SERIES Pediatric Voiding Dysfunction: Current Evaluation and Management Pamela Ellsworth Anthony Caldamone

he prevalence of pedi- Voiding dysfunction and in children is common. atric voiding dysfunction Both are associated with significant effects on quality of life and co- and daytime inconti- morbidities, including urinary tract infections (UTIs) and constipa- nence is difficult to deter- tion. A thorough history, physical examination, and non-invasive eval- Tmine due to varying definitions of uation are essential in determining the etiology. Interventions, such urinary incontinence (UI) and dif- as behavioral therapy/biofeedback and pharmacologic therapies, are ferent study designs. Furthermore, primary treatments. Prevalence rates, current evaluation, and man- few studies have evaluated the agement techniques are discussed in this article. prevalence of the different types of voiding dysfunction in children. Key Words: Voiding dysfunction, urinary incontinence, urinary The prevalence of daytime wetting frequency, constipation, urinary tract infection, varies with age and gender. anticholinergic therapy, urodynamics, Interstim® Overall rates vary from 1% to neuromodulation therapy, children, pediatrics. 10%. In 6 to 7-year-old children, the rate is between 2% to 4%, with a rapid decrease in subsequent Objectives years (Bloom, Seeley, Ritchey, & 1. Explain the clinical impact of voiding dysfunction and UI. McGuire, 1993; Bower, Moore, Shepherd, & Adams, 1996). 2. Describe the evaluation process of children with voiding dysfunction. 3. Identify and describe two behavioral therapies for voiding dysfunction LITERATURE REVIEW in children. Several studies have been per- 4. Discuss benefits and limitations of various pharmacologic therapies formed assessing the prevalence of for children with voiding dysfunction. daytime incontinence in school- aged children. Kajiwara, Inoue, 5. Explain minimally invasive and surgical alternatives to treating Usui, Kurihara, and Usui (2004) voiding dysfunctionin children.

Pamela Ellsworth, MD, FAAP, FACS, is an Associate Professor of Urology, Urological evaluated the micturition habits incontinence was 18% in children Association, Inc., Rhode Island Hospital, and prevalence of daytime urinary between 7 to 10 years of age. With Providence, RI. incontinence in 6,917 Japanese respect to the types of daytime UI, Anthony Caldamone, MD, FAAP, FACS, is primary school children ages 7 to 94.6% of the children had associ- a Professor of Urology of Surgery and 12 years. Daytime UI was defined ated , and 23.8% Pediatrics, Division of Urology, Rhode as any involuntary leakage of had urinary frequency; 4.5% wet Island Hospital, Brown University/Hasbro during the daytime occur- themselves during coughing, Children’s Hospital, Providence, RI. ring more than once per month in sneezing, and laughing. Children Note: Pamela Ellsworth, MD, FAAP, FACS, the 6 months prior to the survey. with daytime UI had a higher inci- disclosed that she is on the speakers’ Bureau and Advisory Boards for Pfizer, Dampness of the underwear was dence of urinary tract infections Allergan, and Novartis. She also discloses included as leakage. The preva- (UTIs) and constipation. that some pharmacologic therapies that are lence of daytime UI was 6.3%, Sureshkumar, Craig, Roy, and not FDA-approved for use in children are equally affecting males and Knight (2000) used a population- presented, including alpha blockers and some anticholinergic agents, as well as use females. Wetting more than once based cross-sectional survey of of minimally invasive procedures. Lack of per week during the day was new entrant primary school chil- approval is noted. noted in 3.6% of the children and dren in Sydney, Australia, to Anthony A. Caldamone, MD, FAAP, FACS, daily wetting in 1.2%. The sponta- assess the prevalence of daytime reported no actual or potential conflict of neous resolution rate for diurnal UI. Their results showed 19.2% of interest in relation to this continuing nursing education article. Note: Objectives and CNE Evaluation Form appear on page 258.

