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Air Cystometry. III. A Clinical Evaluation in Pediatric Patients
Vol. 108, October Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
AIR CYSTOMETRY. III. A CLINICAL EVALUATION IN PEDIATRIC PATIENTS DANIEL C. MERRILL
AND
COLIN MARKLAND
From the Department of Surgery, Division of Urology, University of Minnesota Health Sciences Center, Minneapolis, Minnesota
Air cystometry measures detrusor innervation and the elastic characteristics of the bladder wall. 1 •2 This bladder function test is practical in pediatric patients since it can be performed rapidly with small single lumen catheters. The test has been performed in 137 pediatric patients. METHOD
This technique of air cystometry has been described.1 Infants and boys less than 10 years old were catheterized with a No. 5 or 8 tomac infant feeding tube,* female children and older boys were catheterized with a IOF Foley catheter. Air was infused at a rate of 30 ml. per minute in patients less than 2 years old, at 60 ml. per minute in children from 2 to 10 years old and at 150 ml. per minute in older pediatric patients. Air cystometrograms were performed on 62 normal pediatric patients. These patients had no history of genitourinary disease, no residuum and a negative urine culture. Air cystometrograms were also obtained from 75 pediatric patients being evaluated for bladder dysfunction. The urine cultures from these patients had been sterile for at least 1 month prior to testing. RESULTS: NORMAL
No complications occurred in the 137 air cystometrograms reported in this study. The data obtained from the 62 normal patients are summarized in tables 1 and 2. Detrusor reflex. The detrusor reflex was recorded in all infants less than 2 years old and in 85 per cent of older pediatric patients. The air cystometrograms from a normal newborn boy and a normal 5-year-old girl demonstrated a high amplitude detrusor contraction, similar to those previously described in normal adults (fig. 1, A and B). 2 The inability to demonstrate a detrusor reflex, characteristic of 15 per cent of older children, is shown on the cystometrogram of a normal 6-year-old girl (fig. 1, C). Detrusor reflex Accepted for publication January 28, 1972. This work was supported by United States Public Health Service Training Grant AM 05514, Special Fellowship AM 45213-01 and a grant from the American Urological Association, Inc. 1 Merrill, D. C., Bradley, W. E. and Markland, C.: Air cystometry. I. Technique and definition of terms. J. Urol., 106: 678, 1971. 2 Merrill, D. C., Bradley, W. E. and Markland, C.: Air cystometry. II. A clinical evaluation of normal adults. J. Urol., 108: 85, 1972. : American Hospital Supply Co., Evanston, Illinois.
inhibition was demonstrated in 50 per cent of those tested between the ages of 7 and 16 years (fig. 1, D). Bladder tonus. The graphic representation of bladder pressure was divided into 3 segments (fig. 2). The initial intravesical pressure (TI) decreased with age and in older children was similar to the figures previously reported in adults (table 1) .2 The slopet of the second tonus limb segment (TII) varied inversely with age and the bladder capacity; the average slope of TII was steeper in pediatric patients than in normal adults. The slope of the third segment (TIII) also varied inversely with age and bladder capacity, approaching adult characteristics in older children. Sensation. Most 5-year-old children described the first sensation of filling (FSF), the sensation of fullness and the urge to void or pain (table 1). As in adults, the volume at which the sensory changes occurred was variable and related to bladder capacity. 2 Bladder capacity. In normal adults cystometric bladder capacity was defined as the volume the bladder will accommodate during the second segment of the ton us limb. 2 Bladder capacity was not determined in patients who exhibited a detrusor reflex before the third segment of the tonus limb was reached. In children less than 2 years old, THI is seldom recorded and functional bladder capacity is determined by the onset of the detrusor reflex. Thus, the derived bladder capacities in table 1 are based on the detrusor reflex threshold in patients less than 2 years old and on the second segment of the tonus limb in older children. The bladder capacity doubled between ages 2 and 4 and thereafter increased progressively with age. 1\1icturition pressure. The maximal intra vesical pressure during the detrusor reflex averaged 70 cm. water. There was a wide range in micturition pressure with infants usually generating greater intravesical pressure than older children (table 2). Similar recordings in adults averaged 50 cm. water pressure. 2 Air leaks. Air leaks around the catheter, usually coincidental with the detrusor reflex, occurred in 12 per cent of these patients with no variation owing to age or sex. Initial spike. An initial spike averaging 30 cm. water pressure was recorded on 95 per cent of all pediatric cystometrograms (fig. 2). The initial spike occurred when urine, which enters the catheter upon t A straight line approximation of the true slope is derived by dividing the pressure change during a segment of the tonus limb by the volume infused and is expressed in centimeters of water pressure per 100 ml.
