ABSTRACT Background: Parasacral Transcutaneous Electrical Nerve Stimulation (PTENS) is a treatment used in enuresis refractory to first-line treatment. This review aimed to evaluate the effectiveness of PTENS in treating monosymptomatic enuresis (MNE) in children and adolescents. Methods: The study followed the Preferred Reporting Items for Systematic (PRISMA) guidelines. The search was carried out in the following databases: MEDLINE (via PubMed), Web of Science, SCOPUS, Central Cochrane Library and Physiotherapy Evidence Database (PEDro). The selected studies were randomized clinical trials (RCTs). The "Risk of Bias tool for randomized trials" and the "Risk of Bias VISualization" were used to analyze the risk of bias. Results: Of the 624 studies selected, four RCTs were eligible. Three included 146 children and adolescents aged between six and 16.3 years and used similar PTENS protocols with a frequency of 10 Hz, pulse duration of 700 µs and 20 minutes three times/week. One study enrolled 52 patients aged seven to 14 years used PTENS at home, with a pulse duration of 200 µs and 20 to 60 minutes twice/day. Risk of bias was observed in three studies due to results’ randomization and measurement. Two studies showed a partial response with a reduction in wet nights, one a complete response in 27% of patients, and one showed no improvement. Conclusion: PTENS reduces wet nights’ frequency but does not cure them, except in 27% of patients in one study. Limited RCTs and data heterogeneity are limitations. Background (PTENS firstline first line MNE (MNE Methods PRISMA (PRISMA guidelines databases via PubMed, PubMed , PubMed) Science SCOPUS PEDro. PEDro . (PEDro) RCTs. (RCTs) VISualization Results 62 eligible 163 16 3 16. 1 Hz 70 2 timesweek times week times/week 5 home 6 twiceday twice day twice/day results measurement nights 27 improvement Conclusion them limitations (PEDro (RCTs 7

Abstract Objective: Enuresis is associated with attentional and emotional comorbidities in 20 to 30 % of cases. The Short Screening Instrument for Psychological Problems in Enuresis (SSIPPE) is a questionnaire that allows the initial screening of these comorbidities. This study aimed to translate, culturally adapt, and validate the SSIPPE for Brazilian children and adolescents (SSIPPE-Br). Methods: Six steps were performed for translation and cross-cultural adaptation: translation, synthesis of translations, back-translation, preparation of the pre-final version of the translated instrument, test of comprehensibility of the pre-final version of the tool, and elaboration of the instrument cross-culturally adapted for Brazil, named 13-itens version SSIPPE-Br. To validate the SSIPPE-Br, a cross-sectional study was carried out, in which the validated Brazilian version of the Child and Adolescent Behavior Inventory (CABI) was used. Results: Validation was performed on 127 children and adolescents with a mean age of 9.7 ± 2.8 years, 48 % male. The reliability was estimated using Cronbach’s alpha, ranging from 0.86 to 0.89, indicating good internal consistency. The factorial analysis had a good agreement adjustment (KMO 0.755, Bartlett’s test < 0.001) and explained 70.5 % of the data variability. In the reproducibility analysis, the Kappa coefficient ranged from 0.94 to 1, which can be considered almost perfect. A highly significant (p-value < 0.001) and direct correlation existed between the three SSIPPE-Br domains and all evaluated CABI domains. Conclusion: The SSIPPE-Br is a valid and reliable tool for emotional problems screening and ADHD symptoms in children and adolescents with enuresis whose first language is Brazilian Portuguese. Objective 2 3 cases (SSIPPE translate adapt SSIPPEBr. SSIPPEBr Br . (SSIPPE-Br) Methods crosscultural cross cultural adaptation translations backtranslation, backtranslation back back-translation prefinal pre final crossculturally Brazil 13itens itens 13 Br. SSIPPEBr, Br, crosssectional sectional out (CABI used Results 12 97 9 7 9. 28 8 2. years 4 male Cronbachs Cronbach s alpha 086 0 86 0.8 089 89 0.89 consistency KMO 0755 755 0.755 Bartletts Bartlett 0.001 0001 001 705 70 5 70. variability 094 94 0.9 1 perfect pvalue p value Conclusion Portuguese (SSIPPE-Br 08 0. 075 75 0.75 0.00 000 00 09 07 0.7 0.0

