C I C Introduction
Young children with special health needs often require medical procedures or routines that can be carried out by their parents. With time, most children - depending on developmental level - can learn to do these procedures themselves. This Center Care Bulletin will answer some of your questions about one of these procedures, clean intermittent catheterization (C I C).
What is C I C?
C I C is an abbreviation for "clean intermittent catheterization." It means:
Clean - As germ-free as possible.
Intermittent - Done on a regular schedule several times a day.
Catheterization - Using a catheter or tube to drain urine out of the bladder.
Why is C I C important?
Urine is produced by the kidneys. It flows from the kidneys to the bladder through tubes called the ureters (see Figure 1: The urinary tract). Most people empty their bladders by going to the bathroom four or five times a day. When the bladder is not emptied, infections or other problems can occur. If the bladder is not drained, the urine may pass backward into the ureters. This condition is called reflux . Reflux can cause infection and damage to the kidneys. For many children, C I C helps prevent reflux, urinary tract infection, and toileting "accidents."
Learning to do C I C?
You can talk to your family doctor about C I C, or you may want to talk with a specialist called a urologist - a doctor who has special knowledge of the urinary tract. Your doctor and nurse will provide you with a demonstration of the procedure, an opportunity to do C I C with supervision, and written instructions.
Why should my child learn to do C I C?
We all want our children to be as independent as possible, and an important part of this is learning personal self-care. One way to help children be more self-confident is to let them be responsible for as much of their own care - including C I C - as possible.
What is the best age for my child to learn self-catheterization?
Parents usually do C I C for their child until the child is about five years old. As the child
becomes developmentally ready, he or she can be encouraged to participate in parts of the procedure, such as washing hands or organizing C I C equipment.
A child is often able to carry out his or her own C I C at the age of seven or eight years. At this age, the child may be a little more self-conscious about wetting "accidents," and thus more motivated to learn. You, your child, and your doctor can decide the best time for your child to learn C I C.
How can I tell if my child is ready to learn C I C?
A child is ready to do his or her own C I C when he or she:
• Has a mental age of 5 years
• Has the necessary coordination (fine motor skills); for example, can pick up a soda straw and place it on a tray at a specified location
• Wants to learn C I C
• Has the encouragement and support of parents and other adults
How often will my child need to do C I C? \
Most doctors recommend 4 to 6 times per 24-hour day, with no longer than 8 hours between catheterizations at night.
Can my child do C I C at school?
Yes. Your doctor will write a letter to the school. The letter will outline your child's catheterization program and ask the school nurse or health aide to help your child with C I C. You and your child should demonstrate the specific C I C methods you prefer to use to your child's school nurse or health aide.
How will the school nurse help my child with C I C?
The school nurse or health aide will:
• Get supplies ready
• Help your child with the C I C process
• Check your child's progress
• Watch for any problems
Will it cause concern if my child needs to be out of the classroom several times a day for C I C?
As you plan your child's C I C schedule, talk with your child, the teachers, the school nurse, and your doctor. Careful scheduling, using lunch hours, recess, class breaks, and study halls, can minimize disruption of the school day.
Is there a chance my child might experience an allergic reaction as the result of C I C?
Children with neural tube defects, such as spina bifida, are at risk to develop an allergy to latex. So are children with urological abnormalities. These children may become allergic to the latex in certain products used with C I C. For this reason, we recommend the use of latex-free products.
How can I tell if my child has a latex allergy?
A child who is allergic to latex may have certain symptoms after using a product containing latex. These symptoms may include:
• Itchy, runny nose
• Itchy, watery eyes
• Skin rash with red, itchy bumps
• Swelling of lips, tongue, eyelids
• Breathing problems
How serious is a latex allergy?
Latex allergy can be very serious. It can cause anaphylaxis, an allergic reaction that can be life-threatening.
Can I do anything to keep my child from becoming allergic to latex?
Yes, you can, by not exposing your child to latex. Children who are at risk for latex allergy should avoid products that contain latex. This is true even if a child does not currently have allergic symptoms due to latex exposure.
How can I learn whether my child is allergic to latex?
You can ask your doctor whether your child should be tested for latex allergy. The allergy test is done using a blood test called a RAST, or a skin test.
What should I do if my child has a latex allergy?
Your child will need to avoid products containing latex.
Talk with your health care providers, including your physician and your dentist. They should not use products that contain latex when they care for your child.
Your child should use only latex-free products. Your physician can write a prescription for latex-free catheters, syringes, and gloves to use during C I C and other routines. You can order these through your local pharmacy or medical supply source.
It would be a good idea for your child to wear a medic alert bracelet indicating this allergy.
What other precautions should I take?
You will also need to tell your child's other caregivers. It is very important that they know, so that they can avoid using latex products with your child. Some caregivers you should talk with include:
• Babysitters
• Daycare staff
• Teachers, teacher's aides, and coaches
• School nurse
• Grandparents and other family members
• Your child's friends, and their parents
• Summer camp staff
About Complete Care Medical, Inc.
We are one of the fastest growing fully accredited national catheter suppliers in the United States. We are dedicated to putting Patients first in everything we do, and providing them with convenience, choice and control.
Need a catheter? What size? What brand? What type? WE HAVE IT!
For more about us please visit http://www.ccmedicalinc.com/, or call us Toll Free at 1-800-503-7604!
Wednesday, June 2, 2010
Tuesday, June 1, 2010
Clean Intermittent Catheter Usage
What are the steps for clean intermittent catheterization for girls and boys?
If your child cannot empty his or her bladder completely, or has a problem with urine leakage, your child may need to start a catheterization program. These problems are commonly seen in children with spina bifida, spinal cord injuries, or some urinary tract defects.
The following information explains the steps for CIC. This should not take the place of one-to-one teaching. If your child needs CIC, contact your pediatrician, doctor, or nurse practitioner for more information.
CIC For Girls
- First wash your hands with soap and water, then dry them. You also can use a waterless cleaner, such as an antibacterial cleanser that does not require water.
- Next have your box of supplies within easy reach.
- Place your daughter on her back or position her on the toilet or in her wheelchair. You should practice CIC in the position you will be using most often. If she is on the toilet, separate her legs widely enough to be able to clearly see her urethra. If she is doing her catheterizations herself, she will practice identifying her urethra by touch. When your daughter is learning to catheterize herself, she can use a mirror to see where her urethra is located.
- Clean your daughter's genitalia with a washcloth or disposable wipe.
- Separate the labia and wipe thoroughly from front to back.
