Voiding Dysfunction in Children

Voiding Dysfunction in Children
COL John Roscelli Pediatric Nephrology San Antonio Military Pediatric Center

Perspective Incontinence is part of transitional phase from infantile to adult lower urinary tract function Wetting disorders often considered necessary nuisance & tolerated until child lags behind peers Parental concerns about voiding are common & often supersede the child's anxiety However, voiding dysfunction can be a sign of underlying pathophysiology that needs Rx to prevent Renal/Urologic damage

Agenda How the Lower Urinary Tract Works
Voiding Dysfunction in children with no organic pathology Definition Presentation modes Evaluation Treatment

How the Lower Urinary Tract Works

Bowl and Bladder Function
Lower GU tract tied to lower GI tract Same embryogenic origin: endodermal tissue Up to sixth week gestation urogenital sinus & the hindgut empty into common cloaca Problems with elimination in one usually associated with problems in the other Proper term is Elimination Dysfunction Syndrome

Function of Lower Urinary Tract
STORAGE of adequate volumes of urine at low pressure & with no leakage EMPTYING that is Voluntary Efficient Complete Low pressure

Lower Urinary Tract is a Functionally Integrated Unit
Ureteral Vesicle Junction Bladder Sphincter Urethra Neurologic control mechanisms

Anatomy & Neurophysiology of the Lower Urinary Tract
Bladder (detrusor) Stores urine at low pressure Compresses urine for voiding Urethra Conveys urine from bladder to outside world Sphincter(s) internal & external Controls urine flow & maintain continence between voidings

Nervous system control of Lower Tract
CNS Periaqueductal gray matter receives bladder filling info Frontal/parietal lobes & cingulate gyrus inibit lower micturation centers Hypothalamus center initiate voluntary voiding Pontine Micturation center excites Bladder & inhibits sphincter Cerebellum integrates Spinal Sympathetics T10-L1 via hypogastric Nerve S2-S4 Parasympathetic via Pelvic N Somatic via Pudental N

Nervous system control of Lower Tract
CNS micturition centers T10-L1 S2-S4 CNS micturition centers Exert voluntary control over spinal centers Spinal micturition centers T10-L1 Sympathetics via hypogastric Nerve S2-S4 Parasympathetic via Pelvic N Somatic via Pudental N

Autonomic NS receptor Distribution

Low pressure storage with continence
Outlet obstruction: Sympathetic -adrenergic stimulation of bladder neck & posterior urethra from T10-L1 via Hypogastric Nerve Somatic stimulation of External Sphincter from S2-S4 via Pudental Nerve Bladder Relaxation: -adrenergic stimulation of bladder fundus from T10-L2 via Hypogastric Nerve decreases bladder tone CNS micturition centers T10-L1 S2-S4 Allows continent storage of significant volumes of urine at < 20 mmHg

Voluntary Efficient Complete Low Pressure Voiding
Outlet relaxation: CNS micturition Centers Inhibit sympathetic -adrenergic stimulation of bladder neck/posterior urethra & somatic stimulation of External Sphincter Bladder Contraction: CNS micturition Centers Inhibits -adrenergic bladder relaxation & stimulates Parasympathetic cholinergic stimulation of bladder fundus from S2-S4 via Pelvic Nerve CNS micturition centers T10-L1 S2-S4 Allows complete emptying at pressures < 40 mm Hg

External Sphincter EMG Activity
Normal Voiding Study External Sphincter EMG Activity Bladder Neck Pressures Bladder Pressures Storage (cc) Voluntary Voiding

Normal Voiding Study

Maturation of Voiding Neonatal voiding
Controlled by sacral spinal cord reflex Bladder distention sends signals to sacral spinal cord micturition center Spinal cord micturition center sends efferent signals that cause detrusor contraction & relaxation of external sphincter Results in frequent, complete, low pressure emptying Newborns void 20 x/day with only a slight decrease during the 1st year of life

