Voiding Dysfunction in Children

1. Voiding Dysfunction in Children COL John Roscelli Pediatric Nephrology San Antonio Military Pediatric Center

2. Agenda • How the Lower Urinary Tract Works • Voiding Dysfunction in children with no organic pathology • Definition • Presentation modes • Evaluation • Treatment

3. How the Lower Urinary Tract Works

4. Bowl and Bladder Function • Lower GU tract tied to lower GI tract • Same embryogenic origin: endodermal tissue • Up to sixth week gestation urogenital sinus & the hindgut empty into common cloaca • Problems with elimination in one usually associated with problems in the other • Proper term is Elimination Dysfunction Syndrome

5. Function of Lower Urinary Tract • STORAGE of adequate volumes of urine at low pressure & with no leakage • EMPTYING that is • Voluntary • Efficient • Complete • Low pressure

6. Lower Urinary Tract is a Functionally Integrated Unit • Ureteral Vesicle Junction • Bladder • Sphincter • Urethra • Neurologic control mechanisms

7. Anatomy & Neurophysiology of the Lower Urinary Tract • Bladder (detrusor) • Stores urine at low pressure • Compresses urine for voiding • Urethra • Conveys urine from bladder to outside world • Sphincter(s) internal & external • Controls urine flow & maintain continence between voidings

8. CNS micturition centers T10-L1 S2-S4 Nervous system control of Lower Tract • CNS micturition centers • Exert voluntary control over spinal centers • Spinal micturition centers • T10-L1 • Sympathetics via hypogastric Nerve • S2-S4 • Parasympathetic via Pelvic N • Somatic via Pudental N

9. CNS micturition centers T10-L1 S2-S4 Low pressure storage with continence Outlet obstruction: Sympathetic -adrenergic stimulation of bladder neck & posterior urethra from T10-L1 via Hypogastric Nerve Somatic stimulation of External Sphincter from S2-S4 via Pudental Nerve Bladder Relaxation: -adrenergic stimulation of bladder fundus from T10-L2 via Hypogastric Nerve decreases bladder tone Allows continent storage of significant volumes of urine at < 20 mmHg

10. CNS micturition centers T10-L1 S2-S4 Voluntary Efficient Complete Low Pressure Voiding Outlet relaxation: CNS micturition Centers Inhibit sympathetic -adrenergic stimulation of bladder neck/posterior urethra & somatic stimulation of External Sphincter Bladder Contraction: CNS micturition Centers Inhibits -adrenergic bladder relaxation & stimulates Parasympatheticcholinergic stimulation of bladder fundus from S2-S4 via Pelvic Nerve Allows complete emptying at pressures < 40 mm Hg

11. Normal Voiding Study External Sphincter EMG Activity Bladder Neck Pressures Bladder Pressures Storage (cc) Voluntary Voiding

12. Maturation of VoidingNeonatal voiding • Controlled by sacral spinal cord reflex • Bladder distention sends signals to sacral spinal cord micturition center • Spinal cord micturition center sends efferent signals that cause detrusor contraction & relaxation of external sphincter • Results in frequent, complete, low pressure emptying • Newborns void 20 x/day with only a slight decrease during the 1st year of life

13. Maturation of Voiding • Bladder capacity increases & voiding frequency decrease with growth • Bladder capacity in Ounces (30ml) = Age (yrs) +2 • 1-2 yrs: conscious sensation of bladder fullness develops • 2-3 yrs: Ability to initiate or inhibit voiding voluntarily develops • 2-4 yrs: Voiding comes under reliable voluntary control • By 4 years of age, most children have achieved an adult pattern of micturition

14. Maturation of Voiding • Initially child has better control over external sphincter than bladder • Easier to stop urination than start it • Voiding inhibition done by contracting external sphincter rather than inhibiting bladder contraction • This pattern may be reinforced during toilet training • Persistence of this pattern is bladder sphincter dysnergia

