Biomedical subjects

A J Combs

Publications and source records attributed to A J Combs.

10 recordsLinked to original sources

PubMed1998

Biofeedback therapy for children with dysfunctional voiding.

OBJECTIVES: Biofeedback therapy has been recognized as a treatment option for children with classic dysfunctional voiding (DV) where there is inadequate pelvic floor relaxation during voiding. However, there are few articles that discuss methodology and limited sites where it is available. In the hope of making biofeedback a more practical and accessible option, we report our indications, easy to duplicate methodology, and results. METHODS: Twenty-one consecutive children diagnosed with DV refractory to standard therapy were enrolled in our biofeedback program. Therapy consisted of extensive age-appropriate explanations of DV and demonstrations of normal and abnormal voiding patterns. Cyclic uroflow studies with pelvic floor electromyography are performed, which the child monitors on analog chart and audio recorders. The child returns weekly until consistent relaxation of the pelvic floor during voiding is demonstrated. Timing between sessions is then increased to monitor progress and retention of concepts previously taught. RESULTS: An excellent clinical response was one in which there was consistent relaxation of the pelvic floor throughout voiding, normal flow pattern, and no residual urine volume (urodynamic response), coupled with profound resolution of voiding symptoms. Seventeen of 21 (81%) had an excellent response, 3 (14%) had a fair response, and 1 (5%) was too inconsistent to rate. The average number of sessions to achieve a consistent urodynamic response was 3.7 (range 2 to 14) and full clinical response somewhat longer. Average follow-up since beginning therapy has been 34 months (range 14 to 51). CONCLUSIONS: Biofeedback therapy is an effective method for treating DV with poor pelvic floor relaxation. Although initially labor intensive, it yields sustained positive results in most patients in a short time.

Adolescent↗

PubMed1997

Desmopressin for nocturnal incontinence in the spina bifida population.

PURPOSE: We report our experience with the use of desmopressin in the spina bifida population that is dry during the day but wet at night. MATERIALS AND METHODS: From 1994 to 1996, 18 patients with myelodysplasia were treated with desmopressin for persistent nocturnal enuresis. Initial dose was 40 mcg. before bedtime, decreased by intervals of 10 mcg. every 3 weeks. Patients were kept on the minimum dose required to keep them dry. We reviewed morning catheterized volumes, side effects and dosages needed to stay dry, and compared augmented patients with nonaugmented patients. RESULTS: Of 18 patients 14 (78%) reported marked improvement in nocturnal enuresis. Of 6 augmented patients 5 (83%) are dry compared to 9 of 12 nonaugmented patients (75%). There were no adverse side effects from the use of desmopressin. Average dose to stay dry was 20 mcg. for augmented and 30 mcg. for nonaugmented patients. Of the 4 patients who had persistent nocturnal incontinence despite desmopressin 3 (75%) became dry with a single catheterization in the middle of the night. CONCLUSIONS: Desmopressin is successful in treating nocturnal enuresis in the spina bifida patient with diurnal continence.

Adolescent↗

PubMed1997

The management of unilateral poorly functioning kidneys in patients with posterior urethral valves.

PURPOSE: There is no uniform agreement on how to manage the unilateral nonfunctioning or poorly functioning kidney associated with posterior urethral valves. We studied the results of treatment of our patients to make recommendations regarding management of these kidneys. MATERIALS AND METHODS: We reviewed the records of 13 boys with a history of posterior urethral valves and a unilateral nonfunctioning or poorly functioning kidney, defined as less than 10% of total renal function on 99mtechnetium dimercapto-succinic acid renal scans. Variables investigated included pyelonephritis, hypertension, vesicoureteral reflux, nephroureterectomy, ureteral reimplantation and spontaneous cessation of reflux. We also evaluated how the management of abnormal urodynamic parameters influenced the results of reimplantation or medically induced cessation of reflux. RESULTS: Three of the 6 boys with grade 5 reflux ipsilateral to the poorly functioning kidney required nephroureterectomy at a mean age of 21 months because of recurrent urinary tract infections. Another 4 boys underwent successful ureteral reimplantation, including 2 who had bilateral grade 5 reflux, and 2 who had ipsilateral grade 4 reflux, and grade 3 (1) and grade 2 (1) contralateral reflux. Of 4 boys ipsilateral grade 3 reflux in 3 and bilateral grade 5 reflux in 1 disappeared without surgery after treatment of urodynamic abnormalities. Two patients with poorly functioning kidneys and no reflux did not undergo surgery. Overall 10 of the 13 poorly functioning renal units were not removed, and these patients were free of pyelonephritis and hypertension. Ureteral reimplantation (4 ipsilateral and 3 contralateral) was performed only after urodynamic abnormalities were addressed. All reimplantations were successful. CONCLUSIONS: Based on our results we believed that unilateral poorly functioning kidneys in patients with posterior urethral valves can be safely preserved in select patients without hypertension and pyelonephritis. Reimplantation to correct reflux may be preferable to nephroureterectomy in specific situations, such as when contralateral function is suboptimal and the contralateral ureter needs reimplantation. When indicated, reimplantation can be performed successfully if abnormal urodynamic parameters are addressed preoperatively. In fact, treating abnormal urodynamic findings may lead to spontaneous reflux resolution.