Maturation of Voiding Bladder capacity increases & voiding frequency decrease with growth Bladder capacity in Ounces (30ml) = Age (yrs) +2 1-2 yrs: conscious sensation of bladder fullness develops 2-3 yrs: Ability to initiate or inhibit voiding voluntarily develops 2-4 yrs: Voiding comes under reliable voluntary control By 4 years of age, most children have achieved an adult pattern of micturition

Maturation of Voiding By age 4 Micturition spinal reflex fully modulated by CNS micturition center via a spinobulbospinal tact As bladder fills, desire to empty occurs-child must consciously suppress this desire until he/she can get to toilet With conscious voiding, external sphincter willfully relaxed prior to initiating bladder contraction Sphincter relaxation & bladder contraction, must occur in coordinated fashion for proper emptying

Maturation of Voiding Initially child has better control over external sphincter than bladder Easier to stop urination than start it Voiding inhibition done by contracting external sphincter rather than inhibiting bladder contraction This pattern may be reinforced during toilet training Persistence of this pattern is bladder sphincter dysnergia

Usual sequence of bowel & bladder control
Nocturnal bowel control Daytime bowel control Daytime control of voiding Nocturnal control of voiding

Maturation of Voiding By 4 most children have adult voiding pattern
Brazelton studied 1,170 children & found 26% achieved daytime continence by age 24 months 52.5% by age 27 months 85.3% by age 30 months 98% by age 36 months

Definitions Incontinence in Children
International Children's Continence Society definitions Enuresis: normal voiding that occurs at inappropriate time or involuntarily in socially unacceptable setting nocturnal enuresis- nighttime wetting diurnal enuresis- daytime wetting

Definitions Diurnal enuresis is often interchanged with dysfunctional voiding but they are not the same Not all dysfunctional voiders are incontinent Dysfunctional voiding can be neuropathic or nonneuropathic Neuropathic- voiding disorders caused by neurologic conditions such as spina bifida, transverse myelitis, or spinal cord trauma Nonneuropathic- functional voiding problems in neurologically normal children

Characterization of Voiding Dysfunction
Storage Problem: Failure to Store normal volumes of urine at low pressure & without leakage Non compliant bladder Irritable bladder Inadequate sphincter tone during filling Emptying Problem: Failure to empty completely, on command, efficiently at low pressures Failure of neurological control of bladder Bladder muscle failure Failure of sphincter relaxation during voiding

Clinical Problems from Voiding Dysfunction
Increased bladder pressures resulting in VUR Upper tract damage Bladder hypertrophy leading to detrusor failure Residual Urine UTI Incontinence Social consequences

Voiding Dysfunction in Children with no organic pathology

Voiding Dysfunction in “Normal Children”- 3 Issues
Clinician must 1st suspect voiding dysfunction in certain clinical circumstances in normal children Clinician must then rule out Neurologic, Urologic & other organic (diabetes, concentrating defects) problems Clinician must then characterize & Rx the functional voiding dysfunction

Presentations of Voiding Dysfunction in “Normal” Children
Urologic Presentation GI Presentation Occult Neurologic presentation

Urologic Presentation Signs & Symptoms which suggest voiding dysfunction
Infrequent voiding Frequent voiding Urgency Dysuria Holding maneuvers Straining Poor stream Intermittent stream Incomplete emptying Incontinence Urinary tract infections VUR

Urologic Presentation
It can not be overemphasized to the general pediatrician how important it is that they rule out voiding dysfunction in all their children with recurrent UTIs, VUR or incontinence

GI Presentation Signs & Symptoms which suggest voiding dysfunction
Fecal staining of undergarments Fecal incontinence Constipation Encopresis Obstipation (i.e., severe constipation causing obstruction) Abdominal pains

Occult Neurologic Presentation
Early detection may prevent neurologic damage and its bladder or bowel dysfunction sequelae Complex spina bifida occulta is an important disease entity because of its prevalence in the general population (as much as 1%); Lower back abnormalities such as nevus, dermal sinus, or dimple Abnormal neurologic examination, or foot or gait abnormality

