Continuing MediCal eduCation ProjeCt:

OAB In Special PopulationsCraig V. Comiter, Md

Associate Professor of UrologyDirector, FPMRS Fellowship

Stanford University

Learning Objectives:1. Tounderstandtheriskfactors

forchildrenwithoveractivebladder,andtheevaluationandtreatmentofsimplenocturnalenuresisinchildren.

2. Tounderstandthespecializedevaluationandtreatmentofoveractivebladderintheelderly.

3. Tobeabletodistinguishneurogenicversusnon-neurogeniccausesofoveractivebladdersymptoms.

Physician accreditatiOn statementThe University of North Texas Health Science Center at Fort Worth Office of Professional and Continuing Education is accredited by the American Osteopathic Association to award continuing medical education to physicians.

The University of North Texas Health Science Center at Fort Worth Office of Professional and Continuing Education is accredited by the American Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Physician credit statementThe University of North Texas Health Science Center has requested that the AOA Council on Continuing Medical Education approve this program for 1 hour of AOA Category 2B CME credits. Approval is currently pending.

The University of North Texas Health Science Center at Fort Worth designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit(s)™.

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure record for Craig Vance Comiter, M.D. Last reviewed/edited this information on February 16, 2011.

Coloplast: Consultant; Curant: Consultant or Advisor

QUestiOn 1: Which of the following groups of children with overactive bladder symptoms and urinary incontinence should have specialist management from the outset of their evaluation?

A. Associated vesicoureteral refluxB. Associated urinary tract infectionsC. Associated neuropathyD. Monosymptomatic nocturnal enuresis

QUestiOn 2: Which of the following behavioral interventions have been shown to be effective for frail older people with cognitive and physical impairment for ameliorating the symptoms of overactive bladder (OAB) and urge incontinence?

A. Timed voidingB. Habit trainingC. Combined toileting and exercise therapyD. Prompted voidingE. DDAVP

QUestiOn 3: Which of the following neurologic diseases are typically associated with OAB symptoms?

A. Alzheimer’s diseaseB. Cerebrovascular accidentC. Multiple sclerosisD. Cauda equine syndrome

QUestiOn 4: Transient causes of OAB and urge incontinence in the elderly include which of the following except:

A. Arm and leg restraintsB. DementiaC. Lower extremity edema with congestive heart failureD. Fecal impaction

QUestiOn 5: Initial management of monosymptomatic nocturnal enuresis should include:A. Parental counselingB. Bed alarmC. DesmopressinD. Antimuscarinics

QuEstion onE REFEREnCEs:1. Vega, P.J. and L.A. Pascual, High-pressure bladder: an underlying factor mediating renal damage in the absence of reflux? BJU Int, 2001. 87(6): p. 581-4.2. Koff, S.A., T.T. Wagner, and V.R. Jayanthi, The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children. J Urol, 1998. 160(3 Pt 2): p. 1019-22.3. Bachelard, M., et al., Urodynamic pattern in infants with urinary tract infection. J Urol, 1998. 160(2): p. 522-6.4. Varlam, D.E. and J. Dippell, Non-neurogenic bladder and chronic renal insufficiency in childhood. Pediatr Nephrol, 1995. 9(1): p. 1-5.5. Ural, Z., I. Ulman, and A. Avanoglu, Bladder dynamics and vesicoureteral reflux: factors associated with idiopathic lower urinary tract dysfunction in children. J Urol, 2008. 179(4): p. 1564-7. Retik AB6. Perlmutter AD, Gross RE. Cutaneous ureteroileostomy in children. N Eng J Med 1967; 277:217-22.7. Bauer SB: The management of spina bifida from birth onwards. In Whitaker RH, Woodard JR (eds): Paediatric Urology. London, Butterworths, 1985, pp 87–112.8. Bauer SB: Early evaluation and management of children with spina bifida. In King LR [ed]: Urologic Surgery in Neonates and Young Infants. Philadelphia, WB Saunders, 1988, pp 252–264.9. Wilcock AR, Emery JL: Deformities of the renal tract in children with myelomeningocele and hydrocephalus, compared with those children showing no such deformities. Br J Urol 42:152-9, 1970.10. Hunt GM, Whitaker RH: The pattern of congenital renal anomalies associated with neural tube defects. Dev Med and Child Neurol 29:91-5, 1987.11. Yeung CK, Sihoe JDY. Voiding dysfunction in children: non-neurogenic and neurogenic. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Saunders Elsevier; 2007, pp. 3604-3625.