638
MERRILL AND MARKLAND
TABLE
l. Summary of data showing bladder tonus and bladder sensation during air cystometry in normal children TUI (cm. water/ 100 ml.) Incidence%
Bladder Tonus
Tl (cm. water)
TU (cm. water/ 100ml.)
Age (yrs.): 0-1 1-2 2-5 5-10 10-16
13.0 11.5 7.2 4.0 2.2
0. 7 8.0 4.0 5. 7 5. 2
FSF Ml.(%)
Full Ml.(%)
Urge to Void or Pain Ml.(%)
80 (10) 120 (62)
135 (70) 165 (75)
210 (95) 262 (95)
60 30 26 14
(17) (43) (65) (37)
elastic characteristics. Hyperreflexic bladder contractions were recorded in the cystometrogram of a 7-year-old boy with transverse myelitis (fig. 3, A). Vesical hypotonia and absent bladder sensation were demonstrated in the study of a 5-year-old boy with retroperitoneal sarcoma involving the conus medullaris (fig. 3, B). Detrusor fibrosis, later confirmed by bladder biopsy, was reflected by a shift to the left in the second tonus limb segment and the early appearance of the third segment in a 9-year-old girl with chronic cystitis (fig. 3, C). DISCUSSION
Sensation
Age (yrs.): 0-5 5-10 10-16
Bladder tonus is divided into 3 segments (TI, TII and TIII). .TII and TIII are presented by a straight line representation of the true slope determined by dividing the pressure change during filling by the volume of air infused. FSF refers to the first sensation of filling. The incidence is 100 per cent unless shown in brackets. TABLE 2. Relationship of bladder capacity and maximal intravesical pressure during detrusor reflex to age
Age (yrs.)
Capacity
l\1aximal Intravesical Pressure During Detrusor Reflex (cm. water)
0-1 1-2 2-4 4--6 6-10 10-16
43 80 160 170 205 250
80 66 60 58 67 66
The detrusor reflex determined the bladder capacity in patients less than 2 years old. In older children the bladder capacity corresponds to the volume infused during the second horizontal segment of the tonus limb.
catheterization, is expelled in the initial phase of the cystometrogram. Low amplitude vesical contractions. Low amplitude detrusor contractions, similar to those previously described in adults, were recorded in air cystometrograms from pediatric patients. 3 , 4 Low amplitude contractions, which increase in size and ultimately fuse into a high amplitude detrusor reflex, are shown in the cystometrogram of a 5-year-old girl (fig. 1, B). RESULTS: ABNORMAL
The number of patients was insufficient to derive meaningful cystometric parameters for each disease category. However, the cystometric patterns recorded in patients with known vesical dysfunction did reflect detrusor innervation and bladder wall 3 Plum, B. and Colfelt, R.H.: The genesis of vesical rhythmicity. A.M.A. Arch. Neurol., 2: 487, 1960. 4 Merrill, D. C.: Unpublished data.
