Voiding Disorders In Children
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Transcript of Voiding Disorders In Children
RACP
Office NephrologyOffice Nephrology
Chair: Paul RoyChair: Paul Roy
RACP
UTI & Dysfunctional Voiding DisordersUTI & Dysfunctional Voiding Disorders
Steven McTaggart
Chair: Paul RoyChair: Paul Roy
Voiding Disorders in Children
Dr Steven McTaggart
Queensland Child & Adolescent Renal Service
Royal Children’s and Mater Children’s Hospitals
Brisbane.
•Children rated wetting themselves at school as the third most catastrophic event behind losing a parent and going blind.• Ollendick et al, Behav Res Therapy, 1989.
Outline• Definitions• Classification• Pathogenesis• Evaluation
– History– Physical examination– Investigations
• Overview of Specific Disorders
Definitions
• International Children’s Continence Society (1997)
• Enuresis– Normal voiding that occurs at an inappropriate or
socially-unacceptable time or place– nocturnal or diurnal– diurnal enuresis vs dysfunctional voiding
• neuropathic & nonneuropathic
• Incontinence– Involuntary loss of urine, objectively demonstrable, and
constituting a social or hygienic problem
Classification - Voiding Disorders
• Minor– Extreme daytime urinary frequency syndrome– Stress/giggle incontinence– Postvoid dribbling
• Moderate – Staccato/fractionated voiding Lazy Bladder syndrome
(Dysfunctional voiding)– Urge syndrome (Overactive bladder/Detrusor instability/Unstable
bladder)
• Major– Hinman syndrome (non-neurogenic, neurogenic bladder)– Ochoa syndrome (Urofacial syndrome)– Myogenic detrusor failure
Pathogenesis of Bladder Dysfunction
• Neonate - bladder emptying via sacral spinal cord reflex• ~ 2 yr age develop conscious sensation of bladder fullness spinal
reflex gradually modified and inhibited by pontine micturition centre in brain stem
• Between 2-4 years child develops ability to control voiding - conscious voiding requires relaxation of the external sphincter just prior to detrusor contraction
• Balance between “inhibiting voiding” and “initiating voiding” not fully mastered until ~ 4yrs age
• Note that ethnic,cultural,economic and individual family differences exist in relation to toilet training and the perception that daytime incontinence is abnormal
Pathogenesis of Bladder Dysfunction
• “Bad” bladder behaviours
• Adoption of holding manoeuvres to suppress desire to void
– - leads to overactive detrusor with uninhibited bladder contractions
• develop volitional control over contraction of the external sphincter - external sphincter is used as ‘on-off’ switch for bladder
• - difficulty relaxing sphincter when attempting to void voluntarily (detrusor sphincter discoordination)
–
Pathophysiology of Dysfunctional Voiding
C e ntra l fa ilure to inhib it b la d d e r c o ntra c tio ns
Ho ld ing m a no e uvre s
Dissip a tio n o f d e truso r c o ntra c tio n
Inc o m p le te re la xa tio n o r o ve ra c tivity o f p e lvic flo o r m usc le s d uring m ic turitio n
De truso r-sp hinc te r d ysc o o rd ina tio n
Func tio na l b la d d e r o utflo w o b struc tio n
Sta q c c a to vo id ing
Fra c tio na te d vo id ing
La zy Bla d d e r synd ro m e
Inc o ntine nc e
Se nsa tio n o f Urg e nc y
Urg e Synd ro m e
De truso r C o ntra c tio n d uring Bla d d e r Filling
Pe lvic flo o r use d a s “e m e rg e nc y b ra ke ”
+
Bladder Dysfunction - Associated Problems
VUR
UTI
Dysfunc tio na l vo id ing
“M ilk-b a c k” o f infe c te d urineEffe c ts o n lo c a l d e fe nc e m e c ha nism
sInc re a se d Po st-vo id re sid ua l
C ha ng e in b la d d e r se nsa tio n
Evaluation - History
• Current symptoms and signs– voiding pattern - stream/volume/frequency (diary)
– dysuria/frequency/urgency
– holding manoeuvres
– perineal hygiene - vulvovaginitis/balanitis
– UTI’s
– constipation
• Specific problems in infancy• Age and pattern of toilet training
– primary vs secondary
– longest dry periods
• Family history of urological problems• Social history - think about CSA
Voiding Diary
Holding Maneuvers
Evaluation - Physical Exam
• Exclude structural lesions– Abdominal examination– Genital examination
• labial adhesions/meatal stenosis
• bifid clitoris
• Exclude occult neurological disorders– examine back for signs of occult spina bifida– DTR’s lower limbs– gait– anal wink
Ectopic Ureter
Evaluation - Investigations
• Urinalysis - dipstick, M/C/S, (urine osmolality)• Ultrasound (IVP if suspect ectopic ureter)
– estimate functional bladder capacity & residual
• MCU if abnormal USS• Spinal Imaging• Urodynamics
“Spinning top” urethra
Hinman Syndrome
Evaluation - Role of Spinal Imaging
• Wraige E & Borzyskowski M, Arch Dis Child, 2002• retrospective study - 48 children with voiding dysfunction • closed spina bifida present in 5 patients - only 1 had no cutaneous,
neuro-orthopaedic or lumbosacral spine abnormalities.
