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Voiding Dysfunction in Children COL John Roscelli Pediatric Nephrology San Antonio Military Pediatric Center.

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Presentation on theme: "Voiding Dysfunction in Children COL John Roscelli Pediatric Nephrology San Antonio Military Pediatric Center."— Presentation transcript:

1 Voiding Dysfunction in Children COL John Roscelli Pediatric Nephrology San Antonio Military Pediatric Center

2 Perspective  Incontinence is part of transitional phase from infantile to adult lower urinary tract function  Wetting disorders often considered necessary nuisance & tolerated until child lags behind peers  Parental concerns about voiding are common & often supersede the child's anxiety  However, voiding dysfunction can be a sign of underlying pathophysiology that needs Rx to prevent Renal/Urologic damage

3 Agenda  How the Lower Urinary Tract Works  Voiding Dysfunction in children with no organic pathology  Definition  Presentation modes  Evaluation  Treatment

4 How the Lower Urinary Tract Works

5 Bowl and Bladder Function  Lower GU tract tied to lower GI tract  Same embryogenic origin: endodermal tissue  Up to sixth week gestation urogenital sinus & the hindgut empty into common cloaca  Problems with elimination in one usually associated with problems in the other  Proper term is Elimination Dysfunction Syndrome

6 Function of Lower Urinary Tract  STORAGE of adequate volumes of urine at low pressure & with no leakage  EMPTYING that is  Voluntary  Efficient  Complete  Low pressure

7 Lower Urinary Tract is a Functionally Integrated Unit  Ureteral Vesicle Junction  Bladder  Sphincter  Urethra  Neurologic control mechanisms

8 Anatomy & Neurophysiology of the Lower Urinary Tract  Bladder (detrusor)  Stores urine at low pressure  Compresses urine for voiding  Urethra  Conveys urine from bladder to outside world  Sphincter(s) internal & external  Controls urine flow & maintain continence between voidings

9 Nervous system control of Lower Tract  CNS  Periaqueductal gray matter receives bladder filling info  Frontal/parietal lobes & cingulate gyrus inibit lower micturation centers  Hypothalamus center initiate voluntary voiding  Pontine Micturation center excites Bladder & inhibits sphincter  Cerebellum integrates  Spinal  Sympathetics T10-L1 via hypogastric Nerve  S2-S4 Parasympathetic via Pelvic N Somatic via Pudental N

10 Nervous system control of Lower Tract  CNS micturition centers  Exert voluntary control over spinal centers  Spinal micturition centers  T10-L1  Sympathetics via hypogastric Nerve  S2-S4  Parasympathetic via Pelvic N  Somatic via Pudental N CNS micturition centers T10- L1 S2- S4

11 Autonomic NS receptor Distribution

12 Low pressure storage with continence Outlet obstruction: Sympathetic  -adrenergic stimulation of bladder neck & posterior urethra from T10-L1 via Hypogastric Nerve Somatic stimulation of External Sphincter from S2-S4 via Pudental Nerve Bladder Relaxation:  -adrenergic stimulation of bladder fundus from T10-L2 via Hypogastric Nerve decreases bladder tone Allows continent storage of significant volumes of urine at < 20 mmHg CNS micturition centers T10 -L1 S2- S4

13 Voluntary Efficient Complete Low Pressure Voiding Outlet relaxation: CNS micturition Centers Inhibit sympathetic  -adrenergic stimulation of bladder neck/posterior urethra & somatic stimulation of External Sphincter Bladder Contraction: CNS micturition Centers Inhibits  -adrenergic bladder relaxation & stimulates Parasympathetic cholinergic stimulation of bladder fundus from S2-S4 via Pelvic Nerve Allows complete emptying at pressures < 40 mm Hg CNS micturition centers T10 -L1 S2- S4

14 Normal Voiding Study Bladder Neck Pressures Bladder Pressures External Sphincter EMG Activity Storage (cc) Voluntary Voiding

15 Normal Voiding Study

16 Maturation of Voiding Neonatal voiding  Controlled by sacral spinal cord reflex  Bladder distention sends signals to sacral spinal cord micturition center  Spinal cord micturition center sends efferent signals that cause detrusor contraction & relaxation of external sphincter  Results in frequent, complete, low pressure emptying  Newborns void 20 x/day with only a slight decrease during the 1st year of life

