oab and lut dysfunction: comorbidity of constipation, uti ... · • continued antibiotic...
TRANSCRIPT
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OAB and LUT dysfunction: Comorbidity of constipation, UTI & VUR
Paul F. Austin, MD, FAAP Associate Professor of Urologic Surgery St. Louis Children’s Hospital Washington University School of Medicine
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Lower urinary tract dysfunction UTI • Predictive of bladder storage issue • Urinary stasis = “Holder” • Incomplete emptying • Irritative voiding symptoms
• Urgency • Frequency • Dysuria • Incontinence • Posturing/Holding maneuvers
• OAB
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Detrusor Overactivity
Small OAB
Incomplete Emptying
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Detrusor Overactivity
Small OAB
Incomplete Emptying
No UTI + UTI
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Lower urinary tract dysfunction VUR • Strong association of VUR with LUT dysfunction • Emptying issue
• Voiding dyssynergy • Storage issue
• Altered bladder wall compliance • ↑ bladder pressures
• Frequently accompanied by constipation • Secondary VUR
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Primary reflux Critical anatomy
• Intravesical ureter length relative to diameter
• 5:1 • Proper muscular
attachments • Fixation
• Posterior Support • Compression
• Intramural Ureter
• Submucosal Ureter
• Reflux
• Possible Reflux
• No Reflux
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Primary reflux Critical anatomy
• Intravesical ureter length relative to diameter
• 5:1 • Proper muscular
attachments • Fixation
• Posterior Support • Compression
• Intramural Ureter
• Submucosal Ureter
• Reflux
• Possible Reflux
• No Reflux
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Primary reflux Embryology
• Abnormal ureteral bud • Renal dysplasia
• Displaced ureteral bud • Faulty induction of metanephros
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Bladder outlet obstruction ⇑ Pressure
PUV
Ureterocele
Atresia / Stricture
Neuropathic bladder
Voiding Dysfunction
Anatomic Functional
Secondary reflux
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Non-neurogenic, neurogenic bladder Hinman Syndrome
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Non-neurogenic, neurogenic bladder Hinman Syndrome
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Non-neurogenic, neurogenic bladder Hinman Syndrome
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• Hyperplasia
• Hypertrophy
• Tension / Stretch
Bladder outlet obstruction Smooth muscle response
• Jiang et al, Mol Cell Biol, 29:5104-14.2009
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• Hyperplasia
• Δ Bladder Compliance
Bladder outlet obstruction Smooth muscle response
• Niederhoff et al, J Urol, 184: 1686-1691, 2010
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• Hydronephrosis • Vesicoureteral reflux • Renal damage • Renal failure
• ∆ Bladder compliance
Bladder outlet obstruction Smooth muscle response
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• Recurrent UTI’s • Vesicoureteral reflux: 33-50%
• Addressing overactive bladder or dysfunctional elimination problems • ⇑ reflux resolution 3x compared to controls
• Constipation
• Koff et al, J Urol,122:373-376, 1979 • Koff & Murtagh , J Urol,130:1138-41, 1983 • Homsy et al, J Urol, 134:1168-71, 1985 • Schulman et al, Pediatrics 103:E31,1999 • Uragh et al, J Urol, 179: 1564-1567, 2008
OAB / LUT dysfunction Associated comorbidity
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• Vital to inquire & determine elimination patterns of children with VUR
• Treat bladder dysfunction • Resolution or downgrading VUR with Oxybutynin
• 62% of ureters in 37 children
• Homsy et al, J Urol, 134:1168 – 1171, 1985
Secondary VUR
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Constipation and LUT dysfunction
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Constipation and LUT dysfunction
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Constipation and LUT dysfunction
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• Reduction of 1.6 years in VUR resolution • 1 Grade less severe in VUR resolution
• Koff et al, J Urol, 160:1019-1022,1998
Dysfunctional elimination syndrome (DES)
• Association of fecal elimination disturbances with dysfunctional voiding syndromes
Pts (%)
Breakthrough UTIs
VUR Resolution
(Yrs)
Mean Reflux Grade
DES 66 (46)
54 (82)
6.8 3.2
No DES 77 (54)
16 (23)
5.2 2.3
143 patients – “1º VUR”
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• Voiding abnormalities during infancy • Predisposed to UTI & VUR with spontaneous
improvement
• Urodynamic study of infants with UTI &/or VUR
Males (39 pts) Females (22 pts) Abnormal Voiding
97%
77%
High Voiding Pressures (>40 cm H2O)
92%
66%
• Chandra et al, J Urol, 1996;155(2) 673-677
Transient urodynamic dysfunction in infancy
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Urodynamic dysfunction infancy High grade VUR
• Bladder dysfunction • High filling & voiding pressures • Two year follow-up
• Gradual decrease of initial hypercontractility • ⇑ Bladder capacity • ⇓ voiding pressures
• ⇑ Resolution with ⇓ bladder dysfunction
• Sillén et al, J Urol, 1992;148: 598-599 • Sillén et al, J Urol, 1996; 151: 668-672 • Sillén et al, Br J Urol, 1999; 83 (3) abstr 3: 69-70
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Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children
• Abnormal bladder and bowel function, and VUR are recognized to be associated and linked with each other and UTI
• VUR outcomes are affected by the presence or absence of bladder and bowel dysfunction (BBD)
• Standard: • Symptoms indicative of BBD should be sought in the initial evaluation (including urinary
frequency and urgency, prolonged voiding intervals, daytime wetting, perineal/penile pain, holding maneuvers [posturing to prevent wetting] and constipation/encopresis).
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J Urol 184: 1134-1144, September 2010
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Influence of BBD in VUR management
• Risk of febrile UTI in children with VUR on antibiotic prophylaxis is greater in those with (44%) than without (13%) BBD
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• Forest plots of febrile UTI incidence in children (medical management of BBD vs Non-BBD). Concurrent/prior use of *bladder training, †anticholinergics, ‡stool softeners
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Influence of BBD in VUR management
• Rate of reflux resolution 24 months after diagnosis is less for children with (31%) than without (61%) BBD
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• Forest plots of reflux resolution rate among children receiving antibiotic prophylaxis
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Influence of BBD in VUR management • Rate of cure following endoscopic therapy is less in children with than
without BBD but there is no difference for open surgery
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• Forest plots of reflux resolution in children undergoing intervention with curative intent (open or endoscopic surgery)
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Influence of BBD in VUR management
• Rate of postoperative UTI is greater in children with (22%) than without (5%) BBD
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• Forest plots of UTI incidence in children following open or endoscopic surgery (BBD vs Non-BBD)
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Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children
• Recommendation: • If clinical evidence of BBD is present, treatment of BBD is indicated, preferably before
any surgical intervention for VUR is undertaken. • There are insufficient data to recommend a specific treatment regimen for BBD, but
possible treatment options include behavioral therapy, biofeedback (appropriate for children > age five), anticholinergic medications, alpha blockers and treatment of constipation.
• Monitoring the response to BBD treatment is recommended to determine whether treatment should be maintained or modified.
• Recommendation: • Continued antibiotic prophylaxis is recommended for the child with BBD and VUR due to
the increased risk of UTI while BBD is present and being treated.
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J Urol 184: 1134-1144, September 2010
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Summary
• VUR and UTI are closely associated with bladder and bowel dysfunction
• Treatment of bladder and bowel dysfunction • Facilitate & improves the prognosis of VUR
& UTIs • Improves response rates and interventions
toward VUR and UTIs
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