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Presentation on theme: "VOIDING DYSFUNCTION IN CHILDREN Natalie Barganski, RN, CPNP."— Presentation transcript:


2 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

3 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

4 Physiology of micturition  Two major functional roles of the bladder, storage and elimination of urine  Filling Phase  Storage  Voiding Phase

5 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

6 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

7 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

8 ICCS Definitions  Daytime frequency  Incontinence  Urgency  Hesitancy  Straining

9 ICCS Definitions continued  Weak stream  Intermittent stream  Holding maneuvers  Post-micturition dribbling  Residual urine

10 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

11 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

12 Nocturnal enuresis cont.  Both MNE and NMNE are often hereditary Three major causes:  Nocturnal polyuria  Detrusor overactivity  Increased arousal thresholds Nevéus, T, et. al. ICCS MNE Standardization 2008 INCIDENCE No family history15% One enuretic patient44% Two enuretic parent77%

13 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

14 Etiology  Neurogenic causes  Anatomic causes  Functional causes

15 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 %

16 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

17 Associated conditions  Urinary tract infection  Vesicoureteral reflux  Constipation and dysfunctional elimination syndrome  Behavioral and neurodevelopmental issues  Bladder extrophy, epispadias, ectopic ureter, neurogenic bladder

18 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

19 History & Physical History is the KEY in determining the type of disorder  Birth history  Child’s medical history  Family medical history  Developmental history

20 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

21 Clinical Tools- Voiding Questionnaire

22 Tools- Bladder (Voiding) Diary

23 Tools- Bristol Stool Chart

24 Physical Examination  Focus is on detecting neurologic and urologic abnormalities  Height/weight  Blood pressure  Abdominal palpation  Lower back  Neurologic exam  Genital examination

25 Investigations  UA, culture  Nocturnal urine production  Bladder scan-  Uroflow with or w/o EMG  RUS  VCUG  MRI  Urodynamic studies  Dynamic renal imaging

26 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;

27 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;

28 Management If conservative treatment fails to relieve symptoms treatment is condition specific  NE- desmopressin, alarm, maybe anticholinergics, imipramine  OAB- anticholinergic medication can be beneficial

29 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

30 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

31 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


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