Can VideoUrodynamics Shape Management in Refractory Pediatric Lower Urinary Tract Dysfunction?
Stephen Zderic, MD, Amanda Berry, PhD, Monica Moran, RN, Dana Weiss, MD, Christopher Long, MD, Joy Kerr, DNP, Jason P. Van Batavia, MD, MSTR.
The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Background: Lower urinary tract dysfunction (LUTD) remains a common reason for pediatric urology consultation, and the management of these patients remains time consuming and frustrating for patients, families and providers alike. While many pediatric LUTD patients improve with urotherapy and/or pharmacological intervention, there are a subset in whom symptoms persist despite treatment. What is the next step for these refractory LUTD patients and is there a role for the use of videourodynamics (VUDS) to help guide therapy? What parameters might be used to select patients for this invasive study in order to increase the yield of useful information? We hypothesized that patients with higher symptom scores and more clinic visits would be more likely to have identifiable factors on VUDS leading to management changes.
Methods: Through our IRB approved database, we identified 88 patients with non-neurogenic LUTD over a period from 2015 to 2021 who underwent VUDS. We excluded patients with known neurologic lesions and developmental delay. There were 60 females and 28 males (68%/32%) and their mean age at the time of the study was 10.2 years (SD=4) with a median age of 7.3 years. These patients had been followed for a mean of 5.7 (SD=3.8) office visits prior to obtaining the VUDS (median = 4.75, range 1-15). Self reported symptom scores from a validated questionnaire (DVISS) were available for 76 of these 88 patients. The mean symptom score was 15.4 (SD=6) on a scale ranging from 0 to 30 with any score under 3 being classified as normal; in contrast the mean initial presenting score in our LUTD clinic is 12.
Results: VUDS led to a change in management in 69 (78%) of the 88 patients. Common changes included a change in medication (43/88), institution of CIC (10/88) and surgery (7/88). We identified 9 patients with underactive bladder of whom 5 were started on CIC with resolution of their incontinence. Surgical management consisted of ablation of posterior urethral valves (n=4), injection of BoTox to the external sphincter (n=1), creation of an APV (n=1) and creation of an APV and bladder augment (n=1). The boys with posterior valves merit comment as they presented for LUTD with DVISS scores of 11.75 and were set up for VUDS after a mean of 4.5 visits. These patients underwent cystoscopy and placement of a suprapubic tube, and it was at this time that valves were suspected based on the endoscopic appearance. All 4 patients then underwent VUDS which demonstrated high pressure voiding and abnormalities in flow rate prior to undergoing valve resection. Voiding symptoms and DVISS score have resolved in 3 of these 4 patients and are improved in the 4th patient.
Conclusion: VUDS evaluation for the child with refractory non-neurogenic LUTD may offer diagnostic value and in this series shaped management in 78% of cases. Our criteria for selecting these 88 patients included long standing urinary incontinence that was refractory to biofeedback and medications, a mean of 5.7 visits to clinic for LUTD, and mean DVISS score of 15.4.
Back to 2022 Abstracts