Dysfunctional Voiding - November 2005

pediatrics.uchicago.edu

Dysfunctional Voiding - November 2005

Dysfunctional Voiding

Morning Report

November 18, 2005


Epidemiology

Enuresis is seen worldwide in all cultures and

races

True incidence is unknown

Most textbooks define enuresis starting at age 5

(but does not usually interfere with socialization until ~age 7)

~15% of 5yr olds have primary nocturnal

enuresis

5-10% 10% have diurnal enuresis and dysfunctional

voiding


Enuresis

Definitions

Complete urinary voiding that occurs after a period where urinary urinary

control is anticipated

Expectations for dryness: daytime by 4yrs, nighttime by 5yrs

Nocturnal enuresis ~ wetting during sleep

classified as primary vs. secondary (following a 6mo period of dryness)

Classified as monosymptomatic (bedwetting exclusively) vs.

polysymptomatic (associated with other urinary symptoms)

Diurnal enuresis ~ wetting while awake

More likely to be associated with underlying pathology

Often linked with the term dysfunctional voiding

Accounts for ~15% of all enuretic children


Definitions

Dysfunctional Voiding: Voiding

Neuropathic

• Spina bifida, transverse myelitis, myelitis,

spinal cord trauma, tethered

cord, tumor compression

Non-neuropathic

Non neuropathic

• Functional: Functional:

overactive bladder, lazy bladder syndrome,

Hinman syndrome

• Developmental: Developmental:

giggle incontinence, urge incontinence,

postvoid dribbling

• Genetic: Genetic:

Ochoa syndrome, williams syndrome


Development of Bladder Control

Pattern: Pattern:

nocturnal bowel control control daytime bowel

control control daytime bladder control control nighttime bladder

control

Infants: Infants:

voiding occurs spontaneously as a spinal cord

reflex (~20X/day)

1-2 2 yrs: yrs:

sense bladder fullness and inhibit bladder

contractions (decrease in voiding frequency, increase in volume) via

micturition center in frontal lobe

2-3 3 yrs: yrs:

voluntary voiding via relaxation of pelvic floor

and bladder contraction and voluntary inhibition

4yrs: 4yrs:

adult micturition pattern; ability to contract sphincter

to inhibit voiding


Primary vs. secondary

Urgency, frequency,

continuous

Diurnal incontinence

Slow or intermittent

urinary stream

Posturing maneuvers

Bowel habits

Enuresis: History

Constipation, encopresis

Family history

Caffeinated beverages

Daily fluid intake (volume

and pattern, polydipsia) polydipsia

Developmental

milestones

Sleep disorder

History of UTIs

Psychosocial stressors

h/o punishment/abuse


Enuresis: Physical Exam

Inspect underwear for wetness

If yes yes suggests diurnal or complex enuresis

Neurologic: Neurologic:

exclude occult neurologic disorders

Back for signs of occult dysraphism

Reflexes

Anal sphincter tone/ bulbocavernosus reflex

L5S3 L5 S3 motor and sensory nerves

GI/GU: GI/GU

Abdominal masses, stool mass

Genitalia for aberrant anatomy (ectopic ( ectopic ureters, ureters,

meatal stenosis, stenosis,

labial adhesions, signs of sexual abuse)

Physical exam is almost always normal!


Nocturnal Enuresis

Monosymptomatic nocturnal enuresis is defined by sleep

wetting without other voiding complaints (80-85% (80 85% w/ enuresis)

Organic causes are responsible for


Dysfunctional Voiding

Urinary incontinence and UTIs are the most

common presentations

Present in 40% of kids w/ first UTI; 80% w/ recurrent UTIs

Overactivity of the detrusor muscle develops w/

uninhibited contractions and failed relaxation of

the sphincter

bladder-sphincter sphincter dyssynergy”

dyssynergy

“bladder

Irritative voiding symptoms may be causative:

chemical irritants, UTIs, constipation


Signs/Symptoms

Urinary incontinence (*daytime/nighttime)

Dysuria

Frequency, urgency

Recurrent urinary tract infections

Incomplete emptying

Constipation (due to inability to relax pelvic floor musculature)

Holding maneuvers- maneuvers leg crossing, squatting,

“vincent vincent’s curtsey” curtsey

Small, frequent voids


Classification of Voiding

Dysfunction

Minor dysfunctional disorders

Extraordinary daytime urinary frequency syndrome

Giggle Incontinence

Extraordinary daytime urinary frequency syndrome

Giggle Incontinence

Urge incontinence

Moderate dysfunctional disorders

Overactive bladder

Moderate dysfunctional disorders

Lazy bladder syndrome

Major dysfunctional disorders

Non-neurogenic

Non neurogenic neurogenic bladder

Ochoa syndrome

Myogenic detrusor failure

bladder (Hinman Hinman syndrome)


Overactive Bladder

The most common voiding dysfunction in

children

Peak incidence between 5-7 5 7 yrs old

Bladder instability with urgency and small,

frequent voids

UTIs and constipation are common secondary to

poor emptying (decreased relaxation of pelvic floor musculature)

Treated with timed voiding programs and

anticholinergics


Nonneurogenic-neurogenic

Nonneurogenic neurogenic bladder

(Hinman Hinman Syndrome)

Most severe form of voiding dysfunction

Bladders behave like a neuropathic bladder (w/

no neurologic deficit)

Detrusor decompensation occurs after a

prolonged period of overactivity & functional

urinary obstruction ensues

Recurrent UTIs

Vesicoureteral reflux/ hydronephrosis

Reflux nephropathy

Encopresis and constipation are common

(Elimination Elimination Dysfunction Syndrome)


Evaluation/Diagnosis

Voiding Diary (and bowel elimination)

Urinalysis (infx infx, , glucose, spec.grav) spec.grav and urine culture

Renal and bladder ultrasound (pre and post void)

Obstructive uropathy, uropathy,

hydronephrosis, hydronephrosis,

bladder capacity

VCUG (indicated w/ recurrent UTIs) UTIs

VCUG

VUR, bladder capacity, post-void post void residual, bladder shape

Abdominal X-ray X ray

bony abnormalities, constipation

Urodynamic testing- testing reserved for children not responsive to

conservative treatment

Pressure-flow Pressure flow studies, post-void post void residuals, bladder EMG

Urodynamic


Voiding Diary


1. Bowel regimen! regimen

2. Timed voiding schedules

Management

• Void every 1-2 1 2 hours before the urge

• Watch alarms may be helpful

3. Anticholinergics

• Oxybutynin (ditropan ditropan) ) helps decrease bladder contractions

and increases functional capacity

• Side effects common (flushing, constipation, constipation,

dry mouth)

• Must be used in conjunction with other treatment modalities!

4. Biofeedback

• Kegel (contraction/relaxation) exercises

5. Antibiotics for UTI


Prognosis

Most children experience successful resolution

Establishment of good voiding behavior is the

key to success

Behavioral modification and timed voiding

programs have been shown to cure 75% of pts

within one year

Long-term Long term renal damage may occur in patients

with severe VD and reflux and warrant

aggressive treatment

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