17 Maturation of Voiding  Bladder capacity increases & voiding frequency decrease with growth  Bladder capacity in Ounces (30ml) = Age (yrs) +2  1-2 yrs: conscious sensation of bladder fullness develops  2-3 yrs: Ability to initiate or inhibit voiding voluntarily develops  2-4 yrs: Voiding comes under reliable voluntary control  By 4 years of age, most children have achieved an adult pattern of micturition

18 Maturation of Voiding  By age 4 Micturition spinal reflex fully modulated by CNS micturition center via a spinobulbospinal tact  As bladder fills, desire to empty occurs-child must consciously suppress this desire until he/she can get to toilet  With conscious voiding, external sphincter willfully relaxed prior to initiating bladder contraction  Sphincter relaxation & bladder contraction, must occur in coordinated fashion for proper emptying

19 Maturation of Voiding  Initially child has better control over external sphincter than bladder  Easier to stop urination than start it  Voiding inhibition done by contracting external sphincter rather than inhibiting bladder contraction  This pattern may be reinforced during toilet training  Persistence of this pattern is bladder sphincter dysnergia


21 Usual sequence of bowel & bladder control  Nocturnal bowel control  Daytime bowel control  Daytime control of voiding  Nocturnal control of voiding

22 Maturation of Voiding  By 4 most children have adult voiding pattern Brazelton studied 1,170 children & found  26% achieved daytime continence by age 24 months  52.5% by age 27 months  85.3% by age 30 months  98% by age 36 months

23 Definitions Incontinence in Children  International Children's Continence Society definitions  Enuresis: normal voiding that occurs at inappropriate time or involuntarily in socially unacceptable setting  nocturnal enuresis- nighttime wetting  diurnal enuresis- daytime wetting

24 Definitions  Diurnal enuresis is often interchanged with dysfunctional voiding but they are not the same  Not all dysfunctional voiders are incontinent  Dysfunctional voiding can be neuropathic or nonneuropathic  Neuropathic- voiding disorders caused by neurologic conditions such as spina bifida, transverse myelitis, or spinal cord trauma  Nonneuropathic- functional voiding problems in neurologically normal children

25 Characterization of Voiding Dysfunction  Storage Problem: Failure to Store normal volumes of urine at low pressure & without leakage  Non compliant bladder  Irritable bladder  Inadequate sphincter tone during filling  Emptying Problem: Failure to empty completely, on command, efficiently at low pressures  Failure of neurological control of bladder  Bladder muscle failure  Failure of sphincter relaxation during voiding

26 Clinical Problems from Voiding Dysfunction  Increased bladder pressures resulting in  VUR  Upper tract damage  Bladder hypertrophy leading to detrusor failure  Residual Urine  UTI  Incontinence  Social consequences

27 Voiding Dysfunction in Children with no organic pathology

28 Voiding Dysfunction in “Normal Children”- 3 Issues  Clinician must 1 st suspect voiding dysfunction in certain clinical circumstances in normal children  Clinician must then rule out Neurologic, Urologic & other organic (diabetes, concentrating defects) problems  Clinician must then characterize & Rx the functional voiding dysfunction

29 Presentations of Voiding Dysfunction in “Normal” Children  Urologic Presentation  GI Presentation  Occult Neurologic presentation

30 Urologic Presentation Signs & Symptoms which suggest voiding dysfunction  Infrequent voiding  Frequent voiding  Urgency  Dysuria  Holding maneuvers  Straining  Poor stream  Intermittent stream  Incomplete emptying  Incontinence  Urinary tract infections  VUR

31 Urologic Presentation It can not be overemphasized to the general pediatrician how important it is that they rule out voiding dysfunction in all their children with recurrent UTIs, VUR or incontinence

32 GI Presentation Signs & Symptoms which suggest voiding dysfunction  Fecal staining of undergarments  Fecal incontinence  Constipation  Encopresis  Obstipation (i.e., severe constipation causing obstruction)  Abdominal pains

33 Occult Neurologic Presentation  Early detection may prevent neurologic damage and its bladder or bowel dysfunction sequelae  Complex spina bifida occulta is an important disease entity because of its prevalence in the general population (as much as 1%);  Lower back abnormalities such as nevus, dermal sinus, or dimple  Abnormal neurologic examination, or foot or gait abnormality