- Place a generous amount of the water-soluble lubricant on the end of the catheter with the holes.
- Place the other end of the catheter into a container or let it drain into the toilet.
- Find your daughter's urethra. Gently insert the lubricated end of the catheter into the urethra about 2 to 3 inches. It may become slightly more difficult to insert just prior to entering the bladder. That is because a muscle called the sphincter sits at the opening of the bladder and is naturally tightly contracted. The sphincter will relax as you continue to gently insert the catheter until you reach the bladder and see urine flow.
- Once the catheter is in the bladder, hold it there until the urine flow stops. Then move the catheter slightly, or insert it a little more, to see if the flow continues. Gently press on your daughter's lower abdomen with your hand or ask your daughter to lean forward to be certain there is no more urine in the bladder.
- Slowly remove the catheter, holding your finger at the tip or pinching the catheter end before removing the final portion. Pull catheter out in a downward movement to prevent backflow of urine.
- Wash your hands. Clean and store your catheter as directed.
CIC For Boys
- First wash your hands with soap and water, then dry them. You also can use a waterless cleaner, such as an antibacterial cleanser that does not require water.
- Next have your box of supplies within easy reach.
- Place your son on his back or, if it is easier for both of you, have him sit on the toilet or in his wheelchair. If he is doing his own catheterization, he may stand or sit on the toilet or in his wheelchair.
- Clean the tip of his penis with a washcloth or disposable wipes in a circular motion starting at the center and working outward. If your son is uncircumcised, pull back the foreskin so that the tip of his penis is visible before cleansing.
- Place a generous amount of the water-soluble lubricant on the end of the catheter with the holes.
- Place the other end of the catheter into a container or let it drain into the toilet.
- Hold your son's penis upright. Gently insert the lubricated end of the catheter into the urethra about 4 to 6 inches until urine begins to flow. You may need to lower the penis as you continue to insert the catheter. It may become more difficult to advance the catheter as you get closer to the bladder. Do not worry, this is normal. Continue to gently insert the catheter with steady pressure until you feel the catheter slip into the bladder. Once urine flow begins, insert the catheter about an inch farther to allow the urine to flow better.
- Hold the catheter in place until the urine flow stops. You may gently press on your son's lower abdomen or ask him to squeeze his abdominal muscles or lean forward to be sure the bladder is empty.
- Remove the catheter once the urine flow stops completely. Hold your finger over the end of the catheter while removing it. This will prevent any urine in the tube from dripping out.
- If your son is uncircumcised, gently replace the foreskin over the end of his penis by pushing it forward.
- Wash your hands. Clean and store your catheter as directed.
Supplies Needed
It is best to have all of your supplies organized and ready when you need them. Keep the following items in a clean, dry container such as a plastic shoe box or cosmetic case.
- Catheters. Your doctor will give you a prescription for the appropriate sterile, single-use catheter size for your child.
- Disposable wipes or a washcloth. Your child's genitalia will need to be cleaned before CIC.
- Lubricant. Use only a water-soluble lubricant. Do not use oil-based lubricants such as petroleum jelly because they do not dissolve in water.
- Container. You may need a container to drain the urine into if you are not doing the catheterizations on the toilet, or if you need to keep a record of how much your child drains.
About Complete Care Medical, Inc.
We are one of the fastest growing fully accredited national catheter suppliers in the United States. We are dedicated to putting Patients first in everything we do, and providing them with convenience, choice and control.
Need a catheter? What size? What brand? What type? WE HAVE IT! For more about us please visit www.ccmedicalinc.com, or call us Toll Free at 1-800-503-7604!
If your child cannot empty his or her bladder completely, or has a problem with urine leakage, your child may need to start a catheterization program. These problems are commonly seen in children with spina bifida, spinal cord injuries, or some urinary tract defects.
The following information explains the steps for CIC. This should not take the place of one-to-one teaching. If your child needs CIC, contact your pediatrician, doctor, or nurse practitioner for more information.
CIC For Girls
- First wash your hands with soap and water, then dry them. You also can use a waterless cleaner, such as an antibacterial cleanser that does not require water.
- Next have your box of supplies within easy reach.
- Place your daughter on her back or position her on the toilet or in her wheelchair. You should practice CIC in the position you will be using most often. If she is on the toilet, separate her legs widely enough to be able to clearly see her urethra. If she is doing her catheterizations herself, she will practice identifying her urethra by touch. When your daughter is learning to catheterize herself, she can use a mirror to see where her urethra is located.
- Clean your daughter's genitalia with a washcloth or disposable wipe.
- Separate the labia and wipe thoroughly from front to back.
- Place a generous amount of the water-soluble lubricant on the end of the catheter with the holes.
- Place the other end of the catheter into a container or let it drain into the toilet.
- Find your daughter's urethra. Gently insert the lubricated end of the catheter into the urethra about 2 to 3 inches. It may become slightly more difficult to insert just prior to entering the bladder. That is because a muscle called the sphincter sits at the opening of the bladder and is naturally tightly contracted. The sphincter will relax as you continue to gently insert the catheter until you reach the bladder and see urine flow.
- Once the catheter is in the bladder, hold it there until the urine flow stops. Then move the catheter slightly, or insert it a little more, to see if the flow continues. Gently press on your daughter's lower abdomen with your hand or ask your daughter to lean forward to be certain there is no more urine in the bladder.
- Slowly remove the catheter, holding your finger at the tip or pinching the catheter end before removing the final portion. Pull catheter out in a downward movement to prevent backflow of urine.
- Wash your hands. Clean and store your catheter as directed.
CIC For Boys
- First wash your hands with soap and water, then dry them. You also can use a waterless cleaner, such as an antibacterial cleanser that does not require water.
- Next have your box of supplies within easy reach.
- Place your son on his back or, if it is easier for both of you, have him sit on the toilet or in his wheelchair. If he is doing his own catheterization, he may stand or sit on the toilet or in his wheelchair.
- Clean the tip of his penis with a washcloth or disposable wipes in a circular motion starting at the center and working outward. If your son is uncircumcised, pull back the foreskin so that the tip of his penis is visible before cleansing.
- Place a generous amount of the water-soluble lubricant on the end of the catheter with the holes.
- Place the other end of the catheter into a container or let it drain into the toilet.
- Hold your son's penis upright. Gently insert the lubricated end of the catheter into the urethra about 4 to 6 inches until urine begins to flow. You may need to lower the penis as you continue to insert the catheter. It may become more difficult to advance the catheter as you get closer to the bladder. Do not worry, this is normal. Continue to gently insert the catheter with steady pressure until you feel the catheter slip into the bladder. Once urine flow begins, insert the catheter about an inch farther to allow the urine to flow better.
