies the supplies the periurethral pelvic floor musclesperiurethral pelvic floor muscles
The sensory & motor n. carried by all 3 nerves innervate The sensory & motor n. carried by all 3 nerves innervate the bladder and urethral sphincter the bladder and urethral sphincter
Symp. supply causes Symp. supply causes Detrusor relaxation (B receptors)Detrusor relaxation (B receptors) Smooth m contraction at trigone & bladder neck (alpha receptors)Smooth m contraction at trigone & bladder neck (alpha receptors)
Parasymp. supply causes detrusor contraction Parasymp. supply causes detrusor contraction (muscarinic receptors)(muscarinic receptors)
Pudendal supply causes striated sphincter contractionPudendal supply causes striated sphincter contraction
Within the spinal cord, information from bladder afferents Within the spinal cord, information from bladder afferents integrated with other sources and projected to brain stem integrated with other sources and projected to brain stem centers to coordinate with mic. centerscenters to coordinate with mic. centers
Development of Normal Bladder Function Development of Normal Bladder Function and Micturition Controland Micturition Control
CMG studies on normal infants showedCMG studies on normal infants showed bladder function in young children is very bladder function in young children is very
different from adultsdifferent from adults
During the 1During the 1stst 2-3 years of life 2-3 years of life There is progressive development from initially There is progressive development from initially
indiscriminate infants voiding pattern to more indiscriminate infants voiding pattern to more socially conscious and voluntary (adult) type of socially conscious and voluntary (adult) type of micturition micturition
The natural evolution of bladder control The natural evolution of bladder control entails nervous system & depends on:entails nervous system & depends on:
Progressive increase in bladder functional Progressive increase in bladder functional storage capacity storage capacity
Maturation of voluntary control over the urethral Maturation of voluntary control over the urethral striated muscle sphincterstriated muscle sphincter
Development of direct volitional control over the Development of direct volitional control over the bladder sphincter unit, so that the child can bladder sphincter unit, so that the child can voluntary initiate or inhibit micturition reflex voluntary initiate or inhibit micturition reflex
Change in bladder function parametersChange in bladder function parameters
Voiding frequency Voiding frequency During the 3During the 3rdrd trimester, the fetus voids at rate trimester, the fetus voids at rate
30 times/24 hrs30 times/24 hrs Immediately after birth, this Immediately after birth, this dropsdrops for the 1 for the 1stst
days only days only Increases again after 1Increases again after 1stst 1/52 to reach a peak 1/52 to reach a peak
by 2-4 /52 to an average by 2-4 /52 to an average once/houronce/hour This rate declines to This rate declines to 10-15 times/day10-15 times/day at 6-12 at 6-12
mo.mo. 8-10 times/day8-10 times/day by 2-3 years by 2-3 years
This reduction in voiding frequency This reduction in voiding frequency observed during the 1observed during the 1stst years of life related years of life related mainly to an increase in bladder capacity mainly to an increase in bladder capacity parallel to body growth parallel to body growth
By the age of 12, voiding pattern is very By the age of 12, voiding pattern is very similar to that in adult ( 4-6 voids / day ) similar to that in adult ( 4-6 voids / day )
Bladder capacityBladder capacity An adequate reservoir function of urine storage is An adequate reservoir function of urine storage is
necessary to meet the increase rate of urine production necessary to meet the increase rate of urine production and decreased voiding frequency in the growing childand decreased voiding frequency in the growing child
Bladder capacity can be estimatedBladder capacity can be estimatedFor young infants:For young infants:
Bladder capacity (ml) = 38 + 2.5 * age (mo)Bladder capacity (ml) = 38 + 2.5 * age (mo)
For children:For children:Bladder capacity (ml) = (age [yr] + 2) * 30 koffBladder capacity (ml) = (age [yr] + 2) * 30 koff’’s s
formulaformula
Bladder capacity (ml) = 30 + (age [yr] * 30 HijalmaBladder capacity (ml) = 30 + (age [yr] * 30 Hijalma’’s s formulaformula
In parallel to increase in bladder capacity, the In parallel to increase in bladder capacity, the mean voided volume of each micturation mean voided volume of each micturation increases with ageincreases with age
CMG studies showed that most infants with CMG studies showed that most infants with
incomplete maturation of det.- sphin. coordination incomplete maturation of det.- sphin. coordination before the age 1, are before the age 1, are still able to have satisfactory still able to have satisfactory emptying (>80)emptying (>80)
There are limited studies on detr. pressure at There are limited studies on detr. pressure at voiding in infants due techn. difficultiesvoiding in infants due techn. difficulties
Limited data documented Limited data documented higherhigher maximum detr. maximum detr. pressure with mict. than in adultspressure with mict. than in adults MaleMale infants voided significantly higher pressure than infants voided significantly higher pressure than
females (mean Pdetmax 118 vs. 75cm H20, P<.03) females (mean Pdetmax 118 vs. 75cm H20, P<.03)
Studies showed that Studies showed that highhigh detrusor pressures detrusor pressures noted during micturition were mainly observed noted during micturition were mainly observed only during the 1only during the 1stst year of life & decreased year of life & decreased progressively with ageprogressively with age
Evolution of Normal Micturition ControlEvolution of Normal Micturition Control
Traditionally, it has been assumed that micturition occurs Traditionally, it has been assumed that micturition occurs by simple spinal reflex with no mediation by higher neural by simple spinal reflex with no mediation by higher neural centerscenters
Recent studies showed that even in full term fetuses and Recent studies showed that even in full term fetuses and newborns, mict. Is modulated by newborns, mict. Is modulated by higher centershigher centers
Further extensive modulation occurs during the postnatal Further extensive modulation occurs during the postnatal periodperiod
During the 2During the 2ndnd & 3 & 3rdrd year of life, there is a progressive year of life, there is a progressive development toward a socially conscious continence and development toward a socially conscious continence and a more a more voluntary (adult) type mictvoluntary (adult) type mict. .
The final steps usually achieved at The final steps usually achieved at 3-4 yrs3-4 yrs Most develop the adult pattern of urinary control & will be dry Most develop the adult pattern of urinary control & will be dry
day & nightday & night
The child has learned to inhibit a mict. Reflex and The child has learned to inhibit a mict. Reflex and postpone voiding and voluntarily initiate mict. At socially postpone voiding and voluntarily initiate mict. At socially acceptable time & placeacceptable time & place
Neurologic control of normal mic. occurs at different levels Neurologic control of normal mic. occurs at different levels of CNS from the spinal cord of CNS from the spinal cord ((sacral mic. centerssacral mic. centers)) to the to the brain stem (brain stem (pontine mic. Centerspontine mic. Centers))
Cerebellum, basal ganglion, limbic system, thalamus and Cerebellum, basal ganglion, limbic system, thalamus and hypothalamus, and cerebral cortexhypothalamus, and cerebral cortex
bladder is unique among other visceral organs bladder is unique among other visceral organs its function is under control of somatic and autonomic n. systemits function is under control of somatic and autonomic n. system
Beside acetylcholine & NE, other neurotransmitters Beside acetylcholine & NE, other neurotransmitters involved during bladder stimulationinvolved during bladder stimulation PG substance P, Opioid, vasoactive intestinal peptide, PG substance P, Opioid, vasoactive intestinal peptide,
neuropeptide Yneuropeptide Y
Transitory Detrusor-Sphincter Transitory Detrusor-Sphincter
Discoordination in InfancyDiscoordination in Infancy Studies showed that all children may Studies showed that all children may transiently transiently
display some degree of abnormal bladder-sphincter display some degree of abnormal bladder-sphincter functionfunction
Urodynamic findings show association of Urodynamic findings show association of high high voiding pressuresvoiding pressures and and interruption of flowinterruption of flow BUT BUT nono impairment of overall bladder emptingimpairment of overall bladder empting
This type of dysfunction resolved with a period of This type of dysfunction resolved with a period of successful toilet training, transient or intermittent, successful toilet training, transient or intermittent, and does not persistand does not persist
Non-Neuropathic Non-Neuropathic Bladder Sphincter Bladder Sphincter
Dysfunction Dysfunction in Childrenin Children
Reported Reported 15 %15 % of 6-year old children suffer from of 6-year old children suffer from Non-Neuogenic B.S.DysfunctionNon-Neuogenic B.S.Dysfunction
Dysfunctional voiding mayDysfunctional voiding may starts with detrusor instability with sphincter & pelvic floor starts with detrusor instability with sphincter & pelvic floor
overactivityoveractivity then develops gradually fractionated voiding with then develops gradually fractionated voiding with
increasing PVRincreasing PVR Finally, develops bladder decompensation and the lazy Finally, develops bladder decompensation and the lazy
bladder syndrome bladder syndrome
Distinction between Neuropathic & Non-Distinction between Neuropathic & Non-neuropathic bladder dysfunctions may not be clearneuropathic bladder dysfunctions may not be clear
The term non-neuropathic is based purely on the fact The term non-neuropathic is based purely on the fact that that no obvious and identifiable neurologic lesions no obvious and identifiable neurologic lesions can be identifiedcan be identified
In adults, lower urinary tract function has been well In adults, lower urinary tract function has been well understood and standardization of terminology has been understood and standardization of terminology has been establishedestablished
