Micturation disorders

1. DISORDERS OF MICTURITION
Dr. Sreemayee Kundu
MD PAEDIATRICS

2. CONTENTS
• Introduction
• Physiology of micturition
• Maturation of micturition & sequence
• Voiding disorder-types,evaluation & treatment
• Nocturnal enuresis
• Neurogenic bladder

3. INTRODUCTION
• Urinary bladder functions as a storage organ that
can empty to completion at appropriate time and
place.
• Problems related to bladder are often obvious
like nocturnal enuresis, incontinence, dribbling or
may not be apparent like recurrent UTIs, day time
urgency frequency syndrome.
• Early intervention may prevent renal damage
from retrograde effects of high bladder pressures.

4. PHYSIOLOGY OF MICTURITION
FILLING
• Regular peristaltic contractions move the
urine from the renal pelvis to the bladder.
• Sympathetic systems T11-L2 spinal segments
responsible for effective bladder filling
• Sympathetic & pudendal nerve mediated
inhibition of detrusor contractility with
closure of bladder neck & proximal urethra.

5. PHYSIOLOGY OF MICTURITION
EMPTYING
• Contraction of detrusor muscle, mainly responsible
for emptying bladder during micturition.
• Bladder Neck along with elastic fibers form internal
urethral sphincter
• Urogenital diphragm with its skeletal muscle form
external urethral sphincter.
• Co-ordination among these three structures
responsible for emptying.
• Parasympathetic system S2-S4 for micturition.

6. MATURATION OF BLADDER
FETUS/
AT
BIRTH
Spinal cord reflex Spontaneous micturition
1-2
YEARS
bladder capacity +
Neural maturation of
frontal and parietal lobe
Sensation of bladder filling
present but voiding is reflex
3-4
YEARS
Voluntary control of EUS
when awake(day time)
Can delay micturition
5 YEARS Cortical inhibitory control
achieved
Dry by night
>6 yrs Ability to initiate voiding
even when bladder has
not given a “full” signal
Voiding under socially
acceptable circumstances

7. MATURATION SEQUENCE
• Night time fecal continence
• Daytime fecal continence
• Daytime urine continence
• Night time urine continence

8. DEFINITIONS (ICCS)
1. DECREASED DAYTIME
VOIDING FREQUENCY
</= 3 voidings/day
2. INCREASED DAYTIME
VOIDING FREQUENCY
>/= 8 voidings/day
3. POLYURIA >2 lit/m2 BSA - 24hrs
> 5ml/kg/hr
4. EXPECTED BLADDER
CAPACITY
[30+ (age in yrs x 30)] ml
5. RESIDUAL URINE Excess of 5-20ml indicates
incomplete bladder
emptying

9. DEFINITIONS (ICCS)
URINARY
INCONTINENCE
uncontrollable leakage
of urine
• CONTINUOUS continuous leakage of
urine , not in discrete
portions
malformation or
iatrogenic damage
• INTERMITTENT leakage in discrete
portions during
day/night
night = nocturnal
enuresis
• URGE
INCONTINENCE
associated with
urgency
Ex - overactive
bladder
• VOIDING
POSTPONEMENT
In the presence of
habitual holding
maneuvers

11. VOIDING DISORDER
• Definition: These consist of essentially functional,
abnormal patterns of micturition in the presence
of an intact neuronal pathway and without any
congenital/anatomical abnormality of the urinary
tract. Also called as Functional incontinence.
• Functional UI may be caused by disturbances in
the filling (storage) phase, the voiding phase, or a
combination of both.

12. Classification
Voiding Disorders
(based on clinical symptoms & urodynamics study)
Overactive bladder Dysfunctional voiding
(filling phase disorder) (evacuation phase disorder)
-staccato
-fractional
dysynergia
hypotonic/underactive bladder

13. VOIDING DISORDER
OVERACTIVE BLADDER
• It is a filling phase defect.
• Characterized by frequent episodes of urgency.
• Countered by contractions of pelvic floor
muscles and holding maneuvers.
• Due to underlying detrusor overactivity.
• Also called detrusor instability.
• Can be associated with incontinence (urge
incontinence).

