Urology Neurogenic Bladder B

While performing a videourodynamic study in a three-year-old child, the recommended rate of bladder filling is: A) 10 ml/min. B) 20 ml/min. C) 30 ml/min. D) 40 ml/min. E) 50 ml/min.

A ( 10 ml/min. The rate of bladder filling {ml/min} is calculated by determining the child's predicted bladder capacity {average bladder capacity in ml = age in years %2B 2 X 30} and dividing the result by 10. In this case, {3%2B2} X 30 = 150/10 = 15 ml/min or less. It is important not to fill the bladder too fast as it may result in falsely low levels of detrusor compliance and may produce artifactual detrusor contractions. Filling at 10 percent per minute of the calculated bladder capacity {or less} avoids these problems. Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, pp 3616-3618. 2011 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A two-month-old uncircumcised boy with a sacral dimple undergoes evaluation of a febrile UTI. Ultrasonography shows bilateral hydroureteronephrosis and a conus medullaris at the mid aspect of L4. VCUG shows bilateral Grade IV reflux, slight beaking of the bladder neck and a normal urethra. The next step is: A) CMG. B) cystoscopy. C) MAG-3 renal scan. D) circumcision. E) vesicostomy.

A ( CMG. This infant has a compromised urinary tract and a neurogenic cause must be considered. The conus normally ends above L2 and spinal ultrasound is a convenient and accurate method of screening in the neonatal period. Given his low conus, a CMG would be important to see if filling curve and storage pressure are abnormal. Circumcision is not mandatory. Vesicostomy at this point is premature and cystoscopy is not necessary. The hydronephrosis in this case is related to the bladder dysfunction and a MAG-3 scan is unnecessary.Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, pp 3625-3632. 2009 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

Headache, facial flushing and hypertension during cystoscopy is most commonly seen in patients with: A) cervical cord lesion. B) spinal cord injury between T6 and S2. C) cauda equina injury. D) multiple sclerosis. E) reflex sympathetic dystrophy.

A ( cervical cord lesion. Autonomic dysreflexia is associated with spinal cord injuries at T6 and higher. Symptoms commonly include palpitations, headache, facial flushing and hypertension. It is caused by stimuli below the level of the spinal cord injury precipitating an exaggerated sympathetic response. Treatment should include immediate removal of the stimulus if possible. Calcium channel blockers, alpha adrenergic antagonists and chlorpromazine can be used to treat this condition. The other injuries do not typically cause autonomic dysreflexia.Wein AJ: Lower urinary tract dysfunction in neurologic injury and disease, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 59, p 2026. 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 72-year-old man is noted to have a large bladder on a CT scan performed for colonic diverticular disease. He has no urinary tract symptoms. His prostate is 30 gm and benign. PVR is 150 ml. A urinalysis is negative. The next step is: A) observation. B) alpha-blocker. C) 5-alpha-reductase inhibitor. D) 5-alpha-reductase inhibitor and an alpha-blocker. E) TURP.

A ( observation. PVR measurement has significant intra-individual variability and does not correlate well with other signs or symptoms of lower urinary tract dysfunction. The VA Cooperative Study Group demonstrated that PVR does not predict the outcome of surgery and the majority of men with large residual urine volume did not require surgery during the three year duration of the trial. Men with significant PVRs should be monitored more closely if they elect no therapy. Medical therapy for BPH is indicated in men who have bothersome symptoms that negatively affect quality of life.Kirby R, Lepor H: Evaluation and nonsurgical management of benign prostatic hyperplasia, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 87, p 2770. 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A five-year-old boy with a history of PUV ablation is incontinent day and night. Renal ultrasound shows normal kidneys bilaterally. VCUG shows a mildly trabeculated bladder without VUR and a patent urethra. PVR is 10 ml. He has normal daily bowel movements. The urinalysis is normal, and he has not had any UTIs. The next step is: A) timed voiding. B) nocturnal bladder drainage. C) urodynamic study. D) oxybutynin. E) desmopressin.

A ( timed voiding. Voiding dysfunction and incontinence are common in boys with history of PUV. Over 80% will struggle with incontinence at age five. Nocturnal bladder drainage is usually indicated in the presence of high urinary output which can occur in boys with a history of PUV secondary to a concentrating defect. In such patients, significant hydroureteronephrosis is expected, which this patient does not have. Since he is not retaining urine after voiding, urodynamic test will likely demonstrate a pattern of bladder overactivity. However, it is appropriate to try conservative measures such as timed voiding prior to proceeding with more invasive testing such as urodynamics. Oxybutynin must be used with caution since a possible underlying myogenic dysfunction could lead to outright urinary retention. Desmopressin will not affect bladder dysfunction, which is the primary etiology of incontinence in boys with PUV. Casale AJ: Posterior urethral valves and other urethral anomalies, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 122, p 3597. 2012 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 67-year-old woman underwent an uncomplicated transobturator midurethral monofilament polypropylene sling. One week later, she is asymptomatic but on physical examination there is a partial wound dehiscence with a 0.5 cm segment of exposed polypropylene sling material at the base of the wound. The next step is: A) topical estrogen cream and re-evaluation in several weeks. B) mobilization of vaginal flaps, vaginal wound closure and Penrose drain. C) explantation of the exposed sling material and vaginal wound closure. D) explantation of the entire sling. E) explantation of the sling and placement of an autologous pubovaginal fascial sling.

A ( topical estrogen cream and re-evaluation in several weeks. A small wound dehiscence is likely to heal over time. Since the patient is asymptomatic, immediate surgical intervention is not necessary. Monofilament slings with large pore sizes permit in-growth of fibroblasts and intercalation of macrophages that promote healing. Topical estrogen cream may be beneficial in this postmenopausal female in improving tissue quality and healing. Explantation of the sling is not indicated at this juncture. Timing of primary wound closure is controversial, but drains are not recommended.Dmochowski R, Scarpero H, Starkman J: Tension-free vaginal tape procedures, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 68, p 2269. 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 58-year-old man has frequency and nocturia, an AUA Symptom Score of 22, peak urinary flow rate of 8 ml/sec, and PVR of 200 ml. His prostate is 70 gm with a prominent median lobe. Sitting systolic blood pressure is 140 mm Hg. An orthostatic blood pressure change of 25 mm Hg is not associated with postural symptoms. He is concerned about developing ejaculatory dysfunction. The best treatment is: A) finasteride. B) alfuzosin. C) TUIP. D) transurethral vaporization of the prostate. E) TUMT.