Ocult Neurologic Presentation Spinal cord tethering suggested by
Lower back abnormalities such as nevus, dermal sinus, or dimple Pain in the lower back during stretching of the lower extremities Gait abnormalities Worsening symptoms during growth spurts Severe stool incontinence Complex enuresis refractory to routine Rx

Types of Voiding Dysfunction Disorders in “normal” Children

Minor Voiding Dysfunctional Disorders
Extraordinary daytime urinary frequency syndrome Giggle incontinence Stress incontinence Post void dribbling Vaginal voiding Primary monosymptomatic nocturnal enuresis

Major Voiding Dysfunctional Disorders
Hinman syndrome- non neruogenic neurogenic bladder Ochoa (urofacial) syndrome Hinman syndrome with Autosomal dominant inheritance & facial grimace when smiling Myogenic detrusor failure

Moderate Voiding Dysfunctional Disorders
Overactive bladder/Urge Syndrome Bladder Sphincter Dysnergia Lazy bladder syndrome

Moderate Voiding dysfunctional disorders

Classification of Diurnal Voiding Dysfunction
Term Filling Voiding Post void Residual Urge syndrome Multiple uninhibited detrusor contractions with increased EMG activity and expressions of urgency Usually normal None

Term Filling Voiding Post void Residual Bladder/ sphincter dysfunction Usually normal Increased EMG activity causing diminution or interruption of the urinary flow Variable

Term Filling Voiding Post void Residual Lazy bladder syndrome Abnormally capacious bladder with little or no expression of urge Prolonged, decreased flow with abdominal straining and bursts of EMG activity Always

Evaluation of Voiding Dysfunction

Purpose of evaluation Characterize the Elimination problems to direct treatment Storage problem Emptying problem Continence problem Rule out Neurolgic, Urologic or other organic causes

Evaluation of Dysfunctional Voiding
Index of suspicion History Physical Exam Simple Lab Tests Imaging Urodynamics

History To characterize the Problem
Evaluation of dysfunctional voiding begins with a detailed elimination history History of current elimination problems Detailed voiding history Detailed Stooling history Past elimination/urologic History UTIs Constipation Age of toilet training Intake history- fluids and diet Family history of urologic problems

History To characterize the Problem
Voiding symptoms & pattern of incontinence must be quantified Urgency, frequency, straining, dysuria etc Holding maneuvers such as leg crossing, squatting, or "Vincent's curtsey" Continuous incontinence in a girl suggests ectopic ureter that inserts distal to urethral sphincter or into the vagina

Holding Maneuvers

Ectopic Ureter

3 Day Elimination Diary-Your most powerful diagnostic tool & its CHEAP & BENIGN
Determines BM problems Characterizes voiding Frequency of voids Volume of voids Accidents Associated symptoms Allows Characterization voiding disorder Storage Emptying Continence Good time to do intake diary Parents record liquid intake volume

History Irritable Bladder
Urgency & frequency as Cerebral cortex unable to inhibit reflex bladder contractions triggered during filling Parents need to know where every bathroom is at mall etc When they void, void normally although usually have a small bladder capacity Exhibit behaviors to avoid leakage: Dancing, squatting, holding & posturing Classic sign of bladder instability is "Vincent's curtsy“- squatting posture in girls in which the heel compresses the perineum and thereby obstructs the urethra to prevent urinary leakage If unsuccessful get urge incontinence of small amount of urine These behaviors can lead to bladder sphincter dysnergia

History Infrequent Voider
Typically school girls with recurrent UTI & often with history of intermittent enuresis Postpone voiding as long as possible Don’t like to void in public bathrooms Use holding maneuvers to fight urge to void If holding maneuvers fail get incontinence- “Suzy waits till the last minute to void & then its to late” Develop large capacity bladders- void 2-3 times per day & often don’t have to void on awakening When they void voluntarily it is large volumes, prolonged & requires straining Often don’t take time to completely empty

History Infrequent Voider
Physician must uncover that the child with a wetting problem actually has abnormally few voids & a weak bladder May wait at least an hour after waking to void May void only 2-3 to three times daily, often not at all during school Straining during urination common because detrusor is large-capacity & capable of only weak contractions

