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Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma.

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Presentation on theme: "Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma."— Presentation transcript:

1 Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma Department of Urology Section of Pediatric Urology

2 Objectives Normal Elimination Dysfunctional Elimination Syndrome Non-Neurogenic Neurogenic Bladder Biofeedback Review of the literature

3 Development of Urinary Control Infancy: Reflex voiding –Detrusor contracts when bladder full –External urinary sphincter contracts during filling Voiding pattern in infants (feeding) Development of continence – capacity and control of striated sphincter –Control over spinal micturition reflex

4 Stooling Normally –Newborn meconium passes w/in 24 hrs –First few weeks: BMs 6 X q day –By 5 months: BMs 3 X q day –Age 2: BMs bid –Age 4: BM q day J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

5 Dysfunctional Elimination Unknown etiology Abnormal elimination pattern Bowel or bladder incontinence Withholding maneuvers

6 Holding Maneuvers

7 Dysfunctional Elimination Prevalence approximately 15% (Hellstrom et al. 1991) Overlooked factor in pediatric UTIs 40% of toilet trained with 1 st UTI 80% with recurrent UTI Risk factor for VUR and renal scarring

8 Bad Bladder Habits Infrequent visits to bathroom Inadequate time in bathroom Bad posture Poor hygiene

9 What Happens? Infrequent voiding –Over distended bladder Failure to relax pelvic floor –Voiding against closed sphincter PVR

10 What Happens? Bad posture –Cant relax Bad hygiene or aggressive soaps –Dysuria and incomplete voiding

11 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.

12 Functional Bowel Disturbances Constipation –Hard BM occurring < 3 X per week Most likely to occur in 3 situations Can induce bladder dysfunction 50% of dysfunctional voiding have constipation J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

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14 Functional Constipation Symptoms – Infrequent passage of stool –Hard stool –Palpable stool in abdomen or in rectal vault –Fecal soiling J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

15 Functional Constipation Management: –Parental education (hydration and fiber) –Many require stool softeners –Visit toilet 30-40 minutes after a meal Forward leaning, T&L extension, hip abduction, foot support that allows 90° of hip/knee flexion J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

16 Treatment of Day Time Wetting 1 st line is Behavior Modification –Diary –Bathroom every 2 hrs –Good posture –Ample time –Good hygiene

17 Treatment of Day Time Wetting Treat Constipation Biofeedback –Learn to relax pelvic muscles Medications –Ditropan pressure but CONSTIPATES! –? Role of α-blocker and Botox

18 Non-neurogenic neurogenic bladder (NNGNGB) Nocturnal and diurnal incontinence Dribbling, overflow, urge incontinence Bowel dysfunction Recurrent UTIs Bladder instability Voluntary DSD during voiding

19 NNGNGB –VCUG large PVR –Reflux noted in about 50%

20 NNGNGB - Treatment –Sterilize Urine –Bladder retraining –Normalize bowel function –Anticholinergics eliminate unstable bladder contractions –Sympatholytics and diazepam to reduce outflow resistance –May need CIC

21 Biofeedback Treatment option for children with DSD Goal: develop control over pelvic floor muscles during voiding Visual electromyography feedback Maintain relaxed pelvic floor with voiding Success up to child/parent/physician Problem: can be invasive Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470- 1475.

22 Modified Biofeedback Program Noninvasive UDS Psychological techniques –Externalizing voiding problem –Empowerment and praise Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470-1475. 77 Children Completing Biofeedback Study No. (%) Recurrent UTI59 (76) Day incontinence48 (63) Night incontinence36 (47) Anticholinergic tx38 (49) VUR19 (24) Bowel symptoms44 (58)

23 Modified Biofeedback Program ImprovementNo. (%) Subjective: Pronounced47 (61) Moderate24 (31) None6 (8) Objective: Pronounced47 (61) Moderate28 (36) None2 (3) Concluded: –Effective for 92% of children with DSD Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470-1475.

24 Alpha-blocker therapy be as an alternative to biofeedback for dysfunctional voiding? Efficacy of alpha-blocker vs biofeedback Prospective study 28 pts (12/16) On timed voiding, constipation treatment and anticholinergics for at least 6 mo Pts reevaluated at 3 and 6 months –Incontinence episodes, UTIs, mean urinary flow rates, PVR, and parental satisfaction Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology, 2005; 174, 1612-1615.

25 Alpha-blocker therapy be as an alternative to biofeedback for dysfunctional voiding? Improved post treatment PVR –NO DIFFERENCE Complete improvement in urge incontinence –NO DIFFERENCE Combination effective in refractory cases (5/6) No side effects reported Concluded alpha blockers were a viable alternative Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology, 2005; 174, 1612-1615.

26 Botulinum A Toxin Urethral Sphincter injection in Children with NNGNGB Prospective (10 children) 50-100 units injected Immediately following all but 1 voided without catheterization PVR by 89% Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology, 2005; 174, 1612-1615.

27 Closing Statements Best treatment is prevention DES diagnosis of exclusion Constipation treatment and timed voiding Biofeedback Adjunctive treatment in refractory cases –Alpha blockers –BOTOX

28 Vincenzo Galati Thank You


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