16. Characterization of Voiding Dysfunction • Storage Problem: Failure to Store normal volumes of urine at low pressure & without leakage • Non compliant bladder • Irritable bladder • Inadequate sphincter tone during filling • Emptying Problem: Failure to empty completely, on command, efficiently at low pressures • Failure of neurological control of bladder • Bladder muscle failure • Failure of sphincter relaxation during voiding

17. Clinical Problems from Voiding Dysfunction • Increased bladder pressures resulting in • VUR • Upper tract damage • Bladder hypertrophy leading to detrusor failure • Residual Urine • UTI • Incontinence • Social consequences

18. Voiding Dysfunction in Children with no organic pathology

19. Voiding Dysfunction in “Normal Children”- 3 Issues • Clinician must 1st suspect voiding dysfunction in certain clinical circumstances in normal children • Clinician must then rule out Neurologic, Urologic & other organic (diabetes, concentrating defects) problems • Clinician must then characterize & Rx the functional voiding dysfunction

20. Presentations of Voiding Dysfunction in “Normal” Children • Urologic Presentation • GI Presentation • Occult Neurologic presentation

21. Infrequent voiding Frequent voiding Urgency Dysuria Holding maneuvers Straining Poor stream Intermittent stream Incomplete emptying Incontinence Urinary tract infections VUR Urologic PresentationSigns & Symptoms which suggest voiding dysfunction

22. Urologic Presentation It can not be overemphasized to the general pediatrician how important it is that they rule out voiding dysfunction in all their children with recurrent UTIs, VUR or incontinence

23. GI PresentationSigns & Symptoms which suggest voiding dysfunction • Fecal staining of undergarments • Fecal incontinence • Constipation • Encopresis • Obstipation (i.e., severe constipation causing obstruction) • Abdominal pains

24. Ocult Neurologic PresentationSpinal cord tethering suggested by • Lower back abnormalities such as nevus, dermal sinus, or dimple • Pain in the lower back during stretching of the lower extremities • Gait abnormalities • Worsening symptoms during growth spurts • Severe stool incontinence • Complex enuresis refractory to routine Rx

25. Types of Voiding Dysfunction Disorders in “normal” Children

26. Minor Voiding Dysfunctional Disorders • Extraordinary daytime urinary frequency syndrome • Giggle incontinence • Stress incontinence • Post void dribbling • Vaginal voiding • Primary monosymptomatic nocturnal enuresis

27. Major Voiding Dysfunctional Disorders • Hinman syndrome- non neruogenic neurogenic bladder • Ochoa (urofacial) syndrome • Hinman syndrome with Autosomal dominant inheritance & facial grimace when smiling • Myogenic detrusor failure

28. Moderate Voiding Dysfunctional Disorders • Overactive bladder/Urge Syndrome • Bladder Sphincter Dysnergia • Lazy bladder syndrome

29. Moderate Voiding dysfunctional disorders

30. Evaluation of Voiding Dysfunction

31. Purpose of evaluation • Characterize the Elimination problems to direct treatment • Storage problem • Emptying problem • Continence problem • Rule out Neurolgic, Urologic or other organic causes

32. Evaluation of Dysfunctional Voiding • Index of suspicion • History • History • History • Physical Exam • Physical Exam • Simple Lab Tests • Imaging • Urodynamics

33. HistoryTo characterize the Problem • Evaluation of dysfunctional voiding begins with a detailed elimination history • History of current elimination problems • Detailed voiding history • Detailed Stooling history • Past elimination/urologic History • UTIs • Constipation • Age of toilet training • Intake history- fluids and diet • Family history of urologic problems

34. HistoryTo characterize the Problem • Voiding symptoms & pattern of incontinence must be quantified • Urgency, frequency, straining, dysuria etc • Holding maneuvers such as leg crossing, squatting, or "Vincent's curtsey" • Continuous incontinence in a girl suggests ectopic ureter that inserts distal to urethral sphincter or into the vagina

35. Holding Maneuvers

36. 3 Day Elimination Diary-Your most powerful diagnostic tool & its CHEAP & BENIGN • Determines BM problems • Characterizes voiding • Frequency of voids • Volume of voids • Accidents • Associated symptoms • Allows Characterization voiding disorder • Storage • Emptying • Continence Good time to do intake diary Parents record liquid intake volume

