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electromyography lag time and voiding history.J Urol 2011; 186: 1721.

5. Glassberg KI, Combs AJ and Horowitz M: Non-neurogenic voiding disorders in children andadolescents: clinical and videourodynamic find-ings in 4 specific conditions. J Urol 2010; 184:2123.

6. Heyns CF: Urinary tract infection associated withconditions causing urinary tract obstruction andstasis, excluding urolithiasis and neuropathicbladder. World J Urol 2012; 30: 77.

7. Twaij M: Urinary tract infection in children: a re-view of its pathogenesis and risk factors. J R SocPromot Health 2000; 120: 220.

8. De Paepe H, Hoebeke P, Renson C et al: Pelvic-floortherapy in girlswith recurrent urinary tract infectionsand dysfunctional voiding. Br J Urol 1998; 81: 109.

9. Loening-Baucke V: Urinary incontinence and uri-nary tract infection and their resolution withtreatment of chronic constipation of childhood.Pediatrics 1997; 100: 228.

EDITORIAL COMMENT

This study represents another contribution by the along with uroflowmetry to categorize patients.

authors on the topic of pediatric LUT dysfunction.Our pediatric colleagues argue against evaluatingchildren with afebrile UTIs, mainly to decrease theuse of invasive studies. Pediatric urologists continueto identify why children have infections and developprograms to cure the underlying cause. These pro-grams result in decreased invasive studies anddecreased surgery for VUR.1 A weakness of the newparadigm put forward by the American Academy ofPediatrics is not addressing the evaluation andmanagement of LUT dysfunction or understandingits relationship to UTI. High pressure voidingassociated with VUR and UTIs is a key factor in thedevelopment of renal scars.2

Unfortunately, in this report the diagnosticscheme is divided from treatment results, whichwill be the subject of a second report. Putting thediagnostic scheme and treatment results togetherwould have made this a better publication. Inaddition, it is disappointing that ICCS (Interna-tional Children’s Continence Society) terminologywas not used. Many have encouraged an update ofthe ICCS nomenclature specifically to include EMG

The individual institutional categorization used inthis report does not fit well with the ICCS symp-tomatic classification. We should continue to use theICCS classification and point out its deficienciesbecause it is important that we share terminology toadvance treatment methods and compare resultsfrom different centers.

Identifying and treating LUT dysfunction de-creases UTIs and the need to intervene surgicallyfor VUR. Evaluating children noninvasively with-out VCUG significantly decreases the number ofinvasive studies.3 Our approach results in lessinvasive studies, as our pediatric colleagues desire,but we get to that end point in a much different way.Not treating LUT dysfunction in a child with anafebrile UTI is a mistake.

Patrick H. McKennaDivision of Pediatric Urology

Department of Urology

School of Medicine and Public Health

University of Wisconsin

Madison, Wisconsin

REFERENCES

1. Herndon CD, DeCambre M and McKenna PH: Changing concepts concerning the management of vesicoureteral reflux. J Urol 2001; 166: 1439.

2. Avlan D, G€undo�gdu G, Tas‚kınlar H et al: Relationships among vesicoureteric reflux, urinary tract infection and renal injury in children with non-neurogenic lower urinarytract dysfunction. J Pediatr Urol 2011; 7: 612.

3. McKenna PH and Herndon CD: Voiding dysfunction associated with incontinence, vesicoureteral reflux and recurrent urinary tract infections. Curr Opin Urol 2000; 10: 599.

REPLY BY AUTHOR

While we tried to include the prevalence data pre- underlying cause or driving force behind each LUT

sented in this study and our treatment results in asingle report, the amount of information was toogreat and we thought that the data would bediluted. Treatment results have been published inThe Journal of Urology�.1 Also, we have had diffi-culty using the ICCS symptomatic classificationbecause it focuses on symptoms and not on the

condition. When treating symptoms and not thecause of those symptoms, treatment can be andoften is misdirected. Considering that the ICCS isworking toward a new classification and terminol-ogy statement, we hope that some of the focus willbe on the urodynamic causes of the LUT conditions.As mentioned, “many” think that the ICCS must

1500 URINARY TRACT INFECTION AND REFLUX IN CHILDREN WITH URINARY TRACT DYSFUNCTION

consider the importance of performing simultaneousEMG when uroflowmetry is done to better catego-rize patients for diagnosis and treatment. Yes, we

are part of that “many” and strongly believe thatgone are the days of making diagnostic assumptionsbased on the uroflowmetry pattern alone.2

REFERENCES

1. Fast AM, Nees SN, Van Batavia JP et al: Outcomes of targeted treatment for vesicoureteral reflux in children with nonneurogenic lower urinary tract dysfunction. J Urol2013; 190: 1028.

2. Wenske S, Combs AJ, Van Batavia JP et al: Can staccato and interrupted/fractionated uroflow pattern alone correctly identify the underlying lower urinary tractcondition? J Urol 2012; 187: 2188.