Материал: Oxford American Handbook of Urology ( PDFDrive )

NON-NEUROGENIC VOIDING DYSFUNCTION 567

Investigations

Obtain urinalysis (infection, protein, glucose) and voiding diary and assess flow rate.

In selected cases, US of the renal tract (hydronephrosis, bladder size); VCUG (VUR, post-void residual), videourodynamics (over or underactive detrusor, sphincter dyssynergia), or MRI of the spine (if clinical suspicion of neurological cause) is indicated.

Management

This includes behavioral therapy (bladder retraining, timed voiding, change of voiding posture, psychological support); medication (antibiotics for infection, anticholinergics for bladder overactivity and urgency, laxatives or enemas for constipation); and intermittent catheterization to drain post-void residuals. Surgery is rarely indicated.

Prognosis

Fifteen percent of cases spontaneously resolve per year.

568 CHAPTER 15 Pediatric urology

Nocturnal enuresis

Enuresis is normal but involuntary voiding that occurs at an inappropriate time or social setting, during the day, night, or both. Nocturnal enuresis describes any involuntary loss of urine during sleep.

Prevalence

Approximately 750,000 children over age 7 years will regularly wet the bed. The prevalence in adults is ~0.5%.

Prevalence

Classification

•Primary: never been dry for more than a 6-month period

•Secondary: re-emergence of bed wetting after a period of being dry for at least 6 months

Etiology

•Familial

•Delay in functional bladder maturation

•Altered antidiuretic hormone (ADH) secretion; abnormal decrease in ADH levels at night causes increased urine production (nocturnal polyuria)

•Altered sleep/arousal mechanism

•Psychological factors

•UTI (1% of cases)

Evaluation

•History: frequency of episodes; daytime symptoms; new or recurrent; family history; UTIs; bowel problems; psychosocial history

•Examination: exclude organic causes (neurological disease)

•Investigation: urinalysis (infection, specific gravity is reduced in nocturnal polyuria, glucose, protein); voiding diary

Management

Behavioral

Provide reassurance; bladder training; motivational techniques to improve the child’s self-esteem; conditioning therapy (an alarm is connected to the child’s underwear, which is triggered with the first few drops of urine).

NOCTURNAL ENURESIS 569

Pharmacological

•Imipramine—a tricyclic antidepressant with anticholinergic, antispasmodic properties.

•DDAVP or desmopressin (synthetic analogue of ADH) given intranasally or orally

Prognosis

Fifteen percent of patients have spontaneous resolution of symptoms per year.

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Urological surgery and equipment

Preparation of the patient for urological surgery 572 Antibiotic prophylaxis in urological surgery 574 Complications of surgery in general: DVT and PE 576 Fluid balance and management of shock in the surgical

patient 580

Patient safety in the operating room 582 Transurethral resection (TUR) syndrome 583 Catheters and drains in urological surgery 584 Guide wires 590

Irrigating fluids and techniques of bladder washout 592 JJ stents 594

Lasers in urological surgery 598 Diathermy 600

Sterilization of urological equipment 604

Telescopes and light sources in urological endoscopy 606 Consent: general principles 608

Cystoscopy 610

Transurethral resection of the prostate (TURP) 612 Transurethral resection of bladder tumor (TURBT) 614 Optical urethrotomy 616

Circumcision 618

Hydrocele and epididymal cyst removal 620 Nesbit procedure 622

Vasectomy and vasovasostomy 624 Orchiectomy 626

Urological incisions 628 JJ stent insertion 630

Nephrectomy and nephroureterectomy 632 Radical prostatectomy 634

Radical cystectomy 636 Ileal conduit 640

Percutaneous nephrolithotomy (PCNL) 642 Ureteroscopes and ureteroscopy 646 Pyeloplasty 650

Laparoscopic surgery 652

Endoscopic cystolitholapaxy and (open) cystolithotomy 654 Scrotal exploration for torsion and orchiopexy 656