Voiding Disorders In Children


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  • Urinary incontinence is a normal transitional phase between infantile and adult lower urinary tract function. Consequently wetting disorders often are considered a necessary nuisance associated with the growing years. It usually is tolerated until the child begins to lag behind his or her peers in achieving a state of dryness. Parental concerns about voiding are common and often supersede the child’s anxiety.
  • Estimated 5-10% school-age children experience daytime wetting Twice as common in girls compared with boys
  • Bladder emptying in the neonate occurs as a result of a sacral spinal cord reflex. When the bladder reaches a critical stretch threshold, the detrusor contracts leading to bladder emptying. As the infant gets older, this micturition reflex gradually becomes inhibited by the pontine micturition centre. As the bladder fills to a critical threshold, the desire to empty occurs and the child must conciously suppress this desire until he or she can get to the toilet. At approximately 2 years of age, conscious sensation of bladder fullness develops, although the need to void is not yet fully mastered, occurring at some time between 2 and 4 years of age. With concious voiding, both sphincter relaxation and bladder contraction, must occur in a coordinated fashion for complete bladder emptying. As the gradual increase in functional bladder capacity, maturation of detrusor-sphincter coordination, and progressive development of voluntary control over the whole bladder-sphincter-perineal complex.
  • During the process of attaining bladder control, bad behaviours can be learned at several steps. Children develop the ability to contract the external striated sphincter volitionally at an early age. This is a powerful stimulus to inhibit the detrusor. The external sphincter is used as the on-off switch for the bladder. As bladder capacity increases, children learn holding maneuvers to suppress the desire to void. Over time this can lead to overactivity of the detrusor with uninhibited bladder contractions that the child also tries to suppress. Subsequently, dysfunctional voiding results and the child has difficulty relaxing the sphincter when attempting to void voluntarily. This discoordination between the bladder and bladder outlet results in inefficient bladder emptying, leading to UTI’s. Constipation is also common due to the inability to relax the pelvic floor musculature.
  • In most cases, a well-completed history and physical examination with limited diagnostic studies are adequate to diagnose the underlying aetiology of the presenting case, and treatment may often begin empirically with more invasive testing or rigorous protocols being reserved for patients with persistent difficulties.
  • (note - SBO occurs in up to 30% normal men and 17% of normal women)
  • In a study of 58 children reported in 2000, the average time to resolution of incontinence was 2.7 years, with the range from 0.2 to 6.6 years, using conservative management such as timed voiding, dietary changes, control of constipation and anticholinergic therapy.
  • Voiding Disorders In Children

    1. 1. Office Nephrology Chair: Paul Roy
    2. 2. UTI & Dysfunctional Voiding Disorders <ul><li>Steven McTaggart </li></ul>Chair: Paul Roy
    3. 3. Voiding Disorders in Children Dr Steven McTaggart Queensland Child & Adolescent Renal Service Royal Children’s and Mater Children’s Hospitals Brisbane.
    4. 4. <ul><li>Children rated wetting themselves at school as the third most catastrophic event behind losing a parent and going blind. </li></ul><ul><li>Ollendick et al, Behav Res Therapy, 1989. </li></ul>
    5. 5. Outline <ul><li>Definitions </li></ul><ul><li>Classification </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Evaluation </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Physical examination </li></ul></ul><ul><ul><li>Investigations </li></ul></ul><ul><li>Overview of Specific Disorders </li></ul>
    6. 6. Definitions <ul><li>International Children’s Continence Society (1997) </li></ul><ul><li>Enuresis </li></ul><ul><ul><li>Normal voiding that occurs at an inappropriate or socially-unacceptable time or place </li></ul></ul><ul><ul><li>nocturnal or diurnal </li></ul></ul><ul><ul><li>diurnal enuresis vs dysfunctional voiding </li></ul></ul><ul><ul><ul><li>neuropathic & nonneuropathic </li></ul></ul></ul><ul><li>Incontinence </li></ul><ul><ul><li>Involuntary loss of urine, objectively demonstrable, and constituting a social or hygienic problem </li></ul></ul>
