Voiding Dysfunction in Children COL John Roscelli Pediatric Nephrology San Antonio Military Pediatric Center.

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Transcript Voiding Dysfunction in Children COL John Roscelli Pediatric Nephrology San Antonio Military Pediatric Center.

Voiding Dysfunction in
COL John Roscelli
Pediatric Nephrology
San Antonio Military Pediatric Center
How the Lower Urinary Tract Works
Voiding Dysfunction in children with no
organic pathology
Presentation modes
How the Lower
Urinary Tract Works
Bowl and Bladder Function
 Lower GU tract tied to lower
GI tract
 Same embryogenic origin:
endodermal tissue
 Up to sixth week gestation
urogenital sinus & the hindgut
empty into common cloaca
 Problems with elimination
in one usually associated
with problems in the other
 Proper term is Elimination
Dysfunction Syndrome
Function of Lower Urinary Tract
STORAGE of adequate volumes
of urine at low pressure & with
no leakage
EMPTYING that is
Low pressure
Lower Urinary Tract is a
Functionally Integrated Unit
Ureteral Vesicle Junction
Neurologic control
Anatomy & Neurophysiology of the
Lower Urinary Tract
Bladder (detrusor)
Stores urine at low pressure
Compresses urine for voiding
Conveys urine from bladder to outside
Sphincter(s) internal & external
Controls urine flow & maintain
continence between voidings
Nervous system control of Lower Tract
 CNS micturition centers
 Exert voluntary control
over spinal centers
 Spinal micturition centers
 T10-L1
 Sympathetics via
hypogastric Nerve
 S2-S4
 Parasympathetic via
Pelvic N
 Somatic via Pudental N
Low pressure storage with continence
Outlet obstruction:
Sympathetic -adrenergic
stimulation of bladder neck &
posterior urethra from T10-L1 via
Hypogastric Nerve
Somatic stimulation of External
Sphincter from S2-S4 via Pudental
Bladder Relaxation:
Allows continent storage
of significant volumes of
urine at < 20 mmHg
-adrenergic stimulation of bladder
fundus from T10-L2 via Hypogastric
Nerve decreases bladder tone
Voluntary Efficient Complete Low Pressure Voiding
Outlet relaxation:
Allows complete emptying
at pressures < 40 mm Hg
CNS micturition Centers Inhibit
sympathetic -adrenergic
stimulation of bladder
neck/posterior urethra & somatic
stimulation of External Sphincter
Bladder Contraction:
CNS micturition Centers Inhibits
-adrenergic bladder relaxation &
stimulates Parasympathetic
cholinergic stimulation of bladder
fundus from S2-S4 via Pelvic
Normal Voiding Study
EMG Activity
Bladder Neck Pressures
Bladder Pressures
Storage (cc)
Voluntary Voiding
Maturation of Voiding
Neonatal voiding
Controlled by sacral spinal cord reflex
 Bladder distention sends signals to sacral
spinal cord micturition center
Spinal cord micturition center sends efferent
signals that cause detrusor contraction &
relaxation of external sphincter
Results in frequent, complete, low pressure
Newborns void 20 x/day with only a slight
decrease during the 1st year of life
Maturation of Voiding
Bladder capacity increases & voiding
frequency decrease with growth
 Bladder capacity in Ounces (30ml) = Age (yrs) +2
 1-2 yrs: conscious sensation of bladder
fullness develops
 2-3 yrs: Ability to initiate or inhibit voiding
voluntarily develops
 2-4 yrs: Voiding comes under reliable voluntary
 By 4 years of age, most children have achieved an
adult pattern of micturition
Maturation of Voiding
Initially child has better control over
external sphincter than bladder
Easier to stop urination than start it
Voiding inhibition done by contracting
external sphincter rather than inhibiting
bladder contraction
This pattern may be reinforced during toilet
Persistence of this pattern is bladder
sphincter dysnergia
Characterization of
Voiding Dysfunction
 Storage Problem: Failure to Store normal