History To Identify underlying treatable Pathology
Identify organic pathology Diabetes, epilepsy, obstructive sleep apnea Neurologic problems Urologic problems Identify functional cause that is treatable Voiding symptoms may be sign of sexual abuse Stressful occurrence at home or school can trigger incontinence

Physical Examination 1st step is growth, general health & vital signs including BP 2nd step is to inspect the child's underwear for evidence of wetness or soiling 3rd step is to observe or at least listen to voiding for evidence of weak, slow or intermittent stream 4th step is focused physical exam

Physical Examination Abdomen
Renal masses Distended bladder Large stool mass suggestive of constipation

Physical Examination Perineum & Genitalia
Dampness at beginning of exam & with straining Signs of erythema or irritation may be indicative of vaginal voiding Meatal stenosis in boys & presence of labial adhesions in girls Signs of trauma suggestive of sexual abuse Careful examination of the introitus for an ectopic ureter Location of anus

Focused Neurolgogic Examination
Lumbosacral spine for lipoma, sinus, pigmentation tufts of hair- may be clue to underlying occult myelodysplasia Perineal sensation, anal sphincter tone, lower limb function/gait/sensation & Peripheral reflexes The bulbocavernosus reflex: squeeze glans penis or clitoris & observe or feel reflex contraction of external anal sphincter Checks integrity of the lower motor neuron reflex arcs Absence suggestive of a sacral neurologic lesion

NERVE ROOTS & THEIR ASSOCIATED SENSORY & MOTOR FUNCTIONS
Level Sensation Motor L1 Inguinal area Thigh extension/flexion L2 Anterior/medial thigh L3 Knees, lateral thigh Lower leg flexion L4 Anterior/medial tibia Lower leg extension L5 Lateral tibia Dorsiflexion of foot (cannot walk on heels) S1 Sole of the foot Plantar flexion of foot (cannot walk on toes) S2 Heel of the foot Dorsiflexion of big toe S3, 4 Perineal Plantar flexion of big toe

FOCUSED NEUROLOGIC EXAMINATION
Nerve Root Motor Sensory S1 Plantar flexion Side of foot S2 Big toe extension Back of heel S3 Big toe flexion Perineum

Routine Labs Urine tests best obtained on 1st AM specimen after overnight NPO UA Specific gravity- over rules out significant concentrating defect pH Glucose Blood Protein Microscopic UC

Other Studies that can be obtained prior to referral
Post void residual urine by catheter Abdominal radiograph (KUB) Identifies lumbar-sacral anomalies, bowel gas patterns & amount of stool Renal and bladder ultrasound

Sonography Upper tract Size, contour, echogenicity Hydro-nephrosis
Lower tract Assess bladder wall thickness (nl <3mm when full; 5 mm when empty) Post void residual > 2 mL/kg is abnormal Excellent correlation between residual urine by direct urethral instrumentation & noninvasive sonography

Other Studies that can be obtained prior to referral
Nuclear Medicine renal scan Cortical scan to RO scars or difference in function Functional SCAN with/without lasix to RO obstruction Voiding cystourethrography History of UTIs Family history of VUR

Studies requiring referral
Rarely required but simple & non invasive Uroflometry Very rarely required & invasive Urodynamics with electromyography of the external urinary sphincter

Studies requiring referral Uroflow/Flowmetry
Non invasive assessment of urine flow rates Staccato voiding or intermittent stream Intermittent involuntary sphincter activity during voiding Fractionated & incomplete voiding Abdominal straining needed to assist bladder emptying & contraction of abdominal muscles contracts the sphincter

Studies requiring referral Urodynamics often with video fluro
Parameters used to diagnose urodynamic dysfunction Bladder capacity of <10-15 mL/kg body weight, Postvoid residual of >2 mL/kg body weight, Detrusor hyper-reflexia, (detrusor contractions during bladder filling without urine leakage and intravesical pressure of >40 cm H2 O Voiding detrusor pressure of >70 cm H2 O Dyssynergic increase or lack of suppression of sphincteric EMG with a detrusor contraction.

