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New Horizons in Managing Lower Urinary Tract Dysfunction
in Children
LOWER urinary tract dysfunction (LUTD) is a com- stimulation schedules are used. This well designed, mon condition in childhood with a prevalence rate of placebo controlled study should encourage us to use this patient friendly treatment modality more often, nonneurogenic aetiologies but mainly subdivides although further prospective, controlled studies in into filling phase dysfunctions, ie overactive bladder, large patient groups are needed. This treatment mo- and voiding phase dysfunctions, ie dysfunctional dality should even be considered before using anticho- linergics since side effects are rare and mild.
Most LUTD is initially treated with re-education Sacral nerve stimulation is effective for nonneu- pharmacological and nonpharmacological treat- more, it was the first approach to have a specific ments must be added to urotherapy. For these sup- Food and Drug Administration approved device portive and more invasive treatments most often the widely marketed. In this issue of The Journal end organ is the target, including the detrusor Haddad et al (page 696) present the results of a smooth muscle cells, the urethral striated muscle French multicenter study of neurogenic LUTD in cells and the pelvic floor muscles. Antispasmodics children. This study is exceptional since children such as oxybutynin targeting smooth muscle cells, with neurogenic LUTD are included. The strong in- anticholinergics such as tolterodine targeting mus- terrelation between bladder and bowel is apparent carinic receptor, biofeedback targeting the striated in this study since good bowel and bladder results sphincter and pelvic floor re-education have been are reported. The only objectively measured effect the cornerstones of LUTD treatment in children, was an increase in cystometric bladder capacity. It is expected that this technique will gain interest for With the new treatment modalities used and es- LUTD treatment in children but it should be consid- tablished in adults today we also observe in children ered in those with therapy resistance in whom irre- a shift of the treatment target to the afferent and versible surgery would be the next step.
efferent peripheral nerve systems. Treatments such Finally, in this issue of The Journal the results of as botulinum toxin, which blocks acetylcholine se- the study by Peters et al (page 702) are the first to cretion at the presynaptic junction, all kinds of neu- challenge the excellent, previously published results romodulation, such as transcutaneous nerve stimu- of nerve rerouting that showed up to 85% lation (TENS) and sacral nerve stimulation, and Despite proof that nerve rerouting can create a novel more recently nerve rerouting have the peripheral reflex arc generating a detrusor contraction, this nerve system as a target and are promising for neu- group learned that after 1 year no patient became continent and only 2 of 9 were able to stop catheter- In this issue of The Journal 3 studies in children ization. Effects on bladder compliance and cystomet- report 1 each of these new treatment modalities.
ric bladder capacity were remarkable despite stop- The study of TENS by Lordêlo et al (page 683) ping antimuscarinic treatment. Persistent foot drop from Brazil in this issue of The Journal is one of the cannot be considered a minor complication in chil- first prospective, randomized, controlled studies of dren who are already motor disabled. Although this child friendly treatment modality for overactive promising, this study cautions us that further con- bladder. Recently another controlled trial showed a trolled studies are needed before this nerve rerout- benefit on overactivity symptoms without a differ- ing procedure can be used more routinely.
Unfortunately the voiding phase was not evalu- significant increase in maximum and average voided ated in any of these studies. In the nerve rerouting volume. The problem with studies of TENS is that study the issue is addressed but it is mentioned that they are hard to compare since different settings and sphincter electromyography could not be evaluated 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
NEW HORIZONS IN MANAGING LOWER URINARY TRACT DYSFUNCTION IN CHILDREN due to interference with stimulation of the der- central nervous system and future research with functional magnetic resonance imaging of the brain It is unclear what happens to detrusor dyssyner- should guide us to the possible targets of full bladder gia after nerve rerouting. However, correcting sphincter dyssynergia is the real key to success.
control involves the periaqueductal gray and the Treatment should aim to restore the central inhibi- pontine micturition center. Most probably the final tion of detrusor overactivity and most new treat- horizons in LUTD management are located at the ment modalities demonstrate some effect on the de- trusor. However, at the same time the final aimshould be to restore pontine coordination of the blad- Piet Hoebeke
der sphincter unit. This is not achieved or even addressed in the current studies. Probably the fu- ture horizon of LUTD management lies closer to the REFERENCES
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