QuEstion two REFEREnCEs:1. Diokno, A.C. et al. Prevention of urinary incontinence by behavioral modification program: a randomized, controlled trial among older women in the community. J Urol 171, 1165-1171, 2004.2. Teunissen, T.A., de Jonge, A., van Weel, C. & Lagro-Janssen, A.L. Treating urinary incontinence in the elderly—conservative therapies that work: a systematic review. Journal of Family Practice 53, 25-30, 32 (2004).3. Ostaszkiewicz, J. A clinical nursing leadership model for enhancing continence care for older adults in a subacute inpatient care setting. J Wound Ostomy Continence Nurs 33, 624-629 (2006).4. Loening-Baucke, V. & Anuras, S. Effects of age and sex on anorectal manometry. American Journal of Gastroenterology 80, 50-53 (1985). 5. Ostaszkiewicz, J., Johnston, L. & Roe, B. Timed voiding for the management of urinary incontinence in adults. Cochrane Database of Systematic Reviews, CD002802 (2004).6. Schnelle, J.F., MacRae, P.G., Ouslander, J.G., Simmons, S.F. & Nitta, M. Functional Incidental Training, mobility performance, and incontinence care with nursing home residents. Journal of the American Geriatrics Society 43, 1356-1362 (1995).6. van Houten, P., Achterberg, W. & Ribbe, M. Urinary incontinence in disabled elderly women: a randomized clinical trial on the effect of training mobility and toileting skills to achieve independent toileting. Gerontology 53, 205-210 (2007).7. Palmer M.H: Effectiveness of prompted voiding for incontinent nursing home residents, in Melnyk BM and Fineout-Overholt E: Evidence-Based Practice in Nursing & Healthcare: A Guide to the Best Practice. Philadelphia, Lippincott Williams & Williams, 2005, pp 20-30.

QuEstion thREE REFEREnCEs:1. Honig LS, Mayeux R.: Natural history of Alzheimer’s disease. Aging 2001; 13:171-182.2. Cacabelos R, Rodriguez B, Carrrera C, Caamano J, Beyer K, Lao JI et al.: APOE-related frequency of cognitive and noncognitive symptoms in dementia. Methods Find Exp Clin Pharmacol 1996; 18:693-706.3. Carlo A, Lamassa M, Baldereschi M, Pracucci G, Basile AM, Wolfe CD, et al. Sex differences in the clinical presentation, resource use, and 3-month outcome of acute stroke in Europe: data from a multicenter multinational hospital-based registry. Stroke. 2003 May;34(5):1114-9. 4. Sakakibara R, Hattori T, Yasuda K, Yamanishi T. Micturitional disturbance after acute hemispheric stroke: analysis of the lesion site by CT and MRI. J Neurol Sci. 1996 Apr;137(1):47-56.5. Amarenco G, Kerdraon J, Denys P. [Bladder and sphincter disorders in multiple sclerosis. Clinical, urodynamic and neurophysiological study of 225 cases]. Rev Neurol (Paris). 1995 Dec: 151:722-30.6. Giannantoni A, Scivoletto G, Di Stasi SM, Grasso MG, Vespasiani G, Castellano V. Urological dysfunctions and upper urinary tract involvement in multiple sclerosis patients. Neurourol Urodyn. 1998: 17:89-98.7. Giannantoni A, Scivoletto G, Di Stasi SM, et al. Lower urinary tract dysfunction and disability status in patients with multiple sclerosis. Arch Phys Med Rehabil. 1999 Apr: 80:437-41.

