1. FUNCTIONAL VOIDING DISORDERS NON-NEUROGENIC LOWER URINARY TRACT DYSFUVCTION Dr. H. Al-Hazmi

2. DYSFUNCTIONAL ELIMINATION SYNDROMS OF CHILDHOOD [ DES] DYSFUNCTIONAL ELIMINATION SYNDROMS OF CHILDHOOD [ DES]

3. DES Syndrome with inclusive categorization of all functional bladder, sphincteric and gastrointestinal disorders that pathologically affect the pediatric urinary tractSyndrome with inclusive categorization of all functional bladder, sphincteric and gastrointestinal disorders that pathologically affect the pediatric urinary tract TWO GROUP:TWO GROUP: 1-Harmful 2- harmless 1-Harmful 2- harmless

4. Group 1 1) Hinmans syndrome 2)Unstable bladder 3) Infrequent voiding syndrome 4) Functional bowel disturbances 1) Hinmans syndrome 2)Unstable bladder 3) Infrequent voiding syndrome 4) Functional bowel disturbances

5. GOUP 2 1) Giggle incontinence 2) Post-void dribbling 3) Daytime time urinary frequency syndrome 4) Nocturnal enuresis

6. EVALUATION: Goal: to differentiate between benign disturbances from those harmfulGoal: to differentiate between benign disturbances from those harmful Include:Include: –History –Physical examination –Urine analysis,culture

7. UltrasoundUltrasound MCUGMCUG UrodynamicUrodynamic EndoscopyEndoscopy

8. HINMANS SYNDROME THE NON-NOEUROGENIC NEUROGENIC BLADDER

9. Functional obstruction occur during voiding to produce severe clinical manifestationFunctional obstruction occur during voiding to produce severe clinical manifestation After toilet training and before pubertyAfter toilet training and before puberty Complex symptomsComplex symptoms And /Or stressful family environmentAnd /Or stressful family environment

10. Physical and neurological  NPhysical and neurological  N –Apart from palpably large bladder Rectal: good anal tone, +/- fecal impactionRectal: good anal tone, +/- fecal impaction X- ray and MRI of spine  N X- ray and MRI of spine  N Radiographic studies of UT  abnormalRadiographic studies of UT  abnormal

11. VCUG:VCUG: –Neuropathic bladder –Bladder neck and urethra non obstructing –VUR in 50% Ultrasound:dilatation, damage Ultrasound:dilatation, damage Endoscopy:Endoscopy: –no obstruction –bladder : trabiculation, saculation,...

12. Urodynamic: - DSD with dilatation of posterior urethra -bladder instability with signs of impaired or obstructed bladder emptying in the absence of anatomical or neurological disease.Urodynamic: - DSD with dilatation of posterior urethra -bladder instability with signs of impaired or obstructed bladder emptying in the absence of anatomical or neurological disease.

13. Etiology: DebatedDebated Persistence of pattern of voiding that is transitional between infant and adult typePersistence of pattern of voiding that is transitional between infant and adult type Developed from overlearnd response to bladder instabilityDeveloped from overlearnd response to bladder instability

14. Treatment: Generally follow the lines of treatment NGBGenerally follow the lines of treatment NGB Bladder function most be restored to normalBladder function most be restored to normal

15. Bladder retraining program with biofeedback technique: * upper tract not involved *excellent resultBladder retraining program with biofeedback technique: * upper tract not involved *excellent result Normalization of bladder functionNormalization of bladder function

16. Pharmacologic therapy: - According to UD findingsPharmacologic therapy: - According to UD findings Psychological counseling as neededPsychological counseling as needed CIC: *bladder de-compensation *upper tract dilatation and damageCIC: *bladder de-compensation *upper tract dilatation and damage

17. Secondary effect as VUR, hydronephrosis improve spontaneously after bladder function restored to normalSecondary effect as VUR, hydronephrosis improve spontaneously after bladder function restored to normal

18. THE UNSTABLE BLADDER Bladder hyperactivity occurring during bladder felling

19. 1.URGENCY INCONTINECE SYNDROME 2.SMALL CAPACITY HYPER TONIC SYNDROM 3.CONTINENT BLADDER INSTABILITY

20. The most common pattern of urinary dysfunctional in childhoodThe most common pattern of urinary dysfunctional in childhood 57% of symptomatic children aged 3 to 14 years57% of symptomatic children aged 3 to 14 years Does not represent neuropathyDoes not represent neuropathy Either persistence of infant bladder instability or acquiredEither persistence of infant bladder instability or acquired

