Campbell Pedia Review 2021 Flashcards
Under what conditions is a uroflow reading valid and interpretable?
Voided volume greater than 50 mL and less than 115% of expected bladder capacity.
BC (< 2 yo): Wt (kg) x 8
BC (> 2 yo): (Age + 2) x 30
Five reference uroflow curve types?
Staccato Intermittent Bell shaped Plateau Tower
EMG lag time < 2 seconds
Overactive bladder + tower uroflow curve
Normal: 2-6 seconds lag time
EMG lag time > 6 seconds
Primary bladder neck dysfunction + plateau uroflow curve
Normal: 2-6 seconds lag time
Valid methods to define functional bladder capacity
Voided volume on uroflow + PVR
Largest voided volume on voiding diary
Significance of debris visualized in bladder or collecting system on UTZ
Increased risk of positive urine culture regardless of symptoms
Test for ALL patients who present with LUTS and no prior diagnosis
UA
Cutaneous lesions with highest risk of occult spinal dysraphism
Hemangioma.
Then (highest to lowest): Dermal sinus tract Hypertrichosis (hair tuft) symmetric bifid gluteal simple cutaneous dimple
Gold standard imaging for spinal dysraphism
MRI
Spinal UTZ: neonates up to 6 mos, but lower sensitivity
NO role for CT or PET scans or VUD in SD
Consider spine ultrasound to r/o spinal dysraphism wheb:
skin findings associated with spina bifida, lesions with LOW likelihood of diagnosis of spina bifida (like deviated gluteal cleft) may be more appropriate to use ultrasound if testing is being considered.
Then MRI to confirm if needed.
Test/treatment for LUT dysfunction patients who fail 1st-line conservative therapies
7-day bowel and bladder diary or 48-hour frequency-volume chart.
Elimination diaries can pinpoint a number of issues that may not be elicited during a clinical encounter, including low functional capacity, infrequent voiding, nocturia, and polydipsia.
LUT dysfunction is commonly associated with:
ConstipationNeuropsychiatric issues
Urinary tract infections Vesicoureteral reflux
Appropriate fill rate for CMG pediatric?
5% to 10% of expected bladder capacity per minute
BC (< 2 yo): Wt (kg) x 8
BC (> 2 yo): (Age + 2) x 30
only parameter reliably affected by sedation or anesthesia during urodynamics
Detrusor overactivity
VUR prevalence in children with UTI
30%
Primary reflux is a congenital anomaly of the UVJ with a deficiency of the: ___
Longitudinal muscle of the intravesical ureter, which results in an inadequate valvular mechanism
Accepted ratio of tunnel length to ureteral diameter in normal children
5:1
Non-neurogenic neurogenic bladder
Constriction of the urinary sphincter occurs during voiding in a volutanry form of detrusor-sphincter dyssynergia –> Gradual bladder decompensation and myogenic failure result from incomplete emptying.
and increasing amounts of residual urine.
Most common cause of anatomic bladder obstruction in pediatric patients
PUV
**48% and 70% of patients with posterior urethral valves have vesicoureteral reflux, and relief of obstruction appears to be responsible for resolution of the reflux in a good number of those patients.
Most common structural obstruction in female patients
Presence of a ureterocele that prolapses and obstructs the bladder neck
Initial management of functional causes of reflux
Medical treatment
Signs or symptoms of bladder dysfunction
Dribbling
Urgency
Incontinence
Curtsying behavior in girls, squeezing the penis in boy
Treatment of bladder dysfunction and detrusor overactivity regardless of its severity or cause is directed at: ___
Dampening overactive detrusor contractions
Lowering intravesical pressures
Strong association between the presence of reflux in
patients with neuropathic bladders and intravesical pressures of greater than: ___
40 cm H2O
** presence of reflux in
patients with myelodysplasia and neuropathic bladders, although
upper tract damage can also be seen in lower bladder pressures
Bladder infections and their accompanying inflammation can also cause reflux by
lessening compliance.
elevating intravesical pressures.
distorting and weakening the ureterovesical junction
Accurately grading reflux with coexistent obstruction of the ipsilateral ureteropelvic junction (UPJ)
It is NOT possible!
UTI: Presence of fever and likelihood of VUR:
if fever (and presumably pyelonephritis) is present, the likelihood of discovering VUR is significantly increased. Fever can be associated with less than 100,000 bacterial colonies.