In contrast, neural control over the bladder-sphincter unit In contrast, neural control over the bladder-sphincter unit in children is age dependent and is much more variable in children is age dependent and is much more variable and complex and complex
Etiologic Classification of Etiologic Classification of Bladder DysfunctionBladder Dysfunction
Derangement of Nervous ControlDerangement of Nervous Control::
Congenital malformation of CNSCongenital malformation of CNS, e.g.: , e.g.: myelomeningocele, spina bifida, caudal regression myelomeningocele, spina bifida, caudal regression
synd., tethered cordsynd., tethered cord Developmental disturbancesDevelopmental disturbances, e.g.,:, e.g.,:
Mental retardation, dysfunctional voiding, urge synd.Mental retardation, dysfunctional voiding, urge synd. Acquired conditionsAcquired conditions, e.g.:, e.g.:
CP, progressive degenerative diseases of CNS, CP, progressive degenerative diseases of CNS, transverse myelitis, MS, vascular malformations, transverse myelitis, MS, vascular malformations, trauma of spinal cordtrauma of spinal cord
Disorders of Detrusor & Sphincteric Muscle function:Disorders of Detrusor & Sphincteric Muscle function: Congenital conditionsCongenital conditions
Muscular dystophy, neuronal dyplasiaMuscular dystophy, neuronal dyplasia Acquired conditionsAcquired conditions
Chronic bladder distension, fibrosis of detrusor & bladder wallChronic bladder distension, fibrosis of detrusor & bladder wall
Structural abnormalitiesStructural abnormalities Congenital conditionsCongenital conditions
Bladder extrophy, epispadias, cloacal anomoly, uretroceles, PUV, Bladder extrophy, epispadias, cloacal anomoly, uretroceles, PUV, prune belly syndromeprune belly syndrome
Acquired conditionsAcquired conditions Traumatic stricture, damage to sphincter or urethraTraumatic stricture, damage to sphincter or urethra
Other unclassified conditionsOther unclassified conditions Giggle incontinenceGiggle incontinence Hinman syndromeHinman syndrome Ochoa syndrome (urofacial syndrome)Ochoa syndrome (urofacial syndrome)
Functional classification of bladder Functional classification of bladder dysfunctiondysfunction
based on functional state of the bladder-based on functional state of the bladder-sphincter complex with respect of sphincter complex with respect of detrusor activitydetrusor activity
bladder sensationbladder sensation
bladder compliance and function bladder compliance and function
urethral function urethral function
during the filling & voiding phase of CMGduring the filling & voiding phase of CMG
During the filling phase:During the filling phase:
Detrusor activityDetrusor activity Normal or stableNormal or stable
OveractiveOveractive : phasic involuntary detrusor contractions : phasic involuntary detrusor contractions which occur spontaneously or provoked by alteration which occur spontaneously or provoked by alteration of posture, coughing, walking, jumpingof posture, coughing, walking, jumping
UnstableUnstable: contraction : contraction unrelatedunrelated to underlying neurologic to underlying neurologic disorderdisorder
Detrusor hyperreflexiaDetrusor hyperreflexia : overactivity : overactivity relatedrelated disturbance of disturbance of neural control mechanismneural control mechanism
Bladder sensation during filling phaseBladder sensation during filling phase:: Normal / hypersensitive / hyposensitive / absentNormal / hypersensitive / hyposensitive / absent
Bladder capacityBladder capacity normal/ / high / lownormal/ / high / low
ComplianceCompliance Normal / high / lowNormal / high / low
Urethral functionUrethral function Normal / incompetentNormal / incompetent
During the voiding phaseDuring the voiding phase
Detrusor activityDetrusor activity Normal: Voiding achieved by voluntarily initiated Normal: Voiding achieved by voluntarily initiated
detrusor contractions that is sustained and detrusor contractions that is sustained and cannot cannot usually suppressed voluntarily until after 4 year oldusually suppressed voluntarily until after 4 year old
UnderactiveUnderactive AcontractileAcontractile
Urethral functionUrethral function NormalNormal obstructiveobstructive
Bladder-Sphincter dysfunction Bladder-Sphincter dysfunction during fillingduring filling
Overactive (unstable) bladder, urge Overactive (unstable) bladder, urge syndrome, urge incontinencesyndrome, urge incontinence
Traditionally the infant bladder has been Traditionally the infant bladder has been described as unstable or uninhibited described as unstable or uninhibited
Recent studies showed that bladder is normally Recent studies showed that bladder is normally quiescent and stable even in newbornquiescent and stable even in newborn
Clinically, the condition of (unstable bladder) is Clinically, the condition of (unstable bladder) is best exhibited by best exhibited by URGE SYNDROMEURGE SYNDROME with or with or without urge incontinencewithout urge incontinence
Urge syndromeUrge syndrome characterized frequent attacks of sudden characterized frequent attacks of sudden and imperative sensations of urge due to detrusor and imperative sensations of urge due to detrusor overactivity during filling (girls>boys)overactivity during filling (girls>boys)
The unstable contractions are often counteracted by The unstable contractions are often counteracted by voluntary contractions in the pelvic floor muscles to voluntary contractions in the pelvic floor muscles to externally compress the urethra (hold maneuvers) exhibited externally compress the urethra (hold maneuvers) exhibited as squatting in many casesas squatting in many cases
Urge incontinenceUrge incontinence consists of small quantities of urine consists of small quantities of urine
loss loss More in afternoon when the child plays and is not alert enough to More in afternoon when the child plays and is not alert enough to
contract the pelvic floor in response to the urge sensation contract the pelvic floor in response to the urge sensation
Functional urinary incontinenceFunctional urinary incontinence
Defined as involuntary loss of urine due to failure of Defined as involuntary loss of urine due to failure of control of bladder sphincter unit, frequent enough to control of bladder sphincter unit, frequent enough to cause social or hygienic problem with the absence of cause social or hygienic problem with the absence of underlying anatomic causesunderlying anatomic causes
Stress incontinenceStress incontinence represents involuntary leakage represents involuntary leakage of urine occurring when the intravesical pressure of urine occurring when the intravesical pressure exceeds the bladder outlet or urethral pressure in the exceeds the bladder outlet or urethral pressure in the absence of measurable detrusor contractions absence of measurable detrusor contractions
Unlike adults, true stress incont. Extremlely uncommon in Unlike adults, true stress incont. Extremlely uncommon in neurologically normal children and generally not associated neurologically normal children and generally not associated with abnormal CMGwith abnormal CMG
Giggle incontinence:Giggle incontinence:
Involuntary and typically unpredictable wetting during Involuntary and typically unpredictable wetting during giggling or laughtergiggling or laughter
In contrast to stress incontinence, it produces much In contrast to stress incontinence, it produces much larger volume of urine leak amounting to complete larger volume of urine leak amounting to complete bladder emptying bladder emptying
CMG may be normal or occasionally demonstrate CMG may be normal or occasionally demonstrate some detrusor overactivitysome detrusor overactivity
Rx is difficult bt sometimes a course of anticholinergic Rx is difficult bt sometimes a course of anticholinergic drugs may help drugs may help
Some suggested that itSome suggested that it’’s centrally mediated and s centrally mediated and hereditary disorder that may respond to CNS hereditary disorder that may respond to CNS stimulants as stimulants as methylphenidate methylphenidate
Bladder-Sphincter dysfunction Bladder-Sphincter dysfunction during bladder emptyingduring bladder emptying
Dysfunctional voidingDysfunctional voiding
Characterized by incomplete relaxation or Characterized by incomplete relaxation or overactivity of the pelvic floor muscles during overactivity of the pelvic floor muscles during voiding voiding
Can manifest in different patterns depending on Can manifest in different patterns depending on the degree of outflow obstructionthe degree of outflow obstruction caused and caused and the status of the detrusor activitythe status of the detrusor activity
Staccato and fractionated voidingStaccato and fractionated voiding In staccato voiding the urinary stream is often delayed after In staccato voiding the urinary stream is often delayed after
the onset of detrusor contraction and is typically interrupted the onset of detrusor contraction and is typically interrupted resulting in a few small squirts of urine passed in quick resulting in a few small squirts of urine passed in quick sensationsensation
Interrupted voiding caused by periodic bursts of pelvic floor Interrupted voiding caused by periodic bursts of pelvic floor muscle activities during micturition resulting in muscle activities during micturition resulting in characteristic abrupt elevation of voiding pressure characteristic abrupt elevation of voiding pressure coinciding with paradoxical cessation of urinary flowcoinciding with paradoxical cessation of urinary flow
Flow time usually prolonged and bladder emptying Flow time usually prolonged and bladder emptying incomplete incomplete
Fractionated voidingFractionated voiding is characterized by is characterized by infrequent & incomplete emptying secondary to infrequent & incomplete emptying secondary to detrusor inactivity detrusor inactivity
Micturition occurs in several small discontinuous fractions Micturition occurs in several small discontinuous fractions due to poor detrusor contractionsdue to poor detrusor contractions
Significant PVRSignificant PVR
Abdominal straining usually evident to improve emptyingAbdominal straining usually evident to improve emptying
Straining paradoxically counteracted by reflex increase in Straining paradoxically counteracted by reflex increase in pelvic floor muscles that is triggered by increase in pelvic floor muscles that is triggered by increase in intravesical pressure intravesical pressure