- Hold the catheter in place until the urine flow stops. You may gently press on your son's lower abdomen or ask him to squeeze his abdominal muscles or lean forward to be sure the bladder is empty.
- Remove the catheter once the urine flow stops completely. Hold your finger over the end of the catheter while removing it. This will prevent any urine in the tube from dripping out.
- If your son is uncircumcised, gently replace the foreskin over the end of his penis by pushing it forward.
- Wash your hands. Clean and store your catheter as directed.
Supplies Needed
It is best to have all of your supplies organized and ready when you need them. Keep the following items in a clean, dry container such as a plastic shoe box or cosmetic case.
- Catheters. Your doctor will give you a prescription for the appropriate sterile, single-use catheter size for your child.
- Disposable wipes or a washcloth. Your child's genitalia will need to be cleaned before CIC.
- Lubricant. Use only a water-soluble lubricant. Do not use oil-based lubricants such as petroleum jelly because they do not dissolve in water.
- Container. You may need a container to drain the urine into if you are not doing the catheterizations on the toilet, or if you need to keep a record of how much your child drains.
About Complete Care Medical, Inc.
We are one of the fastest growing fully accredited national catheter suppliers in the United States. We are dedicated to putting Patients first in everything we do, and providing them with convenience, choice and control.
Need a catheter? What size? What brand? What type? WE HAVE IT! For more about us please visit www.ccmedicalinc.com, or call us Toll Free at 1-800-503-7604!
ROCHESTER MEDICAL UNVEILS "MAGIC" INTERMITTENT CATHETERS
Rochester Medical Corporation (NASDAQ:ROCM), Stewartville, Minn., has announced the introduction of Magic3(TM), its new line of intermittent urinary catheters.
Featuring advanced and proprietary m3 technology, Magic3 catheters are the first intermittent catheters created and crafted from a composition of three distinct functional layers. Each of the three all- silicone laminates is uniquely formulated to independently address a particular product attribute required for comfortable, easy, and reliable intermittent catheterization. This means no trade-offs or compromises for the people that depend on intermittent catheters to help them live a healthy, active life.
Commenting on the new Magic3 catheter, Rochester Medical's CEO and president Anthony J. Conway said, "This is a great new product family. The design and construction of an intermittent catheter can fundamentally impact the user's quality of life. Manufacturers have done their best to address issues of comfort and convenience, but until the invention of Magic3 choosing among various products has involved difficult trade-offs.
"Traditional single-layer catheters that are rigid enough for ease of handling can be painful to use and can damage sensitive urethral tissue. Those that are softer and less likely to abrade tissue can be difficult to handle. Also, some catheters are subject to kinks that can impede drainage flow. We believe no single-layer design has been able to fully address each of these critical issues."
Magic3 intermittent catheters leverage Rochester Medical's patent-pending m3 technology to deliver the benefits of a three-layer, all-silicone design. The catheter's special outer layer of nano-smooth soft silicone provides for an unparalleled hydrophilic lubricious surface which reduces trauma, and maximizes patient comfort. The proprietary middle layer of firmer silicone supports confident handling for quick, simple catheter insertion. The innermost layer is designed to resist kinking and leverage the intrinsic hydrophobic (water-repelling) characteristics of silicone to enhance urine flow through the catheter.
Further demonstrating the company's enthusiasm for providing patient friendly, environmentally sound solutions, Rochester Medical has incorporated additional important design enhancements. A streamlined, discreet package with finger holes to assist in opening, along with a new self contained and easy to open water packet make the new Magic3 more user friendly. Environmental improvements include a 25% smaller catheter package, a 70 % smaller water packet, and a box that is 20% more compact.
"The technology and timing of our Magic3 introduction offers a unique opportunity for the company and our customers," commented Jim Carper, Rochester Medical's vice president of Marketing. "Reimbursement changes have heightened the attention being given to best intermittent catheter practices for each user. The assessments being made every day by clinicians, patients, and distributors now include a brand new choice for uncompromised excellence in catheter performance."
Kicking-off a comprehensive marketing campaign, Rochester Medical has begun rolling out the Magic3 intermittent catheter line in the U.S. with introductions to its distribution partners and targeted clinical call points. The marketing campaign will encompass clinicians as well as catheter users. It will include print and web advertising along with participation in national exhibitions, specialty conferences, and regional consumer events.
Concurrently, the new technology is being introduced by Rochester Medical Ltd. in the United Kingdom and Europe where a similar comprehensive marketing campaign is being launched.
For two decades, Rochester Medical Corporation has been developing, manufacturing and marketing latex-free, disposable medical devices and catheters for urological and continence care applications. The all-silicone Magic3 intermittent catheter line is the latest example of the company's commitment to providing innovative solutions to address the needs of patients, caregivers, and clinicians.
Magic3 intermittent catheters are available in male (16"), female (6"), and pediatric (10") lengths and in diameters ranging from 6Fr to 20Fr. The product line also incorporates all of Rochester Medical's coating options and package configurations, including the advanced antibacterial and antibacterial hydrophilic technologies. Most state Medicaid, Medicare, and private insurance companies will cover these advanced catheters; local product suppliers can provide details about specific payor sources. Additional product and ordering information is available by contacting Complete Care Medical, Inc. at 1-800-503-7604 or info@ccmedicalinc.com.
About Complete Care Medical, Inc.
We are one of the fastest growing fully accredited national catheter suppliers in the United States. We are dedicated to putting Patients first in everything we do, and providing them with convenience, choice and control.
Need a catheter? What size? What brand? What type? WE HAVE IT! For more about us please visit http://www.ccmedicalinc.com/, or call us at 1-800-503-7604!
Featuring advanced and proprietary m3 technology, Magic3 catheters are the first intermittent catheters created and crafted from a composition of three distinct functional layers. Each of the three all- silicone laminates is uniquely formulated to independently address a particular product attribute required for comfortable, easy, and reliable intermittent catheterization. This means no trade-offs or compromises for the people that depend on intermittent catheters to help them live a healthy, active life.
Commenting on the new Magic3 catheter, Rochester Medical's CEO and president Anthony J. Conway said, "This is a great new product family. The design and construction of an intermittent catheter can fundamentally impact the user's quality of life. Manufacturers have done their best to address issues of comfort and convenience, but until the invention of Magic3 choosing among various products has involved difficult trade-offs.