Screening of older girls with asymptomatic bacteriuria
No screening studies required
Diagnostic of choice to evaluate upper tracts of patients with proven/suspected VUR
Ultrasound of the kidneys and bladder
Best study for detection of pyelonephritis and cortical renal scarring
DMSA renal scan
Hypertension in children and young adults
Most common cause of severe hypertension: Reflux nephropathy
BBD + VUR
Lowers VUR resolution rates
Higher recurrence rates of VUR after endoscopic correction
Higher breakthrough infections
High incidence of UTI after surgery
Weigert-Meyer rule
Upper pole ureter enters the bladder DISTALLY and MEDIALLY
Lower pole ureter enters the bladder PROXIMALLY and LATERALLY
Bladder changes during pregnancy
Bladder tone decreases because of edema and hyperemia, which are changes that predispose the patient to bacteriuria. In addition, urine volume increases in the upper collecting system as the physiologic dilation of pregnancy evolves.
Common to each type of open surgical repair for reflux is the creation of: ___
Creation of a valvular mechanism that enables ureteral compression with bladder filling and contraction, thus reenacting normal anatomy and function.
Complete ureteral duplications with reflux can be best managed surgically by: ___
A common sheath repair in which both ureters are mobilized with one mucosal cuff.
Because the pair typically share blood supply along their adjoining wall, mobilization as one unit with a “common sheath” preserves vascularity and minimizes trauma
Early postoperative obstruction after ureteral reimplant can occur due to: ___
edema.
subtrigonal bleeding.
a twist or angulation of the ureter.
If EARLY postoperative obstruction occurs after a ureteral reimplant, the next step is: ___
Initial observation and diversion for unabating symptoms.
The large majority of perioperative obstructions subside spontaneously, but placement of a nephrostomy tube or ureteral stent sometimes becomes necessary for unabating symptoms.
Persistent reflux after ureteral implantation: ___
Unrecognized secondary causes of reflux such as neuropathic bladder and severe voiding
dysfunction
Failure to identify and treat secondary causes of reflux is a common cause of the reappearance of reflux
Laparoscopic approach for ureteral reimplantation
Advantages: smaller incisions, less discomfort, and quicker convalescence
Experience is essential
to success
Costs may be increased because of lengthier surgery and the
expense of disposable equipment
Success rate higher than that of open surgery
Toilet-trained children likely to develop recurrent UTI after stopping CAP
Patients with higher grades of VUR
Children with BBD
** Uncircumcised male children older than 1 year do not appear to be at higher risk for development of recurrent UTI after discontinuation of CAP.
Likely to have febrile/symptomatic recurrences in the RIVUR trial
Children with grade III or IV reflux at baseline
BBD at baseline
Management of initial UTI in febrile infants and children 2-24 months of age
Renal and bladder ultrasound after confirmation of UTI by a
properly collected urine specimen for culture and analysis
Almost ___ of low-grade and half of grade III reflux will resolve spontaneously.
80%
If both the ureteropelvic junction (UPJ) and ureterovesical junction (UVJ) require operative repair, the ___ should be repaired first.
UPJ
The cardinal renal anomalies associated with reflux are ___.
Multicystic dysplastic kidney and renal agenesis.
There is a ___ incidence of contralateral reflux after
unilateral reflux is repaired.
10-15%
** Prophylactic bilateral reimplantation for unilateral reflux is not
indicated
Describes visualization of the fetal bladder
fetal bladder typically Empties every 15 to 20 minutes and non-visualization of the bladder necessitates prolonged inspection to make sure that a full bladder was not missed
Incidence of bladder agenesis is ___
Bladder exstrophy is typically associated with
… approximately 1 per 600,000 and is more common in females
…normal amniotic fluid levels, and most cases are diagnosed postnatally.
1st trimester: normal bladder size ____
Megacystis: after 1st trimester, defined as ___
6 mm or less
Bladder that does not empty during 45 minutes of observation
Genetic evaluation of a fetus with megacystis is likely to
demonstrate: ___
Trisomy 13 or 18
Genetic testing: NOT routine.