Studies requiring referral Urodynamics often with video fluro

Studies that should never be done
Cystoscopy with or without urethral dilation or meatotomy These are rarely if ever useful and are expensive & potentially dangerous

Management of Voiding Dysfunction in Children with no treatable Neruologic, Urologic or other organic etiology

Treatment of Voiding Dysfunction Non Pharmacological
Timed voiding is the easiest & most effective Rx & it works for irritable bladder & infrequent voider Regular by the clock voids q 2-3 hours during day Biofeedback Kegel exercises

Treatment of Voiding Dysfunction Pharmacological
Anticholinergic Used for irritable bladder especially with urgency, frequency & urge incontinence Oxybutinin mg/kg per dose 3 x day Dry mouth, constipation, drowsiness & heat intolerance Imipramine used primarily for nocturnal enuresis Low dose UTI prophylaxis

Treatment of Voiding Dysfunction
TREAT STOOLING DYSFUNCTION

UTIs, VUR & Elimination Dysfunction
Strong association between the 3 Treat voiding dysfunction Treat stooling dysfunction

Approach to Voiding Dysfunction

Summary We have reviewed
Function (continent storage & voluntary emptying at low pressures) & how the lower GU tract works & how it matures Relationship with lower GI tract Voiding dysfunction syndromes in normal children When to suspect it- UTIs, VUR, incontinence How to evaluate (history, voiding diary) How to RX voiding dysfunction Timed urination, Treat stooling dysfunction

Voiding Dysfunction in Children with Neurogenic Bladder

Neurological obstruction
Spinal cord injury (SCI) produces profound alterations in lower urinary tract function Incontinence Neurological obstruction Elevated intravesical pressure VUR Increased risk of UTIs Stones

Neurogenic Bladder Made Simple Lack of higher CNS control results in
Inability to sense fullness & voluntarily void Detrusor controlled by un modulated spinal reflex Sphincter with fixed passive resistance- Leak Point Pressure (LPP) Varies between patients may change in same patient At bladder pressures < LPP no leakage At bladder pressures > LPP leakage or urination Sphincter may not relax when bladder contracts- bladder sphincter dysnergia Results in high voiding pressures

Neurogenic Bladder Made Simple
High LPP pressure is good for continence but bad for the kidney Prolonged LPP > than 40 cm H2O have been associated with VUR Upper tract deterioration Decreasing bladder compliance

Neurogenic Bladder Made Simple
Bladder compliance is another key variable & may change over time Determined by neurologic reflex activity & LPP Poor bladder compliance associated with Incontinence UTIs Upper Tract Damage

Focus is on 2 issues Preservation of Renal function Continence
Maintaining normal bladder pressures during filling & voiding Minimizing UTIs Continence Not an issue in first couple of years of life

Evaluation of Newborn with Neurogenic Bladder
Assess upper tract for damage or evidence of high pressure (hydronephrosis) Creatinine, lytes UA & Cultures Renal US CT urography can give more detail if US abnormal Can do non contrast MRI if there is renal failure Some use nuclear studies

Evaluation of Newborn with Neurogenic Bladder
Assess lower tract for evidence of increased voiding pressure Bladder US for bladder hypertrophy & post void residual- obtain in newborn period VCUG for VUR & bladder hypertrophy Urodynamics for LPP & compliance

Newborn with Neurogenic Bladder General Treatment
Prevention Folic Acid- 0.4 mg per day start prior to pregnancy Minimize spinal damage Prenatal Diagnosis Suspect in certain racial groups Prenatal screening  fetoprotein weeks GA Fetal sonography- 17th week GA C Section prior to labor Proper handling post delivery

Newborn with Neurogenic Bladder General Treatment
Latex precautions from birth Latex allergy seen in up to 40% of spina bifida patients Treat GI tract dysfunction Maximize orthopedic function Avoid obesity

