Question one REFERENCES: 8. O’Flynn KJ, Murphy R,Thomas DG. Neurogenic bladder dysfunction in lumbar Continuing Medical Education Project: 1. Vega, P.J. and L.A. Pascual, High-pressure bladder: an underlying factor mediating renal intervertebral disc prolapse. Br J Urol 1992.;69:38-40. Learning damage in the absence of reflux? BJU Int, 2001. 87(6): p. 581-4. 9. Yamanishi T, Yasuda K,Yuki T, Sakakibara R, Uchiyama T, Kamai T, Tsujii T, Yoshida K. 2. Koff, S.A., T.T. Wagner, and V.R. Jayanthi, The relationship among dysfunctional Urodynamic evaluation of surgical outcome in patients with due to central OAB In Special Populations Objectives: elimination syndromes, primary vesicoureteral reflux and urinary tract in children. lumbar disc prolapse. Neurouro Urodyn 2003, 22: 670-675. 1. To understand the risk factors J Urol, 1998. 160(3 Pt 2): p. 1019-22. 10. Inui Y, Doita M, Ouchi K, Tsukuda M, Fujita N, Kurosaka M. Clinical and radiological Craig V. Comiter, MD for children with overactive 3. Bachelard, M., et al., Urodynamic pattern in infants with urinary tract . J Urol, features of lumber spinal stenosis and disc herniation with neurogenic bladder. Spine 2004; Associate Professor of 1998. 160(2): p. 522-6. 29: 869-873. Director, FPMRS Fellowship bladder, and the evaluation 4. Varlam, D.E. and J. Dippell, Non-neurogenic bladder and chronic renal insufficiency in 11. Dong D, Xu Z, Shi B, Chen J, Jiang X, Wang H. Clinical significance of urodynamic studies Stanford University and treatment of simple childhood. Pediatr Nephrol, 1995. 9(1): p. 1-5. in neurogenic bladder dysfunction caused by intervertebral disk hernia. Neurourol Urodyn nocturnal in children. 5. Ural, Z., I. Ulman, and A. Avanoglu, Bladder dynamics and vesicoureteral reflux: factors 2006; 25: 446-450. associated with idiopathic lower urinary tract dysfunction in children. J Urol, 2008. 179(4): 12. Gallien P, Robineau S, Nicolas B, Le Bot MP, Brissot R, Verin M. Vesicourethral Disclosure record for Craig Vance Comiter, M.D. 2. To understand the specialized p. 1564-7. Retik AB dysfunction and urodynamic findings in multiple sclerosis: a study of 149 cases. Arch Phys Last reviewed/edited this information on February 16, 2011. evaluation and treatment of Med Rehabil. 1998 Mar: 79:255-7. Coloplast: Consultant; Curant: Consultant or Advisor 6. Perlmutter AD, Gross RE. Cutaneous ureteroileostomy in children. N Eng J Med 1967; in 277:217-22. 13. Hennessey A, Robertson NP, Swingler R, Compston DA. Urinary, faecal and sexual 7. Bauer SB: The management of spina bifida from birth onwards. In Whitaker RH, Woodard dysfunction in patients with multiple sclerosis. J Neurol. 1999 Nov: 246:1027-32. the elderly. JR (eds): Paediatric Urology. London, Butterworths, 1985, pp 87–112. 14. Kasabian NG, Krause I, Brown WE, Khan Z, Nagler HM. Fate of the upper urinary tract 3. To be able to distinguish in multiple sclerosis. Neurourol Urodyn. 1995: 14:81-5. 8. Bauer SB: Early evaluation and management of children with spina bifida. In King LR [ed]: neurogenic versus non- Urologic Surgery in Neonates and Young Infants. Philadelphia, WB Saunders, 1988, 15. Koldewijn EL, Hommes OR, Lemmens WA, Debruyne FM, van Kerrebroeck PE. pp 252–264. Relationship between lower urinary tract abnormalities and -related parameters in neurogenic causes of 9. Wilcock AR, Emery JL: Deformities of the renal tract in children with myelomeningocele multiple sclerosis. J Urol. 1995 Jul: 154:169-73. overactive bladder symptoms. and hydrocephalus, compared with those children showing no such deformities. Br J Urol 16. Mayo ME, Chetner MP. Lower urinary tract dysfunction in multiple sclerosis. Urology. 42:152-9, 1970. 1992 Jan: 39:67-70. 10. Hunt GM, Whitaker RH: The pattern of congenital renal anomalies associated with 17. Porru D, Campus G, Garau A, et al. Urinary tract dysfunction in multiple sclerosis: is there a relation with disease-related parameters? Spinal Cord. 1997 Jan: 35:33-6. neural tube defects. Dev Med and Child Neurol 29:91-5, 1987. QUESTION 1: Which of the following groups of children with overactive bladder symptoms 11. Yeung CK, Sihoe JDY. Voiding dysfunction in children: non-neurogenic and neurogenic. 18. Litwiller SE, Frohman EM, Zimmern PE. Multiple sclerosis and the urologist. J Urol. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 1999 Mar: 161:743-57. and should have specialist management from the outset of their evaluation? 