B ( alfuzosin. Orthostatic hypotension is not a contraindication for alpha-blockers providing the blood pressure change is not associated with postural symptoms. The effectiveness of alpha-blockers is independent of prostate size. All surgical interventions may cause retrograde ejaculation. Finasteride will decrease semen volume.Kirby R, Lepor H: Evaluation and nonsurgical management of benign prostatic hyperplasia, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 87, pp 2785-2789. 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A six-year-old boy with nocturnal enuresis has been treated with imipramine. He took an excessive dose last night and is lethargic this morning. The best plan is: A) observation. B) cardiac monitoring. C) Kayexalate enema. D) hemodialysis. E) atropine.

B ( cardiac monitoring. Tricyclic antidepressants {TCAs} {e.g. imipramine} can cause toxicity at doses of 10-20 mg/kg. A 50 mg/kg dose is likely to be fatal. ICAs are absorbed in the small bowel and have antimuscarinic actions. Tissue levels, especially in myocardium, are much higher than serum levels. Toxic effects are central and peripheral antimuscarinic actions {amine pump blockage that enhances catecholamine actions} occur as well. Emetics will be too late in this case, the urgent need is cardiac monitoring. Hemodialysis will take more than an hour to institute and is an incorrect priority. Kayexalate will not help. Atropine is contraindicated. Physostigmine, used in the past, doesn't help with the cardiac effects of TCAs and may cause its own rhythm disturbances. Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, pp 3619-3624. 2011 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 65-year-old man with Parkinson's disease has urgency, nocturia, frequency, and urge incontinence. DRE reveals an enlarged prostate. The most likely etiology of his symptoms is: A) impaired detrusor contractility. B) detrusor overactivity. C) detrusor sphincter dyssynergia. D) decreased detrusor compliance. E) antiparkinsonian medications.

B ( detrusor overactivity. Parkinson's disease results in relative dopamine deficiency and cholinergic predominance in the corpus striatum. Voiding dysfunction may occur in up to 70% of patients. The most frequent urodynamic finding is detrusor overactivity. Poor voluntary control of the striated sphincter may occur, but true dyssynergia is uncommon. Male patients with prostatic enlargement cannot be assumed to be symptomatic from bladder outlet obstruction, and voiding symptoms may actually worsen after prostatectomy because of poorly sustained bladder contractions and abnormal sphincter relaxation.Wein AJ: Lower urinary tract dysfunction in neurologic injury and disease, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 59, p 2017-8. 2009 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 54-year-old man who underwent a successful open pyeloplasty 20 years ago develops recurrent flank pain. Diuretic renography reveals recurrent UPJ obstruction with 30%25 ipsilateral renal function. Retrograde pyelogram reveals a 1 cm UPJ stricture. The next step is: A) balloon dilation. B) endopyelotomy. C) re-do pyeloplasty. D) ureterocalycostomy. E) nephrectomy.

B ( endopyelotomy. This is an excellent patient for an endopyelotomy. For secondary UPJ obstruction, it is reasonable to recommend an open or laparoscopic approach to any patient who has failed a primary endourologic management and an endourologic approach to those who have failed an open or laparoscopic repair. The results of endourologic management in this setting are generally excellent. Ureteral stenting and balloon dilation are not good long-term options and nephrectomy is not necessary at this point. Hsu THS 2010 General Neurogenic Bladder, Voiding Dysfunction, Incontinence )

During videourodynamics in a patient with a history of a T8 spinal cord injury, detrusor external sphincter dyssynergia is characterized by simultaneous: A) increased EMG activity, detrusor underactivity, and narrowing of the prostatic urethra. B) increased EMG activity, detrusor overactivity, and narrowing of the membranous urethra. C) decreased EMG activity, detrusor overactivity, and dilation of the prostatic urethra. D) decreased EMG activity, detrusor underactivity, and narrowing of the membranous urethra. E) decreased EMG activity, detrusor underactivity, and dilation of the prostatic urethra.

B ( increased EMG activity, detrusor overactivity, and narrowing of the membranous urethra. Detrusor external sphincter dyssynergia occurs in spinal lesions located between the pons and sacral spinal cord. It is characterized by detrusor overactivity and concomitant involuntary contraction of the external sphincter. This results in a narrowed or closed membranous urethra with a proximally dilated prostatic urethra.Wein AJ: Lower urinary tract dysfunction in neurologic injury and disease, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 59, p 2037. 2011 General Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 48-year-old woman undergoes an uncomplicated transobturator sling procedure for stress urinary incontinence. She complains of left leg and thigh pain with abduction on the first postoperative day. The next step is: A) MRI scan of the pelvis. B) non-steroidal anti-inflammatory drugs. C) sling explantation. D) vaginal re-exploration and adjustment of sling tension. E) sling incision.

B ( non-steroidal anti-inflammatory drugs. Transient, self limited lower extremity pain following transobturator sling procedures occurs in 2-16% of patients undergoing this procedure. This symptom is usually attributed to a subclinical hematoma or a transient neuropathic phenomenon but may also be due to positioning. This generally resolves within several days and NSAIDs will help control the temporary pain. Persistent pain may indicate vaginal extrusion, thigh abscess or other complications related to the tape.Dmochowski R, Scarpero H, Starkman J: Tension-free vaginal tape procedures, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 68, p 2269. 2009 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

Paternity potential in males with spina bifida correlates positively with: A) serum testosterone level. B) sacral neurologic level of lesion. C) reflexogenic erections. D) shunt-dependent hydrocephalus. E) glans penis sensation.

B ( sacral neurologic level of lesion. Studies on sexual function in males with spina bifida have demonstrated that paternity is associated with an L5 or sacral neurologic level. This neurologic level was present in 80% of patients who fathered children. This is in contrast to bladder function, which does not correlate well to the neurologic level of the lesion. The ambulatory status and presence of a ventriculoperitoneal shunt are other important factors associated with paternity. Serum testosterone levels are usually normal. Reflexogenic erections are present in the majority of spina bifida patients and are not predictive of paternity. Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, pp 3639-3640. 2011 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A three-year-old boy who underwent a surgical correction for a high imperforate anus has inability to toilet train. VCUG reveals a large trabeculated bladder, grade 3 left VUR and incomplete bladder emptying. Ultrasound of the abdomen shows two normal kidneys. The next step is: A) spinal ultrasound. B) spinal MRI scan. C) alpha-blocker. D) CIC. E) vesicostomy.