8. O’Flynn KJ, Murphy R,Thomas DG. Neurogenic bladder dysfunction in lumbar intervertebral disc prolapse. Br J Urol 1992.;69:38-40.9. Yamanishi T, Yasuda K,Yuki T, Sakakibara R, Uchiyama T, Kamai T, Tsujii T, Yoshida K. Urodynamic evaluation of surgical outcome in patients with urinary retention due to central lumbar disc prolapse. Neurouro Urodyn 2003, 22: 670-675.10. Inui Y, Doita M, Ouchi K, Tsukuda M, Fujita N, Kurosaka M. Clinical and radiological features of lumber spinal stenosis and disc herniation with neurogenic bladder. Spine 2004; 29: 869-873.11. Dong D, Xu Z, Shi B, Chen J, Jiang X, Wang H. Clinical significance of urodynamic studies in neurogenic bladder dysfunction caused by intervertebral disk hernia. Neurourol Urodyn 2006; 25: 446-450.12. Gallien P, Robineau S, Nicolas B, Le Bot MP, Brissot R, Verin M. Vesicourethral dysfunction and urodynamic findings in multiple sclerosis: a study of 149 cases. Arch Phys Med Rehabil. 1998 Mar: 79:255-7.13. Hennessey A, Robertson NP, Swingler R, Compston DA. Urinary, faecal and sexual dysfunction in patients with multiple sclerosis. J Neurol. 1999 Nov: 246:1027-32.14. Kasabian NG, Krause I, Brown WE, Khan Z, Nagler HM. Fate of the upper urinary tract in multiple sclerosis. Neurourol Urodyn. 1995: 14:81-5.15. Koldewijn EL, Hommes OR, Lemmens WA, Debruyne FM, van Kerrebroeck PE. Relationship between lower urinary tract abnormalities and disease-related parameters in multiple sclerosis. J Urol. 1995 Jul: 154:169-73.16. Mayo ME, Chetner MP. Lower urinary tract dysfunction in multiple sclerosis. Urology. 1992 Jan: 39:67-70.17. Porru D, Campus G, Garau A, et al. Urinary tract dysfunction in multiple sclerosis: is there a relation with disease-related parameters? Spinal Cord. 1997 Jan: 35:33-6.18. Litwiller SE, Frohman EM, Zimmern PE. Multiple sclerosis and the urologist. J Urol. 1999 Mar: 161:743-57.

QuEstion FouR REFEREnCEs:1. Resnick, N.M. & Yalla, S.V. (1985). Management of Urinary Incontinence in the Elderly. NEJM, 313: 800-804.

QuEstion FivE REFEREnCEs:1. Rittig, S., Schaumburg, H. L., Siggaard, C. et al.: The circadian defect in plasma vasopressin and urine output is related to desmopressin response and enuresis status in children with nocturnal enuresis. Journal of Urology, 179: 2389, 2008.2. Butler, R. J., Holland, P.: The three systems: a conceptual way of understanding nocturnal Enuresis. Scandinavian Journal of Urology & Nephrology, 34: 270, 2000.3. Neveus, T., Hetta, J., Cnattingius, S. et al.: Depth of sleep and sleep habits among enuretic and incontinent children. Acta Paediatrica, 88: 748, 1999.4. Hjalmas, K., Arnold, T., Bower, W. et al.: Nocturnal enuresis: an international evidence based management strategy. Journal of Urology, 171: 2545, 2004.5. Al-Waili, N. S.: Increased urinary nitrite excretion in primary enuresis: effects of indomethacin treatment on urinary and serum osmolality and electrolytes, urinary volumes and nitrite excretion. BJU International, 90: 294, 2002.6. Glazener, C. M., Evans, J. H., Peto, R. E.: Alarm interventions for nocturnal enuresis in children.[update in Cochrane Database Syst Rev. 2005;(2):CD002911; PMID: 15846643][update of Cochrane Database Syst Rev. 2001;(1):CD002911; PMID: 11279776]. Cochrane Database of Systematic Reviews: CD002911, 2003.7. Hunsballe, J. M., Hansen, T. K., Rittig, S. et al.: The efficacy of DDAVP is related to the Circadian rhythm of urine output in patients with persisting nocturnal enuresis. Clinical Endocrinology, 49: 793, 1998.8. Glazener, C. M., Evans, J. H.: Desmopressin for nocturnal enuresis in children.[update of Cochrane Database Syst Rev. 2000;(2):CD002112; PMID: 10796860]. Cochrane Database of Systematic Reviews: CD002112, 2002 91. 9. Tullus, K., Bergstrom, R., Fosdal, I. et al.: Efficacy and safety during long-term treatment of primary monosymptomatic nocturnal enuresis with desmopressin. Swedish Enuresis Trial Group. Acta Paediatrica, 88: 1274, 1999.10. Robson, W. L., Shashi, V., Nagaraj, S. et al.: Water intoxication in a patient with the Prader-Willi syndrome treated with desmopressin for nocturnal enuresis. Journal of Urology, 157: 646, 1997.11. Neveus, T.: Oxybutynin, desmopressin and enuresis. Journal of Urology, 166: 2459, 2001.12. Kosar, A., Arikan, N., Dincel, C.: Effectiveness of oxybutynin hydrochloride in the treatment of enuresis nocturna--a clinical and urodynamic study. Scandinavian Journal of Urology & Nephrology, 33: 115, 1999.13. Geller, B., Reising, D., Leonard, H. L. et al.: Critical review of tricyclic antidepressant use in children and adolescents. J Am Acad Child Adolesc Psychiatry, 38: 513, 1999.14. Glazener, C. M. A., Evans, J. H. C., Peto, R. E.: Tricyclic and related drugs for nocturnal enuresis in children.[update of Cochrane Database Syst Rev. 2000;(3):CD002117; PMID: 10908525]. Cochrane Database of Systematic Reviews: CD002117, 2003.15. Yeung CK, Sihoe JDY. Voiding dysfunction in children: non-neurogenic and neurogenic. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Saunders Elsevier; 2007, pp. 3604-3625.

