The changing urodynamic pattern from infancy to adolescence in boys with posterior urethral valves

Abstract

Objective To determine whether bladder dysfunction in boys with posterior urethral valves (PUV) changes from a uniform pattern of hypercontractility during infancy to the hypocontractility found in adolescence, by reviewing serial urodynamic studies. Patients and methods Thirty boys with PUV and no voiding symptoms underwent a total of 86 urodynamic tests (mean 2.8 each). The first urodynamic study was undertaken at 1–4 years of age in 15 boys and at 5–13 years in 15. They were re‐evaluated at least 3 years later; 15 patients underwent the first and last urodynamic study, respectively, at a mean age of 2.8 and 7.7 years (group A), 10 boys at 6.2 and 8.8 years (group B) and five at 9.4 and 15.2 years (group C). In 10 boys aged > 5 years the first and last pressure‐flow studies (PFS) were analysed using an advanced analysis (PFA) to better identify hypocontractility. Results Bladder dysfunction was found in 21 of 30 (70%) boys at the first evaluation and in 18 (60%) at the last. In 25 boys the urodynamic pattern changed. Of the 15 boys in group A, 10 of 12 who had hypercontractility changed to normal (seven), low compliance (one) or hypocontractility (two), and two remained stable; two of the remaining three with normal urodynamic studies changed to hypocontractility, while one was unchanged. Among the 10 boys in group B, six with hypercontractility changed to normal (three) or hypocontractility (three); two with normal urodynamic findings and one with low compliance changed to hypocontractility. Of the five boys in group C who showed severe hypocontractility after puberty, three had a normal pattern, one low compliance and one hypercontractility before puberty. The PFA showed a ‘weak’ detrusor in four of the seven boys who were considered normal on standard PFS. At the urodynamic follow‐up, the PFA pattern changed to a ‘weak’ detrusor in four boys who had a normal (two) or strong (two) detrusor at the first evaluation. Conclusions Bladder dysfunction in boys with PUV changes during childhood and through adolescence. The urodynamic pattern of hypercontractility generally found soon after valve ablation gradually changes to hypocontractility in many boys and this pattern seems to be the rule after puberty. The evidence from this series supports the hypothesis that long‐term detrusor hyperactivity in boys with PUV leads to detrusor failure, but a longitudinal 15‐year follow‐up from birth to puberty is needed to validate this concept.

Executive summary: The International Consultation on Incontinence 2008—committee on: “Dynamic Testing”; for urinary or fecal incontinence. Part 2: Urodynamic Testing in male patients with symptoms of urinary incontinence, in patients with relevant neurological abnormalities, and in children and in frail elderly with symptoms of urinary incontinence

“…A variety of UDS diagnoses before and after treatment were reported. 23,24 The ICI-CDT recommends to consider UDS on an individual basis and recommends further investigation to standardize UDS in boys with (suspected) posterior urethral valves and to determine the (clinical) value of UDS in these cases.…”

“…A variety of UDS diagnoses before and after treatment were reported. 23,24 The ICI-CDT recommends to consider UDS on an individual basis and recommends further investigation to standardize UDS in boys with (suspected) posterior urethral valves and to determine the (clinical) value of UDS in these cases.The ICI-CDT has found only a few studies that characterize the change in LUT function following bladder neck reconstruction in patients with persistent UI after reconstruction for bladder extrophy and no studies have correlated UI with bladder capacity, compliance, DO, and/or LPP, after treatment. 25,26 The ICI-CDT recommends to consider the relevance of UDS after or before (secondary) reconstruction for bladder extrophy on an individualized basis and recommends further investigation to standardize UDS and to determine the (clinical) value of UDS in these cases.…”

Lower abdominal mass in a 16-year old adolescent: an unusual presentation of posterior urethral valves

“…Thirty-eight to 70% of neonatally diagnosed and treated PUV patients develop the "valve bladder syndrome," which represents the spectrum of bladder dysfunction that manifests many years after definitive treatment of valves. 12 Gennaro and colleagues studied the natural history of voiding patterns using urodynamic studies in 30 boys treated for PUV. Bladder dysfunction was present in 70%, and changed from unstable/hypercontractile in infancy, to hypocontractile in childhood, to a true myogenic failure in adolescence, 12 despite early valve ablation.…”

“…12 Gennaro and colleagues studied the natural history of voiding patterns using urodynamic studies in 30 boys treated for PUV. Bladder dysfunction was present in 70%, and changed from unstable/hypercontractile in infancy, to hypocontractile in childhood, to a true myogenic failure in adolescence, 12 despite early valve ablation. Holmdahl suggested that these 3 urodynamic findings are variations of the same basic pattern evolving with time toward decompensation in early presenters, despite early correction of obstruction.…”

Posterior urethral valves: The value of high diversion

“…Close and colleagues [11], [12] reviewed the outcome in 31 boys, of whom 23 underwent valve ablation in the first year of life and compared them with eight boys who had MacKinnon AE: High diversion in PUV a high diversion but without giving clear indications for the choice of procedure. Progressive renal failure was not prevented in either group, which implies that this is determined by pre-existing damage.…”