"Traditional single-layer catheters that are rigid enough for ease of handling can be painful to use and can damage sensitive urethral tissue. Those that are softer and less likely to abrade tissue can be difficult to handle. Also, some catheters are subject to kinks that can impede drainage flow. We believe no single-layer design has been able to fully address each of these critical issues."
Magic3 intermittent catheters leverage Rochester Medical's patent-pending m3 technology to deliver the benefits of a three-layer, all-silicone design. The catheter's special outer layer of nano-smooth soft silicone provides for an unparalleled hydrophilic lubricious surface which reduces trauma, and maximizes patient comfort. The proprietary middle layer of firmer silicone supports confident handling for quick, simple catheter insertion. The innermost layer is designed to resist kinking and leverage the intrinsic hydrophobic (water-repelling) characteristics of silicone to enhance urine flow through the catheter.
Further demonstrating the company's enthusiasm for providing patient friendly, environmentally sound solutions, Rochester Medical has incorporated additional important design enhancements. A streamlined, discreet package with finger holes to assist in opening, along with a new self contained and easy to open water packet make the new Magic3 more user friendly. Environmental improvements include a 25% smaller catheter package, a 70 % smaller water packet, and a box that is 20% more compact.
"The technology and timing of our Magic3 introduction offers a unique opportunity for the company and our customers," commented Jim Carper, Rochester Medical's vice president of Marketing. "Reimbursement changes have heightened the attention being given to best intermittent catheter practices for each user. The assessments being made every day by clinicians, patients, and distributors now include a brand new choice for uncompromised excellence in catheter performance."
Kicking-off a comprehensive marketing campaign, Rochester Medical has begun rolling out the Magic3 intermittent catheter line in the U.S. with introductions to its distribution partners and targeted clinical call points. The marketing campaign will encompass clinicians as well as catheter users. It will include print and web advertising along with participation in national exhibitions, specialty conferences, and regional consumer events.
Concurrently, the new technology is being introduced by Rochester Medical Ltd. in the United Kingdom and Europe where a similar comprehensive marketing campaign is being launched.
For two decades, Rochester Medical Corporation has been developing, manufacturing and marketing latex-free, disposable medical devices and catheters for urological and continence care applications. The all-silicone Magic3 intermittent catheter line is the latest example of the company's commitment to providing innovative solutions to address the needs of patients, caregivers, and clinicians.
Magic3 intermittent catheters are available in male (16"), female (6"), and pediatric (10") lengths and in diameters ranging from 6Fr to 20Fr. The product line also incorporates all of Rochester Medical's coating options and package configurations, including the advanced antibacterial and antibacterial hydrophilic technologies. Most state Medicaid, Medicare, and private insurance companies will cover these advanced catheters; local product suppliers can provide details about specific payor sources. Additional product and ordering information is available by contacting Complete Care Medical, Inc. at 1-800-503-7604 or info@ccmedicalinc.com.
About Complete Care Medical, Inc.
We are one of the fastest growing fully accredited national catheter suppliers in the United States. We are dedicated to putting Patients first in everything we do, and providing them with convenience, choice and control.
Need a catheter? What size? What brand? What type? WE HAVE IT! For more about us please visit http://www.ccmedicalinc.com/, or call us at 1-800-503-7604!
Thursday, May 20, 2010
A Round-up of the Latest Issues in Pediatric Urology
by Mark P. Cain, MD
Introduction
The Pediatric Urology Section at the American Urological Association 98th Annual Meeting in Chicago, Illinois, provided new insights into some of the older problems in the field of pediatric urology. In addition, some excellent reviews were provided for some of the more common clinical issues in this field.
Urethrorrhagia Idiopathica
Urethrorrhagia is a benign condition that usually presents with painless blood spotting in a preadolescent or adolescent male's underwear. This creates significant anxiety for both the patient and parents, despite the fact that this self-limited condition rarely causes long-term clinical sequelae. The presumptive etiology is localized irritation in the bulbar urethra distal to the external sphincter, consistent with the bulbar urethritis commonly described when the patient is evaluated endoscopically. The condition usually presents in peripuberty, and it has been speculated that this may be due to increasing estrogens effecting the development of the mucosa in the posterior urethra. The recommended evaluation has usually included urinalysis and urine culture, as well as an ultrasound of the kidneys and bladder. Invasive testing, such as voiding cystourethrogram, retrograde urethrogram, and cystourethroscopy have been discouraged because they have been ineffective in locating sources of the bleeding.
A new hypothesis regarding the etiology of urethrorrhagia was proposed by Herz and colleagues.[1] The authors hypothesized that urethrorrhagia may be a manifestation of voiding dysfunction with external sphincter dyssynergia, and that management of this underlying voiding dysfunction would result in faster and more durable response to the distressing blood spotting and dysuria. This study evaluated 68 males and 4 females who presented with blood spotting in their underwear, of whom a large percentage also complained of dysuria, constipation, and prior history of urinary tract infection. It should be noted that most patients with simple urethrorrhagia do not have a recent or remote history of urinary tract infection as part of the symptom complex.
The study authors evaluated the patients in a systematic fashion with renal and bladder ultrasound, urinalysis, urine culture, uroflow with electromyogram, and, occasionally, voiding cystourethrogram. The patients were divided into 2 different groups. Group 1 comprised 37 patients (average age, 9.8 years), managed with antibiotics, urinary analgesics, and anticholinergic medication. Group 2 included 35 patients (average age, 8.4 years), managed with an aggressive bladder regimen, including treatment of dysfunctional elimination syndrome with biofeedback and a bowel regimen. In Group 1, a full response was seen in 13 patients and a partial response was seen in 6; no response was seen in 18. The average time to resolution was 12.1 months. In Group 2, a full response was seen in 29 patients and a partial response was seen in 2; no response was seen in 4. Group 2's time to resolution was much quicker, with 5.2 months the mean time to symptom relief.
This was a select group of patients with a combination of both voiding dysfunction and urethral symptoms, including blood spotting and dysuria. This study suggests that a history of underlying dysfunctional elimination syndrome may be an important factor in some of these patients and that management of this particular underlying problem would likely hasten the resolution. Since this is primarily a benign condition that creates a great deal of alarm in the child and parents, the prompt relief of symptoms as demonstrated in this study would suggest that urethrorrhagia be considered in patients presenting with blood spotting with dysuria.