Adolescent↗

PubMed1997

Management of posterior urethral valves on the basis of urodynamic findings.

PURPOSE: Abnormal urodynamic findings are common in boys with a history of posterior urethral valves. However, to our knowledge there are few reports on the results of treating these abnormal findings. We analyzed the treatment of abnormal urodynamic parameters and its outcome in 21 boys who underwent valve ablation. MATERIALS AND METHODS: After valve ablation multichannel urodynamic studies were performed in 31 boys, including 21 in whom studies were done before and after therapy was started for abnormal parameters. Detrusor instability and impaired bladder compliance were treated with anticholinergics or augmentation cystoplasty, and impaired detrusor contractility was managed with clean intermittent catheterization. RESULTS: Before therapy 17 of 21 boys had impaired compliance and detrusor instability, 2 had impaired compliance without instability and 2 had instability alone. After treatment 8 boys had impaired compliance and 4 had detrusor instability. After anticholinergics were initiated new onset myogenic failure in 2 boys necessitated clean intermittent catheterization. Of the 13 patients who presented with urinary incontinence 10 became dry and 3 had improvement with therapy. Vesicoureteral reflux in 10 boys at the time of the initial urodynamic study resolved in 7 with anticholinergic medication and in 1 after clean intermittent catheterization was begun for severely impaired compliance. All 21 boys were treated with anticholinergics and 2 were ultimately treated with augmentation cystoplasty. Clean intermittent catheterization was also instituted in 5 patients, including the 2 who required clean intermittent catheterization after myogenic failure developed. Five boys with high voiding pressures were found to have outlet obstruction due to residual valve tissue in 2, bladder neck obstruction in 2 and urethral stricture in 1 despite normal flow rates in 2. CONCLUSIONS: Urodynamic studies are helpful in guiding therapy in boys after valve ablation. Anticholinergic therapy can improve compliance, decrease detrusor instability, improve continence and eliminate vesicoureteral reflux in the majority of boys, although there is an associated risk of myogenic failure. Flow rates and fluoroscopic voiding studies are often unable to detect outlet obstruction and must be obtained in conjunction with voiding pressure measurements to make this diagnosis.

Follow-Up Studies↗

PubMed1997

Voiding dysfunction following transurethral resection of the prostate: symptoms and urodynamic findings.

PURPOSE: Persistent voiding dysfunction following transurethral resection of the prostate is not uncommon. We determined the correlation, if any, between the subjective complaints in men with voiding dysfunction after transurethral resection of the prostate and the urodynamic findings. MATERIALS AND METHODS: A total of 50 consecutive men with voiding dysfunction following transurethral resection of the prostate was evaluated with the American Urological Association symptom index and multichannel urodynamics. Patients with urethral stricture, urinary retention or prostate cancer were excluded from the study. Urodynamic parameters assessed included detrusor instability, bladder capacity, sphincteric insufficiency using the Valsalva leak point pressure, voiding pressure-flow studies as determined by the Abrams-Griffiths nomogram (obstructed, unobstructed or equivocal) and post-void residual. RESULTS: Mean patient age was 71 years and mean interval from last transurethral resection of the prostate was 58 months (range 2 to 252). Mean total, obstructive and irritative symptom scores were 16.3, 5.8 and 10.5, respectively. A total of 20 patients (40%) complained of incontinence (14 urge and 6 stress). According to the Abrams-Griffiths nomogram 62% of the cases were unobstructed, 16% obstructed and 22% equivocal. Urodynamic abnormalities were demonstrated in 43 patients (86%), and included detrusor instability (54%), obstruction with or without detrusor instability (16%), sphincteric insufficiency (8%), detrusor hypocontractility (4%) and sensory urgency (4%). There was no difference in the total, irritative or obstructive scores among obstructed, unobstructed or equivocal cases. Similarly there was no difference in scores among patients with and without detrusor instability. Age, number of transurethral resections and interval since last transurethral resection were unrelated to pressure-flow results or detrusor instability. Post-void residual was significantly greater in obstructed cases and bladder capacity was significantly less in those with detrusor instability. The cause of incontinence was demonstrated in 19 of 20 patients (95%): 4 (20%) had sphincteric insufficiency and 15 (75%) had detrusor instability. CONCLUSIONS: Symptoms are unreliable in predicting urodynamic findings with respect to obstruction and detrusor instability. There is a high incidence of detrusor instability in patients with voiding dysfunction after transurethral resection of the prostate. Urodynamic obstruction is a less likely occurrence.