ABSTRACT Purpose: This study aimed to analyze the diagnostic accuracy of dynamic and static ultrasound (DSUS) in detecting vesicoureteral reflux (VUR) and renal scarring in a cohort of children with neurogenic bladder (NB). Materials and Methods: A retrospective, longitudinal, observational study was conducted using the Reporting Diagnostic Accuracy Studies guideline. The DSUS (index test) data were compared with voiding cystourethrography (VCUG) and renal scintigraphy 99mTc-dimercaptosuccinic (reference tests). Overall performance for predicting VUR and renal scarring was assessed using renal pelvic diameter (RPD)/distal ureteral diameter and renal parenchymal thinning on DSUS, respectively. Results: A total of 107 patients (66 girls, median age 9.6 years) participated. Seventeen patients (15.9%) presented VUR, eight bilateral. For overall reflux grade, the AUC was 0.624 for RPD and 0.630 for distal ureteral diameter. The diagnostic performance for detecting high-grade VUR was slightly better for DSUS parameters. The AUC was 0.666 for RPD and 0.691 for distal ureteral diameter. The cut-offs of 5 mm for RPD and 6.5 mm for distal ureteral diameter presented the best diagnostic odds ratio (DOR) to identify high-grade VUR. The increase of RPD during detrusor contractions showed an accuracy of 89.2%. The thinness of renal parenchyma presented an accuracy of 88% for renal scarring. Conclusion: DSUS predicts VUR and renal scarring in children with NB with fair to good accuracy, and all measurements exhibited a high negative predictive value (NPV). The increase in RPD during voiding or detrusor contractions proved to be the most accurate parameter for indicating the presence of VUR in this study. Purpose (DSUS (VUR NB. . (NB) Methods retrospective longitudinal guideline index test VCUG (VCUG 99mTcdimercaptosuccinic mTcdimercaptosuccinic 99mTc dimercaptosuccinic mTc reference tests. tests tests) RPD/distal RPDdistal /distal respectively Results 10 66 (6 girls 96 9 6 9. years participated 15.9% 159 15 (15.9% bilateral grade 0624 0 624 0.62 0630 630 0.63 highgrade parameters 0666 666 0.66 0691 691 0.69 cutoffs cut offs 65 6. DOR (DOR 892 89 2 89.2% 88 Conclusion NPV. NPV (NPV) (NB 1 ( 15.9 (15.9 062 62 0.6 063 63 066 069 69 8 89.2 (NPV 15. (15. 06 0. 89. (15 (1

ABSTRACT Objective: This study aimed to translate, and perform a cross-cultural adaptation, and validation of the Vancouver Symptom Score (VSS) for bladder and bowel dysfunction (BBD) for Brazilian children and adolescents Materials and Methods: Six steps were performed for the translation and cross-cultural adaptation: (1) translation, (2) synthesis of translations, (3) back-translation, (4) pre-final version of the translated instrument, (5) pilot test and degree of comprehensibility and (6) elaboration of the Brazilian version of the VSS. For validation, the Brazilian Dysfunctional Voiding Score (DVSS) questionnaire was used. Results: Validation was performed on a sample of 107 children and adolescents with a mean age of 9.2 ± 2.84 years, presenting BBD and 107 without BBD (control group-CG). There was a positive correlation (r = 0.91, 95% CI 0.88 to 0.93, p < 0.0001) between total VSS score and total DVSS score. VSS was higher in patients with BBD (p < 0.0001). The internal consistency estimated by Cronbach's alpha was 0.87 for patients with BBD. The VSS showed excellent diagnostic accuracy in detecting cases, with an area under the ROC curve of 98% (95% CI 0.96 to 0.99, p < 0.001). A cut-off value of >11 points produced a sensitivity of 100% (95% CI 96.4% to 100%) and a specificity of 91.8% (95% CI 85.1% to 95.6%). Conclusion: The translated, cross-culturally adapted, and validated VSS for the Brazilian population is a reliable and valid tool to identify symptoms of BBD in children and adolescents aged five to 16 years, whose first language is Brazilian Portuguese. Objective translate crosscultural cross cultural adaptation (VSS (BBD Methods 1 (1 2 (2 translations 3 (3 backtranslation, backtranslation back back-translation 4 (4 prefinal pre final instrument 5 (5 6 (6 (DVSS used Results 10 92 9 9. 284 84 2.8 years control groupCG. groupCG group CG . group-CG) r 091 0 91 0.91 95 088 88 0.8 093 93 0.93 0.0001 00001 0001 0.0001. Cronbachs Cronbach s 087 87 cases 98 (95 096 96 0.9 099 99 0.99 0.001. 0.001 001 0.001) cutoff cut off 11 >1 100 964 96.4 918 8 91.8 851 85 85.1 95.6%. 956 95.6% 95.6%) Conclusion crossculturally culturally adapted Portuguese ( 28 2. group-CG 09 08 0. 0.000 0000 000 (9 0.00 00 > 96. 91. 85. 95.6 0.0 95.