An interesting abstract provided a retrospective analysis over 14 years of 66 males with urethrorrhagia who presented at an average age of 9 years.[2] The vast majority of patients had blood spotting on their underpants as the presenting symptom, and one third also complained of dysuria. A smaller percentage also complained of a slow urinary stream. An analysis of the radiographic evaluation concluded that upper tract studies do not add any significant information to assist in making the diagnosis. Of the 66 patients, 55 were evaluated with ultrasound and 11 with intravenous pyelogram, and these were all considered essentially normal studies. In contrast, 52 of the 66 patients had a voiding cystourethrogram (VCUG) performed and 11 also had a retrograde urethrogram performed. Fifty-six percent of the voiding studies were normal, but 17% showed bulbar irregularity, 17% showed meatal stenosis, and 4% demonstrated a urethral stricture. Bulbar irregularity was also seen in 36% of the patients on retrograde urethrogram and 27% demonstrated a urethral stricture.
Meatal stenosis was treated with meatotomy, with usual resolution of the symptoms. In 35 of the 66 patients, cystourethroscopy had been performed, usually by the referring urologist. Abnormal findings were identified in all of the patients who had cystoscopy, usually consisting of bulbar inflammation and narrowing. Four patients had a stricture at the time of initial cystoscopy. More important, 4 additional patients developed urethral strictures after the initial cystoscopy was performed, which was described as normal. Based on the findings of their retrospective study, the authors recommended that upper tract studies are unnecessary in the evaluation of young boys with urethrorrhagia.
The voiding study was abnormal in 44% of the patients; the authors suggest that VCUG is beneficial in the diagnosis of idiopathic urethrorrhagia. However, the findings in this study of bulbar irregularity and meatal stenosis would not generally change the management of these patients, as meatal stenosis would usually be evident on physical exam, and the bulbar irregularity did not really change the medical management of these patients. The authors did hypothesize that meatal stenosis may be an etiologic factor in some patients, and this is consistent with distal obstructions suggested in Herz and colleagues' study.[1] As has been recommended by others, these authors advocate avoiding cystourethroscopy, as it could result in iatrogenic strictures, which was demonstrated in 6% of the patient population in this study. If symptoms persist or suggest an obstructive lesion, voiding cystogram or retrograde urethrogram can be performed.
Vesicoureteral Reflux
The management of vesicoureteral reflux has traditionally been medical management with antibiotic prophylaxis, with open surgical correction reserved for those patients with either breakthrough infections, persistence of reflux, or parental preference to proceed with definitive therapy. With the recent US Food and Drug Administration (FDA) approval of another injectable agent, Deflux (dextranomer/hyaluronic acid copolymer; Q-Med; Uppsala, Sweden), that has been widely marketed in the United States, there has been a slow shift in the indications for intervention in some centers. With this potential shift in the treatment recommendations for reflux, it becomes even more necessary to identify patients with a high likelihood of early spontaneous resolution of vesicoureteral reflux.
Gutow and colleagues[3] presented their analysis of timing of reflux during the voiding cystourethrogram as a predictive factor for spontaneous resolution. In total, 168 patients were evaluated, with 245 refluxing ureters. All findings were based on the initial voiding cystourethrogram. The majority of the ureters refluxed during the filling phase, with only 40 ureters refluxing during voiding or high-pressure phase of the study. Of interest, there was no difference in the eventual resolution, the need for eventual surgery, or change in the grade of reflux. The time to resolution was more rapid in the patients with reflux during the filling phase. This is an interesting finding, because the intuitive thought would be that patients with reflux during voiding would have a longer submucosal tunnel and would be more likely to have more rapid resolution of the reflux with observation. The authors hypothesize that the patients who refluxed during the voiding phase were more likely to have underlying voiding dysfunction and be more prone to urinary tract infection with a higher likelihood of intervention. Although their evaluation did not identify statistically significant difference with regard to need for surgery, there was a trend towards greater intervention in those with reflux during voiding. Hypothetically, these patients would also be good candidates for injectable therapy, as with a presumed longer submucosal tunnel they would be expected to have a good result with the subtrigonal implant therapy.
Elmore and colleagues[4] presented their results of the recently FDA-approved agent Deflux. Thirty-five patients completed follow-up evaluation, with voiding cystourethrogram at 3 months, including 54 infected ureters. Results were analyzed following a single Deflux injection. Preoperatively, there was a wide range of grade of reflux, the majority being Society for Fetal Urology (SFU) Grade 2 or 3. Overall, the authors reported that 63% (22 out of 35 ureters) of the patients had a successful outcome. With respect to number of ureters successfully managed, there was a 70% success rate (38 out of 54), which seems to be the recurring number in most of the literature following a single injection of Deflux. The interesting finding in this study was that de novo contralateral reflux was identified in 2 of 35 patients. This is a commonly described finding with unilateral open ureteral reimplantation. The cited risk of contralateral reflux typically ranges between 7% and 20%, depending on how many previous voiding cystourethrograms had been performed that demonstrated unilateral vesicoureteral reflux only. In addition, 1 patient of the 35 developed asymptomatic ureteral obstruction. This is the first patient described in any United States series and stresses the importance of follow-up radiograph evaluation of the upper tracts following ureteral surgery.
Ureteroceles
A review of the current management options for ureteroceles was presented during the Society of Pediatric Urology meeting on April 26, 2003. A panel of video presentations demonstrated the options for surgical intervention for ureteroceles, including open upper tract surgery, laparoscopic upper pole surgery, endoscopic ureterocele puncture, and lower urinary tract reconstruction. The videos demonstrated how each of these approaches could be applied to any patient; with multiple treatment options, however, the procedure should be selected based on patient age, presence of function in the ureterocele unit, and presence of reflux in either the lower pole or other renal units. One alternative approach that has been described previously in highly selected patients is watchful waiting.
