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The Overactive Bladder
C. DEFOURNEY, E. VAN LAECKE, A. RAES, J. DEHOORNE,
G. MOSIELLO, M.L. CAPITANUCCI, P. MASTRACCI, M. MOSCONI,
Paediatric Uro- Nephrologic Centre (PUNC), Ghent University
Pediatric Surgery, Urodynamic Unit, Bambino Gesù Children's
LONG TERM OUTCOME OF TREATMENT OF NON NEUROPATHIC
IS STOLLER AFFERENT NERVE STIMULATION (SANS) USEFUL AND
BLADDER SPHINCTER DYSFUNCTION (NNBSD) IN GIRLS
TOLERATED IN CHILDREN AFFECTED BY VESICO-SPHINCTER DYSFUNCTION?
Does the treatment of NNBSD in girls leads to definite cure or do we learn them to live with their dysfunction. In order to answer this
[Background] Stoller afferent nerve stimulation (SANS) has been
question we re-evaluated bladder function in girls treated between
proved to be effective in adults to treat bladder dysfunction (BD),
while in pediatric age experience is still preliminary. Aims of our
[Methods] A validated questionnaire was sent to 83 girls treated
study were to define SANS tolerability in children and to verify its
between January 1995 and July 1996. All girls were considered cured
clinical efficacy in the treatment of BD.
at that time. They underwent urotherapy and pharmacotherapy.
[Methods] 22 patients (12 female and 10 male), mean age 10.5
Bladder function was evaluated by a questionnaire and by a voiding
years, have been treated by SANS. All patients presented lower
urinary tract symptoms (LUTS) refractory to conventional
[Results] 56 of 83 girls responded (67.5%). Mean age at treatment
treatments(bladder training and/or drugs), related to non
was 6.6 years, mean age at evaluation is 12.7 years. Most
neuropathic BD in 17 cases and neurogenic bladder in 5. The first 10
remarkable results are: 75% of girls consider themselves as cured.
patients were previously enrolled to a psychodiagnostic evaluation
30% still suffer some urine loss during day (minimal loss 10%,
performing anxiety-depression test, visual analogue scale (VAS) and
considerable loss 20%), 30% still suffer nighttime incontinence and
questionnaire of pain(QUID). The SANS workup included 12
43% have nocturia, 10 % of patients still have urinary tract infections,
treatments(1/week) and it was carried out using the standard Stoller
20% have urge during day and only 7% of patients are still under
device. Stimu lation was done for 30 minutes with a fixed pulse of
200 ms and 20 Hz frequency, selecting within range of 1 to 10 mA. All
[Conclusion] From these results we conclude that despite treatment
22 patients underwent voiding diary, standard urodynamic and
still 30 % of girls have symptoms related to bladder sphincter
clinical LUTS data evaluation, prior and after SANS.
dysfunction (6 years after successful treatment). Only a minority of
[Results] Regarding tolerability the psycological behaviour was good
them seeks medical help for these problems. It is therefore
in 4/10 patients, VAS score resulted always normal and in all patients
concluded that a lot of girls with NNBSD will carry this condition into
QUID showed a statistically significant decrease in pain perception.
Clinical symptoms improved in 13/22 patients, while iperactive detrusor contractions resolved in five patients and bladder capacity and residual urine improved in two and five patients respectively.
[Conclusions] SANS has been proved to be well tolerated by children
and to be effective in the treatment of BD. Su bjective symptoms ameliorated more than urodynamics patterns.
P. HOEBEKE, C. RENSON, H. DE PAEPE, E. VAN LAECKE, A. RAES, J. VANDE WALLEDept of Pediatric Urology and Urogenital Reconstruction, Ghent University Hospital
A. RAES, E. VAN LAECKE, J. DEHOORNE, P. HOEBEKE,
PELVIC FLOOR SPASMS IN CHILDREN: AN UNKNOWN CONDITION
Departments of paediatric nephrology and urology, UZG GentGhent, Belgium
[Objective] During the last 5 years 21 children are seen for nighttime pelvic pain. These children typical wake up in the middle of the
night with severe lower abdominal pain. During day they suffer urge syndrome. During urodynamic investigation in these children we
Instable detrusor and small bladder syndrome may benefit from a
found extremely high pelvic floor activity as recorded by high
treatment with anticholinergic drugs together with a
urethral pressure. We therefore started pelvic floor relaxation
bladdervolume-training and urotherapy. Because there is a known
co-morbidity between ADHD-syndrome and bladderdysfunction,
[Methods] All children diagnosed with pelvic floor spasms
anticholinergics may also be prescribed in this patients. With
underwent biofeedback pelvic floor relaxation therapy in order to
oxybutynin however we have seen in the past many side-effects.