14. VOIDING DISORDER
OVERACTIVE BLADDER
• Functional bladder capacity is small.
• Voiding pattern is normal with appropriate
relaxation of pelvic floor muscles.
• Associated with constipation.
( triggers detrusor contraction by stimulation
of stretch receptors in bladder wall by extrinsic
fecal mass or by colonic contractions via shared
neural pathways.)

15. VOIDING DISORDER
DYSFUNCTIONAL VOIDING
• It is a voiding phase defect
• Characterized by infrequent voiding and
straining to void.
• Associated with bladder-sphincter
incoordination.
• Referred as bladder-sphincter dysynergia.
• It may be staccato or fractional voiding.

16. VOIDING DISORDER
DYSFUNCTIONAL VOIDING
Staccato voiding:
• Bursts of pelvic floor muscle activity during
voiding
• Causes interruption in the urine flow.
• Prolonged flow duration and incomplete
voiding.

17. VOIDING DISORDER
DYSFUNCTIONAL VOIDING
Fractionated voiding:
• Micturition occurs in several small fractions.
• Emptying is incomplete due to hypo-activity of
detrusor muscles.
• Abdominal muscles are used to increase
pressure on the bladder (valsalva voiding).
• Irregular but continuous flow rate.

18. VOIDING DISORDER
DYSFUNCTIONAL VOIDING
Underactive bladder:
• Due to under active detrusor muscle.
• Long term result of bladder-sphincter
dysynergia with detrusor decompensation.
• Large post residual volume
• Recurrent UTIs.
• May lead to overflow incontinence.

19. VOIDING DISORDER
Hinman Syndrome
• Severe form of detrusor-sphincter dysynergia.
• Failure of external sphincter to relax during
voiding.
• Trabeculated bladder develops a high
pressure state with B/L VUR and large PVR
akin to a neurogenic bladder without any
obvious neurological abnormality.
• Non –neurogenic neurogenic bladder.

21. OTHER VOIDING DISORDER
GIGGLE INCONTINENCE
• Involuntary voiding during sudden laughter
• Seen in school girls and adolescents.
• Results from instability of bladder
• Due to inappropriate detrusor contraction and
sudden relaxation of urinary sphincter.

22. OTHER VOIDING DISORDER
VOIDING POSTPONEMENT
• Postpones imminent micturition until
overwhelmed by urgency.
• Uses holding maneuvers.
• Associated with low frequency.
• Over-activity of urethral sphincter is a behavioral
maladjustment.
• It is associated with other behavioral problems in
these children.

23. OTHER VOIDING DISORDER
VAGINAL VOIDING
• Seen in obese girls using western toilet.
• May not part their thighs adequately.
• This result in incontinence on standing due to
vaginal pooling.
• Volume of urine – 5-10 ml.
• Most common cause – Labial adhesion

24. OTHER VOIDING DISORDER
POLLAKIURIA
• Child voids extremely frequently at 30-60 min
interval.
• No dysuria, pain or incontinence.
• Nocturia is unusual.
• No organic cause.
• Stress related.

25. EVALUATION- VOIDING DISORDER
History – should assess the following :
• Pattern of incontinence
• Frequency of micturition
• Volume of urine
• Association with urgency or gigling
• Sensation of incomplete voiding

26. EVALUATION- VOIDING DISORDER
History – should assess the following :
• Urine stream
• Recurrent UTI
• Constipation
• Neurologic disorder
• Sexual abuse
• Family history of duplication disorder

27. DYSFUNCTIONAL VOIDING SYMPTOM SCORE QUESTIONAIRE

29. EVALUATION-VOIDING DISORDER
Physical examination
• Abnormal maneuvers – Vincent’s curtsy sign

30. EVALUATION-VOIDING DISORDER
• Abdominal examination:
- Abdominal masses
- Palpable bladder / kidney
- Stool-filled colon
- Abdominal muscle tone

31. EVALUATION-VOIDING DISORDER
• Back and spine examination:
- Significant scoliosis / kyphosis
- Asymmetry of the buttocks, legs, or feet
- Spinal or sacral anomaly
- Naevus
- Small dimple
- Tuft of hair
- Dermal vascular malformation
- Subcutaneous lipoma