** a INCREASED rate of expected genetic anomalies based on
nuchal translucency
Findings associated with improved outcomes for megacystis: ___
Initial bladder dilation of 12 mm or less
Resolution of megacystis by 23 weeks of gestational age d. Normal amniotic fluid levels
Isolated bladder findings without associated congenital
anomalies
** poor outcome: aneuploidy or genetic anomalies
Megacystis microcolon intestinal hypoperistalsis: ___
… suspected of being secondary to dysfunction of ACTIN smooth muscle
**Rare cause of megacystis and is most often detected by the bladder findings
** Once thought to be incompatible with life, survival beyond the neonatal period is now well documented
Bladder duplication will usually be associated with: ___
Genital anomalies
- Most cases of bladder duplication will be associated with genital anomalies and the urethra may or may not be duplicated
- Over 25% will have GI anomalies, and continence is difficult to predict based on the anatomy alone
Congenital bladder diverticula: ___
Most occur through a hiatus in the bladder wall and consist of mucosal lining only
- Definitive test: cystogram
1. 7% reported incidence, most will NOT require resection
- Definitive test: cystogram
Diverticula secondary to connective tissue disorders: ___
Have walls composed of smooth muscle as well as mucosa.
** Also: with multiple diveritcula, histology = smooth muscle + mucosa in the diverticulum wall; recurrence is expected
Most cases of patent urachus: ___
Not associated with bladder obstrution
Recommended resection after treatment of infection
Surgical management can be performed with MIS
Patent omphalomesenteric duct can mimic patent urachus
Non-inflammatory bladder conditions: Bladder hemangiomas are associated with ___
Klippel-Trenaunay or Sturge-Weber syndrome
** Simple RESECTION can be curative.
Fibroepithelial polyps are rare: can be managed simply with endoscopic resection
Nephrogenic adenoma: ___
Mostly benign
Reaction to infection, lithiasis, or injury
More common in adults
80% recurrence after resection (usually cysto), latency 4 years
Eosinophilic cystitis:
Can be treated with steroids, antihistamines, antibiotics
More common in boys
Young children: often self-limited
Biopsy: numerous eosinophils all layers
Cystitis cystica: common in females, antibiotics are a component of treatment
Live birth incidence of classic bladder exstrophy: ___
1 in 50,000
** The incidence of bladder exstrophy has been estimated as between 1 in 10,000 and 1 in 50,000 live births.
Live birth risk of bladder exstrophy in the offspring of bladder exstrophy+epispadias: ___
1 in 70.
** 1 in 70 live births, a 500-fold greater incidence than in the general population
Main theory of embryologic maldeveloplment: ___
Overdevelopment of the cloacal membrane, preventing medial migration of the mesodermal tissue and proper lower abdominal wall development
** Marshall and Muecke: basic defect is an abnormal overdevelopment of the cloacal membrane
Skeletal defects/bone changes in bladder exstrophy: ___
External rotation of the posterior aspect of the pelvis of 12 degrees on each side
Retroversion of the acetabulum
18-degree rotation of the anterior pelvis
30% shortening of the pubic rami in addition to a significant
pubic symphyseal diastasis
Hernias in children with exstrophy: ___
They are noted in 80% of boys and 10% of girls.
Male genital defect exstrophy
Prostate findings in exstrophy
The anterior corporeal segments are 50% shorter than those of healthy control participants.
Volume weight and the cross-sectional area appeared healthy compared with published results from control participants.
Vagina in the
female patient with bladder exstrophy:
Shorter than normal, hardly greater than 6 cm in depth, but of
normal caliber
Structure and innervation of the exstrophic bladder
density and binding affinity of the muscarinic receptors
were similar to norm
Bladder function in patients with bladder exstrophy
Before bladder neck reconstruction, 80% of patients had compliant and stable bladders
Characteristic prenatal appearance of bladder exstrophy
Absence of bladder filling
Low-set umbilicus
Widening of the pubic ramus
Diminutive genitalia
Newborn patient selection for immediate reconstruction is based on: ___
Indentation of the bladder under anesthesia or outward bulging when the child cries
Treatment option: Bladder template too small at time of birth
Delaying closure by age 4 to 6 months with reassessment to see if the bladder will grow
** Closing a small bladder = results in dehiscence
Combined osteotomy was developed for three reasons: ___
(1) osteotomy is performed with the patient in the supine position, as is the urologic repair, thereby avoiding the need to turn the patient;
(2) the anterior approach to this osteotomy allows placement of an external fixator device and intrafragmentary pins under direct vision; and
(3) the cosmetic appearance of this osteotomy is superior to that of the posterior iliac approach.
** Osteotomy reduces the tension in the closed bladder and the lower abdominal wall and to promote continence by restoring the sling of the pelvic floor muscles.
Complications with osteotomy + immobilization techniques for exstrophy: ___
Skin ulceration is associated with use of mummy wrapping.
