THE DYSFUNCTIONAL 'LAZY' BLADDER SYNDROMEIN CHILDREN*

BY

FRANK G. DELUCA, ORVAR SWENSONt, JOHN H. FISHER and ADEL H. LOUTFIFrom the Boston Floating Hospital for Infants and Children, Boston, Massachusetts

The dysfunctional 'lazy' bladder syndrome is oneof the common causes of recurrent urinary tractinfections in children. A complete urologicalwork-up in patients with this syndrome fails toidentify underlying obstructive or neurologicallesions. In a series of 114 cases where the bladderpathology was the main feature, 84 had the dys-functional 'lazy' type of bladder, 12 had cordbladders, and 18 had demonstrable obstructivelesions. The detailed study of these patients andtheir follow-up, particularly from the physiologicalstandpoint, has resulted in a better understandingof the pathogenetic mechanism.The dysfunctional 'lazy' bladder occurred pre-

valently between 2 and 6 years of age and was twiceas common in females as in males. Diagnosis wasusually made late with an average delay of 18 months,probably as a result of minimal urinary tractsymptoms. More than half of the cases initiallypresented with fever of unknown origin, and in anumber of these patients, abdominal pain, nauseaand vomiting were associated symptoms. Theywere treated before admission to the hospitalwith antibiotics on repeated occasions withouta urological cause being suspected. Some patientswere referred to the hospital because ofan abdominalmass which subsequently proved to be an enlargedbladder. Symptoms referable to the urinary tract,when they did occur, varied from infrequent voidingto incontinence and occasionally frequency. Over80% of the patients received one or more courses ofantibiotics before the diagnosis was established.The bladder was palpable in the majority of cases;the kidneys were rarely palpable. No patientpresented with uraemia.

Urine analysis on admission to the BostonFloating Hospital for Infants and Children showedgross pyuria, and the culture indicated significantinfection. The most prevalent organism wasEscherichia coli in about 70% of the cases, 12% of

* A paper read at meeting of the British Association of PaediatricSurgeons in Stockholm, September 1961.

t The Children's Memorial Hospital, Chicago, Illinois.

which were resistant to the commonly used anti-biotics, such as penicillin, streptomycin, tetracyclineand chloramphenicol. The other organisms cul-tured, Proteus vulgaris, Aerobacter aerogenes andPseudomonas, were usually encountered in patientstreated with several courses of antimicrobial agents.They probably represented a super infection and wereresistant in many cases to most antimicrobial agents.

Post-voiding catheterization commonly demon-strated a residual urine which ranged from 30 to200 ml., and this finding was also confirmed by post-voiding cystograms. It should be emphasized thatthe presence of vesico-ureteral reflux may give afalse estimation of the volume of residual urine.This is due to the fact that, after voiding, the urinewhich refluxes into the ureters returns into thebladder. The bladder on cystography was usuallysmooth in contour and enlarged, and ureteral refluxcould be seen (Fig. 1). Occasionally, in early cases,reflux was observed only during micturition.Varying degrees of vesico-ureteral reflux occurredbilaterally in 40 patients and unilaterally in 24patients. Cystoscopic examination revealed a nor-mal bladder neck and rarely trabeculation. In 51patients with reflux, the ureteral orifices were wideand gaping; in 13 they appeared normal. Excretoryurography usually showed hydronephrosis andhydro-ureters (Fig. 2).The function of the dilated ureters was evaluated

by measuring their peristalsis manimetrically. Manycases demonstrated decreased amplitude and fre-quency of peristalsis, while some ureters showedineffectual peristalsis occurring particularly whenthere was severe active infection and reflux. Insome of these patients normal peristaltic activityreturned after treatment.The cystometrographic studies using a Statham

transducer and a polygraph were of particularinterest because of their characteristic abnormalpattern. A normal cystometrogram was charac-terized by occasional small contractions and bya gradual elevation of intravesical pressure whichinitiated involuntary bladder contractions on reach-

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FIG. 1.-Cystogram demonstrating bilateral vesico-ureteral refluxas well as bilateral hydro-ureters and hydronephrosis.

FIG. 2.-Excretory urogram showing hydronephrosis andhydro-ureters.

ing approximately 15 to 20 cm. of water pressure.If the patient did not respond to the urge to void,the contractions disappeared and the intravesicalpressure decreased temporarily to rise again gradu-ally to the previous level at which involuntarycontractions appeared. This phase is attributed tothe ability of the bladder to adapt itself when thestimulus of emptying is ignored (Fig. 3). By con-trast, in the dysfunctional 'lazy' bladder syndrome,the cystometrogram showed a gradual elevation ofthe intravesical pressure beyond the physiologicallimits which normally initiate involuntary bladdercontractions. On further filling, partially effectiveinvoluntary contractions coinciding with the patient'surge to void could be obtained in early cases. Atthis point, by requesting the patient to strain,thereby increasing the intra-abdominal pressure, thecomplete emptying of the bladder was usuallyachieved (Fig. 4a). On the other hand, if the patientdid not respond to the urge to void, the contractionsdisappeared and the intravesical pressure decreasedtemporarily to rise again with the possible appear-ance of less effective involuntary contractions andthe urge to void. This phenomenon of adaptationpartially simulates the one occurring in the normalbladder. It is necessary to emphasize that a cysto-metrogram was considered reliable only whenvesico-ureteral reflux was absent or occurred atelevated bladder pressures. The cystometrogramof the dysfunctional 'lazy' bladder syndrome mayvary from one characterized by a gradual elevation ofintravesical pressure beyond physiological limitswith partially effective involuntary bladder con-tractions to one with no involuntary contractions(Fig. 4b).

