PEDIATRIC UROLOGY
RELATIONSHIP OF VOIDING DYSFUNCTION TO URINARY TRACT INFECTION AND VESICOURETERAL REFLUX IN CHILDREN WARREN SNODGRASS, M.D.
From the Department of Pediatrics, Division of Pediatric Urology, Texas Tech University Health Science Center, Lubbock, Texas
ABSTRACT--A total oJ 109 children were evaluated for urinary tract infections or ?for voiding dysfunction without infections. The relationship of voiding dysfunction to urinary infection and vesicoureteral reflux was then examined in girls. The number of males studied was too small Jot statistical analysis. While 40.6 percent of females with infections had voiding dysfunction, in 66.6 percent of those females having voiding dysyunction injections also developed. Voiding dysfunction was noted in 33.3 percent oJ Jemales with reflux, probably due to the strong association oJ reflux and injections. However, oJ all females with voiding dysfunction, only 20.6 percent also had reflux. These findings were statistically significant (12 = O.01) and suggest that voiding dysfunction is common in girls with infections, perhaps even predisposing to the development oJ injections. However, voiding dysfunction in this population did not predispose to reflux.
~"y and frequency, squatting be~rnal incontinence which persist usual phase of toilet-training in onsidered symptoms of voiding ~¢pically, urodynamic testing in reveals uninhibited bladder conmay be associated with volunthe external sphincter to prevent 3
tt voiding dysfunction occurs in in which urinary infections and reflux are usually detected has ion that it may represent an un~tially treatable, etiology of these towever, few studies of children or reflux have reported the assoce of voiding dysfunction. In'eports have concentrated on ed to specialized centers for uroLg of apparent voiding dysfunccases may not be representative population.
?TOBER 1991
/
This study examines the relationship of voiding dysfunction, urinary infections, and vesieoureteral reflux in an unseleeted group of children referred for urologic evaluation. Material and Methods The study consisted of 109 consecutive children referred for urologic evaluation of urinary tract infections or voiding dysfunction without infection. The patients ranged in age from six weeks to eighteen years. There were 76 females and 11 males with urinary infections, and 13 females and 9 males with voiding dysfunction alone. M1 children with voiding dysfunction experienced frequent urination with urgency, and most also noted squatting behavior and diurnal incontinence. Typically these symptoms had been present continuously since toilet-training, and on that basis were thought not to represent the daytime urinary frequency syndrome ° or
V O L U M E XXXVIII, N U M B E R 4
341
18 t . . . . . . . . . . . . . . . . . . . .[]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N I ° ~ um 6 .................................................... b o .
e
.
.
cl
.
.
.
.
.
.
1
.
2
.
.
.
.
8
.
4
.
.
.
.
5
.
.
.
6
.
.
.
.
.
7
.
.
.
.
8
.
9
....................................... lo ~- ........................... • - ............................
.
.
.
.
10
u718
.
11
TABLEI. No. of Pts.
_
12
~1
i e 16~
1
2
~
4
s
6
7
9
10
11
12
,12
........................................................................................
n
Vesicoureteral Reflux
t 1° t a
V.oicling Dy_sfuncti0 n
8
5
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
o. ~1
1
II 2
.~tl
l 3
4
6
6
• 7
8
t 9
10
Age in Years
11
12
,12
[ ] Females Males
Females < 3 yrs. > 3 yrs. TOTALS Males < 3 yrs. ->3 yrs.
Results Characteristics of the study group are depicted in Figure 1. As expected in children evaluated primarily for urinary infections, most of the patients were young females. Table I shows that of these females, 31.5 percent had vesicoureteral reflux, which is also anticipated in this population. The incidence of voiding dysfunction was 40.6 percent in females over three years of age with infections. The number of males with infections was too small to allow further analysis. In children having voiding dysfunction with no history of urinary infections, reflux was detected in 12.5 percent and 11.1 percent of females and males tested, respectively. Eight of 13 girls consented to VCUG. No male had radiographic evidence of outlet obstruction. A total of 28 patients and 36 ureters demonstrated vesicoureteral reflux. Using the International Reflux Study Committee classification, 3 ureters had grade III reflux, while the remainder were grades I and II.