ABSTRACT Objective: Primary monosymptomatic nocturnal enuresis (PMNE) is a prevalent condition in childhood, and the pathophysiology is multifactorial. This study investigated the relationship between the toilet training process (TT) and PMNE in children and adolescents. Patients and Methods: A case-control study was carried out from 2015 to 2020. The presence of PMNE was identified according to International Children's Continence Society criteria. A semi-structured questionnaire was applied to assess TT. Results: The study included 103 children and adolescents with PMNE and 269 participants with normal psychomotor development without PMNE (control group [CG]). Readiness signals were more remembered and less frequent in participants with PMNE (p=0.001) when compared to control group. No differences were found between the groups regarding the onset age of the daytime TT (p= 0.10), the nocturnal TT (p=0.08), the acquisition of daytime continence (p=0.06), and the type of equipment used for the TT (p=0.99). The use of Child-Oriented approach in group of children with enuresis was lower than in controls [87.4% (90/103) versus 94% (250/266)], respectively (OR= 0.44, 95% CI 0.21-0.94, p = 0.039). Conclusions: The age of onset of TT, acquisition of daytime continence, and the type of equipment were not associated with higher occurrence of PMNE. On the other hand, the Child-Oriented approach was a protective factor for the occurrence of PMNE.

ABSTRACT Introduction: The present study aims to investigate the prevalence of lower tract urinary symptoms (LUTS) and symptoms of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents and their association in a community setting using validated scoring instruments. Materials and Methods: A cross-sectional study was carried out from February 2015 to December 2019, during which the parents or guardians of 431 children and adolescents from 5 to 13 years of age, attending a general pediatric outpatient clinic were interviewed. Results: The prevalence of ADHD symptoms and LUTS were 19.9% and 17.9%, respectively. Of the 82 children and adolescents with ADHD, 28% (23) had LUTS (OR 2.31, 95% CI 1.28 to 3.75, p=0.008). Mean total DVSS score in children in the group of children presenting ADHD symptom was significantly higher than those without ADHD symptom (10.2±4.85 vs. 4.9±2.95, p=0.002). Urgency prevailed among LUTS as the most frequent symptom reported by patients with ADHD symptoms (p=0.004). Analyzing all subscales of the DVSS, the items “When your child wants to pee, can't he wait? “Your child holds the pee by crossing his legs, crouching or dancing?” were higher in those with ADHD symptoms (p=0.01 and 0.02, respectively). Functional constipation was present in 36.4% of children with LUTS and 20.7% without LUTS (OR 4.3 95% CI 1-5.3 p=0.001). Conclusion: Children and adolescents with ADHD symptoms are 2.3 times more likely to have LUTS. The combined type of ADHD was the most prevalent among them.

