1. Voiding Dysfunction in Children
Natalie Barganski, RN, CPNP

2. 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

3. 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

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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 %

16. 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

17. 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 % 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,

18. 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

19. 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,

20. 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

21. Clinical Tools- Voiding Questionnaire

22. 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

23. Tools- Bristol Stool Chart

24. 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

25. 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)

26. 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;

27. 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: Weiner, et al. J Urol 2000;

28. 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

29. 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

30. 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

31. 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-

32. THANK YOU!! QUESTIONS?