1 State University of Medicine and Pharmacy „Nicolae Testemi țanu” Pedaiatric surgery department Faculty of medicine II DIPLOMA THESIS Neurogenic… [601672]

1 State University of Medicine and Pharmacy "Nicolae Testemi țanu"
Pedaiatric surgery department
Faculty of medicine II

DIPLOMA THESIS
Neurogenic urinary bladder in children

Mustafa Nighim
Group 1049 ; 6'th year
Dzero Vera dr. hab. șt. med., prof. un iv.

Chișinău 2016

2 CONTENT
Preface & statement… ……………………………… ….………………………..P. 4
Chapter I…………………………………………… …..…………… ………..P. 5-10
1.1. List of abbreviations …………………………………… …..…………………P. 4 -5
1.2. Abstract….. ………………………………………………… ……………….P. 6
1.3.Introducti on……………………………………………… …………….….…P. 7 -8
1.4. The aim and objective of thesis ……………………… ….……………….……P. 9
Chapter II………………………………… …………… ……..………………P. 10 -16
2.1. Normal Anatomy and physiology of LUT …………… ………………………P. 10
2.2. Storage and emptying function ……………………………… ……..…….P. 10 -11
2.3. Micturition physiology in childhood ……………………………… …………P. 11
2.4. LUT function terminology …………………………………… …………..P. 11 -13
2.5. Urinary tract anomaly in children ………………………… …..………….P. 14 -15
2.6. The LUT function ahn UTI …………………………………. …………………P. 15 -16
Chapter III……………………………………………………… ….…………P. 17 -26
3.1. Etiology ………………………………………………… …………………P. 17 -18
3.2. Signs and symptoms ………………………..………… ….……………….P. 18 -19
3.3. Diagnosis and evaluations of LUT in children ……… …………………..P. 19 -21
3.3.1 . Non -invasive investigation …………………………………… ………..P. 19 -20
3.3.2. Invasive investigation ………………………………..……… …………P. 20 -21
3.4. HRQOL in LUT dysfunction …………..…………………… ……………P. 21 -26
3.4.1. Definition of HRQoL ………………………………… …………………P.21 -22
3.4.2. Measure of HRQoL in chi ldren ………………………… ……….……..P. 22 -23
3.4.3. HRQoL in children w ith CKD or a kidney transplant… ………………..P. 23 -26
Chapter IV ……………………..……………………………………………P. 26 – 39
Management strategy of LUTD …………………………………… …………P. 27 -30
Cases ………………………….………………………………… ……………P. 31 -38
Prognosis ………………………………………………………… ……………….P. 38

3 Conclusion ……………………………………………………… ….……………..P. 39
Referance ………………………………………………… ……………………P. 4 0-52
Figures ………………………………………………………….……………………
Figure 1………………………………………………………….………………..P. 11
Figure 2………………………………………… …………………………………P. 17
Figure 3………………………………………………………….………………..P. 31
Figure 4a..…………………………………………………………………………P. 33
Figure 4b..…………………………………………………………………………P. 34

4 PREFACE
Thesis contain the literature review and medical journals, n ew England journal
of medicine, the NCB (National Center for Biotechnology Information) and books of
the lower urinary tract dysfunction with the epidemiological, pathophysiologic and
diagnostic approaches. then will discuss the surgical aspects and the possible
interventions include the complications and the postoperative treatment and
prognosis .
The thesis main goal to expand the knowledge and to raise awareness of the
health care team, doctors nurses and students who are exposed to this group of
patie nts due to relatively high incidence in children of LOWER URINARY TRACT
DYSFUNCTION globally, since all hospital staff need to treat this group of patients.
statement
I hereby declare that the license thesis titled “ Neurogenic bladder ” is written by me
and has never been submitted to another university or institution of higher education
in the country or abroad. Also, that all sources used, including those on the Internet,
are given in the paper with the rules for avoiding plagiarism:
– all the fragments of text reproduced exactly, even in his own translation from
another language are written between quotation marks and have a detailed reference
source;
– reformulation of the texts in own words written by other authors have detailed
reference;
– summari zing the ideas of other authors have detailed reference to the original text.
CHAPTER I
1.1 LIST OF ABBREVIATIONS
BD Bladder dysfunction
CKD Chronic kidney disease

5 CIC Clean intermittent catheterization
CNS Central nervous system
CRF Chronic renal failure
CBC Cystometric bladder capacity
DCGM -37 Disabkids Chronic Generic Module -37
DD Deceased donor
EBC Expected bladder capacity
ED Emptying dysfunction
EMG Electromyography
ESRD End-stage renal disease
GFR Glomerular filtration rate
HD Hemodialysis
HRQoL Heal th-Related Quality of Life
ICCS International Children’s Continence Society
ICIQ -FLUTS International Consultation on Incontinence Questionnaire Female
Lower Urinary Tract Symptoms
LD Living donor
LUT Lower urinary tract
LUTS Lower urinary tract symptoms
MMV Maximum voided volume
PD Peritoneal dialysis
QoL Quality of Life
SPAR Swedish population registry
Tx Transplantation
UTI Urinary tract infection
UTM Urinary tract malformation

6 1.2 Abstract
Lower urinary tract syndrome is common in children. Incontin ence, urinary
tract infection, vesicoureteral reflux, and constipation are commonly associated with
this syndrome. Examining the clinical history of the afflicted patient plays a major
role in the accurate diagnosis and treatment of lower urinary tract dis order. Along
with pharmacologic treatment, pelvic floor muscle retraining, biofeedback therapy,
and adaptation of a healthy lifestyle are advocated for rapid recovery of patients.
Up to 10% of school -age children suffer from recurrent urinary tract infect ions
(UTIs) and/or urinary incontinence. Lower urinary tract problems are, together with
asthma, the most important chronic disease of the pediatric age group. Diagnosis
must discriminate among those children with functional voiding problems, those with
neuropathic bladders, and those with anatomic anomalies who may need surgery. In
boys with overactive bladder (OAB) and incontinence, urethral obstruction must be
evaluated as the possible cause. Functional incontinence with lower urinary tract
symptoms (LUT S) is very common in girls and can be accompanied by UTI. In girls
with dysfunctional voiding or underactive bladder, other anomalies need to be
excluded because, for many of these girls, LUTS can be a chronic condition that
requires lifelong attention to voiding behavior.
Keywords:
 Urinary bladder dysfunction ;
 Urinary tract infection ;
 Enuresis ;
 Overactive bladder ;
 Pediatric