Failure of the bladder and abdominal wall closure is
associated with the use of spica casting.
Transient femoral nerve palsy is associated with the use of
osteotomy.
Delayed union of the iliac wings may occur after the use of
posterior osteotomy.
Erlangen approach for exstrophy: complete repair
**Performed at 8-10 weeks of age, when infant is larger and has the opportunity to be medically stabilized
After initial primary bladder closure in the newborn –> management of recurrent UTI?
Cystoscopy: examine posterior bladder for erosion of the intrapubic stitch which may cause recurrent infections
Management after successful bladder closure of exstrophy: ___
Calibration of the urethral outlet 4 weeks after closure to ensure free drainage
Ultrasound evaluation of the kidneys and bladder
Complete bladder drainage by suprapubic tube clamping: estimate residual urine
Yearly cystoscopic evaluation
patient with bladder exstrophy who undergoes more than one closure of the bladder and urethral defect, what is the chance of having adequate bladder capacity for later bladder neck reconstruction
60%
**In one study, if a patient underwent two closures, the chance of having an adequate bladder capacity for bladder neck reconstruction was 60%
Four key concepts in reconstruction of epispadias: ___
(1) correction of dorsal chordee
(2) urethral reconstruction,
(3) glanular reconstruction,
(4) penile skin closure
Most important factor to predict success and eventual continence after bladder neck reconstruction: ___
Bladder capacity
After bladder neck reconstruction, within what time period do the majority of patients achieve daytime continence?
1 year
Failed bladder closure in newborn –> when to attempt secondary repair?
6 months: Dehiscence necessitates a 6-month recovery period
Modern staged reconstruction of exstrophy : ___
The modified Cantwell-Ransley repair has replaced the Young technique because there is less urethral tortuosity and fistula rates are lower.
The incidence of fistula formation was 12% at 3 months after epispadias repair.
Continence is more likely in those patients undergoing initial closure before 72 hours of age or those who have closure after 72 hours of age with osteotomy.
Continence rates are higher in those who have a capacity of 85 mL or more at the time of bladder neck reconstruction
Onset of eventual continence was
quicker and the continence rate higher in those who underwent
a successful initial closure with or without osteotomy.
Exstrophy failures: ___
Dehiscence after complete Primary repair may be associated
with corporeal, urethral, and other major soft tissue loss.
Bladder neck reconstruction is designated as a failure if a 3-hour dry interval is not achieved within 2 years after surgery. Management of such failure is with the use of: ___
Bladder neck transection, augmentation cystoplasty, and continent diversion. A majority of bladder neck failures require eventual augmentation or continent diversion.
Risks of ureterosigmoidostomy in the exstrophy population include: ___
pyelonephritis and hyperchloremic acidosis.
** ALSO: rectal incontinence, ureteral obstruction, and delayed development of malignancy
Live birth incidence of cloacal exstrophy: ___
1 in 400,000.
Exceedingly rare!
Neurospinal abnormalities in cloacal exstrophy are true except: ___
Thoracic defects may be noted in 10% of patients
Autonomic bladder innervation is derived from a more medial
location.
Innervation of the duplicated corporal bodies arises from the
sacral plexus and courses medial to the hemibladders.
Functional defects can include minimal lower extremity
function
The embryologic basis for the neurospinal defects associated with cloacal exstrophy has been postulated to be secondary to problems with the disruption of the tissue of the dorsal mesenchyme
Cloacal exstrophy, most common Mullerian anomaly: ___
Partial uterine duplication.
**This anomaly is reported to be as high as 95% (Diamond, 1990). The vast majority of these patients had partial uterine duplication, predominantly a bicornate uterus.
Incidence: omphalocele + cloacal exstrophy
95%. In Diamond’s series, the incidence of omphalocele was 88%, with a majority of all series reporting 95% or greater.
Patients with cloacal exstrophy, hindgut remnants should be preserved in order to: ___
Provide additional length of bowel for fluid absorption. With the recognition of the metabolic changes in patients with ileostomy, an attempt is always made to use the hindgut remnant to provide additional length of bowel for fluid absorption.
Live birth incidence of male epispadias: ___
1 in 117,000
Incidence of reflux in complete epispadias: ___
30-40%
In the complete epispadias group, predominant indicator
of eventual continence: ___
Bladder capacity at the time of bladder neck reconstruction.