21. Pathophysiology: The unstable contraction are involuntary and insuppressibleThe unstable contraction are involuntary and insuppressible The child attempting to maintain continence during contractionThe child attempting to maintain continence during contraction  DYSSYNERGIA  DYSSYNERGIA. NO urodynamic abnormality during voiding

22. Urgency-incontinence Syndrome 60-70% of affected patients60-70% of affected patients Bladder instability + weak or absent sphincteric responseBladder instability + weak or absent sphincteric response HarmlessHarmless Vincents curtseyVincents curtsey UD: instability +minimal dyssynergia or obstructionUD: instability +minimal dyssynergia or obstruction U/S and MCUG: NORMALU/S and MCUG: NORMAL

23. Small-capacity hyper-tonic bladder More prominent urgency and incontinenceMore prominent urgency and incontinence More obvious bladder – sph. Dyssynrgia causing obstructionMore obvious bladder – sph. Dyssynrgia causing obstruction Functional bladder capacity reducedFunctional bladder capacity reduced Due to repetitive functional obstruction during unstable contractionDue to repetitive functional obstruction during unstable contraction

24. Continent bladder instability One third of children with instabilityOne third of children with instability Ability to overcome forceful bladder contraction by extemly tight sphincter constriction  raised intravesival pressureAbility to overcome forceful bladder contraction by extemly tight sphincter constriction  raised intravesival pressure Recurrent UTIRecurrent UTI MCUG: - trabiculation... … - VUR in 50%MCUG: - trabiculation... … - VUR in 50%

25. TREATMENT With maturation contraction cease in most childrenWith maturation contraction cease in most children Goal : to eliminate unstable contraction without interfering with normal voidingGoal : to eliminate unstable contraction without interfering with normal voiding Anti-cholinergic is the mainstay of treatmentAnti-cholinergic is the mainstay of treatment

26. Other : fluid restriction,elimination of caffeine,frequent voidingsOther : fluid restriction,elimination of caffeine,frequent voidings Treatment of constipationTreatment of constipation

27. Successful therapy : *80% eliminating symptoms *complete resolution 2.5 y *eliminate recurrent infection *hasten the resolution of refluxSuccessful therapy : *80% eliminating symptoms *complete resolution 2.5 y *eliminate recurrent infection *hasten the resolution of reflux

28. INFREQUENT VOIDINF SYNDROME

29. More common in girlsMore common in girls Simple voiding infrequently  to bladder decomensationSimple voiding infrequently  to bladder decomensation History is the mainstay of diagnosisHistory is the mainstay of diagnosis CauseCause –  megacystis –  behavioral –  psychogenic –? End stage after bladder instability

30. Diagnostic study usually normalDiagnostic study usually normal UD: - normal except large capacity bladderUD: - normal except large capacity bladder

31. Management: -Patient education -Bladder retraining with timed voiding -Correction of fecal retention -CIC: *severe infrequent voiding *bladder decompensation *bladder decompensation *urine retention *urine retention

32. FUNCTIONAL BOWEL DISTURBANCES

33. Long, historical relationship exist in children among bladder dysfunction, UTI and functional GIT disordersLong, historical relationship exist in children among bladder dysfunction, UTI and functional GIT disorders When constipation treated recurrent UTI reduced to 20% (88%)When constipation treated recurrent UTI reduced to 20% (88%) Bladder instability could be produced by constipationBladder instability could be produced by constipation

34. Diagnosis of constipation:Diagnosis of constipation: - infrequent passage of stools - infrequent passage of stools - small, hard stools - small, hard stools - elongated,wide-bore stools - elongated,wide-bore stools - skids mark in the underwear - skids mark in the underwear - encopresis - encopresis - palpable stool on abdominal exam. - palpable stool on abdominal exam. - abdomial x-ray - abdomial x-ray

35. Treatment: Initial clean-out with laxatives and enemas, followed by maintenance program that combine oral laxative and/or stool softeners with dietary manipulationInitial clean-out with laxatives and enemas, followed by maintenance program that combine oral laxative and/or stool softeners with dietary manipulation

36. GIGGLE INCONTINENCE Common in girlsCommon in girls Laughter is the most common precipitating eventsLaughter is the most common precipitating events Cause unknownCause unknown UD: detruosr hyper-reflexia or tetanic detrusor contraction during laughterUD: detruosr hyper-reflexia or tetanic detrusor contraction during laughter

37. Completely normal voiding habits aside from incontinenceCompletely normal voiding habits aside from incontinence Treatment:Treatment: - frequent voiding - anticholinergic medication - anticholinergic medication

