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

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

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

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.

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

Holding Maneuvers

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

Bad Bladder Habits Infrequent visits to bathroom Inadequate time in bathroom Bad posture Poor hygiene During the process of attaining bladder control, bad behaviours can be learned at several steps. Children develop the ability to contract the external striated sphincter volitionally at an early age. This is a powerful stimulus to inhibit the detrusor. The external sphincter is used as the on-off switch for the bladder. As bladder capacity increases, children learn holding maneuvers to suppress the desire to void. Over time this can lead to overactivity of the detrusor with uninhibited bladder contractions that the child also tries to suppress. Subsequently, dysfunctional voiding results and the child has difficulty relaxing the sphincter when attempting to void voluntarily. This discoordination between the bladder and bladder outlet results in inefficient bladder emptying, leading to UTI’s. Constipation is also common due to the inability to relax the pelvic floor musculature.

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

What Happens? Bad posture Bad hygiene or aggressive soaps Can’t relax Dysuria and incomplete voiding

Children rated wetting themselves at school as the third most catastrophic event behind losing a parent and going blind. Urinary incontinence is a normal transitional phase between infantile and adult lower urinary tract function. Consequently wetting disorders often are considered a necessary nuisance associated with the growing years. It usually is tolerated until the child begins to lag behind his or her peers in achieving a state of dryness. Parental concerns about voiding are common and often supersede the child’s anxiety. Ollendick et al, Behav Res Therapy, 1989.

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 Constipation Hard BM occurring < 3 X per week 75% of time diagnosed on X-ray Most likely to occur in 3 situations Bladder dysfunction (DI) can be induced by large fecal accumulations Anticholinergics tx DI but cause fecal retention and constipation Caution must be exercised Constipation increases the likelihood of voiding dysfunction urinary incontinence, bladder overactivity, discoordinated voiding, large capacity poorly emptying bladder, recurrent UTIs and may influence deterioration of VUR 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.

Functional Constipation Symptoms Infrequent passage of stool Hard stool Palpable stool in abdomen or in rectal vault Fecal soiling Palpable stool in abdomen or in rectal vault, x-ray, or 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.

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.

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

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

Non-neurogenic neurogenic bladder (NNGNGB) Nocturnal and diurnal incontinence Dribbling, overflow, urge incontinence Bowel dysfunction Recurrent UTI’s Bladder instability Voluntary DSD during voiding After toilet training before puberty Nocturnal and diurnal incontinence Dribbling, overflow, urge incontinence Bowel dysfunction Recurrent UTI’s Bladder instability with signs of obstruction in absence of anatomic or neurologic disease Voluntary DSD during voiding

NNGNGB VCUG large PVR Reflux noted in about 50% Radiographically Bladder appears neuropathic (pear or dumbbell shape)

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

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.

Modified Biofeedback Program Noninvasive UDS Psychological techniques Externalizing voiding problem Empowerment and praise 77 Children Completing Biofeedback Study No. (%) Recurrent UTI 59 (76) Day incontinence 48 (63) Night incontinence 36 (47) Anticholinergic tx 38 (49) VUR 19 (24) Bowel symptoms 44 (58) Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470-1475.

Modified Biofeedback Program Improvement No. (%) Subjective: Pronounced 47 (61) Moderate 24 (31) None 6 (8) Objective: 28 (36) 2 (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.

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.

Alpha-blocker therapy be as an alternative to biofeedback for dysfunctional voiding? Improved post treatment PVR NO DIFFERENCE Complete improvement in urge incontinence 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.

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.

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

Thank You Vincenzo Galati