volumes of urine at low pressure & without
 Non compliant bladder
 Irritable bladder
 Inadequate sphincter tone during filling
 Emptying Problem: Failure to empty completely,
on command, efficiently at low pressures
 Failure of neurological control of bladder
 Bladder muscle failure
 Failure of sphincter relaxation during voiding
Clinical Problems from Voiding
Increased bladder pressures resulting in
Upper tract damage
Bladder hypertrophy leading to detrusor
Residual Urine
Social consequences
Voiding Dysfunction in Children
with no organic pathology
Voiding Dysfunction in “Normal
Children”- 3 Issues
Clinician must 1st suspect voiding
dysfunction in certain clinical
circumstances in normal children
Clinician must then rule out Neurologic,
Urologic & other organic (diabetes,
concentrating defects) problems
Clinician must then characterize & Rx the
functional voiding dysfunction
Presentations of Voiding
Dysfunction in “Normal” Children
Urologic Presentation
GI Presentation
Occult Neurologic
Urologic Presentation
Signs & Symptoms which suggest voiding dysfunction
Infrequent voiding
Frequent voiding
Holding maneuvers
Poor stream
Intermittent stream
Urinary tract
Urologic Presentation
It can not be overemphasized
to the general pediatrician
how important it is that they
rule out voiding dysfunction
in all their children with
recurrent UTIs, VUR or
GI Presentation
Signs & Symptoms which suggest voiding dysfunction
Fecal staining of undergarments
Fecal incontinence
Obstipation (i.e., severe constipation
causing obstruction)
Abdominal pains
Ocult Neurologic Presentation
Spinal cord tethering suggested by
Lower back abnormalities such as nevus,
dermal sinus, or dimple
Pain in the lower back during stretching of
the lower extremities
Gait abnormalities
Worsening symptoms during growth spurts
Severe stool incontinence
Complex enuresis refractory to routine Rx
Types of Voiding
Dysfunction Disorders in
“normal” Children
Minor Voiding Dysfunctional Disorders
Extraordinary daytime urinary frequency
Giggle incontinence
Stress incontinence
Post void dribbling
Vaginal voiding
Primary monosymptomatic nocturnal
Major Voiding Dysfunctional Disorders
Hinman syndromenon neruogenic
neurogenic bladder
Ochoa (urofacial)
Hinman syndrome with
Autosomal dominant
inheritance & facial
grimace when smiling
Myogenic detrusor
Moderate Voiding Dysfunctional Disorders
Overactive bladder/Urge
Bladder Sphincter Dysnergia
Lazy bladder syndrome
Moderate Voiding dysfunctional disorders
Evaluation of Voiding
Purpose of evaluation
Characterize the Elimination
problems to direct treatment
Storage problem
Emptying problem
Continence problem
Rule out Neurolgic, Urologic or
other organic causes
Evaluation of Dysfunctional Voiding
Index of suspicion
Physical Exam
Physical Exam
Simple Lab Tests
To characterize the Problem
Evaluation of dysfunctional voiding begins
with a detailed elimination history
History of current elimination problems
Detailed voiding history
Detailed Stooling history
Past elimination/urologic History
Age of toilet training
Intake history- fluids and diet
Family history of urologic problems
To characterize the Problem
Voiding symptoms & pattern of
incontinence must be quantified
Urgency, frequency, straining, dysuria
Holding maneuvers such as leg crossing,
squatting, or "Vincent's curtsey"
Continuous incontinence in a girl
suggests ectopic ureter that inserts distal
to urethral sphincter or into the vagina
Holding Maneuvers
3 Day Elimination DiaryYour most powerful
diagnostic tool & its
Good time to do intake diary
Parents record liquid intake volume
Determines BM problems
Characterizes voiding
Frequency of voids
Volume of voids
Associated symptoms
Allows Characterization
voiding disorder
Irritable Bladder
 Urgency & frequency as Cerebral cortex unable to inhibit