32. EVALUATION-VOIDING DISORDER
• Neurological examination:
- look for any neurological deficit
• Genitalia:
- Location and size of the urethral meatus
- Labial adhesions
- Vaginal pooling

34. VOIDING DIARY

35. EVALUATION-VOIDING DISORDER
Investigations
Urine analysis:
Glycosuria
Bacteriuria
Proteinuria
hyposthenuria
Pyuria

36. EVALUATION - VOIDING DISORDER
USG abdomen:
 Rule out structural anomalies of kidneys and urinary
tract.
 Dilatation of upper urinary tract
 Bladder size
 Wall thickness - >5mm on empty bladder is abnormal
 Evidence of cystitis.
 PVR (Post void residue) determination: >5ml is
significant in a child within 5 min of voiding.

37. EVALUATION - VOIDING DISORDER
Micturating Cystourethrogram(MCU):
–Presence/absence of reflux
–Bladder instability
• Spinning top bladder
• Bladder wall irregularity (trabeculations)
• elongated bladder shape
• filling of posterior urethra

40. EVALUATION - VOIDING DISORDER
• MRI LS spine:
- If neurogenic bladder suspected.
• Urodynamic Study :
- Invasive study reproducing the patient’s
voiding complaints and offer a
pathophysiologic explanation to the problem.
Plan for correct therapeutic intervention

42. TREATMENT - VOIDING DISORDER
–Treatment of intercurrent infections
–Institution of structured voiding patterns with
good hydration, hygiene and timed voiding.
–Treatment of coexisting bowel disorders
• Constipation: Increased fluid intake, high
fibre diet, laxative(polyethylene glycol)
• Encopresis: Child-parent psychological
counseling.

43. TREATMENT - VOIDING DISORDER
Pharmacotherapy:
• Oxybutinin - start with 5mg/day BD to a
max of 15-20mg/day
• Tolterodine - 1mg BD for children aged 5-10
yrs. Minimum side-effects.
• Side effects: Dry mouth, Constipation,
Somnolence, Nausea

44. TREATMENT - VOIDING DISORDER
Biofeedback therapy:
 Retraining children to develop relaxed voiding
 Pelvic floor muscle exercise developed by keigel
 Uroflowmetry based – bell shaped urine flow curve
(6 hrs)
 EMG based – sphincter tone traces (45-60 min)
 Limitations: Requires equipment and expertise

45. TREATMENT - VOIDING DISORDER
Behavioral intervention:
• Useful alternative, also called as bladder
re-education initiative. It has 5 components
– Patient education
– Scheduled voiding regimen with gradual increasing
levels
– Urgency control strategies
– Self monitoring
– Positive reinforcement to learn pelvic floor muscle
relaxation

46. TREATMENT - VOIDING DISORDER
Combination Therapy:
–Biofeedback + alpha blockers
–Terazocin or Doxazocin- (0.5-1mg/day)
–Used in refractory cases of dyfunctional
voiding

47. TREATMENT - VOIDING DISORDER
Clean intermittent catheteration(CIC)
- useful in children with large PVR to lower
intravesical pressures
- instituted usually at night
- very useful in children with valve bladders
considered for renal transplantation

49. NOCTURNAL ENURESIS

50. NOCTURNAL ENURESIS
• Definition: Normal, nearly complete, evacuation of
bladder at a wrong place & time at least twice a month
after 5th year of life.
• 85% of children attain bladder control by 5 years age.
• Remaining 15% will gain continence at a rate of 15%
per year.
• By adolescence 0.5-1% continue to have enuresis.
ENURESIS INCONTINENCE
Complete evacuation of bladder Incomplete evacuation of bladder
Bed soaking wet not
Always functional Organic causes

51. NOCTURNAL ENURESIS
ENURESIS intermittent nocturnal incontinence
a. MONO
SYMPTOMATIC
Without any lower urinary tract symptoms
b. NON-MONO
SYMPTOMATIC
With lower urinary tract symptoms –
daytime incontinence, urgency, holding
maneuvers
c. PRIMARY Previously dry for < 6 mnths/ Never been dry
d. SECONDARY Previously dry for =/> 6 months(minimum)

52. NOCTURNAL ENURESIS
ETIOLOGY
Maturational delay:
• Most common cause
• Spontaneous cure rates increase with age.
• Developmental delay, Anxiety, stress.
• Boys > girls.

