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Uretrovaginal reflux1


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Uretrovaginal reflux1

  1. 1. Urethrovaginal Reflux—A Common Cause of Daytime Incontinence in Girls Sven Mattsson and Gunilla Gladh Pediatrics 2003;111;136-139 DOI: 10.1542/peds.111.1.136 The online version of this article, along with updated information and services, is located on the World Wide Web at: PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2003 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from by on June 17, 2009
  2. 2. Urethrovaginal Reflux—A Common Cause of Daytime Incontinence in Girls Sven Mattsson, MD, Med Dr, and Gunilla Gladh, RN, Med Dr ABSTRACT. Objective. The objective of this study when performed in an erect position.4,5 Such filling was to estimate the frequency of urethrovaginal reflux as in young girls is usually viewed as a normal finding. the cause of daytime incontinence in school-age girls, The condition has mainly been considered in relation and to study the characteristic symptoms and the effect of to suspected bacterial contamination of urine sam- simple instructions intended to amend the problem. ples4 – 6 and as a possible risk for urinary tract infec- Material and Methods. Girls with urethrovaginal re- flux were identified in a group of 169 girls, aged 7 to 15 tion.7 To our knowledge, the role of urethrovaginal years, referred to a specialist clinic because of daytime reflux as the cause of incontinence has not been incontinence. They were evaluated by a noninvasive evaluated. The aims of the present study were to screening protocol, including a careful history and neuro- estimate the frequency of this condition in girls re- urologic examination, bladder diaries, urine analysis, ferred for treatment of daytime incontinence, and to uroflows, and residual urine determined by ultrasound. study its characteristic symptoms and the effect of Girls with urethrovaginal reflux were instructed by a simple instructions intended to amend the problem. urotherapist on how to achieve better toilet habits. Results. Urethrovaginal reflux was found in 21 MATERIALS AND METHODS (12.4%) of 169 girls as the sole (19) or contributing (2) cause of their daytime urinary incontinence. They all had The frequency of urethrovaginal reflux was estimated in a a typical history of small leakage 5 to 10 minutes after consecutive sample of 169 girls, aged 7 to 15 years (median: 10 years), referred to a specialized urotherapeutic clinic because of voidings during the day, confirmed by a specific bladder daytime urinary incontinence. All girls were of normal weight and diary. All were neurologically healthy, and all but 2 had height, and apart from their incontinence, they were all healthy a normal bladder function. The latter 2 girls had residual without known neurologic problems. They were evaluated by a urine and asymptomatic bacteriuria. At follow-up after noninvasive screening protocol including a careful history, clinical median 2 years, all girls were free from postmicturition examination with particular focus on neurourologic status, blad- leakage, but the 2 with residual urine remained daytime der diary for 3 days, urine analysis, and 3 uroflowmetries fol- incontinent with cystometrically proven phasic detrusor lowed by residual urine determination by ultrasound (Bladder- overactivity. Scan 2500, Diagnostic Ultrasound Corporation, Redmond, WA). Conclusions. Urethrovaginal reflux is a common All girls with a history of small urinary leakage shortly after daytime micturitions were further examined. The girls completed cause of urinary incontinence in girls. The diagnosis is additional bladder diaries at home with extra focus on urinary easily obtained by an adequate history, completed leakage episodes 5 to 10 minutes after voidings (Fig 1). At the with a specific bladder diary. The problem is easily second visit, after confirmation of the diagnosis urethrovaginal resolved by proper voiding instructions. Pediatrics reflux, they received instructions by a qualified urotherapist on 2003;111:136 –139; children, urinary incontinence, ure- how to sit properly on the toilet to void with minimal reflux and throvaginal reflux, bladder diary. how to evacuate urine from the vagina (Table 1). The effect of instruction was evaluated by submitted bladder diaries and/or by telephone contact by the urotherapist. D aytime incontinence of different causes oc- curs in 3.1% to 9.5% of school-age girls.1–3 In RESULTS most cases, isolated day wetting is found to be idiopathic, but incontinence may be a first symp- Urethrovaginal reflux was identified as the cause tom of a serious neurologic disorder. A correct diag- of daytime urinary leakage in 21 (12.4%) of 169 girls. nosis can often be obtained by child-adapted nonin- They all had a characteristic pattern of leakage in vasive procedures; only in special cases may invasive connection with voidings. Typically, they were dry investigations be required. when going to the toilet but frequently wet their Urethrovaginal reflux has been recognized as a panties within 5 to 10 minutes after the voiding. This possible cause of urinary leakage in girls.4 Retro- pattern was easily discovered by adequate