Dr.Azad A Haleem AL.MezoriDCH, FIBMS

Lecturer University Of DuhokCollege of Medicine

Pediatrics Department2016

azad82d@gmail.com

Fast and safe technique for collection of

urine in newborns

Main Aspects of presentation

• Introduction• Aims of the study• Patients and Methods • Results & Discussion• Conclusions & Recommendations.

Control of Muscles involved in Micturation

• The detrusor muscle is the (smooth) muscle of the bladder wall and, together with the urethral (internal) sphincter muscle , is innervated by the sympathetic nerve fibres from the lumbar sections of spinal cord, and also by the parasympathetic nerve fibres from sacral segments 2 - 4 of the spinal cord.

• These muscles are NOT under voluntary control.• However, the external urethral sphincter muscle is under

voluntary control, and as such is innervated by the SNS.

INTRODUCTION

Micturation Reflex

• Involuntary Action: by the Peripheral Nervous System (PNS).

• Voluntary Action: by the Cental Nervous System (CNS).

• The micturation reflex is an autonomic spinal cord reflex that initiates urination.

INTRODUCTION

INTRODUCTION• To achieve conscious bladder control, several

conditions must be present: awareness of bladder filling; cortical inhibition (suprapontine modulation) ability to consciously tighten the external

sphincter to prevent incontinence; normal bladder growth; and motivation by the child to stay dry.

INTRODUCTION

Normal Voiding and Toilet Training

• The fetus voids by reflex bladder contraction in concert with simultaneous contraction of the bladder and relaxation of the sphincter.

• The infant has coordinated reflex voiding as often as 15-20 times/day.

• At 2-4 yr, the child is developmentally ready to begin toilet training.

• Girls typically acquire bladder control before boys, and bowel control typically is achieved before bladder control.

INTRODUCTION

Urinary tract infections (UTIs)

• Urinary tract infections (UTIs) occur in 1-3% of girls and 1% of boys.

• The prevalence of UTIs varies with age. During the 1st yr of life, the male : female ratio is 3-5 : 1.

• Beyond 1-2 yr, there is a female preponderance, with a male : female ratio of 1 : 10.

INTRODUCTION

Urine Sample?

• Clean urine samples are necessary for accurate diagnosis of urinary tract infections (UTIs).

• A wide range of clinical interventions for urine collection is described in the literature, including noninvasive and invasive methods.

• The most common non invasive technique is urine collection using sterile bags, which is associated with patient discomfort and samples contamination.

• Obtaining a clean catch urine sample is the recommended method for urine collection in children able to cooperate.

• However, in children lacking sphincter control, urine catch is more difficult and time consuming and invasive methods (catheterisation and needle aspiration of urine from the bladder) are sometimes needed.

• There are some stimulation techniques that facilitate emptying of the bladder in situations of bladder dysfunction.

• Use of such methods in newborns could facilitate the collection of a clean catch urine sample.

INTRODUCTION

The aim of this study was to determine the success rate and

safety of a new noninvasive technique to obtain clean catch

urine samples in newborns.

Aims of the study

Patients and Methods• study location• Heevi pediatrics teaching hospital/

Duhok/Kurdistan/Iraq.• Study Design• A prospective feasibility and safety study • Duration of Data collection.• 2 months from 15th February 2016 to 15th

April 2016

• Selection of the study participants:• 75 participants from both genders their age

less than 30 days.

Patients and Methods

• Exclusion Criteria:• Participants with any illness or any other

apparently congenital disorders.• poor feeding, • dehydration,• drug administration prior to urine collection.

Patients and Methods

Technique

• Two people (physicians) were needed to perform the procedure, and a third to measure the time taken.

• This technique involves a combination of fluid intake and noninvasive bladder stimulation manoeuvres.

• The first step is either breastfeeding or providing formula intake for newborn.

• Twenty five minutes after feeding, the infant's genitals were cleaned.

• A sterile collector was placed near the baby in order to avoid losing urine samples.

• The second step is to hold the baby under their armpits with their legs dangling.

• One examiner then starts bladder stimulation which consists of a gentle tapping in the suprapubic area at a frequency of 100 taps or blows per minute for 30 s.

• The third step is stimulation of the lumbar paravertebral zone in the lower back with a light circular massage for 30 s.

• Both stimulation manoeuvres are repeated until micturition starts, and a midstream urine sample can be caught in a sterile collector .

• Success is defined as the collection of a sample within 5 min of starting the stimulation manoeuvres.

Data Analysis

• SPSS (statistical package for the social sciences) for windows version 19.

• A P-value of less than 0.05 was considered to be statistically significant.

Patients and Methods

RESULTS

The distribution of age & Gender

Participants No. (%)Age (Days)Mean(±SD.)

Boys 48 (64%) 9.62± 7.01

Girls 27 (36%) 13.29± 11

Total 75 (100%) 10.94±8.77

The mean time for sample collection

Participants Time (Seconds)

Median Mean(±SD.)

Boys 92.62±102.1 20

Girls 53.89±73.11 28

Total 79.4 ± 94.05 24

There was an 82.7% success rate (n=62/75)

• Urine was sometimes obtained before the end of the first cycle of stimulation (<60 s) in 35 participants.

• No statistically representative differences with regard to sex were found in success rate, time of sample collection or complications.

• No complications other than controlled crying were observed.

Discussion

• the procedure based on manoeuvres described for patients with bladder dysfunction to stimulate bladder emptying through reflex contraction of the detrusor muscle.

• The detrusor muscle is innervated by the parasympathetic pelvic nerves (S2–S4).

• The spinal micturition reflex is a simple arch reflex. • Distended bladder walls stimulate efferent fibres going to

the medulla, the arch reflex is produced in S2–S4, and afferent fibres stimulate the detrusor muscle which contracts to pass urine.

• This reflex is voluntarily inhibited and controlled in continent individuals by the cortex, but not in newborns.

• In neonates, it can be triggered, as we propose.

• this technique is effective in obtaining a urine sample in a majority of patients in an easy, safe and fast way.

• Bag changes, long waiting times and invasive techniques were avoided.

CONCLUSION AND RECOMMENDATIONS

Conclusions & Recommendations

• A new method to obtain midstream urine in newborns is described.

• It consists of feeding, bladder stimulation and paravertebral lumbar massage.

• The technique has been demonstrated to be safe, quick and effective.

• The discomfort and waste of time usually associated with bag collection methods can be avoided, as well as invasive techniques.

THANKS FOR YOUR ATTENTION