Early treatment improves urodynamic prognosis in neurogenic voiding dysfunction: 20 years of experience<sup>,</sup>

Monteiro, Lucia M. Costa; Cruz, Glaura O.; Fontes, Juliana M.; Vieira, Eliane T.R.C.; Santos, Eloá N.; Araújo, Grace F.; Ramos, Eloane G.

doi:10.1016/j.jped.2016.11.010

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Original articles • J. Pediatr. (Rio J.) 93 (4) • Jul-Aug 2017 • https://doi.org/10.1016/j.jped.2016.11.010 copy

Early treatment improves urodynamic prognosis in neurogenic voiding dysfunction: 20 years of experience^☆ ☆ Please cite this article as: Monteiro LM, Cruz GO, Fontes JM, Vieira ET, Santos EN, Araújo GF, et al. Early treatment improves urodynamic prognosis in neurogenic voiding dysfunction: 20 years of experience. J Pediatr (Rio J). 2017;93:420-7. ^,^☆☆ ☆☆ Study carried out at Fundação Oswaldo Cruz (Fiocruz), Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Rio de Janeiro, RJ, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To evaluate the association between early treatment and urodynamic improvement in pediatric and adolescent patients with neurogenic bladder.

Methodology:

Retrospective longitudinal and observational study (between 1990 and 2013) including patients with neurogenic bladder and myelomeningocele treated based on urodynamic results. The authors evaluated the urodynamic follow-up (bladder compliance and maximum bladder capacity and pressure) considering the first urodynamic improvement in two years as the outcome variable and early referral as the exposure variable, using a descriptive and multivariate analysis with logistic regression model.

Results:

Among 230 patients included, 52% had an early referral. The majority were diagnosed as overactive bladder with high bladder pressure (≥40 cm H₂O) and low bladder compliance (3 mL/cmH₂O) and were treated with oxybutynin and intermittent catheterization. Urodynamic follow-up results showed 68% of improvement at the second urodynamic examination decreasing bladder pressure and increasing bladder capacity and compliance. The percentage of incontinence and urinary tract infections decreased over treatment. Early referral (one-year old or less) increased by 3.5 the probability of urodynamic improvement in two years (95% CI: 1.81-6.77).

Conclusion:

Treatment onset within the first year of life improves urodynamic prognosis in patients with neurogenic bladder and triplicates the probability of urodynamic improvement in two years. The role of neonatologists and pediatricians in early referral is extremely important.

KEYWORDS
Urinary incontinence; Neurogenic bladder; Urodynamics; Treatment; Kidney failure; Follow-up

Variable	n (%)	Improvement <2 years	Crude relative risk	p-value^a a Chi-squared test.
Overall characteristics
Gender				0.271
F	123 (53%)	67.5%	-
M	107 (47%)	59.8%	0.89
Early referral				<0.001
No	111 (48%)	48.6%	-
Yes	119 (52%)	78.2%	1.61
Number of urodynamic evaluations				0.394
2-3	114 (50%)	67.5%	-
4-6	92 (40%)	62.0%	0.92
7-14	24 (10%)	54.2%	0.80
Decade of first evaluation ^b b Missing data: up to 5%.				<0.001
Last 10 years	163 (72%)	76.7%	2.5
10 to 20 years	62 (28%)	30.6%	-
Treatment adherence ^c c Missing data: up to 10%.				0.061
No	106 (51%)	57.5%	-
Yes	101 (49%)	70.3%	1.22

Urodynamic evaluation
Urodynamic diagnosis				0.517
Low compliance	19 (8%)	52.6%	-
Overactive bladder	205 (89%)	64.9%	1.23
Underactive bladder	6 (3%)	66.7%	1.27
Maximum bladder pressure (cmH ₂ O) ^b b Missing data: up to 5%.				0.007
0-40	82 (36%)	54.9%	-
41-80	91 (40%)	63.7%	1.16
>80	53 (23%)	81.1%	1.48
Loss pressure (cmH ₂ O) ^b b Missing data: up to 5%.				0.112
0-40	107 (48%)	57.9%	-
41-80	78 (35%)	69.2%	1.19
>80	39 (17%)	74.4%	1.28
Maximum/expected bladder capacity ^b b Missing data: up to 5%.				0.121
0-0.5	130 (58%)	69.2%	1.38
0.6-1	62 (28%)	62.9%	1.26
>1	32 (14%)	50.0%	-
Compliance (mL/cmH ₂ O) ^c c Missing data: up to 10%.				0.002
0-1	111 (52%)	75.7%	1.43
2-3	66 (31%)	53.0%	1.03
>3	37 (17%)	51.4%	-