7 1.3 INTRODUCTION
In children, the complex composite structure of the lower urinary tract is
functionally controlled at several l evels of the central nervous system; co -ordination
and communication between these levels are not fully developed until the age of 4
years. Furthermore, owing to the impact of sociocultural differences, the age –
dependent neural control over lower urinary t ract function in children is far less
standard than in adults.
In 1973, the 3 -year-old International Continence Society (ICS) established a
committee for the standardization of terminology of lower urinary tract function. This
committee published seven reports approved by the Society, and these reports
became accepted and important tools in clinical practice and research.
With interest in paediatric urodynamics growing rapidly, the need for a separate
report on standardization and definitions for lower urinary tract dysfunction in
children became obvious. Using the International Children’s Continence Society
(ICCS) as body of reference, and the format of the Standardization Committee of the
ICS, the present report was created. The full draft was ratified at the first annual
meeting of the ICCS, in 1997, and a shortened version will be adopted and published
by the Standardization Committee of the ICS.
Standardization of terminology and methodology should facilitate comparison
of results by investigators u sing urodynamic methods in children. The report’s
standardized definitions of dysfunctional entities in children avoid the confusion
caused by the many diagnostic labels for syndromes and types of incontinence
reported in the literature. Future investigati ons of therapy and outcome will benefit
from clear and standard definitions.
The function of the lower urinary tract (LUT) is mainly storage and voiding of urine,
which is regulated by a neural control system in the brain and spinal cord that
coordinates t he activity of the urinary bladder and bladder outlet. Therefore, any
disturbance of the nervous systems that control the LUT, including the peripheral

8 nerves in the pelvis, can result in neurogenic lower urinary tract dysfunction
(NLUTD). Depending on the extent and location of the disturbance, a variety of
different NLUTDs might occur, which can be symptomatic or asymptomatic.
Moreover, NLUTD can cause a variety of long -term complications; the most
dangerous being damage of renal function. As symptoms and long-term
complications do not correlate (9), it is important to identify patients with NLUTD,
and establish if they have a low or high risk of subsequent complications .
According to current knowledge, elevated storage pressure in the bladder,
either alo ne or combined with vesicoureteric reflux (VUR), is the most important risk
factor for renal damage (10)
Sustained elevated storage pressure in the bladder is mainly due to a
combination of increased detrusor activity during the storage phase (detrusor
overactivity [DO] or low compliance), combined with detrusor – sphennchter
dyssynergia (DSD) The combination of these two findings is mainly caused by
suprasacral infrapontine spinal lesions. Furthermore, elevated detrusor leak point
pressure has been demon strated to be a risk factor for renal deterioration in patients
with meningomyelocele (11). Therefore, renal failure has been the leading cause of
death in patients with spinal cord injury for a long time (12).

9 1.4 The aim and objective of the thesis
Aim of the thesis
 Diagnosis of the LUTD is key to managing the patient successfully
 Study of the literature about surgical options for LUTD
Objectives
 To evaluate the clinical and functional, characteristics relevant to the Surgical
management of patients with LUTD
 To study the surgical options forLUTD
 Surgical perspective the past vs current approach
 Outcomes and prognosis of post operative LUTD patients

10
CHAPTER II
2.1 Normal anatomy and physiology of LUT
THE LOWER URINARY TRACT
The urinary tra ct consists of the upper urinary tract, i.e., the kidneys and
ureters, and the LUT, i.e., the bladder, the urethra, and the sphincter system (Figure
1). In healthy individuals the kidneys produce urine continuously passing through the
two ureters to the bl adder for low -pressure storage until eliminated through the
urethra. Several mechanisms prevent retrograde flow of urine to the upper urinary
tract.

Figure 1. The upper and lower urinary tract
2.2 Storage and emptying function
The urinary bladd er has two main functions, the first is to serve as a reliable
reservoir and the second is to empty the urine completely without any difficulties
such as pressing or straining. Important requirements of the bladder are high
compliance during bladder fillin g and the ability to generate adequate pressure to
empty the bladder. In order to meet these demands, the urinary bladder is a highly
expandable muscular sac in which the fibers of the main smooth muscle component,
the detrusor, are arranged in spiral, lon gitudinal, and circular bundles [38]. The
storage and emptying functions are controlled by a complexity of neurological

11 interactions involving the central nervous system (CNS) and three sets of peripheral
nerves: parasympathetic, sympathetic, and somatic n erves [38]. A proper “on -off”-
like coordination between these components is essential for either maintaining
continence or inducing micturition [39].
2.3 Micturition physiology in childhood
Maturation of the CNS as well as adequate social prerequisites is required for
the development of voluntary bladder control. Higher CNS centers are already
involved in micturition in newborns and the infant usually wakes up, at least for a
short while, as the micturition occurs. Incomplete voiding during the first years of life
is common owing to immature detrusor -sphincter coordination but disappears when
voluntary bladder control is achieved [40], often the age of 5 –6 years [41]. Bladder
capacity and voided volumes increase gradually during toilet training allowing the
child to hold the urine voluntarily. Voiding frequency is related to age and decreases
from approximately once per hour in the infancy period [42] to 7–8 times per day in
toddler years [43]. Most school -aged children (7 to 15 yea rs old) void between 3 and
8 times per day [44]. Recent studies have shown that voiding control can be trained
earlier than practiced nowadays in Western cultures. Toilet training before the first
year of life has proved to facilitate a complete bladder em ptying, thus, possibly to
benefit those children with LUT abnormalities [45].
2.4 LUT function – terminology
The International Children’s Continence Society (ICCS) provides guidelines
on terminology and pediatric LUT evaluation in children [46, 47]. The guidelines
describe different manifestations of LUT function and dysfunction aiming at
facilitating understanding and communication between those who take care of
children and adolescents with LUT dysfunction. The guidelines have r ecently been
updated [48].
2.3.3.1. Definitions considering storage and voiding symptoms according to the ICCS
guidelines [47, 48 ]

12 A voiding frequency of 3 to 7 voids daily is suggested to be normal for 7 -year-
olds, but it is inf luenced by diuresis and fluid intake.
Urinary incontinence means repeatedly occurring involuntary leakage of urine
in children of at least 5 years of age. Incontinence is further divided into the
categories continuous and intermittent incontinence, and da ytime incontinence or
enuresis.
Urgency refers to a sudden and unexpected need to void, and is often regarded
as a sign of bladder overactivity.
Nocturia applies to children of at least 5 years of age who wake up at night to
void. This symptom does not n ecessarily indicate LUT malfunction.
Hesitancy signifies difficulty in initiating voiding although the child is ready to void.
Straining implies an effort to increase intra -abdominal pressure to initiate and
maintain voiding.
Weak stream is an observed ur inary stream or uroflow of weak intensity.
Intermittency indicates micturition with several stop and start spurts. However, this is
physiological up to the age of 3 years if straining is not present.
2.3.3.2. Voided volume, expected bladder capacity, and p olyuria according to the
ICCS guidelines [47, 48 ]
Voided volume characterizes the volume of urine measured at micturition and
recorded in the voiding diary. The maximum voided volume (MVV) refers to the
largest volume measured th roughout a 24 -hour cycle.
Expected bladder capacity (EBC) is defined according to the formula: 30 + (30 x age
in years) ml and is applicable to children between aged 4 –12 years. The MVV
(obtained from bladder diary) is defined as small if found to be less than 65%, or as
large if greater than 150% of the EBC.
Polyuria is considered to occur when the urine output exceeds 2,000 ml/m²
body surface area.

