Pediatric Voiding Dysfunction Flashcards
What tests would you order on a 6 yo with spina bifida (s/p back closure as baby, L5 myelomeningocele) who presents with worsening urinary incontinence, urgency, and recurrent UTI?
RBUS
VCUG
UDS
MRI spine
What would be your main dx for 6 yo with spina bifida (s/p back closure as baby, L5 myelomeningocele) who presents with worsening urinary incontinence, urgency, and recurrent UTI?
UDS shows small capacity bladder with intact sensation, poor compliance, uninhibited contractions, high DLPP, VUR
Tethered cord (MRI)
What is normal bladder capacity for a child?
Normal bladder capacity = (age +2) x 30 mL
What is DLPP and what is the upper threshold?
Detrusor leak point pressure – leakage in absence of valsalva or contraction
The detrusor leak point pressure (DLPP) is a measure of the pressure at which the detrusor muscle in the bladder begins to leak urine during the filling phase of the bladder.
The DLPP is measured during urodynamic testing, a diagnostic test used to evaluate bladder function. During the test, a catheter is inserted into the bladder and the bladder is filled with fluid. The pressure in the bladder is measured at various points, including when the detrusor muscle begins to leak urine. The DLPP is the pressure at which this leakage occurs.
sign of poor compliance
>40 cm H20 causes renal damage
Initial treatment for child with detrusor hyperreflexia, poor compliance, VUR, DLPP > 40 cm H20? Without tethered cord.
CIC + AC drug
CaP for VUR
Bowel regimen
Regular f/up UA, UCx, Renal US, Cr
What would be next steps for progression of bladder hostility, pyelonephritis, worsening hydro, or renal function loss?
Augmentation (+ reimplant if VUR)
Mitrofanoff, considered in boys
MACE
In a boy with spina bifida and UI (L4 myelomeningocele), what is initial workup of worsening or uncontrolled leakage?
RBUS
VCUG
UDS
+/- MRI
In a boy with spina bifida and UI (L4 myelomeningocele), RBUS demonstrates L hydro with loss of parenchyma, VCUG demonstrates Grade IV/V L VUR, bladder neck open, what testing would be indicated to assess kidneys?
DMSA
In a boy with spina bifida and UI (L4 myelomeningocele), RBUS demonstrates L hydro with loss of parenchyma, VCUG demonstrates Grade IV/V L VUR, bladder neck open, DMSA demonstrates 65%/35%, L/R.
UDS shows:
small capacity, overactive bladder (DO 30 cm H20, SUI, elevated PVR)
First tx options? If failed first options?
First options: CIC + AC, CaP for VUR
Failed non-invasive:
- Autoaugmentation with ureteral reimplant and bladder neck sling
- Augmentation enterocystoplasty (stomach, ileum, colon) with transvesical ureteral reimplant and sling (autologous or cadaveric vs. AUS)
- Continent vesicostomy (Mitrofanoff with bladder neck closure) + MACE
Complications and management of bladder augmentation:
- Autoaugmentation (detrusor myotomy):
- Damage to urothelium → repair 4-0 chromic
- Persistent bladder leak → continued urethral catheter
- Augmentation enterocystoplasty
- Contraction with incontinence → AC
- Mucus → flush
- Hematuria/dysuria syndrome → stomach only, H2 blocker, HCO3
- Stones → irrigation, extraction
- Spontaneous perforation → peritonitis and death (5-10%), first cath drainage, operate based on clinical suspicion (cystogram can be FN)
- Metabolic acidosis → stomach/colon, can lead to osteoporosis → tx oral NaHCO3 or Na/K Citrate
- Metabolic alkalosis → stomach, H2 blocker
- Malignancy → adenocarcinoma of bowel, or UC bladder, if new blood in urine or recurrent UTI do cysto, B12 deficiency (terminal ileum), pernicious anemia/neuropathy
In patient with lethargy, fever, and VP shunt, what should be done?
Consult NSG to r/o shunt failure
Describe open cystolithotomy on augmented bladder:
- prep and drape
- place foley
- lower midline incision
- place ring retractor
- incise detrusor
- avoid bowel portion of bladder
- remove stones
- close incision in layers
- leave SPT, Foley, drain
Increase interval of CIC and consider irrigation regimen
What are treatment options for 21 yo M with hx of L1 myelomeningocele with UDS demonstrating normal capacity and compliance, SUI but not UUI?
- Periurethral bulking (success low)
- Male sling (may need to CIC after)
- Leadbetter trigonal tubularization
- Tanagho bladder neck tubularization
- Kropp anterior bladder tube implantation
- AUS (revision 5-7 y)
Describe AUS:
- Dorsal lithotomy
- Inguinal incision for pressure reservoir (61-70 H2O used for bulbar urethra)
- Perineal incision for cuff placement → measure urethral circumference (4.5 cm common in bulbar urethra)
- Connect tubing
- Cycle the sphincter
- Lock the cuff in open position
- Leave foley overnight
- Activate at 6 weeks
If a patient has an AUS and develops hydronephrosis, worsening renal function, what is first step? What diagnostic testing is necesary?
First step it to ensure sphincter is working and deactivate it with cuff in open state, catheter to check PVR
US (done as mentioned in stem) VCUG ( to assess for VUR)
Need UDS
What is ddx of 15 yo M with enuresis and neurologic findings (decreased DTR, decreased rectal tone), not previously dx with any congenital issues? What tests should be ordered?
tethered cord
spinal dysraphism
Order: RBUS, KUB, VCUG, UDS, MRI spine
What are treatment options for 15 yo M with tethered cord and small capacity, overactive bladder with high DLPP and no SUI?
- Anticholinergics
- Timed voiding
- Bowel regimen
- CIC
- NSG for cord de-tethering
What surveillance is utilized for spina bifida patient with or without surgical intervention?
Yearly RBUS, Cr (cystatin C)
changes in sxs: UDS
UTIs/blood: cysto
If medication and cord de-tethering do not work for a poorly compliant, small bladder patient with incontinence, what are next steps?
Bladder autoaugmentation or enterocystoplasty
may need CIC
consider continent catheterizable channel
First goal of pediatric NGB management in babies with spinal dysraphism? What tests are done?
protect the kidneys from high bladder pressures and incomplete emptying
ID newborns at risk of renal damage
GET RBUS in first few days of life
* can consider contrast enhanced US
Look for:
hydronephrosis, parenchymal anomalies, bladder appearance
Consider VCUG (once patients can lie on back, once defect closed)
What workup should a baby with spinal dysraphism have in the early months after discharge from the hospital?
Urodynamics and a repeat renal bladder ultrasound are typically obtained around 2-4 months of age.
It is important to highlight that there are no reference values for bladder dynamics this early in life.
Several urodynamic findings have been associated with risk of UTI and kidney scarring including bladder trabeculations, VUR, high storage pressures evidenced by end fill pressure or detrusor leak point pressure > 40 cm H2O, and detrusor sphincter dyssynergia.
Initial CIC determination in infants is utilized until first UDS based on which factors?
consistently high bladder pressures or high residuals
trabeculated bladder
high grade VUR
high grade hydronephrosis
A 2-4 month old with urodynamics that is LOW risk for upper tract damage will have these features
A patient who is very low risk for upper tract damage on urodynamics will have
- a smooth walled bladder without VUR
- low bladder residuals
- low leak point pressures
For a baby’s first urodynamics, urodynamic findings have been associated with risk of UTI and kidney scarring include:
Bladder trabeculations
VUR
High storage pressures evidenced by end fill pressure or detrusor leak point pressure > 40 cm H2O
Detrusor sphincter dyssynergia