UROLOGIC NURSING / August 2008 / Volume 28 Number 4 249 SERIES children had at least one episode Figure 1. of daytime wetting in the 6 Uroflow Demonstrating Staccato Voiding Pattern months prior to the study, 4.2% had wet two or more times per month, and 0.7% wet on a daily basis. Only 16% of the children with daytime wetting sought med- ical attention. Even in the group of children with daily daytime wet- ting, 40% had not received any medical help. Predisposing factors associated with daytime UI were family history, female gender, and a history of recent emotional stress (Sureshkumar et al., 2000). An Australian study assessed the prevalence of in a sample of school-aged children 5 to 12 years of age. The study iden- they are also associated with an resolution of vesicoureteral reflux tified a prevalence of 2% for iso- increased risk of UTIs and consti- (Koff et al., 1998). lated daytime wetting and 4% for pation. Voiding dysfunction and The ramifications of pediatric day and nighttime wetting. The UI together may delay resolution voiding dysfunction and inconti- prevalence of any daytime wetting of vesicoureteral reflux, if present nence extend beyond the child- was 5.5%. A gender bias was not (Koff, Wagner, & Jayanthi, 1998). hood years. Fitzgerald, Brown, identified for daytime wetting The increased risk of UTIs may be Wassel, and Brubaker (2006) stud- (Bower et al., 1996) related to underlying constipation ied a population-based cohort of Hellström, Hanson, Hansson, and may also be associated with 2,109 women 40 to 69 years of age Hjälmås, and Jodal (1990) evaluat- the higher bladder pressures that in a health maintenance organiza- ed micturition habits and preva- are seen in children with both tion. The authors noted that lence of UI in 3,607 7-year-old and dysfunc- women who reported daytime uri- children entering school. Six per- tional voiding. Overactive bladder nary frequency were more likely cent of girls and 3.8% of boys had and dysfunctional voiding may to report adult urgency (odds ratio diurnal incontinence. Wetting produce transient episodes of [OR] 1.9, 95%; confidence interval every week was reported in 3.1% decreased blood flow to the blad- [CI] 1.3 to 2.6; p < 0.001) and that girls and 2.1% boys. In those chil- der mucosa (Mitterberger et al., childhood daytime incontinence dren with diurnal incontinence, 2007). This increased activity of was associated with adult urgency urgency was reported in 82% of the pelvic floor muscles may also UI (OR 2.6, 95%; CI 1.1 to 5.9; p < girls and 74% of boys. create a milk back phenomenon, 0.05). Minassian, Lovatsis, Pascali, Some studies indicate that whereby bacteria in the proximal Alarab, and Drutz, (2006) noted a incidence of overactive bladder is urethra are milked back into the higher prevalence of childhood more common than dysfunctional bladder via contraction of the voiding dysfunction in women voiding. In a study of 1,000 chil- pelvic floor muscles. who had urinary frequency, dren with voiding dysfunction, Underlying constipation may urgency, stress urinary inconti- Hoebeke, Van Laecke, Van Camp, also exacerbate overactive bladder nence (SUI), and urgency urinary Raes, and Van de Walle (2001) symptoms (Warne, Godley, & incontinence (UUI). noted that two-thirds had overac- Wilcox, 2004). In a study of 234 tive bladder and one-third experi- constipated children, 29% were TERMINOLOGY enced dysfunctional voiding. noted to have daytime UI. When Functional incontinence is a Hellerstein and Linebarger (2003) constipation was relieved in 52% term applied to incontinence that noted in a study of 22 children of the patients, these children is unrelated to congenital. ana- based on clinical information that ceased to have UTIs, and 80% had tomical, or neurologic abnormali- 76% of children appeared to have resolution of daytime UI (Loening- ties. Functional UI may be caused overactive bladder, while only 1% Baucke, 1997). by disturbances in the filling had dysfunctional voiding. Finally, dysfunctional voiding (storage) phase, the voiding may have an impact in children phase, or a combination of both. IMPACT with known vesicoureteral reflux. Both storage and voiding phase It is well known that voiding Dysfunctional voiding may in- dysfunctions are associated with dysfunction and UI can signifi- crease the risk of UTIs; however, it an increased risk of UTIs. cantly affect quality of life, but also appears to prolong the rate of According to the International

250 UROLOGIC NURSING / August 2008 / Volume 28 Number 4 SERIES

Table 1. Children’s Continence Society, Types of Functional Incontinence incontinence is defined as a result of a filling phase dysfunction Urge Syndrome (Overactive Bladder) (detrusor overactivity) and is • Frequent episodes of urgency (sudden compelling desire to void that is diffi- called “urge syndrome” or “urge cult to defer) countered by contractions of pelvic floor muscles and holding incontinence.” These terms are maneuvers (squatting, crossing legs, sitting on heels). synonymous with the adult term • Symptoms felt to be related to underlying detrusor overactivity. overactive bladder. When inconti- • Bladder capacity is small.Voiding pattern is normal with appropriate relaxation nence is the result of a voiding of pelvic floor muscles; increased risk of UTIs and constipation. phase dysfunction, it is called • Constipation may serve to trigger detrusor contractions by stimulation of “dysfunctional voiding.” Dysfunc- stretch receptors in the bladder wall by the extrinsic fecal mass, or the colonic tional voiding may be subdivided contractions may increase detrusor contractions via shared neural pathways into staccato voiding, fractionated (Franco, 