reflex bladder contractions triggered during filling
 Parents need to know where every bathroom is at mall etc
 When they void, void normally although usually have a
small bladder capacity
 Exhibit behaviors to avoid leakage: Dancing, squatting,
holding & posturing
 Classic sign of bladder instability is "Vincent's curtsy“- squatting
posture in girls in which the heel compresses the perineum and
thereby obstructs the urethra to prevent urinary leakage
 If unsuccessful get urge incontinence of small amount of urine
 These behaviors can lead to bladder sphincter dysnergia
Infrequent Voider
 Typically school girls with recurrent UTI & often
with history of intermittent enuresis
 Postpone voiding as long as possible
 Don’t like to void in public bathrooms
 Use holding maneuvers to fight urge to void
 If holding maneuvers fail get incontinence- “Suzy waits till the last
minute to void & then its to late”
 Develop large capacity bladders- void 2-3 times per day & often
don’t have to void on awakening
 When they void voluntarily it is large volumes,
prolonged & requires straining
 Often don’t take time to completely empty
To Identify underlying treatable Pathology
Identify organic pathology
Diabetes, epilepsy, obstructive sleep apnea
Neurologic problems
Urologic problems
Identify functional cause that is treatable
Voiding symptoms may be sign of sexual
Stressful occurrence at home or school can
trigger incontinence
Physical Examination
1st step is growth, general health & vital
signs including BP
2nd step is to inspect the child's
underwear for evidence of wetness or
3rd step is to observe or at least listen to
voiding for evidence of weak, slow or
intermittent stream
4th step is focused physical exam
Physical Examination
Renal masses
Distended bladder
Large stool mass suggestive
of constipation
Physical Examination
Perineum & Genitalia
 Dampness at beginning of exam & with
 Signs of erythema or irritation may be
indicative of vaginal voiding
 Meatal stenosis in boys & presence of labial
adhesions in girls
 Signs of trauma suggestive of sexual abuse
 Careful examination of the introitus for an
ectopic ureter
 Location of anus
Focused Neurolgogic Examination
 Lumbosacral spine for lipoma, sinus,
pigmentation tufts of hair- may be clue to
underlying occult myelodysplasia
 Perineal sensation, anal sphincter tone, lower
limb function/gait/sensation & Peripheral
 The bulbocavernosus reflex: squeeze glans
penis or clitoris & observe or feel reflex
contraction of external anal sphincter
 Checks integrity of the lower motor neuron reflex arcs
 Absence suggestive of a sacral neurologic lesion
Nerve Root
Side of foot
Big toe
Back of heel
Big toe
Routine Labs
Urine tests best obtained on 1st AM
specimen after overnight NPO
Specific gravity- over 1.020 rules out
significant concentrating defect
Other Studies that can be obtained
prior to referral
Post void residual urine by
Abdominal radiograph (KUB)
Identifies lumbar-sacral anomalies,
bowel gas patterns & amount of
Renal and bladder ultrasound
Upper tract
Size, contour, echogenicity
 Lower tract
 Assess bladder
wall thickness
(nl <3mm when
full; 5 mm when
 Post void
residual > 2
mL/kg is
Excellent correlation between residual urine by direct
urethral instrumentation & noninvasive sonography
Other Studies that can be obtained
prior to referral
Nuclear Medicine renal scan
Cortical scan to RO scars or
difference in function
Functional SCAN with/without lasix
to RO obstruction
Voiding cystourethrography
History of UTIs
Family history of VUR
Studies requiring referral
Non invasive assessment of urine flow rates
Staccato voiding or
intermittent stream
Intermittent involuntary
sphincter activity during
Fractionated &
incomplete voiding
Abdominal straining