Indicated treatment
Anticholinergic indication ^b b Missing data: up to 5%.				0.004
No	34 (15%)	58.8%	-
Oxybutynin	162 (73%)	69.8%	1.19
Propantheline	25 (11%)	36.0%	0.61
Intermittent catheterization indication ^c c Missing data: up to 10%.				0.667
No	119 (56%)	62.2%	-
Yes	94 (44%)	66.0%	1.06
Antibiotic therapy ^c c Missing data: up to 10%.				0.631
No	155 (73%)	65.2%	-
Yes	57 (27%)	61.4%	0.94
Antibiotic prophylaxis ^b b Missing data: up to 5%.				0.171
No	67 (30%)	56.7%	-
Yes	154 (70%)	66.9%	1.18

Symptoms related to neurogenic bladder
Diurnal urinary incontinence ^d d Missing data: up to 15%.				1.000
No	8 (4%)	62.5%	-
Yes	193 (96%)	66.3%	1.06
Nocturnal urinary incontinence ^d d Missing data: up to 15%.				0.514
No	11 (6%)	54.5%	-
Yes	187 (94%)	66.8%	1.23
Urinary tract infection ^e e Missing data: 22%.				0.214
No	134 (74%)	67.2%	-
Yes	46 (26%)	56.5%	0.84

	Estimated coefficient	Standard error	Adjusted relative risk	95% confidence interval
Intercept	-1.98	0.43	0.14	0.06	0.32^a a p-value <0.05 (Wald test).
Referral in the last 10 years	2.05	0.37	7.76	3.75	16.08^a a p-value <0.05 (Wald test).
Early referral	1.25	0.34	3.50	1.81	6.77^a a p-value <0.05 (Wald test).
Bladder pressure 40-80 cmH₂O	0.56	0.36	1.76	0.86	3.59
Bladder pressure >80 cmH₂O	1.60	0.49	4.98	1.89	13.09^a a p-value <0.05 (Wald test).

UDY	n	Improvement compared with the previous examination	Compensated bladder	Bladder pressure ≤40 cmH₂O	Loss pressure ≤40 cmH₂O	Bladder capacity (median)	Bladder compliance: mL/cmH₂O (median)	Years between urodynamic assessments (median)
1	230	-	0%	35.7%	46.5%	0.44	1.0	-
2	230	68%	14%	40.9%	52.6%	0.68	2.2	1.1
3	167	60%	20%	47.9%	57.5%	0.67	3.0	1.3
4	117	52%	29%	54.7%	64.1%	0.59	4.2	1.4
5	75	64%	28%	52%	62.7%	0.59	3.9	1.4
6	48	56%	31%	52.1%	64.6%	0.55	5.2	1.4

UDY	Diurnal urinary incontinence	Nocturnal urinary incontinence	Urinary tract infection
1	84%	81%	81%
2	82%	80%	80%
3	75%	73%	73%
4	66%	68%	68%
5	77%	72%	72%
6	75%	67%	67%

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E-mail: jped@jped.com.br

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[1] * Corresponding author. E-mails:lucia@fiocruz.br, lucia@iff.fiocruz.br, luciacostamonteiro@gmail.com (L.M. Costa Monteiro).

UDY	Diurnal urinary incontinence	Nocturnal urinary incontinence	Urinary tract infection
1	84%	81%	81%
2	82%	80%	80%
3	75%	73%	73%
4	66%	68%	68%
5	77%	72%	72%
6	75%	67%	67%

UDY	Diurnal urinary incontinence	Nocturnal urinary incontinence	Urinary tract infection
1	84%	81%	81%
2	82%	80%	80%
3	75%	73%	73%
4	66%	68%	68%
5	77%	72%	72%
6	75%	67%	67%

UDY	Diurnal urinary incontinence	Nocturnal urinary incontinence	Urinary tract infection
1	84%	81%	81%
2	82%	80%	80%
3	75%	73%	73%
4	66%	68%	68%
5	77%	72%	72%
6	75%	67%	67%