editorial comment

under voluntary control and can be affected with behavioralmodification.

A subset of patients with dysfunctional elimination presentwith an overactive bladder and when evaluated with a voidingcystourethrogram demonstrates a spinning-top urethra withbladder neck hypertrophy, a dilated urethra and evidence ofnarrowing at the external sphincter. These findings are thoughtto be due to a functional obstruction at the level of the externalsphincter causing increased intraurethral pressure and even-tual urethral dilatation. Therapies have all aimed at relaxingthe bladder and the external sphincter to allow more completeemptying. The addition of alpha blocker therapy could poten-tially act synergistically to facilitate relaxation of the bladderbase and proximal urethral sphincter, which may be a secondarea of functional obstruction due to chronic over stimulationand up-regulation of alpha receptors.15 This effect would poten-tially allow improved funneling of the bladder outlet duringvoiding, resulting in a more rapid improvement in bladderemptying.

Our study adds further support to the evidence suggestinga role for alpha adrenergic blockade therapy in children withincreased post-void residuals and an overactive bladder. Themedication has been proven to be safe in children, and resultsin rapid and significant improvement in bladder emptying.The addition of this therapy early in management has thepotential to eliminate the need for the more labor and time-intensive biofeedback in some patients. In refractory casesalpha blocker therapy may also still be useful as an adjunctto biofeedback therapy.

CONCLUSIONS

Selective alpha blocker therapy appears to be effective forimproving bladder emptying in pediatric patients presentingwith primary symptoms of overactive bladder, recurrent in-fection and increased post-void residual urine. This therapymay be used as either replacement for or in addition tobiofeedback in patients with urinary retention. Further in-vestigations, including randomized prospective trials, arewarranted to help define the role of alpha blocker therapy inchildren with urinary tract dysfunction.

REFERENCES

1. Combs, A. J., Glassberg, A. D., Gerdes, D. and Horowitz, M.:Biofeedback therapy for children with dysfunctional voiding.Urology, 52: 312, 1998

2. DePaepe, H., Hoebeke, P., Renson, C., Van Laeck, E., Raes, A.,Van Hoeke, E. et al: Pelvic-floor therapy in girls with daytimeincontinence and dysfunctionally voiding. Brit J Urol, 81: 109,1998

3. Wiener, J. S., Scales, M. T., Hampton, J., King, L. R., Surwit, R.and Edwards, C. L.: Long-term efficacy of simple behavioraltherapy for daytime wetting in children. J Urol, 164: 786, 2000

4. Herndon, C. D. A., Decambre, M. and McKenna, P. H.: Interac-tive computer games for treatment of pelvic floor dysfunction.J Urol, 166: 1893, 2001

5. Chin-Peuckert, L. and Pippi Salle, J. L.: A modified biofeedbackprogram for children with detrusor-sphincter dyssynergia: 5year experience. J Urol, 166: 1470, 2001

6. Austin, P. F., Homsy, Y. L., Masel, J. L., Cain, M. P., Casale, A. J.and Rink, R. C.: Alpha-adrenergic blockade in children withneuropathic and nonneuropathic voiding dysfunction. J Urol,162: 1064, 1999

7. Berger, R. M., Maizels, M., Moran, G. C., Conway, J. J. andFirlit, C. F.: Bladder capacity (ounces) equals age (years) plus2 predicts normal bladder capacity and aids in diagnosis ofabnormal voiding patterns. J Urol, 129: 347, 1983

8. van Gool, J. D., Vijverberg, M. A. and de Jong, T. P. V. M.:Functional daytime incontinence: clinical and urodynamic as-sessment. Scand J Urol Nephrol, suppl., 141: 58, 1992

9. Stockamp, K., Herrmann, H. and Schreiter, F.: Conservativebladder treatment in myelodysplasia. Urol Int, 31: 93, 1976

10. De Voogt, H. J. and Van Der Sluis, C.: Preliminary evaluation ofalpha-adrenergic blocking agents in children with neurogenicbladder due to myelomeningocele. Dev Med Child Neurol,suppl., 37: 82, 1976