13 Common functional LUT disturbances in children
The most common functional LUT disturbances in child ren without
neurological or structural disorders are enuresis and daytime incontinence. The
prevalence of enuresis and daytime incontinence is 5 –10% in 7 -year-old children
[49, 50]. Daytime incontinence is often caused by detrusor overactivity [43] and is
more common in girls who usually experience concomitant urgency symptoms. This
condition tends to give rise to such as postponing micturition as long as possible
using various “holding maneuvers”, e.g., s quatting with the heel against the
perineum. Constipation with or without fecal incontinence is common in these
children and may play an important role in LUT dysfunction [51]. The same group of
children may have incomplete voids with residual urine and is subsequently at higher
risk of developing UTI [52]. The cause of detrusor overactivity is debated but it may
originate from a mild delay in the maturation of the CNS which interferes with the
ability to gain voluntary control over the micturition reflex [43, 52] .
Enuresis occurs more often in boys and may be combined with daytime
incontinence or urgency symptoms. Pathogenetic factors of importance are difficulty
to wake up in response to activation of the micturition reflex, noct urnal polyuria,
and/or inability to manage detrusor contractions [43].
Daytime incontinence and enuresis are known to have a negative impact on
self-esteem and HRQoL in the affected children [53]. However, since self -esteem has
been shown to become normal ized after a successful treatment, it is important to offer
treatment as soon as the child is motivated [54, 55] .

14 2.5 URINARY TRACT ANOMALIES IN CHILDREN
In contrast to adults, about 35% of children with CKD in its advanced stag es
have underlying urological anomalies [56]. In adult patients with ESRD, congenital
anomalies of the kidney and urinary tract account for less than 5%, with diabetic and
non-diabetic glomerulopathies dominating the disease spectrum [9, 57].
Common congenital urological disorders include posterior urethral valve
(PUV), vesico -ureteric junction (VUJ) and pelvi -ureteric junction (PUJ) obstruction,
VUR, neuropathic bladder, and prune belly syndrome. Acquired urological disorders
include renal tract stones, urethral strictures, neuropathic bladder, and tumors [58].
LUT abnormalities can have a devastating effect on renal function [56]. If
unsolved, the ongoing urinary output in combination with urinary tract obstruction
causes an increased pressure which dilates the collecting system proximal to the
obstruction. The elevated pressure in turn damages the tubules, which leads to a
decreased urine -concentrating ability and, consequently, polyuria. Polyuria may in
turn lead to chronic bladder over -distension, bladder wall thickening, loss of
compliance, secondary detrusor over -activity and subsequent problems involving
incontinence and enuresis [56]. The impaired drainage of the urine from the upper
urinary tract a lso imposes a risk for VUR, hydronephrosis, UTI, and renal damage
[28, 56]. The injury to the glomeruli is often secondary to the processes mentioned
above, but regardless of the cause, it leads to a redu ced glomerular filtration rate
(GFR) and progressive CKD [58].
Urological disorders in children often lead to voiding disturbances, which
occurs for example in boys with PUV. Other underlying urological causes that affect
bladder function are neuropathic bladder secondary to spinal abnormalities, VUR,
and prune belly syndrome [28].
Children with CKD due to non -urological disorders may also suffer from
polyuria. Many hereditary disorders affect tubular function and the ability to
concentrate the urine. Eve n if not combined with an outflow obstruction, polyuria is
associated with a risk of developing a large capacity bladder with impaired sensation

15 of distension or over -distension with an underactive bladder as the clinical endpoint
[59]. Severe oliguria or anuria is common in children on long -term dialysis and is
associated with an increased risk of developing a small, defunctionalized, poorly
compliant, high -pressure bladder, and subsequent upper urinary tract damage [56,
60].
LUT function in children with CKD due to other causes than urological ones is
not a well -studied subject area. However, a large capacity bladder, emptying
problems and incontinence, possibly indicating LUT dysfunction, were reported by
Van der Weide et al. to be common also in children with CKD of non -urological
origin [59].
2.6 THE LUT FUNCTION AND UTI
Several mechanisms are important in the host defense against UTIs, for
instance, the interaction between normal bacterial flora and potential pathogens,
desqu amation of epithelial cells with adhering bacteria, local production of
antibacterial peptides and other immunological mechanisms [61]. The most important
defense mechanism is, however, a regular and complete emptying of urine from the
bladder and the urin ary tract. This will prevent bacteria from colonizing the bladder
and invading the upper urinary tract [62]. In children with structural or functional
LUT abnormalities, this most important defense mechanism is disturbed [61, 63,
64].
In the pre -antibiotic era children who did not die from their UTIs often
recovered with substantial renal damage as a sequel of the infection [61]. Important
research revealed the association between UTIs, vesicoureteral ref lux (VUR), and
renal damage [65, 66], and therefore much effort was concentrated on finding out
how to deal with VUR. Further research showed that renal damage could be
prevented equally well by either antibacterial prophylaxis or by anti -reflux operations
[67]. However, in a substantial number of children who experienced recurrent UTIs
and renal damage, no VUR was detected [64]. These children often suffered from

16 incontinence and other signs consistent with LUT dysfunction, a cond ition that later
proved to be another major risk factor for recurrent UTIs [63, 64] .

Figure 2- uti

17 CHAPTER III
3.1 Etiology
Neurogenic bladder is bladder dysfunction (flaccid or spastic) caused by
neurologic damage. Symptoms can include overflow incontinence, frequency,
urgency, urge incontinence, and retention. Risk of serious co mplications (eg,
recurrent infection, vesicoureteral reflux, autonomic dysreflexia) is high. Diagnosis
involves imaging and cystoscopy or urodynamic testing. Treatment involves
catheterization or measures to trigger urination.
Any condition that impairs bl adder and bladder outlet afferent and efferent signaling
can cause neurogenic bladder . Causes may involve the CNS (eg, stroke, spinal injury,
meningomyelocele, amyotrophic lateral sclerosis), peripheral nerves (eg, diabetic,
alcoholic, or vitamin B 12 deficiency neuropathies; herniated disks; damage due to
pelvic surgery), or both (eg, Parkinson disease, multiple sclerosis, syphil is). Bladder
outlet obstruction often coexists and may exacerbate symptoms.
Aetiological classification of lower urinary tract dysfunction
The bladder and urethra form a functional unit and their interaction cannot be
ignored. The unit has two opposed an d alternating functions, i.e. storage and
evacuation of urine. When reference is made to the hydrodynamic function or to the
whole anatomical unit as a storage organ, vesica urinaria, the correct term is
‘bladder’. When the smooth muscle structure known as muscularis detrusor vesicae is
being discussed, then the correct term is ‘detrusor’. For simplicity, bladder/detrusor
and urethra will be considered separately in the classifi cation of lower urinary tract
dysfunction.
Terms should be objective and defin able, and should apply to the whole range
of abnormality. If other investi gators disagree with the classification presented below,
or prefer to use terms that are not defined herein, they should ensure that their
terminology is clear. In the present class ification, nocturnal enuresis has been
excluded, as this condition is not related to any specific lower urinary tract
dysfunction.