Infrequent voiding and (lazy bladder) syndromeInfrequent voiding and (lazy bladder) syndrome Described together as they represent a spectrum of Described together as they represent a spectrum of
diseases that are more commonly occurs in diseases that are more commonly occurs in girlsgirls
The lazy bladder syndrome is generally regarded as the The lazy bladder syndrome is generally regarded as the endpoint of long standing dysfunctional voiding endpoint of long standing dysfunctional voiding occurring in a fully decompensated systemoccurring in a fully decompensated system
Due to chronic functional outflow obst., there is gradual Due to chronic functional outflow obst., there is gradual deterioration in detrusor contractility and emptying deterioration in detrusor contractility and emptying efficiencyefficiency
PVR & bladder capacity increase progressively with PVR & bladder capacity increase progressively with inefficient emptying inefficient emptying
Bcs urge sensation is either absent or diminished, Bcs urge sensation is either absent or diminished, voiding is very infrequent and occasionally the child may voiding is very infrequent and occasionally the child may not void for 8-10 hrs or longer if engaged in activity not void for 8-10 hrs or longer if engaged in activity
Typical presentation, the mother always complains that Typical presentation, the mother always complains that the child never voids unless told to do so the child never voids unless told to do so
Other presentationsOther presentations Recurrent UTI, Overflow incontinence, constipationRecurrent UTI, Overflow incontinence, constipation
CMG findingsCMG findings Large bladder capacity, very high compliance on filling, absent Large bladder capacity, very high compliance on filling, absent
detrusor contractions, voiding associated with increased detrusor contractions, voiding associated with increased abdominal pressuresabdominal pressures
HinmanHinman’’s Syndrome & Occult Neuropathic s Syndrome & Occult Neuropathic bladderbladder Different names:Different names:
Nonneurogenic neurogenic bladder / subclinical neurogenic bladder Nonneurogenic neurogenic bladder / subclinical neurogenic bladder / Hinman syndrome / occult neuropathic bladder/ Hinman syndrome / occult neuropathic bladder
Acquired form of bladder-sphincteric dysfunction in childrenAcquired form of bladder-sphincteric dysfunction in children
characterized by a combination of characterized by a combination of bladder bladder decompensation with incontinence, poor emptying, and decompensation with incontinence, poor emptying, and recurrent UTIrecurrent UTI
Most children have significant bowel dysfunctionMost children have significant bowel dysfunction
Has all the clinical & CMG features of neuropathic Has all the clinical & CMG features of neuropathic dysfunction but NO neuologic pathologydysfunction but NO neuologic pathology
CMG shows marked sphincteric overactivity with abrupt CMG shows marked sphincteric overactivity with abrupt contractions of pelvic floor contractions of pelvic floor
Ochoa (urofacial) syndrome:Ochoa (urofacial) syndrome: Children have all classic features of dysfunctional Children have all classic features of dysfunctional
voiding, including urinary incontinence, recurrent voiding, including urinary incontinence, recurrent UTI, constipation, reflux, Upper tract damage + UTI, constipation, reflux, Upper tract damage + peculiar painful or apparently crying facial peculiar painful or apparently crying facial expression during smilingexpression during smiling
Autosomal recessive, located on chromosome Autosomal recessive, located on chromosome 1010
CMG shows sustained contraction of external CMG shows sustained contraction of external sphincter during voidingsphincter during voiding
Of 66 children reported by Ochoa:Of 66 children reported by Ochoa: 33% renal functional impairment33% renal functional impairment 26% HTN26% HTN 24% ESRD24% ESRD
Bcs neural ganglion controlling the facial Bcs neural ganglion controlling the facial muscles are situated very close to the pontine muscles are situated very close to the pontine micturition centersmicturition centers A small genetically predetermined congenital A small genetically predetermined congenital
neurologic lesion in this area may be responsible neurologic lesion in this area may be responsible for both the peculiar facial expression & bladder for both the peculiar facial expression & bladder dysfunctiondysfunction
Postvoid dibblingPostvoid dibbling Involuntary leakage of urine immediately after voidingInvoluntary leakage of urine immediately after voiding
Refers to post toilet trained girls who dribble soon after Refers to post toilet trained girls who dribble soon after standing up after a void and otherwise normal with no standing up after a void and otherwise normal with no other urinary symptomsother urinary symptoms
May be result of May be result of vesicovaginal refluxvesicovaginal reflux where urine is where urine is trapped in the vagina during voiding & once the child trapped in the vagina during voiding & once the child stands, the urine dribble outstands, the urine dribble out
When in doubt, can be confirmed by MCUGWhen in doubt, can be confirmed by MCUG
Harmless, tends to resolve with ageHarmless, tends to resolve with age
Child may be taught to empty her vagina by simply Child may be taught to empty her vagina by simply voiding with her thigh apart & leaning forward after voiding with her thigh apart & leaning forward after voiding before getting upvoiding before getting up
Dysfunctional Elimination Syndrome, Dysfunctional Elimination Syndrome, Constipation, & Bladder Dysfunction Constipation, & Bladder Dysfunction
DES refers to broad spectrum of functional DES refers to broad spectrum of functional disturbances that may affect the urinary tract disturbances that may affect the urinary tract including that of functional bowel disturbances including that of functional bowel disturbances
The close proximity of the rectum to posterior The close proximity of the rectum to posterior bladder wall make it possible that bladder wall make it possible that gross distension of the rectum by impacted feces can gross distension of the rectum by impacted feces can
result in mechanical compression of the bladder & result in mechanical compression of the bladder &
bladder neck leading to urinary obstructionbladder neck leading to urinary obstruction
Classified as : Classified as :
Functional disorder of fillingFunctional disorder of filling Overactive, overdisteded, insensate bladder, may be Overactive, overdisteded, insensate bladder, may be
associated with fecal impaction or rectal distension with associated with fecal impaction or rectal distension with infrequent call to stoolinfrequent call to stool
Functional disorder of emptyingFunctional disorder of emptying Over recruitment of pelvic floor activity during voiding Over recruitment of pelvic floor activity during voiding
causing interrupted / incomplete emptying, with defecation causing interrupted / incomplete emptying, with defecation difficulties due to nonrelaxation of puborectalis or pain on difficulties due to nonrelaxation of puborectalis or pain on defecationdefecation
DES influenced the clinical outcome of ureteric DES influenced the clinical outcome of ureteric reimplantation surgery for VURreimplantation surgery for VUR
Children with constipation had the highest likehood of Children with constipation had the highest likehood of developing breakthrough UTI & requires surgerydeveloping breakthrough UTI & requires surgery
DES had an adverse effect on the rate of spontaneous DES had an adverse effect on the rate of spontaneous reflux resolution requiring an average reflux resolution requiring an average 1.6 years1.6 years longer to longer to outgrow reflux than in children without DESoutgrow reflux than in children without DES
After successful Rx of constipationAfter successful Rx of constipation 89%89% of those with daytime incontinence and of those with daytime incontinence and 63%63% of nighttime of nighttime
incontinence became dry incontinence became dry Loening-Baucke et al (1997)Loening-Baucke et al (1997)
Management of the underlying dysfunction should be Management of the underlying dysfunction should be
given priority in the treatment protocol of children with given priority in the treatment protocol of children with conditions such as VUR / incontinence / UTI bsc conditions such as VUR / incontinence / UTI bsc successful Rx may significantly improve outcomesuccessful Rx may significantly improve outcome
Relationship Betw. Bladder Sphincter Relationship Betw. Bladder Sphincter Dysfunction, VUR, & Recurrent UTI Dysfunction, VUR, & Recurrent UTI
Impairment in the function of lower tract often Impairment in the function of lower tract often coexists with recurrent UTI & VUR without coexists with recurrent UTI & VUR without neurologic pathologyneurologic pathology
The most common abnormalities of lower tract The most common abnormalities of lower tract coexist with VUR are coexist with VUR are Detrusor overactivityDetrusor overactivity Uncoordinated detrusor sphincter during voidingUncoordinated detrusor sphincter during voiding
Reflux may be worsened by detrusor instabilityReflux may be worsened by detrusor instability
Studies showed that infants with UTI & VUR Studies showed that infants with UTI & VUR have high prevalence of high voiding detrusor have high prevalence of high voiding detrusor pressurepressure
MaleMale refluxers have higher maximum detrusor refluxers have higher maximum detrusor pressure > femalepressure > female May be due to high urethral resistance of the longer May be due to high urethral resistance of the longer
male urethra and smaller urethral meatus with male urethra and smaller urethral meatus with anatomic difference in the external urethral sphincteranatomic difference in the external urethral sphincter
Spontaneous resolution of VUR may be delayed Spontaneous resolution of VUR may be delayed in presence of abnormal dynamics of the in presence of abnormal dynamics of the bladderbladder
Successful Rx of underlying bladder dysfunction Successful Rx of underlying bladder dysfunction result in marked increase in the rate of result in marked increase in the rate of spontaneous resolution of reflux & recurrent UTIspontaneous resolution of reflux & recurrent UTI