discUssiOn Of QUestiOn OneA. Associated vesicoureteral reflux (correct)

B. Associated urinary tract infections (correct)Impaired lower urinary tract function often coexists with recurrent infections and with vesicoureteral reflux (VUR), even in the absence of any identifiable neurologic pathology. High pressure storage, detrusor overactivity, dysfunctional voiding, or incomplete bladder emptying have been reported in a significant proportion of children with VUR. Voiding cystography in children with incontinence often uncovers concomitant VUR. The common abnormalities affecting the lower urinary tract found to coexist with reflux are, in fact, detrusor overactivity and dis-coordination between detrusor and the sphincter function during micturition. This can lead to persistent reflux, high pressure voiding with pyelonephritis, and ultimately upper tract deterioration. These abnormalities are thought to occur secondary to urinary tract infection, or are acquired during toilet training. Reflux from incompetence of the uretero-vesical junction may persist or even when associated with detrusor overactivity.

C. Associated neuropathy (correct)Detrusor-sphincter dyssynergia (DSD) can result from a variety of neurologic lesions, typically located in the suprasacral spinal cord. This pathologic voiding dysfunction contributes to urinary incontinence, urinary tract infections, VUR, and ultimately renal scarring or renal insufficiency.

Therefore, management of detrusor sphincter dysfunction in children must focus first and foremost on renal preservation.

Neurospinal dysraphism is by far the most common cause of DSD in children, presenting with various patterns and severities of detrusor-sphincter dysfunction. While 15 % of neonates with myelodysplasia may not display any signs of lower urinary tract dysfunction initially, the development of storage and voiding dysfunction still likely over time. Up to one-third of myelodysplastic pubertal children will develop either detrusor areflexia or DSD, many of whom will ultimately suffer from upper tract deterioration, if not appropriately managed. The key treatment goals are preservation of renal function and achieving urinary and fecal continence. Clean (self) intermittent catheterization is typically the recommended treatment for children with DSD, often in association with surgical creation of continent reservoir.

D. Monosymptomatic nocturnal enuresis (incorrect)Primary nocturnal enuresis (NE) is a common disorder among early school age children. Controversy exists regarding the etiology of NE, but multiple pathologic factors are likely to blame. One such factor is that production of nocturnal urine in enuretic children may simply exceed bladder storage capacity during sleep. Nocturnal polyuria may results from abnormal nocturnal anti-diuretic hormone (ADH) production, or due to diminution of functional bladder capacity during sleep. This “mismatch” between urine production and bladder capacity leads to bedwetting. Alternatively, there may be bladder- sphincter dysfunction. Alternatively, sleep arousal disturbances and brain stem dysfunction may be causing an inability of the child to awaken despite a full bladder. Enuretics are typically more difficult to arouse than age-matched controls. Finally, the bladder may empty due to detrusor overactivity, which may occur only during sleeping hours, despite normal storage during wakeful periods during the day.

discUssiOn Of QUestiOn twOBehavioral interventions are strongly recommended for frail older patients, as such therapies can be quite successful, with essentially no risk. Certain behaviors are particularly recommended for those frail elderly with cognitive and physical impairments that may interfere

with self-care and with learning new behaviors. The behavioral treatments require active caregiver participation. They include:

A. Timed voiding (correct)The individual voids at fixed intervals (e.g. every 3 hours). This program does not require education or reinforcement, but requires only passive participation.

B. Habit training (correct)The caregiver identifies the incontinent patient’s particular voiding pattern, including incontinence episodes. A toileting schedule can then pre-empt incontinence episodes.