2007). voiding, and poor bladder empty- ing due to an underactive detrusor Dysfunctional Voiding (see Figure 1). Non-neurogenic Different types: neurogenic bladder dysfunction • Staccato voiding – Bursts of pelvic floor muscle activity during voiding caus- most likely represents the end- ing interruption in the flow of urine. Flow duration is prolonged and bladder stage of dysfunctional voiding emptying is incomplete (see Figure 1). (Nørgaard, van Gool, Hjälmås, • Fractionated voiding – Micturition occurs in several small fractions, emptying Djurhuus, & Hellström, 1998). A is incomplete due to hypo-activity of the detrusor muscles. Abdominal mus- recently defined form of dysfunc- cles are used to increase the bladder pressure during voiding (valsalva void- tional voiding is voiding post- ing). Irregular but continuous flow rate. Voiding frequency is low, bladder ponement, which appears to be capacity is large. clinically different than dysfunc- • Poor bladder emptying secondary to underactive detrusor (lazy bladder syn- tional voiding (Lettgen et al., drome) – May be a long-term result of dysfunctional voiding related to detru- 2002). The combination of dys- sor decompensation. No detrusor contraction during voiding; abdominal pres- functional voiding and constipa- sure drives voiding. Large post-void residual and recurrent UTIs are common. tion/encopresis is referred to as • Non-neurogenic neurogenic bladder (Hinman-Allen syndrome). May be the dysfunctional elimination syn- end stage of voiding dysfunction. Must rule out neurologic abnormality. drome. Another form of voiding Decreased bladder capacity and poor compliance noted on urodynamics. phase dysfunction that is probably Detrusor overactivity is often present; increased activity of pelvic floor muscles more common than originally during voiding (see Figure 2). Must be followed closely because there is risk thought is primary bladder neck for upper tract damage. dysfunction. Other forms of UI • Dysfunctional elimination syndrome – Used to describe coexistence of include giggle incontinence and significant constipation/encopresis and dysfunctional voiding. vesciovaginal entrapment (vaginal reflux voiding) (see Table 1). Other Conditions • Voiding postponement – Postpone imminent micturition until overwhelmed by EVALUATION urgency.Thought that overactivity of the urethral sphincter is a behavioral mal- The evaluation of voiding adjustment because there is a higher frequency of behavioral issues in these dysfunction and UI in children children compared to children with overactive bladder (Lettgen et al., 2002). starts with a detailed and struc- • Giggle incontinence – Etiology not known, but there are 2 theories. One the- tured history, a focused physical ory is that laughter induces a generalized hypotonic state with urethral relax- examination, and a urinalysis. ation; the other is that laughter triggers the micturition reflex overriding central Ancillary tests, such as a bladder inhibitory mechanisms (MacKeith, 1959; Williams, 1984). scan, post-void residual (PVR), • Vesicovaginal entrapment (vaginal reflux voiding) – May be secondary to labi- and uroflow/electromyelogram al adhesions, funnel-shaped hymen, or inappropriate positioning on the toilet (EMG), are often helpful in estab- bowl. lishing the diagnosis. Further • Primary bladder neck dysfunction – Not commonly identified in children. tests, such as renal/bladder ultra- Diagnosed by video urodynamics, or delayed or incomplete opening of blad- sound, voiding cystourethrogram der neck during voiding. Low flow rate but no increase in pelvic floor muscle (VCU), and formal urodynamics activity. Symptoms include hesitancy, frequency, urgency, decreased force of tests, may be indicated depend- stream, pelvic pain/discomfort with voiding, feeling of incomplete emptying, ing on the patient’s history and and sometimes incontinence. physical examination.

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Table 2. tion between dysfunctional void- Voiding and Bowel Habit Questions ing and dysfunctional elimination syndrome has been noted in chil- Voiding dren with a history of sexual • Does your child void in the morning immediately upon awakening? abuse. In a study of 300 patients • Does your child need prompting to void? evaluated for voiding dysfunction • How often does your child go to the bathroom to void? over a 3-year period, 18 with dys- • Does your child have a single stream when voiding, or is it interrupted? functional voiding had a history of sexual abuse preceding the onset • Does you child exhibit any holding maneuvers (squatting, crossing legs, sitting of urinary symptoms (Ellsworth, on heels)? Merguerian, & Copening, 1995). • Does your child leak urine during the day, and if so, how many times per day? Additional information should be • Does your child leak urine at night, and if so, how many nights per week? obtained about prior UTIs regard- • What is the volume and type of fluid intake (especially caffeine)? less of whether the child was • Is your child given permission to void at school when needed (older children) or febrile and if any radiologic prompted to void at regular intervals (younger children)? workup was performed. Table 2 lists several questions that can Bowel help identify the child’s voiding • How often does your child move his or her bowels? and bowel regimen. • Does your child have any fecal soiling? A list of current medications should be obtained since many • What are the characteristics of your child’s stool? Are they hard, pellet-like, very large, or very small? medications may affect bowel function. A family history of voiding/bowel issues should also Figure 2. be assessed because there