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 INCIDENCE Three major causes: Nocturnal polyuria Detrusor overactivity No family history 15% One enuretic patient 44% 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 scanUroflow 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!! 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