B ( spinal MRI scan. Spinal cord abnormalities, including tethered cord or thickened or fatty filum terminale and lipoma have been noted in 20-50% of patients with imperforate anus. The severity of the lesion is proportional to the severity of the rectal lesion. In this case, the patient has a high-imperforate anus. VCUG reveals trabeculation, VUR into one kidney, and incomplete bladder emptying - a collection of findings for possible neurogenic bladder dysfunction. The best test is an MRI scan to rule-out spinal cord lesions since the kidneys are presently normal and the bladder has some subtle findings. Due to ossification of the spine a spinal ultrasound cannot rule-out a tethered spinal cord after three months of life. Vesicostomy, CIC, and antimuscarinic and alpha-blocker medications are premature at this point without formal diagnosis of neurogenic bladder and urodynamic study.Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, pp 3647-3648. 2012 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 55-year-old man with hypertension and erectile dysfunction treated with amlodipine 10 mg and sildenafil 25 mg complains of LUTS and has an International Prostate Symptom Score (IPSS) score of 18. His prostate exam is benign. He opts for alpha-blocker therapy. He should be instructed to: A) switch to vardenafil. B) use tamsulosin 0.4 mg daily at any time. C) use tamsulosin 0.4 mg daily separated by 4 hours from sildenafil. D) use tamsulosin 0.4 mg daily separated by 12 hours from sildenafil. E) decrease amlodipine dose before combining tamsulosin and sildenafil.

B ( use tamsulosin 0.4 mg daily at any time. The use of sildenafil 25 mg has no impact on the type of alpha-blocker used, its dose or the timing in relationship to sildenafil use. Sildenafil doses greater than 25 mg {50 mg or 100 mg}, require separation from any alpha-blocker by a period of 4 hours. Tadalafil may be used at any dose with tamsulosin 0.4 mg. The concerns about hypotension induced by concomitant use of sildenafil and alpha-blockers also pertains to vardenafil.http://www.fda.gov/cder/foi/label/2002/20895s11s15s18lbl.pdfLue TF, Broderick GA: Evaluation of nonsurgical management of erectile dysfunction and premature ejaculation, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 22, p 778. 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 53-year-old T-5 paraplegic woman undergoes intra-detrusor botulinum toxin injections for intractable incontinence between catheterizations. She should be told that: A) botulinum toxin type B is most frequently used. B) a repeat injection will likely be needed within three months. C) a total dose of 200 units has been shown to have proven efficacy. D) a dose of 100 units per injection site will be used. E) general anesthesia is required for the procedure.

C ( a total dose of 200 units has been shown to have proven efficacy. Intra-detrusor injections of botulinum toxin type A have been effectively utilized to treat neurogenic overactive bladder. However, this is not an FDA-approved indication. A total dose of 200-300 units has been shown to have efficacy for this condition, with typically 10 units injected per site. This is an office procedure, with intravesical lidocaine administered prior to injection. In the majority of studies, botulinum toxin A injections last six to nine months. The most common side effects of botulinum toxin A include impaired bladder emptying, hematuria, and UTI.Schurch B, Denys P, Kozma CM, et al: A improves the quality of life of patients with neurogenic urinary incontinence. EUR UROL 2007;52:850-858. 2009 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 58-year-old man undergoes urodynamics for the evaluation of severe urinary incontinence following radical prostatectomy. Stress urinary incontinence occurs with a Valsalva maneuver to 40 cm H₂O. Detrusor pressure prior to the onset of volitional micturition at 400 ml is 3 cm H₂O. Voiding occurs completely by Valsalva maneuver. PVR is 10 ml. The best long term treatment is: A) periurethral bulking agent. B) transperineal bone anchored cadaveric fascial sling. C) artificial urinary sphincter. D) sacral neuromodulation. E) suprapubic tube.

C ( artificial urinary sphincter. Stress incontinence is the most common type of incontinence after radical prostatectomy. Options include artificial urinary sphincter, sling and periurethral bulking agents. Placement of a sling in this individual {resulting in a fixed urethral resistance} carries a risk of urinary retention due to the Valsalva voiding pattern and the use of cadaveric tissue for male sling does not appear to be as efficacious in the long term as synthetic materials. Periurethral bulking agents are unlikely to provide long term relief of stress urinary incontinence in males. A suprapubic tube will not address the sphincteric incontinence. Sacral neuromodulation is unlikely to have any effect on the sphincteric incontinence.Nitti VW, Blaivas JG: Urinary incontinence: Epidemiology, pathophysiology, evaluation, and management overview, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 60, p 2077. 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 17-year-old girl with neurogenic bladder secondary to meningomyelocele had an artificial urinary sphincter placed two years ago. At that time, her detrusor LPP was 15 cm H₂O at bladder capacity of 350 ml. Two years later, she is continent, but renal ultrasonography shows new moderate bilateral hydronephrosis. The most likely etiology is: A) sphincter erosion. B) ureterovesical junction obstruction due to the sphincter. C) decreased bladder compliance. D) excessive sphincter cuff pressure. E) changing neurologic lesion.

C ( decreased bladder compliance. New hydronephrosis after artificial urinary sphincter {AUS} placement is a well described complication. It is usually due to decreased bladder compliance that was unrecognized at the time of AUS placement or has developed subsequent to and as a result of the outlet resistance from the AUS. It is essential to monitor bladder compliance following AUS placement. A changing neurologic lesion {such as tethered cord} is unlikely to occur in a patient who has completed linear growth.Adams MC, Joseph DB: Urinary tract reconstruction in children, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 124, p 3668. 2008 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 27-year-old quadriplegic woman has urinary incontinence. Videourodynamics reveal a detrusor LPP of 65 cm H₂O at 100 ml without VUR. Abdominal LPP is 105 cm H₂O. The best management is: A) indwelling urethral catheter. B) intradetrusor botulinum toxin injection. C) ileovesicostomy. D) augmentation cystoplasty and pubovaginal fascial sling. E) appendicovesicostomy and augmentation cystoplasty.

C ( ileovesicostomy. This patient has dangerously elevated intravesical pressures and a continuously draining ileovesicostomy will permit low pressure bladder emptying. An indwelling catheter has the risk of UTI, stones, cancer and urethral erosion. The incompetent outlet of the ileovesicostomy acts as a pop off as the bladder fills and therefore the intravesical pressure will remain safe. Bladder neck fascial sling is not necessary as it is unlikely that this individual will have stress incontinence per urethra given her high abdominal LPP and her limited mobility. She is a quadriplegic and catheterization following augmentation cystoplasty through an abdominal stoma or her urethra increases her risks dependence on a caretaker and is not practical.Moy ML 2010 General Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 74-year-old woman has symptomatic stress incontinence and detrusor overactivity, but would like to avoid surgery. The best pharmacologic approach is: A) oxybutynin. B) bethanechol. C) imipramine. D) terazosin. E) ephedrine.