Air cystometry produces an accurate continuous recording of intravesical pressure. Since the test can be performed rapidly with small single lumen catheters it is a practical method of evaluating bladder function in infants as well as older children. The distinction between normal and abnormal cystometric patterns is f!tcilitated if an accurate continuous recording of intravesical pressure is obtained. If an insensitive recorder is used, or if intermittent observations are made from a water manometer, it may be difficult to differentiate normal low and high amplitude contractions from uninhibited bladder contractions. In air cystometry the detrusor contractions associated with neurovesical dysfunction appear as multiple spikes of varying amplitude, while normal low amplitude activity is characterized by O to 15 cm. water deflections, which have a broad base, are rounded in appearance, usually increase progressively in amplitude and ultimately summate into a normal appearing high amplitude detrusor contraction. A normal cystometrogram also may be confused with an abnormal cystometric pattern if bladder filling is continued after the initial high amplitude detrusor contraction has been recorded, since subsequent contractions may appear to be uninhibited. Because volitional control of rnicturition is not possible before the age of 2 to 4 years the detrusor contractions in normal infants have been termed uninhibited. 5 , 6 This terminology is confusing since uninhibited is also used to describe the abnormal bladder contractions recorded in adult patients with lesions of the corticoregulatory tracts. 7 Infant bladder contractions should not be referred to as uninhibited for 2 reasons. First, although difficult to document in humans, uninhibited bladder contractions in adults undoubtedly represent a different neurophysiological process than the one responsible for normal infantile bladder function. Second, a normal infantile bladder contraction (fig. 1, A) is dissimilar to the cystometric detrusor contractions usually recorded in patients with lesions of the corticoregulatory tracts (fig. 4). Normal bladder function 5 Nash, D. F. E.: Development of micturition control with special reference to enuresis; Hunterian Lecture. Ann. Roy. Coll. Surg., 6: 318, 1949. 6 Lapides, J. and Diokno, A. C.: Persistence of the infant bladder as a cause for urinary infection in girls. J. UroL, 103: 243, 1970. 7 Lapides, J.: Cystometry. J.A.M.A., 201: 618, 1967.
639
AIR CYSTOMETRY
A
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60
2
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20 0
4
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TIME - minutes
Fm. 1. Four air cystometrograms from normal pediatric patients. FSF refers to first sensation of filling. Rate of fill was 30 ml. per minute in A and 60 ml. per minute in B, C and D. A, newborn boy. B, 5-year-old girl. C, 6-year old girl. D, 7-year-old boy demonstrates depression of detrusor reflex. Patient was asked to ,nhibit at points marked by arrows.
100
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40
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5
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TIME min Fm. 2. Air cystometrogram from 8-year-old girl shows 3 segments of tonus limb. Rate of fill 60 ml. per minute. in infancy is characterized, as in older children and adults, by a single high amplitude detrusor reflex, which may be preceded by several low amplitude detrusor contractions. In contrast, uninhibited detrusor contractions are characterized by multiple detrusor responses of varying amplitude which occur in no particular sequence. Thus, the term uninhibited should be reserved for patients with neurovesical dysfunction, while detrusor contractions recorded in normal infants should be referred to as normal for age or infantile. The air cystometric patterns obtained from children with central and peripheral nervous system lesions are similar to the tracings reported by previ-
ous investigators using water cystometry.8 • 9 The air cystometrograms in patients with upper motor neuron lesions are characterized by absent or abnormal sensation and a premature uncontrollable detrusor contraction. Lower motor neuron lesions are characterized by absent or abnormal sensation, absent detrusor reflex and hypotonia. Detrusor fibrosis 8 Ruch, T. C. and Tang, P.: The higher control of the bladder. In: The Neurogenic Bladder. Edited by S. Boyarsky. Baltimore: The Williams & Wilkins Co., 1967. 9 Bors, E. H. and Comarr, A. E.: Neurological Urology: Physiology of Micturition, Its Neurological Disorders and Sequelae. Baltimore: University Park Press, 1971.
640
MERRILL AND MARKLAND
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Fm. 3. Three air cystometrograms from pediatric patients show bladder dysfunction. Bladder was filled at rate of 60 ml. per minute for each cystometrogram. A, 7-year-old boy with transverse n1yelitis. B, 5-year-old boy following removal of retroperitoneal sarcoma. C, 9-year-old girl with chronic cystitis. u ·5
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TIME min.
Fm. 4. Air cystometrogram from 30-year-old woman with multiple sclerosis. Rate of fill 60 ml. per minute.
is characterized by normal sensory changes during filling, absence of the detrusor reflex and a tonus limb which is shifted to the left (hypertonia). SUMMARY
Air cystometry is an accurate, rapid and safe method to evaluate bladder function in pediatric patients. The air cystometrograms obtained from normal infants were similar to those previously de-
scribed in adult patients, the only differences being the inability of infants to describe sensory changes during filling and the inability of infants to inhibit the detrusor reflex on command. An air cystometrogram documenting sensory changes, the presence or absence of the detrusor reflex and, in older children, reflex inhibition will allow differentiation of normal detrusor function from the various types of bladder dysfunction in most patients.