learn them to counteract pelvic pain due to these spasms. In those
Tolterodine has definitely less side-effects in normal children, but if
girls in whom detrusor hyperactivity was seen on urodynamics
this is also the case in ADHD children is not known. Over the last
concomitant anticholinergic treatment was given (oxybutynin).
years the drug has been prescribed in such patients, despite of the
[Results] Between January 1998 and January 2002 symptomatic
non-registration in children, because of the unacceptable high
pelvic floor spasms were diagnosed in 21 children (19 girls / 2 boys).
frequency of side-effects of oxybutynin.
Pelvic floor relaxation biofeedback was successful for treatment of
[Aim of the study] Comparative study between Tolterodine
this condition in 17 of 21 children. Mean duration of therapy was 3
(2mg/day) and oxybutynin (15mg/day) in children with ADHD.
months (12 weekly sessions) and on long term follow up relaps was
[Methods] Case-control-study. Patients were matched for age and
seen in 3 of 17 successfully treated children. 10 of 17 successfully
sex. Registration of side-effects and effect (during 3 month's)
treated children received anticholinergics.
[Study-population] Age 5-14y, 30 children in each group,
[Conclusion] Pelvic floor spasms in children (which can be secondary
to detrusor hyperactivity) respond well to pelvic floor relaxation
[Results] In the oxybutynin group 12 patients stopped the drug <3m,
because of side-effects (hypernervositas, concentration-disorder). In 9 other patients there was significant worsening of the ADH-symptoms according to the parents. In the detrusitol-group 5 children interrupted therapy < 3 m: 2 for the price, 1 for accomodation-problems, 2 for worsening of ADHD-symptoms. Only in 3 other patients there was suspicion of more ADHD-symptoms. There was no difference in effect on the bladder-function.
The Overactive Bladder
[Conclusion] The side-effect-ratio between Tolterodine and
Central nervous system disorders (81%) were the most common
oxybutynin is definitely in favour of Tolterodine in children with
adverse events, 26.2% showed flushing, 12.2% had abnormal visual
accomodation and 25.2 %had gastrointestinal complaints (constipation, diarrhoea, abdominal pain). Withdrawal of the non-selective antimuscarinic drug resulted in total recovery from adverse events. The remaining 39.6% of group 1 switched to
tolterodine due to lack improvement in micturition variables. Introduction of tolterodine in group I and II caused no serious adverse
D. BATINIC , G. MÜRTZ , F. MARTIN , F. SCHNABEL , T. GRAMATTÈ ,
events. Nine patients (3.5%) reported side effects and only 2
discontinued treatment. There were no reports of flushing,
1Childrens University Hospital Salata, Zagreb, Croatia
hyperpyrexia and troubles of visual accomodation. In group 1 we
observed a mean decrease in urgency by 38.7 %, a mean increase in
3Institute of Clinical Pharmacology, Technical University Dresden
maximal bladdercapacity by 33.6% and the number of incontinence
episodes decreased by 64.8%. In group 2 we observed equivalent values with a significant (p<0.001) change in maximal
EFFICACY AND TOLERABILITY OF PROPIVERINE IN CHILDREN
bladdercapacity (49.7%), incontinence episodes (64.8%) and
SUFFERING FROM OVERACTIVE BLADDER - A DOUBLE-BLIND,
RANDOMIZED, CLINICAL TRIAL VERSUS OXYBUTYNIN AND PLACEBO
[Conclusions] The results of this retrospective analysis suggest that tolterodine is well tolerated in children and offers an effective
[Aim of the study] C omparison of efficacy and tolerability of
treatment for urinary symptoms due to overactive bladder.
propiverine, oxybutynin and placebo in children with overactive
Tolterodine is superior to non-selective antimuscarinic drugs, with
bladder (enuresis diurna, diurna et nocturna, nocturna with urge).
respect to adverse events, allowing more compliance and more
[Methods] 266 children (propiverine 85; oxybutynin 91; placebo 90)
were recruited. 10 mg propiverine b.i.d., 5 mg oxybutynin b.i.d. or placebo were administered during a treatment period of 12 weeks. Efficacy was assessed by micturition diaries. In a subpopulation (n = 100) bladder capacity at maximal urge was evaluated. Tolerability
was assessed by directly questioning of adverse events.