Evaluation of Non-Neurogenic Evaluation of Non-Neurogenic Bladder Sphincter Dysfunction Bladder Sphincter Dysfunction
HistoryHistory Majority present after toilet training with symptoms of Majority present after toilet training with symptoms of
nighttime / daytime urinary incontinence or both nighttime / daytime urinary incontinence or both May present earlier with UTI or VURMay present earlier with UTI or VUR Hx should include questions to exclude neurologic & Hx should include questions to exclude neurologic &
congenital abnormalitiescongenital abnormalities Bowel dysfunction can coexist in the form of Bowel dysfunction can coexist in the form of
encorpresis, constipation and fecal impactionencorpresis, constipation and fecal impaction Urinary Hx should include symptoms of storage & Urinary Hx should include symptoms of storage &
voiding of urinevoiding of urine
Physical examination:Physical examination: Usually normalUsually normal Careful examination is required Careful examination is required Occasionally, palpable bladder may be foundOccasionally, palpable bladder may be found External genitalia examinationExternal genitalia examination Abnormalities of lower spineAbnormalities of lower spine
Neural tubal defectNeural tubal defect Asymmetrical gluteal foldsAsymmetrical gluteal folds Hairy patchHairy patch Dermovascular malformationDermovascular malformation Lipomatous abnormality of sacral regionLipomatous abnormality of sacral region
Rectal exam. may reveal impacted stoolRectal exam. may reveal impacted stool
LaboratoryLaboratory
Not routinely requiredNot routinely required
Urine analysis may be performed to R/O Urine analysis may be performed to R/O bacteruria & glucosuriabacteruria & glucosuria
Serum & urine osmolarity may be looked in case Serum & urine osmolarity may be looked in case of nocturnal enuresis of nocturnal enuresis
UltrasoundUltrasound
11stst line investigation line investigation
Simple, reliable, available, & noninvasive toolSimple, reliable, available, & noninvasive tool
Provides anatomical & functional problemsProvides anatomical & functional problems
Recently used to measure bladder parameters used in Recently used to measure bladder parameters used in calculating bladder volume & wall thickness index (BVWI)calculating bladder volume & wall thickness index (BVWI)
BVWI classified into normal / thick / thinBVWI classified into normal / thick / thin
Studies showed these classifications corresponded Studies showed these classifications corresponded closely to CMG findings of bladder dysfunctionsclosely to CMG findings of bladder dysfunctions
This classification can act as reliable tool to guide for This classification can act as reliable tool to guide for further invasive investigationsfurther invasive investigations
Other imaging studiesOther imaging studies:: Radiologic examination of the spine may be Radiologic examination of the spine may be
necessary to exclude neuologic causesnecessary to exclude neuologic causes MCUGMCUG may be needed to R/O VUR & to assess may be needed to R/O VUR & to assess
the status of the urethrathe status of the urethra
Urodynamics studiesUrodynamics studies:: To describe the physiologic parameters To describe the physiologic parameters
involved in bladder mechanics during filling & involved in bladder mechanics during filling & voiding voiding
Urodynamics (cont.)Urodynamics (cont.)
UroflowUroflow
In children, normal flow rate are different from adults In children, normal flow rate are different from adults
Usually there is poor correlation betw. Qmax & outflow Usually there is poor correlation betw. Qmax & outflow resistanceresistance
Bcs the detrusor is able to exert much stronger contractions to Bcs the detrusor is able to exert much stronger contractions to counteract any increased resistancecounteract any increased resistance
Pattern of flow curve is importantPattern of flow curve is important
Patterns of uroflow curve:Patterns of uroflow curve:
Bell shapeBell shape : normal : normal Tower shapeTower shape : produced by explosive voiding : produced by explosive voiding
contractions which is seen in overactive bladdercontractions which is seen in overactive bladder Low plateauLow plateau : representative of outlet obstruction : representative of outlet obstruction Staccato patternStaccato pattern : seen with sphincteric overactivity : seen with sphincteric overactivity
during voiding with peak and throughs throughtout during voiding with peak and throughs throughtout voiding voiding
Interrupted voidingInterrupted voiding : seen in a contractile or : seen in a contractile or underactive bladder underactive bladder
Urodynamics (cont.)Urodynamics (cont.)
Conventional fill urodynamic studiesConventional fill urodynamic studies Bladder catheter introduced transurethrally or Bladder catheter introduced transurethrally or
suprapubicallysuprapubically The use of SPC has been suggested as a better The use of SPC has been suggested as a better
alternative to transurethral catheterization alternative to transurethral catheterization
Natural fill urodynamic studiesNatural fill urodynamic studies The child is asked to drink to allow the bladder to fill up on its The child is asked to drink to allow the bladder to fill up on its
own rateown rate Artificial filling may inhibit the detrusor response and attenuate Artificial filling may inhibit the detrusor response and attenuate
its maximum contractile potential, making detrusor instability its maximum contractile potential, making detrusor instability less pronounced & undetectableless pronounced & undetectable
Natural fill cystometry is the preferred technique in childrenNatural fill cystometry is the preferred technique in children The combined use of artificial & natural filling CMG is helpful to The combined use of artificial & natural filling CMG is helpful to
accurately delineate the underlying bladder dysfunctionaccurately delineate the underlying bladder dysfunction
Ambulatory urodynamic studiesAmbulatory urodynamic studies
Management of Non-Neuropathic Management of Non-Neuropathic Bladder-Sphincter DysfunctionBladder-Sphincter Dysfunction
Behavior Modification & standard UrotherapyBehavior Modification & standard Urotherapy UrotherapyUrotherapy is a nonpharmacologic nonsurgical is a nonpharmacologic nonsurgical
combination of cognitive, behavioural, & physical therapy combination of cognitive, behavioural, & physical therapy to normalize micturiton pattern & prevent functional to normalize micturiton pattern & prevent functional disturbances of lower tractdisturbances of lower tract
Children & parents education on proper voiding Children & parents education on proper voiding mechanicsmechanics
Instructions how and when to voidInstructions how and when to void
Teaching children correct positions during voidingTeaching children correct positions during voiding
Behavior Modification & standard Urotherapy Behavior Modification & standard Urotherapy (cont.)(cont.)
Teaching how to relax the pelvic floor and Teaching how to relax the pelvic floor and avoid strainingavoid straining
Modification of drinking and voiding habits to Modification of drinking and voiding habits to include proper hydration with timed voidinginclude proper hydration with timed voiding
Assessment of their bowel function Assessment of their bowel function
Urotherapy. Pelvic floor rehabilitation with real Urotherapy. Pelvic floor rehabilitation with real time biofeedback monitoringtime biofeedback monitoring
Biofeedback and pelvic floor rehabilitationBiofeedback and pelvic floor rehabilitation
Biofeedback is based on the concept of building self Biofeedback is based on the concept of building self perception on detrusor contractions and pelvic floor perception on detrusor contractions and pelvic floor relaxation in the ptrelaxation in the pt
By combining uroflow with real time monitoring, child is By combining uroflow with real time monitoring, child is able to see how well he / she is voiding able to see how well he / she is voiding
Biofeedback is proven to be highly effective either on Biofeedback is proven to be highly effective either on its own or in combination with standard urotherapyits own or in combination with standard urotherapy
Urotherapy. Biofeedback with real time uroflowmetryUrotherapy. Biofeedback with real time uroflowmetry
NeuromodulationNeuromodulation
Recent studies reported that transcutaneous Recent studies reported that transcutaneous electrical nerve stimulation (TENS) is simple, electrical nerve stimulation (TENS) is simple, cost effective, noninvasive treatment modalitycost effective, noninvasive treatment modality
The use of low frequency electrical current to The use of low frequency electrical current to
inhibit detrusor activity in adults is commoninhibit detrusor activity in adults is common Appears to modulate excitatory & inhibitory Appears to modulate excitatory & inhibitory
components of bladder control components of bladder control
Bowel managementBowel management
Principles include rectal emptying of impacted stool and Principles include rectal emptying of impacted stool and maintenance of regular soft stoolsmaintenance of regular soft stools
Oral laxatives or rectal enemasOral laxatives or rectal enemas
Dietary modificationDietary modification
Correct toilet posture & correct recruitment of Correct toilet posture & correct recruitment of abdominal muscles in the defecation processabdominal muscles in the defecation process
Parental education Parental education
MedicationsMedications Antimuscarinic agentsAntimuscarinic agents
These agents are the gold standard in Rx of These agents are the gold standard in Rx of overactive bladderoveractive bladder
Muscarinic receptors are found in detrusor muscleMuscarinic receptors are found in detrusor muscle
Bladder contractions are initiated by stimulation of Bladder contractions are initiated by stimulation of these receptors with the release of Ach from these receptors with the release of Ach from cholinergic n.cholinergic n.
Main action of antimuscarinic drugs on M1 & M3 Main action of antimuscarinic drugs on M1 & M3 receptor subtypes, thought to be responsible of receptor subtypes, thought to be responsible of detrusor overactivitydetrusor overactivity
Antimuscarinic agents (cont.)Antimuscarinic agents (cont.)