9th ed. Philadelphia, PA: Saunders Elsevier; 2007, pp. 3604-3625. question four REFERENCES: A. Associated vesicoureteral reflux question two REFERENCES: 1. Resnick, N.M. & Yalla, S.V. (1985). Management of Urinary Incontinence in the Elderly. B. Associated urinary tract infections 1. Diokno, A.C. et al. Prevention of urinary incontinence by behavioral modification NEJM, 313: 800-804. C. program: a randomized, controlled trial among older women in the community. J Urol 171, Associated neuropathy question five REFERENCES: 1165-1171, 2004. D. Monosymptomatic 2. Teunissen, T.A., de Jonge, A., van Weel, C. & Lagro-Janssen, A.L. Treating urinary 1. Rittig, S., Schaumburg, H. L., Siggaard, C. et al.: The circadian defect in plasma incontinence in the elderly—conservative therapies that work: a systematic review. Journal and output is related to response and enuresis status in of Family Practice 53, 25-30, 32 (2004). children with nocturnal enuresis. Journal of Urology, 179: 2389, 2008. 3. Ostaszkiewicz, J. A clinical nursing leadership model for enhancing continence care for 2. Butler, R. J., Holland, P.: The three systems: a conceptual way of understanding nocturnal older adults in a subacute inpatient care setting. J Wound Ostomy Continence Nurs 33, Enuresis. Scandinavian Journal of Urology & Nephrology, 34: 270, 2000. 624-629 (2006). 3. Neveus, T., Hetta, J., Cnattingius, S. et al.: Depth of and sleep habits among enuretic QUESTION 2: Which of the following behavioral interventions have been shown to be 4. Loening-Baucke, V. & Anuras, S. Effects of age and sex on anorectal manometry. and incontinent children. Acta Paediatrica, 88: 748, 1999. American Journal of Gastroenterology 80, 50-53 (1985). 4. Hjalmas, K., Arnold, T., Bower, W. et al.: Nocturnal enuresis: an international evidence effective for frail older people with cognitive and physical impairment for ameliorating the symptoms 5. Ostaszkiewicz, J., Johnston, L. & Roe, B. Timed voiding for the management of urinary based management strategy. Journal of Urology, 171: 2545, 2004. of overactive bladder (OAB) and urge incontinence? 5. Al-Waili, N. S.: Increased urinary nitrite excretion in primary enuresis: effects of incontinence in adults. Cochrane Database of Systematic Reviews, CD002802 (2004). A. Timed voiding 6. Schnelle, J.F., MacRae, P.G., Ouslander, J.G., Simmons, S.F. & Nitta, M. Functional indomethacin treatment on urinary and serum osmolality and electrolytes, urinary volumes Incidental Training, mobility performance, and incontinence care with nursing home and nitrite excretion. BJU International, 90: 294, 2002. B. Habit training residents. Journal of the American Geriatrics Society 43, 1356-1362 (1995). 6. Glazener, C. M., Evans, J. H., Peto, R. E.: Alarm interventions for nocturnal enuresis in C. children.[update in Cochrane Database Syst Rev. 2005;(2):CD002911; PMID: 15846643] Combined toileting and exercise therapy 6. van Houten, P., Achterberg, W. & Ribbe, M. Urinary incontinence in disabled elderly D. women: a randomized clinical trial on the effect of training mobility and toileting skills to [update of Cochrane Database Syst Rev. 2001;(1):CD002911; PMID: 11279776]. Cochrane Prompted voiding achieve independent toileting. Gerontology 53, 205-210 (2007). Database of Systematic Reviews: CD002911, 2003. E. DDAVP 7. Palmer M.H: Effectiveness of prompted voiding for incontinent nursing home residents, 7. Hunsballe, J. M., Hansen, T. K., Rittig, S. et al.: The efficacy of DDAVP is related to the in Melnyk BM and Fineout-Overholt E: Evidence-Based Practice in Nursing & Healthcare: A Circadian rhythm of urine output in patients with persisting nocturnal enuresis. Clinical Guide to the Best Practice. Philadelphia, Lippincott Williams & Williams, 2005, pp 20-30. Endocrinology, 49: 793, 1998. 8. Glazener, C. M., Evans, J. H.: Desmopressin for nocturnal enuresis in children.[update of question three REFERENCES: Cochrane Database Syst Rev. 2000;(2):CD002112; PMID: 10796860]. Cochrane Database of Systematic Reviews: CD002112, 2002 91. 1. Honig LS, Mayeux R.: Natural history of Alzheimer’s disease. Aging 2001; 13:171-182. QUESTION 3: Which of the following neurologic are typically associated with 2. Cacabelos R, Rodriguez B, Carrrera C, Caamano J, Beyer K, Lao JI et al.: APOE-related 9. Tullus, K., Bergstrom, R., Fosdal, I. et al.: Efficacy and safety during long-term treatment frequency of cognitive and noncognitive symptoms in . Methods Find Exp Clin of primary monosymptomatic nocturnal enuresis with desmopressin. Swedish Enuresis Trial OAB symptoms? Pharmacol 1996; 18:693-706. Group. Acta Paediatrica, 88: 1274, 1999. A. Alzheimer’s disease 3. Carlo A, Lamassa M, Baldereschi M, Pracucci G, Basile AM, Wolfe CD, et al. Sex differences 10. Robson, W. L., Shashi, V., Nagaraj, S. et al.: Water intoxication in a patient with the in the clinical presentation, resource use, and 3-month outcome of acute stroke in Europe: data Prader-Willi syndrome treated with desmopressin for nocturnal enuresis. Journal of Urology, B. Cerebrovascular accident from a multicenter multinational hospital-based registry. Stroke. 