PEDIATRIC UROLOGY

Congenital adrenal hyperplasia and lower urinary tract symptoms
Davies MC, Crouch NS, Woodhouse CR, Creighton SM
Academic Department of Obstetrics and Gynaecology, University College London, London, UK
BJU Int. 2005; 95: 1263-6

• Objectives: To assess urinary symptoms in adult women with congenital adrenal hyperplasia (CAH), as feminizing surgery in infancy is current standard practice for CAH and one of the indications for surgery is to reduce urinary symptoms.
• Patients, Subjects and Methods: In a case-control study, 19 women with CAH, of whom 16 had had childhood feminizing genital surgery, and age-matched women with no CAH, were evaluated. Subjects and controls completed the Bristol Female Lower Urinary Tract Symptoms (BFLUTS) questionnaire.
• Results: Urge incontinence was reported in 13 (68%) patients and three (16%) controls (P = 0.003); stress incontinence was present in 47% and 26%, respectively (P = 0.31). Results from the controls were comparable with those documented in larger studies on normal populations. Nine of the patients felt that their urinary symptoms had an adverse effect on their lives, compared with only one of the controls (P = 0.008).
• Conclusion: Patients with a diagnosis of CAH are more likely to have significant urinary symptoms than normal controls. At present it is not clear whether this is a result of surgery or an effect of CAH. In at least two-thirds of patients surgery did not achieve the objective of reducing urinary symptoms.
  
  
• Editorial Comment
  The authors perform a questionnaire study of lower urinary tract symptoms in patients with congenital adrenal hyperplasia. They found a strikingly high rate of urge incontinence and an increased rate of stress incontinence in these patients compared with controls. Almost 50% of patients were bothered by their urinary tract symptomatology.
  This is an important first step in reporting urinary tract function in women with CAH. The results point to a significant problem and demonstrate that this is an issue that we should assess more carefully in the future treatment and evaluation of these patients.
  However, there are certain caveats. Only 19 CAH patients were evaluated and 3 had not had any genital or urinary tract surgery. Moreover, in the others, it is very unclear what exact surgery these patients had undergone and whether the procedure was performed by a specialist. Moreover, the same group has reported that many of these operations were inadequate in a similar group of patients. Because this was a questionnaire study (which may have the benefit of eliciting more symptomatology by virtue of its anonymity), we know nothing about urinary flow, residual urine or any other objective parameters of voiding. Strikingly, despite the fact that 47% felt the symptoms had an adverse effect on their lives, the patients apparently had not sought evaluation or treatment. Clearly more study is needed.
  Overall, this is an important study that reminds us of the need to be aware of these possible symptoms. It highlights how important it is for all of us to be aware of this issue and to offer evaluation and treatment for these problems.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA