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Voiding Disorders In Children

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Voiding Disorders In Children

  1. 1. Office Nephrology Chair: Paul Roy
  2. 2. UTI & Dysfunctional Voiding Disorders <ul><li>Steven McTaggart </li></ul>Chair: Paul Roy
  3. 3. Voiding Disorders in Children Dr Steven McTaggart Queensland Child & Adolescent Renal Service Royal Children’s and Mater Children’s Hospitals Brisbane.
  4. 4. <ul><li>Children rated wetting themselves at school as the third most catastrophic event behind losing a parent and going blind. </li></ul><ul><li>Ollendick et al, Behav Res Therapy, 1989. </li></ul>
  5. 5. Outline <ul><li>Definitions </li></ul><ul><li>Classification </li></ul><ul><li>Pathogenesis </li></ul><ul><li>Evaluation </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Physical examination </li></ul></ul><ul><ul><li>Investigations </li></ul></ul><ul><li>Overview of Specific Disorders </li></ul>
  6. 6. Definitions <ul><li>International Children’s Continence Society (1997) </li></ul><ul><li>Enuresis </li></ul><ul><ul><li>Normal voiding that occurs at an inappropriate or socially-unacceptable time or place </li></ul></ul><ul><ul><li>nocturnal or diurnal </li></ul></ul><ul><ul><li>diurnal enuresis vs dysfunctional voiding </li></ul></ul><ul><ul><ul><li>neuropathic & nonneuropathic </li></ul></ul></ul><ul><li>Incontinence </li></ul><ul><ul><li>Involuntary loss of urine, objectively demonstrable, and constituting a social or hygienic problem </li></ul></ul>
  7. 7. Classification - Voiding Disorders <ul><li>Minor </li></ul><ul><ul><li>Extreme daytime urinary frequency syndrome </li></ul></ul><ul><ul><li>Stress/giggle incontinence </li></ul></ul><ul><ul><li>Postvoid dribbling </li></ul></ul><ul><li>Moderate </li></ul><ul><ul><li>Staccato/fractionated voiding  Lazy Bladder syndrome (Dysfunctional voiding) </li></ul></ul><ul><ul><li>Urge syndrome (Overactive bladder/Detrusor instability/Unstable bladder) </li></ul></ul><ul><li>Major </li></ul><ul><ul><li>Hinman syndrome (non-neurogenic, neurogenic bladder) </li></ul></ul><ul><ul><li>Ochoa syndrome (Urofacial syndrome) </li></ul></ul><ul><ul><li>Myogenic detrusor failure </li></ul></ul>
  8. 8. Pathogenesis of Bladder Dysfunction <ul><li>Neonate - bladder emptying via sacral spinal cord reflex </li></ul><ul><li>~ 2 yr age develop conscious sensation of bladder fullness  spinal reflex gradually modified and inhibited by pontine micturition centre in brain stem </li></ul><ul><li>Between 2-4 years child develops ability to control voiding - conscious voiding requires relaxation of the external sphincter just prior to detrusor contraction </li></ul><ul><li>Balance between “inhibiting voiding” and “initiating voiding” not fully mastered until ~ 4yrs age </li></ul><ul><li>Note that ethnic,cultural,economic and individual family differences exist in relation to toilet training and the perception that daytime incontinence is abnormal </li></ul>
  9. 9. Pathogenesis of Bladder Dysfunction <ul><li>“ Bad” bladder behaviours </li></ul><ul><li> Adoption of holding manoeuvres to suppress desire to void </li></ul><ul><ul><li>- leads to overactive detrusor with uninhibited bladder contractions </li></ul></ul><ul><li> develop volitional control over contraction of the external sphincter - external sphincter is used as ‘on-off’ switch for bladder </li></ul><ul><li> - d ifficulty relaxing sphincter when attempting to void voluntarily (detrusor sphincter discoordination) </li></ul>
