THE USE OF RADIOGRAPHY, URODYNAMIC STUDIES AND CYSTOSCOPY IN THE EVALUATION OF VOIDING DYSFUNCTION

• Published in: Pediatrics (Evanston) Vol. 104; no. 3; p. 814
• Main Authors: Parekh, Dipen J, Pope, John C, Adams, Mark C, Brock, John W. III
• Format: Journal Article
• Language: English
• Published: American Academy of Pediatrics 01-09-1999
• Subjects: Pediatrics
• ISSN: 0031-4005

Background: Children with dysfunctional voiding disorders are often subjected to radiologic, cystoscopic or urodynamic evaluations in an effort to find an anatomic or organic cause. Our objective was to determine the role of the above investigations in the evaluation, management and ultimate outcome of a large patient population with voiding dysfunction from within a single institution. Methods: 858 patients with dysfunctional voiding disorders seen from 1991 to 1998 were evaluated retrospectively. A thorough history and physicial with specific emphasis on voiding patterns was elicited and urinalysis performed in all patients. Ultrasound of the urinary system was performed in 808 patients (94%) with 19 (2.2%) patients undergoing IVP. VCUG was performed in 480 patients (56%), 407 of which had a history of urinary tract infection. Cystoscopy was performed in 43 patients (5%) and a formal urodynamic study was performed in 26 (3%). Behavioral therapy was practiced in 620 patients (72%), 395 patients (46%) received antibiotics, 380 patients (44%) received anticholinergics, 135 patients (16%) were placed on bowel regulation regimen for concomitant bowel elimination problems and 53 patients (6.5%) were simply observed. Results: Mean age at referral was 6 years (range 2-14) with 73% of patients being females and 27% being males. The physical examination was unremarkable with regard to the abdomen, back, genitalia, and the neurologic system in all patients. Ultrasound of the upper urinary system was normal in 784 patients (97%) with insignificant pyelectasis seen in 24 (3%). IVP was normal in all 19 studies. VCUG was normal in 310 patients (64.5%). Unilateral and bilateral low grade reflux was seen in 77 and 17 patients respectively. Unilateral high grade vesicoureteral reflux was seen in only 2 children. Urodynamic studies were performed in 26 patients who did not respond to standard management. Detrusor instability was observed in 16 patients, low bladder capacity in 5, detrusor sphincter dyssynergia in 3, poor compliance in 5, and sensory urgency and delayed sensation in 1 patient each. One patient had a completely normal study. Cystoscopy revealed normal findings in 14 patients, trabeculations in 20, inflammation in 11 and 2 patients were found to have type 1 posterior urethral valves. Conclusions: The incidence of upper tract changes and positive anatomic findings in patients with voiding dysfunction is too low to justify routine radiologic evaluation and cystoscopy. However, in patients presenting with urinary tract infection, there remains an important role for VCUG. We do not recommend the routine use of urodynamics in patients with voiding disorders as it does not change the management or influence the final outcome. A good history and physical leads to the correct diagnosis and treatment in the vast majority of children. Focus on correction of faulty voiding behavior with judicious use of antibiotics and anticholinergic therapy will lead to a favorable outcome in a vast majority of these children.