34 Ocult Neurologic Presentation Spinal cord tethering suggested by  Lower back abnormalities such as nevus, dermal sinus, or dimple  Pain in the lower back during stretching of the lower extremities  Gait abnormalities  Worsening symptoms during growth spurts  Severe stool incontinence  Complex enuresis refractory to routine Rx

35 Types of Voiding Dysfunction Disorders in “normal” Children

36 Minor Voiding Dysfunctional Disorders  Extraordinary daytime urinary frequency syndrome  Giggle incontinence  Stress incontinence  Post void dribbling  Vaginal voiding  Primary monosymptomatic nocturnal enuresis

37 Major Voiding Dysfunctional Disorders  Hinman syndrome- non neruogenic neurogenic bladder  Ochoa (urofacial) syndrome  Hinman syndrome with Autosomal dominant inheritance & facial grimace when smiling  Myogenic detrusor failure

38 Moderate Voiding Dysfunctional Disorders  Overactive bladder/Urge Syndrome  Bladder Sphincter Dysnergia  Lazy bladder syndrome

39 Moderate Voiding dysfunctional disorders

40 Classification of Diurnal Voiding Dysfunction TermFillingVoidingPost void Residual Urge syndrome Multiple uninhibited detrusor contractions with increased EMG activity and expressions of urgency Usually normal None

41 Classification of Diurnal Voiding Dysfunction TermFillingVoidingPost void Residual Bladder/ sphincter dysfunction Usually normal Increased EMG activity causing diminution or interruption of the urinary flow Variable

42 Classification of Diurnal Voiding Dysfunction TermFillingVoidingPost void Residual Lazy bladder syndrome Abnormally capacious bladder with little or no expression of urge Prolonged, decreased flow with abdominal straining and bursts of EMG activity Always

43 Evaluation of Voiding Dysfunction

44 Purpose of evaluation  Characterize the Elimination problems to direct treatment  Storage problem  Emptying problem  Continence problem  Rule out Neurolgic, Urologic or other organic causes

45 Evaluation of Dysfunctional Voiding  Index of suspicion  History  Physical Exam  Simple Lab Tests  Imaging  Urodynamics

46 History To characterize the Problem  Evaluation of dysfunctional voiding begins with a detailed elimination history  History of current elimination problems  Detailed voiding history  Detailed Stooling history  Past elimination/urologic History  UTIs  Constipation  Age of toilet training  Intake history- fluids and diet  Family history of urologic problems

47 History To characterize the Problem  Voiding symptoms & pattern of incontinence must be quantified  Urgency, frequency, straining, dysuria etc  Holding maneuvers such as leg crossing, squatting, or "Vincent's curtsey"  Continuous incontinence in a girl suggests ectopic ureter that inserts distal to urethral sphincter or into the vagina

48 Holding Maneuvers

49 Ectopic Ureter

50 3 Day Elimination Diary- Your most powerful diagnostic tool & its CHEAP & BENIGN  Determines BM problems  Characterizes voiding  Frequency of voids  Volume of voids  Accidents  Associated symptoms  Allows Characterization voiding disorder  Storage  Emptying  Continence Good time to do intake diary Parents record liquid intake volume

51 History Irritable Bladder  Urgency & frequency as Cerebral cortex unable to inhibit reflex bladder contractions triggered during filling  Parents need to know where every bathroom is at mall etc  When they void, void normally although usually have a small bladder capacity  Exhibit behaviors to avoid leakage: Dancing, squatting, holding & posturing  Classic sign of bladder instability is "Vincent's curtsy“- squatting posture in girls in which the heel compresses the perineum and thereby obstructs the urethra to prevent urinary leakage  If unsuccessful get urge incontinence of small amount of urine  These behaviors can lead to bladder sphincter dysnergia

52 History Infrequent Voider  Typically school girls with recurrent UTI & often with history of intermittent enuresis  Postpone voiding as long as possible  Don’t like to void in public bathrooms  Use holding maneuvers to fight urge to void  If holding maneuvers fail get incontinence- “Suzy waits till the last minute to void & then its to late”  Develop large capacity bladders- void 2-3 times per day & often don’t have to void on awakening  When they void voluntarily it is large volumes, prolonged & requires straining  Often don’t take time to completely empty