C ( imipramine. Imipramine has both a strong direct inhibitory action on bladder smooth muscle and a stimulant effect on the bladder outlet. The net result is that it promotes urinary storage by preventing detrusor overactivity and increasing urethral resistance. Phenylpropanolamine, phenylephrine, and ephedrine are sympathomimetic agents. The net result of alpha-adrenergic stimulation is an increase in the resting urethral pressure. On a theoretic basis this should enhance continence due to sphincter abnormalities, but there is no effect on detrusor overactivity. Oxybutynin has antimuscarinic and smooth muscle relaxant effects and has no role in the treatment of stress incontinence. Terazosin would exacerbate this patient's stress incontinence. Bethanechol is a cholinomimetic and would be expected to increase or aggravate detrusor overactivity. Resnick NM, Yalla SV: Geriatric incontinence and voiding dysfunction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 71, p 2318. 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 15-year-old girl paraplegic athlete has qualified for the Para Olympics. Her overactive neurogenic bladder has been well-controlled with oxybutynin XL 10 mg bid. She has recently become intolerant of antimuscarinic medication due to severe heat intolerance induced with training. Without antimuscarinic medication, she has uncontrollable urinary incontinence. With the Olympics only seven weeks away, you recommend: A) intravesical instillations of oxybuyinin. B) intravesical instillation of resiniferatoxin. C) intravesical injection of botulinum A toxin. D) placement of a sacral nerve stimulator. E) transcutaneous neural modulation.

C ( intravesical injection of botulinum A toxin. Approximately 30% of the patients treated with standard oxybutynin therapy and 15% using slow release formula will develop symptomatic complaints of dry mouth, constipation, and heat intolerance. To reduce the side-effects, intravesical oxybutynin may be used, however, approximately 15-20% of the patients will discontinue the intravesical oxybutinin therapy because of persistent side-effects or clinical ineffectiveness.New strategies for treating neurogenic detrusor overactivity in antimuscarinic refractory or intolerant patients include intravesical administration of resiniferatoxin or botulinum-A toxin injections into the detrusor muscle. In patients with spinal cord injuries, reorganization of the micturition reflex after the interruption of spinal cord pathways induces C fiber afferents to become mechanoreceptors which initiate reflex voiding. Resiniferatoxin inhibits stimulatory transmission from the bladder's afferent C fibers. Botulinum-A toxin selectively blocks acetylcholine release from presynaptic parasympathetic neuromuscular junctions thereby preventing detrusor hyperactivity. Clinical trials comparing the efficacy of single dose intravesical resiniferatoxin versus intravesical injections of botulinum-A toxin reveal both provide beneficial clinical and urodynamic results. Botulinum-A toxin injections however provide significantly superior clinical and urodynamic benefits over a longer time period than intravesical resiniferatoxin.There are few studies documenting the efficacy and clinical applicability of sacral nerve stimulators in patients with neural injuries or congenitally maldeveloped nerves. Transcutaneous low-frequency neuromodulation has been used commonly in adults and less frequently in neurologically normal children to inhibit detrusor overactivity and treat urge incontinence. To date, the long-term results of transcutaneous neuromodulation in patients with neural injuries have not been described. Aslan AR, Kogan BA: Conservative management in neurogenic bladder dysfunction. CURR OPINION IN UROL 2002;12:473-477.Giannantoni A, Di Stasi SM, Stephen RL, et al: Intravesical resiniferatoxin versus botulinum-A toxin injections for neurogenic detrusor overactivity: A prospective randomized study. J UROL 2004;172:240-243. 2011 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 43-year-old woman undergoes placement of a sacral neuromodulator with implantable pulse generator. Three months following placement she reports pain at the generator site that does not improve after the device is turned off. Physical exam is unremarkable. The next step is: A) reprogram the device at alternate settings. B) explantation of entire device. C) local exploration of implantable generator. D) relocation of generator to alternate site. E) treatment with amoxicillin or cephalexin for one week and re-evaluate.

C ( local exploration of implantable generator. Since turning off the device had no impact on pain, reprogramming it is unlikely to be of any benefit. The device may not need to be completely explanted at this point. A local exploration may obviate a seroma, or perhaps improper location. Relocation would be recommended only if local exploration revealed no abnormalities, and the location was felt to be causative. Vasavada SP, Rackley RR: Electrical stimulation for storage and emptying disorders, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 64, pp 2160-2161. 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A six-month-old boy has a posterior sagittal anoplasty for a high imperforate anus. After the urethral catheter is removed, he has persistent urinary retention. The most likely cause is: A) pudendal nerve injury. B) bladder neck injury. C) lumbosacral spine anomaly. D) failure to close urethrorectal fistula. E) unrecognized pelvic abscess.

C ( lumbosacral spine anomaly. There is a 13% to 45% incidence of anomalies of the lumbosacral spine in imperforate anus, resulting in 7%-18% incidence of neurogenic bladder. This may first become evident after repair of the anal lesion. Children with imperforate anus should be carefully checked for a neurogenic bladder. The pudendal nerve is not involved in bladder function. The other responses are rare.Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, pp 3647-3648. 2008 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

During transabdominal placement of an artificial urinary sphincter reservoir for post-radical prostatectomy urinary incontinence, the peritoneal cavity is entered. There is no bowel injury. The next step is: A) close the wound and terminate the procedure. B) close the wound and relocate the reservoir to another abdominal location. C) place the reservoir intraperitoneally and complete the procedure. D) close the peritoneum and place the reservoir above the rectus abdominis musculature. E) convert to a trans-scrotal placement of the reservoir.

C ( place the reservoir intraperitoneally and complete the procedure. Inadvertent entry into the abdominal cavity may occur during placement of an artificial urinary sphincter. In the absence of bowel injury, this is of no consequence and the procedure can be completed as planned. Placement of the reservoir above the rectus abdominis may result in postoperative herniation of this component.Staskin DR, Comiter CV: Surgical treatment of male sphincteric urinary incontinence: The male perineal sling and artificial urinary sphincter, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 74, p 2400. 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 55-year-old continent woman has persistent UTIs ten months following a synthetic urethral sling. Cystoscopy reveals the sling protruding through the left anterior-lateral bladder wall with an encrusted 1.5 cm stone. The next step is: A) cystolithalopaxy with repeat cystoscopy in three months. B) transvaginal cystostomy and removal of intravesical portion of the sling with encrusted stone. C) suprapubic cystotomy with removal of the stone and intravesical portion of the tape. D) cystolithalopaxy followed by retropubic exploration with extravesical explantation of the sling and closure of the bladder defect. E) complete removal of the tape and stone through a retropubic and vaginal approach and placement of autologous pubovaginal fascial sling.