ap- Abnormal Gluteal Cleft pears to be some familial tenden- cies for overactive bladder. A list of prior surgeries should be doc- umented. Physical Examination A focused physical examina- tion should be performed on all children presenting with voiding dysfunction or UI. Simply watch- ing the child walk through the office door can provide useful information regarding the child’s neurologic status. An abdominal examination should be per- formed to assess for abdominal masses, a distended bladder, or stool-filled colon. The child’s back should be examined to assess for significant scoliosis/ History training process (delayed or pro- kyphosis and asymmetry of the History is often obtained from longed, never achieved), family buttocks, legs, or feet, as well as the parent/caregiver but should issues (family stressors that in- other signs of occult neurospinal also include the child. Often, par- clude move, separation/divorce, dysraphism in the lumbosacral ents of toilet-trained children will death, new siblings), history of sex- area (subcutaneous lipoma, skin not be aware of their child’s bowel ual abuse, and the child’s current discoloration, hair growth) (see regimen or voiding habits at voiding and bowel regimen. Figure 2). A neurological exami- school. The history should take Children with attention deficit nation would include assessing into account perinatal history, tim- hyperactivity disorder have a perineal sensation and lum- ing of developmental milestones, greater risk of incontinence and bosacral reflexes (standing on the child’s mental status (attentive- may be more challenging to treat toes, anal reflex, and tone and ness, academic performance at (Crimmins, Rathbun, & Husmann, bulbocavernsosus reflex). The school, behavioral issues, fine and 2003; Duel, Steinberg-Epstein, genitalia are examined, includ- gross motor coordination), toilet- Hill, & Lerner, 2003). An associa- ing the location and size of the

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Figure 3. Figure 4. Increased Pelvic Floor Muscle Activity During Voiding Plain Film of the Abdomen (KUB) Demonstrating Large Amount of Stool

urethral meatus. In girls, labial curring prior to the onset of void- adhesions should be ruled out. ing and continuing until voiding is complete. A prolonged voiding Laboratory Tests pattern on the uroflow/EMG A urinalysis should be per- without increased pelvic floor formed to rule out glucosuria, muscle activity in a male should bacteriuria, proteinuria, hypos- raise the suspicion of bladder sis, renal scarring) should have a thenuria (low specific gravity), outlet obstruction, a urethral VCUG as well. It is useful to have and pyuria. stricture, or posterior urethral a renal/bladder ultrasound per- valves (Figure 3). formed with pre and post-void Ancillary Tests Normally, a child should be bladder volume determinations. A bladder scan, PVR determi- able to empty to a PVR of only 5 However, the child is often nation, and uroflow/EMG are cc. An increased PVR (in the prompted to drink excessive useful adjuncts in the evaluation authors’ practice, PVR > 20 cc amounts of fluids to ensure that and diagnosis of a child with but varies with the age of the the bladder is “full” at the time of voiding dysfunction. In addition child and whether there is a his- the study. This may lead to a very to assisting the provider to deter- tory of UTIs) should prompt fur- distended bladder at the time of mine the etiology of voiding dys- ther evaluation and the institu- the study and inadequate empty- function, these tests provide the tion of a double voiding regimen ing of the bladder related to the child with tangible evidence of (void once, wait a minute, and marked distention. Therefore, the underlying voiding dysfunc- then void again). the child should drink some flu- tion and may serve as forms of A renal/bladder ultrasound ids an hour or so prior to the biofeedback in managing the should be performed in males study and try not to void within child’s voiding dysfunction. With who present with daytime UI to an hour or two of the study. The a uroflow, the practitioner can rule out posterior urethral valves goal is a full but not markedly show the child whether he or she and in children with a history of distended bladder. Further, it is is voiding with a normal stream UTIs who have not had a previ- recommended that a kidney/ (a bell shaped curve) or if there is ous radiologic evaluation. A ureter/bladder (KUB) plain film dysfunctional voiding (a staccato VCUG is generally obtained in be obtained in children in whom or fractionated stream). In an males with a history of UTIs there is a suspicion of constipa- EMG display, the child can iden- (febrile and nonfebrile) and in tion (see Figure 4). tify his or her pelvic floor mus- whom the renal/bladder ultra- Further tests, such as urody- cles and visualize the increase or sound demonstrates a distended namics studies (UDS) and mag- decrease in EMG activity based bladder with a thickened bladder netic resonance imaging (MRI) of on the contraction or relaxation of wall or a dilated posterior ure- the spine will be dictated by the pelvic floor muscles. A normal thra with or without hydro- child’s history, physical exami- pattern on uroflow/EMG is asso- . Girls with a history of nation, and response to therapy. ciated with silencing of the febrile UTIs or with an abnormal UDS testing is reserved for those pelvic floor muscle activity oc- renal ultrasound (hydronephro- children who fail behavioral and