18 Disturbance of pertinent nervous or psychological control
Congenital malformations of the CNS. These include; myel -omeningo cele;
occult spinal dysraphism; caudal regression sequence (e.g. syringocele,
diastematomyelia, sacral malformations, certain cases of anal atresia); tethered cord
syndrome.
Developmental disturbances. Urge syndrome; dysfunctional voiding; mental
retardat ion and delayed psychomotor development; ADD –like syndromes.
Acquired conditions. Cerebral spasticity (perinatal asphyxia); progressively
degenerative diseases of the CNS associated with central spasticity (e.g.
Hallervorden -Spatz disease); multiple scler osis; Guillain –Barre´ syn drome;
radiculitis; transverse myelitis; spinal cord trauma; spinal cord infections (e.g.
schistosomiasis); tumours (e.g. sacrococcygeal teratoma); vascular malfor mations of
the spinal cord; iatrogenic trauma to the pelvic plexus .
Disorders of smooth and striated muscle function
Congenital conditions. Duchenne ’s muscular dystrophy, spinal muscular
atrophy, neuronal dysplasia (megaco -lon–megacystis syndrome).
Acquired conditions. Chronic bladder distension; over -distension injury ; fibrosis of
detrusor and bladder wall.
3.2 Signs and symptoms
Overflow incontinence is the primary symptom in patients with a flaccid
bladder. Patients retain urine and have constant overflow dribbling. adolecence
typically also have erectile dysfunctio n.
Patients with spastic bladder may have frequency, nocturia, and spastic
paralysis with sensory deficits; most have intermittent bladder contractions causing
urine leakage and, unless they lack sensation, urgency. In patients with detrusor –
sphincter dys synergia, sphincter spasm during voiding may prevent complete bladder
emptying.
Common complications include recurrent UTIs and urinary calculi.
Hydronephrosis with vesicoureteral reflux may occur because the large urine volume

19 puts pressure on the vesico ureteral junction, causing dysfunction with reflux and, in
severe cases, nephropathy. Patients with high thoracic or cervical spinal cord lesions
are at risk of autonomic dysreflexia (a life -threatening syndrome of malignant
hypertension, bradycardia or ta chycardia, headache, piloerection, and sweating due to
unregulated sympathetic hyperactivity). This disorder may be triggered by acute
bladder distention (due to urinary retention) or bowel distention (due to constipation
or fecal impaction).
3.3 DIAGNOSIS AND EVALUATION OF LUT FUNCTION IN CHILDREN
A comprehensive history and physical examination are the cornerstone tools in
the diagnostic evaluation of children and adolescents with LUT dysfunction. Further
diagnostic tools are categorized into invasive an d non -invasive urodynamics.
3.3.1 Non-invasive urodynamic investigations
A bladder diary consists of a 48 -hour frequency and volume chart and is used
to obtain information about such parameters as voided volumes, voided frequency,
urinary outputs, fluid i ntake, and associated symptoms [47, 68]. Different scoring
systems and questionnaires have been developed for measuring LUT dysfunction and
the emotional impact of urinary incontinence [69-72]. However, few of them have
been cross -culturally validated and tested for reliability.
Uroflowmetry measures the flow rate, the voided volume, and the voiding time
during urination. The voiding pattern is presented as a uroflow curve. Five different
curve shapes occur: bell -shaped, tower -shaped, staccato -shaped, interrupted -shaped,
and plateau -shaped (see “Material and Methods”). These curve shapes may serve as
guides to the underlying pathology [51]. Repeated measurements are required to
confirm suspected dysfunctional voiding [48, 73]. Uroflowmetry may be combined
with electromyography (EMG) to measure the pelvic floor muscle activity during
voiding [74].
As mentioned earlier, a child should empty the bladder comp letely.
Assessment of post -void residual urine is therefore an important diagnostic tool and
the assessment should be performed within a maximum of five minutes after

20 completing the uroflow measurement. Real -time equipment is preferred for
diagnostic use. Post-void residual urine exceeding 20 ml at repeated measurements
indicates incomplete bladder emptying [47].
The bladder diary, uroflowmetry, and residual urine measurements may be
referred to as “urodynamic screening”.
3.3.2 Invasive urodynamic investig ations:
Cystometry – invasive urodynamic studies (cystometry and pressure flow
studies) are not routinely performed to evaluate LUT function in children but have a
given place in the evaluation of LUT function in children with neurogenic bladder,
structura l anomalies of LUT, and/or functional voiding problems resistant to
treatment [51, 52]. Since the investigation is known to be associated with
psychological distress due to the transurethral or suprapubic catheterization, it is
important to reduce child and parental distress by an adequate preparation prior to the
procedure, and additionally, thereby also ensure a safe and reliable examination [48,
75, 76]. A non -invasive evaluati on allows us to identify children who will benefit
from invasive urodynamics [77, 78]. Cystometry is used to record urodynamic
conditions during the filling phase of the micturition cycle. Bladder sensation,
detrusor activity, bla dder compliance, and bladder capacity are parameters
concerning the obtained bladder storage function and serve as important markers to
identify children at risk for upper urinary tract damage [52, 77, 79] .
Further explanation :
 Postvoid residual volume
 Renal ultrasonography
 Serum creatinine
 Usually cystography, cystoscopy, and cystometrography with urodynamic
testing
Diagnosis is suspected clinically. Usually, postvoid residual volume is
measured, renal ult rasonography is done to detect hydronephrosis, and serum
creatinine is measured to assess renal function.

21 Further studies are often not done in patients who are not able to self –
catheterize or ask to go to the bathroom (eg, severely debilitated elderly or post-
stroke patients).
In patients with hydronephrosis or nephropathy who are not severely
debilitated, cystography, cystoscopy, and cystometrography with urodynamic testing
are usually recommended and may guide further therapy. Cystography is used to
evaluate bladder capacity and detect reflux. Cystoscopy is used to evaluate duration
and severity of retention (by detecting bladder trabeculations) and to check for
bladder outlet obstruction. Cystometrography can determine whether bladder volume
and pressure are high or low; if done during the recovery phase of flaccid bladder
after spinal cord injury, it can help evaluate detrusor functional capacity and predict
rehabilitation prospects (see Voiding Disorders:Testing ). Urodynamic testing of
voiding flow rates with sphincter electromyography can show whether bladder
contraction and sphincter relaxation are coordinated (se e Voiding Disorders:Testing ).
3.4 HRQOL
Over the last few decades, medical, surgical, and immunological advances
have dramatically improved treatment outcomes and long -term survival rates for
children with CKD or a kidney transplant [14, 26]. However, optimal care of
pediatric renal patients should aim not only at excellent survival rates, but also at
attention to how the children feel and get along with everyday life [88]. In this
context, HRQoL has become an important health indicator for treatment outcome as
well as measure of the impact of the condition in people suffering from various
diseases, including children with CKD at different stages [88-90].
3.4.1 Definition of HRQoL
QoL is often used synonymously with HRQoL but is a general concept lacking
consensus on a clear definition. QoL includes a broader range of a spects, e.g.,
environmental and economic issues, and can adapt different meanings to different
individuals depending on the context [91]. The term has traditionally referred to
health status, physical functioning, symptoms, psychosocial adjustment, well -being,

