Diagnosis and Management of Bladder Dysfunction in Neurologically Normal Children

Abstract

Normal bladder and urethral sphincter development as well as neural/volitional control over bladder-sphincter function are essential steps for regular lower urinary tract function. These maturational sequences are clinically evident by the age of 5 years. However, in 17–22% of children, symptoms persist beyond that age, characterizing lower urinary tract dysfunction (LUTD). The clinical spectrum is wide and includes overactive bladder, voiding postponement, underactive bladder, infrequent voiding, extraordinary daytime only urinary frequency, vaginal reflux, bladder neck dysfunction, and giggle incontinence. LUTD may lead to vesicoureteral reflux and recurrent urinary tract infections, increasing the likelihood of renal scarring. LUTD is often associated with constipation and emotional/behavioral disorders such as anxiety, depression, aggressiveness, and social isolation, making diagnosis, and treatment imperative. Diagnosis of LUTD is essentially based on clinical history, investigation of bladder storage, voiding symptoms (urinary frequency, daytime incontinence, enuresis, urgency) and constipation. Dysfunctional Voiding Score System (DVSS) is a helpful tool. Physical examination focuses on the abdomen to investigate a distended bladder or palpable fecal mass, the lumbosacral spine, and reflex testing. Bladder diaries are important for recording urinary frequency and water balance, while uroflowmetry is used to assess voided volume, maximum flow, and curve patterns. Bladder ultrasonography to measure post-void residual urine volume and urodynamics are used as supplemental tests. Current first line treatment is urotherapy, a combination of behavioral measures to avoid postponing micturition, and a restricted diet for at least 2 months. Anticholinergics, β3 agonists and neuromodulation are alternative therapies to manage refractory overactive bladder. Cure rates, at around 40%, are considered satisfactory, with daytime symptoms improving in 32% of cases. Furthermore, children who are also constipated need treatment, preferentially with polyethylene glycol at doses of 1–1.5 g/kg in the 1st 3 days and 0.25–0.5 g/kg thereafter until the 2-month period of behavioral therapy is complete. If urotherapy fails in cases of dysfunctional voiding, the next step is biofeedback to teach the child how to relax the external urethral sphincter during micturition. Success rate is around 80%. Children with underactive bladder usually need a combination of clean intermittent catheterization, alpha-blockers, biofeedback and neuromodulation; however, cure rates are uncertain.

Is there a unique symptom in lower urinary tract dysfunction in children?

“…UF is the most commonly performed procedure to evaluate patients with LUTS in pediatric urological practice, as the test is non‐invasive and has been thought to be diagnostic for specific LUT conditions with different flow patterns 6‐8,16,17 . However, there are also studies reporting that the use of UF alone without an EMG may be insufficient in the evaluation of LUTD, as it may lead to misdiagnosis 10,18 .…”

“…It represents approximately 40% of patients presenting to the pediatric urology clinics 3,4 . There is currently no clear consensus regarding the diagnosis and management of children with LUTD, due to the subjectivity of the symptoms and the limitations of the commonly used tests, such as uroflowmetry (UF) 5‐7 …”

Voiding Disorders in Pediatrician’s Practice

“…Despite ongoing clinical trials therapy remains off label in children. 20,21 Voiding postponement-Urinary incontinence is due to overfilling of bladder. The child often performs holding maneuvers to prevent incontinence.…”

“…31 A summary of the urotherapy recommendations is presented in Table 3. 7,9,10,12,21,32 Summary Every pediatrician will encounter children with voiding disorders. The main role of the primary care physician is to isolate a group of patients who may have an organic cause of the disorder and as a result may require urgent diagnostics and pharmacological or surgical intervention.…”

An Allergic Risk Factor Analysis of Extraordinary Daytime Only Urinary Frequency in Children

“… 4 Children’s EDOUF is currently considered to be a benign self-limited disease that is usually spontaneously relieved within three to five months. 5 Children usually present with normal intelligence and good growth and development. 6 However, if the symptoms persist all year round, if the frequency of urination is serious (ie, sometimes occurring once every five minutes), or if, as occurs in rare cases, there are nocturia symptoms, the daily lives of the children and their parents are seriously affected.…”