Spontaneous bladder rupture secondary to posterior urethral valves in a boy with Down syndrome

We describe a case of a 3-year-old boy with Down syndrome who developed a bladder rupture as a consequence of an undiagnosed posterior urethral valve (PUV). He had a history of urinary tract infections and constipation and was acutely admitted in poor condition and underwent laparotomy that revealed peritoneal sepsis secondary to bladder perforation. Bladder was drained using a suprapubic catheter and the condition of the boy gradually improved. Once stable, a cystourethroscopy confirmed the presence of PUV. Video-urodynamic studies performed at the check cystoscopy showed the bladder to be of reduced compliance (end fill pressure at 100 mL fill 30 cmH2O) with raised voiding pressures (76–100 cmH2O) and significant incomplete bladder emptying. Currently, the patient is doing very well, serum creatinine has normalised, he is infection-free and thriving; his bladder is managed with a vesicostomy.

Clean Intermittent Self-Catheterization in the Treatment of Urinary Tract Disease

This chapter summarizes the landmark experience of introducing clean intermittent catherization in a small case series of pediatric and adult patients with incomplete bladder emptying due to various etiologies. Patients were taught to self-catheterize themselves after having washed their hands, or their mothers were instructed to do so. All adult patients reported that control of their urinary difficulties helped them return to “live a normal, happy life.” The pediatric patients remained afebrile and continent, without urinary tract infections during the study period. Most adult patients also remained free from urinary tract infections during the study period. This study demonstrated the safety and efficacy of a clean, non-sterile approach to intermittent catheterization.

Intravesical Botox for Overactive Bladder: How to Minimize Complications and Manage Failures

Intravesical Botox has become a widespread treatment for patients with refractory overactive bladder. Further to its acknowledged efficacy, both physicians and patients must be fully aware of possible complications, such as urinary tract infections, incomplete bladder emptying or even urinary retention and the possible need for intermittent self-catheterizations, fatigue, muscle weakness, transient hematuria and autonomic dysreflexia. Careful patient selection, particularly in terms of comorbidities, caution with technical aspects of the procedure such as the use of fine specifically designed injection needles, treatment of baseline UTIs or bacteriuria and avoidance of bladder overfilling could be the main measures, in addition to rigorous patient follow-up, to minimize the risk of post-Botox UTIs, hematuria, autonomic dysreflexia, and retention. Management of Botox failures is currently an unchartered area, starting with the definition of failure per se. Nevertheless, dose increase, particularly in neurogenic patients, increase of treatment frequency, switch to abobotulinumtoxinA, prolongation of injection intervals with add-on oral therapy, use of percutaneous tibial nerve stimulation or sacral neuromodulation and alleviation of risk factors for failure such as UTIs may be part of the management algorithm for Botox failures. As there is little evidence base to support such proposals and as the use of intravesical Botox is increasingly becoming a part of common urological practice, further research into the field of Botox failures and complications is needed so that both physicians and patients are granted with more solid, viable options.

Pseudodiverticulum: A rare late complication of the Boari flap procedure for lower ureteric repair

The Boari bladder flap is a vital tool in the armamentarium of the urologist. It is used to maintain continuity of the urinary system when dealing with diseased segments of the mid and lower ureter. It is, however, associated with long-term complications. We present the case of a 46-year-old woman who developed a rare pseudodiverticulum as a consequence of the procedure. This patient had undergone a right-sided laparoscopic Boari bladder flap for a right distal ureteric stricture secondary to pelvic endometriosis, and presented 10 years later at our urology department with long-standing irritative voiding symptoms and a feeling of incomplete voiding. Radiological and endoscopic investigation revealed the presence of a capacious pseudodiverticulum which was seen on ultrasound to retain a significant amount of urine post micturition and then to empty back into her bladder, strongly suggesting that this was the cause of her sensation of incomplete bladder emptying. She had minimal symptom bother and no recurrent urinary tract infections, calculi or tumour, and it was decided that no further operative management was necessary and that her condition could be managed her conservatively. To the best of our knowledge, this is only the second case describing this rare, long-term complication of a Boari flap. Level of evidence: Level 5.

Clinical Factors Associated With the Feeling of Incomplete Bladder Emptying in Women With Little Postvoided Residue

Purpose: To investigate the clinical factors associated with the feeling of incomplete bladder emptying in female patients with lower urinary tract symptoms (LUTS).Methods: Records were obtained from a prospectively maintained database for 353 female patients without a history of treatment for LUTS. Patients with comorbidities that may affect voiding function and with postvoid residual (PVR) volume >20 mL or PVR volume-to-bladder capacity ratio of >10% were excluded. Finally, 211 patients were eligible for the study.Results: Patients were stratified according to the severity of the feeling of incomplete emptying: non-severe group (n=147, 69.7%) and severe group (n=64, 30.3%). The severe group showed longer time to maximum flow rate (Qmax) and greater total overactive bladder symptom score (OABSS). No differences in age, PVR volume, and diagnosis of overactive bladder (OAB) were found between the 2 severity groups. Multivariable analysis identified the severity of the feeling of incomplete emptying to be significantly associated with time to Qmax and minimum volume of voids. Time to Qmax was identified as a significant predictor of severe symptoms in women with OAB. In addition, the feeling of incomplete emptying, total OABSS, and minimum volume of voids were significantly associated with quality of life.Conclusions: Female patients with the feeling of incomplete emptying who have insignificant PVR volume exhibited severe voiding symptoms and low quality of life. The treatment strategy should be focused on improving the minimum volume of voids and shortening the time to Qmax.