AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Background

Voiding dysfunction is a common problem in children and accounts for as many as 40% of pediatric urology clinic visits. The challenge for the clinician is to differentiate a pathologic pattern of urgency or incontinence due to an underlying urologic abnormality from benign conditions related to incomplete or abnormal toilet training. Normal voiding frequency in children (after attainment of bladder control or age 5 y) is defined as 4-7 voids per day. Voiding symptoms (eg, urgency, frequency, incontinence) reflect alterations in urinary bladder function. The pathogenesis of voiding disorders is best understood and managed when considered as deviations from the normal voiding cycle consisting of bladder filling with urine storage followed by bladder emptying with voiding.

Infants regularly void by detrusor (bladder muscle) contraction as much as hourly, with small voided volumes and incomplete bladder emptying. With increasing age, bladder function matures and bladder capacity increases. Children aged 2-5 years have increased awareness of bladder fullness and develop the ability to volitionally void or inhibit voiding until it is socially acceptable. During this period, acquisition of cortical control of micturition occurs. Many forms of voiding dysfunction can be thought of as a delay in the acquisition of daytime urinary control, which typically occurs by age 4 years.

Daytime wetting is considered a problem in developmentally normal children aged 4 years or older who are wet several days each week and in previously continent children who develop daytime wetting.

Persistent daytime urinary incontinence may have an underlying neurologic, anatomic, infectious, or functional basis. This article focuses on daytime voiding disorders in children without neurologic, anatomic, obstructive, or infectious abnormalities of the urinary tract; however, any child with evidence of neurological dysfunction (eg, cutaneous signs, physical examination findings, severely refractory voiding dysfunction, urodynamic evidence of neurogenic bladder) should be further evaluated for occult neurologic lesions. Isolated nocturnal enuresis, which may be considered a form of voiding disorder, is considered elsewhere and is not reviewed here.

Pathophysiology

The micturition cycle involves 2 discrete processes: (1) bladder filling and storage of urine and (2) bladder emptying with voiding. These functions are cyclic in nature.

During the filling phase of micturition, regulatory influence of the sympathetic nervous system allows the bladder to expand at low pressure. Urine storage is a coordinated response of the sympathetic-mediated inhibition of detrusor contractile activity. The primary neurotransmitter for sympathetic activity is norepinephrine.

Expulsion of urine normally occurs as a result of simultaneous voiding contraction of the detrusor muscle and relaxation of the bladder outlet (urethra, bladder neck, and pelvic floor muscles). This is mediated by the parasympathetic nervous system, in which the primary neurotransmitter is acetylcholine. During bladder filling, afferent impulses are transmitted to sensory neurons in the dorsal root ganglia of sacral spinal segments 2-4 and convey information to the brainstem. Nerve impulses from the brainstem during bladder filling inhibit parasympathetic outflow from the sacral spinal micturition center. During the voiding phase, inhibition of the sacral parasympathetic outflow is removed, and detrusor contraction occurs. Somatic impulses traveling along the pudendal nerve act to relax the muscle of the external sphincter. The result is expulsion of urine with minimal outlet resistance.

CNS control over the lower urinary tract coordinates the micturition cycle. Normal development is characterized by increasing awareness of bladder distension and acquisition of the ability to inhibit voiding. Voiding symptoms in the neurologically and anatomically intact child, who has neither a urinary tract infection (UTI) nor local urethral irritation, is a result of functional disturbance of the normal micturition cycle.

Frequency

United States

A study of children aged 5-9 years (n = 583) showed that urinary urgency and pelvic-tightening maneuvers to postpone voiding and prevent leakage were the most common voiding problems.¹ Urge incontinence was reported in 7% of girls and in 3% of boys.

Daytime wetting has been reported to decrease with age. The prevalence of daytime wetting with a frequency of at least once every 2 weeks was 10% in children aged 5-6 years, 5% in children aged 6-12 years, and 4% in children aged 12-18 years.

International

Large studies from Sweden have addressed the frequency of voiding disorders in school-aged children. A Swedish study of 7-year-old students (n = 3556) showed that 21% of girls and 18% of boys had moderate to severe urinary urgency.² Daytime urinary incontinence occurred at least once weekly in 3.1% of girls and 2.1% of boys.

Mortality/Morbidity

A child with a voiding disorder may have few symptoms or frequent urinary tract problems. Children with functional voiding disorders may have ongoing urge incontinence, urinary dribbling, or recurrent UTIs. These children may experience severe social and emotional problems because of the voiding disorder.

