Voiding Dysfunction in Children Natalie Barganski, RN, CPNP

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

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 IN REVIEW OF THE PHYSIOLOGY OF MICTURITION The normal coordination of the central and peripheral nervous systems permit the filling of the bladder and urine storage at low pressure with high outlet resistance--- and voiding with low outlet resistance and sustained detrusor contraction

Physiology of micturition Two major functional roles of the bladder, storage and elimination of urine Filling Phase Storage Voiding Phase Filling- this phase requires the activation of the sympathetic nervous system beta receptors of the bladder fundus results in detrusor muscle relaxation- to eliminate any bladder contractions. Activation of sympathetic alpha receptors at the bladder neck result in contraction and increased outlet resistance. The pudendal nerve motor neurons contracts the external urinary sphincter also closing the bladder outlet to ensure continence Storage- a normal bladder is highly compliant and allows storage of urine at low pressures < 30 cm H20 at full capacity---when bladder stores urine at higher pressures >40 cm H20 kidney injury may occur Voiding- as filling occurs bladder wall distention activates mechanoreceptors which send a signal thru the cord to the pontine micturition center (brainstem). Then a descending signal from the pontine results in a inhibition of the pudendal motor neurons which relaxes the external urinary sphincter, stimulation of the PS outflow result in detrusor contraction, inhibition of the sympathetic nervous system through hypogastric nerves relaxes the bladder neck.

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 Infants void ~ 20 times a day, development of bladder control is a progressive maturation process

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

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

ICCS Definitions Daytime frequency Incontinence Urgency Hesitancy Straining DF-voiding 8 or more times during waking hours, decreased frequency is 4 times or less IN– uncontrolled leakage of urine , either continuous or intermittent URGENCY – sudden and unexpected experience of an immediate need to void HESITANCY- difficulty in the initiation of voiding – applied to children of any age who have achieved bladder control STRAIN- using abdominal pressure to initiate and maintain voiding- can be pertinent in all age groups

ICCS Definitions continued Weak stream Intermittent stream Holding maneuvers Post-micturition dribbling Residual urine Weak stream- stream- ejection of urine with a weak force – pertinent in all age groups Int stream-voiding in several discrete bursts rather than a continuous stream- normal physiologic pattern in kids 3 and younger Holding- behavior used to postpone voiding or suppress urgency Dribbling- involuntary urine leakage after completion of voiding –children who have achieved bladder control regardless of age Residual Urine- urine left after voiding – defined as an excess of 5-20 mls

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

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 MNE – true MNE is less than half of all enuretics Primary- wet bed past age 5, Secondary – risk for occult tethered cord Nighttime wetting- continence follows a maturational process, bladder relaxed while asleep, normal arousal response to void, inhibit bladder contraction via spinal micturition reflex, these do not happen some of them don’t do these and they do not reduce urination production, more common in boys with behavioral issues FBC- smaller capacity, frequent daytime voiding = DDAVP resistant enuresis Nocturnal polyuria, conflicting data on whether these children sleep deeper Developmental delay, genetic risk factor- high in 2 parents with enuresis Psychological stressors – unstable home life

Nocturnal enuresis cont. Both MNE and NMNE are often hereditary Three major causes: Nocturnal polyuria Detrusor overactivity Increased arousal thresholds INCIDENCE No family history 15% One enuretic patient 44% Two enuretic parent 77% Hereditary- go over chart Polyuria- some have polyuria due lack of normal nocturnal increase of vasopressin, others increased solute excretion Detrusor- usually seen in patients with NMNE but also can be seen in MNE, this can also be caused by constipation Increased arousal thresholds- this used to be debatable but now fairly well proven to be the case Nevéus, T, et. al. ICCS MNE Standardization 2008

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 OAB- abnormal detrusor contractions during filling VP/UAB- habitually postpone micturition, low frequency, over time will develop underactive bladder with weak detrusor Dys void- habitually contracts urethral sphincter during voiding, as in VD the problem can happen throughout the storage and voiding phase, this is only the voiding phase, 3 uroflow measurements show curves with a staccato pattern. Other names Hinman syndrome, non-neurogenic neurogenic, detrusor sphincter dyssynergia. Other- giggle only when laughing Vaginal- urine trapping in vaginal vault and leaking after voiding PBND- delayed or incomplete opening of the bladder neck during voiding

Etiology Neurogenic causes Anatomic causes Functional causes Neurogenic causes- disrupt the innervation of the bladder or external sphincter– MMC, trauma to CNS like spinal cord injury, occult neurologic lesions Anatomic – these children usually have a history of never gaining urinary control, the defect usually bypasses the bladder outlet, or obstruction of the bladder outlet (PUV) Functional- mostly idiopathic bladder dysfunction without neuro or anatomic cause- these are caused my maturational delay, abnormal aquired toilet training habits, prolongation of infantile bladder behavior, neurobehavioral issues

