Incidence of Anatomic Abnormalities In Boys with Overactive Bladder Symptoms

Purpose: The evaluation and treatment of boys with symptoms of overactive bladder (OAB) is challenging, treatment approaches vary widely, and treatment outcomes are worse then in female patients.  Urodynamics and voiding cystourethrogram (VCUG) require conscious catheterization and may fail to identify anatomic abnormalities and delay appropriate therapy. We report our experience and outcomes with an alternative diagnostic algorithm for boys with OAB which combines noninvasive uroflowmetry studies and selective cystourethroscopy in patients with specific voiding patterns.

Methods: With local IRB approval a prospectively collected database of 2,702 children evaluated in our clinic for lower urinary tract dysfunction was queried for boys presenting with urinary urgency, urinary frequency, or dysuria. Hospital and clinic records were reviewed.  Data including age, presenting symtoms, results of diagnostic studies, surgical and medical therapies, and symtomatologic outcomes were analyzed. Symptomatologic outcomes were based upon patient or parent report and classified as resolved, improved, or unimproved.

Results: The SIU lower urinary tract dysfunction data base of 2,702 children was queried and yielded 349 boys evaluated for symptoms of OAB.  Evaluation with uroflowmetry prompted cystourethroscopy in 79/349 (22.6%).  One or more anatomic abnormalities were discovered and treated at the time of cystourethroscopy in 37 (46.8%) patients.  Posterior urethral valves (PUV) were present in 34 patients, PUV and anterior urethral valves in 1 patient, PUV and urethral duplication in 1 patient and urethral stricture in 1 patient.  Thirty-four of 37 (92%) patients with a surgically correctable anatomic abnormality followed up at least once postoperatively.  At a mean follow-up of 14.9 months (range 1.0 to 63), symptoms had resolved in 15/34 (42.8%).  Fifteen patients (45.7%) were classified as improved.  Four of 34 (11.8%) patients were unimproved.  Twenty-two of 34 (64.7%) patients with at least one postoperative evaluation also had postoperative uroflowmetry.  Among these 22 patients, mean peak flow rate increased by 42.2%(p=0.002), mean average flow rate increased by 44.4%(p=0.0002), mean voiding time decreased by 32.2%(p=0.04), and post-void residual volume decreased by 46.7.7%(p=0.06) compared to preoperative values.

Conclusions:  46.8% of boys with symptoms of overactive bladder evaluated with cystoscopy were found to have one or more anatomic abnormality.  This approach avoids conscious catheterization and identifies and treats the significant number of anatomic abnormalities in a timely fashion.  Initiating medical treatment without excluding anatomic abnormalities may contribute to the historically high rate of treatment failure in this group.