Outcomes of watchful waiting for ureteroceles were presented from a group in Ottawa, Canada.[5] In a carefully selected group of 11 patients enrolled from 1990-2001, they demonstrated that watchful waiting was a reasonable option in some patients who present with ureteroceles. All 11 patients in the series presented with an antenatal diagnosis. No patient had high-grade lower pole vesicoureteral reflux, significant obstruction, severe hydronephrosis in the upper pole, or history of urinary tract infection. Patients were all managed with antibiotic prophylaxis for a mean of 1.5 years. They were evaluated with voiding cystourethrogram, ultrasound, and upper tract functional studies at diagnosis, followed by ultrasound every 3-6 months for 2 years and then 6 months thereafter. The majority of patients had low-grade hydronephrosis of SFU Grade 2 or less. This resolved in over half of the patients during follow-up. In addition, associated reflux to the lower pole was only Grade 2 or 3 in 6 patients, and in 5 patients it resolved with watchful waiting. Only 1 patient required surgery for breakthrough urinary tract infection. The difference between this study and the previous series presented in the literature[4] was that watchful waiting had previously been recommended only in patients with reasonable upper pole function. In this series, the function of the upper pole segment did not affect the outcome of watchful waiting. It should be mentioned that this was a very carefully selected group of patients who were followed carefully over time. In analyzing the patients, 4 presented with a single-system ureterocele with no evidence of obstruction, and in most centers, surgical intervention would not be considered in this patient. The 7 remaining patients all had ectopic ureteroceles, but again only had mild hydronephrosis in the upper pole and lower-grade reflux. In selecting patients for observational therapy, these criteria should be kept in mind.
Bladder Augmentation
Enterocystoplasty continues to be the most commonly used method for bladder augmentation. Despite its widespread use, there are short-term and long term risks associated with this procedure, including mucus production, electrolyte disturbances, increased risk of bladder stones, long-term risk of perforation, and also a small risk of malignancy. Ureterocystoplasty has been advocated in patients with dilated and poorly functioning upper tracts or with very dilated distal ureters. Most reports have shown favorable response in using the ureter as an alternative to augmentation cystoplasty.
Husmann and coworkers[6] presented their long-term results using ureterocystoplasty as an alternative to bladder augmentation with a bowel source. The study included 22 patients accumulated over the last 15 years. All patients presented with incontinence, and 18 out of 22 had a neuropathic bladder as the etiology of their urinary incontinence. Four had a history of posterior urethral valves. Two patients underwent ureterocystoplasty using segments from both ureters. Fourteen of the patients presented with a refluxing megaureter and 8 had nonrefluxing megaureters. The patients were evaluated based on strict urodynamic criteria of end-fill capacity with pressures < 40 cm of water. When augmented with a single-system ureter, they found a 2.5-fold increase in bladder capacity; when both ureters were used, a 3- to 4.5-fold increase in pressure-specific bladder capacity was seen. Despite the improvement in overall bladder capacity in the majority of the patients, the outcomes based on continence were less satisfactory. Only 9% of the patients were continent and voiding after the ureterocystoplasty. Nine percent were also continent and voiding with the addition of anticholinergic medications. Twenty-three percent were continent, but required intermittent catheterization to empty. An additional 13% were continent with intermittent catheterization and anticholinergics. This left 45% or almost half of the patients with persistent incontinence after ureterocystoplasty, and all of these patients eventually required repeat augmentation with an intestinal segment. Also of note, 1 patient developed perforation of the ureterocystoplasty following renal transplantation and died of overwhelming sepsis. The authors point out that although the risk of mucus, cancer, and stone are decreased with ureterocystoplasty, this procedure is associated with a reoperation rate of almost 50% and does not avoid the long-term risk of perforation seen in intestinal bladder augmentation.
References
1. Herz DB, Weiser A, Franco I, Reda E, Levitt S. Voiding dysfunction as an etiology for bulbar urethritis (urethrorrhagia) in children. Program and abstracts of the American Urological Association 98th Annual Meeting; April 26-May 1, 2003; Chicago, Illinois. Abstract 410.
2. Palagira AV, Steinhardt GF, Dector RM. A retrospective analysis on the diagnosis and management of idiopathic urethrorrhagia. Program and abstracts of the American Urological Association 98th Annual Meeting; April 26-May 1, 2003; Chicago, Illinois. Abstract 412.
3. Gutow SG, Karellas M, Murphy JP, Gatti JM. Prognostic value of reflux during the filling versus voiding phase of the VCUG. Program and abstracts of the American Urological Association 98th Annual Meeting; April 26-May 1, 2003; Chicago, Illinois. Abstract 416.
4. Elmore JM, Ewalt DH, Snodgrass WT. Initial results of Deflux injection for vesicoureteral reflux: the Dallas experience. Program and abstracts of the American Urological Association 98th Annual Meeting; April 26-May 1, 2003; Chicago, Illinois. Abstract 487.
5. Leonard MP, DiRenna T. Watchful waiting for antenatally detected ureteroceles. Program and abstracts of the American Urological Association 98th Annual Meeting; April 26-May 1, 2003; Chicago, Illinois. Abstract 420.
6. Husmann DA, Snodgrass W, Kramer SA. Ureterocystoplasty: How good is it? Program and abstracts of the American Urological Association 98th Annual Meeting; April 26-May 1, 2003; Chicago, Illinois. Abstract 485.
About Complete Care Medical, Inc.
We are one of the fastest growing fully accredited national catheter suppliers in the United States. We are dedicated to putting Patients first in everything we do, and providing them with convenience, choice and control. Need a catheter? What size? What brand? What type? WE HAVE IT!
For more about us please visit http://www.ccmedicalinc.com/
Introduction
The Pediatric Urology Section at the American Urological Association 98th Annual Meeting in Chicago, Illinois, provided new insights into some of the older problems in the field of pediatric urology. In addition, some excellent reviews were provided for some of the more common clinical issues in this field.
Urethrorrhagia Idiopathica
Urethrorrhagia is a benign condition that usually presents with painless blood spotting in a preadolescent or adolescent male's underwear. This creates significant anxiety for both the patient and parents, despite the fact that this self-limited condition rarely causes long-term clinical sequelae. The presumptive etiology is localized irritation in the bulbar urethra distal to the external sphincter, consistent with the bulbar urethritis commonly described when the patient is evaluated endoscopically. The condition usually presents in peripuberty, and it has been speculated that this may be due to increasing estrogens effecting the development of the mucosa in the posterior urethra. The recommended evaluation has usually included urinalysis and urine culture, as well as an ultrasound of the kidneys and bladder. Invasive testing, such as voiding cystourethrogram, retrograde urethrogram, and cystourethroscopy have been discouraged because they have been ineffective in locating sources of the bleeding.
A new hypothesis regarding the etiology of urethrorrhagia was proposed by Herz and colleagues.[1] The authors hypothesized that urethrorrhagia may be a manifestation of voiding dysfunction with external sphincter dyssynergia, and that management of this underlying voiding dysfunction would result in faster and more durable response to the distressing blood spotting and dysuria. This study evaluated 68 males and 4 females who presented with blood spotting in their underwear, of whom a large percentage also complained of dysuria, constipation, and prior history of urinary tract infection. It should be noted that most patients with simple urethrorrhagia do not have a recent or remote history of urinary tract infection as part of the symptom complex.