    7. 7. Classification - Voiding Disorders <ul><li>Minor </li></ul><ul><ul><li>Extreme daytime urinary frequency syndrome </li></ul></ul><ul><ul><li>Stress/giggle incontinence </li></ul></ul><ul><ul><li>Postvoid dribbling </li></ul></ul><ul><li>Moderate </li></ul><ul><ul><li>Staccato/fractionated voiding  Lazy Bladder syndrome (Dysfunctional voiding) </li></ul></ul><ul><ul><li>Urge syndrome (Overactive bladder/Detrusor instability/Unstable bladder) </li></ul></ul><ul><li>Major </li></ul><ul><ul><li>Hinman syndrome (non-neurogenic, neurogenic bladder) </li></ul></ul><ul><ul><li>Ochoa syndrome (Urofacial syndrome) </li></ul></ul><ul><ul><li>Myogenic detrusor failure </li></ul></ul>
    8. 8. Pathogenesis of Bladder Dysfunction <ul><li>Neonate - bladder emptying via sacral spinal cord reflex </li></ul><ul><li>~ 2 yr age develop conscious sensation of bladder fullness  spinal reflex gradually modified and inhibited by pontine micturition centre in brain stem </li></ul><ul><li>Between 2-4 years child develops ability to control voiding - conscious voiding requires relaxation of the external sphincter just prior to detrusor contraction </li></ul><ul><li>Balance between “inhibiting voiding” and “initiating voiding” not fully mastered until ~ 4yrs age </li></ul><ul><li>Note that ethnic,cultural,economic and individual family differences exist in relation to toilet training and the perception that daytime incontinence is abnormal </li></ul>
    9. 9. Pathogenesis of Bladder Dysfunction <ul><li>“ Bad” bladder behaviours </li></ul><ul><li> Adoption of holding manoeuvres to suppress desire to void </li></ul><ul><ul><li>- leads to overactive detrusor with uninhibited bladder contractions </li></ul></ul><ul><li> develop volitional control over contraction of the external sphincter - external sphincter is used as ‘on-off’ switch for bladder </li></ul><ul><li> - d ifficulty relaxing sphincter when attempting to void voluntarily (detrusor sphincter discoordination) </li></ul>
    10. 10. Pathophysiology of Dysfunctional Voiding
    11. 12. Bladder Dysfunction - Associated Problems
    12. 13. Evaluation - History <ul><li>Current symptoms and signs </li></ul><ul><ul><li>voiding pattern - stream/volume/frequency (diary) </li></ul></ul><ul><ul><li>dysuria/frequency/urgency </li></ul></ul><ul><ul><li>holding manoeuvres </li></ul></ul><ul><ul><li>perineal hygiene - vulvovaginitis/balanitis </li></ul></ul><ul><ul><li>UTI’s </li></ul></ul><ul><ul><li>constipation </li></ul></ul><ul><li>Specific problems in infancy </li></ul><ul><li>Age and pattern of toilet training </li></ul><ul><ul><li>primary vs secondary </li></ul></ul><ul><ul><li>longest dry periods </li></ul></ul><ul><li>Family history of urological problems </li></ul><ul><li>Social history - think about CSA </li></ul>
    13. 14. Voiding Diary
    14. 15. Holding Maneuvers
    15. 16. Evaluation - Physical Exam <ul><li>Exclude structural lesions </li></ul><ul><ul><li>Abdominal examination </li></ul></ul><ul><ul><li>Genital examination </li></ul></ul><ul><ul><ul><li>labial adhesions/meatal stenosis </li></ul></ul></ul><ul><ul><ul><li>bifid clitoris </li></ul></ul></ul><ul><li>Exclude occult neurological disorders </li></ul><ul><ul><li>examine back for signs of occult spina bifida </li></ul></ul><ul><ul><li>DTR’s lower limbs </li></ul></ul><ul><ul><li>gait </li></ul></ul><ul><ul><li>anal wink </li></ul></ul>
    16. 17. Ectopic Ureter
    17. 18. Evaluation - Investigations <ul><li>Urinalysis - dipstick, M/C/S, (urine osmolality) </li></ul><ul><li>Ultrasound (IVP if suspect ectopic ureter) </li></ul><ul><ul><li>estimate functional bladder capacity & residual </li></ul></ul><ul><li>MCU if abnormal USS </li></ul><ul><li>Spinal Imaging </li></ul><ul><li>Urodynamics </li></ul>
    18. 19. “ Spinning top” urethra
    19. 20. Hinman Syndrome