[Results] Efficacy: The weekly enuretic events decreased for
U. GRIGOLEIT , S. LASCHKE , M. SCHULDT , G. MÜRTZ ,
propiverine (pre 11.2; post 6.4) and oxybutynin (pre 10.9; post 6.3).
Due to placebo effects (pre 11.6; post 7.5) no significanct treatment
1Department of Urology, Berufsgenossenschaftliche Unfallklinik,
differences resulted. However, bladder capacity at maximal urge
increased significantly with propiverine (pre 133.9; post 162.8;
2Department of Urology, University Heidelberg
p<0.05) and oxybutynin (pre 138.3; post 167.4; p<0.05), but not with
3Department of Paediatric Surgery, University Greifswald
Tolerability: The frequency of adverse events was significantly
5Department of Urology and Children Urology, Klinikum
higher in the oxybutynin compared to the propiverine or placebo
[Conclusions] The study demonstrated a superior tolerability of propiverine compared to oxybutynin. Enuretic events decreased
EFFICACY AND SAFETY OF PROPIVERINE HYDROCHLORIDE IN
comparably in all three groups. However, urodynamic data
CHILDREN WITH CONGENITAL OR TRAUMATIC DETRUSOR
demonstrated propiverine and oxybutynin being equally effective in
the treatment of overactive bladder in children.
[Aims of the study] Clean intermittent catheterization (CIC) and anticholinergics are established therapeutic strategies in children with detrusor hyperreflexia (DH). Efficacy and safety of propiverine
hydrochloride, an anticholinergic with additional spasmolytic effect on the smooth muscle cell, were evaluated in these children.
A. RAES, G. PHILIPPE, E. VAN LAECKE, J. DEHOORNE,
[Methods] In four clinics, specialised in treatment of children with
DH, the patient files were scrutinised for propiverine treatment.
Urodynamic parameters before and after treatment and adverse
events were recorded retrospectively. [Results] 74 children (40 boys, 34 girls; age range 11 months 19.9
RETROSPECTIVE ANALYSIS OF EFFICACY AND TOLERABILITY OF
years) suffering from DH mainly of congenital (myelomeningocele,
TOLTERODINE IN CHINLREN WITH OVERACTIVE BLADDER
tethered cord) or traumatic (spinal cord injury) aetiology were analyzed. The average treatment duration was 31 months.
[Objective] To evaluate the efficacy and tolerability of tolterodine
Altogether 172 patient years of propiverine treatment were
in children with an overactive bladder, treated in a single enuresis
documented, individual daily dosages varied (5 - 75 mg propiverine;
[Materials and methods] We performed a retrospective analysis of a
Efficacy: Urodynamic parameters improved significantly during
database of a total of two hundred and fifty-six patients (175 boys
propiverine treatment (explorative paired t-tests): Maximum
and 81 girls, age range 3 years to 17 years, mean age 8,33 years) with
bladder capacity pre 161.2 ( 97), post 252.2 ( 117) ml; p 0.001;
urodynamically confirmed bladder overactivity. The children
maximum detrusor pressure pre 43.8 ( 39), post 27.1 ( 26) cm H O;
received tolterodine tartrate (dose range of 0.5 mg - 4 mg orally)
p=0.002; compliance pre 7.6 ( 6), post 17.0 ( 16) ml / cm H O; p0.001.
replacing anticholinergic drugs (oxybutynin chloride or
Safety: Due to the retrospective character of the analysis the
oxyfencyclimine-hydrochloride n =205, group 1) or as initial therapy
frequency of adverse events was lower than in prospective clinical
(n =51, group 2). Tolerability was assessed from adverse events by a
trials: 1/74 patients reported accommodation disorders and nausea.
standardised questionnaire. Efficacy assessment was based on
[Conclusions] Propiverine is effective and well tolerated in children
micturition diary variables, mean change of maximum bladder
suffering from DH, even under long term treatment.
capacity and number of incontinent episodes/24h.
[Results] The mean treatment time was 9.32 months with a range from 1.5 months to 23.4 months. The final dose was 0.1 mg /kg orally daily, divided into two doses.
In group 1, 60.4% switched to tolterodine due to serious adverse events during treatment with non-selective antimuscarinic drugs.