UROLOGIC NURSING / August 2008 / Volume 28 Number 4 253 SERIES medical therapy and those with emergency procedures, such as Anticholinergic agents. There suspected neurologic lesions. squatting, that attempt to provide are limited randomized placebo- MRI of the spine is obtained to urethral compression. With dys- controlled studies available to rule out a tethered cord when functional voiding, the goal is to assess the efficacy of anticholiner- there is a lumbosacral skin have children learn to void with a gic agents in children with abnormality, or if there is an completely relaxed pelvic floor urge syndrome/overactive bladder. abnormal plain X-ray of the and to avoid using abdominal Similarly, there are few agents spine. pressure to void. approved by the Food and Drug Biofeedback is a technique in Administration (FDA) for use in Management which physiological activity is children. These agents include Despite the prevalence of monitored, amplified, and con- immediate release oxybutynin and pediatric voiding dysfunction veyed to the patient as visual or sustained release oxybutynin and daytime wetting, there is a acoustic signals. These signals (Ditropan). Although, not approved paucity of well-designed studies provide the patient with informa- by the FDA, pediatric studies are evaluating the therapeutic impact tion about unconscious physio- being performed using tolterodine of various behavioral and pharma- logical processes and have been (Detrol®) in children with overac- cologic therapies. A Cochrane used for both voiding phase (dys- tive bladder (Hjälmas, Hellstrom, review (Sureshkumar, Bower, functional voiding) and filling/ Mogren, Läckgren, & Stenberg, Craig, & Knight, 2003) evaluating storage phase (detrusor overactiv- 2001; Raes et al., 2001) and imme- therapies for UI in children from ity) abnormalities. McKenna, diate-release trospium chloride 1996 to 2001 identified only five Herndon, Connery, and Ferrer (Sanctura®) (Lopez, Miguelez, studies that used a randomized (1999) developed a program uti- Caffarati, Estornell, & Anguera, controlled design. Of these five lizing computer games integrated 2003). The goals of anticholinergic studies, one evaluated the use of into the pelvic floor muscle train- therapy in children with overactive alarm therapy for daytime UI, ing program and found that it bladder are to increase bladder and four studies evaluated phar- engaged children and maintained capacity and decrease detrusor macotherapy. Two of these phar- their attention. In children with overactivity, which results in an macotherapy studies evaluated , improvement increased interval between voids, terodiline, an agent that has been was noted in 89% with 61% increased voided volume, and dry- withdrawn from use due to car- cured. Constipation improved in ness between voids. diac toxicity. Of the two remain- 100% and resolved completely in Although these agents appear ing studies, one evaluated the 33%. Encopresis also improved in to be clinically effective, there are use of imipramine, which did not 100% and resolved in 73%. limited well-designed studies significantly increase maximum Biofeedback is limited by the abil- available that fully investigate functional bladder capacity, and ity of the child to cooperate with these drugs. Side effects are com- the other study evaluated oxybu- the health care provider who is mon and should be reviewed tynin versus biofeedback. This running the session. Children with parents along with measures study did not show a decrease in with learning disabilities and to prevent and treat the associat- the percentage of children with no behavioral problems are not ideal ed side effects. More commonly improvement in the frequency of candidates for biofeedback. encountered side effects include daytime wetting after nine months facial flushing, dry mouth, and of treatment with either biofeed- Pharmacologic Therapy constipation. Children prone to back or oxybutynin (Ditropan®). Pharmacologic therapy has a constipation should be started on role in pediatric voiding dys- a bowel regimen; bowel habits Behavorial Therapies function. Currently, only anti- should be regulated prior to start- Behavioral therapy starts with cholinergic agents are approved ing an anticholinergic agent. education regarding normal blad- for use in pediatric urge syn- Oxybutynin can affect sweating, der function and responses to drome/overactive bladder. Alpha and during the summer, it is urgency. Children are placed on a blockers are being used off-label important that parents are cau- timed voiding regimen of every in children with symptoms sug- tious regarding heat exposure. two to three hours and are gestive of primary bladder neck Concerns have been raised, par- instructed to avoid caffeinated, dysfunction, although they are ticularly in the neurogenic blad- carbonated, and highly acidic flu- not currently approved for use in der population, regarding central ids. The goal of behavioral thera- children. Intravesical injection of nervous system and cognitive py in children with urge syn- botulinum-A toxin is experimen- side effects of oxybutynin. Palmer, drome/overactive bladder is to tal but has been used in refracto- Zebold, Firlit, and Kaplan (1997) learn to suppress the first sensa- ry cases of pediatric voiding dys- noted side effects of agoraphobia, tion of need to void by normal function. hyperactivity, headache, and in- central inhibition rather than somnia in children with myelo-