Antimuscarinic, such as Antimuscarinic, such as OxybutyninOxybutynin, act by , act by reducing the frequency & intensity of involuntary reducing the frequency & intensity of involuntary contractions causing increase in functional bladder contractions causing increase in functional bladder capacitycapacity
The nonselective pattern of activity and penetration The nonselective pattern of activity and penetration of BBB are known to induce systemic & central S/E of BBB are known to induce systemic & central S/E
Alpha adrenergic blockersAlpha adrenergic blockers The density of the noradrenergic nerves The density of the noradrenergic nerves
increases markedly toward the bladder neck increases markedly toward the bladder neck particularly in particularly in malesmales
The normal response to NE is relaxation & The normal response to NE is relaxation & contraction of the bladder neckcontraction of the bladder neck
Alpha blockers used in pts with Alpha blockers used in pts with evidence of evidence of
bladder neck dysfunctionbladder neck dysfunction for relaxation of for relaxation of bladder neck bladder neck
Other medicationsOther medications Tricyclic antidepressentsTricyclic antidepressents
E.g. E.g. impiramineimpiramine
Effective in increasing urine storage by decreasing Effective in increasing urine storage by decreasing detrusor contractility & increasing outlet resistancedetrusor contractility & increasing outlet resistance
Precise mechanism is not clearPrecise mechanism is not clear
Possible effect on bladder by inhibition of NE Possible effect on bladder by inhibition of NE reuptake, producing alpha adrenergic stimulationreuptake, producing alpha adrenergic stimulation
Associated with high S/E Associated with high S/E
Beta-Adrenergic agonists Beta-Adrenergic agonists Can cause significant increase in bladder Can cause significant increase in bladder
capacity capacity Bt can also cause significant CVS S/EBt can also cause significant CVS S/E
Parasympathicomimetics / Ca Parasympathicomimetics / Ca antagonists / K Ch. Openers / PG antagonists / K Ch. Openers / PG inhibitorsinhibitors Rarely used in children due to unfavorable S/E Rarely used in children due to unfavorable S/E
or to lack of proven efficacyor to lack of proven efficacy
Clean intermittent CatheterizationClean intermittent Catheterization
Necessary in pts with decompensated bladders or lazy Necessary in pts with decompensated bladders or lazy bladder syndromebladder syndrome
Regular emptying of the bladder to achieve low Regular emptying of the bladder to achieve low pressure emptying which improves detrusor pressure emptying which improves detrusor contractility & bladder emptying functioncontractility & bladder emptying function
Some of these children may be able to eventually be Some of these children may be able to eventually be weaned from use of this procedure weaned from use of this procedure
SurgerySurgery Indicated when conservative management with Indicated when conservative management with
nonpharmacologic & pharmacologic Rx failsnonpharmacologic & pharmacologic Rx fails
Bladder augmentation may be performed to Bladder augmentation may be performed to produce low pressure system with increased produce low pressure system with increased bladder capacity bladder capacity
Augmentation using intestinal segments such Augmentation using intestinal segments such as colon / ileum / stomachas colon / ileum / stomach
Augmentation has its metabolic complications Augmentation has its metabolic complications
Surgery (cont.)Surgery (cont.)
Surgical means has been employed to reduce Surgical means has been employed to reduce urethral / sphincteric pressure as alternative to urethral / sphincteric pressure as alternative to alpha blockersalpha blockers
Ballon dilatation of bladder neck & botulinum A Ballon dilatation of bladder neck & botulinum A toxin injection into the sphinctertoxin injection into the sphincter has been used has been used Requires repeated attempts Requires repeated attempts ? Long term effect & efficacy ? Long term effect & efficacy
Neuropathic Neuropathic Dysfunction Dysfunction
of of Lower Urinary Tract Lower Urinary Tract
Neuropathic Dysfunction of Lower Urinary TractNeuropathic Dysfunction of Lower Urinary Tract
Neurospinal dysraphismsNeurospinal dysraphisms MyelodysplasiaMyelodysplasia Lipomeningocele & other spinal dysraphismsLipomeningocele & other spinal dysraphisms
Sacral agenesis Sacral agenesis Central nervous system insultsCentral nervous system insults
Cerebral palsyCerebral palsy
Traumatic injuries to the spineTraumatic injuries to the spine
Neurospinal dysraphismsNeurospinal dysraphisms
MyelodysplasiaMyelodysplasia The most common cause of neurogenic The most common cause of neurogenic
bladder dysfunction in childrenbladder dysfunction in children Formation of spinal cord & vertebral column Formation of spinal cord & vertebral column
begins at 18begins at 18thth day of gestation day of gestation Closure of canal proceeds in caudal direction Closure of canal proceeds in caudal direction Closure complete at 35 daysClosure complete at 35 days ? Mechanism that results in closure and wt ? Mechanism that results in closure and wt
produces dysraphism produces dysraphism
Incidence reported 1 / 1000 birthsIncidence reported 1 / 1000 births Incidence increases with more than one member Incidence increases with more than one member
affectedaffected The medical Research Council Vitamin Study The medical Research Council Vitamin Study
Group recommends that women of childbearing Group recommends that women of childbearing age take 4mg/d of folic acid beginning at least age take 4mg/d of folic acid beginning at least 2/12 before pregnancy2/12 before pregnancy
Folate deficiency can lead to myelodysplastic Folate deficiency can lead to myelodysplastic abnormality abnormality
Relationship Incidence
General population 0.7-1.0
Mother with one affected child 20-50
Mother with two affected children 100
Patient with myelodysplasia 40
Mother older than 35 years 30
Sister of mother with affected child 10
Sister of father with affected child 3
Nephew who is affected 2
Myelodysplasia Myelodysplasia various abnormal conditions of the vertebral column various abnormal conditions of the vertebral column
that affect spinal cord functionthat affect spinal cord function Meningocele Meningocele
Occurs when just the meninges ( no neual elements ) Occurs when just the meninges ( no neual elements ) extend beyond the confines of vertebral canalextend beyond the confines of vertebral canal
Myelomeningocele Myelomeningocele Neural tissue, either nerve root or portions of spinal Neural tissue, either nerve root or portions of spinal
cord has evaginated with the meningocelecord has evaginated with the meningocele LipomyelomeningoceleLipomyelomeningocele
Fatty tissue has developed with the cord structures and both Fatty tissue has developed with the cord structures and both extend with the protruding sac extend with the protruding sac
Myelomeningocele accounts for > 90% of all open Myelomeningocele accounts for > 90% of all open spinal dysraphic statesspinal dysraphic states
Most spinal defects at lumber vertebraeMost spinal defects at lumber vertebrae
Location Incidence (%)
Cervical-high thoracic 2
Low thoracic 5
Lumbar 26
Lumbosacral 47
Sacral 20
Usually, the meningocele is made of flimsy covering Usually, the meningocele is made of flimsy covering of transparent tissueof transparent tissue
It may be opened with CSF leakIt may be opened with CSF leak For this reason, urgent repair is necessary For this reason, urgent repair is necessary Sterile precautions showed be applied after birth till time of Sterile precautions showed be applied after birth till time of
repairrepair
85 %85 % associated with Arnold-Chiari malformation associated with Arnold-Chiari malformation Cerebral tonsils herniate down through the foramen Cerebral tonsils herniate down through the foramen
magnummagnum Herniation causes obstruction of the 4Herniation causes obstruction of the 4thth ventricle & ventricle &
preventing the CSF from entering the subarchnoid spacepreventing the CSF from entering the subarchnoid space
ItIt’’s possible that leakage of CSF from the open spinal s possible that leakage of CSF from the open spinal column accounts for herniation of posterior brain stem down column accounts for herniation of posterior brain stem down the foramen magnum hydrocephalusthe foramen magnum hydrocephalus
Neurologic lesion produced by this condition variesNeurologic lesion produced by this condition varies Depending on what neural element have everted with the Depending on what neural element have everted with the
meningocele sacmeningocele sac
The bony vertebral level often provides little or no clue to The bony vertebral level often provides little or no clue to the exact neurologic lesion producedthe exact neurologic lesion produced
10%10% of newborn with MM exhibit no abnormality in CMG of newborn with MM exhibit no abnormality in CMG
24%24% of children with normal lower tract at birth, develop of children with normal lower tract at birth, develop upper motor neuron changes over time upper motor neuron changes over time
Newborn assessmentNewborn assessment Renal U/SRenal U/S with measurement of post void residual is performed as with measurement of post void residual is performed as
early as possible after birth early as possible after birth Before / after closure of spinal defect Before / after closure of spinal defect
CMGCMG is delayed until it is delayed until it’’s safe to transport the child to the s safe to transport the child to the urodynamic suit and place him on the back or side for the urodynamic suit and place him on the back or side for the testtest
If the infant cannot empty the bladder after spontaneous void If the infant cannot empty the bladder after spontaneous void or with Crede maneuver, or with Crede maneuver, CICCIC is begun even before CMG is is begun even before CMG is donedone