needed to assist bladder
emptying & contraction of
abdominal muscles
contracts the sphincter
Studies requiring referral
Urodynamics often with video fluro
Studies that should never be done
Cystoscopy with or without
urethral dilation or
These are rarely if ever useful
and are expensive &
potentially dangerous
Management of Voiding
Dysfunction in Children with
no treatable Neruologic,
Urologic or other organic
Treatment of Voiding Dysfunction
Non Pharmacological
Timed voiding is the easiest & most
effective Rx & it works for irritable
bladder & infrequent voider
Regular by the clock voids q 2-3 hours
during day
Kegel exercises
Treatment of Voiding Dysfunction
Used for irritable bladder especially with
urgency, frequency & urge incontinence
Oxybutinin 0.1-0.15 mg/kg per dose 3 x day
 Dry mouth, constipation, drowsiness & heat intolerance
Imipramine used primarily for nocturnal
Low dose UTI prophylaxis
Treatment of Voiding Dysfunction
Approach to Voiding Dysfunction
Child with Suspected Voiding Dysfunction
Day Time wetting/Incontinence
Recurrent UTIs
Persistant or worsening VUR
Rule out Organic Pathology
History, physical
Renal Bladder US, VUCG if UTIs
Follow up
Elimination Diary
Treat Constipation
Consider Antibiotic Prophylaxis for UTIs
Intiate timed voiding plan
Continued Problems
Urology referal
Urodynamic Studies
Urge Syndrome
Bladder/Sphincter Dysfunction
Lazy Bladder
Normal Study
Timed Voiding
Timed Voiding
Check Compliance with
Timed Voiding Program
Assess motivation
Consider psychological evluation
We have reviewed
 Function (continent storage & voluntary
emptying at low pressures) & how the lower GU
tract works & how it matures
 Relationship with lower GI tract
 Voiding dysfunction syndromes in normal
 When to suspect it- UTIs, VUR, incontinence
 How to evaluate (history, voiding diary)
 How to RX voiding dysfunction
 Timed urination,
 Treat stooling dysfunction
Voiding Dysfunction in
Children with Neurogenic
Spinal cord injury (SCI) produces profound
alterations in lower urinary tract function
Neurological obstruction
Elevated intravesical pressure
Increased risk of UTIs
Neurogenic Bladder Made Simple
Lack of higher CNS control results in
 Inability to sense fullness & voluntarily void
 Detrusor controlled by un modulated spinal reflex
 Sphincter with fixed passive resistance- Leak
Point Pressure (LPP)
 Varies between patients may change in same patient
 At bladder pressures < LPP no leakage
 At bladder pressures > LPP leakage or urination
 Sphincter may not relax when bladder contractsbladder sphincter dysnergia
 Results in high voiding pressures
Neurogenic Bladder Made Simple
High LPP pressure is good for
continence but bad for the kidney
Prolonged LPP > than 40 cm H2O have been
associated with
Upper tract deterioration
Decreasing bladder compliance
Neurogenic Bladder Made Simple
Bladder compliance is another key
variable & may change over time
Determined by neurologic reflex
activity & LPP
Poor bladder compliance associated
Upper Tract Damage
Focus is on 2 issues
Preservation of Renal function
Maintaining normal bladder
pressures during filling & voiding
Minimizing UTIs
Not an issue in first couple of
years of life
Evaluation of Newborn with Neurogenic
Assess upper tract for damage or evidence
of high pressure (hydronephrosis)
Creatinine, lytes
UA & Cultures
Renal US
CT urography can give more detail if US
Can do non contrast MRI if there is renal failure
Some use nuclear studies
Evaluation of Newborn with Neurogenic
Assess lower tract for evidence of
increased voiding pressure
Bladder US for bladder hypertrophy &
post void residual- obtain in newborn
VCUG for VUR & bladder hypertrophy
Urodynamics for LPP & compliance
Newborn with Neurogenic Bladder
General Treatment
Folic Acid- 0.4 mg per day start prior to
