SERIES Pediatric Voiding Dysfunction: Current Evaluation and Management Pamela Ellsworth Anthony Caldamone he prevalence of pedi- Voiding dysfunction and urinary incontinence 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 urinary urgency, and 23.8% Pediatrics, Division of Urology, Rhode as any involuntary leakage of had urinary frequency; 4.5% wet Island Hospital, Brown University/Hasbro urine 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 enuresis 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 overactive bladder 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