THE JOURNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
AIR CYSTOMETRY. III. A CLINICAL EVALUATION IN PEDIATRIC PATIENTS DANIEL C. MERRILL
AND
COLIN MARKLAND
From the Department of Surgery, Division of Urology, University of Minnesota Health Sciences Center, Minneapolis, Minnesota
Air cystometry measures detrusor innervation and the elastic characteristics of the bladder wall. 1 •2 This bladder function test is practical in pediatric patients since it can be performed rapidly with small single lumen catheters. The test has been performed in 137 pediatric patients. METHOD
This technique of air cystometry has been described.1 Infants and boys less than 10 years old were catheterized with a No. 5 or 8 tomac infant feeding tube,* female children and older boys were catheterized with a IOF Foley catheter. Air was infused at a rate of 30 ml. per minute in patients less than 2 years old, at 60 ml. per minute in children from 2 to 10 years old and at 150 ml. per minute in older pediatric patients. Air cystometrograms were performed on 62 normal pediatric patients. These patients had no history of genitourinary disease, no residuum and a negative urine culture. Air cystometrograms were also obtained from 75 pediatric patients being evaluated for bladder dysfunction. The urine cultures from these patients had been sterile for at least 1 month prior to testing. RESULTS: NORMAL
No complications occurred in the 137 air cystometrograms reported in this study. The data obtained from the 62 normal patients are summarized in tables 1 and 2. Detrusor reflex. The detrusor reflex was recorded in all infants less than 2 years old and in 85 per cent of older pediatric patients. The air cystometrograms from a normal newborn boy and a normal 5-year-old girl demonstrated a high amplitude detrusor contraction, similar to those previously described in normal adults (fig. 1, A and B). 2 The inability to demonstrate a detrusor reflex, characteristic of 15 per cent of older children, is shown on the cystometrogram of a normal 6-year-old girl (fig. 1, C). Detrusor reflex Accepted for publication January 28, 1972. This work was supported by United States Public Health Service Training Grant AM 05514, Special Fellowship AM 45213-01 and a grant from the American Urological Association, Inc. 1 Merrill, D. C., Bradley, W. E. and Markland, C.: Air cystometry. I. Technique and definition of terms. J. Urol., 106: 678, 1971. 2 Merrill, D. C., Bradley, W. E. and Markland, C.: Air cystometry. II. A clinical evaluation of normal adults. J. Urol., 108: 85, 1972. : American Hospital Supply Co., Evanston, Illinois.
inhibition was demonstrated in 50 per cent of those tested between the ages of 7 and 16 years (fig. 1, D). Bladder tonus. The graphic representation of bladder pressure was divided into 3 segments (fig. 2). The initial intravesical pressure (TI) decreased with age and in older children was similar to the figures previously reported in adults (table 1) .2 The slopet of the second tonus limb segment (TII) varied inversely with age and the bladder capacity; the average slope of TII was steeper in pediatric patients than in normal adults. The slope of the third segment (TIII) also varied inversely with age and bladder capacity, approaching adult characteristics in older children. Sensation. Most 5-year-old children described the first sensation of filling (FSF), the sensation of fullness and the urge to void or pain (table 1). As in adults, the volume at which the sensory changes occurred was variable and related to bladder capacity. 2 Bladder capacity. In normal adults cystometric bladder capacity was defined as the volume the bladder will accommodate during the second segment of the ton us limb. 2 Bladder capacity was not determined in patients who exhibited a detrusor reflex before the third segment of the tonus limb was reached. In children less than 2 years old, THI is seldom recorded and functional bladder capacity is determined by the onset of the detrusor reflex. Thus, the derived bladder capacities in table 1 are based on the detrusor reflex threshold in patients less than 2 years old and on the second segment of the tonus limb in older children. The bladder capacity doubled between ages 2 and 4 and thereafter increased progressively with age. 1\1icturition pressure. The maximal intra vesical pressure during the detrusor reflex averaged 70 cm. water. There was a wide range in micturition pressure with infants usually generating greater intravesical pressure than older children (table 2). Similar recordings in adults averaged 50 cm. water pressure. 2 Air leaks. Air leaks around the catheter, usually coincidental with the detrusor reflex, occurred in 12 per cent of these patients with no variation owing to age or sex. Initial spike. An initial spike averaging 30 cm. water pressure was recorded on 95 per cent of all pediatric cystometrograms (fig. 2). The initial spike occurred when urine, which enters the catheter upon t A straight line approximation of the true slope is derived by dividing the pressure change during a segment of the tonus limb by the volume infused and is expressed in centimeters of water pressure per 100 ml.