The study authors evaluated the patients in a systematic fashion with renal and bladder ultrasound, urinalysis, urine culture, uroflow with electromyogram, and, occasionally, voiding cystourethrogram. The patients were divided into 2 different groups. Group 1 comprised 37 patients (average age, 9.8 years), managed with antibiotics, urinary analgesics, and anticholinergic medication. Group 2 included 35 patients (average age, 8.4 years), managed with an aggressive bladder regimen, including treatment of dysfunctional elimination syndrome with biofeedback and a bowel regimen. In Group 1, a full response was seen in 13 patients and a partial response was seen in 6; no response was seen in 18. The average time to resolution was 12.1 months. In Group 2, a full response was seen in 29 patients and a partial response was seen in 2; no response was seen in 4. Group 2's time to resolution was much quicker, with 5.2 months the mean time to symptom relief.
This was a select group of patients with a combination of both voiding dysfunction and urethral symptoms, including blood spotting and dysuria. This study suggests that a history of underlying dysfunctional elimination syndrome may be an important factor in some of these patients and that management of this particular underlying problem would likely hasten the resolution. Since this is primarily a benign condition that creates a great deal of alarm in the child and parents, the prompt relief of symptoms as demonstrated in this study would suggest that urethrorrhagia be considered in patients presenting with blood spotting with dysuria.
An interesting abstract provided a retrospective analysis over 14 years of 66 males with urethrorrhagia who presented at an average age of 9 years.[2] The vast majority of patients had blood spotting on their underpants as the presenting symptom, and one third also complained of dysuria. A smaller percentage also complained of a slow urinary stream. An analysis of the radiographic evaluation concluded that upper tract studies do not add any significant information to assist in making the diagnosis. Of the 66 patients, 55 were evaluated with ultrasound and 11 with intravenous pyelogram, and these were all considered essentially normal studies. In contrast, 52 of the 66 patients had a voiding cystourethrogram (VCUG) performed and 11 also had a retrograde urethrogram performed. Fifty-six percent of the voiding studies were normal, but 17% showed bulbar irregularity, 17% showed meatal stenosis, and 4% demonstrated a urethral stricture. Bulbar irregularity was also seen in 36% of the patients on retrograde urethrogram and 27% demonstrated a urethral stricture.
Meatal stenosis was treated with meatotomy, with usual resolution of the symptoms. In 35 of the 66 patients, cystourethroscopy had been performed, usually by the referring urologist. Abnormal findings were identified in all of the patients who had cystoscopy, usually consisting of bulbar inflammation and narrowing. Four patients had a stricture at the time of initial cystoscopy. More important, 4 additional patients developed urethral strictures after the initial cystoscopy was performed, which was described as normal. Based on the findings of their retrospective study, the authors recommended that upper tract studies are unnecessary in the evaluation of young boys with urethrorrhagia.
The voiding study was abnormal in 44% of the patients; the authors suggest that VCUG is beneficial in the diagnosis of idiopathic urethrorrhagia. However, the findings in this study of bulbar irregularity and meatal stenosis would not generally change the management of these patients, as meatal stenosis would usually be evident on physical exam, and the bulbar irregularity did not really change the medical management of these patients. The authors did hypothesize that meatal stenosis may be an etiologic factor in some patients, and this is consistent with distal obstructions suggested in Herz and colleagues' study.[1] As has been recommended by others, these authors advocate avoiding cystourethroscopy, as it could result in iatrogenic strictures, which was demonstrated in 6% of the patient population in this study. If symptoms persist or suggest an obstructive lesion, voiding cystogram or retrograde urethrogram can be performed.
Vesicoureteral Reflux
The management of vesicoureteral reflux has traditionally been medical management with antibiotic prophylaxis, with open surgical correction reserved for those patients with either breakthrough infections, persistence of reflux, or parental preference to proceed with definitive therapy. With the recent US Food and Drug Administration (FDA) approval of another injectable agent, Deflux (dextranomer/hyaluronic acid copolymer; Q-Med; Uppsala, Sweden), that has been widely marketed in the United States, there has been a slow shift in the indications for intervention in some centers. With this potential shift in the treatment recommendations for reflux, it becomes even more necessary to identify patients with a high likelihood of early spontaneous resolution of vesicoureteral reflux.
Gutow and colleagues[3] presented their analysis of timing of reflux during the voiding cystourethrogram as a predictive factor for spontaneous resolution. In total, 168 patients were evaluated, with 245 refluxing ureters. All findings were based on the initial voiding cystourethrogram. The majority of the ureters refluxed during the filling phase, with only 40 ureters refluxing during voiding or high-pressure phase of the study. Of interest, there was no difference in the eventual resolution, the need for eventual surgery, or change in the grade of reflux. The time to resolution was more rapid in the patients with reflux during the filling phase. This is an interesting finding, because the intuitive thought would be that patients with reflux during voiding would have a longer submucosal tunnel and would be more likely to have more rapid resolution of the reflux with observation. The authors hypothesize that the patients who refluxed during the voiding phase were more likely to have underlying voiding dysfunction and be more prone to urinary tract infection with a higher likelihood of intervention. Although their evaluation did not identify statistically significant difference with regard to need for surgery, there was a trend towards greater intervention in those with reflux during voiding. Hypothetically, these patients would also be good candidates for injectable therapy, as with a presumed longer submucosal tunnel they would be expected to have a good result with the subtrigonal implant therapy.
Elmore and colleagues[4] presented their results of the recently FDA-approved agent Deflux. Thirty-five patients completed follow-up evaluation, with voiding cystourethrogram at 3 months, including 54 infected ureters. Results were analyzed following a single Deflux injection. Preoperatively, there was a wide range of grade of reflux, the majority being Society for Fetal Urology (SFU) Grade 2 or 3. Overall, the authors reported that 63% (22 out of 35 ureters) of the patients had a successful outcome. With respect to number of ureters successfully managed, there was a 70% success rate (38 out of 54), which seems to be the recurring number in most of the literature following a single injection of Deflux. The interesting finding in this study was that de novo contralateral reflux was identified in 2 of 35 patients. This is a commonly described finding with unilateral open ureteral reimplantation. The cited risk of contralateral reflux typically ranges between 7% and 20%, depending on how many previous voiding cystourethrograms had been performed that demonstrated unilateral vesicoureteral reflux only. In addition, 1 patient of the 35 developed asymptomatic ureteral obstruction. This is the first patient described in any United States series and stresses the importance of follow-up radiograph evaluation of the upper tracts following ureteral surgery.