ABSTRACT Purpose: Toilet training (TT) is an important marker in a child's physical and psychosocial development. The present study aimed to evaluate aspects associated to delayed TT. Material and Methods: We interviewed 372 parents of children who had completed TT up to 48 months before the interview. The questionnaires were applied at school exits when parents went to pick their children up and at public parks. Questions included demographics, aspects related to TT, dysfunction voiding symptom score and evaluation of constipation. Results: The interviews were performed at a mean of 15.3±10.4 (0 to 47) months after the end of TT. Girls accounted for 53% of the sample. The mean age at finishing TT was 31.6±9.3 months and similar in both genders (p=0.77). TT occurred before school entry in 45.7% of the children and medical advice for TT was sought only by 4.8% of the parents. No association was observed of age at completing TT and presence of lower urinary tract symptoms (LUTS) (p=0.57) and/or constipation (p=0.98). In the univariate analysis, prematurity (OR=2.7 [95% CI 2.3-3.1], p <0.0001) and mothers who work outside their household (OR=1.8 [95% CI 1.4-2.3], p <0.0001) were associated to delayed TT. Conclusion: Children completed TT at a mean of 2 years and 7 months of age. The age of completing TT was not related to LUTS and/or constipation. Premature children and those whose mothers work outside the home finish TT later.

ABSTRACT Introduction Evidence indicates an increase in the prevalence of enuresis in individuals with sickle cell disease. The present study aims to evaluate the prevalence and impact of enuresis on quality of life in individuals with sickle cell disease. Materials and Methods This cross-sectional study evaluated individuals with sickle cell disease followed at a reference clinic, using a questionnaire designed to evaluate the age of complete toilet training, the presence of enuresis and lower urinary tract, and the impact on quality of life of these individuals. Results Fifty children presenting SCD (52% females, mean age ten years) were included in the study. Of those, 34% (17/50) presented as HbSC, 56% with HbSS (28/50), 2% Sα-thalassemia (1/5) and 8% the type of SCD was not determined. The prevalence of enuresis was 42% (21/50), affecting 75% of subjects at five years and about 15% of adolescents at 15 years of age. Enuresis was classified as monosymptomatic in 33.3% (7/21) and nonmonosymptomatic in 66.6% (14/21) of the cases, being primary in all subjects. Nocturia was identified in 24% (12/50), urgency in 20% (10/50) and daytime incontinence 10% (5/50) of the individuals. Enuresis had a significant impact on the quality of life of 67% of the individuals. Conclusion Enuresis was highly prevalent among children with SCD, and continues to be prevalent throughout early adulthood, being more common in males. Primary nonmonosymptomatic enuresis was the most common type, and 2/3 of the study population had a low quality of life.

Resumo Objetivos Crianças com síndrome de Down apresentam desenvolvimento psicomotor atrasado, fator que influencia o nível de dificuldade do treinamento esfincteriano. O presente estudo tem como objetivo estimar a idade em que o treinamento esfincteriano é iniciado e concluído em crianças com SD em comparação com crianças com desenvolvimento psicomotor normal, avaliar o método e o tipo de treinamento esfincteriano utilizado com maior frequência, bem como sua associação com sintomas do trato urinário inferior e constipação funcional. Métodos Um estudo caso-controle foi realizado de 2010 a 2015. Todos os pais preencheram um questionário destinado a avaliar o processo de treinamento esfincteriano. O sintomas do trato urinário inferior foram avaliados por meio da aplicação do Dysfunctional Voiding Symptom Score. A presença de constipação funcional foi avaliada de acordo com os critérios Roma III. Resultados O estudo incluiu 93 crianças com síndrome de Down e 204 crianças com desenvolvimento psicomotor normal (Grupo de Controle [GC]). A idade média em que as crianças iniciaram o treinamento esfincteriano foi de 22,8 meses naquelas com SD e 17,5 meses no GC (p = 0,001). Em crianças com SD, a idade média ao concluir o treinamento esfincteriano foi de 56,2 meses e 27,1 meses no GC (p = 0,001). Entre as crianças com SD, as do sexo feminino concluíram o treinamento esfincteriano mais cedo (p = 0,02). O método de treinamento esfincteriano mais utilizado foi a abordagem voltada para a criança em ambos os grupos. Não houve associação com a presença de sintomas do trato urinário inferior ou constipação funcional e a idade no início e na conclusão do treinamento esfincteriano em ambos os grupos. Conclusão Crianças com síndrome de Down apresentaram tempo de treinamento esfincteriano prolongado. Estudos longitudinais prospectivos são essenciais para obter uma visão do treinamento esfincteriano dessas crianças.

