www.jped.com.br
ORIGINAL
ARTICLE
Clinical
course
of
a
cohort
of
children
with
non-neurogenic
daytime
urinary
incontinence
symptoms
followed
at
a
tertiary
center
夽
,
夽夽
Adrienne
Lebl
a,∗,
Simone
Nascimento
Fagundes
a,
Vera
Hermina
Kalika
Koch
baInstitutodaCrianc¸a,FaculdadedeMedicina,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil
bPediatricNephrologyUnit,InstitutodaCrianc¸a,FaculdadedeMedicina,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil
Received18December2014;accepted6May2015
Availableonline21September2015
KEYWORDS
Diagnosis;
Urinaryincontinence; Pediatrics;
Urinarytract; Qualityoflife; Child
Abstract
Objective: Tocharacterizeacohortofchildrenwithnon-neurogenicdaytimeurinary
inconti-nencefollowed-upinatertiarycenter.
Methods: Retrospectiveanalysisof50medicalrecordsofchildrenwhohadattainedbladder
controlorminimumageof5years,usingastructuredprotocolthatincludedlowerurinary
tractdysfunctionsymptoms,comorbidities,associatedmanifestations,physicalexamination,
voidingdiary,complementarytests,therapeuticoptions,andclinicaloutcome,inaccordance
withthe2006and2014InternationalChildren’sContinenceSocietystandardizations.
Results: Femalepatientsrepresented86.0%ofthissample.Meanagewas7.9yearsandmean
follow-up was 4.7 years.Urgency (56.0%), urgencyincontinence (56.0%), urinary retention
(8.0%),nocturnalenuresis(70.0%),urinarytractinfections(62.0%),constipation(62.0%),and
fecalincontinence(16.0%)werethemostprevalentsymptomsandcomorbidities.Ultrasound
examinations showedalterationsin53.0% ofthecases;theurodynamicstudy showed
alter-ationsin94.7%.Atthelastfollow-up,32.0%ofpatientspersistedwithurinaryincontinence.
Whenassessingthediagnosticmethods,85%concordancewasobservedbetweenthepredictive
diagnosisofoveractivebladderattainedthroughmedicalhistoryplusnon-invasiveexamsand
thediagnosisofdetrusoroveractivityachievedthroughtheinvasiveurodynamicstudy.
Conclusions: Thissubgroupofpatientswithclinicalcharacteristicsofanoveractivebladder,
withnohistoryofurinarytractinfection,andnormalurinarytractultrasoundanduroflowmetry,
couldstarttreatmentwithoutinvasivestudiesevenatatertiarycenter.Approximately
one-thirdofthepatientstreatedatthetertiarylevelremainedrefractorytotreatment.
©2015SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Allrightsreserved.
夽 Pleasecitethisarticleas:LeblA,FagundesSN,KochVH.Clinicalcourseofacohortofchildrenwithnon-neurogenicdaytimeurinary incontinencesymptomsfollowedatatertiarycenter.JPediatr(RioJ).2016;92:129---35.
夽夽StudyconductedatthePediatricNephrologyOutpatientClinic,InstitutodaCrianc¸a,HospitaldasClínicas,FaculdadedeMedicina, UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil.
∗Correspondingauthor.
E-mail:adrienne.lebl@gmail.com(A.Lebl). http://dx.doi.org/10.1016/j.jped.2015.04.005
PALAVRAS-CHAVE
Diagnóstico; Incontinência urinária; Pediatria; Sistemaurinário; Qualidadedevida; Crianc¸a
Cursoclínicodeumacoortedecrianc¸ascomincontinênciaurináriadiurnanão neurogênicaacompanhadaemservic¸oterciário
Resumo
Objetivo: Caracterizar uma coorte de crianc¸as comincontinência urinária diurna não
neu-rogênicaacompanhadaemservic¸oterciário.