22 life satisfaction, and happiness [92]. In the context of medical outcomes, QoL has a
clear connection to subjective and objective health and disease and treatment -related
well-being [93]. Health, as defined by the World Health Organization (WHO) [94] as
-“a state of complete physical, mental and social well -being, and not merely the
absence of disease” – is an important component of quality of life [95].
HRQoL is a part of the broader concept of QoL. A variety of definitions and
models across different health and illness conditions have been used to explain the
concept HRQoL [96]. HRQoL is related to one’s health and described as a
“multidimensional concept covering physical, mental, social and behavioral
components of well -being and function as perceived by patients and/or other
observers” [93, 95, 96]. This latter definition of HRQoL agrees with the one used in
this thesis.
3.4.2 Measure of HRQoL in children
Measuring HRQoL in children and adolescents e ncounters unique demands,
compared to measuring in adults [89]. A meaningful development of a QoL
instrument requires consideration of age -related issues, as well as maturity and
cognitive development [93]. Another question has been how to get reliable ans wers
from children. Agreement between child and parent ratings concerning the child’s
HRQoL has also been questioned. The child ratings are, however, preferable
whenever possible even though HRQoL ratings obtained from a parent or caregiver
may serve as an additional source of information [93, 97] .
The development of appropriate instruments for measuring HRQoL in both
healthy and chronically ill children has been encouraging, a number of them fulfilling
requirements of age and cogn itive appropriateness [89]. Generally, HRQoL measures
can be divided into two main categories: generic and disease -specific measures [89,
91]. Generic questionnaires address issues not directly related to disease and can
provide i nformation from healthy children as well as children with different diseases
or conditions. This allows comparisons across different groups and for comparisons
with the general population. The criticism of generic instruments is that they may fail

23 to captu re information of particular concern in certain groups [91]. Disease -specific
instruments may be useable for detecting important clinical information. Their
limitation is, however, that a comparison of HRQoL measurements with those in
other illness groups is not possible [93]. Generic measures with disease -specific
modules are also available; an example being the widely used PedsQoL [98]. The
European KIDSCREEN/DISABKIDS project has developed similar instruments for
measure of generic, chronic illness gener ic and condition -specific (disease -specific)
aspects of HRQoL [90, 99 -101].
In this thesis, two questionnaires, one generic and one chronic generic, were
used to measure the HRQoL. The Kidscreen -27 and the Disabkids Chronic Generi c
Module -37 (DCGM -37) instruments were chosen because they were developed in
Europe and provide a European reference material. The two instruments allow
assessment of generic and chronic illness generic aspects of HRQoL in children and
adolescents and are usable in health research and clinical settings in different cultures
[90]. The European KIDSCREEN and DISABKIDS projects developed the
instruments in a cross -cultural approach, were in close collaboration with each other
and used the same methodology. The developmental process included literature
research, expert panels and focus groups with children in order to identify items and
dimensions, and then finally field testing and pilot studies. The same methodological
approach allows combining of both measure s [90].
3.4.3 HRQoL in children with CKD or a kidney transplant
HRQoL in children and adolescents with CKD with a focus on different stages
of CKD and different treatment modalities has been studied only sparsely. A few
studies have evaluated HRQoL before the children has reached ESRD [12]. Gerson et
al. [102] have described HRQoL in children with mild to moderate CKD and
reported impairments in physical, school, emotional, and social functioning, as well
as poorer overall HRQoL co mpared to the general population. Furthermore, anemia,
short stature, and shorter disease duration were found to be variables predicting
HRQoL impairments [102-104]. Gerson et al. reported that HRQoL was already

24 affected in the ea rly stages of CKD, but did not deteriorate between stages 1 and 3
[102]. Other researchers have studied children with CKD in advanced stages (stage 4
and 5) and reported reduced physical and psychosocial functioning in comparison
with healthy children [105-107].
The CKiD (Chronic Kidney Disease in Children) Study identified important
factors associated with a negative influence on HRQoL. Short stature (<5th percentile
for height), sleep disturbances, fatig ue, and urinary incontinence were found to be
common conditions affecting HRQoL [102, 108-110]. The authors pointed out the
importance of detecting and providing treatment for these problems.
Children and adolescents with ESRD have reported a variety of problems such
as an impaired sense of self -worth, uncertainty about the future, and limitations in
physical and psychosocial capacities [111], and children receiving long -term dial ysis
have been shown to have even lower overall health and well -being than those treated
for newly diagnosed cancer [112]. Optimizing the care of children and adolescents
with ESRD regularly and standardized assessments of HRQoL a re necessary to
identify areas where support is required [25, 113].
Kidney transplantation is a successful therapy with excellent outcomes in
pediatric patients [114]. A number o f reports have indicated better HRQoL in
pediatric renal recipients than in those receiving dialysis [112, 114 -116]. There are,
however, conflicting results with other authors reporting no differences in most of
HRQoL domains in c hildren on dialysis as opposed to those with a renal transplant
[106, 117 , 118]. Several studies have pointed out factors which may have a negative
influence on HRQoL in pediatric renal recipients. Neurod evelopmental delays and
cognitive impairments interfering with psychosocial adjustment are some of them
[119] . Impairments in physical functioning and exercise capacity contribute to
diminished well -being [120]. Medication -related negative effects such as weight
gain, headache and fatigue are other common factors affecting several domains of
HRQoL and thus are important to pay attention to in pediatric renal recipients ####
Neurogenic bladder is bladder dysfunction (flaccid or spastic) caused by neurologic

25 damage. Symptoms can include overflow incontinence, frequency, urgency, urge
incontinence, and retention. Risk of serious complications (eg, recurrent infection,
vesicoureteral reflux, autonomic dysreflexia) is high. Diagnosis involves imaging and
cystoscopy or urodynamic testing. Treatment in volves catheterization or measures to
trigger urination.
Any condition that impairs bladder and bladder outlet afferent and efferent
signaling can cause neurogenic bladder . Causes may involve the CNS (eg, stroke,
spinal injury, meningomyelocele, amyotrophic lateral sclerosis), peripheral nerves
(eg, diabetic, alcoholic, or vitamin B 12 deficiency neuropathies; herniated disks;
damage due to pelvic surgery), or both (eg, Parkinson disease, multiple sclerosis,
syphilis). Bladder outlet obstruction often coexists and may exacerbate symptoms.
In flaccid (hypotonic) neurogenic bladder , volume is large, pressure is low, and
contractions are absent. It may result from peripheral nerve damage or spinal cord
damage at the S2 to S4 level. After acute cord damage, in itial flaccidity may be
followed by long -term flaccidity or spasticity, or bladder function may improve after
days, weeks, or months.
In spastic bladder, volume is typically normal or small, and involuntary
contractions occur. It usually results from brain damage or spinal cord damage above
T12. Precise symptoms vary by site and severity of the lesion. Bladder contraction
and external urinary sphincter relaxation are typically uncoordinated (detrusor –
sphincter dyssynergia).
Mixed patterns (flaccid and spast ic bladder) may be caused by many disorders,
including syphilis, diabetes mellitus, brain or spinal cord tumors, stroke, ruptured
intervertebral disk, and demyelinating or degenerative disorders (eg, multiple
sclerosis, amyotrophic lateral sclerosis).

