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Solving bladder problems helps manage reflux: Evaluate causes of infections early. (Clinical Rounds).

ATLANTA -- Strategies to correct dysfunctional bladder dynamics are an important element in the management of vesicoureteral reflux in children, Dr. Edwin A. Smith said at a pediatric meeting sponsored by Children's Healthcare of Atlanta and Emory University.

Urinary tract infections (UTIs), which are the most common bacterial disease in the first 3 months of life, are responsible for 20% of pediatric office visits. Such infections, when accompanied by vesicoureteral reflux, markedly increase the risk of hypertension and end-stage renal disease.

And, recurrence of UTIs is likely:

* One-fourth of girls who have had one episode are likely to have another.

* Half of those who have had two episodes will have a third.

In three-fourths of cases, three episodes will be followed by more. Causes and consequences of UTIs "should be evaluated early--not after several infections," said Dr. Smith of Emory University.

Urine culture is essential for accurate diagnosis of UTI in view of the unreliability of urinalysis. In particular, dipstick diagnosis is "pitifully insensitive." Tests that are based on nitrite detection catch just 30% of infections, while the leukocyte esterase test identifies 48%-78%, he noted.

Detection of reflux and renal scarring requires imaging studies, which are indicated for:

* The first UTI in boys.

* The second UTI in girls.

* Girls who are under 3 years of age, or who have a strong family history, voiding dysfunction, or poor growth.

Medical prophylaxis (primarily antibiotics to prevent further UTIs) are first-line management for most reflux.

Bladder dynamics play an important role in reflux and also should be addressed, Dr. Smith said. Ninety percent of girls with UTIs have abnormal voiding habits, including 60% who have uninhibited bladder and 30% who are infrequent voiders. And, the rate of recurrence in UTI is twice as high in the presence of voiding dysfunctions, he said.

Unstable bladder, usually characterized by urgency, frequency, and urge incontinence, generates reflux and can perpetuate it. "Parents complain that the child waits until the last minute to go to the bathroom, but this is not volitional," he said. Staccato, often dysuric, voiding also is common.

In this condition, bladder contractions occur as the bladder fills. The child clamps down on the sphincter to avoid leakage, and then has difficulty relaxing it for voiding. The bladder wall becomes thickened and less compliant, raising bladder pressure and challenging the vesicoureteral junction. "Posturing" typical of this condition--"curtsying" and crossing of legs, for example--represents maneuvers by the child to compress the urethra and prevent urine leakage.

In lazy bladder syndrome, a child with a large-capacity bladder voids only at long intervals, and the sense of filling is progressively diminished. The resulting urinary stasis promotes UTIs, Dr. Smith said.

Treatment of bladder dysfunction includes training in frequent, regular, and relaxed voiding, using scheduling and relaxation techniques such as biofeedback. Children also should avoid bladder stimulants such as caffeine. Constipation is another condition that should be addressed, since retention of stool in the rectosigmoid causes external compression of the bladder that promotes detrusor instability.

Anticholinergic therapy (with oxybutynin or hyoscamine) has been shown to be extremely helpful when reflux occurs in the context of bladder instability. In fact, reflux is twice as likely to resolve when children with voiding dysfunction are given these drugs, compared with the response of those without dysfunction.
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Author:Sherman, Carl
Publication:Pediatric News
Geographic Code:1USA
Date:Aug 1, 2001
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