Urinary Bladder Disorders in Children: Towards Better Understanding and Treatment

Non-neurogenic lower urinary tract dysfunction is common in children. Their management is still being refined in keeping with the improvement in the understanding of pathophysiology and patient perceptions. Studies in this thesis aim to improve the understanding and treatment of four aspects of lower urinary tract dysfunction in children as outlined below. A systematic review was conducted using a "prognostic review methodology" and a random effect meta-analysis was performed. 46 studies including 2979 children with PUV were included in the analysis. The median follow-up was 102 months (IQR 66-116 months). The risk of end stage kidney disease (ESKD)(stage V CKD) in children with PUV is estimated to be 19% (95%CI 14-24%), with an additional risk of 26% (95%CI 21-31%) for developing chronic kidney disease (CKD). Our review also identifies elevated nadir creatinine in the first year of life (RR 3.17; 95% Cl 1.20- 7.75, p=0.01) and presence of lower urinary tract dysfunction in early childhood (RR 4.22; 95% Cl 1.44- 12.43) as reliable predictors of ESKD. Antenatal diagnosis (RR 0.85; 95% CI0.52- 1.38) or treatment era (p=0.09) did not influence outcomes. The review also found unexplained, residual heterogeneity in majority of the meta-analyses. The findings will not only assist clinicians in patient counseling but also in planning therapy and future research. Our experience of ambulatory urodynamics in children with refractory bladder function using a blue tooth enabled device included a total of 12 studies, which were performed in ten children (median duration 8 hours, range 4-24 hours). Ambulatory urodynamics were performed concurrently with conventional urodynamic studies in seven children. Ambulatory studies identified abnormalities, which were not detected on conventional urodynamics in six out of seven children. These additional findings have been shown to improve treatment outcomes in a majority (5/7) of carefully selected children. Ambulatory urodynamic studies were well tolerated by children. We have also evaluated the inter-observer agreement in reporting of detrusor overactivity in urodynamic studies in children. Although, the inter-observer agreement was lower for conventional than for ambulatory urodynamics (kappa =0.13, 95% confidence intervals 0.05- 0.21 and Kappa = 0.25, 95% confidence intervals 0.17- 0.33 respectively), the overall agreement was low for both. The above studies may play an important role in both; resurrecting the role of ambulatory urodynamics in selected children with lower urinary tract dysfunction as well as initiating an informed debate on the standards of reporting of urodynamics in children