638
MERRILL AND MARKLAND
TABLE
l. Summary of data showing bladder tonus and bladder sensation during air cystometry in normal children TUI (cm. water/ 100 ml.) Incidence%
Bladder Tonus
Tl (cm. water)
TU (cm. water/ 100ml.)
Age (yrs.): 0-1 1-2 2-5 5-10 10-16
13.0 11.5 7.2 4.0 2.2
0. 7 8.0 4.0 5. 7 5. 2
FSF Ml.(%)
Full Ml.(%)
Urge to Void or Pain Ml.(%)
80 (10) 120 (62)
135 (70) 165 (75)
210 (95) 262 (95)
60 30 26 14
(17) (43) (65) (37)
elastic characteristics. Hyperreflexic bladder contractions were recorded in the cystometrogram of a 7-year-old boy with transverse myelitis (fig. 3, A). Vesical hypotonia and absent bladder sensation were demonstrated in the study of a 5-year-old boy with retroperitoneal sarcoma involving the conus medullaris (fig. 3, B). Detrusor fibrosis, later confirmed by bladder biopsy, was reflected by a shift to the left in the second tonus limb segment and the early appearance of the third segment in a 9-year-old girl with chronic cystitis (fig. 3, C). DISCUSSION
Sensation
Age (yrs.): 0-5 5-10 10-16
Bladder tonus is divided into 3 segments (TI, TII and TIII). .TII and TIII are presented by a straight line representation of the true slope determined by dividing the pressure change during filling by the volume of air infused. FSF refers to the first sensation of filling. The incidence is 100 per cent unless shown in brackets. TABLE 2. Relationship of bladder capacity and maximal intravesical pressure during detrusor reflex to age
Age (yrs.)
Capacity
l\1aximal Intravesical Pressure During Detrusor Reflex (cm. water)
0-1 1-2 2-4 4--6 6-10 10-16
43 80 160 170 205 250
80 66 60 58 67 66
The detrusor reflex determined the bladder capacity in patients less than 2 years old. In older children the bladder capacity corresponds to the volume infused during the second horizontal segment of the tonus limb.
catheterization, is expelled in the initial phase of the cystometrogram. Low amplitude vesical contractions. Low amplitude detrusor contractions, similar to those previously described in adults, were recorded in air cystometrograms from pediatric patients. 3 , 4 Low amplitude contractions, which increase in size and ultimately fuse into a high amplitude detrusor reflex, are shown in the cystometrogram of a 5-year-old girl (fig. 1, B). RESULTS: ABNORMAL
The number of patients was insufficient to derive meaningful cystometric parameters for each disease category. However, the cystometric patterns recorded in patients with known vesical dysfunction did reflect detrusor innervation and bladder wall 3 Plum, B. and Colfelt, R.H.: The genesis of vesical rhythmicity. A.M.A. Arch. Neurol., 2: 487, 1960. 4 Merrill, D. C.: Unpublished data.
Air cystometry produces an accurate continuous recording of intravesical pressure. Since the test can be performed rapidly with small single lumen catheters it is a practical method of evaluating bladder function in infants as well as older children. The distinction between normal and abnormal cystometric patterns is f!tcilitated if an accurate continuous recording of intravesical pressure is obtained. If an insensitive recorder is used, or if intermittent observations are made from a water manometer, it may be difficult to differentiate normal low and high amplitude contractions from uninhibited bladder contractions. In air cystometry the detrusor contractions associated with neurovesical dysfunction appear as multiple spikes of varying amplitude, while normal low amplitude activity is characterized by O to 15 cm. water deflections, which have a broad base, are rounded in appearance, usually increase progressively in amplitude and ultimately summate into a normal appearing high amplitude detrusor contraction. A normal cystometrogram also may be confused with an abnormal cystometric pattern if bladder filling is continued after the initial high amplitude detrusor contraction has been recorded, since subsequent contractions may appear to be uninhibited. Because volitional control of rnicturition is not possible before the age of 2 to 4 years the detrusor contractions in normal infants have been termed uninhibited. 5 , 6 This terminology is confusing since uninhibited is also used to describe the abnormal bladder contractions recorded in adult patients with lesions of the corticoregulatory tracts. 7 Infant bladder contractions should not be referred to as uninhibited for 2 reasons. First, although difficult to document in humans, uninhibited bladder contractions in adults undoubtedly represent a different neurophysiological process than the one responsible for normal infantile bladder function. Second, a normal infantile bladder contraction (fig. 1, A) is dissimilar to the cystometric detrusor contractions usually recorded in patients with lesions of the corticoregulatory tracts (fig. 4). Normal bladder function 5 Nash, D. F. E.: Development of micturition control with special reference to enuresis; Hunterian Lecture. Ann. Roy. Coll. Surg., 6: 318, 1949. 6 Lapides, J. and Diokno, A. C.: Persistence of the infant bladder as a cause for urinary infection in girls. J. UroL, 103: 243, 1970. 7 Lapides, J.: Cystometry. J.A.M.A., 201: 618, 1967.