26 Chapter IV
Treatment
 Catheterization
 Increased fluid intake
 Surgery if conservative measures fail
Prognosis is good if the disorder is diagnosed and treated before kidneys are
damaged.
Specific treatment involves catheterization or measures to trigger urin ation.
General treatment includes renal function monitoring, control of UTIs, high fluid
intake to decrease risk of UTIs and urinary calculi (although this measure may
exacerbate incontinence), early ambulation, frequent changes of position, and dietary
Ca restriction to inhibit calculus formation.
For flaccid bladder, especially if the cause is an acute spinal cord injury,
immediate continuous or intermittent catheterization is needed. Intermittent self –
catheterization is preferable to indwelling urethral catheterization, which has a high
risk of recurrent UTIs and, in men, a high risk of urethritis, periurethritis, prostatic
abscesses, and urethral fistulas. Suprapubic catheterization may be used if patients
cannot self -catheterize.
For spastic bladder, tr eatment depends on the patient’s ability to retain urine.
Patients who can retain normal volumes can use techniques to trigger voiding (eg,
applying suprapubic pressure, scratching the thighs); anticholinergics may be
effective. For patients who cannot ret ain normal volumes, treatment is the same as
that of urge incontinence including drugs and sacral nerve stimulation.
Surgery is a last resort. It is usually indicated if patients have had or are at risk
of severe acute or chronic sequelae or if social circ umstances, spasticity, or
quadriplegia prevents use of continuous or intermittent bladder drainage.
Sphincterotomy (for men) converts the bladder into an open draining conduit. Sacral
(S3 and S4) rhizotomy converts a spastic into a flaccid bladder. Urinary diversion
may involve an ileal conduit or ureterostomy.

27 An artificial, mechanically controlled urinary sphincter, surgically inserted, is
an option for patients who have adequate bladder capacity, good bladder emptying,
and upper extremity motor skills an d who can comply with instructions for use of the
device; if patients do not comply, life -threatening situations (eg, renal failure,
urosepsis) can result.
Management strategy of LUTD
The primary goal of treatment of LUT dysfunction is to normalize bladder
function and to prevent kidney injury. Surgical interventions may be required as
treatment for children with structural or neurogenic LUT anomalies.
The first -line treatment for children with various LUT disturbances is bladder
rehabilitation. This treatm ent model is based on cognitive behavioral principles and
includes such components as providing knowledge about normal LUT and bowel
function and which behavioral changes are needed to correct the voiding habits. The
child is given instructions about timed voiding in order to train the voluntary central
nervous control of the micturition [80]. Training of a relaxed voiding posture is basic
and can be administered by means of instructions and simple exercises to gain
awareness of the relaxed or contracted pe lvic floor muscles [81, 82]. Regular follow –
up visits to repeat the instruction and increase understanding and motivation give
valuable and encouraging support [80].
Voiding school was developed by Glad Mattsson et al. as an alter native to the
individual treatment model [83]. This form is applicable for children in small groups
and has shown positive results with regard to reducing UTIs and incontinence. More
specific urotherapeutic nonmedical interventions used include different f orms of
biofeedback training, electrical stimulation, and clean intermittent catheterization
(CIC) [84]. Children with anatomical LUT abnormalities, such as obstructive
uropathy or a severe VUR, may need surgical corrections, often primarily, to relief
the obstruction or facilitate urine drainage from the upper urinary tract. Older
children with neurogenic bladder sometimes require enlargement of the bladder or
other reconstruction procedures to improve bladder compliance [56].

28 Management of LUT dysfunction , when the causes are other than functional
disturbances, may require additional interventions to achieve acceptable storage and
emptying function. Frequent voids and double micturition are useful methods to
optimize bladder emptying in children with post -void residual urine [56].
Anticholinergic medication is used as a complement to improve storage by relaxing
the detrusor muscle and increasing compliance. Polyuria in children as well as
infrequent voiding habits should be addressed in order to prevent bla dder distension.
Overnight catheter drainage has been reported to be an effective therapy in children
with severe polyuria in order to prevent chronic bladder distension and kidney
function deterioration [52, 56, 85].
CIC has become a safe and effective treatment option for children with severe
bladder emptying problems of various etiologies [52]. CIC is the treatment of choice
in children with neurogenic bladder dysfunction for minimizing the consequences of
detrusor sphincter dyssynergia [52, 56]. Early treatment with CIC not only reduces
the risk for UTIs and kidney damage but also helps to enhance urinary continence in
these children [86, 87] .
Therapies for neurogenic bladder fall into four categories: physical –
psychological, electrical -stimulatory, drug therapy and surgery. The correct therapy
or combination of therapies is determined by symptoms, type and extent of nerve
damage, and a comprehensive consultation with the patient to determine his needs,
abilities and desires.
Physical -psychological therapy
Physical -psychologi cal therapy, also called timed voiding, can reduce
problems caused by overactive bladder. It combines will power and exercise. The
patient is asked to keep a voiding diary, which is a daily record of the amount and
time of fluid intake, times of urination, and episodes of leakage. The record creates a
pattern that may initially allow patients to determine the times of the day they should
be in close proximity to a bathroom. These are also the times when a patient should
attempt to urinate. The intervals bet ween voiding times are gradually extended as the

29 patient gains control over voiding. This conditioning is often coupled with physical
exercises, principally Kegel exercises, which strengthen pelvic muscles. The Valsalva
maneuver, an exertion used to pass s tool, may also be sufficient to empty a bladder.

Electrical -stimulatory therapy
Electrical -stimulatory therapy is a recent advance. Electrodes and a small
stimulator are implanted in a minor surgical procedure. The electrodes are placed
near targeted ner ves. The stimulator is placed beneath the skin. The stimulator
delivers electrical impulses that mimic those that would normally be delivered by
nerves if they were undamaged. The device has been approved by the U.S. Food and
Drug Administration to treat u rge incontinence, urgency -frequency syndromes, and
urinary retention in patients in whom other therapies have failed.
Drug therapy
There are as yet no drugs that target specific muscles such as the sphincter.
However there are classes of drugs that reduce muscle spasms and tremors and other
drugs that induce contractions. These can someti mes be effective in appropriate
neurogenic bladder conditions.
Surgical management
Catheterization, although not strictly a surgical procedure, is not infrequently
employe d to ensure complete bladder drainage. It involves the insertion of a thin tube
through the urethra and into the bladder. A number of patients can learn to insert the
catheter themselves. The therapy is called Clean Intermittent Catheterization (CIC).
Exce ptional sanitary procedures must be followed as the risk of urinary tract infection
is significant with any type of catheterization. Another therapy, indwelling
catheterization, places a catheter in the bladder for extended periods. These prevent
bladder d istension by continually draining urine into a bedside collector. Again,
infection is a concern.

