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Urge Syndrome and Urge Incontinence Arch Dis Child: first published as 10.1136/adc.64.11.1629 on 1 November 1989. Downloaded from Archives of Disease in Childhood, 1989, 64, 1629-1634 Personal practice Urge syndrome and urge incontinence J D VAN GOOL* AND G A DE JONGEt *Department of Paediatric Nephrology, University Hospital for Children and Youth, Utrecht, and tDepartment of Paediatrics, Vrije Universiteit, Amsterdam, The Netherlands Diurnal enuresis is still the common denominator tractions give rise to urgency and frequency early in for children who wet their pants. A closer look at the filling phase; in the other pattern, incomplete children with daytime wetting, however, shows that relaxation of striated urethral and pelvic floor there are two distinct categories: one with classic muscles interrupts actual voiding and causes a diurnal enuresis and normal bladder function, and staccato urinary flow. the other with urinary incontinence caused by an As these patterns of bladder sphincter over- 'urge syndrome', with bladder sphincter dysfunction, activity are detectable with urodynamic techniques and a conspiciously high incidence of recurrent we decided to investigate prospectively a selected urinary tract infections. group of children of school age whose presenting Overactivity of the detrusor and urethral muscles symptoms were persistent daytime wetting, urgency, is now an established cause for bladder sphincter and frequency. copyright. dysfunction in children, and it is usually associated with symptoms such as urgency, frequency, daytime Patients wetting, and urinary tract infections. 1-5 The symp- toms of dysfunction induced by overactivity have in Ninety girls and three boys with urge incontinence the past been blamed on either the detrusor muscle and recurrent urinary tract infections were studied. or the urethral closure mechanism, resulting in two They were referred after the failure of previous different concepts of diagnosis and treatment.6 attempts at treatment to a combined service of the Cystometric findings of uninhibited detrusor activity departments of paediatric nephrology and child in children with recurrent urinary tract infections psychology in our University Children's Hospital. http://adc.bmj.com/ and urge syndrome were interpreted as persistent For every child a documented history of urinary infantile bladder, occult neuropathic bladder, or tract infections was available; all the children had isolated or subclinical neurogenic bladder. Accord- had full uroradiological investigations (excretory ingly, treatment consisted of rehabilitation pro- urography and voiding cystourethrography), and all grammes and anticholinergic drugs. Cystoscopy and results were available for review. Our part of the voiding cystourethrography, on the other hand, comprehensive evaluation consisted of psychological showed abnormalities that were labelled as wide interviews of children and parents, of elaborate bladder neck anomaly or 'spinning top' urethra, history taking with emphasis on voiding habits and on September 30, 2021 by guest. Protected distal urethral stenosis, external sphincter spasticity, urge, and of urodynamic studies. or sphincter dyssynergia, popularising the concepts Each urodynamic investigation consists of simul- of urethral dysfunction and stenosis, and of urethral taneous recording of the bladder pressure, abdo- dilatation or urethrotomy as methods of treatment. minal pressure, electromyographical activity of the Urodynamic studies showing the interaction be- external anal sphincter, and urine flow rate. Several tween bladder and sphincter muscles by simulta- recordings are made, both during filling of the neous registration of bladder pressure and urethral bladder and emptying of the bladder, without sphincter activity at first added even more labels to anaesthesia or sedation. the two controversial concepts, and widened the Bladder filling and registration of bladder pressure range of possible treatments. Recent reviews7 8 are done through one small soft transurethral support the idea that most labels can be brought catheter (Charriere size 6). The catheter has a filling down to patterns of bladder sphincter overactivity: lumen and a microtransducer at the tip (MTC in one pattern, strong uninhibitable detrusor con- microtip transducer, PPD Hellige). The bladder is 1629 Arch Dis Child: first published as 10.1136/adc.64.11.1629 on 1 November 1989. Downloaded from 1630 van Gool and de Jonge filled with a sterile 0-9% saline solution, the filling tained until the urge to void has passed, which can rate not exceeding 15 ml/minute. Abdominal pres- take up to several minutes. sure is registered with a Charriere size 4 catheter Most children do not succeed completely (if at all) containing a microtip transducer