Treatment of Neurogenic Bladder in the infant based on Evaluation
Low LPP, normal bladder function- observation Flaccid bladder unable to empty- Clean Intermittent Catheterization- CIC Hyperreflexic &/or non compliant bladder- CIC with anticholinergics CIC if needed done every 3 hours NO CREDE If upper tracts deteriorate- vesicostomy

Treatment of Neurogenic Bladder Continence, Bladder Pressures & UTIs
Urologic Rx Based on bladder/sphincter physiology Low LPP, normal bladder function Observation for neonates CIC for continence in older children Flaccid bladder unable to empty- CIC Hyperreflexic &/or non compliant bladder- CIC with anticholinergics Oxybutynin 0.1 mgk/Kg per dose 3 X per day

Treatment of Neurogenic Bladder Continence, Bladder Pressures & UTIs
CIC is key- s bladder pressures, improves continence & eliminates residual urine CIC in newborns done every 3 hours NO CREDE If upper tracts deteriorate- vesicostomy In older children CIC can be made easier with Continent Catheterizable stomas Especially valuable in males who still have perineal sensation or children with poor coordination Metroffanof uses appendix as conduit

Improving Continence Continent Catherizable Stomas
Appendix (Mitrofanoff), section of ileum or colon placed from umbilicus to bladder & tunneled into bladder to prevent reflux Indicated in Wheel-chair bound patients with severe scoliosis lordosis Poor upper extremity function Males with intact urethral sensation

Bladder Augmentation Indicated when medical therapy fails to achieve adequate low-pressure capacity with continence Variety of substances and surgical techniques used each with problems Use of intestinal tract allows absorption or secretion of electrolytes from or into urine All require religious CIC to avoid rupture

Bladder Augmentation Variety of Methods
Ileum & colon Hyperchloremic hypokalemia acidosis, mucous Stomach Less mucous Can cause hyperkalemic metabolic aklalosis Can cause hematuria and dysuria due to acid Rx with H2 blockers Dilated ureter of non functioning kidney None of problems seen with GI tract Detrusor mytomy (autoaugmentation)

Bladder Augmentation using Segment of Ileum

Improving Continence by Increasing Sphincter Resistance
 Adrenergic drugs (phenylpropanolamine, pseudoephedrine) increase sphincter tone Usually only marginally effective Surgical techniques Periurethral injections Bladder neck suspension & Sling procedures Artificial urinary sphincter

Vesicoureteral Reflux (VUR)
40-65% of neurogenic bladder patients have VUR Rx aimed at reducing bladder pressures rather than fixing the VUR CIC Bladder Augmentation Prophylactic antibiotics controversial Surgical correction of VUR indicated for Deterioration of upper tracts Recurrent pyelonephritis

Urinary Tract Infections
Bacteruria- rule not the exception J Peds 126; 1995; 490

Urinary Tract Infections
Treatment of asymptomatic bacteriuria in SCI patients of no proven benefit Do not treat cultures treat patients Working definition of true UTI in these patients is fever with + UC

Rx of Urinary Tract Infections
Symptomatic UTIs treated with narrowest spectrum antibiotics for the shortest possible time Same antibiotics as used for Rx of complicated UTIs in general population

Rx of Urinary Tract Infections
Prophylaxis does not decrease UTIs or asymptomatic bacteruria- (J Peds 132;1998;704) Some still use if there is VUR Other methods also unsuccessful Cranberry juice- J Peds 135; 1999; 698 Single use sterile catheter Peds 108;2001;2001

Summary We have reviewed
Function (storage & voluntary emptying at low pressures) & how the lower GU tract works & how it matures Relationship with lower GI tract Voiding dysfunction in normal children When to suspect it- UTIs, VUR, incontinence How to evaluate (voiding diary) & Rx it (timed urination) Evaluation & Rx of children with neurogenic bladder- focus on preserving upper tract & continence

References Pediatric Clinics N America 48; Dec & Fernandes; The Unstable Bladder in children; Journal Peds; 118; 1991; 831 Pediatrics in Review; Volume 21 Number 10 October 2000;

Voiding Dysfunction in Children

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