53. NOCTURNAL ENURESIS
ETIOLOGY
ADH: (circadian rhythm, more secretion at night
and peak from 4am-8am)
• Loss of circadian rhythm
• Impaired response of kidneys to ADH.

54. NOCTURNAL ENURESIS
ETIOLOGY
Bladder capacity:
• Imbalance between the bladder capacity and
nocturnal urine production.
• If bladder capacity is less, may lead to enuresis.

55. NOCTURNAL ENURESIS
ETIOLOGY
Genetics:
• 1 parent – 40% ,Both– 70% chance
• Linked with chromosomes 8,12,13 & 22
• ENUR 1 gene on long arm of chr-13
• Autosomal dominant
• modulated by environmental factors and
other genes.

56. NOCTURNAL ENURESIS
ETIOLOGY
 Sleep factor: Inadequate arousal– impair
vasopressin secretion– polyuria.
Co-morbid conditions:
- Constipation
-ADHD

57. NOCTURNAL ENURESIS
INVESTIGATIONS
Less than 5% - organic causes
Uncomplicated enuresis - no further evaluation
 Clinical & Neurological Examination
Urine R/E: Rule out infection, proteinuria and
glycosuria in all children
Voiding dairy: Urine output (frequency,volume),
fluid intake – 2 days, day time accidental voiding ,
bladder symptoms, bowel habits- 7 days

58. NOCTURNAL ENURESIS
USG abdomen and MCU: For suspected
neurological and urological dysfunction.
Screening test: Uroflowmetry + pelvic floor
and abdominal muscle EMG
Cystometry: Invasive and only in suspected
functional voiding disorder

59. NOCTURNAL ENURESIS
TREATMENT
Supportive measures Pharmacotherapy

60. NOCTURNAL ENURESIS
TREATMENT
Supportive measures
• Timely treatment - prevent psychological damage
to the child and provide relief to the family
• Assess the level of motivation of the child and
parents
• General advice to all enuretic children
• Active treatment after the age of 6 years.

61. NOCTURNAL ENURESIS
TREATMENT
Supportive measures
• Caffeinated drinks like coffee, tea and soda
should be avoided in evening.
• Adequate fluid intake :
- 40% morning
- 40% afternoon
- 20% evening.

62. NOCTURNAL ENURESIS
TREATMENT
Supportive measures
• Dry bed training :
a) emptying bladder before retiring to bed
b) encourage bed time resolution
c) keeping wet and dry night charts
d) rewarded for active co-operations

63. NOCTURNAL ENURESIS
TREATMENT
Supportive measures
• Bladder training exercises:
- for those with smaller functional bladder
capacity
- Recent trials show these are not effective.

64. NOCTURNAL ENURESIS
TREATMENT
Supportive measures
• Motivational therapy :
- reassurance
- emotional support
- positive reinforcement
- Gift technique

65. NOCTURNAL ENURESIS
TREATMENT
Supportive measures
• Behavioral modification
- Good bladder and bowel habits
• Stool softener
• Supportive parent, motivated child and
Paediatrician with time n patience.

66. NOCTURNAL ENURESIS
TREATMENT
Supportive measures
• Alarms:
- To elicit a conditioned response
- Awakening to the sensation of full bladder.
- Best for children >7yrs of age.
- Use at least for 6 months (min 2 -3 moths
trial)
- Continue till 14 consecutive dry nights are
achieved.