A few children with a functional voiding disorder (ie, nonneurogenic neurogenic bladder [Hinman-Allen syndrome]), have marked dysfunctional voiding and may incur significant renal damage.

Race

No known studies have shown the incidence of voiding disorders related to race.

Sex

Studies on the prevalence of voiding disorders in school children indicate that daytime urinary incontinence occurs more frequently in girls (7%) than in boys (3%).

Age

A functional voiding disorder in a neurologically and anatomically healthy child is not usually recognized before the acquisition of daytime urinary control.

Many children have a transient period of urinary urgency, occasionally with wetting accidents, when daytime continence is first being achieved. Most of these children develop normal urinary control in a relatively short period; however, some children may have persistence of urinary urgency and wetting.

Other children may have a normal voiding pattern until a UTI or an emotionally traumatic event triggers the onset of voiding symptoms.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

History

• Voiding symptoms (eg, urgency, frequency, incontinence) may be transient, intermittent, or persistent. The presence of incontinence (uncontrollable leakage of urine) is only applicable to children aged 5 years or older. Infrequent voiding, overflow incontinence, or straining to urinate are worrisome symptoms.
• Transient voiding symptoms are commonly encountered as a result of nonspecific urethritis or periurethral irritation due to vaginitis, or a UTI. Symptoms may occur without a recognized explanation.
• Symptoms caused by local factors usually clear after the irritant is removed and the local inflammation subsides. Local factors include the following:
• • Detergents in bubble bath or shampoo, which may remove protective secretions from the urethral mucosa
  • Mechanical and chemical irritation from urine-soaked underclothes
  • Local irritation due to tight undergarments
• Causes of voiding dysfunction include uninhibited detrusor contractions (overactive bladder [OAB]), dysfunction of the pelvic floor musculature (dysfunctional voiding), or decreased force of detrusor contractions (underactive bladder).
• OAB, which is also referred to as detrusor instability, urge syndrome, and urge incontinence, is the result of overactive detrusor contractions during the filling phase of micturition.
• • During voiding, normal bladder emptying occurs. This pattern of uninhibited contractions in a child with neurogenic bladder, such as occurs with myelodysplasia, is called detrusor hyperreflexia.
  • Uninhibited detrusor contractions are thought to result from a lack of inhibitory cerebral control over detrusor contractions during bladder filling. Theories on the cause of OAB have included maturation delay, prolongation of infantile bladder behavior, or abnormality of acquired toilet training habits.
  • The hallmark symptom of OAB in children is urgency, and children with this symptom can be clinically diagnosed based on the definition by the International Children’s Continence Society.³ A careful history usually reveals that the child has had ongoing urinary urgency with various posturing maneuvers in an attempt to prevent incontinence. The children are commonly evaluated because of daytime urinary incontinence or UTI.
  • Children with OAB may have a history of holding maneuvers such as standing on tiptoes, crossing of the legs, or squatting with the heel pressed into the perineum.
  • The problem may have been present since daytime urinary control began developing or can develop in a child who previously had a normal voiding pattern. The appearance of detrusor instability in a child who previously had daytime urinary control may occur after a UTI or may appear with no apparent triggering event.
  • OAB can occur in children with recurrent UTIs and is a risk factor for UTI. This voiding disorder may contribute to persistence of vesicoureteral reflux (VUR) and to the recurrence of VUR after ureteral reimplantation.
  • When chronic constipation has been present in a child with a voiding disorder, it may be the primary cause of bladder dysfunction.
• OAB and constipation are so frequently associated that the term “dysfunctional elimination syndrome” has been introduced in the literature. 
• • The effects of constipation on bladder function may be related to the direct effect of retained fecal material distending the rectosigmoid colon or due to shared neural input.
• • Constipation can be the primary or contributing cause of a voiding disorder; therefore, constipation should always be considered in the evaluation of a child with voiding symptoms.
• • Many children and families are reluctant to discuss stooling history. Often, neither the child nor the parent appears to have accurate information about stooling frequency or character.
• • Indicators of constipation include the following:
  • • Infrequent passage of stools
    • Small hard stools or elongated wide-bore stools
    • Encopresis
    • Palpable stool on abdominal examination
    • Soiling in the underwear (often misinterpreted as being due to improper or careless wiping)
    • Large quantities of stool in the colon, especially the rectosigmoid area on abdominal radiography
• Giggle incontinence is the occurrence of involuntary complete bladder evacuation induced by laughter and typically appears in children aged 5-7 years.
• • Giggle incontinence can persist throughout the school years but usually improves or disappears with age. The voiding pattern is otherwise normal.