Métodos: Análiseretrospectivade50prontuáriosdecrianc¸ascomcontrolemiccionalouidade
mínimadecincoanos,pormeiodeprotocoloestruturado,queincluiusintomasdedisfunc¸ão
dotratourinárioinferior,comorbidades,manifestac¸õesassociadas,exameclínico,diário
mic-cional,examessubsidiários,opc¸õesterapêuticaseevoluc¸ãoclínica,conformenormatizac¸ões
daInternationalChildren’sContinenceSociety,de2006e2014.
Resultados: Eram do sexo feminino 86% dos pacientes. A idade média foi de 7,9 anose o
seguimentomédiode4,7anos.Urgência(56,0%),urge-incontinência(56,0%),retenc¸ãourinária
(8,0%),enuresenoturna(70,0%),infecc¸ãodotratourinário(62,0%),constipac¸ão(62,0%)eperda
fecal(16,0%)foramosprincipaissintomasecomorbidades.Examesdeultrassomapresentaram
alterac¸õesem53,0%doscasos,eoestudourodinâmico,em94,7%.Naúltimaconsulta,32,0%
dospacientesaindaapresentavamincontinênciaurinária.Aoanalisarosmétodosdiagnósticos,
observou-seconcordânciade85,0%entreodiagnósticopreditivodebexigahiperativaobtido
pela históriaclínica maisexamesnão invasivos eodiagnóstico de hiperatividade detrusora
obtidopeloestudourodinâmico
Conclusão: Osubgrupodepacientescomquadroclínicocaracterísticodebexigahiperativa,sem
antecedentesdeinfecc¸ãourinária,ultrassomdeviasurináriaseurofluxometrianormal
pode-riainiciartratamentosemanecessidadedeestudosinvasivos,inclusiveemservic¸oterciário.
Aproximadamenteumterc¸odospacientescomincontinênciaurináriaatendidosem servic¸os
terciáriospermanecemrefratáriosaotratamento.
©2015SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Todososdireitos
reservados.
Introduction
Functionalurinaryincontinence(UI) is definedas involun-tarylossof urineinasociallyinappropriateplaceor time for a child withbladder control, or aged≥5years, with-out neurological damage and with adequate neurological developmentforage.1,2
Incontinencecanbecharacterizedascontinuousor inter-mittent,and diurnal or nocturnal. Continuous UI is more associatedwithcongenitalmalformations,suchasectopic ureter,whiletheintermittenttypeisusuallyamanifestation ofaheterogeneousgroupoflowerurinarytractdysfunctions (LUTDs).3Itiscalled‘‘daytimeurinaryincontinence’’when itoccurswhenthe child isawake, and‘‘nocturnal enure-sis’’(NE)whenitoccursexclusivelyduringsleep.Patients withintermittentUIwhenawakeaswellasduringsleepare diagnosedashavingdaytimeUIandNE.2,3
In addition to the social and hygiene impact on the child, voiding dysfunctions significantly affect the quality oflifeofpatientsandtheirfamilies,andcanpersistbeyond childhood.4LUTDisassociatedwithincreasedriskofurinary tractinfection,delayinvesicoureteralrefluxresolution,and lossofrenalfunction.5,6
Directed and detailed anamnesis, the use of a voiding diary,andcarefulphysicalexaminationareessentialforthe diagnosis,which,inturn,iscriticaltodefinetheappropriate treatment.The4-hurinetestforinfants,uroflowmetry,and ultrasonography(US)arethenon-invasiveteststhatprovide relevantdiagnostictools.7,8However,thesedataandexams, whenperformedwithinadequatemethodology,oftenresult
ininconclusivedata,leadingtotheunnecessaryindication of invasive urodynamic study for diagnostic clarification, increasingthe sufferingof thepatientandfamily, aswell asthediagnosistimeandcosts.9
InBrazil, few studies have analyzed the prevalence of daytimeUIinchildren,letalonethediagnosticinvestigation andtreatmentofpediatricpatientswithnoevident struc-turalalterationsandneurologicabnormalitieswithdaytime UIfollowedinchildren’stertiarycarecenters.10,11
Theobjectiveofthisstudywastocharacterizeacohort of children withdaytime UI without neurological damage followed in a tertiary center, and to verify the concord-ance between the diagnosis of overactive bladder andits urodynamicmanifestation,i.e.,detrusoroveractivity.
