Abstract: Symptomatic bladder dysfunction occurs at some time in most patients with multiple sclerosis. The relapsing-remitting course and progressive loss of mobility associated with multiple sclerosis make management of urinary urgency and incontinence difficult. Urodynamic evaluation serves as a guideline for appropriate treatment. After accurate diagnosis of bladder dysfunction, a management program is developed with use of fluid schedules, voiding techniques, neuropharmacologic manipulation, intermittent catheterization, surgical treatment, and other adjunctive measures as indicated. The goals of treatment are to protect and preserve renal function, relieve symptomatic voiding dysfunction, and avoid subsequent urinary complications. A management program should be individualized, dynamic, and monitored with periodic, systematic urologie review to maintain these goals.

Abstract: Objective. To determine if mild renal pelvic dilatation at renal ultrasound (RUS) is a reliable sign of vesicoureteral reflux (VUR) at voiding cystourethrogram (VCUG) in children. Materials and methods. All patients less than 10 years of age who had RUS and VCUG on the same day during a 2-year period were identified in a computerized database. The appearance of the collecting system of each kidney was classified into two groups: group 0 – no dilatation (≤ 2-mm anteroposterior diameter of the renal pelvis) and group 1 – 3 to 10-mm AP diameter of the renal pelvis without caliectasis. VUR at VCUG was graded using the International Reflux Study Committee system. Results. Four hundred fifty-five patients (76 boys; 379 girls) with 910 kidneys were included. VUR occurred in 268 kidneys in 174 patients. There were 820 group 0 kidneys and 90 group 1 kidneys. Kidneys classified as group 1 (25.0 % had reflux) were no more likely to have reflux than were kidneys with nondistended (group 0) collecting systems (31.2 % had reflux). There was no statistical difference in the rate of reflux in patients with group 1 renal pelvic distention (39.2 % refluxed) and a normal collecting system (33.3 % refluxed) (P = 0.365). Conclusion. The frequency of vesicoureteral reflux in children with mild renal pelvic distention is not significantly different than in children with no distention. Therefore, mild dilatation of the renal pelvis should not be considered an indication for voiding cystourethrography.

Abstract: The diagnosis of urethral diverticula in women can be difficult. Several imaging modalities have been described for evaluating this entity: urethrography; transabdominal, transrectal, transvaginal, and transperineal ultrasonography; computed tomography (CT); and magnetic resonance (MR) can be helpful in evaluating a diverticulum and its relationship to the urethra. We report on four women aged 36 to 42 years with urethral diverticula. Transrectal ultrasonography (TRU) was the most useful diagnostic test in our series. TRU showed 7 urethral diverticula and provided information about its shape, volume, and content as well as its spatial relationship about its shape, volume, and content as well as its spatial relationship to the urethra. In two cases, multiple diverticula were detected when only a single lesion was clinically suspected. Transabdominal sonography failed to demonstrate small diverticula. CT examination did not provide additional information except for the passage of the contrast from the urethra to the diverticulum in one of the cases. Voiding cystourethrogram was positive in only one patient.

Abstract: There have been two major opinions on the pathology or nature of the bladder neck contracture One is an organic fibrosis, and the other is an accentuated sympathetic nervous function, or detrusor bladder neck dyssynergia The existence of active detrusor bladder neck dyssynergia in neurogenic bladder was reported in a urodynamical manner using microtip transducer catheters However, it has not been confirmed whether or not detrusor bladder neck dyssynergia is responsible for bladder neck contracture in patient without neurogenic bladder The present study was designed to determine by means of video urodynamic study whether or not bladder neck contracture would be of the same nature as detrusor bladder neck dyssynergia in non-neurogenic bladder subjects The study included 32 male subjects of 16-84 years old (average 523): 17 bladder neck contracture subjects including 7 subjects associated with minimum complications (4 with trapped benign prostatic hyperplasia and 3 with incomplete neurological lesion) and 15 non-bladder neck contracture subjects (10 healthy volunteers, 2 chronic prostatitis, 3 prostatodynia) A 5-microtip transducer catheter was used to measure the pressure in the bladder and at the bladder neck, the external urethral sphincter and the bulbous urethra during voiding Proper localization of the transducers was done with an image intensifier Bladder outlet obstruction localized at the bladder neck (diameters smaller than 075 cm) on voiding cystourethrogram was defined as bladder neck contracture Detrusor bladder neck dyssynergia was defined where pressures were higher at the level of bladder neck than in the bladder during detrusor contraction An alpha-blocker, terazosin hydrochloride (05 mg, bid, two weeks), was orally administered to subjects judged to have detrusor bladder neck dyssynergia by the above methods for the purpose of confirming whether detrusor bladder neck dyssynergia was really due to accentuated sympathetic nervous function Detrusor bladder neck dyssynergia was found in seven cases with bladder neck contracture: 6 cases with bladder neck contracture with minimum complications and only 1 case with bladder neck contracture without complications (p < 001) Detrusor bladder neck dyssynergia was found at the beginning and ending of micturition, but not at maximum flow In six cases with detrusor bladder neck dyssynergia, the condition disappeared after terazosin In conclusion, detrusor bladder neck dyssynergia was not thought to be a major factor of voiding dysfunction in bladder neck contracture in non-neurogenic bladder In the presence of sympathetic hyperactivity or in cases with increased number of alphareceptors, detrusor bladder neck dyssynergia occurs, being predominantly noted in trapped benign prostatic hyperplasia and neurological disorder patients