  10. 10. Pathophysiology of Dysfunctional Voiding
  11. 12. Bladder Dysfunction - Associated Problems
  12. 13. Evaluation - History <ul><li>Current symptoms and signs </li></ul><ul><ul><li>voiding pattern - stream/volume/frequency (diary) </li></ul></ul><ul><ul><li>dysuria/frequency/urgency </li></ul></ul><ul><ul><li>holding manoeuvres </li></ul></ul><ul><ul><li>perineal hygiene - vulvovaginitis/balanitis </li></ul></ul><ul><ul><li>UTI’s </li></ul></ul><ul><ul><li>constipation </li></ul></ul><ul><li>Specific problems in infancy </li></ul><ul><li>Age and pattern of toilet training </li></ul><ul><ul><li>primary vs secondary </li></ul></ul><ul><ul><li>longest dry periods </li></ul></ul><ul><li>Family history of urological problems </li></ul><ul><li>Social history - think about CSA </li></ul>
  13. 14. Voiding Diary
  14. 15. Holding Maneuvers
  15. 16. Evaluation - Physical Exam <ul><li>Exclude structural lesions </li></ul><ul><ul><li>Abdominal examination </li></ul></ul><ul><ul><li>Genital examination </li></ul></ul><ul><ul><ul><li>labial adhesions/meatal stenosis </li></ul></ul></ul><ul><ul><ul><li>bifid clitoris </li></ul></ul></ul><ul><li>Exclude occult neurological disorders </li></ul><ul><ul><li>examine back for signs of occult spina bifida </li></ul></ul><ul><ul><li>DTR’s lower limbs </li></ul></ul><ul><ul><li>gait </li></ul></ul><ul><ul><li>anal wink </li></ul></ul>
  16. 17. Ectopic Ureter
  17. 18. Evaluation - Investigations <ul><li>Urinalysis - dipstick, M/C/S, (urine osmolality) </li></ul><ul><li>Ultrasound (IVP if suspect ectopic ureter) </li></ul><ul><ul><li>estimate functional bladder capacity & residual </li></ul></ul><ul><li>MCU if abnormal USS </li></ul><ul><li>Spinal Imaging </li></ul><ul><li>Urodynamics </li></ul>
  18. 19. “ Spinning top” urethra
  19. 20. Hinman Syndrome
  20. 21. Evaluation - Role of Spinal Imaging <ul><li>Wraige E & Borzyskowski M, Arch Dis Child, 2002 </li></ul><ul><ul><ul><li>retrospective study - 48 children with voiding dysfunction </li></ul></ul></ul><ul><ul><ul><li>closed spina bifida present in 5 patients - only 1 had no cutaneous, neuro-orthopaedic or lumbosacral spine abnormalities. </li></ul></ul></ul><ul><li>Ritchey et al,J Urol 1994 </li></ul><ul><ul><ul><li>127 children - 17 (38%) bony spina bifida occulta </li></ul></ul></ul><ul><ul><ul><li>10/48 underwent MRI - 1 had lipoma requiring resection </li></ul></ul></ul><ul><li>Recommendations for Screening </li></ul><ul><ul><li>neurological /neuro-orthopaedic abnormality </li></ul></ul><ul><ul><li>secondary enuresis or deterioration in primary enuresis </li></ul></ul><ul><ul><li>significant associated bowel abnormality </li></ul></ul><ul><ul><li>?urodynamic study suggesting neurogenic bladder </li></ul></ul><ul><ul><li>?failure to respond to conventional treatment </li></ul></ul>
  21. 22. Evaluation - Urodynamic Studies <ul><li>Not required for majority of children </li></ul><ul><li>Indicated if; </li></ul><ul><ul><li>evidence of/at risk of upper tract deterioration </li></ul></ul><ul><ul><ul><li>hydroureteronephrosis </li></ul></ul></ul><ul><ul><ul><li>high grade VUR </li></ul></ul></ul><ul><ul><ul><li>recurrent episodes of pyelonephritis </li></ul></ul></ul><ul><ul><li>suspicion or evidence of neurological abnormality </li></ul></ul><ul><ul><li>significant daytime enuresis that fails to respond to conventional treatment </li></ul></ul><ul><ul><li>(unexplained secondary enuresis - cystoscopy is preferable) </li></ul></ul>