Methods
Studydesign
Inclusioncriteria
Patients with an initial complaint of daytime UI, with or without urinary tract infection, of both genders, agedat least5yearsorwithbladdercontrol,withaminimum follow-upperiodof6monthswereincluded.
Exclusioncriteria
Patients with neurogenic bladder, genetic syndromes, chronicencephalopathy,severecognitiveimpairment, uro-genitalmalformations,chronickidneydisease, monosymp-tomatic NE, and LUTD without UI were excluded from analysis.
Studyprotocol
Allmedicalrecordsthatincludedthefollowingdiseasecodes wereanalyzed,accordingtothe10theditionofthe Interna-tionalClassification ofDiseases (ICD-10):R32(Unspecified UI);R33(Urinaryretention); R39.1(Otherdifficultieswith micturition); N31 (Neuromuscular dysfunction of bladder, notelsewhereclassified);N32(Otherdisordersofbladder); and N39(Other disorders of the urinary tract). Diagnoses werebasedstrictlyonmedicalrecordinformation.
Asearchofthemedicalrecordswascarriedoutusinga structuredprotocol,12andthedatawerereportedina stan-dardizedspreadsheetwith180variables.Thefollowingdata wererecorded:gender;birthdate;dateoftheinitial treat-ment(T1);anthropometricdata;bodymassindex(BMI)for age;bloodpressure;characteristicsofurinaryincontinence; urinarysymptoms,accordingtocriteriaoftheICCS2006and 2014 (urinaryfrequency,urinary urgency,urgency inconti-nence, insensible losses, and postural maneuvers/urinary retention); NE; history of urinary tract infection; bowel habits(constipationandfecalincontinence);physical exam-ination;andvoidingdiarydata.Additionaltestswerealso investigated, such as laboratory tests (urinalysis, urine culture,urinecalcium,urea,andcreatinine),urinarytract US,uroflowmetryandurodynamics, voiding cystourethrog-raphyandrenalscintigraphy(99Dimercaptosuccinicacid-99 Tc-DMSA), treatment, and outcome with curerate at the first(T1)andfinal(T2)consultationrecordedinthemedical chart.
Variablesofinterest
According toICCS criteria, the patientwas considered as having‘‘urgency’’whenthemedicalrecordsdescribedthat heorshereportedsuddenandunexpectedsenseof imme-diate need for urination; ‘‘urgency incontinence’’ when urinaryleakagewasdescribed asassociatedwithurgency; ‘‘urinaryretention’’if medicalrecordsindicated that the patient postponed or suppressed urination by postural maneuvers; ‘‘increasedurinary frequency’’ if the patient mentioned more than eight voids per day; and ‘‘reduced frequency’’whenthepatientreportedthreeorfewervoids perday.
The patient was considered ‘‘constipated’’ when the medicalrecordsmentioned‘‘dry,’’‘‘painful’’or‘‘hardened stools,’’‘‘painwhendefecating,’’andlessthanthreebowel movements a week, according to the Roma III criteria.13
Patientswithprevious urinaryinfectionwerethosewhose medical record reported febrile process associated with positive urine culture; recurrent urinary infections were consideredwhentherewerethreeormorecasesofurinary infectionsperyear.
Diagnosticinvestigation:imaging,radiological,and urodynamictests
USresultswereanalyzedinrelationtokidneyandbladder morphologies, the presence of spinning top urethra, and thepresence of bladder residualvolume. The description of trabeculation and/or increased bladder wall thickness >0.3cmwasconsidered a sign ofvoiding effortand prob-ablebladderfillingoremptyingdysfunction.2,14Description ofresidual urine>20mLor >10% of the expectedbladder capacity(EBC, withEBC=[age (years)+1]×30mL in chil-drenaged≤6yearsandbladderresidue>20mLor>15%of theEBC)inchildren≥7years,wasconsideredpathological andindicativeofprobablevoidingdisorder.