53 History Infrequent Voider  Physician must uncover that the child with a wetting problem actually has abnormally few voids & a weak bladder  May wait at least an hour after waking to void  May void only 2-3 to three times daily, often not at all during school  Straining during urination common because detrusor is large-capacity & capable of only weak contractions

54 History To Identify underlying treatable Pathology  Identify organic pathology  Diabetes, epilepsy, obstructive sleep apnea  Neurologic problems  Urologic problems  Identify functional cause that is treatable  Voiding symptoms may be sign of sexual abuse  Stressful occurrence at home or school can trigger incontinence

55 Physical Examination  1st step is growth, general health & vital signs including BP  2nd step is to inspect the child's underwear for evidence of wetness or soiling  3 rd step is to observe or at least listen to voiding for evidence of weak, slow or intermittent stream  4 th step is focused physical exam

56 Physical Examination Abdomen  Renal masses  Distended bladder  Large stool mass suggestive of constipation

57 Physical Examination Perineum & Genitalia  Dampness at beginning of exam & with straining  Signs of erythema or irritation may be indicative of vaginal voiding  Meatal stenosis in boys & presence of labial adhesions in girls  Signs of trauma suggestive of sexual abuse  Careful examination of the introitus for an ectopic ureter  Location of anus

58 Focused Neurolgogic Examination  Lumbosacral spine for lipoma, sinus, pigmentation tufts of hair- may be clue to underlying occult myelodysplasia  Perineal sensation, anal sphincter tone, lower limb function/gait/sensation & Peripheral reflexes  The bulbocavernosus reflex: squeeze glans penis or clitoris & observe or feel reflex contraction of external anal sphincter  Checks integrity of the lower motor neuron reflex arcs  Absence suggestive of a sacral neurologic lesion


60 NERVE ROOTS & THEIR ASSOCIATED SENSORY & MOTOR FUNCTIONS LevelSensationMotor L1Inguinal areaThigh extension/flexion L2Anterior/medial thigh Thigh extension/flexion L3Knees, lateral thigh Lower leg flexion L4Anterior/medial tibia Lower leg extension L5Lateral tibiaDorsiflexion of foot (cannot walk on heels) S1Sole of the footPlantar flexion of foot (cannot walk on toes) S2Heel of the footDorsiflexion of big toe S3, 4PerinealPlantar flexion of big toe

61 FOCUSED NEUROLOGIC EXAMINATION Nerve RootMotorSensory S1Plantar flexion Side of foot S2Big toe extension Back of heel S3Big toe flexion Perineum

62 Routine Labs  Urine tests best obtained on 1 st AM specimen after overnight NPO  UA  Specific gravity- over 1.020 rules out significant concentrating defect  pH  Glucose  Blood  Protein  Microscopic  UC

63 Other Studies that can be obtained prior to referral  Post void residual urine by catheter  Abdominal radiograph (KUB)  Identifies lumbar-sacral anomalies, bowel gas patterns & amount of stool  Renal and bladder ultrasound

64 Sonography  Lower tract  Assess bladder wall thickness (nl <3mm when full; 5 mm when empty)  Post void residual > 2 mL/kg is abnormal  Upper tract  Size, contour, echogenicity  Hydro-nephrosis Excellent correlation between residual urine by direct urethral instrumentation & noninvasive sonography

65 Other Studies that can be obtained prior to referral  Nuclear Medicine renal scan  Cortical scan to RO scars or difference in function  Functional SCAN with/without lasix to RO obstruction  Voiding cystourethrography  History of UTIs  Family history of VUR

66 Studies requiring referral  Rarely required but simple & non invasive  Uroflometry  Very rarely required & invasive  Urodynamics with electromyography of the external urinary sphincter

67 Studies requiring referral Uroflow/Flowmetry Non invasive assessment of urine flow rates  Staccato voiding or intermittent stream  Intermittent involuntary sphincter activity during voiding  Fractionated & incomplete voiding  Abdominal straining needed to assist bladder emptying & contraction of abdominal muscles contracts the sphincter

68 Studies requiring referral Urodynamics often with video fluro  Parameters used to diagnose urodynamic dysfunction  Bladder capacity of <10-15 mL/kg body weight,  Postvoid residual of >2 mL/kg body weight,  Detrusor hyper-reflexia, (detrusor contractions during bladder filling without urine leakage and intravesical pressure of >40 cm H 2 O  Voiding detrusor pressure of >70 cm H 2 O  Dyssynergic increase or lack of suppression of sphincteric EMG with a detrusor contraction.