37. HistoryIrritable Bladder • Urgency & frequency as Cerebral cortex unable to inhibit reflex bladder contractions triggered during filling • Parents need to know where every bathroom is at mall etc • When they void, void normally although usually have a small bladder capacity • Exhibit behaviors to avoid leakage: Dancing, squatting, holding & posturing • Classic sign of bladder instability is "Vincent's curtsy“- squatting posture in girls in which the heel compresses the perineum and thereby obstructs the urethra to prevent urinary leakage • If unsuccessful get urge incontinence of small amount of urine • These behaviors can lead to bladder sphincter dysnergia

38. HistoryInfrequent Voider • Typically school girls with recurrent UTI & often with history of intermittent enuresis • Postpone voiding as long as possible • Don’t like to void in public bathrooms • Use holding maneuvers to fight urge to void • If holding maneuvers fail get incontinence- “Suzy waits till the last minute to void & then its to late” • Develop large capacity bladders- void 2-3 times per day & often don’t have to void on awakening • When they void voluntarily it is large volumes, prolonged & requires straining • Often don’t take time to completely empty

39. HistoryTo Identify underlying treatable Pathology • Identify organic pathology • Diabetes, epilepsy, obstructive sleep apnea • Neurologic problems • Urologic problems • Identify functional cause that is treatable • Voiding symptoms may be sign of sexual abuse • Stressful occurrence at home or school can trigger incontinence

40. Physical Examination • 1st step is growth, general health & vital signs including BP • 2nd step is to inspect the child's underwear for evidence of wetness or soiling • 3rd step is to observe or at least listen to voiding for evidence of weak, slow or intermittent stream • 4th step is focused physical exam

41. Physical ExaminationAbdomen • Renal masses • Distended bladder • Large stool mass suggestive of constipation

42. Physical ExaminationPerineum & Genitalia • Dampness at beginning of exam & with straining • Signs of erythema or irritation may be indicative of vaginal voiding • Meatal stenosis in boys & presence of labial adhesions in girls • Signs of trauma suggestive of sexual abuse • Careful examination of the introitus for an ectopic ureter • Location of anus

43. Focused Neurolgogic Examination • Lumbosacral spine for lipoma, sinus, pigmentation tufts of hair- may be clue to underlying occult myelodysplasia • Perineal sensation, anal sphincter tone, lower limb function/gait/sensation & Peripheral reflexes • The bulbocavernosus reflex: squeeze glans penis or clitoris & observe or feel reflex contraction of external anal sphincter • Checks integrity of the lower motor neuron reflex arcs • Absence suggestive of a sacral neurologic lesion

45. FOCUSED NEUROLOGIC EXAMINATION

46. Routine Labs • Urine tests best obtained on 1st AM specimen after overnight NPO • UA • Specific gravity- over 1.020 rules out significant concentrating defect • pH • Glucose • Blood • Protein • Microscopic • UC

47. Other Studies that can be obtained prior to referral • Post void residual urine by catheter • Abdominal radiograph (KUB) • Identifies lumbar-sacral anomalies, bowel gas patterns & amount of stool • Renal and bladder ultrasound

48. Sonography • Upper tract • Size, contour, echogenicity • Hydro-nephrosis • Lower tract • Assess bladder wall thickness (nl <3mm when full; 5 mm when empty) • Post void residual > 2 mL/kg is abnormal Excellent correlation between residual urine by direct urethral instrumentation & noninvasive sonography

49. Other Studies that can be obtained prior to referral • Nuclear Medicine renal scan • Cortical scan to RO scars or difference in function • Functional SCAN with/without lasix to RO obstruction • Voiding cystourethrography • History of UTIs • Family history of VUR

50. Studies requiring referral Uroflow/Flowmetry Non invasive assessment of urine flow rates • Staccato voiding or intermittent stream • Intermittent involuntary sphincter activity during voiding • Fractionated & incomplete voiding • Abdominal straining needed to assist bladder emptying & contraction of abdominal muscles contracts the sphincter