If If Crede maneuverCrede maneuver is effective in emptying the bladder, it is effective in emptying the bladder, it’’s s performed at regular basis instead of CIC until lower tract is performed at regular basis instead of CIC until lower tract is
fully evaluatedfully evaluated
The normal bladder capacity in newborn is The normal bladder capacity in newborn is 10-15ml10-15ml Residual urine of <5 ml is acceptableResidual urine of <5 ml is acceptable
Other tests should be performed Other tests should be performed UrinanalysisUrinanalysis & & cultureculture Serum Serum creatininecreatinine Careful Careful neurologic examination of LLneurologic examination of LL
Once spinal closure has healed sufficientlyOnce spinal closure has healed sufficiently Renal U/S & renal scanRenal U/S & renal scan for reassessment of upper tract for reassessment of upper tract VCUGVCUG CMGCMG
FindingsFindings 15-20%15-20% of newborns have abnormal urinary tract on of newborns have abnormal urinary tract on
radiological exam. when first evaluatedradiological exam. when first evaluated 3%3% have hydro 2ndry to spinal shock, probably from spinal canal have hydro 2ndry to spinal shock, probably from spinal canal
closureclosure 15%15% have abnormalities that develop in utero as result of abnormal have abnormalities that develop in utero as result of abnormal
lower tract due to outlet obstructionlower tract due to outlet obstruction
CMG in newborn showed that CMG in newborn showed that 63%63% have bladder have bladder contractionscontractions
A combination of bladder contractility & external sphincter A combination of bladder contractility & external sphincter activity results in activity results in synergic synergic (26%)(26%) Dyssynergic with / out poor detrusor complianceDyssynergic with / out poor detrusor compliance (37%) (37%) Complete denervation Complete denervation (36%)(36%)
This categorization of lower tract function has been This categorization of lower tract function has been useful bcs it reveals useful bcs it reveals Which child is at risk for urinary tract changesWhich child is at risk for urinary tract changes Who should be treated prophylacticallyWho should be treated prophylactically Who needs close surveillenceWho needs close surveillence Who can be monitored at great intervalsWho can be monitored at great intervals
It appears that outlet obstruction is a major It appears that outlet obstruction is a major contributor to the development of urinary tract contributor to the development of urinary tract deteriorationdeterioration
RecommendationsRecommendations
Expectant management revealed that infants with outlet Expectant management revealed that infants with outlet obst. in the form of DSD are at considerable risk for urinary obst. in the form of DSD are at considerable risk for urinary tract deteriorationtract deterioration
These pts should be treated prophylacticallyThese pts should be treated prophylactically
CIC alone OR in combination with anticholinergic when CIC alone OR in combination with anticholinergic when Detrusor filling pressures > 40 cm H2ODetrusor filling pressures > 40 cm H2O Voiding pressures > 80-100 cm H2OVoiding pressures > 80-100 cm H2O Resulted in an incidence of urinary tract deterioration Resulted in an incidence of urinary tract deterioration
of only 8-10% of only 8-10%
Oxybutynin hydrochlorideOxybutynin hydrochloride administered in a administered in a dose of 1 mg / year of age BID dose of 1 mg / year of age BID
In neonates & children < 1year, dose < 1mg & In neonates & children < 1year, dose < 1mg & increase proportionally as the age reaches 1 yearincrease proportionally as the age reaches 1 year
On rare occasions when overactive or poor On rare occasions when overactive or poor compliant bladder fails to respond, augmentation compliant bladder fails to respond, augmentation cystoplasty may be neededcystoplasty may be needed
Neurologic findings & recommendationsNeurologic findings & recommendations
Neurologic lesion in myelodysplasia is a dynamic Neurologic lesion in myelodysplasia is a dynamic disease process in which changes take place disease process in which changes take place throughout childhoodthroughout childhood
When a change is noted on neurologic, orthopedic, or When a change is noted on neurologic, orthopedic, or urodynamic assessment, radiologic investigation of the urodynamic assessment, radiologic investigation of the CNS often revealsCNS often reveals Tethering of the spinal cord Tethering of the spinal cord A syrinx or hydromyelia of the cordA syrinx or hydromyelia of the cord Increased intracranial pressure due shunt malfunctionIncreased intracranial pressure due shunt malfunction Partial herniation of the brain stem and cerebellem Partial herniation of the brain stem and cerebellem
MRIMRI is the test of choice as it reveals anatomic is the test of choice as it reveals anatomic details of the spinal column & CNSdetails of the spinal column & CNS
Sequential urodynamicsSequential urodynamics testing on yearly basis testing on yearly basis beginning in the newborn period and continuing beginning in the newborn period and continuing until until 5 yrs old 5 yrs old
It may be necessary to repeat CMG if upper tract It may be necessary to repeat CMG if upper tract dilates 2ndry to impaired drainage from a poor dilates 2ndry to impaired drainage from a poor compliant detrusor compliant detrusor
Sphincter Activity Recommended Tests Frequency
Intact-synergic Postvoid residual volume q 4 mo
IVP or renal echo q 12 mo
UDS q 12 mo
Intact-dyssynergic† IVP or renal echo q 12 mo
UDS q 12 mo
VCUG or RNC‡ q 12 mo
Partial denervation Postvoid residual volume q 4 mo
IVP or renal echo q 12 mo
UDS§ q 12 mo
VCUG or RNC‡ q 12 mo
Complete denervation Postvoid residual volume q 6 mo
Renal echo q 12 mo
Surveillance in infants with myelodysplasia Surveillance in infants with myelodysplasia
Management of VURManagement of VUR
VUR occurs in VUR occurs in 3-5 %3-5 % of newborns with of newborns with myelodysplasiamyelodysplasia
Usually associated with poor detrusor Usually associated with poor detrusor compliance, detrusor overactivity or DSDcompliance, detrusor overactivity or DSD
If untreated, incidence of VUR in these infants at If untreated, incidence of VUR in these infants at risk increases with time until risk increases with time until 30-40%30-40% affected by affected by 5 years of age5 years of age
VUR grade 1-3 who void spontaneously or who have VUR grade 1-3 who void spontaneously or who have complete lesions with little or no outlet resistance with complete lesions with little or no outlet resistance with good bladder emptyinggood bladder emptying Prophylactic Abx onlyProphylactic Abx only
High grade refluxHigh grade reflux CIC CIC to ensure complete emptyingto ensure complete emptying
Children who cannot empty their bladder spontaneously Children who cannot empty their bladder spontaneously regardless of the graderegardless of the grade Treated with Treated with CICCIC
Children with poor detrusor compliance with / out hydroChildren with poor detrusor compliance with / out hydro To add To add anticholenergic drugsanticholenergic drugs to lower intravesical pressure and to lower intravesical pressure and
ensure adequate upper tract decompensation ensure adequate upper tract decompensation
Bacteriuria occurs in 56% of children with CIC & Bacteriuria occurs in 56% of children with CIC & not harmfulnot harmful
Except in presence of high grade reflux Except in presence of high grade reflux
Symptomatic UTI & renal scarring rarely occurs in lesser grades of Symptomatic UTI & renal scarring rarely occurs in lesser grades of refluxreflux
Crede maneuver should be avoided in children with Crede maneuver should be avoided in children with refluxreflux, especially those with reactive external sphincter, especially those with reactive external sphincter
In results in a reflex response in external sphincter that increases In results in a reflex response in external sphincter that increases urethral resistance & raises the pressure needed to expel urine from urethral resistance & raises the pressure needed to expel urine from bladderbladder
Aggravating the degree of reflux & accentuating its watter hammer Aggravating the degree of reflux & accentuating its watter hammer effect on kidneys effect on kidneys
VesicostomyVesicostomy drainage rarely required today drainage rarely required today but indicated in but indicated in
Infants who has severe reflux that CIC & Infants who has severe reflux that CIC & anticholenergic fail to improve upper tract anticholenergic fail to improve upper tract drainage drainage
Parents cannot adapt to catheterization programParents cannot adapt to catheterization program
Who are not good candidates for augmentation Who are not good candidates for augmentation cystoplastycystoplasty
The indications of antireflux surgery are not very The indications of antireflux surgery are not very different from those with normal bladderdifferent from those with normal bladder
Recurrent symptomatic UTI while receiving Recurrent symptomatic UTI while receiving adequate Abx therapy & appropriate CIC techniquesadequate Abx therapy & appropriate CIC techniques
Persistent hydro despite effective emptying of the Persistent hydro despite effective emptying of the bladder & lowering of intravesical pressurebladder & lowering of intravesical pressure
Severe reflux with anatomic abnormality at the UVJSevere reflux with anatomic abnormality at the UVJ
Reflux that persists into puberty Reflux that persists into puberty
Presence of reflux in any child undergoing surgery Presence of reflux in any child undergoing surgery to increase outlet resistanceto increase outlet resistance
Antireflux surgery can be very effective in children with Antireflux surgery can be very effective in children with neurogenic bladder dysfunction as long as itneurogenic bladder dysfunction as long as it’’s combined s combined with measures to ensure complete bladder emptying with measures to ensure complete bladder emptying