2003 May;34(5):1114-9. 157: 646, 1997. C. Multiple sclerosis 4. Sakakibara R, Hattori T, Yasuda K, Yamanishi T. Micturitional disturbance after acute 11. Neveus, T.: , desmopressin and enuresis. Journal of Urology, 166: 2459, 2001. D. hemispheric stroke: analysis of the lesion site by CT and MRI. J Neurol Sci. 1996 12. Kosar, A., Arikan, N., Dincel, C.: Effectiveness of oxybutynin hydrochloride in the Cauda equine syndrome Apr;137(1):47-56. treatment of enuresis nocturna--a clinical and urodynamic study. Scandinavian Journal of 5. Amarenco G, Kerdraon J, Denys P. [Bladder and sphincter disorders in multiple sclerosis. Urology & Nephrology, 33: 115, 1999. Clinical, urodynamic and neurophysiological study of 225 cases]. Rev Neurol (Paris). 1995 13. Geller, B., Reising, D., Leonard, H. L. et al.: Critical review of use Dec: 151:722-30. in children and adolescents. J Am Acad Child Adolesc , 38: 513, 1999. 6. Giannantoni A, Scivoletto G, Di Stasi SM, Grasso MG, Vespasiani G, Castellano V. 14. Glazener, C. M. A., Evans, J. H. C., Peto, R. E.: Tricyclic and related drugs for nocturnal Urological dysfunctions and upper urinary tract involvement in multiple sclerosis patients. enuresis in children.[update of Cochrane Database Syst Rev. 2000;(3):CD002117; PMID: QUESTION 4: Transient causes of OAB and urge incontinence in the elderly include which Neurourol Urodyn. 1998: 17:89-98. 10908525]. Cochrane Database of Systematic Reviews: CD002117, 2003. of the following except: 7. Giannantoni A, Scivoletto G, Di Stasi SM, et al. Lower urinary tract dysfunction and disability 15. Yeung CK, Sihoe JDY. Voiding dysfunction in children: non-neurogenic and neurogenic. status in patients with multiple sclerosis. Arch Phys Med Rehabil. 1999 Apr: 80:437-41. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. A. Arm and leg restraints 9th ed. Philadelphia, PA: Saunders Elsevier; 2007, pp. 3604-3625. B. Dementia C. Lower extremity edema with congestive heart failure D. Fecal impaction Physician Accreditation Statement Physician Credit Statement The University of North Texas Health Science Center at Fort Worth The University of North Texas Health Science Center has requested Office of Professional and Continuing Education is accredited by the that the AOA Council on Continuing Medical Education approve this American Osteopathic Association to award continuing medical program for 1 hour of AOA Category 2B CME credits. Approval is education to physicians. currently pending. QUESTION 5: Initial management of monosymptomatic nocturnal enuresis should include: The University of North Texas Health Science Center at Fort Worth The University of North Texas Health Science Center at Fort Worth A. Parental counseling Office of Professional and Continuing Education is accredited by designates this enduring material for a maximum of 1 AMA PRA B. Bed alarm the American Council for Continuing Medical Education (ACCME) Category 1 Credit(s)™. C. Desmopressin to provide continuing medical education for physicians. Physicians should claim only the credit commensurate with the D. Antimuscarinics extent of their participation in the activity. Discussion of Question One with self-care and with learning new that urge incontinence with preserved sensation is more likely with Endocrine disorders (e.g., heart failure, uncontrolled ) A. Associated vesicoureteral reflux (correct) behaviors. The behavioral treatments frontal lobe impairment, while decreased bladder sensation relates to Restricted mobility (e.g., hip fracture population, arthritis, back pain, require active caregiver participation. parietal lobe involvement. B. Associated urinary tract infections (correct) restraints) They include: Impaired lower urinary tract function often coexists with recurrent C. Multiple sclerosis (correct) Stool Impaction infections and with vesicoureteral reflux (VUR), even in the absence of A. Timed voiding (correct) In patients with multiple sclerosis, urinary symptoms can be variable, However, recent investigations have called into questions the therapeutic any