Abstract: Purpose. We have observed a difference in the radiographic appearance of the body of the bladder (trabeculated) and its base (smooth) in boys with severely obstructing posterior urethral valves. We wanted to determine if (1) this was a reproducible finding and (2) there was an anatomic and/or physiologic explanation for it. Materials and methods. We reviewed the initial voiding cystourethrogram in 47 boys with severe posterior urethral valves. The interureteric ridge was used as the division between the body and base of the bladder. The presence of trabeculation for each region was recorded. Results. Ages ranged from 1 day to 6 years at the time of initial cystographic evaluation (median 14 days). The body of the bladder was trabeculated and the base smooth in 72 % (34 patients). In the remaining patients, both the body and base were smooth. In no patient was the base trabeculated. Conclusions. The cystographic morphology of the urinary bladder in boys with posterior urethral valves can be explained by its neuroanatomy. The body of the bladder, which contracts during voiding because of parasympathetic (cholinergic) stimulation, becomes trabeculated. The bladder base relaxes during voiding due to sympathetic (alpha adrenergic) stimulation and remains smooth. Thus, this difference in the cystographic appearance of the two parts of the urinary bladder reflects the normal innervation and the mechanics of micturition in boys with urethral obstruction.

Abstract: OBJECTIVE: The aim of this study was to determine the urodynamic characteristics of patients with vesico-ureteral reflux (VUR) and detrusor instability (DI) followed by medical treatment. PATIENTS AND METHODS: The urodynamic and cystographic findings in a group of 24 patients between 4 and 18 years of age (mean 7.6 years) with a simultaneous diagnosis of VUR and DI were reviewed. All of them presented with recurrent urinary tract infections. Twenty were female of whom eight also had enuresis and daytime symptoms. Mean follow-up was 40 months (range 18-97 months). VUR was diagnosed by voiding cystourethrogram and classified according to the grades proposed by the "International reflux study on children". RESULTS: All but 6 patients had at least a 15% reduction in age-adjusted capacity. No relationship was observed between the severity of VUR (measured as the addition of reflux grades in both units of each patient) and reduction in bladder capacity or compliance. Seven patients had upper tract damage (either scars or a decrease in size or function on the renogram). Upper tract damage was significantly more frequent in patients with bilateral reflux (regardless of the type of DI). Patients with unilateral reflux and sustained instability had significantly less upper tract damage. Results of treatment are reported separately. CONCLUSIONS: In these patients, the severity of VUR did not seem to have an impact on bladder capacity or compliance. The risk factors for upper tract damage in this series differ from those found by other authors.

Abstract: Not infrequently, in pediatric practice one is confronted by anxious parents of children with voiding abnormalities. These include children who wet themselves, have frequent micturtion, urgency or dribbling. In these subjects investigations like urinalysis, renal ultrasound, intravenous urogram or voiding cystourethrogram (VCUG) are usually conducted. Often, the results of these investigations are normal. More recently, these voiding abnormalities have been approached in a more scientific way and it is possible to detect underlying alterations in lower urinary tract dynamics as the cause of these problems(l). Appropriate pharmacological therapy may provide a satisfactory and lasting solution to this vexed problem. The present preliminary study was, therefore, designed to evaluate the cystometric findings in children with non-neurogenic voiding dysfunctions.

Abstract: UTI is a common and important clinical problem in infants and young children, with a prevalence of 5.3% among febrile infants seen in our Emergency Department. White females with rectal temperature > or = 39 degrees C are at particularly high risk (prevalence, 17%). Several studies have highlighted the limitations of the standard urinalysis for identifying UTI in infants and young children and have recommended performance of both urinalysis and urine culture. Alternative methods such as dipstick urinalysis, although attractive because of ease of performance, are inadequate as a screen for UTI. Hemocytometer WBC counts of an uncentrifuged urine specimen can be performed in an office or hospital-based laboratory with minimal training. Performance of Gram-stained smears, however, is most appropriate for the hospital-based laboratory. In the hospital setting where both tests can readily be performed, the positive predictive value of the combination of pyuria and bacteriuria (85%) allows prompt institution of antimicrobial therapy before culture results are available, whereas the lower positive predictive value of the single finding of either pyuria or bacteriuria (40%) justifies delaying treatment decisions until culture results are available. In the office setting where hemocytometer counts can easily be performed, culturing only specimens with pyuria and those of children presumptively treated with antimicrobials will result in the identification of almost all patients with true UTI, sparing large health care expenditures. Although the urine culture is traditionally regarded as the gold standard of UTI, positive urine cultures may occur secondary to contamination or in cases of ABU, leading to a false diagnosis of UTI. In contrast we found pyuria to be a reliable marker to discriminate infection from colonization of the urinary tract. The sustained absence of an inflammatory response, on repeat UA within 24 h, constitutes strong evidence that infection is absent. Management of ABU is controversial; many experts recommend withholding antibiotics because eradication of low virulence organisms may be followed by colonization with more virulent species that cause pyelonephritis. Preliminary results of our ongoing treatment trial suggest that management of young febrile children with UTI as outpatients receiving oral cefixime is as efficacious as inpatient management with intravenous cefotaxime. Results of renal ultrasound and DMSA scan at the time of infection have not modified management in any patient. Accordingly selective rather than routine performance of ultrasound is recommended. A voiding cystourethrogram at 1 month and a DMSA scan 6 months later have been valuable in identifying patients with vesicoureteral reflux and renal scarring, respectively. Among patients initially identified as having acute pyelonephritis, the incidence of renal scarring at 6 months has been substantially more frequent (approximately 40%) than we had expected. However, the long term implications of small scars identified with renal scintigraphy remain to be determined.