Theresultsoffreeuroflowmetrywererecorded accord-ing to the curves format. Bell curves were considered normal;tower-shaped curvesascharacteristic of detrusor overactivity; staccato curves, as dysfunctional urination; intermittent,ashypotonicbladder;andflattenedcurves,as organicorfunctionalobstruction.Urodynamicstudieswere performed at the Urology Departmentof HC-FMUSP using standardizedmethodology.
Thereports ofvoidingcystourethrographyverifyingthe presenceanddegreeofvesicoureteralreflux(VUR),bladder trabeculation, diverticula, and spinning top urethra were identified.DMSA scintigraphy disclosed the description of renalscars,suggestinglossofkidneyfunction.
Treatment
Ingeneral, treatment wasperformed through urotherapy, biofeedback,andposturaltherapy,usinglaxatives, prophy-lacticantibiotics, and specific drugs for the treatment of LUTDs(anticholinergics,suchasoxybutyninandtolterodine; alpha-blockers,suchasdoxazosinandtamsulosin;or antide-pressants,suchasimipramine).
Analysisofdiagnosticconcordanceandpredictive valueofoveractivebladderdiagnosisobtainedby anamnesisdataandnoninvasivetests
The diagnosis of overactive bladder,attained throughthe anamnesis data, was implied in the medical record by: symptomsofurgencyand/orurgencyincontinence;urinary frequency greater than eight times per day; lack of data onpast urinarytractinfections; andnormaluroflowmetry andultrasoundoftheurinarytract,withoutbladder resid-ualvolume,trabeculation,orotheralterations.Toverifythe existenceof concordance,thisdiagnosis wascomparedto thatofdetrusoroveractivity,obtainedthroughurodynamic study,whichisconsideredthegoldstandard.15
Evolutionandcurerate
wereassessedtoestablishtheparametersofcure(patient withouturinary symptoms),improvement(reductionof at least50%ofvoidingsymptoms)orunchanged(no improve-mentinvoidingsymptoms).2
Statisticalanalysis
Descriptive analysis of continuous and categorical varia-bles wasperformed. Continuous variables were described bymeans(±standarddeviation).LUTDsymptomvariables, associatedmanifestations,andcomorbiditiesin T1andT2 were analyzed by the nonparametric McNemar test. The concordancebetweenthediagnoses ofoveractivebladder attainedthroughanamnesisdataplus non-invasive exami-nation(USanduroflowmetry)andthediagnosisofdetrusor overactivitybyinvasiveurodynamicstudy---thelatter con-sideredtobethegoldstandard---wascomparedbyCohen’s Kappacoefficient.Inallcomparisons,wereconsidered sig-nificanttestsp<0.05.
Ethicalaspects
The study was approved by the Ethics Committee for ResearchProjectAnalysisofHC-FMUSPonAugust18,2011 (Protocol0489/11).
Results
Initially, 103 patients were included in the study, but 53 did not participate because they did not meet the pre-determinedinclusioncriteria.Ofthe50assessedpatients, 43werefemales(86.0%).Themeanagewas7.9years.The meanfollow-upperiodofpatientsattendedtoat the out-patientclinicwas4.7±3.2years.
Five patients had a z-score <−1 for BMI for age, 42 had normal weight, and three patients had z-score >+1. Bloodpressure<90thpercentilewasobservedin48(96.0%) patients;twopatientshadbloodpressurebetweenp90%and p95%,andhadtheirbloodpressurelevelsnormalizedduring follow-up.