38. Post-void Dribbling Occurs in normal girls after toilet trainingOccurs in normal girls after toilet training Viding normal and dry nightViding normal and dry night Result from vaginal refluxResult from vaginal reflux Observed during MCUGObserved during MCUG Improves with ageImproves with age

39. Treated by two simple measureTreated by two simple measure (1) Voiding by facing the back of commode (1) Voiding by facing the back of commode (2) After voiding and while setting the child leans forward to touch her toes with her hands (2) After voiding and while setting the child leans forward to touch her toes with her hands

40. Daytime urinary frequency syndrome Relatively commonRelatively common Sudden,severe,and often dramatic daytime urinary frequency without incontinence in healthy young childrenSudden,severe,and often dramatic daytime urinary frequency without incontinence in healthy young children Stop with sleepStop with sleep Natural history: spontaneous resolution after several monthsNatural history: spontaneous resolution after several months

41. Cause unknownCause unknown - Seasonal variation - Seasonal variation - psychosocial stresses - psychosocial stresses - hyper calciuria (30%) - hyper calciuria (30%). Diagnosis by exclusion. No known therapy. Reassurance of family

42. ENURISIS Involuntary discharge of urineInvoluntary discharge of urine Nocturnal - Diurnal – MixedNocturnal - Diurnal – Mixed Primary – SecondaryPrimary – Secondary Mono-symptomatic – Polysympt.Mono-symptomatic – Polysympt.

43. 15% of children still wet at night at age 5 years15% of children still wet at night at age 5 years 50% common in boys50% common in boys 15% resolution rate per year15% resolution rate per year 80% only at night and no other abnormalities  MNE80% only at night and no other abnormalities  MNE NOCTURNAL ENURESIS

44. Etiology: MNE symptoms rather than a diseaseMNE symptoms rather than a disease Multiple theories but no single explanationMultiple theories but no single explanation Multiple factors may operate in each individualMultiple factors may operate in each individual

45. Theories : 1- sleep factors:1- sleep factors: * NE not related to sleep pattern, depth of sleep, or sleep arousal pattern * NE not related to sleep pattern, depth of sleep, or sleep arousal pattern

46. 2- Alteration in vasopressin secretion : - lack of circadian rhythm - Bladder fullness stimulate AVP - Developmental delay

47. 3- Developmental delay.3- Developmental delay. 4 - hereditary factors4 - hereditary factors * if both parents: 77% child NE * if both parents: 77% child NE * IF one parent : 44% child NE * IF one parent : 44% child NE. 5 - Organic UT disease. 6 - Miscellaneous factors

48. Evaluation History, P/E, Urinalysis + C/SHistory, P/E, Urinalysis + C/S Radiographic studies are not indicated when the screening evaluation is negativeRadiographic studies are not indicated when the screening evaluation is negative

49. Characteristics of a negative screening evaluation for NE Age prepubertalAge prepubertal Enuresis has been lifelongEnuresis has been lifelong Wetting occurs only at nightWetting occurs only at night No daytime symptomsNo daytime symptoms No history of UTINo history of UTI Negative U/A and C/SNegative U/A and C/S Normal P/ENormal P/E

50. Urodynamic : Reduced functional bladder capacityReduced functional bladder capacity Unstable bladder contraction noted in15-20% with pure MNEUnstable bladder contraction noted in15-20% with pure MNE Unstable bladder contraction are not the cause for sleeping wetting in MNEUnstable bladder contraction are not the cause for sleeping wetting in MNE

51. TRATEMENT Started after 7 years of age Started after 7 years of age  GeneralGeneral 1- Maintain a voiding diary 2- D/C fluid intake 2h before sleep 3- Void before sleep 3- Void before sleep

52. A-pharmacologic therapy 1- Anticholinergic (oxybutynin)1- Anticholinergic (oxybutynin) * no role in management of MNE. 2- Desmopresin (DDAVP) * more effective in reducing the number of wet nights per week than at curing bedwetting * more effective in reducing the number of wet nights per week than at curing bedwetting. 3- imipramine

53. B- Behavioral modification: 1- Bladder retraining: 1- Bladder retraining: * retention control training * retention control training * to reverse functional bladder capacity

54. 2- Responsibility reinforcement 2- Responsibility reinforcement *required motivated child, conscientious parents and close rapport between the physician and family *required motivated child, conscientious parents and close rapport between the physician and family * Gold star chart * Gold star chart

55. 3- conditioning therapy 3- conditioning therapy – using the urinary alarm is the most effective of eliminating bedwetting – cure rate : 60-100% –Relapse : 24%

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