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,

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 1st 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
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.

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

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

11. 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.

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
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,

14. 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,

15. Functional Constipation
Management:
Parental education (hydration and fiber)
Many require stool softeners
Visit toilet 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,

16. Treatment of Day Time Wetting
1st 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 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

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

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,

22. 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,

23. 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,

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,

25. 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,

26. Botulinum A Toxin Urethral Sphincter injection in Children with NNGNGB
Prospective (10 children)
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,

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. Thank You
Vincenzo Galati