69 Studies requiring referral Urodynamics often with video fluro

70 Studies that should never be done  Cystoscopy with or without urethral dilation or meatotomy  These are rarely if ever useful and are expensive & potentially dangerous

71 Management of Voiding Dysfunction in Children with no treatable Neruologic, Urologic or other organic etiology

72 Treatment of Voiding Dysfunction Non Pharmacological  Timed voiding is the easiest & most effective Rx & it works for irritable bladder & infrequent voider  Regular by the clock voids q 2-3 hours during day  Biofeedback  Kegel exercises

73 Treatment of Voiding Dysfunction Pharmacological  Anticholinergic  Used for irritable bladder especially with urgency, frequency & urge incontinence  Oxybutinin 0.1-0.15 mg/kg per dose 3 x day  Dry mouth, constipation, drowsiness & heat intolerance  Imipramine used primarily for nocturnal enuresis  Low dose UTI prophylaxis

74 Treatment of Voiding Dysfunction TREAT STOOLING DYSFUNCTION

75 UTIs, VUR & Elimination Dysfunction  Strong association between the 3  Treat voiding dysfunction  Treat stooling dysfunction

76 Approach to Voiding Dysfunction


78 Summary We have reviewed  Function (continent storage & voluntary emptying at low pressures) & how the lower GU tract works & how it matures  Relationship with lower GI tract  Voiding dysfunction syndromes in normal children  When to suspect it- UTIs, VUR, incontinence  How to evaluate (history, voiding diary)  How to RX voiding dysfunction  Timed urination,  Treat stooling dysfunction

79 Voiding Dysfunction in Children with Neurogenic Bladder

80 Spinal cord injury (SCI) produces profound alterations in lower urinary tract function  Incontinence  Neurological obstruction  Elevated intravesical pressure  VUR  Increased risk of UTIs  Stones

81 Neurogenic Bladder Made Simple Lack of higher CNS control results in  Inability to sense fullness & voluntarily void  Detrusor controlled by un modulated spinal reflex  Sphincter with fixed passive resistance- Leak Point Pressure (LPP)  Varies between patients may change in same patient  At bladder pressures < LPP no leakage  At bladder pressures > LPP leakage or urination  Sphincter may not relax when bladder contracts- bladder sphincter dysnergia  Results in high voiding pressures

82 Neurogenic Bladder Made Simple  High LPP pressure is good for continence but bad for the kidney  Prolonged LPP > than 40 cm H2O have been associated with  VUR  Upper tract deterioration  Decreasing bladder compliance

83 Neurogenic Bladder Made Simple  Bladder compliance is another key variable & may change over time  Determined by neurologic reflex activity & LPP  Poor bladder compliance associated with  Incontinence  UTIs  Upper Tract Damage

84 Focus is on 2 issues  Preservation of Renal function  Maintaining normal bladder pressures during filling & voiding  Minimizing UTIs  Continence  Not an issue in first couple of years of life

85 Evaluation of Newborn with Neurogenic Bladder  Assess upper tract for damage or evidence of high pressure (hydronephrosis)  Creatinine, lytes  UA & Cultures  Renal US  CT urography can give more detail if US abnormal  Can do non contrast MRI if there is renal failure  Some use nuclear studies

86 Evaluation of Newborn with Neurogenic Bladder  Assess lower tract for evidence of increased voiding pressure  Bladder US for bladder hypertrophy & post void residual- obtain in newborn period  VCUG for VUR & bladder hypertrophy  Urodynamics for LPP & compliance

87 Newborn with Neurogenic Bladder General Treatment  Prevention  Folic Acid- 0.4 mg per day start prior to pregnancy  Minimize spinal damage  Prenatal Diagnosis  Suspect in certain racial groups  Prenatal screening   fetoprotein- 16-17 weeks GA  Fetal sonography- 17th week GA  C Section prior to labor  Proper handling post delivery

88 Newborn with Neurogenic Bladder General Treatment  Latex precautions from birth  Latex allergy seen in up to 40% of spina bifida patients  Treat GI tract dysfunction  Maximize orthopedic function  Avoid obesity