NA 26 (40.6%)
76 5 6
NA 1
TABLE 1I.
Relationship oj and UTls in females over
and reflux in 109 consecutive children.
bladder irritability in the presence of infection. Furthermore, no patient had enuresis alone. Urodynamie testing was not done. Radiographic evaluation of children with infections consisted of voiding eystourethrography (VCUG) and either intravenous pyelography or renal ultrasonography. One female and one male refused the VCUG. Children with voiding dysfunction without infection also underwent VCUG. All 9 males and 8 of 13 females consented to the examination. Statistical analysis was performed using the ehi-square test.
12 64
KEY: VD = voiding dysfunction: voiding dysfunction and reflux. *One child refused VCUG.
FIGURE 1. Incidence of UTI, voiding dysfunction,
342
VD
,12
r 15
t
Number of c,
VD 39 pts. UTI 64 pts.
UTI 26 (66.6 %) VD 26 (40.6%)
KEY: VD = voiding dysfunction; tion. *p = 0.01.
There were 49 childre function, 39 females and males, 26 (66.6%) also ha As noted, 5 females declin maining 34 females, 7 (2E the 10 males, one had in demonstrated reflux. No dysfunction was found to genic neurogenic bladder The relationship betwc tion, urinary tract infect teral reflux was further e Because the number of m were excluded from the st Table II shows the tel dysfunction and urinary t male children; 66.6 perc v o i d i n g d y s f u n c t i o n al Furthermore, of all femah tions, 40.6 percent also nc tion. These distribution highly significant (p = 0.q The relationship betwe tion and vesicoureteral ref III. Only 20.6 percent of: dysfunction also had reflu males with demonstrated function coexisted in 33.3 ings were also highly signi Comme The children reported : all referrals during a th
UROLOGY
/
OCTOBER 1991
/
VOL1
III. Relationship of voiding dys]unction reflux in ]emales over three years of age* tl
No R 27 (79.4°7o) No VD
7 (20.6%) VD 7 (33.3070)
id i~: t t!
14 (66.6%)
~i:~D = voiding dysfunction; B = reflux.
~ 0:0L
~
,[~j§:~atients, 34 u n d e r w e n t V C U G .
~ e : e v a l u a t m n of urmary tract infections ~0'iding dysfunction without infection. With ~eX6eptions, radiographic studies were not ~ h y the pediatrieian before referral. As ex~ most of the ehildren were evaluated af~u~i~ary infections. Young females pre~nated, and of these, 31.7 percent were also ~ : : t 0 have reflux, whieh is consistent with ~i~gs of previous studies, x0Consequently, the ~ t s in this study appear to be representa~6f those typically encountered in clinical of voiding dysfunction was ermined. All patients with were speefieally questioned 1proms of urgency and frebehavior, and diurnal ineonrents did not volunteer these g attributed such behavior to or to the child "playing too ag voiding." Children with ~iifig dysfunction but no history of infection voiding symptoms. Voiding dys~t~!9~ hsually had been present since toiletbih i!i and in all eases for at least one year. raphie evaluation, these ~dwith oxybutynin, with all t or resolution of the sympfunction. hildren with urinary infeeorted the incidence of assoIsfunetion. Lapides and with eystometry 71 girls acting uninhibited bladder ereent. Similarly, our study t40.6 percent of females with infeetoilet-training had voiding dysfune.while the number of males seen with after three years of age was small, i (16.6 %) had voiding dysfunction. ~.12 have evaluated children referred !s voiding dysfunction. Urodynamie ~as demonstrated uninhibited bladder Ks, with or without external sphine~rgia, in 47 to 74 percent. Urinary in-
?i;i
ocToBE
199
