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 No family history 15%

INCIDENCE

One enuretic patient 44%  Detrusor overactivity Two enuretic parent 77%  Increased arousal thresholds Nevéus, T, et. al. ICCS MNE Standardization 2008

Daytime Urinary Incontinence

Due 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 incontinence Four – six year olds – up to 20% have daytime urinary incontinence Decreases 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 incontinence

Main 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 & Physical

History 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

Management

  When 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

Management

If 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 hypocontractility 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?