254 UROLOGIC NURSING / August 2008 / Volume 28 Number 4 SERIES dysplasia using intravesical oxy- Figure 5. butynin chloride. Interstim® Neurostimulator and Placement in the Alpha-blockers. The ration- Upper Gluteal Region ale for use of alpha-blockers in voiding dysfunction is based on the presence of alpha-adrenergic receptors in the bladder outlet and proximal urethra. Stimula- tion of these receptors leads to smooth muscle contraction and increased outlet resistance. Thus, antagonism of the alpha-recep- tors would lead to relaxation of the bladder outlet and proximal urethra (Restorick & Mundy, 1989). However, the role of alpha-blockers in pediatric void- ing dysfunction remains investi- gational, and parents must be cautioned that alpha-blockers are not approved by the FDA for use in children with voiding dys- function. Currently, there are no randomized, placebo-controlled studies evaluating the safety and efficacy of alphablockers. Limited studies have supported a role for alpha- blockers in chil- dren with dysfunctional voiding. One study demonstrated an improvement in diurnal inconti- nence in 83% of children and improvement in urinary urgency in 70% of children (Cain, Wu, Austin, Herndon, & Rink, 2003). Franco (2007) noted that in his experience, alpha-blockers have been effective in treating chil- dren with overactive bladder who had failed biofeedback ther- apy. Botulinum-A toxin (Botox®) is a potent neurotoxin that blocks neuronal acetylcholine secretion by binding to presynaptic nerve endings. Botulinum-A toxin has 21 children with refractory non- intravesical injection of botu- been demonstrated to be effective neurogenic detrusor overactivity linum-A toxin include the need in neurogenic overactivity in who were injected intravesically for general anesthesia in chil- adults, and more recently, has with 100 IU of botulinum-A dren, the lack of long-term effica- been demonstrated to have high toxin. All children had decreased cy, and subsequent treatments. short-term effectiveness in adults bladder capacities for age, uri- for overactive bladder (Flynn, nary urgency, and UUI. Of the 15 Minimally Invasive Therapies Webster, & Amundsen, 2004). children with six-month follow Neuromodulation is a proce- There are limited studies using up, nine had resolution of dure that is approved by the FDA intravesical injection of botu- urgency and UUI after one injec- for the treatment of UUI, linum-A toxin in children with tion session, three had a partial urgency-frequency syndrome, neurogenic and non-neurogenic response (50% decrease in and functional urinary obstruc- detrusor overactivity. Hoebeke et urgency and UUI), and three did tion in adults, but it is not al. (2006) prospectively studied not respond. Limitations of approved for use in children. The

UROLOGIC NURSING / August 2008 / Volume 28 Number 4 255 SERIES mechanism of action of neuro- incontinence. Constipation im- MANAGEMENT OF modulation is not fully under- proved in 80% of the 23 RECURRENT UTIs stood. It is thought that stimulat- patients. Complications cited Children with voiding dys- ing the afferent sacral nerve were seroma anterior to the neu- function who develop frequent induces inhibitory stimuli in the rostimulator device, transient recurrent symptomatic UTIs (for efferent nerve to the bladder, episode of skin sensitivity over example, one every two to three causing an interneuronal change the device site, two neurostimu- months) may benefit from pro- in the spinal reflex arc and/or lator failures, and one lead that phylactic antibiotic therapy while spinobulbous reflex arc. Another required revision. The overall the child’s underlying voiding proposed theory is that neuro- complication rate was 22%. dysfunction and bowel dysfunc- modulation inhibits activity of tion are being treated. The choice afferent c-fibers, which become Surgical Therapies of prophylaxis will vary, depend- dominant in neurogenic bladder Bladder augmentation is ing on resistance patterns in dysfunction (Myers & Sung, rarely required for non-neuro- the area and the child’s prior 2006). The procedure typically is genic voiding dysfunction. The urine culture results. However, performed in two stages. In the goal of bladder augmentation is trimethoprim-sulfamethoxazole first stage, percutaneous trans- to increase the storage function (Bactrim®) and nitrofurantoin foraminal access to the third of the bladder and decrease (Macrobid®) are typically the sacral spine nerve is achieved, intravesical pressure. Rarely, it first-line antibiotics for prophy- and if the appropriate neurologic may be indicated in children laxis (Committee on Quality responses occur to confirm prop- with non-neurogenic neurogenic Improvement, Subcommittee on er location, the quadripolar lead bladder with persistent poor Urinary Tract Infection, 1999). is implanted. A tunneled subcu- compliance and elevated detru- The usual prophylactic dose is taneous extender connects the sor pressures refractory to anti- one-third to one-half of the treat- lead to an external neurostimula- cholinergic therapy and clean ment dose given on a once-daily tor device for programming to intermittent catheterization. basis. More recently, the role of begin the sacral nerve stimula- prophylactic antibiotics in chil- tion trial, usually lasting two to MANAGEMENT OF dren with recurrent UTIs has four weeks (see Figure 5). BOWEL SYMPTOMS been questioned. In a review If there is a 50% or greater Critical to the management of from a network of 27 primary improvement in symptoms, the pediatric voiding dysfunction is care pediatric practices, antimi- patient then undergoes a second the management of any underly- crobial prophylaxis was not asso- procedure to implant the perma- ing bowel dysfunction. It is ciated with decreased risk of ® nent Interstim neurostimulator important to identify those chil- recurrent UTI but was associated in the upper gluteal region. More dren with bowel dysfunction with increased risk of resistant recently, a smaller version of the during the initial evaluation by infections in the children studied neurostimulator has been ap- asking questions