This study is another important contribution to our under-standing of the role of bladder-sphincter dysfunction in highgrade VUR in infants. In 1996 these authors reported uro-dynamic findings in 11 male infants with dilating VUR.1 In11 of the 17 refluxing ureters reflux was simultaneous withunstable detrusor contractions during the second half offilling. In 1998 Yeung et al reported 4 different abnormalurodynamic patterns in 24 infants with dilating reflux onnatural filling urodynamic studies.2 In 2 of 5 infants withinadequate bladder the bladder emptying dynamics changeddramatically toward a normal pattern after the bladder wasdrained. In 2004 Sjostrom et al found bladder dysfunctionand UTIs to be negative prognostic factors for spontaneousresolution of high grade reflux in infants (reference 2 inarticle). So it is disappointing to learn that treatment ofbladder-sphincter dysfunction and recurrent UTIs did notimprove the chance of spontaneous resolution of reflux inthese 20 patients.

One may speculate about the treatment or characteristicsof the population in this study. If the male infants demon-strated detrusor instability, as the males did in their previ-ous report, anticholinergic therapy in conjunction with CICmay have been better treatment. In the study by Koff andMurtagh of older children reflux resolution was attributed totreatment of detrusor instability with anticholinergic medi-cation (reference 4 in article). These 20 children treated withCIC had a more severe grade of reflux than the whole group,and 18 of the 20 had recurrent UTIs. They may representthe more severe end of the spectrum of dilating reflux andbladder-sphincter dysfunction. So the conclusion that CICdoes not help infant high grade reflux resolve in infantsbased on experience with these 20 patients and with nocontrol group may be an overgeneralization.

There were 2 encouraging results in this study. Even ininstances of severe dilating reflux, bladder-sphincter dys-function and recurrent UTIs the children had adequatebladder emptying during the toilet training years. Also, re-current breakthrough UTIs resolved with CIC or spontane-ously with age in most cases.

From an academic perspective it would be rewarding toknow if treatment of bladder-sphincter dysfunction couldhelp resolution of reflux. However, from a practical view onemust consider whether years of catheterizing the child every3 hours and 1 to 2 times during the night is preferable to

reimplantation surgery. Certainly, as these authors indi-cate, CIC may be useful in select instances of recurrentinfections in these infants until they are old enough to un-dergo reimplantation surgery.

Jean G. HollowellEastern Virginia School of Medicine

Norfolk, Virginia

1. Sillen U, Bachelard M, Hansson S, Hermansson G, Jacobson Band Hjalmas K: Video cystometric recording of dilating re-flux in infancy. J Urol 1996; 155: 1711.

2. Yeung CK, Godley ML, Dhillon HK, Duffy PG and Ransley PG:Urodynamic patterns in infants with normal lower urinarytracts or primary vesico-ureteric reflux. Br J Urol 1998; 81:461.

REPLY BY AUTHORS

We previously reported the urodynamic pattern in younginfants, showing overactivity during filling in more than60% (reference 1 in comment). We have also seen this uro-dynamic pattern change, with a decrease in overactivity,and an increase in bladder capacity and residual urine.1

Results describing the evolution of the urodynamic patternin the 20 children included in the present study and in theentire study group of 115 are presently under preparation.However, of the 20 children studied 60% had overactivityduring filling at age 1.5 months (at presentation), ie beforestarting CIC. At the age CIC was started (median 10months) 40% of the children had instability with a markedincrease in bladder capacity and residual urine. At the latestfollowup 30% of the patients had instability.

We did not consider overactivity as the most prominentproblem of the bladder dysfunction in these children, sincethe maximal pressure at contraction was low at followup,and because poor emptying was much more obvious. Weagree with Wan that the bladder dysfunction and reflux areprobably due to congenital abnormalities of insertion of theureter and bladder outlet and, thus, are different from thebladder dysfunction seen in older children concomitant withlower grades of reflux.

1. Sillén U, Bachelard M, Hermansson G and Hjälmås K: Grossbilateral reflux in infants: gradual decrease of initial detru-sor hypercontractility. J Urol 1996; 155: 668.

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