Allpatientsreportedlossofurine.Atotalof24(48.0%) patientsreportedurinaryincontinenceandurgency incon-tinence episodes; 22 (44.0%) reported daytime urinary incontinence;andfour(8.0%)characterizedtheirlossesas urgency incontinence episodes only. The main symptoms of LUTD described in the initial anamnesis were urgency (n=28; 56.0%), urgency incontinence (n=28; 56.0%), and urinaryretention(n=4;8.0%).Themaincomorbiditieswere: urinarytractinfections(n=31;62.0%), NE(n=35;70.0%), constipation(n=31;62.0%),andfecalloss(n=8;16.0%),as showninTable1.
A voiding diary wascompleted by33 (66.0%) patients, ofwhom21(63.6%)hadincreasedurinaryfrequency>eight timesa day. Six(18.2%) patients hadNEand four(12.1%) reportedlossofurine.
In T1, urinary tract US was performed in 49 (98.0%) patients, disclosing post-voiding residual volume in 16 (61.5%)patients,bladderthickeninginsix(23.0%),and uni-lateralchronicpyelonephritisinthree(11.5%).
Table 1 Demographic data, clinical results, and
labora-torytestsofacohortof50childrenwithfunctionaldaytime
urinaryincontinencetreatedatatertiaryservice.
Femalegender,n(%) 43(86.0)
Meanage,years 7.9±3.0
Timeoffollow-up,years 4.7±3.2
Symptoms,%
Daytimelosses 100
Abnormalurinaryfrequency 63.6
Urgency 56.0
Nocturnalenuresis 70.0
Urinaryinfection 62.0
Constipation 62.0
Ultrasound,%
Bladderresidualvolume 61.5
Bladdertrabeculation 23.0
Chronicpyelonephritis 11.5
Uroflowmetry,%
Normalcurve 78.8
Urethrocystography,%
Diverticula 16.7
Vesicoureteralreflux 27.8
Urodynamicstudy,%
Detrusoroveractivity 71.0
Detrusoroveractivity+dysfunctionalvoiding 21.0
Voidingcystourethrographywasperformedin36(72.0%) children. Of these, 18 (50.0%) showedsome abnormality: unilateralvesicoureteralreflux(n=3;16.7%);bilateralVUR (n=2; 11.1%), with four (80.0%) of the five VUR patients showingVURdegree≥III;trabecularbladder(n=12;11.1%); diverticula (n=3; 16.7%); and spinning top urethra (n=3; 16.7%).Somepatientshadmorethanoneanatomical alter-ation,asshowninTable1.
Free uroflowmetry was performed in 33 patients, and it wasdescribed asnormal in26 (78.8%). Among patients submitted to the urodynamic study, 36 (94.7%) had uro-dynamic alterations, namely: detrusor overactivity in 27 (71.0%),detrusoroveractivityanddysfunctionalvoiding in eight(21.0%),anddysfunctionalvoidinginone(2.7%);two patients had normal results. The incidence of abnormal imagingtests,uroflowmetry,urodynamics,andrenal scintig-raphyisshowninTable2.
Table2 Compilation oftheabnormal results ofimaging
tests, uroflowmetry, and urodynamic study ina cohortof
50 children with functional daytime urinary incontinence
treatedatatertiaryservice.
Typeofexam Abnormalfinding
n/total(%)
Urinarytractultrasound 26/49(53.0)
Uroflowmetry 7/33(21.2)
Urodynamicstudy 36/38(94.7)
Voiding
cystourethrography
18/36(50.0)
Staticrenalscintigraphy
with99mTc
All 50 patients underwent urotherapy, four underwent physicalposturaltherapy,andfourothers,biofeedback.
The prescribed drug treatments included oxybutynin (anticholinergic) to 28 (56%) patients; doxazosin (alpha-blocker)tothree(6.0%);tamsulosin(alpha-blocker)toone (2.0%); association of oxybutynin and tamsulosin to one (2.0%); and imipramine (antidepressant) to one patient (2.0%). Twelve patients (24.0%) showed irregular adher-enceto treatment. The mean timeof anticholinergicuse was 2.9 years (±2.30), and for alpha-blockers, 1.3 years (±0.58). Lactulose was prescribed to 12 (24.0%) patients withconstipation.Prophylacticantibioticswereprescribed to25 (50.0%) patients withrecurrent urinary tract infec-tions.The mean periodof prophylacticantibiotic usewas 2.5years(±1.52).