regarding bowel (Conway et al., 2007). proved for use. Neuromodulation habits (see Table 2). As with using Interstim (Medtronic, Min- voiding dysfunction, a behav- MANAGEMENT OF OTHER neapolis, MN) has been demon- ioral approach to the manage- CAUSES OF INCONTINENCE strated to be effective in dysfunc- ment of bowel dysfunction is tional elimination syndrome. important. Bowel regimens con- Giggle Incontinence Humphreys et al. (2006) placed an sisting of timed attempts at hav- There are very few studies Interstim in 23 patients who were ing a bowel movement are evaluating the management of gig- 6 to 15 years of age and who pre- important. Children are encour- gle incontinence. It is felt that gig- sented with symptoms of dys- aged to try to have a bowel move- gle incontinence resolves by functional voiding, enuresis, ment after meals, taking advan- adulthood. The management of incontinence, UTIs, bladder pain, tage of the gastrocolic reflex. It is giggle incontinence varies and , urgency, fre- important that the child has includes the use of anticholiner- quency, constipation and/or enough fiber in his or her diet gic agents in those children in fecal soiling. The researchers fol- and is drinking enough fluids. whom an unstable bladder con- lowed these children for a mean Those children who fail to traction is suspected (Chandra, of 13.3 months after Interstim improve with simple dietary and Saharia, Shi, & Hill, 2002) and use placement. Of the 19 patients behavioral measures will benefit of alpha-sympathomimetic agents with UI, 16% had complete reso- from the addition of laxatives, or methylphenidate (Ritalin®) (Sher lution, 68% had improvement, such as polyethylene glycol 3350 & Reinberg, 1996) in those in 11% had no change, and 5% (Miralax®). whom muscle relaxation is the noted worsening of their UI. suspected etiology. Timed void- Four patients did not have ing to ensure regular bladder

256 UROLOGIC NURSING / August 2008 / Volume 28 Number 4 SERIES emptying can also help in function will vary depending on Flynn, M.K., Webster, G.D., & Amundsen, decreasing the volume of urine the etiology of the child’s voiding C.L. (2004). The effect of botulinum- a toxin on patients with severe urge lost during giggle incontinence dysfunction. urinary incontinence. Journal of episodes. Urology, 172(6), 2316-2320. References Franco, I. (2007). Overactive bladder in Vesicovaginal Reflux Austin, P.F., Homsy, Y.L., Masel, J.L., children. Part I: Pathophysiology. (Vaginal Reflux Voiding, Cain, M.P., Casale, A.J., & Rink, R.C. Journal of Urology, 178(3), 761-768. (1999). Alpha-adrenergic blockade Hellström, A.L., Hanson, E., Hansson, S., Vaginal Entrapment) in children with neuropathic and Hjälmås, K., & Jodal, U. (1990). Proper toileting position nonneuropathic voiding dysfunc- Micturition habits and incontinence treats vesicovaginal reflux. Chil- tion. Journal of Urology, 162(3), in 7-year-old Swedish school dren should be instructed to sit 1064-1067. entrants. European Journal of Bloom, D.A., Seeley, W.W., Ritchey, M.I., Paediatrics, 149(6), 434-437. upright, all the way back on the & McGuire, E.J. (1993). Toilet habits Hellerstein, S., & Linebarger, J.S. (2003). toilet with their back against the and continence in children: An Voiding dysfunction in pediatric back of the toilet bowl and legs opportunity sampling in search of patients. Clinical Pediatrics, 42(1), apart. normal parameters. Journal of 43-49. Urology, 149(5), 1087-1090. Hjälmås, K., Hellström, A.L., Mogren, K., Bower, W.F., Moore, K.H., Shepherd, R.B., Läckgren, G., & Stenberg, A. (2001). Primary Bladder Neck & Adams, R.D. (1996). The epidemi- The overactive bladder in children: Dysfunction ology of childhood enuresis in A potential future indication for Primary bladder neck dys- Australia. British Journal of Urology, tolterodine. British Journal of function is typically identified in 78(4), 602-606. Urology International, 87(6), 569- Cain, M.P., Wu, S.D., Austin, P.F., 574. young adult males with lower Herndon, C.D., & Rink, R.C. (2003). Hoebeke, P., De Caestecker, K., Vande urinary tract symptoms (LUTS) Alpha-blocker therapy for children Walle, K., Dehoorne, J., Raes, A., and is managed with alpha- with dysfunctional voiding and uri- Verleyen, P., & Van Laecke E. (2006). adrenergic antagonists medica- nary retention. Journal of Urology, The effect of botulinum-A toxin in 170(4), 1514-1517. tion. Alpha-adrenergic antago- incontinent children with therapy Chandra, M., Saharia, R., Shi, Q., & Hill, resistant overactive detrusor. Journal nists are not currently approved V. (2002). Giggle incontinence in of Urology, 176(1), 328-330. for use in children with voiding children: A manifestation of detru- Hoebeke, P., Van Laecke, E., Van Camp, dysfunction. However, small sor instability. Journal of Urology, C., Raes, A., & Van de Walle, J. studies have demonstrated their 168(5), 2184-2187. (2001). One thousand video-urody- Committee on Quality Improvement, namic studies in children with non- efficacy in mixed populations of Subcommittee on Urinary Tract neurogenic bladder sphincter dys- children with voiding dysfunc- Infection. (1999). Practice parame- function. British Journal of Urology tion (Austin et al., 1999; Cain et ter: The diagnosis, treatment, and International, 87(6), 575-580. al., 2003). evaluation of the initial urinary tract Humphreys, M.R., Vandersteen, D.R., infection in febrile infants and Slezak, J.M., Hollatz, P., Smith C.A., young children. Pediatrics, 103, 849. Smith, J.E., et al. (2006). Preliminary CONCLUSION Conway, P.H., Cnaan, A., Zaoutis, T., results of sacral neuromodulation in Voiding dysfunction and UI Henry, B.V., Grundmeier, R.W., & 23 children. Journal