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Vesicoureteral reflux and voiding dysfunction: a prospective study
1Department of Pediatrics, Hospital de Santa Maria, Universidade Classica de Lisboa, Lisbon, Portugal.
Insights
Medical treatment targeting bladder instability and vesicoperineal incoordination effectively resolved primary vesicoureteral reflux in children. This approach showed significantly higher success rates compared to antibiotic prophylaxis alone.
Area of Science:
- Pediatric Urology
- Urodynamics
- Pharmacological Interventions
Background:
- Primary vesicoureteral reflux (VUR) in children can be associated with elevated bladder pressures and abnormal perineal muscle activity.
- Previous treatment of VUR primarily involved prophylactic antibiotics, with variable success rates.
- The role of bladder dysfunction and vesicoperineal incoordination in VUR pathogenesis requires further investigation.
Purpose of the Study:
- To evaluate the efficacy of medical management targeting urodynamic abnormalities in children with primary vesicoureteral reflux.
- To compare the outcomes of this targeted medical treatment with those of traditional antibiotic prophylaxis.
Main Methods:
- Prospective study of 53 children with primary VUR treated with medications (baclofen, flavoxate, dicyclomine, diazepam) for urodynamic dysfunctions.
- Retrospective review of 48 children with primary VUR treated with prophylactic antibiotics only.
- Urodynamic evaluations were performed before and after treatment to assess bladder pressures and perineal muscle activity.
Main Results:
- In the prospective group, 91.8% of ureters showed complete resolution of reflux, and 8.2% were downgraded after medical treatment.
- Post-treatment urodynamics revealed normalized bladder pressures in 83.7% of children whose reflux resolved.
- The antibiotic-only group had significantly lower resolution rates (53.7%) and higher rates of unchanged or upgraded reflux.
Conclusions:
- Vesicoperineal incoordination and bladder instability are significant factors in the development and persistence of primary VUR.
- Targeted medical treatment addressing these urodynamic factors offers a highly effective therapeutic strategy for pediatric VUR.
- This approach demonstrates superior outcomes compared to prophylactic antibiotic therapy alone.
Abstract:
We prospectively studied 53 young children (45 less than 4 years old) between 1985 and 1988 with primary vesicoureteral reflux (grades I to V, 74 ureters). All patients had elevated bladder pressures during bladder filling and/or voiding on urodynamic evaluation, which sometimes were associated with abnormal perineal muscle activity. Baclofen, flavoxate, dicyclomine and diazepam were given individually or in combination for each type of dysfunction for 12 to 30 months. Reflux disappeared in 68 ureters (91.8 per cent) and it was downgraded in 6 (8.2 per cent). Urodynamic evaluation at the end of treatment revealed normal bladder pressures in 46 children (83.7 per cent of the ureters in which reflux resolved). Another group of 48 children with primary vesicoureteral reflux (grades I to IV, 67 ureters) seen between 1980 and 1985 was reviewed retrospectively. All patients had been treated with prophylactic antibiotics only. Reflux resolved in 53.7 per cent of the ureters, and it was downgraded in 19.4 per cent, unchanged in 22.4 per cent and upgraded in 4.5 per cent. Urodynamic studies performed in 1985 showed that all persistent cases of reflux in the retrospective group had urodynamic findings similar to those found in the prospective group. These data suggest that vesicoperineal incoordination as well as bladder instability can be important factors in causing and perpetuating reflux, and that medical treatment of these factors individually or in combination may affect therapeutic perspectives of this pathological condition.