Dysfunctional Elimination Syndrome Vincenzo Galati, D.O.

Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma Department of Urology Section of Pediatric Urology

Objectives

• Normal Elimination • Dysfunctional Elimination Syndrome • Non-Neurogenic Neurogenic Bladder • Biofeedback • Review of the literature

Development of Urinary Control

• Infancy: Reflex voiding – Detrusor contracts when bladder full – External urinary sphincter contracts during filling • Voiding pattern in infants (feeding) • Development of continence – ↑ capacity and control of striated sphincter – Control over spinal micturition reflex

Stooling

• Normally – Newborn meconium passes w/in 24 hrs – First few weeks: BMs 6 X q day – By 5 months: BMs 3 X q day – Age 2: BMs bid – Age 4: BM q day J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

Dysfunctional Elimination

• Unknown etiology • Abnormal elimination pattern • Bowel or bladder incontinence • Withholding maneuvers

Holding Maneuvers

Dysfunctional Elimination

• Prevalence approximately 15% (Hellstrom et al. 1991) • Overlooked factor in pediatric UTIs • 40% of toilet trained with 1 st UTI • 80% with recurrent UTI • Risk factor for VUR and renal scarring

Bad Bladder Habits

• Infrequent visits to bathroom • Inadequate time in bathroom • Bad posture • Poor hygiene

What Happens?

• Infrequent voiding – Over distended bladder • Failure to relax pelvic floor – Voiding against closed sphincter • ↑ PVR

What Happens?

• Bad posture – Can’t relax • Bad hygiene or aggressive soaps – Dysuria and incomplete voiding

•Children rated wetting themselves at school as the third most catastrophic event behind losing a parent and going blind.

Ollendick et al, Behav Res Therapy, 1989.

Functional Bowel Disturbances

• Constipation – Hard BM occurring < 3 X per week • Most likely to occur in 3 situations • Can induce bladder dysfunction • 50% of dysfunctional voiding have constipation J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

Functional Constipation

• Symptoms – Infrequent passage of stool – Hard stool – Palpable stool in abdomen or in rectal vault – Fecal soiling J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

Functional Constipation

• Management: – Parental education (hydration and fiber) – Many require stool softeners – Visit toilet 30-40 minutes after a meal • Forward leaning, T&L extension, hip abduction, foot support that allows 90 ° of hip/knee flexion J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

Treatment of Day Time Wetting

• 1 st line is Behavior Modification – Diary – Bathroom every 2 hrs – Good posture – Ample time – Good hygiene

Treatment of Day Time Wetting

• Treat Constipation • Biofeedback – Learn to relax pelvic muscles • Medications – Ditropan  ↓ pressure but CONSTIPATES!

– ? Role of α-blocker and Botox

Non-neurogenic neurogenic bladder (NNGNGB)

• Nocturnal and diurnal incontinence • Dribbling, overflow, urge incontinence • Bowel dysfunction • Recurrent UTI’s • Bladder instability • Voluntary DSD during voiding

NNGNGB

– VCUG  large PVR – Reflux noted in about 50%

NNGNGB - Treatment

– Sterilize Urine – Bladder retraining – Normalize bowel function – Anticholinergics eliminate unstable bladder contractions – Sympatholytics and diazepam to reduce outflow resistance – May need CIC

Biofeedback

• Treatment option for children with DSD • Goal: develop control over pelvic floor muscles during voiding • Visual electromyography feedback • Maintain relaxed pelvic floor with voiding • Success up to child/parent/physician • Problem: can be invasive Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470 1475.

Modified Biofeedback Program

• Noninvasive UDS • Psychological techniques – Externalizing voiding problem – Empowerment and praise 77 Children Completing Biofeedback Study Recurrent UTI Day incontinence Night incontinence Anticholinergic tx VUR Bowel symptoms No. (%) 59 (76) 48 (63) 36 (47) 38 (49) 19 (24) 44 (58) Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470-1475.

Modified Biofeedback Program

Improvement Subjective: Pronounced Moderate None Objective: Pronounced Moderate None No. (%) 47 (61) 24 (31) 6 (8) 47 (61) 28 (36) 2 (3) • Concluded: – Effective for 92% of children with DSD Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470-1475.

Alpha-blocker therapy be as an alternative to biofeedback for dysfunctional voiding?

• Efficacy of alpha-blocker vs biofeedback • Prospective study 28 pts (12/16) • On timed voiding, constipation treatment and anticholinergics for at least 6 mo • Pts reevaluated at 3 and 6 months – Incontinence episodes, UTIs, mean urinary flow rates, PVR, and parental satisfaction Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology, 2005; 174, 1612-1615.

Alpha-blocker therapy be as an alternative to biofeedback for dysfunctional voiding?

• Improved post treatment PVR – NO DIFFERENCE • Complete improvement in urge incontinence – NO DIFFERENCE • Combination effective in refractory cases (5/6) • No side effects reported • Concluded alpha blockers were a viable alternative 70 60 50 40 30 20 10 0 PVR Bio (ml) PVR AB (ml) Flow Bio (ml/s) Flow AB (ml/s) 0 months 3 months 6 months Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology, 2005; 174, 1612-1615.

Botulinum A Toxin Urethral Sphincter injection in Children with NNGNGB • Prospective (10 children) • 50-100 units injected • Immediately following all but 1 voided without catheterization • PVR ↓ by 89% 400 350 300 250 200 150 100 50 0 B ef or e 2 W ks 4 W ks 3 M o 6 M o PVR (ml) DLPP (cm H2O) Q max (ml/sec) Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology, 2005; 174, 1612-1615.

Closing Statements

• Best treatment is prevention • DES diagnosis of exclusion • Constipation treatment and timed voiding • Biofeedback • Adjunctive treatment in refractory cases – Alpha blockers – BOTOX

Thank You

Vincenzo Galati