Since the advent of CIC, success rate for antireflux surgery Since the advent of CIC, success rate for antireflux surgery approached 95 %approached 95 %
The endoscopic injection of Deflux has altered the The endoscopic injection of Deflux has altered the management of reflux in children with MMmanagement of reflux in children with MM
Its long term effects are yet to be appreciated Its long term effects are yet to be appreciated
ContinenceContinence Initial attempts at achieving continence include Initial attempts at achieving continence include
CIC & drug therapy to maintain low intravesical CIC & drug therapy to maintain low intravesical pressure pressure
DrugsDrugs Glycopyrrolate (Robinol)Glycopyrrolate (Robinol) : most potent oral : most potent oral
anticholenergic drug available today same other S/Eanticholenergic drug available today same other S/E Tolteradine (Detrol):Tolteradine (Detrol): newly approved, equally effective newly approved, equally effective
as oxybutynin with fewer S/Eas oxybutynin with fewer S/E Hyoscyamine (levsin)Hyoscyamine (levsin) : potency less, fewer S/E : potency less, fewer S/E Intravesical oxybutyninIntravesical oxybutynin : fewer S/E compared to oral : fewer S/E compared to oral
Botulinum roxin ABotulinum roxin A injected into the detrusor injected into the detrusor muscle has been effectively used muscle has been effectively used Paralyzes the bladder for varying period of time Paralyzes the bladder for varying period of time May become viable Rx in the futureMay become viable Rx in the future
Alpha sympathomimetic agentsAlpha sympathomimetic agents If CMG reveals that urethral resistance is inadequate to If CMG reveals that urethral resistance is inadequate to
maintain continencemaintain continence PhenylpropanolaminePhenylpropanolamine is the most effective agent is the most effective agent
SurgerySurgery
Viable option when drug therapy fails to achieve Viable option when drug therapy fails to achieve continencecontinence
Generally intervention is delayed till 5 yrs oldGenerally intervention is delayed till 5 yrs old
Enterocystoplasty using sigmoid, cecum & small Enterocystoplasty using sigmoid, cecum & small intestineintestine
If bladder neck or urethral resistance is insufficient to If bladder neck or urethral resistance is insufficient to allow adequate storage, bladder neck reconstruction is allow adequate storage, bladder neck reconstruction is consideredconsidered
Currently, Deflux injections at the bladder neck Currently, Deflux injections at the bladder neck are being advocated are being advocated enhances outlet resistanceenhances outlet resistance Alternative to bladder neck reconstructionAlternative to bladder neck reconstruction No long term dataNo long term data
Continent urinary diversion with closure of Continent urinary diversion with closure of bladder neck has been used to provide better bladder neck has been used to provide better quality of life for intractable urethral quality of life for intractable urethral incompetenceincompetence
SexualitySexuality
In several studies, In several studies, 28-40%28-40% of MM had one or more sexual of MM had one or more sexual encountersencounters
All of them had a desire to marry & to bear childrenAll of them had a desire to marry & to bear children
In one study, In one study, 72%72% of male subjects have erection, 2/3 of male subjects have erection, 2/3 were able to ejeculatewere able to ejeculate
Other studies revealed Other studies revealed 70-80%70-80% of MM women were able to of MM women were able to become pregnantbecome pregnant
The degree of sexuality is inversely proportional The degree of sexuality is inversely proportional to the level of neuologic dysfunctionto the level of neuologic dysfunction
Boys reach puberty at age similar to normal boysBoys reach puberty at age similar to normal boys
In MM Girls, breast development & menarche In MM Girls, breast development & menarche start 2 yrs earlier than usual normal girlsstart 2 yrs earlier than usual normal girls
Bowel functionBowel function The external anal sphincter in innervated by the same The external anal sphincter in innervated by the same
nerves that modulate the external urethral sphincternerves that modulate the external urethral sphincter
The internal anal sphincter is influenced by more The internal anal sphincter is influenced by more proximal n. from sympathatic nervous systemproximal n. from sympathatic nervous system
The internal sphincter reflexively relaxes in response to The internal sphincter reflexively relaxes in response to anal distensionanal distension
Consequently, bowel incontinence is frequently Consequently, bowel incontinence is frequently unpredictableunpredictable
Incontinence not associated with the attainment of Incontinence not associated with the attainment of urinary incontinenceurinary incontinence
Lipomeningocele & other Lipomeningocele & other Spinal dysraphismSpinal dysraphism
Group of congenital defects that affects the Group of congenital defects that affects the formation of spinal column but formation of spinal column but do not result do not result in open vertebral canalin open vertebral canal
Incidence of lipomeningocele in families Incidence of lipomeningocele in families 0.043%0.043%
Lesion have no obvious outward signsLesion have no obvious outward signs
Lipomeningocele
Intradural lipoma
Diastematomyelia
Tight filum terminale
Dermoid cyst/sinus
Aberrant nerve roots
Anterior sacral meningocele
Cauda equina tumor
Types of occult spinal dysraphisms
>90%>90% have cutaneous abnormalities overlying the have cutaneous abnormalities overlying the spinesspines Small dimpleSmall dimple Skin tag to a tuft of hairSkin tag to a tuft of hair Dermal vascular malformationDermal vascular malformation Very noticeable subcutaneous lipomaVery noticeable subcutaneous lipoma
Asymmetrically curving gluteal cleftAsymmetrically curving gluteal cleft
Careful inspection of the legs may show high arched foot / Careful inspection of the legs may show high arched foot / alterations in the configuration of the toes / discrepancy in alterations in the configuration of the toes / discrepancy in muscle size / shortness / decreased strength in one leg muscle size / shortness / decreased strength in one leg typically the ankle / gait abnormalitytypically the ankle / gait abnormality
Small lipomeningocele Hair patch
Dermal vascular malformation
dimple
Abnormal gluteal cleft
Absent perineal sensation / back pain / Absent perineal sensation / back pain / secondary incontinence may be notedsecondary incontinence may be noted
Abnormal lower tract function in 40-90%Abnormal lower tract function in 40-90% Abnormality increase with ageAbnormality increase with age Difficulty with toilet trainingDifficulty with toilet training Urinary incontinence after period of drynessUrinary incontinence after period of dryness Recurrent UTIRecurrent UTI Fecal soilingFecal soiling
Majority perfectly normal neurologic examinationMajority perfectly normal neurologic examination
CMGCMG
Abnormal lower tract function in 1/3 of infants < 18/12Abnormal lower tract function in 1/3 of infants < 18/12
Most likely abnormality is UMN lesion characterized by Most likely abnormality is UMN lesion characterized by overactive bladder &/or hyperactive sacral reflexesoveractive bladder &/or hyperactive sacral reflexes
Rarely, mild form of DSDRarely, mild form of DSD
LMN signs occurs in 10% onlyLMN signs occurs in 10% only
All children > 3 yrs who have not been operated All children > 3 yrs who have not been operated on OR whom occult dysraphism has been lately on OR whom occult dysraphism has been lately diagnosed diagnosed
Have upper or lower lesion or in combination on Have upper or lower lesion or in combination on CMG (92%) within 2 yrsCMG (92%) within 2 yrs
When observed expectantly from infancy after Dx When observed expectantly from infancy after Dx was made, 58% deteriorate was made, 58% deteriorate
Pathogenesis Pathogenesis
Various occult spinal dysraphic lesions produces different Various occult spinal dysraphic lesions produces different neuologic findings, Reasons:neuologic findings, Reasons:
Compression on the cauda equina or sacral n. roots by Compression on the cauda equina or sacral n. roots by expanding lipoma or lipomeningoceleexpanding lipoma or lipomeningocele
Tension on the cord from tethering 2ndry to differential growth Tension on the cord from tethering 2ndry to differential growth rates in bony vertebrae and neural elements while the lower end rates in bony vertebrae and neural elements while the lower end of the cord is held in place by lipoma or thickened filum terminaleof the cord is held in place by lipoma or thickened filum terminale
Fixation of the split lumbosacral cord by intervertebral bony Fixation of the split lumbosacral cord by intervertebral bony specule or fibrous bandspecule or fibrous band
Normally, the conus medullaris ends just below Normally, the conus medullaris ends just below the L2 vertebraae at birth and recedes upward to the L2 vertebraae at birth and recedes upward to T12 by adulthoodT12 by adulthood
When the cord does not rise or fixed in place bcs When the cord does not rise or fixed in place bcs of these lesions, ischemic injury may ensueof these lesions, ischemic injury may ensue
Correction of the lesion in infancy result not only Correction of the lesion in infancy result not only in stabilization, bt also in improvement in the in stabilization, bt also in improvement in the neurologic pictures in many instancesneurologic pictures in many instances
RecommendationsRecommendations MRI MRI Spinal U/S in children < 3/12Spinal U/S in children < 3/12
At this age, vertebral bones have not ossified At this age, vertebral bones have not ossified Useful screening tool for visualization of spinal canalUseful screening tool for visualization of spinal canal
Currently, most NS advocates laminectomy & Currently, most NS advocates laminectomy & removal of the intraspinal process as completely removal of the intraspinal process as completely as possible, without injuring nerve roots or cord to as possible, without injuring nerve roots or cord to release the tether and prevent further injury from release the tether and prevent further injury from subsequent growth subsequent growth