C. Combined toileting and exercise therapy (correct)This functional intervention incorporates strengthening exercises into toileting routines by caregivers. Alternatively, physical therapists may work on toileting and mobility skills. Severe cognitive and physical impairments, or lack of full-time caregiver availability may preclude the use of this active intervention.

D. Prompted voiding (correct)Prompted voiding involves encouraging going to the bathroom with contingent social approval, is designed to foster patient requests for toileting as well as self-initiated toileting, and decrease the number of UI episodes.

E. DDAVP (incorrect)DDAVP is not a behavioral intervention, but rather a pharmacotherapeutic intervention. DDAVP should not be used in frail elderly because of the risk of hyponatremia.

discUssiOn Of QUestiOn threeNeurogenic bladder is precisely defined as defective functioning of the urinary bladder due to impaired nerve supply. Neuropathies can

profoundly and negatively affect the urinary system – with respect to the bladder and the upper tracts. Although the term is often misused to describe abnormal bladder function, it is important that the physician precisely define the neurologic disease and

the voiding dysfunction caused by that disease in order to facilitate accurate diagnosis and efficacious treatment.

A. Alzheimer’s disease (correct)Alzheimer’s disease, the most common type of dementia, is characterized by worsening of the memory, impaired cognitive functioning, and in the advanced stages, loss of self-hygiene, eating, dressing and ambulation. Even in the absence of motor dysfunction, urinary incontinence is common. The onset of incontinence usually correlates with the disease progression and affects 23 % to 48 % of those afflicted with Alzheimer’s disease. While inappropriate toileting can affect patients in the advanced stages of disease, detrusor overactivity is the primary cause of incontinence in the majority of patients.

B. Cerebrovascular accident (correct) Strokes represent the third most common cause of death in Western countries (following heart disease and cancer). Approximately 1 in 200 older patients will suffer from a stroke, 80 to 90% of whom are over the age of 65. Approximately 46% of females and 37% of males develop urinary incontinence following cerebral vascular accident. Urinary incontinence typically results from the loss of central inhibition. However, the loss of bladder perception may also contribute. It appears

that urge incontinence with preserved sensation is more likely with frontal lobe impairment, while decreased bladder sensation relates to parietal lobe involvement.

C. Multiple sclerosis (correct)In patients with multiple sclerosis, urinary symptoms can be variable, and can also change over time. OAB sx are the most frequent complaint, with urinary frequency (32 to 99%), urgency (32 to 85%), and urge incontinence (19 to 80 %). Obstructive urinary symptoms are less common, with difficult voiding and chronic or acute urinary retention affecting a minority of patients.

D. Cauda equina syndrome (incorrect) Central lumbar disc prolapse typically compresses one or more sacral nerves. It is not surprising, therefore, that the most common urinary symptom associated with lumbar disc prolapse is acute urinary retention. The typical urodynamic findings are an acontractile detrusor with impaired bladder sensation. Severe denervation of the pelvic floor and external urethral sphincter can result in neurogenic stress incontinence. With early intervention (resulting from a high level of suspicion), two thirds of patients may recover urinary function following acute urinary retention. Much less common, OAB symptoms secondary to detrusor overactivity result from sacral nerve root irritation.

discUssiOn Of QUestiOn fOUrReversible causes of incontinence should be sought in the elderly. These transient causes can be remembered via the mnemonic “DIAPPERS”. Often more than one cause may contribute, and therefore treating several of these reversible causes may prove efficacious in reducing or curing the voiding dysfunction.

A. Arm and leg restraints (correct)Restricted mobility, especially in the setting of urgency with reduced warning time for

urination can significantly contribute to incontinence. Often, a bedside commode, bedpan, or urinal (for men), can bypass this problem.

B. Dementia (incorrect)Although treatments for dementia may slow the progression of disease, urinary incontinence usually correlates with advanced, irreversible alterations in cognition. Delirium, on the other hand, is defined as a temporary alteration in sensorium, and often resolves when the offending cause (e.g. medication, unfamiliar surroundings, metabolic derangement) is remedied.

C. Lower extremity edema with congestive heart failure (correct)Retained fluid and edema are typically mobilized upon lying down, increased the filtered load faced by the kidneys. Increased urine production typically occurs, which may be prevented by fluid management, and prevention of fluid retention. For example, properly timed diuretic use, or lower extremity compressive stockings, or dietary modification may prevent the build-up of fluid that ultimately may contribute to polyuria and urge incontinence.