questions grade filling of the vagina is frequently found in during history taking and supported by the specific association with voiding cystourethrography, even bladder diary, as shown in Fig 1 from a typical girl with urinary leakages at 5 of 6 voidings during the day. Characteristically, the leakages were rather From the Division of Pediatrics, Department of Molecular and Clinical small but enough to wet the panties. Medicine, Faculty of Health Sciences, Linkoping, Sweden. ¨ Although not necessary or specific for the diagno- Received for publication Mar 14, 2002; accepted July 30, 2002. sis,4,5 urethrovaginal reflux can frequently be ob- Reprint requests to (S.M.) Division of Pediatrics, Department of Molecular served in micturition cystourethrography (Fig 2). and Clinical Medicine, Faculty of Health Sciences, SE-581 85 Linkoping, ¨ Sweden. E-mail: The illustrated investigation was performed to ex- PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad- clude ureteric reflux in a girl with repeated distal emy of Pediatrics. urinary tract infections. In practice, the diagnosis of 136 PEDIATRICS Vol. 111 No. 1 January 2003 Downloaded from by on June 17, 2009
  3. 3. Fig 1. A typical bladder diary for a 9-year-old girl with daytime urinary leakage caused by urethrovaginal reflux. TABLE 1. Voiding Instructions for Girls With Urethrovaginal mal. However, 6 had a previous history of 1 (2 girls) Reflux or more (4 girls) episodes of acute cystitis. Despite Sit steadily on the toilet brim, legs fully supported. referral because of daytime incontinence, 3 girls had Keep the legs well apart. primary nocturnal enuresis. This elaborate list Lean the trunk forward (as much as you can) making the pelvic should not conceal that the majority of the girls with tilt forward and the urinary stream more vertical. urinary leakage attributable to urethrovaginal reflux Separate the labia before voiding. At end of voiding, use toilet paper to press and lift the had normal bladder function at the time of evalua- perineum forward/upward (from the base of the vagina and tion. away from the rectum) to empty urine from the vagina. All girls with urethrovaginal reflux received a thorough voiding instruction by a qualified uro- therapist, as outlined in Table 1. Their problem with postmicturition urinary leakage immediately re- urethrovaginal reflux is obtained by the finding that solved. At follow-up (median: 2 years), all girls but 2 the girls can evacuate urine from the vagina after remained continent and all but 1 with recurrent acute voidings. Furthermore, their incontinence problem is cystitis became free from urinary tract infections. For resolved by teaching them how to sit and void to these 19 girls (11.2%), the urethrovaginal reflux was minimize vaginal reflux and how to empty the va- apparently the sole cause of their daytime urinary gina (Table 1). leakage. The 2 girls, who at first visit had residual The girls with urethrovaginal reflux had the same urine, remained incontinent with cystometrically age distribution, 7 to 15 years, as the total group of proven phasic detrusor overactivity. Both had lasting girls with daytime incontinence. There was no obvi- asymptomatic bacteriuria, and 1 had lasting residual ous deviation in the shape of their urethral meatus, urine. Clearly, the original leakage problem of these external genitals, or hymenal ring compared with the girls was attributable to a combination of urethro- normal anatomy of girls in the same age group. Their vaginal reflux and urge incontinence. The third girl neurourologic findings were also normal. Voiding with asymptomatic bacteriuria became dry despite frequency was 4 to 8 voidings per day (median: 5), remaining bacteriuria. At follow-up, the 3 girls with which is within the normal range for healthy school- nocturnal enuresis were all dry at night. aged girls.8 All but 1 had normal urinary flows; the exceptional girl had several voidings with inter- rupted flow curves. She and another girl were the DISCUSSION only ones who voided with residual urine ( 20 mL). Urethrovaginal reflux is a surprisingly common Both girls also had asymptomatic bacteriuria, as did cause of urinary leakage in schoolgirls. It was the a third girl without signs of bladder dysfunction. For major problem in 10% of the girls referred to a the remaining 18 girls, the urine analysis was nor- specialized clinic for daytime incontinence. The di- ARTICLES 137 Downloaded from by on June 17, 2009