There was a clear reduction in complaintsfrom T1 to T2, which decreased from 100% to 32.0%. The evolution regardingcure,improvement,orpersistenceofLUTD symp-tomsaftertreatment (T2)isshownin Fig.1.Fig.2shows theevolutionoftheincidenceofurinarytractinfections.
RegardingthevoidingsymptomsofLUTD,68%ofpatients showedimprovementorcure.
An 85% concordance was found between the diagnosis ofoveractivebladderobtainedbyanamnesisand noninva-sive exams (US and free uroflowmetry) and the diagnosis ofdetrusoroveractivityobtainedbyurodynamicstudywith Cohen’skappacoefficient,withp<0.05.
p-value* <0.001
Percentage of urinary complaints**,
%
Urgenc
y
Urgency incontinenc
e
Urinary retention
Nocturnal enuresi
s
Constipation Encopresis
70
60
50
40
30
20
10
0
* McNemar test (one-sided)
Type of complaint
Consultation
First Last
** Reported
<0.001 <0.001 <0.001 <0.001 0.082
Figure1 Comparisonofvoidingsymptoms,associated
man-ifestations,andcomorbiditiesbetweenthefirst (T1)andlast
medicalconsultation(T2) inacohortofchildrenwithurinary
incontinencefollowedattertiarycenter(McNemartest).
70
60
50
40
30
20
10
Urinary complaints**,
%
First consultation Last consultation
* McNemar test (one-sided) ** Reported
*p<0.001
UTI (per year)
26% (13)
>3 times 2% (1)
≤3 times
≤3 times 22% (11)
> 3 times 12% (6)
Not specified 28% (14)
Figure2 Evolution regardingthe incidenceofUTI andUTI
recurrenceaftertreatmentinacohortofchildrenwithurinary
incontinencefollowedatatertiarycenter(McNemartest).
UTI,urinarytractinfection.
Discussion
Theanalysisofthisgroupofpatientsshowedaprevalence ofthefemalegender,meanageatstartoftreatmentof7 years,longfollow-upperiod(4.7±3.2years),highincidence of urinary symptoms, NE, constipation and fecal inconti-nence,UTI, UTI recurrence,urologicalabnormalities, and kidneylesions.
The most prevalentLUTD in this study was overactive bladder and its urodynamic manifestation, i.e., detrusor overactivity.Itwasverified,similarlytootherstudies,that apercentageofpatientstreatedattertiaryservicesachieve cure;othersshowimprovement,butbecomedependenton medication;andapproximately30%arerefractoryto treat-ment---agroupthatcouldreachadulthoodwithLUTD.16,17A concordanceof85%throughCohen’skappacoefficient,with
p<0.05,wasalsoobservedfor thediagnosis ofoveractive bladder,withanamnesisdataandnoninvasivetests,andthe diagnosisof detrusoroveractivityobtained byurodynamic study.
ItisdifficulttocalculatetheexactprevalenceofUI,as moststudiesusedifferentmethodologicalstrategiesanddo notalwaysusetheICCSterminology.3,18
The nutritional classification of the patients in the present study showed that 96.0% had normal weight and 4.0%wereoverweight,whichdoesnotconfirmtheliterature datathatdescribesapositiveassociation betweenobesity andLUTDinchildren.19
In the assessed cohort, the manifestation of NE was 70.0%,i.e.,amuchhighervaluethanthatdescribedinthe generalpediatricpopulation,whichis7.5%,demonstrating thefrequentassociationofthisentitywithdaytimeurinary loss.20
constipation in children is underestimated, because most parents do not have such information, and the children, withouttheuseoftoolssuchastheBristolscale,givepoor reportsaboutitsoccurrence.