89 Treatment of Neurogenic Bladder in the infant based on Evaluation  Low LPP, normal bladder function- observation  Flaccid bladder unable to empty- Clean Intermittent Catheterization- CIC  Hyperreflexic &/or non compliant bladder- CIC with anticholinergics  CIC if needed done every 3 hours  NO CREDE  If upper tracts deteriorate- vesicostomy

90 Treatment of Neurogenic Bladder Continence, Bladder Pressures & UTIs  Urologic Rx Based on bladder/sphincter physiology  Low LPP, normal bladder function  Observation for neonates  CIC for continence in older children  Flaccid bladder unable to empty- CIC  Hyperreflexic &/or non compliant bladder- CIC with anticholinergics  Oxybutynin 0.1 mgk/Kg per dose 3 X per day

91 Treatment of Neurogenic Bladder Continence, Bladder Pressures & UTIs  CIC is key-  s bladder pressures, improves continence & eliminates residual urine  CIC in newborns  done every 3 hours  NO CREDE  If upper tracts deteriorate- vesicostomy  In older children CIC can be made easier with Continent Catheterizable stomas  Especially valuable in males who still have perineal sensation or children with poor coordination  Metroffanof uses appendix as conduit

92 Improving Continence Continent Catherizable Stomas  Appendix (Mitrofanoff), section of ileum or colon placed from umbilicus to bladder & tunneled into bladder to prevent reflux  Indicated in  Wheel-chair bound patients with severe scoliosis lordosis  Poor upper extremity function  Males with intact urethral sensation

93 Bladder Augmentation  Indicated when medical therapy fails to achieve adequate low-pressure capacity with continence  Variety of substances and surgical techniques used each with problems  Use of intestinal tract allows absorption or secretion of electrolytes from or into urine  All require religious CIC to avoid rupture

94 Bladder Augmentation Variety of Methods  Ileum & colon  Hyperchloremic hypokalemia acidosis, mucous  Stomach  Less mucous  Can cause hyperkalemic metabolic aklalosis  Can cause hematuria and dysuria due to acid  Rx with H2 blockers  Dilated ureter of non functioning kidney  None of problems seen with GI tract  Detrusor mytomy (autoaugmentation)  None of problems seen with GI tract

95 Bladder Augmentation using Segment of Ileum

96 Improving Continence by Increasing Sphincter Resistance   Adrenergic drugs (phenylpropanolamine, pseudoephedrine) increase sphincter tone  Usually only marginally effective  Surgical techniques  Periurethral injections  Bladder neck suspension & Sling procedures  Artificial urinary sphincter

97 Vesicoureteral Reflux (VUR)  40-65% of neurogenic bladder patients have VUR  Rx aimed at reducing bladder pressures rather than fixing the VUR  CIC  Bladder Augmentation  Prophylactic antibiotics controversial  Surgical correction of VUR indicated for  Deterioration of upper tracts  Recurrent pyelonephritis

98 Urinary Tract Infections  Bacteruria- rule not the exception  J Peds 126; 1995; 490

99 Urinary Tract Infections  Treatment of asymptomatic bacteriuria in SCI patients of no proven benefit  Do not treat cultures treat patients  Working definition of true UTI in these patients is fever with + UC

100 Rx of Urinary Tract Infections  Symptomatic UTIs treated with narrowest spectrum antibiotics for the shortest possible time  Same antibiotics as used for Rx of complicated UTIs in general population

101 Rx of Urinary Tract Infections  Prophylaxis does not decrease UTIs or asymptomatic bacteruria- (J Peds 132;1998;704)  Some still use if there is VUR  Other methods also unsuccessful  Cranberry juice- J Peds 135; 1999; 698  Single use sterile catheter Peds 108;2001;2001

102 Summary We have reviewed  Function (storage & voluntary emptying at low pressures) & how the lower GU tract works & how it matures  Relationship with lower GI tract  Voiding dysfunction in normal children  When to suspect it- UTIs, VUR, incontinence  How to evaluate (voiding diary) & Rx it (timed urination)  Evaluation & Rx of children with neurogenic bladder- focus on preserving upper tract & continence

103 References  Pediatric Clinics N America 48; Dec 01 1489-1503 & 1505-1518  Fernandes; The Unstable Bladder in children; Journal Peds; 118; 1991; 831  Pediatrics in Review; Volume 21 Number 10 October 2000; 336-341

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