Aged↗

PubMed1996

A new technique for assessing detrusor leak point pressure in patients with spina bifida.

PURPOSE: We report a new modification of the technique used to measure detrusor leak point pressure in patients with myelodysplasia and discuss its clinical implications. MATERIALS AND METHODS: We assessed detrusor leak point pressure during standard multichannel urodynamics in 77 patients with spina bifida. At leakage and in the absence of a detrusor contraction detrusor pressure is noted and the catheter is removed. With the cessation of leakage the catheter is reinserted and detrusor pressure is again noted. This cycle is repeated several times and the average difference is noted. In 23 patients there was no identifiable detrusor leak point pressure. The remaining 54 patients with a detrusor leak point pressure are included in this report. Also reviewed were renal ultrasound studies and voiding cystourethrograms for each patient. RESULTS: Three groups of patients were identified: 1 (20 patients)-detrusor leak point pressure greater than 40 and less than 40 cm. water with the catheter in and out, respectively; 2 (29)-detrusor leak point pressure consistently less than 40 cm. water with the catheter in and out, and 3 (5)-detrusor leak point pressure consistently greater than 40 cm. water with the catheter in and out. There was a 5% incidence of upper tract changes in group 1 and a 40% incidence in group 3. All patients in group 2 had normal upper tracts. CONCLUSIONS: A difference in upper tract changes was noted between groups 1 and 3, although in both groups detrusor leak point pressure was greater than 40 cm. water using standard measurement techniques and similar rates of upper tract changes would have been expected. Our modification may be a more accurate measurement of detrusor leak point pressure. It provides a better means of identifying patients at increased risk for renal deterioration and assessing outlet resistance.

Child↗

PubMed1996

The role of urodynamics in the evaluation of voiding dysfunction in men after cerebrovascular accident.

PURPOSE: The etiology of voiding dysfunction was determined in men after a cerebrovascular accident who were at risk for obstructive uropathy to evaluate whether the cause of voiding dysfunction could be predicted by the type (obstructive or irritative) or onset of symptoms. MATERIALS AND METHODS: We evaluated 38 men with complaints of voiding dysfunction following a cerebrovascular accident. All patients were of the age when bladder outlet obstruction secondary to benign prostatic hyperplasia would otherwise be prevalent. After a comprehensive history and physical examination, all patients underwent multichannel urodynamic studies at a medium fill rate (20 to 50 ml. per minute). Findings were classified by the Abrams-Griffiths nomogram as obstruction, no obstruction or equivocal. RESULTS: Mean patient age was 70 years (range 54 to 87). Patients were grouped according to the presenting voiding complaints (purely irritative in 42%, purely obstructive in 34% or mixed in 24%). In 34 patients (89%) the onset of symptoms paralleled the occurrence of the cerebrovascular accident. Detrusor hyperreflexia was noted in 82% of the patients. There was no statistically significant difference in the occurrence of detrusor hyperreflexia among the 3 symptom groups (Fisher's exact test). Pressure-flow analysis clearly showed obstruction in 24 patients (63%), no obstruction in 9 (24%) and equivocal results in 5 (13%) according to the nomogram. There was no statistically significant difference in the incidence of obstruction among the 3 symptom groups (Fisher's exact test). CONCLUSIONS: Presenting symptoms did not predict the urodynamic findings of bladder outlet obstruction or detrusor hyperreflexia. The significant incidence of onset of symptoms after stroke suggests that the cerebrovascular accident induced voiding dysfunction in the face of preexisting bladder outlet obstruction may exacerbate the symptoms of the latter condition or vice versa.

Aged↗

PubMed1996

Correlation of Valsalva leak point pressure with subjective degree of stress urinary incontinence in women.