30 Urethral stents, something like an internal catheter, can be surgically inserted
through the sphincter muscle to expand it and allow urine to be drained.
The s phincter can be surgically weakened by a procedure called sphincter
resection, which removes a portion of the muscle or the muscle may be removed in
its entirety in a sphincterotomy.
Artificial sphincters are a mechanical intervention. These devices consis t of a
cuff that fits around the bladder neck, a pressure regulating balloon and a pump that
inflates the cuff. The balloon is placed beneath the abdominal muscles. The pump is
placed in the labia in women and in the scrotum for men. Other locations includ e
placement beneath the skin of the abdominal wall or thigh. Activation of the pump
diverts fluid from the cuff to the balloon allowing the sphincter muscle to relax and
urine to pass. The cuff automatically re -inflates automatically in 3 to 5 minutes.
Urinary diversion creates a stoma (opening) through which urine is diverted to
a collection pouch.
Although many of these procedures may initially appear to create a burden,
they have the purpose of preventing kidney damage. If left untreated, Neurogenic
Bladder could lead to renal disease (kidney failure) which requires either a kidney
transpla nt or dialysis to maintain life

Figure3 -Artificial sphincter

31 CLINICAL CASE
Svetlana, a 9 -year-old girl, presents with re current urinary tract infection
(UTIs) and daytime urinary incontinence associated with constipation. She has had
three documented UTIs in the last year. Each time , her urine culture grow more than
100,000 Escherichia coli. The Symptoms include urgency, frequency, pain with
urination, and increas ed urinary incontinence. Her mother called for an appointment
because she had a n accident at school a couple of weeks ago. She is continuing to
experience dampness in her underwear on a daily basis. Urgency and frequency occur
several times per week. She experiences 1 to 2 complete accidents, typically at home,
per week. Related to h er bowel , she is stooling every day, but reports that her stool is
“little, round, hard balls” or “small, hard pieces.” She reports she strains to have a
bowel movement.
Past medical history: Svetlana’s past medical history is ne gative for any
chronic diso rder, and she has no allergies. She has never been hospitalized nor has
she had any surgeries. She is currently taking a multi -vitamin every day.
Physical examination: Weight 26.58 kg (11%); Height 1.34 M (2 6%); BMI
14.78 kg/m2 (11%) Svetlana is an alert, cooperative, and well -appearing child.
Cardiac: Api cal pulse is regular and with no murmur. Respiratory: Breath sounds are
clear and equal to auscultation. GI: Abdomen is soft and non -tender without hepato –
splenomegaly , hernias or masses. Spine is straight .
Urinalysis: Within normal limits.
Past renal and bladder ultrasound results: Svetlana had a renal and bl adder
ultrasound when she was four years -old because of her history of UTIs and urinary
incontinence. There wa s no renal stones, hydronephrosis , or pe rinephric fluid
collection. There was normal blood flow to both renal hilar regions. The bladder was
partially distended and had an abnormal thickened bladder wall. The renal and
bladder ultrasound was otherwise unremarkable.

32 Impression and Plan:
Impress ion: Daytime urinary incontinence with underlying constipation and
continued recurrent UTIs. Discussed 4 -point s education program to improve u rinary
and bowel habits with the mother and Svetlana to help decrease symptoms: (1)
increase fluid intake, bring w ater bottle to school; (2) urinate every 1.5 hours during
the day; make sure teachers are on board with this at school; (3) use proper voiding
habits such as wiping from front to back after a stool; and (4) manage constipation by
increasing dietary fiber a nd taking Miralax on a daily basis to produce a daily, soft,
normal -caliber stool.
Plan : Will have Svetlana work on her 4 -point elimination program for 3
months. If symptoms persist, we will obtain results from uroflowmetry, perineal
electromyography and p ost void residual (uroflow, EMG, PVR) to assess the cause of
her urinary issues.
Svetlana’s urinary symptoms persist, so she is asked to come in for uroflow,
electromyogram (EMG) and post -void residual (PVR) to determine the underlying
cause of her urinary issues.
Uroflow . Svetlana’s urofl ow results are shown in Figure 4.a .

Figure 4.a

33 Figure 4 . Uroflow results
Svetlana’s uroflow results show:
Peak flow: 13.5 ml/s (low)
Voiding flow: 19 sec (low)
Voided volume: 63 ml (low)
Average flow rate: 5.2 ml/s (l ow)
The flow pattern is: staccato (abnormal) EMG. Sphincter and abdominal
activity were recorded with EMG pads placed on the patient’s perineum (pel vic floor)
and abdomen. Figure 4.b shows the EMG results.

Figure 4.b . Example of a patient’s with a norma l EMG

34 PVR. Svetlana’s PVR results show:
Amount: 173 ml
% of voided volume: 275 (large abnormal post void residual)
Uroflow, EMG, PVR Impression and Plan: Flow pattern is staccato, low
urinary flow rate, incomplete urinary bladder emptying, small bladder capacity, and
increased muscle activity of both the pelvic floor and abdominal muscles during
urination. Large post void residual in combination with constipation and
dysfunctional voiding is contributing to recurrent UTIs.
Svetlana may benefit fr om pelvic floor muscle retraining using biofeedback.
Recommend biofeedback and institution of anticholinergics once low residual proven
on two separate PVRs.
FINAL DIAGNOSIS
Based on the clinical presentation and diagnostic testing and exams , the patient
was diagnosed with lower urinary tract dysfunction (LUTD), constipation, and
incomplete bladder emptying.
Svetlana starts biofeedback as was recommended based on uroflow, EMG,
PVR results and final diagnosis. After 3 sessions of biofeedback Susie is showing
some behavioral improvement: she is following the timed voiding plan (goal: every
1.5 hours), continues to take Miralax (polyethylene glycol), and is doing pelvic floor
exercises at home. She reports that her constipation is improving and her stools are
softer (Type 3, 4 on the Bristol Chart). She denies any dampness or accidents in the
past 2 weeks and denies encopresis. Unfortunately, she struggles with increasing fluid
and fiber and she had a recent UTI, which is being treated with Amoxicillin. Uroflow,
EMG, and PVR are scheduled to assess objective progress of the treatment plan.
Susie will continue with biofeedback until there is objective improvement of pelvic
floor muscle dysfunction and decreased post void residual.
Treatment . Conservative managemen t is the initial treatment strategy for
children presenting with the primary complaint of LUTD sympt oms without
anatomic abnormalities . Foc us on modification of the child’s urinary and bowel

35 habits in an attempt to ameliorate incontinence and prevent UTI before more invasive
testing and treatment strategies are undertaken. Improvement of bowel function is
one of the main goals in managing the voiding symptoms and UTIs that are part of
LUTD. Program differ in exact protocol; however, most emphasize patient education
as the initial approach to treat LUTD.
Education . Primary care providers should begin management for LUTD with
education as up to 25% of the patients will improve with education alone without
further evaluation or treatment which should decrease the need for referrals.
Education concerning proper posture during voiding should be emphasized to
minimize abdominal musculature straining. Proper sitting technique with buttock and
foot support and comfortable hip position is necessary to enable voiding without
recruitment of the abdominal muscles. Additionally, elimination education is very
important. Part of the elimination education should explain how voiding works and
the anatomy of the muscles involved in the voiding. The remainder of the elimination
education should focus on these 4 key components:
Increased fluids : encourage patient to bring water bottle to school
Timed voiding : patient should void every 1.5 hours; involve teachers at school
Bowel program: goal is to develop large, soft daily bowel movement;
encourage patient to increase fiber intake and take MiraLax; use the Bristol Scale to
explain bowel function (goal for patient is to achieve a score of 3 or 4 on the Bristol
Scale)
Hygiene: this is important to limit UTIs and local skin inflammat ion that may
contribute to holding maneuvers and DV; female patient should avoid bubble baths
and wipe from front to back after stools.
If education does not resolve the LUTD symptoms, then the patient should
undergo uroflow, EMG, PVR and ultrasound to ass ess the underlying cause of the
urinary issues. Recommendations for further treatment are made based on results of
these tests. Table 1 summarizes the treatment recommendations based on results of
uroflow, EMG and PVR.

