title: Psychosocial and respiratory disease related to severe bladder dysfunction and non-monosymptomatic enuresis.
abstract: OBJECTIVE
  Complicated bladder dysfunctions (BD) (associated with infections/urological complications or irresponsive to treatment) are a small proportion of all cases, but are highly morbid, clinically and psychosocially. Our aim is to describe a cohort of complicated pediatric BD, using subgroup analysis to compare presentations and responses to treatment among genders, age groups, and patients with or without non-monosymptomatic enuresis (NME). We also relate severe BD to other health conditions or to social/behavioral problems and report treatment results.
  
  
  METHODS
  Thirty-five cases of complicated BD were reviewed. Neurogenic bladders and anatomical urological problems were excluded. Justifications for referral, comorbidities, and social aspects/familial dynamics were studied. Overactive bladders were primarily treated with oxybutynin. Transcutaneous parasacral neuromodulation was used in case of insufficient response or unbearable side effects. For infrequent voiders, timed voiding and transcutaneous neuromodulation were counseled.
  
  
  RESULTS
  Incontinence/enuresis were the motives for referral in only a third of the cases. UTI (42.9%) was the main reason for referral. Hydronephrosis was observed in 8.6% of the children. Respiratory/ENT problems, obesity, and precocious puberty were highly prevalent. Schooling problems and neuropsychiatric disease were common. Social problems were common. Five patients presented urological problems secondary to BD (hydroureteronephrosis, VUR, trabeculated bladder). Twenty percent of cases required high anticholinergic doses and 37.1% transcutaneous electrostimulation. Eight (22.9%) patients abandoned but later resumed therapy, and 14.6% did not follow treatment. Boys tended to be older than girls and presented NME, respiratory, and behavioral problems more often, with a significant difference for asthma and anxiety/depression. Associated health problems and neuropsychiatric treatment tended to be more frequent among those presenting NME. Non-enuretic children tended to show better results from treatment (see Table).
  
  
  CONCLUSIONS
  The social characteristics of our population (severe cases, socially deprived, very poor, not well educated, and with limited access to health care) determine a very specific sampling. Our research demonstrated that even severe cases of BD affecting socially deprived children may be treated, with adhesion to treatment and results comparable with other cohorts of BD, although the children need multidisciplinary attention and close follow-up. Boys, older children, and NME are more difficult to treat and often have other associated health and behavioral problems. Stress-related conditions were common in severe BD. A relatively high occurrence of precocious puberty was an unexpected finding in our research.
authors.affiliation: Urology and Pediatric Surgery Departments, Antonio Pedro University Hospital, Federal Fluminense University, Rio de Janeiro, Brazil. Electronic address: lisieux@uol.com.br.
authors.forename: Lisieux Eyer
authors.initials: LE
authors.lastname: de Jesus
authors.affiliation: Urology and Pediatric Surgery Departments, Antonio Pedro University Hospital, Federal Fluminense University, Rio de Janeiro, Brazil.
authors.forename: Alberto
authors.initials: A
authors.lastname: Tomé
authors.affiliation: Urology and Pediatric Surgery Departments, Antonio Pedro University Hospital, Federal Fluminense University, Rio de Janeiro, Brazil.
authors.forename: Diego
authors.initials: D
authors.lastname: Cobe
authors.affiliation: Urology and Pediatric Surgery Departments, Antonio Pedro University Hospital, Federal Fluminense University, Rio de Janeiro, Brazil.
authors.forename: Pedro
authors.initials: P
authors.lastname: Camelier
mesh_terms: D002648:Child; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D053206:Nocturnal Enuresis / Q000175:diagnosis / Q000209:etiology*; D011618:Psychotic Disorders / Q000150:complications* / Q000175:diagnosis; D012140:Respiratory Tract Diseases / Q000150:complications* / Q000175:diagnosis; D012189:Retrospective Studies; D013997:Time Factors; D001743:Urinary Bladder / Q000503:physiopathology*; D001745:Urinary Bladder Diseases / Q000150:complications* / Q000175:diagnosis; D014554:Urination / Q000502:physiology*
keywords: Bladder dysfunction; Comorbidities; Pediatric; Polysymptomatic enuresis