van Gool Jan D, de Jong Tom P V M, Winkler-Seinstra Pauline, Tamminen-Möbius Tytti, Lax Hildegard, Hirche Herbert, Nijman Rien J M, Hjälmås Kelm, Jodal Ulf, Bachmann Hannsjörg, Hoebeke Piet, Walle Johan Vande, Misselwitz Joachim, John Ulrike, Bael An
Institute for Medical Informatics, Biometry and Epidemiology, Essen-Duisburg University, Essen, Germany; Pediatric Renal Center, WKZ/UMC, Utrecht, The Netherlands.
Neurourol Urodyn. 2014 Jun;33(5):482-7. doi: 10.1002/nau.22446. Epub 2013 Jun 15.
Functional urinary incontinence causes considerable morbidity in 8.4% of school-age children, mainly girls. To compare oxybutynin, placebo, and bladder training in overactive bladder (OAB), and cognitive treatment and pelvic floor training in dysfunctional voiding (DV), a multi-center controlled trial was designed, the European Bladder Dysfunction Study.
Seventy girls and 27 boys with clinically diagnosed OAB and urge incontinence were randomly allocated to placebo, oxybutynin, or bladder training (branch I), and 89 girls and 16 boys with clinically diagnosed DV to either cognitive treatment or pelvic floor training (branch II). All children received standardized cognitive treatment, to which these interventions were added. The main outcome variable was daytime incontinence with/without urinary tract infections. Urodynamic studies were performed before and after treatment.
In branch I, the 15% full response evolved to cure rates of 39% for placebo, 43% for oxybutynin, and 44% for bladder training. In branch II, the 25% full response evolved to cure rates of 52% for controls and 49% for pelvic floor training. Before treatment, detrusor overactivity (OAB) or pelvic floor overactivity (DV) did not correlate with the clinical diagnosis. After treatment these urodynamic patterns occurred de novo in at least 20%.
The mismatch between urodynamic patterns and clinical symptoms explains why cognitive treatment was the key to success, not the added interventions. Unpredictable changes in urodynamic patterns over time, the response to cognitive treatment, and the gender-specific prevalence suggest social stress might be a cause for the symptoms, mediated by corticotropin-releasing factor signaling pathways.
功能性尿失禁在8.4%的学龄儿童中导致相当高的发病率，主要是女孩。为比较奥昔布宁、安慰剂以及膀胱训练治疗膀胱过度活动症（OAB），以及认知治疗和盆底训练治疗排尿功能障碍（DV），设计了一项多中心对照试验，即欧洲膀胱功能障碍研究。
70名女孩和27名经临床诊断为OAB和急迫性尿失禁的男孩被随机分配至安慰剂组、奥昔布宁组或膀胱训练组（第一组），89名女孩和16名经临床诊断为DV的男孩被随机分配至认知治疗组或盆底训练组（第二组）。所有儿童均接受标准化认知治疗，并在此基础上增加上述干预措施。主要结局变量为伴有或不伴有尿路感染的日间尿失禁情况。治疗前后均进行了尿动力学研究。
在第一组中，15%的完全缓解率发展为安慰剂组治愈率39%、奥昔布宁组治愈率43%、膀胱训练组治愈率44%。在第二组中，25%的完全缓解率发展为对照组治愈率52%、盆底训练组治愈率49%。治疗前，逼尿肌过度活动（OAB）或盆底肌过度活动（DV）与临床诊断不相关。治疗后，这些尿动力学模式至少在20%的患者中重新出现。
尿动力学模式与临床症状之间的不匹配解释了为何认知治疗是成功的关键，而非附加干预措施。尿动力学模式随时间的不可预测变化、对认知治疗的反应以及特定性别的患病率表明，社会压力可能是由促肾上腺皮质激素释放因子信号通路介导的症状原因。