Abstract Objectives Children with Down syndrome have delayed psychomotor development, which is a factor that influences the level of difficulty in toilet training. The current study aims to estimate the age toilet training starts and completes in children with DS compared to children with normal psychomotor development and to evaluate the method and type of toilet training most frequently used, as well as its association with lower urinary tract symptoms and functional constipation. Methods A case-control study was carried out from 2010 to 2015. All parents completed a questionnaire designed to assess the toilet training process. Lower urinary tract symptoms were assessed through the application of the Dysfunctional Voiding Symptom Score. The presence of functional constipation was assessed according to the Rome III criteria. Results The study included 93 children with Down syndrome and 204 children with normal psychomotor development (control group [CG]). The mean age of toilet training onset was 22.8 months in those with DS and 17.5 months in the CG (p = 0.001). In children with DS, the mean age when completing toilet training was 56.2 months and 27.1 months in the CG (p = 0.001). Among children with DS, females completed toilet training earlier (p = 0.02). The toilet training method used most often was child-oriented approach in both groups. No association was observed with the presence of lower urinary tract symptoms or functional constipation and the age of beginning and completing toilet training in both groups. Conclusion Children with Down syndrome experienced prolonged toilet training time. Prospective longitudinal studies are essential to gain insight into the toilet training of these children.

Resumo Introdução: A criptorquidia é uma condição comum e prevalente em pacientes com síndrome de Down. Fatores ambientais, como o tabagismo, estão associados a malformações fetais. A avaliação da prevalência do criptorquidismo e a associação com tabagismo dos pais na síndrome de Down podem contribuir para alertar os profissionais de saúde e familiares sobre a prevenção dos danos causados pelo criptorquidismo e os possíveis fatores predisponentes. Objetivo: Avaliar a prevalência de criptorquidismo na síndrome de Down e a associação com tabagismo materno e paterno. Método: Quarenta (40) pacientes acompanhados em um centro de referência para atendimento da síndrome de Down foram avaliados por meio de questionário semiestruturado para avaliação de antecedentes parentais e características sociodemográficas, bem como de exames físico e laboratoriais complementares. Resultados: Criptorquidia foi observada em 27,5% dos pacientes (IC95% 15,98-42,96). Nesses pacientes, o criptorquidismo foi encontrado em 55% (5/9) das crianças cujas mães fumavam e em 19,35% (6/31) daquelas cujas mães não fumavam (OR = 5,26 [IC95% 1,06-25,41]; p=0,032). Do mesmo modo, o tabagismo paterno foi observado com maior frequência entre crianças com criptorquidia, 63,36% (7/11) e 31,03% (9/29), respectivamente (OR = 3,89 [IC95% 0,91-16,73]; p=0,060). Conclusão: A prevalência de criptorquidismo é alta em pacientes com síndrome de Down. Podemos mostrar uma forte associação entre hábito tabágico dos pais e ocorrência de criptorquidismo, especialmente no caso de tabagismo materno.

Summary Introduction: Cryptorchidism is a common and prevalent condition in patients with Down syndrome. Environmental factors, such as smoking, can be associated with malformations during fetal development. The study of the prevalence of cryptorchidism and its association with parental tobacco use in Down syndrome can contribute to alert health care professionals, patients and family members regarding the prevention of the harms caused by cryptorchidism and its possible predisposing factors. Objective: To evaluate the prevalence of cryptorchidism in Down syndrome and its association with maternal and paternal smoking. Method: Forty (40) patients of a public clinic specialized in Down syndrome were evaluated, using a semi-structured questionnaire for evaluation of antecedents and sociodemographic characteristics, as well as physical and complementary examinations. Results: Cryptorchidism was observed in 27.5% of the patients (95CI 15.98-42.96). Of these, 55% (5/9) were the children of mothers who smoked during pregnancy, and 19.35% (6/31) were the children of mothers who did not smoke during pregnancy (OR = 5.26 [95CI 1.06-25.41]; p=0.032). Similarly, paternal smoking was also observed in greater frequency among the parents of cryptorchid patients compared with subjects with descended testis, 63.36% (7/11) and 31.03% (9/29), respectively (OR = 3.89 [95CI 0.91-16.73]; p=0.060). Conclusion: The prevalence of cryptorchidism is high in patients with Down syndrome. We can show a strong association between smoking parents and the occurrence of cryptorchidism, especially when it comes to maternal smoking.