C ( suprapubic cystotomy with removal of the stone and intravesical portion of the tape. Intravesical erosion of synthetic tapes have been reported and are either missed intraoperative perforations or they occur due to pressure necrosis with penetration of the bladder wall. The recommended treatment is removal of the foreign body from the bladder. Extraction of the intravesical portion through a suprapubic cystotomy results in disappearance of all symptoms. Complete removal of the tape is very difficult and may result in recurrent stress urinary incontinence. Cystolithalopaxy will not remove the tape leaving a persistent foreign body and nidus for recurrent stone formation and UTIs. Transvaginal cystotomy risks postoperative vesicovaginal fistula formation and using this operative approach it will be difficult to access the anterior bladder wall. Cystolithalopaxy will be unnecessary if the surgeon is planning a retropubic exploration.Dmochowski R, Scarpero H, Starkman J: Tension-free vaginal tape procedures, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 68, p 2263.Tsivian A, Kessler O, Mogutin B, et al: Tape related complications of the tension-free vaginal tape procedure. J UROL 2004;171:762-764. 2009 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A five-year-old girl is evaluated for a febrile UTI. She has daytime urgency and rare wetting. She is dry at night. Physical examination is normal. A renal US is normal and a VCUG shows bilateral grade 2 VUR. Spina bifida occulta at L5 is noted on the scout film. The next steps are prophylactic antibiotics and: A) spinal MRI scan. B) urodynamics. C) timed voiding. D) oxybutynin. E) endoscopic correction of reflux.

C ( timed voiding. Spina bifida occulta is often identified on spine films. In a child with a normal physical examination the chance of a spinal cord abnormality is very small. These children should be treated the same as other children with urgency and daytime wetting. The initial management is timed voiding and maintenance of a voiding diary. Since it is very likely that this VUR will resolve with behavioral modification surgical management including endoscopic treatment is not indicated. Urodynamics would be reserved for those children that are refractory to medical management. MRI scan of the spine is not indicated.Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, p 3604. 2012 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

The most important risk factor for progressive hydronephrosis in patients with myelomeningocele is: A) high grade VUR. B) detrusor overactivity. C) decreased detrusor compliance. D) LPP > 40 cm of H₂O. E) striated sphincter dyssynergia.

D ( LPP > 40 cm of H₂O. While all of the factors listed can produce hydronephrosis, a LPP of > 40 cm of water, if left untreated, has uniformly been associated with progressive hydronephrosis. High grade reflux is most likely secondary to the neurogenic bladder. Patients with an elevated LPP should be treated aggressively with CIC and antimuscarinics to prevent hydronephrosis. If this is not successful augmentation cystoplasty maybe indicated in the older patient and vesicostomy in the neonate or infant.Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, p 3634. 2009 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 16-year-old girl with a neurogenic bladder remains incontinent despite an aggressive program of CIC and antimuscarinic medications. Videourodynamic evaluation demonstrates a flaccid, large capacity bladder and low urethral resistance. The best long-term management is CIC and: A) periurethral bulking agent. B) bladder neck tubularization. C) an artificial urinary sphincter. D) a pubovaginal fascial sling. E) a Mitrofanoff procedure.

D ( a pubovaginal fascial sling. The best treatment in this situation is the pubovaginal sling. An advantage of the sling procedure for postpubertal females is that the dissection between the urethra and the vagina can be performed transvaginally, an approach considered by many to be simpler than pelvic dissection required for placement of an artificial urinary sphincter. Bladder neck tubularization produces a significant reduction in bladder capacity and the frequent necessity for reoperations to correct problems with catheterization. Periurethral bulking agents can provide short-term improvement, however the long-term effectiveness remains open to question. A Mitrofanoff procedure will not solve the problem of low outlet resistance. Adams MC, Joseph DB: Urinary tract reconstruction in children, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 124, p 3665. 2009 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

Successful toilet training in children requires: A) voluntary control over the periurethral smooth muscle. B) volitional control over the internal sphincter. C) autonomic control of detrusor contractions. D) an increase in bladder capacity. E) a decrease in bladder pressure.

D ( an increase in bladder capacity. Successful toilet training involves achievement of an adult pattern of urinary control and depends on the outcome of at least three separate events in the development of the bladder. First, bladder capacity must increase to serve as an adequate reservoir. Second, voluntarily control over the periurethral striated muscle sphincter must occur. Finally, direct central control over the spinal reflex that controls the detrusor smooth muscle must develop to voluntarily initiate or inhibit detrusor contraction. By the age of 4, most children have matured their urinary tract function and have developed an adult pattern of urinary control. The adult pattern is characterized during bladder filling by an absence of unstable or overactive detrusor contractions. Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, pp 3605-3607. 2009 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

An eight-year-old 30 kg boy with spina bifida has an appendicocecostomy for the antegrade continence enema (ACE) procedure. Postoperatively, he has persistent fecal incontinence and severe constipation with little to no fecal response within two hours of placing 3000 cc of water into the ACE stoma. The next step is: A) add 1/4 cup of baby shampoo to the colonic irrigations. B) add a bottle of magnesium citrate to the bowel irrigations. C) change to polyethylene glycol colonic irrigations. D) convert to a descending colon stoma or tube for the ACE. E) diverting colostomy.

D ( convert to a descending colon stoma or tube for the ACE. Two major problems are found to exist with cecal or colon stomas 1} stomal stenosis will develop in up to 30% of patients; this can be managed with either stomal revision or placement of a cecostomy tube through the stenotic channel. 2} washout failure, defined as failure to pass little or any of the enema from the rectum within one to two hours following instillation of irrigation fluid. Approximately 5-10% of patients with washout failure will need a diverting colostomy. The maximum amount of tap water that can be used for ACE irrigations before alterations in serum sodium will occur can be calculated by the formula of body weight {kg} x 0.035 L/kg for example in this 30 kg child. 30 kg x 0.035 liters/kg = 1.05 liters maximum volume. The physician may use water volumes higher than what is calculated but the risk of hyponatremia rises with higher volumes, the onset of hyponatremia and the risk of water intoxication will of course be dependent upon the type of fluid instilled and dwell time within the bowel. If water volumes greater than calculations are used the patients serum electrolytes should be checked at monthly intervals until they can be documented to be stable, after that time electrolytes can be checked with routine follow-up. Alternatives to significantly increasing the volume of calculated instilled fluid involve changing irrigant fluid to polyethylene glycol irrigations, long term use of this substance is however associated with the intermittent development of C. difficile colitis. Magnesium citrate or phosphate enemas may be instilled in the ACE prior to washout to decrease irrigant volume however these maneuvers have been associated with resultant hypermagnesemia, hyperphosphatemia and hypocalcemia. In patients with washout failure following high volume irrigations of a right colonic ACE altering the stomal site/colonic tube to the left colon has been documented to reduce the volume of irrigant; result in successful fecal continence and save the majority of these patients from the need for a diverting colostomy. Malone PS: The antegrade continence enema procedure. BJU INTERN 2004;93:248-249. Churchill BM, De Ugarte DA, Atkinson JB: Left-colon antegrade continence enema {LACE} procedure for fecal incontinence. J PED SUR 2003;38:1778-1780. Dey R, Ferguson C, Kenny SE, et al: After the honeymoon - medium-term outcome of antegrade continence enema procedure. J PED SUR 2003;38:65-68. Yerkes EB, Rink RC, King S, et al: Tap water and the Malone antegrade continence enema: A safe combination? J UROL 2001;166:1476-1478. 2010 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 65-year-old man with rectal carcinoma treated by abdominal perineal resection develops urinary incontinence two years later. His urinalysis is normal and PVR is 300 ml. Renal ultrasound demonstrates moderate bilateral hydronephrosis. The most likely urodynamic findings are: A) detrusor overactivity with bladder outlet obstruction. B) detrusor overactivity with external sphincter dyssynergia. C) detrusor areflexia with normal compliance. D) detrusor areflexia with poor compliance. E) impaired bladder contractility with intrinsic sphincter deficiency.

D ( detrusor areflexia with poor compliance. Permanent lower urinary tract dysfunction occurs in 15-20% of patients following radical pelvic surgery. The typical pattern is one of detrusor areflexia or hypocontractility in the presence of fixed residual striated sphincter tone. This fixed tone represents a functional obstruction that frequently results in decreased detrusor compliance. Although poor proximal sphincter function can also occur {intrinsic sphincter deficiency}, this is often masked by prostate bulk in male patients.Wein AJ: Lower urinary tract dysfunction in neurologic injury and disease, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 59, p 2032. 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A healthy newborn boy has bilateral Grade 4 VUR. This is most commonly associated with: A) low outlet resistance. B) uninhibited detrusor contractions, coordinated voiding. C) poor bladder compliance. D) high pressure voiding with high residual. E) lack of detrusor contractility.

D ( high pressure voiding with high residual. Reflux in newborn boys is commonly high grade and associated with uninhibited detrusor contractions during filling, high pressure voiding due to elevated outlet resistence, detrusor-sphincter dyssynergy, and high postvoid residuals. Uninhibited, detrusor contractions associated with coordinated voiding is normal in infants and not associated with high grade VUR. Compliance and contractility are generally within the range of normal for these boys. The best treatment for infant boys with high grade VUR is prophylactic antibiotics and observation. Most of these infants will decrease their outlet resistance and resolve their VUR with neurourologic maturation during the first year of life.Yeung CK, Godley ML, Dhillon HK, et al: Urodynamic patterns in infants with normal lower urinary tracts or primary vesico-ureteric reflux. BRI J UROL 1998 81:461-467. Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, p 3614. 2010 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

An eight-year-old boy with spina bifida is managed with CIC. He has chronic bacteriuria but normal renal function and no reflux. The most appropriate management is: A) sterile intermittent catheterization. B) antibiotic suppression. C) cystoscopy. D) observation. E) intravesical antibiotics.

D ( observation. Approximately half of the children on CIC have chronic bacteriuria. Despite suppressant antibiotic therapy, the majority of these patients continue to have chronic bacteriuria and suppressant therapy often leads to colonization with more resistant strains. Children on CIC who are clinically well without evidence of pyelonephritis or reflux require no treatment for chronic bacteriuria. Cystoscopy holds no value in this circumstance. Sterile intermittent catheterization has not been shown to decrease bacteriuria consistently when compared to clean CIC. Intravesical antibiotics are also uncertain in terms of benefit in this circumstance and are not even considered unless the child is suffering consequences of recurring symptomatic UTI and has failed other approaches.Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, pp 3635-3637. 2010 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A one-week-old boy is observed to void in small amounts with 5 to 10 minute intervals between several voiding episodes. He is otherwise well. The next step is: A) bladder and kidney ultrasound. B) VCUG. C) check PVR. D) observation. E) retrograde urethrogram.

D ( observation. Normal infantile voiding patterns often include frequent small volume, and incomplete voids. Using serial ultrasound, documenting the time and number of voids in neonates and carefully weighing their diapers has confirmed these findings. In the absence of other clinical findings, no specific evaluation should be undertaken. Renal and bladder ultrasound, although non-invasive, is not indicated. The remaining tests are invasive and not indicated in a normal infant.Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, pp 3604-3606. Yeung CK, Godley ML, Ho CK, et al: Some new insights into bladder function in infancy. BRI J UROL 1995;76:235-240. 2008 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 48-year-old man has a two-week history of low back pain and difficulty voiding. Physical examination reveals an absent bulbocavernosus reflex and loss of perineal sensation. MRI scan of the spine confirms an L4-L5 disc protrusion. The most likely distribution of his neural injury is: A) parasympathetic alone. B) sympathetic alone. C) pudendal alone. D) parasympathetic and pudendal. E) sympathetic and pudendal.