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 %

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

Associated conditions Urinary tract infection Vesicoureteral reflux Constipation and dysfunctional elimination syndrome Behavioral and neurodevelopmental issues Bladder extrophy, epispadias, ectopic ureter, neurogenic bladder UTI- clear association but not a causal relationship, VD predisposes children to recurrent UTI and renal injury VUR- multiple studies show the association of VUR and VD, voiding against a closed sphincter can increase bladder pressure and contribute to the development of VUR– cost of care for VUR assoc with VD in high as they have a higher incidence of UTI, longer time to VUR resolution, and increased failure rate of surgical correction DES- anorectal and lower urinary tract function are interrelated. 30-88% of children with VD are constipated –relationship between abnormal bowel and bladder function is called dysfunctional elimination syndrome- rectal distention in the constipated child places direct pressure on the posterior bladder wall-> detrusor contraction or impaired emptying, there can be increased parasympathetic activity due to colonic and rectal distention -> detrusor contraction BEHAVIORAL- these functional causes are behavioral issues arising from toilet training or personal stress. Children with ADHD, were more likely to report symptoms of incontinence , enuresis,

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 Thorough history and physical , birth history- delivery, prematurity, neonatal resus, toilet training history, neurodevelopmental delay

History & Physical History is the KEY in determining the type of disorder Birth history Child’s medical history Family medical history Developmental history Birth – any signs of perinatal or neonatal insult, perinatal anoxia, congenital infection Medical history- congential abnormalities, syndromes Family- enuresis, incontinence, diabetes, renal problems or urological problems, age of achievement of bladder continence Developmental- walking, talking, dressing,

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 This list is very general the questions we ask are VERY specific Toilet- what age? How did it go? Prolonged, delayed, stressful, period of dryness after toilet training Voiding- frequency, amount frequency of incontinent episodes, voided volume, Symptoms- urgency, pain with urination, holding maneuvers, hesitancy, dribbling, straining, weak stream, Diet- water, fiber, coke, tea, coffee, chocolate, kool-aid, fluids intake at least rough estimation- to detect polydipsia – diabetes? Or kidney disease? Bowel- frequency, consistency of stool, fecal soiling, Family- postponemtent may be due to mad a parents Behavioral- questions due to screen children for significant psychiatric comorbidity Sleep- difficult to arouse, snoring- important as some bedwetters become dry when an upper airway obstruction has been removed

Clinical Tools- Voiding Questionnaire

Tools- Bladder (Voiding) Diary Gives me voiding frequency, total voiding volume in 24 hrs, average and range of the voided volumes, patters of urine incontinence, fluid intake, patterns of bowel activity

Tools- Bristol Stool Chart

Physical Examination Focus is on detecting neurologic and urologic abnormalities Height/weight Blood pressure Abdominal palpation Lower back Neurologic exam Genital examination Lower back- cutaneous signs of occult spinal dysraphism, asymmetrical gluteal cleft, lipoma, presacral dimple, hair patch, Neuro- gait, lower extremity strength, fine motor coordination Genital- abnormalities, sexual abuse, prolapsing utereocele, constant wetness

Investigations UA, culture Nocturnal urine production Bladder scan- Uroflow with or w/o EMG RUS VCUG MRI Urodynamic studies Dynamic renal imaging Nocturnal urine > 130 % of of EBC. EBC = 30 + (age in years X 30)

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 Anorectal and LUT function are interrelated This must be treated first before any behavioral or pharmacologic therapy can be successful Another study had 66% had improvement in bladder emptying by treatment of constipation alone. Loening-Baucke, V. Pediatrics 1997; 100-228

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 Behavior- voiding schedules- these are usually the initial approach, timed voiding every 2 hours, with alarm watch, double voiding, proper posture, avoidance of caffeine, orange juice, if have UTIS- add cranberry juice and yogurt, perineal hygiene, avoiding of holding maneuvers, urinate before sense of urgency, empty completely, avoid abdominal straining– parents can have a reward system- COUNSELING Liberal water intake during the days is important 30ml/kg each day most ingested before returning home from school. Physical activity Allen, et al. Urology 2007; 69:962 Weiner, et al. J Urol 2000; 164-786

Management If conservative treatment fails to relieve symptoms treatment is condition specific NE- desmopressin, alarm, maybe anticholinergics, imipramine OAB- anticholinergic medication can be beneficial -NE- alarm presumed to cure NE, cochrane review of 56 trials concluded alarm therapy resulted in dryness in 2/3 of children, beginnings are important - phone call- f/u 3-4 weeks, continued until dry 14 consecutive nights, DDAVP- careful in patients with excessive fluid intake-> water intoxication, hyponatremia, convulsions- higher incidence with spray, antichols if behavior and constipation treated first and residual urine or low voiding frequency can be excluded- careful side effect –constipation, also aggressiveness (ditropan), decrease saliva so good hygiene. Imipramine ONLY as third line treatment – not sure why it works some think it is because it changes childs arousal mechanism, risk of tolerance, cardiotoxic -Underactive- no antichols cause may increase incomplete bladder emptying Antichols- decrease the frequency of uninhibited detrusor contractions during the filling phase and increase capacity, most common Ditropan- careful can cause constipation, dry mouth, flushing, heat intolerance, also Detrol- Alpha adrenergic receptor antagonists- act as smooth muscle relaxants at the bladder neck and proximal urethra- NNDV and urinary retention

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

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

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 Done with urostym-

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