** In the epispadias group, ALSO in the exstrophy group.
Exstrophy-epispadias
variants: ___
Pseudoexstrophy: musculoskeletal defects characteristic of the
complex, with a normal urinary tract
“Covered” exstrophy: isolated ectopic bowel segment has frequently been noted
Duplicate exstrophy: An isolated segment of bladder is left on the abdominal wall, with a complete urinary tract within the bladder
Superior vesical variant: musculature and skeletal defects are exactly the same as those in classic exstrophy; however, the persistent cloacal membrane ruptures only at the uppermost portion
Common embryologic origin has been postulated for developments of all of the variants
Sexual function and libido: ___
Normal in both males and females.
Most common complication after pregnancy in female
exstrophy
Cervical and uterine prolapse
Psychologic studies of male and female children with bladder
exstrophy: ___
They do not have clinical psychopathology
Single-stage reconsturction of complete primary exstrophy repair ADVANTAGES: ___
The possibility of correcting the penile, bladder, and bladder neck abnormalities of bladder exstrophy with one operation.
The ability to achieve urinary continence without bladder neck reconstruction.
Lower complication rates than previous attempts at single-
stage reconstruction.
Initiation of bladder cycling early in life
Factors that increase the success of reconstruction of bladder exstrophy:
Immobilization with external fixators, Buck traction, a spica cast, or a mummy wrap
Antibiotic therapy
Urinary diversion through ureteral stenting and suprapubic
urinary drainage
Adequate nutritional support
Single-stage reconstruction by using the complete primary exstrophy repair technique can be safely performed because: ___
The blood supply to the corpus cavernosal bodies and that to the urethral wedge are independent of each other.
proximal limit(s) of dissection by using the complete primary exstrophy repair technique is/are: ___
The muscles of the pelvic floor
Factors that mitigate AGAINST use of a single-stage reconstruction technique for cloacal exstrophy :___
large omphalocele.
wide pubic diastasis.
concomitant myelomeningocele.
small bladder plate.
Complilcations of complete primary exstrophy repair technique: ___
urethrocutaneous fistula
corporeal devascularization
hydronephrosis
hypospadias
Common antenatal ultrasonographic findings: ___
oligohydramnios.
empty scrotal sac.
hydroureteronephrosis.
distended bladder
Most appropriate indication for antenatal intervention in a fetus with prune-belly syndrome
Progressive oligohydramnios.
** progressively decreased amniotic fluid most probably represents an obstructed bladder due to an atretic urethra associated with functioning kidneys, which can be treated by bladder decompression
Common urinary tract findings in prune-belly syndrome: ___
renal dysplasia
ureteropyelocaliectasis
vesicoureteral reflux
urachal diverticulum
Common nonurinary findings in patients with prune-belly syndrome: ___
Flaccid abdomen due to nonhomogeneous deficiency of the abdominal musculature.
Impalpable testes.
Pectus carinatum.
Pulmonary deficiency.
Organ system MOST likely to impact the early life of the patient with prune-belly syndrome: ___
Pulmonary
** it is the pulmonary hypoplasia due to oligohydramnios, often aggravated by the lack of abdominal muscle support, that impacts survival, thereby requiring prolonged respiratory support.
Prognosis of untreated prune-belly syndrome: ___
Most patients present some degree of urinary tract dilatation.
Recurrent urinary tract infection increases the risk of renal
damage.
Abdominal wall laxity may be associated with ineffective
cough and respiratory illnesses.
Bladder emptying may improve spontaneously with time.
Dilatation of the upper urinary tract of patients with prune-belly syndrome: ___
The degree of dilation is not proportional to the abdominal wall laxity
Lower urinary tract of patients with prune-belly syndrome: ___
Large postvoid residuals occur due to poorly contractile
detrusor and diminished bladder sensation
Urethra of prune-belly syndrome patients: ___
The lack of bladder neck hypertrophy is typical of the posterior urethral dilatation
** Characteristic dilatation of the posterior urethra is mostly due to the lack of support by prostatic tissue, dilatation being present even in the presence of a normal distal urethra.
Abdominal undescended testes in prune-belly syndrome: ___
the adequate time for orchidopexy is between 6 and 18 months of age
orchidopexy can be successfully carried out without the Fowler- Stephens technique before the second year of age
no need of hormonal supplementation
otential fertility with assisted reproduction techniques
Management of patients with prune-belly syndrome: ___
The spontaneous improvement of the urinary tract dilatation with time is the basis for the clinical management, particularly in grade III prune belly syndrome (PBS) patients.