68. NOCTURNAL ENURESIS
Pharmacotherapy:
Treatment initiated
Continue for 2 weeks
Assess efficacy and adjust dose
If child dry
Maintain for 3 to 6 months
Gradually wean over 3 to 4 weeks

69. Medications for Enuresis
DRUG DOSE DURATION AGE FOR
USE
DDAVP nasal
spray
10 – 40 mcg/
day
Until 4 weeks
dry
Any if
supervised
Oxybutynin 5 – 20 mg/day 3 -6 months > 6 years
Imipramine 0.9 – 1.5
mg/kg/day
(25 – 50 mg)
3 -6 months > 7 years
Tolterodine 1 mg twice
daily
Until
uninhibited
blader
improves
5 – 10 years

70. NEUROGENIC BLADDER

71. NEUROGENIC BLADDER
• Neurogenic bladder dysfunction is usually
congenital
• Results from neural tube defects and other
spinal anomalies
• Acquired and traumatic lesions of spinal cord
are less common

72. NEUROGENIC BLADDER
Causes:
– Spinal dysraphism
• Meningocoele
• Meningomyelocoele
• Spina bifida occulta
• Sacral agenesis

73. NEUROGENIC BLADDER
Causes:
– Spinal trauma
• Sacrococcygeal teratoma
– Spinal tumours
– Degenerative disorders
• Autonomic neuropathy
• Transverse myelitis

74. NEUROGENIC BLADDER
Effects:
-Socially unacceptable incontinence
-Renal failure
Types:
1. Bladder sphincter dysynergia
2. Synergic low pressure incontinent bladder
3. Completely denervated bladder

75. NEUROGENIC BLADDER
Evaluation:
-Physical examination
-MRI LS spine
-USG
-MCU
-DMSA

76. NEUROGENIC BLADDER
Treatment:
– Constipation- laxatives
– Crede’s maneuver- suprapubic massage causes
reflex bladder contraction and should be avoided.
– CIC: Improves the outcome significantly by
maintaining low intravesical pressures
– Oxybutinin: decreases detrusor overactivity
– Antibiotics: before CIC in dilated upper tract.

77. NEUROGENIC BLADDER
Treatment:
– Surgery:
• Bladder augmentation in low capacity bladder
• Urinary diversion for upper tract deterioration
despite conservative measures
Sphincterotomy in bladder outlet obstruction
Reimplantation of ureters in vesicoreteral reflux.

78. Case 1:
A twelve year old male child presented
with complaints of intermittent pain in the
shaft of the penis of 3 years duration.
associated with urgency and frequency.

81. Case 1:
Ultrasound had shown- evidence of cystitis,
IVP had been interpreted as showing a trabeculated
bladder.
Cystoscopy reported normal.
Uroflow EMG was advised to confirm / exclude
dysfunctional voiding.
Uroflow showed a bell shaped curve with a peak flow of
20mls/sec.
What was striking was the complete silence of the
external sphincter during voiding indicating good synergy
between the detrusor and the external sphincter

82. Case 1:
Voiding dysfunction was therefore totally eliminated.
Once dysfunctional voiding is identified on the Uroflow EMG
remedial measures can be instituted.
The simplest is double voiding – asking the child to go back, sit on
the toilet and void again.
This is efficacious for the preoccupied child who is busy with a
computer game or a TV programme and tries to postpone voiding.
For the older adolescent who has made a habit of not voiding in
school and has thereby enlarged her bladder to an unusual capacity,
timed voiding is the answer.
these children should be encouraged to drink more fluids and to void
at regular intervals.

83. Case 2:
A ten year old obese girl was brought with
severe wetting and constipation refractory to
anticholinergics and alpha blockers.

84. Case 2:
Micturiting Cystourethrogram showed vaginal
pooling after voiding and a dribble on standing
up.
Uroflow EMG showed an interrupted pattern
of voiding (staccato voiding) with low peak flow
and pronounced detrusor activity.

85. Case 2:
She was advised
1) Anticholinergics to prevent unstable bladder
contractions,
2) Diazepam at night to enable to relax chronically
contracted external sphincter
3) Double voiding and relaxed voiding aiming to
completely empty bladder and to eliminate dribbling
4) Posture on the toilet was reversed to eliminate
vaginal voiding. Reverse posture is to spread the
thighs wide apart, so that vaginal pooling is avoided
5) Weight reduction.
6) Treatment of constipation

86. REFERENCES
• Nelson Textbook of Pediatrics
• Pediatric Nephrology – Srinastava & Bagga
• Practical approach to a nocturnal enuresis &
voiding dysfunction - IJPP 2012; 14(2)
• Demystifying voiding dysfunction - IJPP
2007IJPP 2012; 14(2)

87. THANK
YOU