Ureteroceles
A review of the current management options for ureteroceles was presented during the Society of Pediatric Urology meeting on April 26, 2003. A panel of video presentations demonstrated the options for surgical intervention for ureteroceles, including open upper tract surgery, laparoscopic upper pole surgery, endoscopic ureterocele puncture, and lower urinary tract reconstruction. The videos demonstrated how each of these approaches could be applied to any patient; with multiple treatment options, however, the procedure should be selected based on patient age, presence of function in the ureterocele unit, and presence of reflux in either the lower pole or other renal units. One alternative approach that has been described previously in highly selected patients is watchful waiting.
Outcomes of watchful waiting for ureteroceles were presented from a group in Ottawa, Canada.[5] In a carefully selected group of 11 patients enrolled from 1990-2001, they demonstrated that watchful waiting was a reasonable option in some patients who present with ureteroceles. All 11 patients in the series presented with an antenatal diagnosis. No patient had high-grade lower pole vesicoureteral reflux, significant obstruction, severe hydronephrosis in the upper pole, or history of urinary tract infection. Patients were all managed with antibiotic prophylaxis for a mean of 1.5 years. They were evaluated with voiding cystourethrogram, ultrasound, and upper tract functional studies at diagnosis, followed by ultrasound every 3-6 months for 2 years and then 6 months thereafter. The majority of patients had low-grade hydronephrosis of SFU Grade 2 or less. This resolved in over half of the patients during follow-up. In addition, associated reflux to the lower pole was only Grade 2 or 3 in 6 patients, and in 5 patients it resolved with watchful waiting. Only 1 patient required surgery for breakthrough urinary tract infection. The difference between this study and the previous series presented in the literature[4] was that watchful waiting had previously been recommended only in patients with reasonable upper pole function. In this series, the function of the upper pole segment did not affect the outcome of watchful waiting. It should be mentioned that this was a very carefully selected group of patients who were followed carefully over time. In analyzing the patients, 4 presented with a single-system ureterocele with no evidence of obstruction, and in most centers, surgical intervention would not be considered in this patient. The 7 remaining patients all had ectopic ureteroceles, but again only had mild hydronephrosis in the upper pole and lower-grade reflux. In selecting patients for observational therapy, these criteria should be kept in mind.
Bladder Augmentation
Enterocystoplasty continues to be the most commonly used method for bladder augmentation. Despite its widespread use, there are short-term and long term risks associated with this procedure, including mucus production, electrolyte disturbances, increased risk of bladder stones, long-term risk of perforation, and also a small risk of malignancy. Ureterocystoplasty has been advocated in patients with dilated and poorly functioning upper tracts or with very dilated distal ureters. Most reports have shown favorable response in using the ureter as an alternative to augmentation cystoplasty.
Husmann and coworkers[6] presented their long-term results using ureterocystoplasty as an alternative to bladder augmentation with a bowel source. The study included 22 patients accumulated over the last 15 years. All patients presented with incontinence, and 18 out of 22 had a neuropathic bladder as the etiology of their urinary incontinence. Four had a history of posterior urethral valves. Two patients underwent ureterocystoplasty using segments from both ureters. Fourteen of the patients presented with a refluxing megaureter and 8 had nonrefluxing megaureters. The patients were evaluated based on strict urodynamic criteria of end-fill capacity with pressures < 40 cm of water. When augmented with a single-system ureter, they found a 2.5-fold increase in bladder capacity; when both ureters were used, a 3- to 4.5-fold increase in pressure-specific bladder capacity was seen. Despite the improvement in overall bladder capacity in the majority of the patients, the outcomes based on continence were less satisfactory. Only 9% of the patients were continent and voiding after the ureterocystoplasty. Nine percent were also continent and voiding with the addition of anticholinergic medications. Twenty-three percent were continent, but required intermittent catheterization to empty. An additional 13% were continent with intermittent catheterization and anticholinergics. This left 45% or almost half of the patients with persistent incontinence after ureterocystoplasty, and all of these patients eventually required repeat augmentation with an intestinal segment. Also of note, 1 patient developed perforation of the ureterocystoplasty following renal transplantation and died of overwhelming sepsis. The authors point out that although the risk of mucus, cancer, and stone are decreased with ureterocystoplasty, this procedure is associated with a reoperation rate of almost 50% and does not avoid the long-term risk of perforation seen in intestinal bladder augmentation.
References
1. Herz DB, Weiser A, Franco I, Reda E, Levitt S. Voiding dysfunction as an etiology for bulbar urethritis (urethrorrhagia) in children. Program and abstracts of the American Urological Association 98th Annual Meeting; April 26-May 1, 2003; Chicago, Illinois. Abstract 410.
2. Palagira AV, Steinhardt GF, Dector RM. A retrospective analysis on the diagnosis and management of idiopathic urethrorrhagia. Program and abstracts of the American Urological Association 98th Annual Meeting; April 26-May 1, 2003; Chicago, Illinois. Abstract 412.
3. Gutow SG, Karellas M, Murphy JP, Gatti JM. Prognostic value of reflux during the filling versus voiding phase of the VCUG. Program and abstracts of the American Urological Association 98th Annual Meeting; April 26-May 1, 2003; Chicago, Illinois. Abstract 416.
4. Elmore JM, Ewalt DH, Snodgrass WT. Initial results of Deflux injection for vesicoureteral reflux: the Dallas experience. Program and abstracts of the American Urological Association 98th Annual Meeting; April 26-May 1, 2003; Chicago, Illinois. Abstract 487.
5. Leonard MP, DiRenna T. Watchful waiting for antenatally detected ureteroceles. Program and abstracts of the American Urological Association 98th Annual Meeting; April 26-May 1, 2003; Chicago, Illinois. Abstract 420.
6. Husmann DA, Snodgrass W, Kramer SA. Ureterocystoplasty: How good is it? Program and abstracts of the American Urological Association 98th Annual Meeting; April 26-May 1, 2003; Chicago, Illinois. Abstract 485.
About Complete Care Medical, Inc.
We are one of the fastest growing fully accredited national catheter suppliers in the United States. We are dedicated to putting Patients first in everything we do, and providing them with convenience, choice and control. Need a catheter? What size? What brand? What type? WE HAVE IT!
For more about us please visit http://www.ccmedicalinc.com/
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