identifiable neurologic pathology. High pressure storage, detrusor The individual voids at fixed intervals and can also change over time. OAB sx are the most frequent complaint, benefit of replacement therapy and of treating asymptomatic overactivity, dysfunctional voiding, (e.g. every 3 hours). This program with urinary frequency (32 to 99%), urgency (32 to 85%), and urge bacteriuria in elderly patients. or incomplete bladder emptying does not require education or incontinence (19 to 80 %). Obstructive urinary symptoms are less have been reported in a significant reinforcement, but requires only common, with difficult voiding and chronic or acute urinary retention Unlike acute (and reversible) , dementia is a chronic disease with proportion of children with VUR. passive participation. affecting a minority of patients. a high prevalence of urinary incontinence due to detrusor overactivity and/or inappropriate toileting. Voiding cystography in children B. Habit training (correct) D. Cauda equina syndrome (incorrect) with incontinence often uncovers The caregiver identifies the incontinent patient’s particular voiding Central lumbar disc prolapse typically compresses one or more sacral Discussion of Question five concomitant VUR. The common pattern, including incontinence episodes. A toileting schedule can then nerves. It is not surprising, therefore, that the most common urinary Nocturnal enuresis (NE) appears to result from either a mismatch abnormalities affecting the lower pre-empt incontinence episodes. symptom associated with lumbar disc prolapse is acute urinary retention. between bladder capacity, nocturnal urine output, nocturnal detrusor urinary tract found to coexist with The typical urodynamic findings are an acontractile detrusor with overactivity, and/or decreased arousal ability during sleep. Night wetting C. Combined toileting and exercise therapy (correct) reflux are, in fact, detrusor overactivity impaired bladder sensation. Severe denervation of the pelvic floor and is considered normal until age 5. A maturation delay contributes to a This functional intervention incorporates strengthening exercises into and dis-coordination between detrusor external urethral sphincter can result in neurogenic incontinence. detrusor overactivity, a lack of arginine vasopressin (DDAVP) release/ toileting routines by caregivers. Alternatively, physical therapists may and the sphincter function during micturition. This can lead to persistent With early intervention (resulting from a high level of suspicion), response, or increased nocturnal solute excretion [39,40], and/or a work on toileting and mobility skills. Severe cognitive and physical reflux, high pressure voiding with pyelonephritis, and ultimately upper two thirds of patients may recover urinary function following acute decreased ability to awaken to full bladder sensations. Treatment should impairments, or lack of full-time caregiver availability may preclude tract deterioration. These abnormalities are thought to occur secondary urinary retention. Much less common, OAB symptoms secondary to therefore address these deficiencies. to , or are acquired during . Reflux the use of this active intervention. detrusor overactivity result from sacral nerve root irritation. A. Parental counseling (correct) from incompetence of the uretero-vesical junction may persist or even D. Prompted voiding (correct) Discussion of Question four As the age at which the child and his or her parent begins to be when associated with detrusor overactivity. Prompted voiding involves encouraging going to the bathroom with Reversible causes of incontinence should concerned about bedwetting varies, it is important that both the family C. contingent social approval, is designed to foster patient requests for Associated neuropathy (correct) be sought in the elderly. These transient and child are motivated to achieve nighttime continence. If the child toileting as well as self-initiated toileting, and decrease the number Detrusor-sphincter dyssynergia (DSD) can result from a variety of causes can be remembered via the and/or the parents are not bothered by the bedwetting, or are not of UI episodes. neurologic lesions, typically located in the suprasacral spinal cord. This mnemonic “DIAPPERS”. Often more than motivated to intervene with either behavioral therapy or pharmacotherapy, pathologic voiding dysfunction contributes to urinary incontinence, E. DDAVP (incorrect) one cause may contribute, and therefore then resolution is unlikely to be any more likely