fections have generally occurred in 60 percent of these children. The relative incidence of infection in females and males with voiding dysfunction usually has not been reported, although one study 2 found that 66 percent of females and 11 percent of males also had infections. Similarly, in our population, 66.6 percent of females and only 10 percent of males with voiding dysfunction had urinary infection. As shown in Table III, the statistical findings that 40.6 percent of females with urinary infection had voiding dysfunction and that of all females with voiding dysfunction, 66.6 percent had infections are highly significant (p = 0.01). Consequently, it appears voiding dysfunction is commonly found in females with infections and when present, may even predispose to the development of infeetions. The mechanism by which this occurs is not known. The high intravesical pressures found with voiding dysfunction may cause mueosal isehemia and thereby compromise bladder defenses? Others have observed turbulent urinary flow in voiding dysfunction which could wash bacteria from the urethra into the bladder. 7 Turbulence in the shorter female urethra may explain the higher incidence of infections in females than in males with voiding dysfunction. Several other factors contributing to the development of urinary infections in children have been identified. ~° These inelude impairment of host defenses by genetic factors, deficient perineal resistance, or structural abnormalities of the urinary tract. Bacterial virulence properties which allow adherence to the urothelium are also important. Of these factors, only anatomic abnormalities can generally be clinically corrected to prevent infection. Yet structural abnormalities, other than reflux, are uncommon.
The importance of identifying voiding dysfunction is then not only due to its prevalence but also beeause it can be medically treated. All children in this study have responded to oxybutynin, although follow-up is too brief to comment on the effectiveness of this therapy in preventing infections. Aneedotally, control of voiding dysfunction has stopped recurring infections in some of these children, as has been noted by others. 4'6 Consequently, it seems appropriate to identify and treat children, especially females, with voiding dysfunction to prevent urinary infections. The observation that high intravesical pressures occur with voiding dysfunction also has
V O L U M E XXXVIII, N U M B E B 4
343
led to speculation that vesieoureteral reflux could develop. This would be analogous to the secondary onset of reflux documented in overtly neurogenie bladders having "leak point" pressures exceeding 40 em of water, la Furthermore, reflux is usually detected in children three to six years old, which coincides with the peak incidence of voiding dysfunction. 8 In fact, it has been reported that children whose voiding dysfunction is treated with antieholinergie medication resolve at a faster rate than do children w i t h reflux but no v o i d i n g dysfunction. 6 Finally, some failures of ureteroneoeystostomy can be attributed to unrecognized voiding dysfunction. 14 In the present study, voiding dysfunction was noted in 33.3 percent of females over three years of age with reflux. However, this relates primarily to the strong associations of both reflux and voiding dysfunction to urinary infection in these females. Of all females with voiding dysfunction studied with VCUG, only 20.6 percent had reflux. As shown in Table III, these findings were statistically highly significant (p = 0.01). Furthermore, in 10 males with voiding dysfunction, reflux was detected in only 1 (10%). Few previous studies of children with reflux have reported the associated incidence of voiding dysfunction. Instead, others have evaluated those referred with obvious voiding dysfunction and found reflux in as many as 50 percent. 5,s The high incidence of reflux noted in these studies as compared with the present group most likely reflects p a t i e n t selection. P r o b l e m children referred to specialized centers for urodynamic testing probably have more severe voiding dysfunction than do those encountered in routine practice. In fact, the highest reported association of voiding dysfunction to reflux has been in children with the non-neurogenie neurogenie bladder syndrome, s,'2 not seen in this group. Furthermore, one recent study which attempted to distinguish degrees of voiding dysfunction found reflux in only 24 percent of children with hyperreflexia as compared with 50 percent with detrusor-external sphincter dyssynergia. 3 Most children with voiding dysfunction do not appear to have severely deranged mieturition. Consequently, it is likely that if voiding dysfunction does cause reflux, it occurs by compromise of a borderline orifice rather than by distortion of previously normal ureteral anatomy. Certainly this must not account for the
