For the 2018 edition of the EAU Paediatric Urology Guidelines, the Guidelines Office have transitioned to a modified GRADE methodology. For each recommendation within the guidelines there is an accompanying online strength rating form which addresses a number of key elements namely:
- the overall quality of the evidence which exists for the recommendation;
- the magnitude of the effect (individual or combined effects);
- the certainty of the results (precision, consistency, heterogeneity and other statistical or study related factors);
- the balance between desirable and undesirable outcomes;
- the impact of patient values and preferences on the intervention;
- the certainty of those patient values and preferences.
These key elements are the basis which panels use to define the strength rating of each recommendation. The strength of each recommendation is determined by the balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence, and nature and variability of patient values and preferences. The strength of each recommendation is represented by the words ‘strong’ or ‘weak’.
In addition, four chapters of the Guidelines have been updated through a structured assessment of the literature and these aadditional references and text updates have been incorporated.
Key changes in the 2018 publication:
- Section 3.9 - Day-time lower urinary tract conditions: Both the literature and the text have been revised extensively;
- Section 3.10 - Monosymptomatic enuresis - bedwetting: the literature and the text have been revised
- extensively;
- Section 3.11 - Management of neurogenic bladder: Both the literature and the text have been revised
- extensively;
- Section 3.15 - Obstructive pathology of renal duplication: ureterocele and ectopic ureter: The literature has been updated resulting in minor amendments to the text.
1.5.1 New and changed recommendations
3.9.5 Recommendations for the management of day-time urinary tract conditions
| Recommendations | LE | Strength rating |
| Use two day voiding diaries and/or structured questionnaires for objective evaluation of symptoms, voiding drinking habits and response to treatment. | 2 | Strong
|
| Use a stepwise approach, starting with the least invasive treatment in managing day-time lower urinary tract dysfunction (LUTD) in children. | 4 | Weak
|
| Initially offer urotherapy involving bladder rehabilitation and bowel management. | 2 | Weak |
| If bladder bowel dysfunction is present, treat bowel dysfunction first, before treating the lower urinary tract condition. | 2 | Weak
|
| Use pharmacotherapy (mainly antispasmodics and anticholinergics) as second line therapy in OAB. | 1 | Strong
|
| Use antibiotic prophylaxis if there are recurrent infections. | 2 | Weak |
| Re-evaluate in case of treatment failure; this may consist of (video) urodynamics magnetic resonance imaging of lumbosacral spine and other diagnostic modalities, guiding off-label treatment which should only be offered in highly experienced centres. | 3 | Weak
|
3.10.5 Recommendations for the management of monosymptomatic nocturnal enuresis – bedwetting
| Recommendations | LE | Strength rating |
| Do not treat children less than five years of age in whom spontaneous cure is likely, but inform the family about the involuntary nature, the high incidence of spontaneous resolution and the fact that punishment will not help to improve the condition. | 2 | Strong |
| Use voiding diaries or questionnaires to exclude day-time symptoms. | 2 | Strong |
| Perform a urine test to exclude the presence of infection or potential causes such as diabetes insipidus. | 2 | Strong |
| Offer supportive measures in conjunction with other treatment modalities, of which pharmacological and alarm treatment are the two most important. | 1 | Strong
|
| Offer desmopressin in proven night-time polyuria. | 1 | Strong |
| Offer alarm treatment in motivated and compliant families. | 1 | Strong |
3.11.6 Recommendations for the management of neurogenic bladder
Recommendations
| LE | Strength rating |
| Urodynamic studies should be performed in every patient with spina bifida as well as in every child with high suspicion of a neurogenic bladder to estimate the risk for the upper urinary tract and to evaluate the function of the detrusor and the sphincter. | 2 | Strong
|
| In all newborns, intermittent catheterisation (IC) should be started soon after birth. In those with a clear underactive sphincter and no overactivity starting IC may be delayed. If IC is delayed, closely monitor babies for urinary tract infections, upper tract changes (US) and lower tract (UD). | 3 | Strong |
| Start early anticholinergic medication in the new-borns with suspicion of an overactive detrusor. | 2 | Strong |
| The use of suburothelial or intradetrusoral injection of onabotulinum toxin A is an alternative and a less invasive option in children who are refractory to anticholinergics in contrast to bladder augmentation. | 2 | Strong |
| Treatment of faecal incontinence is important to gain continence and independence. Treatment should be started with mild laxatives, rectal suppositories as well as digital. If not sufficient transanal irrigation is recommended, if not practicable or feasible, a Malone antegrade colonic enema (MACE)/Antegrade continence enema (ACE) stoma should be discussed. | 3 | Strong |
| Ileal or colonic bladder augmentation is recommended in patients with therapy-resistant overactivity of the detrusor, small capacity and poor compliance, which may cause upper tract damage and incontinence. The risk of surgical and non-surgical complications and consequences outweigh the risk for permanent damage of the upper urinary tract +/- incontinence due to the detrusor. | 2 | Strong |
| In patients with a neurogenic bladder and a weak sphincter, a bladder outlet procedure should be offered. It should be done in most patients together with a bladder augmentation. | 3 | Weak |
| Creation of a continent cutaneous catheterisable channel should be offered to patients who have difficulties in performing a IC through the urethra. | 3 | Weak |
| A life-long follow-up of renal and reservoir function should be available and offered to every patient. Addressing sexuality and fertility starting before/during puberty should be offered. | 3 | Weak |
| Urinary tract infections are common in children with neurogenic bladders, however, only symptomatic UTIs should be treated. | 3 | Weak |
3.15.5 Recommendations for the management of obstructive pathology of renal duplication±
ureterocele and ectopic ureter
| Recommendations | LE | Strength rating | ||
| Ureterocele | Diagnosis | Use ultrasound (US), radionuclide studies (mercaptoacetyltriglycine (MAG3)/dimercaptosuccinic acid (DMSA)), voiding cystourethrography (VCUG), magnetic resonance urography, high-resolution magnetic resonance imaging (MRI), and cystoscopy to assess function, to detect reflux and rule out ipsilateral compression of the lower pole and urethral obstruction. | 3 | Weak
|
| Treatment | Select treatment based on symptoms, function and reflux as well on surgical and parenteral choices: observation, endoscopic decompression, ureteral re-implantation, partial ephroureterectomy, complete primary reconstruction. | 3 | Weak
| |
Offer, early endoscopic decompression to patients with an obstructing ureterocele. | ||||
| Ectopic ureter | Diagnosis | Use US, DMSA scan, VCUG or MRI for a definitive diagnosis. | 3 | Weak
|
| Treatment | In non-functioning moieties with recurrent infections, heminephro-ureterectomy is a definitive solution. Ureteral reconstruction (ureteral re- implantation/ ureteroureterostomy/ureteropyelostomy and upper-pole ureterectomy) are other therapeutic options, especially in cases in which the upper pole has function worth preserving. | 3 | Weak | |