  • Episodes of incontinence may occur with giggling in some children; in others, they are induced by only vigorous laughter.
  • The etiology is unknown. Giggle incontinence is not a form of stress incontinence, nor is it due to weakness of the sphincter.
  • The authors of one study found a high incidence of daytime voiding symptoms in patients in whom they diagnosed giggle incontinence.⁴ The authors concluded that laughter induced unstable detrusor contractions in children susceptible to detrusor instability.
• Other factors may result in daytime wetting.
• • Many children aged 3-5 years tend to delay urination because of intense concentration on playing or watching television or using electronic toys. As a result, they occasionally have damp or soaked clothing. If the voiding pattern is otherwise normal, this pattern of voiding dysfunction usually subsides with increase effort towards scheduled voiding.
• • Vaginal reflux of urine from voiding in a knees-closed position can cause dampness when the child assumes an upright posture after voiding or postvoid dribbling.
  • Labial adhesions of the labia minora may cause daytime wetting due to the pooling of urine in the vagina. Treatment of the labial adhesions eliminates this cause of urinary incontinence.
  • If incontinence is persistent and continually ongoing, an ectopic ureter should be suspected and prompts evaluation by a urologist, who can often make the diagnosis based on renal ultrasound, voiding cystourethrography (VCUG), and physical examination findings.
  • The diagnosis of a neurogenic bladder is usually evident from the patient's history; occasionally, occult neuropathic bladder dysfunction can be discovered based on evaluation for urinary symptoms.
  • Daytime wetting in a previously continent child prompts the clinician to consider the possibility of sexual abuse or other trauma.
• Dysfunctional voiding involves failure to relax the urethra and pelvic floor muscles with voiding and is caused by overactivity of the urethral sphincter or pelvic floor muscles during the voiding phase of the micturition cycle. This pattern of voiding incoordination in a child with a neurogenic bladder is called detrusor sphincter dyssynergia.
• • Although the etiology is unknown, it is thought to reflect a deviation in the normal development of urinary control. As daytime urinary control is achieved, many children have a transitional phase in which pelvic withholding maneuvers are used to prevent incontinence. Most children then develop a pattern of coordinated voiding that make it unnecessary to contract the external sphincter to prevent incontinence. Few children who have a delay in establishing cerebral control over detrusor contractions continue to use pelvic-tightening maneuvers; over time, these appear to become involuntary. Others have suggested that this pattern of dysfunction of the pelvic floor muscles is a consequence of overtraining of the urinary bladder.
  • Dysfunctional voiding symptoms vary from mild daytime frequency and postvoid dribbling to daytime and nighttime wetting, urgency, urge incontinence, pelvic holding maneuvers, and UTIs. In the most severe form, children with dysfunctional voiding resemble those with neurogenic bladder or anatomic bladder outlet obstruction.
  • Children with this condition can have increased intravesical pressure upon voiding, incomplete bladder emptying, UTIs, persistent VUR, dilatation of the upper tract (hydronephrosis), or, rarely, renal damage.
  • Evaluation of patients with suspected dysfunctional voiding should be performed by a urologist, and may include voiding cystourethrography, urinary tract ultrasonography, urodynamic studies, and, in some instances, MRI of the lumbosacral spine to rule out a neurologic etiology.
• Underactive bladder syndrome describes children who void infrequently.
• • Infrequent voiding is diagnosed if a child voids 3 or fewer times in 24 hours or if a child does not void for 12 hours. These children may also use abdominal straining to void.
  • The pattern of infrequent voiding is clinically important. The detrusor muscle may be hypocontractile, and voiding may be accomplished by increased intra-abdominal pressure (abdominal straining) as the driving force to expel urine. The diagnosis may be confirmed by urodynamic study. 
  • This voiding pattern may be a variant of normal. However, if identified, the voiding pattern should be treated with behavioral modification of the child's voiding regimen.

Physical

No notable findings are noted upon physical examination of a child with voiding dysfunction; however, a thorough examination should be performed to evaluate for other sources of voiding symptoms.

• Perform a careful physical examination to rule out an abnormality of the lumbosacral area that suggests occult spinal dysraphism, which includes a sacral dimple or tuft of hair, dermal vascular malformations, a small lipomeningocele, or absence of the gluteal cleft with flattened buttocks.
• The neurologic examination should include assessment of motor strength, deep tendon reflexes, perineal sensation, gait, and coordination.
• Carefully examine the genitalia to be certain they are normal. Look for labial adhesions in girls and meatal stenosis in boys. In girls, the genitalia should be examined evaluate for sexual abuse, as one study reported that 6% of patients evaluated for voiding dysfunction had a history of sexual abuse (89% of that group was female).⁵ Rashes in the perineal or genital areas may indicate fungal infections that result from chronic wetness.