344
majority of children ' therapy with antieholil be useful in those situati ditions coexist. In summary, voiding mon finding in female~, infections and, when p: infections to occur. The~ seen in the relatively sm led. Because most fer diagnosed during evalu~ tion, it is not surprisin voiding dysfunction, t function per se was not t cause of reflux in this pc voiding dysfunction in c and/or reflux does reprq able condition and in vJ therapy may stop reeui in the resolution of refl~ able part of the therapc
ACKNOWLEDGMENT.To Jo~ University, Lubbock, Texas, Refer I. Allen TD, and Bright TC: with dysfunctional voiding prob 2. Firlit CF, Smey P, and Ki: flow studies in children, J Urol 3. Mayo ME, and Burns MW: sor instability alone and dysfune 316), J Urol 141: 248A (1989). 4. Lapides J, and Diokno AC: as a cause for urinary infection : 5. Koff SA, Lapides J, and Pi tract infection and reflux with I and voluntary sphincterie obstrt 6. Koff SA, and Murtagh E children: effect of treatment on and on vesicoureteral reflux rest 7. van Cool J, and Tanagho and recurrent urinary tract inf, (1977). 8. Allen TD: Vesicoureteral J functional voiding, in Halson J, flux Neuropathy, New York, Ma~ 171. 9. Koff SA, and Byard MA: syndrome of childhood, J Urol 1 10. Bickerton GD, and Ducke pediatric patients, A.U.A. Up& 11. Webster GD, Koefoot R]? abnormalities in neurologically 1 dysfunction, J Urol 132:74 (19~ 12. Bauer SB, et ah The uns Clin North Am 7:321 (1980). 13. MeGuire EJ, Woodside j Prognostic value of urodynami tients, J Urol 126:205 (1981). 14. Noe HN: The role of dy complication of ureteral reimpla 126:205 (1981).
UROLOGY
/
OCTOBER 1991
/
'v
RELATIONSHIP OF VOIDING DYSFUNCTION TO URINARY TRACT INFECTION AND VESICOURETERAL REFLUX IN CHILDREN WARREN SNODGRASS, M.D.
From the Department of Pediatrics, Division of Pediatric Urology, Texas Tech University Health Science Center, Lubbock, Texas
ABSTRACT--A total oJ 109 children were evaluated for urinary tract infections or ?for voiding dysfunction without infections. The relationship of voiding dysfunction to urinary infection and vesicoureteral reflux was then examined in girls. The number of males studied was too small Jot statistical analysis. While 40.6 percent of females with infections had voiding dysfunction, in 66.6 percent of those females having voiding dysyunction injections also developed. Voiding dysfunction was noted in 33.3 percent oJ Jemales with reflux, probably due to the strong association oJ reflux and injections. However, oJ all females with voiding dysfunction, only 20.6 percent also had reflux. These findings were statistically significant (12 = O.01) and suggest that voiding dysfunction is common in girls with infections, perhaps even predisposing to the development oJ injections. However, voiding dysfunction in this population did not predispose to reflux.
~"y and frequency, squatting be~rnal incontinence which persist usual phase of toilet-training in onsidered symptoms of voiding ~¢pically, urodynamic testing in reveals uninhibited bladder conmay be associated with volunthe external sphincter to prevent 3
tt voiding dysfunction occurs in in which urinary infections and reflux are usually detected has ion that it may represent an un~tially treatable, etiology of these towever, few studies of children or reflux have reported the assoce of voiding dysfunction. In'eports have concentrated on ed to specialized centers for uroLg of apparent voiding dysfunccases may not be representative population.