  4. 4. Fig 2. Urethrovaginal reflux shown by micturition cystourethrography in an 8-year-old girl. A, Side view of the bladder filled with contrast medium at the start of voiding. B, End of void picture with almost empty bladder and vagina filled with contrast medium. agnosis is easily obtained by a careful history, com- hind the low barrier of the hymen. The vagina has pleted with an adequate bladder diary. In affected also a more horizontal position before puberty, girls, the anatomy of the urethral meatus and exter- which may contribute to the vaginal reflux. nal genitals is apparently normal for the age. Most When the girl rises from the toilet, urine will start affected girls also have a normal bladder function. to dribble and wet the panties. For some girls, the The condition is very gratifying to handle, because it majority of leakage may occur when they start to is rapidly amended by proper instructions about move. Others may squeeze out urine first when they voiding position and how to evacuate the vagina increase the abdominal pressure by laughing or from reflux urine. coughing. In most cases, the leakage is just a few The mechanisms behind urethrovaginal reflux are milliliters, which is enough to leave a wet spot in the not quite clear. Presumably, the problem arises from panties. The described course of events explains the the specific anatomic situation in young girls, as the typical history of girls with urethrovaginal reflux— condition is not found in postpubertal girls or women. In young girls, the urethral opening is close they are dry when going to the toilet but wet when to the vagina and hymenal ring with the labia minora leaving. and majora small and in close proximity. Even with- Urethrovaginal reflux is frequently found when out anatomic adhesions, the labia may stick together performing voiding cystourethrography4 – 6 in girls. and direct the urine backwards. Therefore, the urine Such findings are not diagnostic, because most girls may pass through the vaginal opening and stay be- with radiologically demonstrated reflux have no 138 INCONTINENCE AND URETHROVAGINAL REFLUX Downloaded from by on June 17, 2009
  5. 5. symptom of urinary leakage. Either the vagina is not ACKNOWLEDGMENTS filled during everyday voidings or empties sponta- ¨ The study was supported by grants from Ostergotlands Land- ¨ neously before the girl gets up from the toilet. What- sting and from the Research Fund of the University Hospital of Linkoping. ¨ ever the case, this finding has caused some concern Urotherapists Monica Eldh and Monica Brannstrom and spe- ¨ ¨ regarding bacterial contamination of urine samples cialist nurse Kerstin Rydmyr provided voiding instructions to the for culture.4 – 6 It can be expected that urethrovaginal girls. Assistant Professor Margareta Resjo kindly supplied the ¨ reflux in some girls may cause genital irritation, radiograph. smarting, bad smell, and vaginal discharge. The con- REFERENCES dition may also contribute to lower urinary tract 1. Hellstrom A-L, Hansson S, Hansson E, Hjalmås K, Jodal U. Micturition ¨ ¨ infections.7 In agreement, a relatively high propor- habits and incontinence in 7-year-old Swedish school entrants. Eur tion of the girls with urethrovaginal reflux (43%) had J Pediatr. 1990;149:434 – 437 a history of urinary tract infections. Most became free 2. Mattsson S. Urinary incontinence and nocturia in healthy school chil- dren. Acta Paediatr. 1994;83:950 –954 of infections when their problem with urethrovagi- 3. Bower WF, Moore KH, Shepherd RB, Adams RD. The epidemiology of nal reflux resolved. childhood enuresis in Australia. Br J Urol. 1996;78:602– 606 4. Kelalis PP, Burke EC, Stickler GB, Hartman GW. Urinary vaginal reflux CONCLUSION in children. Pediatrics. 1973;51:941–943 5. Davis LA, Chunley WF. The frequency of vaginal reflux during mic- Urethrovaginal reflux is a surprisingly common turition—its possible importance to the interpretation of urine cultures. cause of daytime urinary leakage in girls. The con- Pediatrics. 1966;38:293–294 dition is easily diagnosed by an adequate history and 6. Tamburrini O, Palescandolo P, Bartomoleo-De Iuri A, Dolezalova H, amended by instructions aimed at improving toilet Porta E. Urethro-vaginal reflux. Radiol Med (Torino). 1984;70:11–12 7. Linshaw MA. Controversies in childhood urinary tract infections. World habits. With no need for specialized urologic inves- J Urol. 1999;17:383–395 tigations, the outpatient pediatrician can properly 8. Mattsson S. Voiding frequency, volumes and intervals in healthy school handle the condition. children. Scand J Urol Nephrol. 1994;28:1–11 CONFLICT OF INTEREST IN BIOTECHNOLOGY “I don’t think there has ever been a time in the history of modern scientific research when such a large proportion of those engaged in academic biological research are so involved with for-profit biotechnology companies. Now there are a lot of benefits to these activities, such as technology transfer. On the other hand, it is hard to find scientists who are not potentially conflicted by their financial interests in these companies. Full disclosure solves a lot of these issues, but when you think of the erosion of the confidence the public may have in what scientists say, these conflicts, real or perceived, become very important.“ Harold Shapiro, ex-president of Princeton University, quoted in The New York Times, July 2, 2002 Submitted by Student ARTICLES 139 Downloaded from by on June 17, 2009
  6. 6. Urethrovaginal Reflux—A Common Cause of Daytime Incontinence in Girls Sven Mattsson and Gunilla Gladh Pediatrics 2003;111;136-139 DOI: 10.1542/peds.111.1.136 Updated Information including high-resolution figures, can be found at: & Services References This article cites 8 articles, 2 of which you can access for free at: Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Genitourinary Tract Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Reprints Information about ordering reprints can be found online: Downloaded from by on June 17, 2009