Causes

• Causes of voiding dysfunction include uninhibited detrusor contractions (OAB), dysfunction of the pelvic floor musculature (dysfunctional voiding), or decreased force of detrusor contractions (underactive bladder).

DIFFERENTIALS

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Other Problems to be Considered

Urethritis

WORKUP

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Lab Studies

• Urinalysis and quantitative urinary culture should be performed to evaluate for UTI. On urinalysis, the specific gravity (concentration) of the urine is noted as well as any evidence of underlying voiding problems based on the presence of hematuria, proteinuria, or glucosuria.

Imaging Studies

• Imaging is typically not performed. Renal or bladder ultrasonography, VCUG, radiography of the lumbosacral spine, or MRI of the lumbosacral spine may be required in select cases.
• If dribbling and ongoing wetting have been present lifelong, evaluation should be performed for an ectopic ureter in the form of an intravenous urography.

Procedures

• Special equipment for uroflow, bladder ultrasound, and urodynamics are typically available only at urologic facilities.
• Noninvasive uroflowmetry and postvoid residual urine quantification (bladder ultrasonography or scanning) are useful, noninvasive tools in evaluating children for lower urinary tract dysfunction.
• Urodynamic testing is not usually required; however, in select cases, urodynamic studies should be performed to detect uninhibited detrusor contractions, dysfunction of the pelvic floor muscles, or a hypotonic bladder.