?TOBER 1991
/
This study examines the relationship of voiding dysfunction, urinary infections, and vesieoureteral reflux in an unseleeted group of children referred for urologic evaluation. Material and Methods The study consisted of 109 consecutive children referred for urologic evaluation of urinary tract infections or voiding dysfunction without infection. The patients ranged in age from six weeks to eighteen years. There were 76 females and 11 males with urinary infections, and 13 females and 9 males with voiding dysfunction alone. M1 children with voiding dysfunction experienced frequent urination with urgency, and most also noted squatting behavior and diurnal incontinence. Typically these symptoms had been present continuously since toilet-training, and on that basis were thought not to represent the daytime urinary frequency syndrome ° or
V O L U M E XXXVIII, N U M B E R 4
341
18 t . . . . . . . . . . . . . . . . . . . .[]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N I ° ~ um 6 .................................................... b o .
e
.
.
cl
.
.
.
.
.
.
1
.
2
.
.
.
.
8
.
4
.
.
.
.
5
.
.
.
6
.
.
.
.
.
7
.
.
.
.
8
.
9
....................................... lo ~- ........................... • - ............................
.
.
.
.
10
u718
.
11
TABLEI. No. of Pts.
_
12
~1
i e 16~
1
2
~
4
s
6
7
9
10
11
12
,12
........................................................................................
n
Vesicoureteral Reflux
t 1° t a
V.oicling Dy_sfuncti0 n
8
5
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
o. ~1
1
II 2
.~tl
l 3
4
6
6
• 7
8
t 9
10
Age in Years
11
12
,12
[ ] Females Males
Females < 3 yrs. > 3 yrs. TOTALS Males < 3 yrs. ->3 yrs.
Results Characteristics of the study group are depicted in Figure 1. As expected in children evaluated primarily for urinary infections, most of the patients were young females. Table I shows that of these females, 31.5 percent had vesicoureteral reflux, which is also anticipated in this population. The incidence of voiding dysfunction was 40.6 percent in females over three years of age with infections. The number of males with infections was too small to allow further analysis. In children having voiding dysfunction with no history of urinary infections, reflux was detected in 12.5 percent and 11.1 percent of females and males tested, respectively. Eight of 13 girls consented to VCUG. No male had radiographic evidence of outlet obstruction. A total of 28 patients and 36 ureters demonstrated vesicoureteral reflux. Using the International Reflux Study Committee classification, 3 ureters had grade III reflux, while the remainder were grades I and II.
NA 26 (40.6%)
76 5 6
NA 1
TABLE 1I.
Relationship oj and UTls in females over
and reflux in 109 consecutive children.
bladder irritability in the presence of infection. Furthermore, no patient had enuresis alone. Urodynamie testing was not done. Radiographic evaluation of children with infections consisted of voiding eystourethrography (VCUG) and either intravenous pyelography or renal ultrasonography. One female and one male refused the VCUG. Children with voiding dysfunction without infection also underwent VCUG. All 9 males and 8 of 13 females consented to the examination. Statistical analysis was performed using the ehi-square test.
12 64
KEY: VD = voiding dysfunction: voiding dysfunction and reflux. *One child refused VCUG.
FIGURE 1. Incidence of UTI, voiding dysfunction,
342
VD
,12
r 15
t
Number of c,
VD 39 pts. UTI 64 pts.
UTI 26 (66.6 %) VD 26 (40.6%)
KEY: VD = voiding dysfunction; tion. *p = 0.01.
There were 49 childre function, 39 females and males, 26 (66.6%) also ha As noted, 5 females declin maining 34 females, 7 (2E the 10 males, one had in demonstrated reflux. No dysfunction was found to genic neurogenic bladder The relationship betwc tion, urinary tract infect teral reflux was further e Because the number of m were excluded from the st Table II shows the tel dysfunction and urinary t male children; 66.6 perc v o i d i n g d y s f u n c t i o n al Furthermore, of all femah tions, 40.6 percent also nc tion. These distribution highly significant (p = 0.q The relationship betwe tion and vesicoureteral ref III. Only 20.6 percent of: dysfunction also had reflu males with demonstrated function coexisted in 33.3 ings were also highly signi Comme The children reported : all referrals during a th
UROLOGY
/
OCTOBER 1991
/
VOL1
III. Relationship of voiding dys]unction reflux in ]emales over three years of age* tl
No R 27 (79.4°7o) No VD
7 (20.6%) VD 7 (33.3070)
id i~: t t!
