Presentación de PowerPointkidneykidsja.com/wp-content/uploads/VOIDING-DISORDERS-IN...Enuresis...
Transcript of Presentación de PowerPointkidneykidsja.com/wp-content/uploads/VOIDING-DISORDERS-IN...Enuresis...
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1ST JAMAICAN PAEDIATRIC NEPHROLOGY CONFERENCE
Jamaica Conference Centre
Kingston, Jamaica October 4th 2014
in association with
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VOIDING
DISORDERS IN
CHILDREN
Dr. Colin Abel
Paediatric Urologist
Bustamante Children’s Hospital
Associate Lecturer
University of the West Indies
Jamaica
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The Bladder is an abdominal organ which
functions to store and empty urine.
VOIDING DISORDERS IN CHILDERN
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Bladder wall has 3 layers:
Mucosa
Detrusor muscle – meshwork of smooth muscle fibres
Adventitia
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Detrusor muscle relaxes (compliance) to allow
urine to fill the bladder.
Micturition involves coordination of detrusor
muscle contraction and bladder sphincter
relaxation.
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Micturition control mechanisms depend on
Intact neural pathway
Awareness of social norms
Gradual increase in function bladder capacity
Maturation of Detrusor / Sphincter coordination
Development of voluntary control over the whole bladder sphincteric – perineal complex.
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Normal Bladder Capacity (ml)
25 mls/ year of life + 25 mls
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Classification of bladder dysfunction
Derangement of nervous system.
Congenital Malformations – Myelomeningocoele.
Development Disturbances – Mental Retardation.
Acquired Conditions – Cerebral Palsy, Spinal
Cord injury .
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Classification of bladder dysfunction
Disorders of Detrusor and Sphincteric Muscle
function.
Congenital Conditions eg. Muscular dystrophy
Acquired Conditions eg chronic bladder
distension.
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Classification –
Structural Abnormalities
Congenital conditions e.g. Prune belly, PUV
Acquired conditions e.g. Traumatic stricture
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Voiding disorder / dysfunction describes a
constellation of problems that interfere with
efficient storage and evacuation of urine.
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Symptoms include:
Day and or night wetting
Urgency
Frequency
Urinary dribbling
Infrequent voiding
Weak or intermittent stream
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Prevalence – Age 4 – 10 years
Female to Male 1.5 : 1
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Two Categories:
Filling phase dysfunction
Detrusor hypertrophy unstable contractions
Incomplete emptying at bladder neck altered
Closure of VUJ VUR infections
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Categories continued
Voiding Phase – Probably a learnt behaviour that results from child’s attempt to suppress impending or actual bladder contractions by inappropriately contracting urethra and pelvic floor muscles rather than relaxing during voiding.
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Result –
Cycle of increased voiding pressure of detrusor
sphincter dyssynergia that produces inefficient voiding
Staccato voiding
Frequency with small volumes
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Overall Result
Dysfunctional Voiding
UTI
VUR
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Symptoms - Review
Children 4 years and older
Diurnal enuresis
Urgency
Frequency
Elevated post void residuals
UTI
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Patient Evaluation
History urinary and GIT symptoms important
Onset and duration of symptoms
Psychological profile
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Physical Examination
Look for developmental or anatomical Problems
Neurological examination
GU and GIT assessment – full bladder, soiling
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Investigations
Urinalysis and urine culture
Treatment of UTI
Urinary prophylaxis
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Investigations
KUB
Constipation
Urolithiasis
Spinal abnormalities
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Investigations Abdomino pelvic ultrasounds
Upper or lower tract abnormalities.
Post void urine volume – 10% of expected capacity is significant.
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Voiding Cystourethragram
VUR
Bladder trabeculation
Post void volume
Spinning top urethra
indicative of habitual high pressure voiding due to poor pelvic relaxation
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SPINNING TOP URETHRA
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URODYNAMIC studies –
Measure the relationship between pressure
and volume of the bladder.
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URODYNAMIC studies evaluate
bladder filling
detrusor activity
rectal activity
internal and external sphincteric activity
urinary flow
efficiency of emptying
urinary leakage.
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Normal Bladder filling pressure <30 cm H2O
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Children with
Unstable filling phase Pressure greater
Unstable voiding than 30 cm H2O
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Treatment - Initially conservative
Combined with medical and behavioural
management .
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Behavioural Management
encourages socially acceptable behaviour
reinforces desired behaviour
with a system of rewards
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Behavioural Management
Diet and Fluids
appropriate fluid intake
avoid foods that are bladder irritants
e.g. Caffeine, chocolate, food colourings
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Behavioural Management
Toilet diaries
assess voiding patterns
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Timed Voiding
Double Voiding
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Pelvic muscle retraining
Kegel exercises
contraction and relaxation of pelvic muscles.
Biofeedback
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Medical Management
Pharmacologic Agents
Detrusor Muscle (smooth muscle) relaxation.
Bladder sphincter (striated muscle) relaxation.
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Detrusor Muscle Relaxation
Antimuscarinic drugs relax detrusor muscle
Anticholinergic drugs act on nerve terminals to
block contractility of detrusor muscle
The effective action of these 2 agents
promotes muscle relaxation increased bladder
capacity
eg: - Oxybutynin
- Tolterodine
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a Adrenergic antagonists
initiate smooth muscle relaxation of the bladder neck
reduction of the bladder contractions
facilitation of smoother bladder emptying.
e.g. - Terazosin
- Doxazosin
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Tricyclic antidepressants exert a local anaesthetic effect on the bladder.
Decreased detrusor contractility
Increased outlet resistance
Increased bladder capacity
e.g. Imipramine
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Length of Treatment
3 to 6 months on average.
Up to 2 years if indicated.
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Enuresis (Nocturnal) Diagnosis made after age 5 years.
Rule out UTI and anatomical abnormalities
Fluid restriction
Timed voiding at night
Alarms
Imipramine
Desmopressin
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Summary 1
Voiding dysfunction is a common problem
Variety of symptoms
Prone to UTI
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Summary 2
Complete history and physical examination.
Rule out anatomical or physiological causes.
Successful management with behavioural and pharmacological therapies.
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