Minimize spinal damage
Prenatal Diagnosis
Suspect in certain racial groups
Prenatal screening
  fetoprotein- 16-17 weeks GA
 Fetal sonography- 17th week GA
C Section prior to labor
Proper handling post delivery
Newborn with Neurogenic Bladder
General Treatment
Latex precautions from birth
Latex allergy seen in up to 40% of
spina bifida patients
Treat GI tract dysfunction
Maximize orthopedic function
Avoid obesity
Treatment of Neurogenic Bladder
Continence, Bladder Pressures & UTIs
Urologic Rx Based on
bladder/sphincter physiology
Low LPP, normal bladder function
Observation for neonates
CIC for continence in older children
Flaccid bladder unable to empty- CIC
Hyperreflexic &/or non compliant
bladder- CIC with anticholinergics
Oxybutynin 0.1 mgk/Kg per dose 3 X per day
Treatment of Neurogenic Bladder
Continence, Bladder Pressures & UTIs
CIC is key- s bladder pressures, improves
continence & eliminates residual urine
CIC in newborns
done every 3 hours
If upper tracts deteriorate- vesicostomy
In older children CIC can be made easier with
Continent Catheterizable stomas
Especially valuable in males who still have perineal
sensation or children with poor coordination
 Metroffanof uses appendix as conduit
Improving Continence
Continent Catherizable Stomas
 Appendix (Mitrofanoff),
section of ileum or colon
placed from umbilicus to
bladder & tunneled into
bladder to prevent reflux
 Indicated in
 Wheel-chair bound patients
with severe scoliosis lordosis
 Poor upper extremity function
 Males with intact urethral
Bladder Augmentation
Indicated when medical therapy fails to
achieve adequate low-pressure capacity
with continence
Variety of substances and surgical
techniques used each with problems
Use of intestinal tract allows absorption or
secretion of electrolytes from or into urine
All require religious CIC to avoid rupture
using Segment
of Ileum
Improving Continence by Increasing
Sphincter Resistance
 Adrenergic drugs (phenylpropanolamine,
pseudoephedrine) increase sphincter tone
Usually only marginally effective
Surgical techniques
Periurethral injections
Bladder neck suspension & Sling procedures
Artificial urinary sphincter
Vesicoureteral Reflux (VUR)
40-65% of neurogenic bladder patients
have VUR
Rx aimed at reducing bladder pressures
rather than fixing the VUR
Bladder Augmentation
Prophylactic antibiotics controversial
Surgical correction of VUR indicated for
Deterioration of upper tracts
Recurrent pyelonephritis
Urinary Tract Infections
Bacteruria- rule not the exception
 J Peds 126; 1995; 490
Urinary Tract Infections
Treatment of asymptomatic
bacteriuria in SCI patients of no
proven benefit
Do not treat cultures treat patients
Working definition of true UTI in
these patients is fever with + UC
Rx of Urinary Tract Infections
Symptomatic UTIs treated with
narrowest spectrum antibiotics for
the shortest possible time
Same antibiotics as used for Rx of
complicated UTIs in general population
Rx of Urinary Tract Infections
Prophylaxis does not decrease UTIs
or asymptomatic bacteruria- (J Peds
Some still use if there is VUR
Other methods also unsuccessful
Cranberry juice- J Peds 135; 1999; 698
Single use sterile catheter Peds
We have reviewed
 Function (storage & voluntary emptying at low
pressures) & how the lower GU tract works &
how it matures
 Relationship with lower GI tract
 Voiding dysfunction in normal children
 When to suspect it- UTIs, VUR, incontinence
 How to evaluate (voiding diary) & Rx it (timed
 Evaluation & Rx of children with neurogenic
bladder- focus on preserving upper tract &
Pediatric Clinics N America 48; Dec 01
1489-1503 & 1505-1518
Fernandes; The Unstable Bladder in
children; Journal Peds; 118; 1991; 831
Pediatrics in Review; Volume 21 Number
10 October 2000; 336-341