14 (66.6%)
~i:~D = voiding dysfunction; B = reflux.
~ 0:0L
~
,[~j§:~atients, 34 u n d e r w e n t V C U G .
~ e : e v a l u a t m n of urmary tract infections ~0'iding dysfunction without infection. With ~eX6eptions, radiographic studies were not ~ h y the pediatrieian before referral. As ex~ most of the ehildren were evaluated af~u~i~ary infections. Young females pre~nated, and of these, 31.7 percent were also ~ : : t 0 have reflux, whieh is consistent with ~i~gs of previous studies, x0Consequently, the ~ t s in this study appear to be representa~6f those typically encountered in clinical of voiding dysfunction was ermined. All patients with were speefieally questioned 1proms of urgency and frebehavior, and diurnal ineonrents did not volunteer these g attributed such behavior to or to the child "playing too ag voiding." Children with ~iifig dysfunction but no history of infection voiding symptoms. Voiding dys~t~!9~ hsually had been present since toiletbih i!i and in all eases for at least one year. raphie evaluation, these ~dwith oxybutynin, with all t or resolution of the sympfunction. hildren with urinary infeeorted the incidence of assoIsfunetion. Lapides and with eystometry 71 girls acting uninhibited bladder ereent. Similarly, our study t40.6 percent of females with infeetoilet-training had voiding dysfune.while the number of males seen with after three years of age was small, i (16.6 %) had voiding dysfunction. ~.12 have evaluated children referred !s voiding dysfunction. Urodynamie ~as demonstrated uninhibited bladder Ks, with or without external sphine~rgia, in 47 to 74 percent. Urinary in-
?i;i
ocToBE
199
fections have generally occurred in 60 percent of these children. The relative incidence of infection in females and males with voiding dysfunction usually has not been reported, although one study 2 found that 66 percent of females and 11 percent of males also had infections. Similarly, in our population, 66.6 percent of females and only 10 percent of males with voiding dysfunction had urinary infection. As shown in Table III, the statistical findings that 40.6 percent of females with urinary infection had voiding dysfunction and that of all females with voiding dysfunction, 66.6 percent had infections are highly significant (p = 0.01). Consequently, it appears voiding dysfunction is commonly found in females with infections and when present, may even predispose to the development of infeetions. The mechanism by which this occurs is not known. The high intravesical pressures found with voiding dysfunction may cause mueosal isehemia and thereby compromise bladder defenses? Others have observed turbulent urinary flow in voiding dysfunction which could wash bacteria from the urethra into the bladder. 7 Turbulence in the shorter female urethra may explain the higher incidence of infections in females than in males with voiding dysfunction. Several other factors contributing to the development of urinary infections in children have been identified. ~° These inelude impairment of host defenses by genetic factors, deficient perineal resistance, or structural abnormalities of the urinary tract. Bacterial virulence properties which allow adherence to the urothelium are also important. Of these factors, only anatomic abnormalities can generally be clinically corrected to prevent infection. Yet structural abnormalities, other than reflux, are uncommon.
