VOIDING DYSFUNCTION IN CHILDREN

Natalie Barganski, RN, CPNP

Objectives

The learner will be familiar with the presentation of voiding dysfunction

The learner will be familiar with the evaluation of voiding dysfunction

The learner will be familiar with different treatment options for voiding dysfunction

Physiology of micturition Muscles of the bladder and the internal

urinary sphincter are innervated by autonomic nerves, sympathetic and parasympathetic

These nerves are integrated at various sites in the spinal cord, brain stem, midbrain, and higher cortical centers

Physiology of micturition Two major

functional roles of the bladder, storage and elimination of urine

Filling Phase

Storage

Voiding Phase

Micturition continued It evolves from involuntary bladder

emptying during infancy to daytime urinary continence, usually around 4 years of age, then night time incontinence usually by 5 -7 years of age

It is usually achieved after successful nighttime daytime bowel continence

Voiding Dysfunction General term to

describe abnormalities in either the filling and/or emptying of the bladder

It constitutes ~ 40% of the Pediatric Urology Clinic

International Children’s Continence Society Global multidisciplinary organization of

clinicians involved in the care of children with lower urinary tract dysfunction

Standardized definitions for voiding dysfunction symptoms and disorders

These definitions mostly apply to children who are five or more years of age

ICCS Definitions Daytime frequency

Incontinence

Urgency

Hesitancy

Straining

ICCS Definitions continued

Weak stream

Intermittent stream

Holding maneuvers

Post-micturition dribbling

Residual urine

Categories Nocturnal enuresis or nighttime

incontinence Continuous or intermittent

daytime urinary incontinence – these disorders are generally applied to children at least 5 years of age or older

Nocturnal enuresis

Monosymptomatic enuresis (MNE)

Nonmonosymptomatic enuresis (NMNE)– occurs in children with enuresis who also describe other LUT symptoms

Primary or secondary enuresis- 85% of all cases of childhood enuresis in primary

Nocturnal enuresis cont. Both MNE and

NMNE are often hereditary

Three major causes:

Nocturnal polyuria

Detrusor overactivity

Increased arousal thresholds

Nevéus, T, et. al. ICCS MNE Standardization 2008

INCIDENCE

No family history 15%

One enuretic patient

44%

Two enuretic parent

77%

Daytime Urinary IncontinenceDue to underlying abnormalities of bladder

function Overactive bladder

Voiding postponement and underactive bladder

Dysfunctional voiding

Other conditions- giggle incontinence, vaginal voiding, primary bladder neck dysfunction

Etiology Neurogenic

causes

Anatomic causes

Functional causes

Prevalence Nocturnal enuresis- 15% - 20% of 5 year

olds, decreases with increasing age Daytime urinary incontinenceFour – six year olds – up to 20% have

daytime urinary incontinenceDecreases with age Five – Six year old children – 10 %Six – Twelve year old children- 5 %Twelve – Eighteen year old children- 4 %

Categories based on risk Minor Daytime

frequency Giggle

incontinence Stress

incontinence Post void-

dribbling Nocturnal

enuresis

Moderate Underactive

bladder Overactive

bladder Dysfunctional

elimination syndrome

Severe Hinman Ochoa Myogenic failure

Associated conditions Urinary tract infection

Vesicoureteral reflux

Constipation and dysfunctional elimination syndrome

Behavioral and neurodevelopmental issues

Bladder extrophy, epispadias, ectopic ureter, neurogenic bladder

Assessment of urinary incontinenceMain goals:

Find those that are at risk for upper tract deterioration in order to prevent of renal impairment

Establish the cause of incontinence

Improve quality of life

History & PhysicalHistory is the KEY in determining the type

of disorder Birth history

Child’s medical history

Family medical history

Developmental history

Voiding History Toilet training history Voiding schedule Symptoms of voiding dysfunction Diet intake, including fluid intake

(caffeinated) Bowel habits Family conflict or stress, behavior,

peer relations Sleep Treatment strategies

Clinical Tools- Voiding Questionnaire

Tools- Bladder (Voiding) Diary

Tools- Bristol Stool Chart

Physical Examination Focus is on detecting neurologic and

urologic abnormalities Height/weight Blood pressure Abdominal palpation Lower back Neurologic exam Genital examination

Investigations UA, culture Nocturnal urine

production Bladder scan- Uroflow with or w/o

EMG RUS VCUG MRI Urodynamic studies Dynamic renal

imaging

Management FIRST- Treatment of Constipation

40% of children with LUT symptoms have constipation

Large retrospective study of 234 patients showed a resolution of constipation was associated with elimination of wetting in 89% and 63 % of children with daytime or nighttime urinary incontinence, and prevention of UTIs

Loening-Baucke, V. Pediatrics 1997; 100-228

ManagementWhen to start

treatment? When the child is ready!

Nonpharmacolgic or conservative treatment- Voiding Behavior Modification

A partial response with > 50% reduction of incontinent episodes

Allen, et al. Urology 2007; 69:962 Weiner, et al. J Urol 2000; 164-786

ManagementIf conservative treatment fails to relieve

symptoms treatment is condition specific

NE- desmopressin, alarm, maybe anticholinergics, imipramine

OAB- anticholinergic medication can be beneficial

Management Underactive bladder- timed voiding is

important, avoid anticholinergics, alpha adrenergic blockade has been helpful in relaxing bladder outlet

Non-neurogenic dysfunctional voiding- concern for upper urinary tract deterioration, may need urodynamics, pelvic floor relaxation techniques, biofeedback, or an alpha antagonist

Dysfunctional voiding

Compensatory detrusor hypertrophy and hyperplasia

Small capacity trabeculated bladder that may elevate bladder pressures

Vesicoureteral reflux and resultant upper tract renal

damage

Detrusor decompensation

and hypocontractilit

y

May

need

CIC or surgery

Management Biofeedback- therapy teaches children

how to identify and control the muscle groups involved in voiding

Reserved for children with detrusor sphincter dyssynergia contributing to daytime incontinence despite behavior modifications/pharmacotherapy

Helpful in children with significant post void residuals who have recurrent UTI and constipation

THANK YOU!! QUESTIONS?