It should be noted that the cystometrogram ofthe dysfunctional bladder differs from the oneassociated with peripheral lesions of the para-sympathetic system of the bladder. In the latterlesions the bladder may lack tone as well asinvoluntary contractions. The dysfunctional bladder,however, has normal tone as evidenced by itsability to adapt itself to variations in bladdervolume.From the cystometrographic studies of the dys-

functional 'lazy' bladder which demonstrated anelevated threshold for the initiation of bladdercontractions as well as the ease and rapid adaptationof the bladder to inhibition of voiding, we believethat this condition is more related to a derangedbladder function rather than to an anatomicaland/or neurological abnormality. The abnormallyhigh threshold has developed from the habitualneglect of the patient to empty the bladder ongetting the urge to micturate, which has resulted

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FIG. 3.-Normal cystometrogram demonstrating normal contractions at 20 cm. H20 pressure.

FiG. 4a.-Characteristic cystometrogram of dysfunctional 'lazy' bladder demonstrating minimal involuntary bladder contractions and abnormal intravesicalpressure of 35 cm. H20.

FIG. 4b.-Cystometrogram of dysfunctional 'lazy' bladder demonstrating no involuntary bladder contractions.

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FIG. 5.-Cystogram after therapy demonstrating no reflux.

in the bladder yielding and its subsequent enlarge-ment. In other words, this closely simulatesmany children with chronic constipation who havealso lost the urge to evacuate in response to thenormal stimuli. Both conditions with further

TABLE 1PERISTALTIC ACTIVITY OF THE URETERS

After TherapyBeforeTherapy No Improve-

Improved ment

Normal . 42 42Poor .26 20 6Absent .16 9 7

Total number of cases 84 71 13

TABLE 2URETERAL REFLUX

After TherapyBeforeTherapy No Reflux

Reflux Present

20 20 6Unilateral reflux ...... .. 24 18 6Bilateral reflux 40 26 14

Total numbei of cases . . 84 64 20

neglect develop into a vicious cycle. In chronicconstipation we get megarectum and megacolon;whereas, in the dysfunctional 'lazy' bladder we getbladder enlargement and infection. The uretero-vesical junction ultimately becomes incompetent andvesico-ureteral reflux occurs, favouring the spreadof infection and contributing to dilatation of theureters. The secondary sequelae are far moreserious in the urinary tract than they are in the casesof chronic constipation.The exact role of infection in the pathogenesis of

the dysfunctional 'lazy' bladder is not clearlydefined. With the present diagnostic measures wecan only say that infection accentuates the derangedbladder function. Further experimental and clinicalstudy may eventually clarify the role of infection.The management of these patients necessitates

regular follow-up to evaluate the efficacy of therapyand the status of the urinary tract. Early cases withresidual urine of less than 50 ml. and not associatedwith reflux are treated conservatively. They aretrained to void voluntarily every three to four hourswith the aim of re-establishing the urge to void at alow threshold stimulus and the return of normalbladder size. Infection should be treated with aspecific antimicrobial agent during the acuteepisodes for no longer than five to nine days, to befollowed by long-term suppressive therapy of eithersulfisoxazole, methenamine mandelate, or nitro-furantoin. These patients are followed monthlywith a urine culture and colony count. Casescomplicated with minimal ureteral reflux are firstmanaged conservatively. These patients areinstructed to practise double or triple micturition toensure complete emptying of the bladder.

If, after six months of conservative treatment,there is no response, then the medical measures maybe rendered effective by diminishing the normalbladder neck resistance by performing a Y-V plastyof the bladder neck. Plastic repair of the ureteralorifice is indicated when ureteral reflux occurs atlow bladder pressures and when peristalses arepresent.

Following the management outlined, out of the42 patients with ineffectual ureteral peristalses, 29showed an improvement of peristalsis (Table 1).No reflux could be demonstrated in 44 patients,while it persisted only during micturition or atelevated bladder pressures in the remaining 20(Fig. 5 and Table 2).

Excretory urography showed regression of thehydronephrosis and hydro-ureter in those withoutreflux (Fig. 6). The cystometrograms in theimproved cases demonstrated more effectualinvoluntary and voluntary contractions (Fig. 7).

No reflux .. ..

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DYSFUNCTIONAL 'LAZY' BLADDER SYNDROME

Normal bladder function was also confirmed by aresidual urine of less than 10 ml.

ConclusionThe dysfunctional 'lazy' bladder syndrome is

characterized by progressive urinary tract changes.Once diagnosed, it is necessary to evaluate the extentof the disease in order to institute the propertherapy. Patients with minimal pathological changesrespond favourably to conservative treatment.Advanced cases with high residual urine and severedegree of reflux necessitate prompt surgical therapy,consisting of Y-V plasty of bladder neck withoccasional plastic repair of the ureteral orifices.

SummaryA disorder of bladder function neither obstructive

nor neurological but secondary to habitual urinaryretention and infection is described.The delay in diagnosis is attributed to the minimal

urinary tract symptoms. The cystometrographicpattern of the dysfunctional 'lazy' bladder syndromeis described. The pathogenesis of the conditionbased on the cystometrographic studies is postulated.The patients were followed up for six months to nineyears. The results of therapy of 84 patients withdysfunctional bladder is reviewed. FIG. 6.-Excretory urogram showing improvement of hydronephrosis

and hydro-ureters.

FIG. 7.-Cystometrogram after therapy demonstrating more effectual involuntary bladder contractions and normal intravesical bladder pressure.

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