D. Fecal Impaction (correct)Fecal impaction (and to a lesser degree constipation) can lead to urinary incontinence. This finding is not unique to older adults, but may also contribute to voiding dysfunction in children with dysfunctional elimination.

The mnemonic DIAPPERS stands for the following transient conditions: DeliriumInfection (e. g., urinary tract infection)Atrophic urethritis or vaginitis (thin, dry vaginal and urethral epithelium)Pharmacology (e.g., diuretics, anticholinergics, narcotics, sedatives, alcohol)Psychological disorders (especially depression)

Endocrine disorders (e.g., heart failure, uncontrolled diabetes)Restricted mobility (e.g., hip fracture population, arthritis, back pain, restraints)Stool Impaction

However, recent investigations have called into questions the therapeutic benefit of hormone replacement therapy and of treating asymptomatic bacteriuria in elderly patients.

Unlike acute (and reversible) delirium, dementia is a chronic disease with a high prevalence of urinary incontinence due to detrusor overactivity and/or inappropriate toileting.

discUssiOn Of QUestiOn fiveNocturnal enuresis (NE) appears to result from either a mismatch between bladder capacity, nocturnal urine output, nocturnal detrusor overactivity, and/or decreased arousal ability during sleep. Night wetting is considered normal until age 5. A maturation delay contributes to a detrusor overactivity, a lack of arginine vasopressin (DDAVP) release/response, or increased nocturnal solute excretion [39,40], and/or a decreased ability to awaken to full bladder sensations. Treatment should therefore address these deficiencies.

A. Parental counseling (correct)As the age at which the child and his or her parent begins to be concerned about bedwetting varies, it is important that both the family and child are motivated to achieve nighttime continence. If the child and/or the parents are not bothered by the bedwetting, or are not motivated to intervene with either behavioral therapy or pharmacotherapy, then resolution is unlikely to be any more likely than typically occurs with age (approximately 15% per year resolution).

B. Bed alarm (correct)The enuresis alarm is the most effective treatment for mon-symptomatic NE, by facilitating arousal from sleep. Enuresis alarm therapy is associated with a nine times lower likelihood of relapse than antidiuretic pharmacotherapy (relapse rate = 15-30% at 6 months). With virtually no risk, and the highest efficacy of all treatment, alarm therapy should be considered in every patient.

C. Desmopressin (correct)Pharmacological treatment is designed to address the three likely causes of NE mentioned above.

It would make sense, therefore, that nocturnal polyuria respond the best to desmopressin.

Desmopressin has been shown to be approximately 5 times more efficacious than placebo.

Unfortunately, relapse after short-term treatment is common, with long-term efficacy approximately equal to the sponatenous rate of resolution. While dDAVP is generally well-tolerated there have been case reports of severe water retention with hyponatremia and convulsions, but these are infrequent.

D. Antimuscarinics (incorrect)Oxybutynin is occasionally used as an alternative treatment for some children who fail to respond to DDAVP. The drug is particularly useful for those with combined day and nighttime incontinence.

While imipramine (tricyclic antidepressant) has demonstrated success in a number of children (typically a decrease of one wet night per week, but a lasting cure rate of only 17%), because tricyclic antidepressants have potential cardiotoxic side effects they are not generally recommended for treatment of this non-lethal disorder.

Further evaluation may be indicated in the setting of treatment failure, to diagnose any other treatable storage dysfunction. Yeung, et al reported that 44 percent of treatment failures with desmopressin or the enuresis alarm] have normal daytime bladder function but marked detrusor overactivity during sleep resulting in enuresis.

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ACTIVITY TITle: OaB in special populations dATes VAlId: 2011 CRedITs AVAIlAble: 1 Category 2B, aOa; 1 Category 1 AMA PRA™

fUll NAme: degRee(s):

last 4 digits of ssN: or AoA Number: (for tracking) (if applicable)

mAIlINg AddRess:

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1To understand the risk factors for children with overactive bladder, and the evaluation and treatment of simple nocturnal enuresis in children.

2 To understand the specialized evaluation and treatment of overactive bladder in the elderly.

3 To be able to distinguish neurogenic versus non-neurogenic causes of overactive bladder symptoms.

4 To what extent this activity is fair and balanced.

5 Likelihood that you will implement change in your practicebased on information from this activity.

6 Your OVERALL rating of this activity.

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How will you use the information presented to improve the care of your patients?

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