PURPOSE: We correlated symptoms of stress urinary incontinence in women with intrinsic urethral function, as measured by Valsalva leak point pressure. In addition, we assessed the effects of urethral hypermobility, baseline resting abdominal pressure, patient age and menopausal status on Valsalva leak point pressure. MATERIALS AND METHODS: We evaluated 64 consecutive women (mean age 50 years, range 20 to 79) with complaints of stress urinary incontinence. Initially the patient history was obtained and the subjective degree of stress urinary incontinence was graded as 1, 2 or 3 according to the SEAPI-QMN classification. Multichannel video urodynamics were then performed. At a volume of 150 to 200 ml. (or half bladder capacity when functional capacity was less than 150 ml.) filling was stopped. Resting, coughing and progressive Valsalva maneuvers were performed to determine Valsalva leak point pressure and the presence of urethral hypermobility. Valsalva leak point pressure was defined as the minimum total vesical pressure required to cause urinary incontinence in the absence of a detrusor contraction. Urodynamics were completed and detrusor instability or stress induced instability was noted. RESULTS: Of the 64 women 52 (81.3%) had stress urinary incontinence. The exact test for trend demonstrated a statistically significant difference in the number of patients with a Valsalva leak point pressure of 90 cm. water or less (p = 0.0002) and 60 cm. water or less (p = 0.0002) among the 3 symptom groups. There was no correlation between Valsalva leak point pressure and resting vesical (which equals abdominal) pressure, patient age or menopausal status, or urge incontinence or detrusor instability among the 3 groups. CONCLUSIONS: The subjective degree of stress urinary incontinence can predict intrinsic urethral function as measured by Valsalva leak point pressure. Higher grades of stress urinary incontinence have a higher likelihood of a low Valsalva leak point pressure. Many women with grade 2 or 3 stress urinary incontinence have a Valsalva leak point pressure of 90 cm. water or less despite urethral hypermobility and they may have a component of intrinsic urethral deficiency.

Age Factors↗

PubMed1995

Significance of rectal contractions noted on multichannel urodynamics.

Independent rectal contractions are frequently noted when performing multichannel urodynamics and are often considered to be artifactual. In an effort to determine if this activity is indeed significant, we reviewed 430 consecutive multichannel urodynamic studies performed on 289 patients. All studies were performed using an analog recorder at 0.5 mm/sec paper speed. Multichannel pressures included total vesical pressure measured by a urethral catheter, total abdominal pressure measured by a rectal balloon catheter, subtracted detrusor pressure (vesical minus abdominal), and uroflow measurement when possible. Rectal contractions were defined as multiple fluctuations in abdominal pressure as measured by the rectal balloon catheter which were independent of changes in total vesical pressure. These fluctuations could not be reproduced by abdominal stressing or Kegel-type maneuvers. Contractions were noted to be of high or low amplitude, continuous or intermittent. Of the 289 patients, 109 (38%) had a study positive for rectal contractions. Similarly, 168 of 430 studies (38%) were positive. In patients with neurologic disease, rectal contractions were noted in 61/120 (51%). In patients with no history of neurologic disease, 48/169 (29%) had rectal contractions (P < 0.001). Furthermore, when patients without a history of neurologic disease were evaluated with respect to the presence of detrusor instability, a positive study was noted in 27/67 (40%) with instability but in only 21/102 (21%) of patients without instability (P = 0.005). Rectal contractions also occurred with a higher frequency in patients with bladder hyperactivity of any etiology.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1994

Correlation of the AUA symptom index with urodynamics in patients with suspected benign prostatic hyperplasia.

The AUA symptom index is widely used to access patients with suspected benign prostatic hyperplasia (BPH). In order to determine how well symptoms as assessed by this index correlate with urodynamic findings, we evaluated 83 patients referred to our urology clinics with symptoms of BPH. All patients completed the AUA symptom index and then underwent a multichannel urodynamic evaluation. Patients were classified as obstructed, unobstructed, or equivocal according to the Abrams Griffiths nomogram. The AUA symptom index was recorded as the total score and, for purposes of symptom classification, further subdivided into an obstructive score (questions 3, 5, and 6) and an irritative score (questions 1, 2, 4, and 7). The mean age of the 83 patients was 67 (45-84). The mean total AUA symptom score was 16.6 (6-34), mean obstructive score was 6.1 (0-15), and the mean irritative score 10.4 (3-20). Pressure flow analysis using the Abrams-Griffiths nomogram classified 28 patients (34%) as obstructed, 17 (20%) as unobstructed, and 38 (46%) as equivocal. Using the analysis of variance procedure (ANOVA) there was no statistically significant difference in the mean total (P = 0.446), obstructive (P = 0.979), or irritative (P = 0.136) scores. Detrusor instability was present in 45 patients (54%). While total and obstructive scores were not significantly different in patients with detrusor instability vs. those with stable bladders, irritative scores were higher in patients with instability (P = 0.028) using the T-test procedure. Using ANOVA, the difference in post void residual (PVR) between the groups was not quite statistically significant (P = 0.057).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