11. Seiferth, J.: Types of neurogenic bladder in children with spinabifida, and response to treatment with phenoxybenzamine.Dev Med Child Neurol, suppl., 37: 94, 1976

12. Harrison, N. W., Whitfield, H. N. and Williams, D. I.: The placeof alpha-blocking drugs in the treatment of children withneuropathic bladders. Urol Int, 32: 224, 1977

13. Bradley, W. E., Rockswold, G. L., Timm, G. W. and Scott, F. B.:Neurology of micturition. J Urol, 115: 481, 1976

14. Restorick, J. M. and Mundy, A. R.: The density of cholinergic andalpha and beta adrenergic receptors in the normal and hyper-reflexic human detrusor. Br J Urol, 63: 32, 1989

15. Moore, C. K., Leendusky, M. and Longhurst, P. A.: Relationshipof mass of obstructed rat bladders and responsiveness to ad-renergic stimulation. J Urol, 168: 1621, 2002

EDITORIAL COMMENT

Voiding dysfunction is commonly encountered in daily practice. Itsetiology is multifactorial and consequently treatment must be mul-timodal with an emphasis placed on the dominant etiological factors.It is not surprising to see some patients respond to one form oftherapy to which others may be frustratingly resistant.

The authors studied a group of patients with voiding dysfunction.They presented with the usual symptoms of incontinence, urgencyand urinary tract infection. In addition all shared a high post-voidresidual urine (mean 22% of age expected capacity). Almost a thirdhad vesicoureteral reflux and half were constipated. PVR was re-duced to a mean of 2.7% of age expected capacity with alpha blockerswhile maintaining multimodal therapy including behavioral modifi-cation, anticholinergics and antibiotics as dictated by symptoms.Constipation was also treated. In addition to the statistically signif-icant reduction of PVR, diurnal incontinence and urgency also im-proved. No mention is made of the occurrence of further episodes ofurinary tract infection, reflux resolution or constipation status.

Although this study is a pilot and suffers from lack of randomiza-tion, it does make a strong case for advocating the use of alphablockers in the presence of increased PVR. Effective and rapid dim-inution was noted in the majority of patients and the medication waswell tolerated except in 2 patients.

The authors surmise that the up-regulation and increased tonicityof the proximal urethral sphincter may contribute to bladder over-activity. This theory is quite plausible if bladder neck overactivitymay be considered as an integral part of detrusor overactivity albeitunder the control of a different set of receptors. Although there areno alpha receptors in the external sphincter as such, they have beendemonstrated in its blood vessels. Vasospasm at the external sphinc-ter may stimulate it to contract. Thus, alpha blockers may also havean effect at the external sphincter level by improving its blood supplyand allowing it to relax. The same goal may be achieved with biofeed-back and pelvic floor rehabilitation, which however does not addressthe proximal urinary sphincter. The bottom line is that to achieveeffective voiding, a synergistic balance must be obtained between thedetrusor and both urinary sphincters. It appears from this study thatalpha blockers have a place of choice in achieving this goal.

The authors recognize that further documentation of precise mech-anisms and sites of action are necessary. Long-term safety in chil-dren must be established with alpha blockers as is the case withmany other medications. Meanwhile, this study opens the way to theuse of an additional effective therapeutic modality for the manage-ment of voiding dysfunction that is associated with incomplete void-ing. Used judiciously, this treatment may lead to a more rapid andeffective resolution of the retention component of voiding dysfunctionwhich may in turn reduce bladder overactivity and its associatedsymptoms.

Yves HomsyDepartment of SurgeryUniversity of South FloridaTampa, Florida

ALPHA BLOCKER THERAPY FOR DYSFUNCTIONAL VOIDING AND URINARY RETENTION1516