    20. 21. Evaluation - Role of Spinal Imaging <ul><li>Wraige E & Borzyskowski M, Arch Dis Child, 2002 </li></ul><ul><ul><ul><li>retrospective study - 48 children with voiding dysfunction </li></ul></ul></ul><ul><ul><ul><li>closed spina bifida present in 5 patients - only 1 had no cutaneous, neuro-orthopaedic or lumbosacral spine abnormalities. </li></ul></ul></ul><ul><li>Ritchey et al,J Urol 1994 </li></ul><ul><ul><ul><li>127 children - 17 (38%) bony spina bifida occulta </li></ul></ul></ul><ul><ul><ul><li>10/48 underwent MRI - 1 had lipoma requiring resection </li></ul></ul></ul><ul><li>Recommendations for Screening </li></ul><ul><ul><li>neurological /neuro-orthopaedic abnormality </li></ul></ul><ul><ul><li>secondary enuresis or deterioration in primary enuresis </li></ul></ul><ul><ul><li>significant associated bowel abnormality </li></ul></ul><ul><ul><li>?urodynamic study suggesting neurogenic bladder </li></ul></ul><ul><ul><li>?failure to respond to conventional treatment </li></ul></ul>
    21. 22. Evaluation - Urodynamic Studies <ul><li>Not required for majority of children </li></ul><ul><li>Indicated if; </li></ul><ul><ul><li>evidence of/at risk of upper tract deterioration </li></ul></ul><ul><ul><ul><li>hydroureteronephrosis </li></ul></ul></ul><ul><ul><ul><li>high grade VUR </li></ul></ul></ul><ul><ul><ul><li>recurrent episodes of pyelonephritis </li></ul></ul></ul><ul><ul><li>suspicion or evidence of neurological abnormality </li></ul></ul><ul><ul><li>significant daytime enuresis that fails to respond to conventional treatment </li></ul></ul><ul><ul><li>(unexplained secondary enuresis - cystoscopy is preferable) </li></ul></ul>
    22. 23. Urge Syndrome
    23. 24. Staccato Voiding ‘ Lazy Bladder’
    24. 25. General Principles of Treatment
    25. 26. General Principles of Treatment <ul><li>Treat constipation </li></ul><ul><li>Ensure adequate fluid intake </li></ul><ul><li>Bladder retraining </li></ul><ul><ul><li>Timed voiding schedule </li></ul></ul><ul><ul><li>Double voiding if large post-void residual </li></ul></ul><ul><ul><li>Physiotherapy - pelvic floor retraining </li></ul></ul><ul><ul><li>Biofeedback </li></ul></ul><ul><li>Medications </li></ul><ul><ul><li>Antibiotic prophylaxis if UTI </li></ul></ul><ul><ul><li>Anticholinergics eg propantheline, oxybutinin </li></ul></ul>
    26. 27. Minor Voiding Disorders <ul><li>Extreme Daytime Urinary Frequency </li></ul><ul><ul><li>Sudden onset daytime urinary urgency/frequency </li></ul></ul><ul><ul><li>No dysuria or incontinence </li></ul></ul><ul><ul><li>Exclude idiopathic hypercalciuria </li></ul></ul><ul><ul><li>Reassurance </li></ul></ul><ul><li>Stress/Giggle Incontinence </li></ul><ul><ul><li>Mostly self-limiting </li></ul></ul><ul><ul><li>Trial anticholinergics if troublesome </li></ul></ul><ul><li>Postvoid Dribbling (Vaginal voiding) </li></ul><ul><ul><li>Related to posture during voiding </li></ul></ul><ul><ul><li>Toilet retraining </li></ul></ul>
    27. 28. Lazy Bladder Syndrome <ul><li>Characterised by; </li></ul><ul><ul><li>Large capacity, hypotonic bladder </li></ul></ul><ul><ul><li>Infrequent voiding </li></ul></ul><ul><ul><li>Poor urinary stream </li></ul></ul><ul><ul><li>Abdominal straining to void </li></ul></ul><ul><li>Incontinence between voiding due to overflow </li></ul><ul><li>Decreased sensation of bladder fullness </li></ul><ul><li>Incomplete emptying predisposes to UTI </li></ul><ul><li>Mx - Timed voiding / Double voiding </li></ul><ul><ul><ul><li>- Treat constipation if present </li></ul></ul></ul><ul><ul><ul><li>- Antibiotics for UTI </li></ul></ul></ul><ul><ul><ul><li>- Physio / Biofeedback </li></ul></ul></ul>
    28. 29. Urge Syndrome <ul><li>Most common voiding dysfunction </li></ul><ul><li>Peak ages 5-7 years </li></ul><ul><li>Characterised by; </li></ul><ul><ul><li>urgency, frequency </li></ul></ul><ul><ul><li>holding manoeuvres eg squatting </li></ul></ul><ul><ul><li>usually normal bladder emptying </li></ul></ul><ul><li>UTI’s and constipation common </li></ul><ul><li>Mx - Treat constipation </li></ul><ul><li>- Increase fluid intake </li></ul><ul><ul><ul><li>- Timed voiding </li></ul></ul></ul><ul><ul><ul><li>- Anticholinergics </li></ul></ul></ul>
    29. 30. Voiding Disorders - Summary
    30. 31. Long Term Outcome <ul><li>Kuh et al, 1999. </li></ul><ul><ul><li>Longitudinal study of 1333 women with urinary incontinence (mean age 48 years) </li></ul></ul><ul><ul><li>50% reported stress incontinence </li></ul></ul><ul><ul><li>22% reported urge incontinence </li></ul></ul><ul><ul><li>8% had severe symptoms </li></ul></ul><ul><ul><li>women who had daytime wetting as a child were more likely to have severe symptoms </li></ul></ul>
    31. 32. The End