than typically occurs urinary tract infections, VUR, and ultimately renal scarring or renal DDAVP is not a behavioral intervention, but rather a pharmacotherapeutic treating several of these reversible causes with age (approximately 15% per year resolution). insufficiency. intervention. DDAVP should not be used in frail elderly because of the may prove efficacious in reducing or curing B. Bed alarm (correct) Therefore, management of detrusor sphincter dysfunction in children risk of hyponatremia. the voiding dysfunction. The enuresis alarm is the most effective treatment for mon-symptomatic must focus first and foremost on renal preservation. Discussion of Question three A. Arm and leg restraints (correct) NE, by facilitating arousal from sleep. Enuresis alarm therapy is Neurospinal dysraphism is by far the most common cause of DSD in Neurogenic bladder is precisely defined as defective functioning of the Restricted mobility, especially in the setting associated with a nine times lower likelihood of relapse than antidiuretic children, presenting with various patterns and severities of detrusor- due to impaired nerve supply. Neuropathies can of urgency with reduced warning time for pharmacotherapy (relapse rate = 15-30% at 6 months). With virtually sphincter dysfunction. While 15 % of neonates with myelodysplasia profoundly and negatively can significantly contribute to incontinence. Often, a bedside no risk, and the highest efficacy of all treatment, alarm therapy should may not display any signs of lower urinary tract dysfunction initially, affect the commode, bedpan, or urinal (for men), can bypass this problem. be considered in every patient. – with respect to the the development of storage and voiding dysfunction still likely over B. C. Desmopressin (correct) bladder and the upper Dementia (incorrect) time. Up to one-third of myelodysplastic pubertal children will develop Although treatments for dementia may slow the progression of disease, Pharmacological treatment is designed to either detrusor areflexia or DSD, many of whom will ultimately suffer tracts. Although the address the three likely causes of NE term is often misused to urinary incontinence usually correlates with advanced, irreversible from upper tract deterioration, if not appropriately managed. The key alterations in cognition. Delirium, on the other hand, is defined as a mentioned above. treatment goals are preservation of renal function and achieving urinary describe abnormal bladder temporary alteration in sensorium, and often resolves when the It would make sense, therefore, that nocturnal and fecal continence. Clean (self) intermittent catheterization is typically function, it is important that the physician offending cause (e.g. medication, unfamiliar surroundings, metabolic respond the best to desmopressin. the recommended treatment for children with DSD, often in association derangement) is remedied. with surgical creation of continent reservoir. precisely define the Desmopressin has been shown to be approximately neurologic disease and C. Lower extremity edema with congestive heart failure (correct) D. 5 times more efficacious than . Monosymptomatic nocturnal enuresis (incorrect) the voiding dysfunction caused by that disease in order to facilitate Retained fluid and edema are typically mobilized upon lying down, Unfortunately, relapse after short-term treatment is common, with Primary nocturnal enuresis (NE) is a common disorder among early accurate diagnosis and efficacious treatment. increased the filtered load faced by the kidneys. Increased urine long-term efficacy approximately equal to the sponatenous rate of school age children. Controversy exists regarding the etiology of NE, production typically occurs, which may be prevented by fluid management, A. Alzheimer’s disease (correct) resolution. While dDAVP is generally well-tolerated there have been but multiple pathologic factors are likely to blame. One such factor is and prevention of fluid retention. For example, properly timed Alzheimer’s disease, the most common type of dementia, is characterized case reports of severe water retention with hyponatremia and convulsions, that production of nocturnal urine in enuretic children may simply use, or lower extremity compressive stockings, or dietary modification exceed bladder storage capacity during sleep. Nocturnal polyuria may by worsening of the memory, impaired cognitive functioning, and in the but these are infrequent. advanced stages, loss of self-hygiene, eating, dressing and