The importance of identifying voiding dysfunction is then not only due to its prevalence but also beeause it can be medically treated. All children in this study have responded to oxybutynin, although follow-up is too brief to comment on the effectiveness of this therapy in preventing infections. Aneedotally, control of voiding dysfunction has stopped recurring infections in some of these children, as has been noted by others. 4'6 Consequently, it seems appropriate to identify and treat children, especially females, with voiding dysfunction to prevent urinary infections. The observation that high intravesical pressures occur with voiding dysfunction also has
V O L U M E XXXVIII, N U M B E B 4
343
led to speculation that vesieoureteral reflux could develop. This would be analogous to the secondary onset of reflux documented in overtly neurogenie bladders having "leak point" pressures exceeding 40 em of water, la Furthermore, reflux is usually detected in children three to six years old, which coincides with the peak incidence of voiding dysfunction. 8 In fact, it has been reported that children whose voiding dysfunction is treated with antieholinergie medication resolve at a faster rate than do children w i t h reflux but no v o i d i n g dysfunction. 6 Finally, some failures of ureteroneoeystostomy can be attributed to unrecognized voiding dysfunction. 14 In the present study, voiding dysfunction was noted in 33.3 percent of females over three years of age with reflux. However, this relates primarily to the strong associations of both reflux and voiding dysfunction to urinary infection in these females. Of all females with voiding dysfunction studied with VCUG, only 20.6 percent had reflux. As shown in Table III, these findings were statistically highly significant (p = 0.01). Furthermore, in 10 males with voiding dysfunction, reflux was detected in only 1 (10%). Few previous studies of children with reflux have reported the associated incidence of voiding dysfunction. Instead, others have evaluated those referred with obvious voiding dysfunction and found reflux in as many as 50 percent. 5,s The high incidence of reflux noted in these studies as compared with the present group most likely reflects p a t i e n t selection. P r o b l e m children referred to specialized centers for urodynamic testing probably have more severe voiding dysfunction than do those encountered in routine practice. In fact, the highest reported association of voiding dysfunction to reflux has been in children with the non-neurogenie neurogenie bladder syndrome, s,'2 not seen in this group. Furthermore, one recent study which attempted to distinguish degrees of voiding dysfunction found reflux in only 24 percent of children with hyperreflexia as compared with 50 percent with detrusor-external sphincter dyssynergia. 3 Most children with voiding dysfunction do not appear to have severely deranged mieturition. Consequently, it is likely that if voiding dysfunction does cause reflux, it occurs by compromise of a borderline orifice rather than by distortion of previously normal ureteral anatomy. Certainly this must not account for the
344
majority of children ' therapy with antieholil be useful in those situati ditions coexist. In summary, voiding mon finding in female~, infections and, when p: infections to occur. The~ seen in the relatively sm led. Because most fer diagnosed during evalu~ tion, it is not surprisin voiding dysfunction, t function per se was not t cause of reflux in this pc voiding dysfunction in c and/or reflux does reprq able condition and in vJ therapy may stop reeui in the resolution of refl~ able part of the therapc
ACKNOWLEDGMENT.To Jo~ University, Lubbock, Texas, Refer I. Allen TD, and Bright TC: with dysfunctional voiding prob 2. Firlit CF, Smey P, and Ki: flow studies in children, J Urol 3. Mayo ME, and Burns MW: sor instability alone and dysfune 316), J Urol 141: 248A (1989). 4. Lapides J, and Diokno AC: as a cause for urinary infection : 5. Koff SA, Lapides J, and Pi tract infection and reflux with I and voluntary sphincterie obstrt 6. Koff SA, and Murtagh E children: effect of treatment on and on vesicoureteral reflux rest 7. van Cool J, and Tanagho and recurrent urinary tract inf, (1977). 8. Allen TD: Vesicoureteral J functional voiding, in Halson J, flux Neuropathy, New York, Ma~ 171. 9. Koff SA, and Byard MA: syndrome of childhood, J Urol 1 10. Bickerton GD, and Ducke pediatric patients, A.U.A. Up& 11. Webster GD, Koefoot R]? abnormalities in neurologically 1 dysfunction, J Urol 132:74 (19~ 12. Bauer SB, et ah The uns Clin North Am 7:321 (1980). 13. MeGuire EJ, Woodside j Prognostic value of urodynami tients, J Urol 126:205 (1981). 14. Noe HN: The role of dy complication of ureteral reimpla 126:205 (1981).
UROLOGY
/
OCTOBER 1991
/
'v
