- Email: [email protected]
Discussion following Dr. Bauer’s presentation
DISCUSSION FOLLOWING DR. BAUER’S PRESENTATION Jacek L. Mostwin, MD, DPhil (Baltimore, MD): Robert D. Jeffs, MD, in Baltimore, used to talk about these children who had urinary tract infection with bladder overactivity. This would lead to the sensation of dysuria, which would then give rise to a remembered pattern of unpleasant voiding that the child would then fight. Therefore, long after the infection was treated, there would be the persistent memory of painful urination. Then, you would get into vicious cycles of functional obstruction and perhaps set the stage for further infections. Stuart B. Bauer, MD (Boston, MA): We see a substantial number of children who get urinary infections within the first few months of toilet training because they are now learning to hold and prevent themselves from going. This sets the stage for their dysfunctional elimination problems later on. Jeffrey P. Weiss, MD (New York, NY): So, I take it you are using anticholinergics in these patients who have been trained. Now, what about refluxes in those who are pretraining? Is there any consideration of void dysfunction in those patients? Dr. Bauer: We have not given those children anticholinergic drugs, but we have talked about it in our group. Dr. Weiss: What is your technique with urodynamics? Do you use a rectal catheter? Do you use subtraction pressures? Dr. Bauer: We use rectal pressures, and we record the events when they have straining so we can separate true detrusor contractility from straining. Dr. Weiss: Would you suggest now liberalizing the indications for urodynamics in children? If you are doing periodic voiding cystometrography in pediatric patients with vesi-
UROLOGY 60 (Supplement 5A), November 2002
coureteral reflux, would you instead do videourodynamics to gain additional pressure-flow data? Dr. Bauer: We are actually doing nuclear cystography for all the children who come in for urinary infection. We are doing it simultaneously to see if they have reflux associated with or without hyperreflexia. But I think that urodynamic studies are probably as important if not more important than the voiding cystourethrography in these children because voiding dysfunction is more common than reflux as a cause for infection. Jerry G. Blaivas, MD (New York, NY): Are there any clinical counterparts to seeing reflux during the detrusor contraction as opposed to during filling? Dr. Bauer: No. People have tried to say high-pressure reflux may go away more rapidly than low-pressure reflux that occurs during filling, but there have not been any good studies that have addressed that carefully. Dr. Weiss: What if I see someone who has been refluxing since birth at a high level, then, at age 1 or 2 years, these issues are resolved? I would like to stop giving them antibiotics, but I am warning the parents that the minute they get trained, there may be trouble. What do you do at that point? Dr. Bauer: I talk to the parents about appropriate voiding patterns because once children train, many times parents do not pay any attention. It is surprising to me that when you ask the children directly about their voiding patterns, the parents are amazed at the flow patterns and how infrequently their children urinate. To minimize the children’s risk of infection after toilet training, I talk to parents about how to appropriately get the children to void on a regular basis, take time to empty, and to have bowel movements on a daily basis.
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UROLOGY 60 (Supplement 5A), November 2002
coureteral reflux, would you instead do videourodynamics to gain additional pressure-flow data? Dr. Bauer: We are actually doing nuclear cystography for all the children who come in for urinary infection. We are doing it simultaneously to see if they have reflux associated with or without hyperreflexia. But I think that urodynamic studies are probably as important if not more important than the voiding cystourethrography in these children because voiding dysfunction is more common than reflux as a cause for infection. Jerry G. Blaivas, MD (New York, NY): Are there any clinical counterparts to seeing reflux during the detrusor contraction as opposed to during filling? Dr. Bauer: No. People have tried to say high-pressure reflux may go away more rapidly than low-pressure reflux that occurs during filling, but there have not been any good studies that have addressed that carefully. Dr. Weiss: What if I see someone who has been refluxing since birth at a high level, then, at age 1 or 2 years, these issues are resolved? I would like to stop giving them antibiotics, but I am warning the parents that the minute they get trained, there may be trouble. What do you do at that point? Dr. Bauer: I talk to the parents about appropriate voiding patterns because once children train, many times parents do not pay any attention. It is surprising to me that when you ask the children directly about their voiding patterns, the parents are amazed at the flow patterns and how infrequently their children urinate. To minimize the children’s risk of infection after toilet training, I talk to parents about how to appropriately get the children to void on a regular basis, take time to empty, and to have bowel movements on a daily basis.
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