  22. 23. Urge Syndrome
  23. 24. Staccato Voiding ‘ Lazy Bladder’
  24. 25. General Principles of Treatment
  25. 26. General Principles of Treatment <ul><li>Treat constipation </li></ul><ul><li>Ensure adequate fluid intake </li></ul><ul><li>Bladder retraining </li></ul><ul><ul><li>Timed voiding schedule </li></ul></ul><ul><ul><li>Double voiding if large post-void residual </li></ul></ul><ul><ul><li>Physiotherapy - pelvic floor retraining </li></ul></ul><ul><ul><li>Biofeedback </li></ul></ul><ul><li>Medications </li></ul><ul><ul><li>Antibiotic prophylaxis if UTI </li></ul></ul><ul><ul><li>Anticholinergics eg propantheline, oxybutinin </li></ul></ul>
  26. 27. Minor Voiding Disorders <ul><li>Extreme Daytime Urinary Frequency </li></ul><ul><ul><li>Sudden onset daytime urinary urgency/frequency </li></ul></ul><ul><ul><li>No dysuria or incontinence </li></ul></ul><ul><ul><li>Exclude idiopathic hypercalciuria </li></ul></ul><ul><ul><li>Reassurance </li></ul></ul><ul><li>Stress/Giggle Incontinence </li></ul><ul><ul><li>Mostly self-limiting </li></ul></ul><ul><ul><li>Trial anticholinergics if troublesome </li></ul></ul><ul><li>Postvoid Dribbling (Vaginal voiding) </li></ul><ul><ul><li>Related to posture during voiding </li></ul></ul><ul><ul><li>Toilet retraining </li></ul></ul>
  27. 28. Lazy Bladder Syndrome <ul><li>Characterised by; </li></ul><ul><ul><li>Large capacity, hypotonic bladder </li></ul></ul><ul><ul><li>Infrequent voiding </li></ul></ul><ul><ul><li>Poor urinary stream </li></ul></ul><ul><ul><li>Abdominal straining to void </li></ul></ul><ul><li>Incontinence between voiding due to overflow </li></ul><ul><li>Decreased sensation of bladder fullness </li></ul><ul><li>Incomplete emptying predisposes to UTI </li></ul><ul><li>Mx - Timed voiding / Double voiding </li></ul><ul><ul><ul><li>- Treat constipation if present </li></ul></ul></ul><ul><ul><ul><li>- Antibiotics for UTI </li></ul></ul></ul><ul><ul><ul><li>- Physio / Biofeedback </li></ul></ul></ul>
  28. 29. Urge Syndrome <ul><li>Most common voiding dysfunction </li></ul><ul><li>Peak ages 5-7 years </li></ul><ul><li>Characterised by; </li></ul><ul><ul><li>urgency, frequency </li></ul></ul><ul><ul><li>holding manoeuvres eg squatting </li></ul></ul><ul><ul><li>usually normal bladder emptying </li></ul></ul><ul><li>UTI’s and constipation common </li></ul><ul><li>Mx - Treat constipation </li></ul><ul><li>- Increase fluid intake </li></ul><ul><ul><ul><li>- Timed voiding </li></ul></ul></ul><ul><ul><ul><li>- Anticholinergics </li></ul></ul></ul>
  29. 30. Voiding Disorders - Summary
  30. 31. Long Term Outcome <ul><li>Kuh et al, 1999. </li></ul><ul><ul><li>Longitudinal study of 1333 women with urinary incontinence (mean age 48 years) </li></ul></ul><ul><ul><li>50% reported stress incontinence </li></ul></ul><ul><ul><li>22% reported urge incontinence </li></ul></ul><ul><ul><li>8% had severe symptoms </li></ul></ul><ul><ul><li>women who had daytime wetting as a child were more likely to have severe symptoms </li></ul></ul>
  31. 32. The End