Sacral AgenesisSacral Agenesis
The absence of part or all of 2 or more lower The absence of part or all of 2 or more lower vertebral bodiesvertebral bodies
Teratogenic factors play a role Teratogenic factors play a role IDDM mothers have 1% of giving birth to a child with IDDM mothers have 1% of giving birth to a child with
sacral agenesissacral agenesis 16% of children with sacral agenesis have a mother 16% of children with sacral agenesis have a mother
with IDDM with IDDM Maternal insulin-Ab complexes noted to cross the Maternal insulin-Ab complexes noted to cross the
placenta placenta
Deletion of chr.7q36 has a role Deletion of chr.7q36 has a role Maternal drug exposure (Minoxidil) reported to Maternal drug exposure (Minoxidil) reported to
cause sacral agenesiscause sacral agenesis Familial cases if sacral agenesis associated with Familial cases if sacral agenesis associated with
Curarino syndrome Curarino syndrome Presacral massPresacral mass Sacral agenesisSacral agenesis Anorectal malformationAnorectal malformation Deletion in chr.7, leading to HLXB9 genetic mutationDeletion in chr.7, leading to HLXB9 genetic mutation
Association with VACTERL syndrome Association with VACTERL syndrome reportedreported
Diagnosis of sacral agenesisDiagnosis of sacral agenesis
Presentation bimodal Presentation bimodal ¾ at early infancy ¾ at early infancy Remainder at 4-5 yrs Remainder at 4-5 yrs
can be Dx parentally due to frequent use of U/Scan be Dx parentally due to frequent use of U/S
If not detected prenatally or at birth, Dx is delayedIf not detected prenatally or at birth, Dx is delayed
May present with failed attempts at toilet training May present with failed attempts at toilet training
Sensation intact & lower limb function is normal Sensation intact & lower limb function is normal usuallyusually
The only clue beside the high index of The only clue beside the high index of suspicion issuspicion is Flattened buttocksFlattened buttocks Low gluteal cleft Low gluteal cleft
Palpation of the coccyx is used to detect Palpation of the coccyx is used to detect absent vertebraeabsent vertebrae
Dx confirmed with a lateral film of lower spineDx confirmed with a lateral film of lower spine
MRI is diagnosticMRI is diagnostic
Gluteal crease is short and seen only inferiorly
FindingsFindings CMGCMG
UMNL - 35%UMNL - 35% LMNL - 40%LMNL - 40% No signs of denervation at all - 25%No signs of denervation at all - 25%
UMNLUMNL Overactive detrusorOveractive detrusor Exaggerated sacral reflexesExaggerated sacral reflexes Absence of voluntary control over sphincter functionAbsence of voluntary control over sphincter function DSD no sphincteric deenervationDSD no sphincteric deenervation Bladder is thick wall (or trabeculated), with closed Bladder is thick wall (or trabeculated), with closed
bladder neck on VCUG or U/Sbladder neck on VCUG or U/S
LMN LMN Acontractile detrusor Acontractile detrusor Partial or complete denervation of external sphincter Partial or complete denervation of external sphincter Diminished or absent sacral reflexesDiminished or absent sacral reflexes Bladder smooth and small with opened bladder neck Bladder smooth and small with opened bladder neck
The presence or absence of bulbocavernous reflex is an The presence or absence of bulbocavernous reflex is an indicator of an UMNL / LMNL respectively indicator of an UMNL / LMNL respectively
UTI present in 75% over timeUTI present in 75% over time
VUR occurs in UMNL (75%) and in LMNL (40%)VUR occurs in UMNL (75%) and in LMNL (40%)
RecommendationsRecommendations
CMG / Ultrasound / VCUG or nuclear CMG / Ultrasound / VCUG or nuclear
cystographycystography
UMNLUMNL Anticholinergic Anticholinergic +/- CIC+/- CIC If anticholinergic ineffective in controlling If anticholinergic ineffective in controlling
overactive detrusor, augmentation cystoplasty overactive detrusor, augmentation cystoplasty required required
LMNLLMNL CIC & alpha sympathomimetics drugs for CIC & alpha sympathomimetics drugs for
those who cannot empty the bladders or stay those who cannot empty the bladders or stay dry between CICdry between CIC
Injection of bulking agents Injection of bulking agents Artificial urinary sphincter implantationArtificial urinary sphincter implantation
+ Rx bowel dysfunction+ Rx bowel dysfunction
Associated conditions with sacral agenesisAssociated conditions with sacral agenesis
Imperforate anusImperforate anus Alone or part of anomalies ( VATER / VACTERL )Alone or part of anomalies ( VATER / VACTERL ) Male > female 1.5:1Male > female 1.5:1 Sacral agenesis occurs with spectrum of hindgut Sacral agenesis occurs with spectrum of hindgut
abnormalities in Currarino syndromeabnormalities in Currarino syndrome Associattion with fistula to the lower tract is commonAssociattion with fistula to the lower tract is common Most common findings on CMGMost common findings on CMG
UMNL with overactive bladderUMNL with overactive bladder And or DSD And or DSD
CNS insultsCNS insults
Cerebral palsyCerebral palsy Nonprogressive injury of the brain occurring in Nonprogressive injury of the brain occurring in
the perinatal period that produces either a the perinatal period that produces either a neuromuscular disability, a specific symptom neuromuscular disability, a specific symptom complex, or cerebral dysfunctioncomplex, or cerebral dysfunction
Incidence is 1.5 / 1000 birthsIncidence is 1.5 / 1000 births Lesions classified according to which Lesions classified according to which
extremities involved and wt kind of dysfunctionextremities involved and wt kind of dysfunction Spastic diplegia is the most commonSpastic diplegia is the most common
Female Male
High High
Anorectal agenesis Anorectal agenesis
With rectovaginal fistula Without fistula
With rectourethral (prostatic) fistula
Rectal atresia Without fistula
Intermediate Rectal atresia
Rectovestibular fistula Intermediate
Rectovaginal fistula Rectovestibular urethral fistula
Anal agenesis without fistula Anal agenesis without fistula
Low Low
Anovestibular fistula Anocutaneous fistula
Anocutaneous fistula Anal stenosis
Anal stenosis Rare malformation
Cloacal malformation
Rare malformation
Most children has total urinary controlMost children has total urinary control
23.5% has persistent incontinence 23.5% has persistent incontinence
The presence of incontinence is often The presence of incontinence is often related to the extent of physical impairmentrelated to the extent of physical impairment
Abnormal bladder & urethral sphincter Abnormal bladder & urethral sphincter
function was found in almost all function was found in almost all
Type Number %
Upper motor neuron lesion 49 86
Mixed upper +lower motor neuron lesion 5 9.5
Incomplete lower motor neuron lesion 1 1.5
No urodynamic lesion 2 3
Type of Lesion No. of Patients
Upper motor neuron
Uninhibited contractions 35
Detrusor sphincter dyssynergy 7
Hyperactive sacral reflexes 6
No voluntary control 3
Small-capacity bladder 2
Hypertonia 2
Lower motor neuron
Excessive polyphasia 5
↑ Amplitude +↑ duration potentials 4
Factor UMN (No. of Patients) LMN (No. of Patients)
Prematurity 10 1
Respiratory distress/arrest/apnea
9 2
Neonatal seizures 5 -
Infection 5 -
Traumatic birth 5 -
Congenital hydrocephalus 3 -
Placenta previa/abruption 2 2
Hypoglycemia ± seizures 2 -
Intracranial hemorrhage 2 -
Cyanosis at birth 1 3
No specific factor noted 15 -
RecommendationsRecommendations
Overactive bladder treated with anticholinergicOveractive bladder treated with anticholinergic
+/- CIC +/- CIC
Dorsal rhizotomy in selected group of children Dorsal rhizotomy in selected group of children who fail to respond to less invasive measureswho fail to respond to less invasive measures
Traumatic injuries to the spineTraumatic injuries to the spine
Rarely encountered in childrenRarely encountered in children
Pts with upper thoracic or cervical lesion are likely Pts with upper thoracic or cervical lesion are likely to have autonomic dysreflexia with spontaneous to have autonomic dysreflexia with spontaneous discharge of alpha1 stimulants during bladder filling discharge of alpha1 stimulants during bladder filling & with contraction of detrusor& with contraction of detrusor
Monitoring of BP & availability of alpha blockers are Monitoring of BP & availability of alpha blockers are mandatory during VCUG or CMG mandatory during VCUG or CMG
ManagementManagement If retention immediately after trauma, foley If retention immediately after trauma, foley
catheter is inserted and kept in place as short catheter is inserted and kept in place as short time as possibletime as possible Until the pt is stable and aseptic CIC can be started Until the pt is stable and aseptic CIC can be started
safely on regular basis safely on regular basis
The goal is balanced voiding at pressures < 40 The goal is balanced voiding at pressures < 40 cmH2O, which reduces the 30% risk of urinary cmH2O, which reduces the 30% risk of urinary tract deterioration seen in poorly managed ptstract deterioration seen in poorly managed pts
If cannot be achieved, CIC is continuedIf cannot be achieved, CIC is continued
Anticholinergic drugs (P.O. or intavesically) Anticholinergic drugs (P.O. or intavesically) added as they are effective in reducing added as they are effective in reducing overactive bladderoveractive bladder
Alternative RxAlternative Rx
External urethral sphincterotomyExternal urethral sphincterotomy Urethral stent placementUrethral stent placement Injection of botulinum A toxin (Botox) into the external Injection of botulinum A toxin (Botox) into the external
sphincter sphincter Continent catheterizable abdominal urinary stoma in Continent catheterizable abdominal urinary stoma in
pts with low cervical or upper thoracic lesions who pts with low cervical or upper thoracic lesions who cannot easily catheterize themselvescannot easily catheterize themselves