D ( parasympathetic and pudendal. The clinical picture is consistent with cauda equina syndrome, which is associated with disc disease {severe central posterior disc protrusion} and other spinal canal pathologies that involve the L4-S2 region. Additional features of the presentation include loss of voluntary control of both anal and urethral sphincters and of sexual responsiveness. The most consistent urodynamic finding is that of a normally compliant areflexic bladder with either normal innervation or incomplete denervation of the perineal floor musculature. Disc protrusions of the lumbar spine interfere with the parasympathetic and somatic innervation of the lower urinary tract, striated sphincter and other pelvic floor musculature, and afferent activity from the bladder and affected somatic segments to the spinal cord. Wein AJ: Lower urinary tract dysfunction in neurologic injury and disease, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 59, pp 2031-2033. 2010 General Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 72-year-old man on LH-RH agonist therapy reports difficulty voiding 30 months following brachytherapy for localized prostate cancer, and undergoes TURP. Before brachytherapy, his prostate volume was 30 gm, his PSA was 5.2 ng/ml and International Prostate Symptom Score (IPSS) was 7. The factor most likely to correlate with incontinence following TURP is: A) pre-operative PSA. B) prostate volume. C) treatment with LH-RH agonist therapy. D) time since brachytherapy. E) preoperative IPSS.

D ( time since brachytherapy. Rates of incontinence can be high in patients undergoing TURP following brachytherapy {at least 18%}. The presence of obstructive symptoms at the time of TURP, and a period of at least two years since brachytherapy are associated with a greater likelihood of incontinence. Treatment with Lupron, prostate size, pretreatment IPSS, dosage of brachytherapy, and pre-treatment PSA do not seem to affect the likelihood of incontinence. Kollmeier MA, Stock RG, Cesaretti J, Stone NN: Urinary morbidity and incontinence following transurethral resection of the prostate after brachytherapy. J UROL 2005;173:808-812. 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A five-year-old girl is treated for cystitis. She has urge incontinence four days per week and nocturnal enuresis. A VCUG shows no reflux. Physical examination is normal. The next step is: A) DDAVP®. B) oxybutynin. C) imipramine. D) timed voiding. E) observation.

D ( timed voiding. Enuresis is a common problem in five-year-old children. Diurnal enuresis is present in 7-8%, and nocturnal enuresis in 15%. Pharmacologic management may be considered, but the initial treatment should be timed voiding. This will improve the enuresis and decrease the risk for subsequent infection. If timed voiding is not effective, the patient may be treated with either imipramine or oxybutynin. Since nocturnal enuresis is common at that age and the spontaneous resolution rate is 10-15% per year, treatment with DDAVP® is typically reserved for children over seven years of age. Observation leaves the child wet and is not appropriate.Canning DA, Nguyen MT: Evaluation of the pediatric urology patient, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 110, pp 3204-3205. 2008 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

One month after L5 laminectomy, a 30-year-old woman develops lower extremity weakness, a residual urine of 300 ml, and an intermittent urinary stream. Videourodynamics demonstrates detrusor-sphincter dyssynergia. The most likely explanation is: A) pseudodyssynergia. B) recurrent lumbar disk herniation. C) cauda equina syndrome. D) undiagnosed multiple sclerosis. E) permanent nerve injury from disk.

D ( undiagnosed multiple sclerosis. The urodynamic finding of detrusor external sphincter dyssynergia {DESD} indicates that a suprasacral spinal lesion is present. This cannot be explained by a recurrent hernia or permanent injury to L5. The most likely supraspinal lesion in a woman this age is multiple sclerosis.Wein AJ: Lower urinary tract dysfunction in neurologic injury and disease, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 59, pp 2019-2020. 2011 General Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 68-year-old man with bothersome voiding dysfunction completes a voiding diary revealing 12 voids in 24 hours with volumes ranging from 30 ml to 150 ml, nocturia x 3, and one episode of incontinence. PVR is 50 ml. PSA is 1.8 ng/ml. Non-invasive uroflowmetry reveals a flattened pattern with a peak flow of 6 ml/sec. His condition is best described as: A) BPH. B) bladder outlet obstruction. C) detrusor overactivity. D) detrusor underactivity. E) LUTS.

E ( LUTS. BPH is a histological diagnosis. This patient has not had a biopsy. Bladder outlet obstruction is a urodynamic diagnosis made on the basis of the relationship between pressure and flow. The poor flow rate in this case may be due to either detrusor underactivity or bladder outlet obstruction and is not diagnostic of either entity. Detrusor overactivity and detrusor underactivity are a urodynamic diagnosis that cannot be made in the absence of a pressure-flow urodynamic study. LUTS is a generic term describing lower urinary tract symptoms and does not imply an underlying pathology or pathophysiology. Kaplan, S., et al, AUA Guideline on the Management of BPH: Diagnosis and Treatment Recommendations. Chapter 1, p.25. http://www.auanet.org 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 72-year-old man with a 45 g benign prostate has frequency, urgency, and urge incontinence six months after TUMT. His AUA Symptom Score is 20 with a high degree of bother while taking an alpha-blocker. PVR is 175 cc. Pressure flow study shows detrusor overactivity with incontinence, a voiding pressure of 55 cm H₂O, and a flow rate of 7 ml/sec. The best treatment is: A) CIC. B) 5-alpha-reductase inhibitor. C) antimuscarinic and 5-alpha-reductase inhibitor. D) repeat TUMT. E) TURP.

E ( TURP. In patients who have obstruction and detrusor overactivity relief of the obstruction will generally result in resolution of the detrusor overactivity. Although antimuscarinics may help the patient's symptoms, they do not treat the underlying problem. 5-alpha-reductase inhibitors reduce prostate volumes and modestly improve symptoms but may not treat the underlying obstruction and will take four to six months to achieve the maximal effect in this bothered patient. CIC will not treat the underlying problem of bladder outlet obstruction. TUMT is not as effective as TURP in improving the objective signs of outflow obstruction as evidenced by this man's persistent obstruction.Fitzpatrick JM: Minimally invasive and endoscopic management of benign prostatic hyperplasia, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 88, pp 2819-2821 Roehrborn CG, McConnell, JD, Barry MJ, et al: Guideline on the management of benign prostatic hyperplasia. AUA Education and Research, 2003, p 28 2009 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A seven-year-old girl has daytime incontinence that is not associated with infection. She has marked constipation and encopresis. Her physical examination reveals a normal appearing spine, and a normal neurologic examination. Her bladder is not percussible, and urinalysis is normal. The next step is timed voiding and: A) spinal MRI scan. B) VCUG. C) urodynamic evaluation. D) oxybutynin. E) bowel management.

E ( bowel management. In the absence of a UTI, a VCUG or urodynamic evaluation is overly invasive. A spinal MRI scan is not warranted in the absence of any neurologic abnormality or spinal defect. Although oxybutynin is acceptable empiric treatment, it will likely make the constipation worse. Aggressive treatment of the constipation has been shown to benefit not only the encopresis, but also the urinary incontinence. Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, pp 3614-3619. 2011 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 24-year-old man with a gunshot wound shattering the L-4 vertebral body achieves stable neurogenic bladder dysfunction nine months later. Pressure flow urodynamic studies will likely show: A) detrusor overactivity, sphincter dyssynergia. B) detrusor overactivity, normal sphincter EMG. C) detrusor areflexia, sphincter dyssynergia. D) detrusor areflexia, normal sphincter EMG. E) detrusor areflexia, denervation potentials on EMG.