• Ritchey et al,J Urol 1994• 127 children - 17 (38%) bony spina bifida occulta• 10/48 underwent MRI - 1 had lipoma requiring resection
• Recommendations for Screening– neurological /neuro-orthopaedic abnormality– secondary enuresis or deterioration in primary enuresis– significant associated bowel abnormality– ?urodynamic study suggesting neurogenic bladder– ?failure to respond to conventional treatment
Evaluation - Urodynamic Studies
• Not required for majority of children• Indicated if;
– evidence of/at risk of upper tract deterioration• hydroureteronephrosis• high grade VUR• recurrent episodes of pyelonephritis
– suspicion or evidence of neurological abnormality
– significant daytime enuresis that fails to respond to conventional treatment
– (unexplained secondary enuresis - cystoscopy is preferable)
UrgeSyndrome
Staccato Voiding ‘Lazy Bladder’
General Principles of Treatment
VUR
UTI
Dysfunc tio na l vo id ing
“M ilk-b a c k” o f infe c te d urineEffe c ts o n lo c a l d e fe nc e m e c ha nism
sInc re a se d Po st-vo id re sid ua l
C ha ng e in b la d d e r se nsa tio n
C o nstip a tio n
General Principles of Treatment
• Treat constipation• Ensure adequate fluid intake• Bladder retraining
– Timed voiding schedule
– Double voiding if large post-void residual
– Physiotherapy - pelvic floor retraining
– Biofeedback
• Medications– Antibiotic prophylaxis if UTI
– Anticholinergics eg propantheline, oxybutinin
Minor Voiding Disorders
• Extreme Daytime Urinary Frequency– Sudden onset daytime urinary urgency/frequency
– No dysuria or incontinence
– Exclude idiopathic hypercalciuria
– Reassurance
• Stress/Giggle Incontinence– Mostly self-limiting
– Trial anticholinergics if troublesome
• Postvoid Dribbling (Vaginal voiding)– Related to posture during voiding
– Toilet retraining
Lazy Bladder Syndrome
• Characterised by;– Large capacity, hypotonic bladder
– Infrequent voiding
– Poor urinary stream
– Abdominal straining to void
• Incontinence between voiding due to overflow• Decreased sensation of bladder fullness• Incomplete emptying predisposes to UTI• Mx - Timed voiding / Double voiding
• - Treat constipation if present • - Antibiotics for UTI
• - Physio / Biofeedback
Urge Syndrome
• Most common voiding dysfunction• Peak ages 5-7 years• Characterised by;
– urgency, frequency
– holding manoeuvres eg squatting
– usually normal bladder emptying
• UTI’s and constipation common• Mx - Treat constipation
• - Increase fluid intake• - Timed voiding• - Anticholinergics
Urge Syndrome Lazy Bladder Diurnal Enuresis
Other names Detrusor instability Dysfunctional voiding
Pathogenesis Uninhibited bladdercontractions during filling
Bladder-sphincterdiscoordination
Unclear
Symptoms ‘Minor’ wettingUrgencyFrequencyHolding manoeuvres
‘Minor’ wettingSometimes urgency
Uncontrolled voidingNo/deny urgeComplete bladder emptying
Voiding Pattern Small volumeFrequent voiding
Large volumesInfrequent voidingLarge post-void residual
Normal voiding
AssociatedProblems
UTIConstipation
UTIConstipation
Behavioural problemsEncoporesis(UTI)
Management Treat constipationIncrease fluid intakeTimed voidingAnticholinergics
Treat constipationTimed voidingDouble voiding
Psychosocial assessmentBehavioural program
Voiding Disorders - Summary
Long Term Outcome
• Kuh et al, 1999.– Longitudinal study of 1333 women with urinary
incontinence (mean age 48 years)– 50% reported stress incontinence– 22% reported urge incontinence– 8% had severe symptoms– women who had daytime wetting as a child were
more likely to have severe symptoms
The End