36 Table 1. Summary of treatment recomme ndations based off of uroflow, EMG,
PVR
Uroflow, EMG, PVR
Results Pelvic floor muscle
retraining using
biofeedback
recommended? Medication Recommended
Pelvic floor dysfunction,
large bladder capacity,
high PVR Yes None
Pelvic floor dysfunction,
small bla dder capacity,
low PVR Yes Early institution of
anticholinergics
Pelvic floor dysfunction,
small bladder capacity,
high PVR Yes Anticholinergics (initiated
once PVR is lowered by
biofeedback)
Relaxation of pelvic floor
muscle activity, low
flow, delay to flow
(typically seen in males
only) No Alpha -blockers

Pelvic Floor Muscle Retraining (PFMR). PFMR using biofeedback therapy
is the next line of treatment after conservative approaches. Goals of biofeedback
therapy differ according to the kind of LUTD, b ut in each case the awareness of the
pelvic floor to alter the patients voiding habits is the main objective. In children with
hyperactive pelvic floor, biofeedback therapy focuses on relaxation and a return of
normal flow. For children with overactive bla dder and incontinence, use of the
guarding reflex of the pelvic floor musculature can maintain continence during
uninhibited contractions. In addition, biofeedback can teach these children to void

37 optimally and ensure that there is no decompensation of the detrusor muscle that
occurs with the lazy bladder syndrome.
At our institution, PFMR is administered by an urotherapist in 6 to 10
individual 1 -hour sessions. The first session concentrates on isolation of the pelvic
floor musculature through Kegel exerci ses in patients while being monitored on
EMG. Surface EMG leads are placed at the 4 – and 10 -o’clock positions on the
perineum, and an abdominal lead is placed on the rectus abdominis muscles. If Kegel
exercises are difficult to achieve, then the pelvic flo or is actively contracted by
rolling the knees and feet in and out with each leg held straight and each heel in
place. This exercise forces the patient to use the pelvic floor and the subsequent
Kegel exercises. Each subsequent session begins with a discus sion of the patient’s
progress regarding UTIs, incontinence, constipation, and doing Kegel exercises at
home. The session then moves to relaxation exercises followed by short repetitions of
quick flicks monitored on EMG to ensure isolation of the pelvic fl oor with relaxation
of the abdomen. The session advances to cycles of contraction s, relaxation, and quick
flick exercises while being monitored with EMG. The contraction and relaxation of
the pelvic floor are used to achieve goals in video games such as go lf, growing
flowers, or spaceships. Use of this type of biofeedback has been successful, with 87%
of patients re porting subjective improvement.
Pharmacologic Therapy . About 80% of patients respond to PFMR using
biofeedback. The remaining 20% of patients of ten require pharmacologic therapy.
The use of pharmacologic therapy in the treatment of LUTD is an adjunct to the
standard urotherapy. Pharmacotherapy may be used generally in 2 ways: to enhance
bladder emptying and bladder filling.
Alpha -adrenergic blocka de of receptors at the bladder neck and urethra results
in relaxation of smooth muscle and theoretically enables more complete bladder
emptying. Male patients with low flow, delay to flow and relaxation of pelvic floor
muscle activity as displayed on the u roflow, EMG, PVR likely have smooth muscle

38 dysfunction and respond well to alpha blockers (e.g. doxazosin). In our experience,
approximately 3% of patients with LUTD have this problem.
Anticholinergic therapy is used to facilitate bladder filling by inhibi ting
detrusor contractions. The place of anticholinergics has moved from being a primary
intervention in the treatment of overactive bladder syndrome to a more ancillary role
with biofeedback. For patients with small bladder capacity a nd low PVR that have
undergone three sessions of biofeedback, early institution of anticholinergics (e.g.
oxybutynin) is part of the treatment plan. For children with small bladder capacity
and high PVR, a full series of biofeedback sessions (6 -10) is often necessary to
isolat e pelvic floor muscles and lower PVR before initiation of anticholinergics.
About 87% of these patients with small -capacity bladders improve with biofeedback
and the addition of anticholinergics.
CASE CONCLUSION
LUTD is a common disorder that may be under -reported by parents and
clinicians. Although the prognosis is favorable in most cases, serious long -term
complications can occur, including renal failure. Thorough history, physical, and
step-wise evaluation will determine appropriate treatment strategies. Advances in the
understanding of the underlying pathology of this common disorder have led to
revolution in management, from expensive and potentially harmful medications and
surgeries to noninvasive, effective behavioral management. Primary care provider s
are encouraged to start elimination education before referral as this may result in a
25% cure rate.
Prognosis
The prognosis for recovery depends on the type, severity, and location of the
lesion causing the bladder problem and can be organized by dysfun ctions that are
permanent, dysfunctions that resolve with treatment of the condition, and
dysfunctions that require medical and/or surgical intervention.

39 Permanent bladder dysfunction includes those patients with complete
transaction of the spinal cord. Th ese individuals remain on intermittent or indwelling
catheterization for the rest of their lives.
Causes of temporary, syndromic urinary incontinence include pol yneuropathy
secondary to B-12 deficiency. This improves with nutritional correction.
Patients with upper motor neuron lesions (eg, strokes, MS, and spinal cord
pathology) may have to depend on medications for the rest of their lives, although
some degree of recovery may be expected. Those with anatomic derangements like
pelvic floor weakness may fi nd symptomatic improvement with surgical correction.

CONCLUSIONS
Neurological disorders are a significant issue in rehabilitation services and it
can lead to lower tract dysfunction, which causes LUTS. Storage symptoms are more
common, especially urge inc ontinence. Current literature reports that a further
optimization of the rehabilitation potential of neurologically ill patients is possible
through an implementation of urological basic measures into the neurological
treatment routine.
Neurogenic bladder dysfunction can be successfully treated to achieve goals of
urinary continence, prevention of renal damage from chronically high detrusor
pressures, and minimizing risk of urinary tract infections or bladder overdistension. A
comprehensive multidisciplinar y bladder retraining program can best achieve these
goals utilizing patient education, instruction in catheter use/care, medications, and/or
bladder or urethral surgical procedures. Experimental works in lumbar -to-sacral
nerve rerouting and in regenerative medicine including use of stem cells to mitigate
or reverse spinal cord damage producing neurogenic bladder dysfunction are still in
their infancy, and more research will be needed to see if the promising results of
some small pilot studies are confirmed in larger, controlled studies with long -term
followup .

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