639
AIR CYSTOMETRY
A
100
I
75
75
50
.,'0;: E u
0
I
50
I /
25
25
~JJ
2
0
3
LLI
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B
100
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100
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0
2
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4
D
C 80
·g
60
2
75
~ ::,
'5 ,.,_
40
50 25 0 0
~ 2
20 0
4
3
0
2
3
TIME - minutes
Fm. 1. Four air cystometrograms from normal pediatric patients. FSF refers to first sensation of filling. Rate of fill was 30 ml. per minute in A and 60 ml. per minute in B, C and D. A, newborn boy. B, 5-year-old girl. C, 6-year old girl. D, 7-year-old boy demonstrates depression of detrusor reflex. Patient was asked to ,nhibit at points marked by arrows.
100
...
-~ GI
80
60 E u I
LLI
a:: ::,
40
V, V,
LLI
a::
Q.
20
T II
0 3
2
4
5
6
TIME min Fm. 2. Air cystometrogram from 8-year-old girl shows 3 segments of tonus limb. Rate of fill 60 ml. per minute. in infancy is characterized, as in older children and adults, by a single high amplitude detrusor reflex, which may be preceded by several low amplitude detrusor contractions. In contrast, uninhibited detrusor contractions are characterized by multiple detrusor responses of varying amplitude which occur in no particular sequence. Thus, the term uninhibited should be reserved for patients with neurovesical dysfunction, while detrusor contractions recorded in normal infants should be referred to as normal for age or infantile. The air cystometric patterns obtained from children with central and peripheral nervous system lesions are similar to the tracings reported by previ-
ous investigators using water cystometry.8 • 9 The air cystometrograms in patients with upper motor neuron lesions are characterized by absent or abnormal sensation and a premature uncontrollable detrusor contraction. Lower motor neuron lesions are characterized by absent or abnormal sensation, absent detrusor reflex and hypotonia. Detrusor fibrosis 8 Ruch, T. C. and Tang, P.: The higher control of the bladder. In: The Neurogenic Bladder. Edited by S. Boyarsky. Baltimore: The Williams & Wilkins Co., 1967. 9 Bors, E. H. and Comarr, A. E.: Neurological Urology: Physiology of Micturition, Its Neurological Disorders and Sequelae. Baltimore: University Park Press, 1971.
640
MERRILL AND MARKLAND
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3 TIME - minutes
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Fm. 3. Three air cystometrograms from pediatric patients show bladder dysfunction. Bladder was filled at rate of 60 ml. per minute for each cystometrogram. A, 7-year-old boy with transverse n1yelitis. B, 5-year-old boy following removal of retroperitoneal sarcoma. C, 9-year-old girl with chronic cystitis. u ·5
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LL
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2
3
4
5
6
TIME min.
Fm. 4. Air cystometrogram from 30-year-old woman with multiple sclerosis. Rate of fill 60 ml. per minute.
is characterized by normal sensory changes during filling, absence of the detrusor reflex and a tonus limb which is shifted to the left (hypertonia). SUMMARY
Air cystometry is an accurate, rapid and safe method to evaluate bladder function in pediatric patients. The air cystometrograms obtained from normal infants were similar to those previously de-
scribed in adult patients, the only differences being the inability of infants to describe sensory changes during filling and the inability of infants to inhibit the detrusor reflex on command. An air cystometrogram documenting sensory changes, the presence or absence of the detrusor reflex and, in older children, reflex inhibition will allow differentiation of normal detrusor function from the various types of bladder dysfunction in most patients.