inserted high into in countering the imperative need to void with the rectum. The electromyographical signal from external compression of the urethra, and more often the anal sphincter (a measure for pelvic floor than not some urine will escape. This loss of urine is activity) is picked up with surface electrodes, involuntary and incomplete; it never takes the amplified and monitored with an oscilloscope, and course of a complete micturition. It is a specific form registered on a chart recorder together with the of incontinence-urge incontinence. amplified pressure signals. The smallness and ease of operation of the microtip transducers (together OCCURRENCE ACCORDING TO AGE AND SEX with patience on the part of the investigator) are The urge syndrome is seldom seen in boys. The prerequisites for successful paediatric urodynamics, prevalence in girls aged 4 to 12 years is reported to and when the procedure is properly explained, most be 1-3/1000. Parents usually state that symptoms children tolerate the investigation extremely well. and signs started around age 4 to 5; parental At or near the end of the filling phase the child is attitudes towards incontinence become less permis- asked to cough, and to change from a supine to sive at that age, however, and careful questioning a standing or sitting position, so that detrusor may discover an earlier age for the first occurrence instability may be detected. Bladder emptying is -often in conjunction with the first urinary tract recorded with the child in the appropriate voiding infection. position. Abdominal pressure is subtracted electron- Around puberty the prevalence starts to decrease, ically from bladder pressure, to differentiate true and in adolescence it is low. The 'female urethra detrusor activity from effects of abdominal straining. syndrome' might be an adult counterpart of the urge All events are recorded continuously without having syndrome in girls, but prospective studies are not to ask the child to use inappropriate 'holding available to prove this postulate.'5 16 manoeuvres' in the important transition phase Fig 1 shows the age distribution for 93 childrencopyright. between filling and micturition. Methods, definitions, with urge syndrome all of whom were referred to our and units conform to the standards recommended by department of paediatric nephrology because of the International Continence Society. incontinence and recurrent urinary tract infections. Signs and symptoms URINARY TRACT INFECTIONS The correlation between urinary tract infections and Characteristically, children with the urge syndrome the urge syndrome is generally accepted, but hard to have sudden attacks of uninhibitable urge to void, specify.' 2 4 8 17 A first infection may mark the inducing forceful compression of the urethra to beginning of a long series of recurrent infections and http://adc.bmj.com/ avoid unwanted loss of urine2 3 7-14 Usually the persisting symptoms of the urge syndrome; in other first attacks do not occur before the end of the morning. During the course of the day the attacks increase in number as well as in severity. The syndrome may have a nocturnal component too, as some children also experience sudden urge and loss * Boys of urine during the night. The urge to void comes suddenly and unexpectedly. G irls on September 30, 2021 by guest. Protected The sensation is so imperative that loss of urine can only be avoided by maximal compression of the urethra both by forceful contraction of all pelvic floor muscles and by external mechanical compres- sion. Every child has his or her own method of external compression-a common one is squatting on one foot, with the heel of the foot against the perineum. This asymmetrical squat conveys a sense of elegance-it resembles an obeisance and Vincent,9 0 2 3 4 5-6 7-8 9-10 11-12 13-14 15-16 17:18 >1 who first described it, termed it the 'curtsey' sign. In Age (years) assuming this position children often pretend that Fig 1 Age and sex distribution of93 children with urge something was dropped on to the floor, or that a syndrome and recurrent urinary tract infections who were shoelace had become untied. Compression is sus- referred for cognitive bladder training. Arch Dis Child: first published as 10.1136/adc.64.11.1629 on 1 November 1989. Downloaded from Urge syndrome and urge incontinence 1631 cases, however, recurrent urinary tract infections It is not clear whether the constipation is caused seem to appear only during the course of the by the habit of contracting all pelvic floor muscles syndrome. each time an urge to void is experienced. The Although urinary tract infections may not con- association between chronic constipation and urge stitute the primary cause of the urge syndrome they syndrome, first described by Vincent, merits
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