E ( detrusor areflexia, denervation potentials on EMG. An injury to the vertebral column at L-4 injures the cauda equina and, depending on the extent of neural damage, will produce a loss of motor and sensory fibers to the bladder, pelvic floor, and external sphincter. Detrusor sphincter dyssynergia is produced by suprasacral spinal cord lesions that interrupt the ascending and descending pathways between the sacral spinal cord and the center for reflex detrusor and urethral function in the brain stem. Reflex detrusor function requires sacral root and sacral cord integrity. While an areflexic bladder faces fixed internal sphincter activity, that activity is normal and not truly dyssynergic. Since within the sacral and lumbar canal the nerve roots are intermingled, a lesion that produces detrusor areflexia would be expected to have a similar effect on the external sphincter; hence, the denervation potentials. Wein AJ: Lower urinary tract dysfunction in neurologic injury and disease, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 59, pp 2024-2025. 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

The therapy with the highest success and lowest relapse rate for uncomplicated primary nocturnal enuresis is: A) behavioral modification. B) oxybutynin. C) imipramine. D) DDAVP. E) nocturnal enuretic alarm.

E ( nocturnal enuretic alarm. To date, the etiology of primary nocturnal enuresis is poorly understood. Research has shown that many children will have a reduced functional bladder capacity and an element of overactive bladder contractions while sleeping. Most children will also have an element of elevated arousal threshold while sleeping. Many single and combination treatment modalities have been used including the urinary alarm, anticholinergics, DDAVP, and imipramine. However, the modality that has the highest success and the lowest relapse rate is the nocturnal enuretic alarm. The correct use of the alarm is commonly misunderstood. It is best used in conjunction with the parents' involvement in which they confirm that the child awakens when the alarm goes off since the child will often sleep through the alarm. The child then gets up and voids to completion. The alarm therapy may take up to three to four months to be successful. Parents and children need to be educated on its correct use and the labor intensive nature of this therapy. When used correctly, success rates have been reported to be 70-80% with low rates of relapse. All forms of pharmacotherapy have lower rates of success and much higher rates or relapse. Behavior modification using techniques such as timed voiding or retention training are not effective tools to address nocturnal enuresis.Neveus T, Eggert P, Evans J, et al: International Children's Continence Society. Evaluation of and treatment for monosymptomatic enuresis: A standardization document from the International Children's Continence Society. J UROL 2010;183:441-447. 2012 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )

A 48-year-old woman complains of stress incontinence. She denies any symptoms of urge incontinence. On exam she has urethral hypermobility. Videourodynamics confirms the diagnosis of stress incontinence with mobility. Detrusor overactivity is demonstrated at 400 ml with a detrusor contraction of 25 cm H₂O. The best next step is: A) oxybutynin. B) pseudoephedrine and oxybutynin. C) transurethral collagen injection. D) transvaginal needle suspension. E) sling procedure.

E ( sling procedure. The patient's complaint is stress incontinence. Detrusor overactivity may be asymptomatic and occurs in up to 69% of normal volunteers with ambulatory monitoring. In patients with mixed symptoms when stress symptoms predominate and stress incontinence is objectively demonstrated, surgical repair will alleviate all the symptoms 50-70% of the time. Antimuscarinic therapy may treat her detrusor overactivity but this is not her complaint. Imipramine and pseudoephedrine will improve her stress incontinence but they are not definitive therapy. Transurethral collagen injections are not approved for women with urethral hypermobility. A sling procedure will treat her stress incontinence from her hypermobility and has a 70% chance of alleviating her detrusor overactivity. Transvaginal needle suspensions are inferior to sling procedure for the treatment of stress urinary incontinence. Nitti VW, Blaivas JG: Urinary incontinence: Epidemiology, pathophysiology, evaluation, and management overview, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 60, pp 2076-2077. 2008 Adult Neurogenic Bladder, Voiding Dysfunction, Incontinence )

The earliest clinical manifestation of a tethered spinal cord in children is: A) constipation. B) upward Babinski reflex. C) lower limb weakness, gait abnormality. D) increased deep tendon reflexes of the lower limb. E) urinary incontinence secondary to detrusor overactivity.

E ( urinary incontinence secondary to detrusor overactivity. Currently one third of the symptomatic patients undergoing detethering of the spinal cord will present with urologic complaints, 50% will present with the late findings of lower limb weakness/gait disturbance and approximately 15% with back pain. Bowel dysfunction is a rare presenting complaint. Damage from a tethered cord is the result of inadequate oxygen metabolism in the spinal cord. The cord becomes tethered between the site of tethering and where the anterior and posterior nerve roots exit the canal. Repetitive flexion and extension and/or Valsalva activity of any type kinks the arterioles and venules, thereby reducing blood supply to the tethered cord. The clinical findings of tethered cord come from accumulative hypoxemic damage and may occur at any age. The diverse structure of the spinal cord plays a large role in the pathogenesis of this disorder; specifically interneuronal axon connections have the highest oxygen requirements and are the first to become damaged. Clinically, this means the pelvic nerves and the sacral reflex arc will be the first to manifest the hypoxic damage, lower limb weakness and back pain occurring at a later time. Once an MRI scan depicts a tethered or abnormally lying cord, surgical detethering will not correct the MRI picture. Long-term follow up has revealed that up to 20% of tethered cords may redevelop symptomatic findings of re-tethering. The inability of the MRI scan to rule out re-tethering places the urologist and urodynamic testing in a key position. Specifically serial urodynamic tests or electromyography of the muscles involved with the sacral reflex arc are monitored at set intervals usually three months post surgical release of the cord and then again at six to twelve month intervals. Alterations in the urodynamic tests will result in increase attentiveness by the neurosurgeon for the development of re-tethering of the spinal cord. Yeung CK, Sihoe JD, Bauer SB: Voiding dysfunction in children: Non-neurogenic and neurogenic, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 123, pp 3643-3645. Wein AJ: Lower urinary tract dysfunction in neurologic injury and disease, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 59, p 2030. 2010 Pediatric Neurogenic Bladder, Voiding Dysfunction, Incontinence )