** Continuous antibiotic prophylaxis must be employed in the more vulnerable patients to prevent pyelonephritic injuries
** no increased detrusor activity or hypertrophic bladder neck in these patients, there is no indication for the use of antimuscarinic drugs or alpha-blockers
** Persistent and elevated postvoid residual must be treated by timed voiding and/or clean intermittent catheterization
Surgical management of PBS patients: ___
Even when reduction cystoplasty is performed, significant postvoid results may remain or recur
** urinary tract reconstruction can be performed simultaneously with abdominoplasty, orchidopexy, and circumcision
**reconstruction aims to decrease the ureteral redundancy by removing the distal, more dilated ureteral segments and reimplanting them in the bladder
** removal of the urachal diverticulum and part of the noncontractile bladder dome is usually performed, but it doesn’t prevent the persistence or recurrence of significant postvoid residual.
RBUS findings of PUV: ___
hypertrophy and apparent elevation of the bladder neck.
multiple bladder diverticula
rupture of an upper pole calyceal fornix causing distortion of
the renal capsule
Antenatal diagnosis and management of posterior urethral valves
Thickened dilated bladder with bilateral upper tract dilation are pathognomonic findings
Significant renal cortical dysplasia is a contraindication to antenatal intervention.
Early reports suggest that fetal cystoscopy and valve ablation might offer better outcomes than vesicoamniotic shunting.
Antenatal interventions should only be offered in select cases as outcomes are not universally predictable.
Cause of renal impairment in patients with PUV
Increased intravesical storage pressures transmitted to the ureter, renal pelvis, and glomerular units causing architectural and functional changes
Vesicoureteric reflux + dysplasia (VURD) syndrome, long-term renal function:
No better or worse long-term renal function, still requiring close observation
**VURD is NOT a renal protective phenomenon. These children often have evidence of renal dysplasia detectable in the solitary functioning kidney, increasing the likelihood of significant long-term renal impairment.
Antenatal Imaging findings suspicious of posterior urethral valves
thickened bladder wall.
bilateral pelvicaliectasis with ureterectasis.
oligohydramnios.
ambiguous genitalia.
dilated posterior urethra (keyhole sign)
Most common cause of early neonatal mortality in a baby affected by posterior urethral valves:
Pulmonary hypoplasia
3-yr old circumcised boy with urinary incontinence, afebrile UTI, RBUS: moderate bilateral hydroureteronephrosis, NEXT STEP:
VCUG
** A high index of suspicion for posterior urethral valves must be assumed when a boy presents with lower urinary tract symptoms, especially recurrent urinary tract infections, but also overflow incontinence, gross hematuria, renal dysfunction, and, less commonly, ejaculatory dysfunction.
Fetal intervention for obstructive uropathy secondary to posterior urethral valves has been shown to: ___
Lead to improved pulmonary function in the neonate
Premature neonate, 2500 g
Impaired renal function, bilateral hydroureteronephrosis R>L
1 week of bladder cath. –> cystoscopy precluded by small genitalia
Creation of a vesicostomy
** vesicostomy allows decompression of the obstructed system, allows continued bladder cycling, and is easily managed with diapers. Upper tract diversion is a reasonable option, but does require bilateral incisions and also a complex follow-up surgery that can risk injury to the developing ureters.
4 yr old boy, s/p ablation of PUV in infancy; voiding with no incontinence; stable renal function, no UTI;
High grade VUR left with stable hydroureteronephrosis (no change since infancy): BEST MANAGEMENT?
Conservative management with timed voiding and
anticholinergic therapy
** Ureteral reimplantation is an option in atypical cases where urinary tract infections continue despite maximal bladder therapy.
Evolution of three contractility patterns in PUV:
(1) detrusor hyperreflexia in infancy and early childhood
(2) decreasing intravesical pressures and improved compliance bladder in childhood
(3) increased capacity bladder with hypocontractility and atony in adolescence
Associated with development of valve bladder syndrome:
High voiding pressures
Incomplete bladder emptying with high post-void residuals
Renal tubular and glomerular impairment
Bilateral hydroureteronephrosis
** while the bladder initially compensates for outlet obstruction by generating high voiding pressures, it begins to experience higher volumes of urine due to increasing urine production as the child grows –> detrusor continuously stretched –> impairs bladder contractility
Risk factors affecting prognosis of infant with PUV: ___
age at diagnosis
renal dysplasia with or without vesicoureteral reflux
nadir creatinine during first year of life
recurrent urinary tract infections
bladder dysfunction