of Urology, in children is common. Both are Keren, R. (2007). Recurrent urinary 176(5), 2227-2231. associated with significant ef- tract infections in children. The Kajiwara, M., Inoue, K., Usui, A., Journal of the American Medical Kurihara, M., & Usui, T. (2004). The fects on quality of life and comor- Association, 298(2), 179-186. micturition habits and prevalence of bidities, including constipation Crimmins, C.R., Rathbun, S.R., & daytime urinary incontinence in and UTIs. A careful history, Husmann, D.A. (2003). Management Japanese primary school children. physical examination, and limit- of urinary incontinence and noctur- Journal of Urology, 171(1):403-407. nal enuresis in attention-deficit ed laboratory evaluation is useful Koff, S.A., Wagner, T.T., & Jayanthi, V.R. hyperactivity disorder. Journal of (1998) The relationship among dys- in determining the etiology of Urology, 170(4), 1347-1350. functional elimination syndromes, daytime UI. Behavioral therapy Duel, B.P., Steinberg-Epstein, R., Hill, M., primary vesicoureteral reflux and is important in all forms of func- & Lerner, M. (2003). A survey of urinary tract infections in children. tional incontinence. Medical voiding dysfunction in children The Journal of Urology, 160, 1019- with attention deficit-hyperactivity 1022. therapy varies with the etiology. disorder. Journal of Urology, 170(4), Lettgen, B., von Gontard, A., Olbing, H., Rarely, minimally invasive and 1521-1534. Heiken-Löwenau C., Gaebel, E., & surgical alternatives are needed Ellsworth, P.I., Merguerian, P.A., & Schmitz, I. (2002). Urge inconti- for refractory cases. Constipation Copening, M.E. (1995). Sexual nence and voiding postponement in abuse: Another causative factor in and UTIs are often seen in chil- children: Somatic and psychosocial dysfunctional voiding. Journal of factors. Acta Pediatrica, 91(9), 978- dren with voiding dysfunction, Urology, 153(3), 773-776. 984. and these conditions must also Fitzgerald, M.P., Brown, J.S., Wassel, Loening-Baucke, V. (1997). Urinary be evaluated and treated. F.Y.R., & Brubaker, L. (2006). incontinence and urinary tract infec- Behavioral therapy is important Childhood urinary symptoms pre- tion and their resolution with treat- dict adult overactive bladder symp- ment of chronic constipation of in the treatment of both voiding toms. Journal of Urology, 175, 989- childhood. Pediatrics, 100(2), 228- and bowel dysfunction. Addi- 993. 232. tional therapies for voiding dys- continued on page 283

UROLOGIC NURSING / August 2008 / Volume 28 Number 4 257 Pediatric Voiding is associated with reduced perfusion Sher, P., & Reinberg, Y. (1996). Successful of the . British Journal treatment of giggle incontinence with Dysfunction: Current of Urology, 99(4), 831-835. methylphenidate. Journal of Urology, Evaluation and Management Myers, D.L., & Sung, V.W. (2006). Interstim: 156(2), 656-658. continued from page 257 An implantable device for implacable Sureshkumar, P., Bower, W., Craig, J.C., & urinary symptoms. OBG Manage- Knight, J.F. (2003). Treatment of day- Lopez, P., Miguelez, C., Caffarati, J., ment, 18(10). time urinary incontinence in chil- Estornell, F., & Anguera, A. (2003). Nørgaard, J.P., van Gool, J.D., Hjälmås, K., dren: A systematic review of random- Trospium chloride for the treatment Djurhuus, J.C., & Hellström, A.L. ized controlled trials. Journal of of detrusor instability in children. (1998). Standardization and defini- Urology, 170(1), 196-200. Journal of Urology, 170(5), 1978-81. tions in lower urinary tract dysfunc- Sureshkumar, P., Craig, J., Roy, L.P., & MacKeith, R.C. (1959). Micturition tion in children. International Knight, J.F. (2000). Daytime urinary induced by giggling? Cataplexy. Children’s Continence Society. British incontinence in primary school chil- Archives of Diseases of Childhood, Journal of Urology, 81(Suppl 3), 1-16. dren: A population-based survey. 34, 358. Palmer, L.S., Zebold, K., Firlit, C.F., & Kaplan, Journal of Pediatrics, 137(6), 814-818. McKenna, P.H., Herndon, C.D., Connery, S., W.E. (1997) Complications of intravesi- Warne, S.A., Godley, M.L., & Wilcox, D.T. & Ferrer, F.A. (1999). Pelvic floor mus- cal oxybutynin chloride therapy in the (2004). Surgical reconstruction of cle retraining in pediatric voiding pediatric myelomeningocele popula- cloacal malformations can alter blad- dysfunction using interactive com- tion. The Journal of Urology, 157(2), der function: A comparative study puter games. Journal of Urology, 638-640. with anorectal anomalies. Journal of 162(3), 1056-1063. Raes, A., Hoebeke, P., Segaert, I., Van Urology, 172(6), 2377-2381. Minassian, V.A., Lovatsis, D., Pascali, D., Laecke, E., Dehoorne, J., & Vande Williams, D.I. (1984). Giggle incontinence. Alarab M., & Drutz H.P. (2006). Effect Walle, J. (2004). Retrospective analy- Acta Urologica Belgica, 52(2), 151- of childhood dysfunctional voiding sis of efficacy and tolerability of 153. on urinary incontinence in adult tolterodine in children with overac- women. Obstetrics and Gynecology, tive bladder. European Urology, 45(2), Additional Reading 107(6), 1247-1251. 240-244. Järvelin, M.R., Vikeväinen-Tervonen, L., Mitterberger, M., Pallwein, L., Gradl, Restorick, J.M., & Mundy, A.R. (1989). The Moilanen, I., & Huttunen, N.P. (1988). J., Frauscher, F., Neuwirt, H., density of cholinergic and alpha and Enuresis in seven-year-old children. Leunhartsberger, N., et al. (2007). beta adrenergic receptors in the nor- Acta Pediatrica Scandinavia, 77(1), Persistent detrusor over activity after mal and hyper-reflexic human destru- 148-153. transurethral resection of the prostate sor. British Journal of Medicine, 63, 32.

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