TheprevalenceofUTIinthisstudywas62.0%,i.e.much higherthanthatinthegeneralpediatricpopulation(11.0%), butsimilartothatfoundinchildrenwithUI,describedinup to50.0%ofpatients.23
Urodynamicswereperformedin76.0%ofpatientsinthis study; theywere altered in 94.7% of cases, and detrusor overactivitywaspresentin71.0%ofcases,representingthe mostprevalenturodynamicdiagnosis,consistentwith liter-aturedata.3
Regarding the prevalence of gender, age, follow-up period,urinarysymptoms,incidenceofUTIs,thefrequency ofassociationwithVUR,andthecurerate,theresultsofthis studyweresimilartostudiespublishedintertiaryservices, consideringthepreviouslymentionedlimitations.17,24,25
For overactive bladder, the analysis of diagnostic con-cordance between the clinical diagnosis obtained by anamnesis, withinvestigation of the presence of urgency and/orurgency incontinencesymptomsandincreased uri-naryfrequency,withnohistoryof urinarytractinfections andnormalnon-invasivetests,andthediagnosisofdetrusor overactivity at the urodynamic study showed 85.0% con-cordancethroughCohen’skappacoefficient,withp<0.05. The diagnosis ofdysfunctionalvoiding does not allowthis analysis; the diagnosis of dysfunctional voiding can only be defined by the presence of the staccato curve in the uroflowmetry with electromyography, or by urodynamic study.3Inliterature,onlytwootherstudiesperformedthis type of analysis: Ramamurthy et al.25 described a con-cordance between the diagnosis of overactive bladder by anamnesisandnoninvasivetests, withsensitivity of88.4% andspecificityof72.7%whencomparedtotheurodynamic diagnosisof detrusoroveractivity;while Baeletal.15 con-ductedaprospectivemulticenterstudyin151childrenwith LUTD, obtaining inconclusive results. In the latter study, therewasaconcordanceofonly33%betweenthediagnoses ofoveractivebladderanddetrusoroveractivityinthe urody-namicstudy;theauthorshighlightthefactthatmostofthe includedpatients werediagnosedwithdysfunctional void-ing,an incidence that, according to the authors, didnot representthetypicalsampleoftheservice.
The evolution of the therapeutic response in UI in this study wascure in 36% of patients, and improvement (decreaseofatleast50%ofcomplaints) in32%ofpatients who continued using the medication. These results are comparable to those obtained by Glad Mattson et al.,16 achievedinatertiaryhospital.
Thelimitationsofthisstudywerethoserelatedtoa retro-spectivestudy,withdifficultiesarisingfrominaccuratenotes inmedicalrecords,multipleobserversfollowingthepatient, aswellastemporalvariationsininstitutionalavailabilityof humanandtechnicalresources.26
The present study found, in this group of patients, high prevalence of voiding symptoms, urinary infections, urological abnormalities, kidney lesions, and poorer cure rate,suggestingthat thissubgroup ofpatients couldhave adifferent pathogenesis whencompared topatients with non-neurological daytime UI, studied in large groups of schoolchildrenoringeneraloutpatientclinics.
Theinitialclinicaldiagnosisshouldresultfromthesum oftheclinicalvariablesandnoninvasivetests.Thediagnosis ofoveractivebladderrepresentsasyndromicdiagnosisand couldjustify the startof thetreatment, afterassessment of suggestive clinical history, normal physical examina-tion, negative history of UTI, and normal non-invasive test results.27 The urodynamic test shouldbeindicated in patientswithsymptomsofoveractivebladderrefractoryto treatment, aswell asthose patients in whom an organic causeissuspectedduringthediagnosticinvestigation.28The use of such conduct, including in tertiary services, could resultinadecreaseinthenumberofinvasiveprocedures, reducingthediscomfortofthepatientandfamily,timeuntil thestartofthetreatment,andhospitalcosts.29
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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