The Overactive Bladder
A.D. MARSCHALL-KEHREL , G. MÜRTZ , G. Kramer
Departments of Urology and Physiology , College of Medicine,
1Urology Consultant, Vorstadt 20, Oberursel
3Berufsgenossenschaftliche Unfallklinik MurnauGermany
THE EFFECTS OF BOTULINUM TOXIN A ON THE DETRUSOR MUSCLE IN RATS
AN EMPIRICAL TREATMENT ALGORITHM FOR INCONTINENT CHILDREN
[Purpose] There is little data on the effects of botulinum toxin A (BoTx A) on detrusor muscle in the literature. An experimental study
[Aims of the study] Response rates of monotherapeutic strategies of
was conducted to investigate the effect of BoTx A on the detrusor
incontinent children evidence limited success only. This
retrospective analysis was performed to test whether
[Materials and Methods] Sprague-Dawley rats were used to make the
complementary therapies in incontinent children might improve
detrusor muscle strip (length: 8mm, width: 2mm). An isometric
force transducer in the physiologic salt solution was used to measure
[Methods] Patient records of 457 enuretic or incontinent children
the contraction and relaxation of this muscle strip. A contraction
(1998 - 2001) were scrutinized. Children were investigated
was induced by acetylcholine (ACh) and electrical field stimulation
according to ICCS-standards (1). Primary endpoint was the
(40V, 20Hz, 3sec), and relaxation was induced by verapamil and
achievement of continence, secondary endpoint the improvement of
sodium nitroprusside. The BoTx A concentration was 0.1U/ml. The
functional bladder capacity (FBC). Seventy incontinent children (2)
relaxation and contraction of the detrusor muscle in the BoTx A-
were treated with propiverine (0.8 mg/kg/day; Mictonetten) and
treated group were analyzed and compared with those in the control
reevaluated after four weeks (period 1). In non-responders and
partial responders complementary therapies were initiated for 12
[Results] The time to the maximum contraction induced by
weeks (period 2). These therapies were chosen on an empirical
electrical field stimulation was lengthened and the time of recovery
basis: selective alpha-blocker in functional bladder neck
to the basal state after terminating electrical field stimulation was
obstruction, DDAVP in excessive nocturnal urine production and
also increased by BoTx A (p<0.05). However, the contractile reaction
biofeedback for increased pelvic floor activity during micturition.
induced by ACh and the relaxing reaction induced by verapamil and
[Results] Demography: 70 patients; 22 girls, 48 boys; age range 5 14
sodium nitroprusside after maintaining the maximum contraction
induced by ACh 10 M was not influenced by BoTx A.
Results of the different treatment strategies (tab. 1):
[Conclusions] The results of this experimental study suggest that the
time delay of the maximum contraction induced by electrical field
stimulation occurred by blocking ACh release at the neuronal endings
and the time delay of the recovery to the basal state after
terminating electrical field stimulation occurred by reducing
[Conclusions] Propiverine monotherapy in incontinent children is
1Department of Molecular and Clinical Medicine, Division of
In partial and non-responders tailored complementary therapies
induce further improvements (3). Therefore combination therapies
for partial and non-responders appear promising.
Faculty of Health Sciences Linköping, Sweden
THE BLADDER COOLING TEST IN CHILDREN WITH NON-NEUROGENIC BLADDER PROBLEMS
[Background] The bladder cooling test, BCT, activates a primitive neonatal reflex that becomes suppressed by descending signals in older children. The aim of this study was to evaluate the BCT in children with non-neurogenic bladder problems.
[Methods] The BCT was evaluated in a consecutive series of 265 children (169 girls and 96 boys, 1 month - 18 years) with non-neurogenic bladder problems. The test was performed at the end of an ordinary cystometry by a rapid infusion of body-warm saline (about a third of the cystometric capacity) followed by the same volume of cold saline (4-8°C). The test was considered positive if a detrusor contraction above 30 cm/H O was evoked by the cold fluid
but not by the warm.
[Results] Most children <4 years (24/30) had VUR (IV-V), the rest a history of UTIs. The BCT was positive in 14/15 below 1 year and in 9/12 below 2 years. All but one test (1/12) was negative between 2-4 years. Seven of these negative tests were repeats in children with positive BCT before 2 years. Most older children (>4 years) had urge incontinence and/or dysfunctional voiding. The frequency of positive BCT was highest (57%) in the interval 4-6 years with a gradual decline to 12 years. Only 1/35 older than 12 years had a positive test. [Conclusion] The conversion of positive to negative BCTs at 2-4 years presumably represents normal maturation. Positive tests in older children with urge incontinence suggest delayed maturation of the central control of the bladder.
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