ambulation. may prevent the build-up of fluid that ultimately may contribute to results from abnormal nocturnal anti-diuretic hormone (ADH) D. Even in the absence of motor dysfunction, urinary incontinence is polyuria and urge incontinence. Antimuscarinics (incorrect) production, or due to diminution of functional bladder capacity during Oxybutynin is occasionally used as an alternative treatment for some common. The onset of incontinence usually correlates with the disease D. Fecal Impaction (correct) sleep. This “mismatch” between urine production and bladder capacity children who fail to respond to DDAVP. The drug is particularly useful progression and affects 23 % to 48 % of those afflicted with Alzheimer’s Fecal impaction (and to a lesser degree ) can lead to leads to bedwetting. Alternatively, there may be bladder- sphincter for those with combined day and nighttime incontinence. dysfunction. Alternatively, sleep arousal disturbances and brain stem disease. While inappropriate toileting can affect patients in the urinary incontinence. This finding is not unique to older adults, but dysfunction may be causing an inability of the child to awaken despite advanced stages of disease, detrusor overactivity is the primary cause may also contribute to voiding dysfunction in children with While (tricyclic antidepressant) has demonstrated success a full bladder. Enuretics are typically more difficult to arouse than of incontinence in the majority of patients. dysfunctional elimination. in a number of children (typically a decrease of one wet night per week, but a lasting cure rate of only 17%), because tricyclic antidepressants age-matched controls. Finally, the bladder may empty due to detrusor B. Cerebrovascular accident (correct) The mnemonic DIAPPERS stands for the following transient conditions: overactivity, which may occur only during sleeping hours, despite have potential cardiotoxic side effects they are not generally Strokes represent the third most common cause of death in Western Delirium normal storage during wakeful periods during the day. recommended for treatment of this non-lethal disorder. countries (following heart disease and cancer). Approximately 1 in Infection (e. g., urinary tract infection) Discussion of Question two 200 older patients will suffer from a stroke, 80 to 90% of whom are Further evaluation may be indicated in the setting of treatment failure, Atrophic urethritis or vaginitis (thin, dry vaginal and urethral epithelium) Behavioral interventions are strongly recommended for frail older over the age of 65. Approximately 46% of females and 37% of males to diagnose any other treatable storage dysfunction. Yeung, et al reported Pharmacology (e.g., , , narcotics, sedatives, patients, as such therapies can be quite successful, with essentially no develop urinary incontinence following cerebral vascular accident. that 44 percent of treatment failures with desmopressin or the enuresis alcohol) risk. Certain behaviors are particularly recommended for those frail Urinary incontinence typically results from the loss of central inhibition. alarm] have normal daytime bladder function but marked detrusor elderly with cognitive and physical impairments that may interfere However, the loss of bladder perception may also contribute. It appears Psychological disorders (especially ) overactivity during sleep resulting in enuresis. CME/CECredit Request Form Complete online at www.RegisterWithUNT.com

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1 A B C D E learning objectives P F g vg E To understand the risk factors for children with overactive 2 A B C D E 1 bladder, and the evaluation and treatment of simple nocturnal      3 A B C D E enuresis in children. To understand the specialized evaluation and treatment of 2      4 A B C D E overactive bladder in the elderly.

5 A B C D E To be able to distinguish neurogenic versus non-neurogenic 3      causes of overactive bladder symptoms.

online: content P F g vg E www.RegisterWithUNT.com 4 To what extent this activity is fair and balanced.      Verification Code: 00000 Likelihood that you will implement change in your practice 5      mail to: based on information from this activity. UNThsc/pace Office      3500 Camp Bowie Blvd 6 Your OVERALL rating of this activity. Fort Worth, TX 76107 practice or fax to: How will you use the information presented to improve the care of your patients? 817-735-2598 Your certificate will be mailed within three weeks 7 of receipt.

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