Case stuart bauer tuesday

Case Studies
Stuart B. Bauer, MD
President, ICCS
Department of Urology
Children’s Hospital Boston
Case #1
O.D.: 4 y/o female with episodic day & night wetting,
Recurrent UTI, controlled with antibiotics
fecal soiling practically every day despite bowel program
PE – normal CNS, upper + lower extremities
low gluteal cleft
Case #1
O.D.: Urodynamics revealed:
Small capacity poorly compliant bladder w DO
Started CIC + Tx with oxybutynin + rotating Abx
Became dry + no UTIs
CMG g h capacity + markedly improved compliance
Case #2
H.C.: 4½ y/o boy - normal birth & development
Toilet trained easily age 2
Age 3½ yrs - mild scoliosis noted & left foot turned in
Age 4 - day frequency + occasional enuresis which
progressed to almost nightly within 6 mos.
BM’s daily (type IV [BSFS]) and no soiling
Referred to orthopedist d/t progressive L foot weakness
Next steps?
PE revealed spinal abn + subtle mass L side lumbar spine
Hyperactive LE deep tendon reflexes, nl anus, nl perineal
sensation, pes cavus L foot
Further work-up?
MRI of spine
Urodynamic testing prior to potential spinal surgery
Case #2
Case #2
Case #2
Case #3
J.G.: 7 y/o boy w 1o NMNE + day wetting since toilet training
Wet every night – never a dry night
Day wetting several times per day – damp underwear
BM’s daily, Type 3 & 4 BSFS
No past history of UTI
Next steps?
PE: normal spine
Urine C/S & UA: negative, nl [no sugar, nl sp.gr.]
Time voiding schedule helped a little but still wet frequently
Further testing versus instituting treatment?
If Rx what would be your approach?
If further W/U, what tests would you order now?
Case #3
US - Kidneys OK. PVR = 12 mls
Bladder wall somewhat thickened
Uroflowmetry – normal flow, but prolonged. PVR = 3 mls
Urodynamic testing
Case #3
Urodynamic testing:
Small capacity (for
age)
Good compliance
Marked DO
h voiding pressure
Case #3
Next step?
VCUG
Case #4
O.M.: 14 y/o girl w myelodysplasia w L4 neurologic level
wet daily on CIC and various anticholinergics
tried ditropan and detrol without success + SE
(dry mouth mental changes)
CMG – 109 cc cap. Bladder
with early rise in pressure,
LPP = 45 cm H2O
Sphincter EMG (not shown)
partial denervation w/o
reflexes but activity h with
filling
Case #4
O.M.: Next Steps?
Alternative anticholinergics?
Augmentation cystoplasty?
Botulinum toxin into the bladder wall
CMG – improved capacity
bladder (221 cc) with later
h in pressure at 190 cc
LPP - no Δ (45 cm H2O)
Clinically – immediate
improvement in dryness;
by 2 3 weeks completely dry
between CIC, day + night