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Medical Care

• OAB (detrusor instability)
• • The goal is to foster development of cerebral inhibition of detrusor contractions during bladder filling so that urgency and urge incontinence do not occur. No known medication or procedure has been shown to accomplish this; however, certain interventions appear to help.
• • A voiding retraining program is an essential component of management. In most instances, the voiding retraining program should be tried for 1-2 months before an anticholinergic medication is introduced. One study reported as many as 76% of children with daytime incontinence never had an adequate trial of preliminary nonpharmacologic measures. 
  • One study evaluated the response to treatment in 63 children with daytime incontinence initially treated with nonanticholinergic methods; by the second visit, 6% of patients were dry, 38% of patients showed significant improvement, and 37% of patients showed slight improvement.⁶
  • Guidelines for a voiding retraining program include the following:
  • • Children should have a footstool or other solid surface placed in front of the commode so that their feet are on a solid surface. The child should remove his or her underpants or lower them to the ankles to permit relaxed separation of the thighs. During voiding, the child should be comfortable and relaxed and not rushed to void (eg, during a television commercial).
    • Boys should be instructed to free their penis before voiding. The zipper or buttons should be completely opened. If the underwear constricts the penis, this should be corrected. Boys should be relaxed and take sufficient time to completely empty the bladder.
    • Successful management requires ongoing support, instruction, and education. Children should be taught to understand that normal urination is the result of relaxing the sphincters and permitting the bladder muscle to expel the urine, not a matter of forced voiding using the abdominal muscles. 
    • A timed voiding schedule should be used when the child is awake, even in those with urinary frequency. Children should be encouraged to void before a sense of urgency is present in order to develop a regular voiding pattern. Time voiding is instituted with bladder evacuation every 2-3 hours “by the clock” when the child is awake. This is an essential component of bladder retraining. Writing letters to a school nurse, teacher, or principal to carry out this program is necessary and of value.
    • Introduce calendars to keep records of voiding patterns and bowel movements. The latter is important, even in the child with no history of constipation, particularly if an anticholinergic medication is introduced.
  • Prophylactic antibacterial therapy should be used in children with recurrent UTIs and in those with VUR.
  • Anticholinergic medications (see Medication) are frequently helpful in children who do not respond to conservative measures. However, these medications are meant to help the child develop a normal voiding pattern and are not long-term solutions. Ultimately, the child must develop the ability to use cerebral mechanisms to inhibit detrusor contractions.
• Constipation and detrusor instability
• • When constipation is diagnosed in a child with voiding dysfunction, treating the constipation is important to determine if it is the cause of the bladder symptoms. In one study of the relationship between constipation and incontinence, resolution of constipation was associated with 89% resolution of concomitant urinary incontinence.⁷
  • Treatment of chronic constipation includes a high-fiber diet, sometimes with the addition of laxative medication. One option is treatment with Miralax (see  Medication), which is prepared by diluting the powder and administering it once a day or more frequently. This therapy has gained widespread use for constipation. One study of 46 children with urinary incontinence and constipation treated with Miralax found that 39% of patients became dry, 56% of patients had improvement in their wetting, and only 5% were unchanged.⁸
• Other sources of incontinence
• • Treatment results for giggle incontinence are difficult to assess because of the high rate of spontaneous resolution with maturity. Patients may need to accommodate the problem by trying to avoid situations that cause laughter when in public places. If incontinence frequently occurs, a trial of a timed voiding schedule with addition of an anticholinergic agent with may be warranted. One uncontrolled study of 7 children reported success with methylphenidate as the authors related the condition functionally to cataplexy.⁹
  • Wetting secondary to vaginal reflux may be resolved by teaching the child proper voiding technique. The child may void in a reverse sitting position on the commode, which causes the thighs to be abducted and the labia majora to separate. If this is unsuccessful, the child may assume an upright position over the commode immediately after voiding to empty the vagina.
  • Labial adhesions have been attributed to local inflammation and a hypoestrogenic state in a preadolescent child. Local irritation caused by aggressive cleansing may play a role. Recommended treatment consists of conservative observation, application of a topical estrogen cream to only the fused area, or physician lysis of adhesions. After the adhesions have separated, a bland petroleum jelly should be applied to the medial surfaces of the labia minora once daily for 1-2 months.
  • If no specific diagnostic etiology is found, management of persistent and otherwise asymptomatic daytime urinary incontinence is primarily supportive.
• Dysfunctional voiding (failure to relax the urethra and pelvic floor muscles while voiding)
• • Dysfunctional voiding is the most worrisome functional voiding disorder in children because, rarely, it can progress in a pattern similar to a neurogenic bladder or outlet obstruction. In the infrequent instances of severe bladder dysfunction the condition has been termed nonneurogenic neurogenic bladder (Hinman-Allen syndrome).
  • Treatment of this voiding disorder, which has been described as a disharmony between the detrusor and sphincters, consists of a voiding retraining program with emphasis on good voiding technique and suppressive antibacterial agents for those prone to UTIs.
  • When the upper urinary tract is normal, management should focus on the development of effective relaxed voiding using the interventions described for detrusor instability. Biofeedback training for carrying out Kegel exercises (pelvic floor relaxation and contraction) has been successful in many centers.
  • Anticholinergic medication is not useful to treat sphincter dysfunction.
• Underactive bladder syndrome
• • Children who void as infrequently as 2-3 times every 24 hours should be encouraged to undertake more frequent voiding to avoid potential problems at a later age. They are at risk for UTIs because prolonged bladder incubation of urine compromises the protective effect of regular bladder emptying, which clears bacteria that gain access to the bladder during voiding.
  • Urinary incontinence is usually due to overflow from a large hypotonic bladder. Those with persistent voiding symptoms or UTIs should undergo urodynamic evaluation. Children with large capacity hypotonic urinary bladders who are unwilling or unable to comply with an improved voiding schedule may benefit from clean intermittent catheterization.

Consultations

Reasons to obtain evaluation by a urologist include the following:

• Suspicion of neurologic or anatomic etiology
• Lack of familiarity or training in diagnosis and treatment of children with voiding dysfunction
• Symptoms not responsive to behavioral modification
• Constant continuous incontinence
• UTI
• VUR
• Suspected renal damage (elevated creatinine levels, hydronephrosis)

MEDICATION

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Pharmacologic therapy of voiding dysfunction in children usually centers on treating uninhibited detrusor contractions during filling and, at times, decreasing bladder outflow resistance. Most of the neurohumoral stimulus for bladder contraction is the stimulation of muscarinic-cholinergic receptor sites on bladder smooth muscle. Anticholinergic agents can depress uninhibited bladder contractions, but effects on normal contractions with subsequent incomplete bladder emptying  and retention must also be considered. In rare instances, bladder outlet resistance is increased because of stimulation of alpha1-adrenergic receptors in the bladder neck, and this effect may be decreased by the use of alpha1-adrenoreceptor blockers. 

• Oxybutynin is approved by the US Food and Drug Administration (FDA) for treatment of OAB in children and has traditionally been the treatment of choice.
• • Despite the prevalence and significance of pediatric daytime incontinence, few prospective randomized trials assessing treatments have been published. This problem was documented by a 2003 review of studies of pediatric incontinence that found only one randomized controlled study that evaluated currently used treatment; that study reported no benefit in the combination of biofeedback and oxybutynin.¹⁰
  • One of the larger studies of oxybutynin evaluated 144 children, two thirds of whom were treated with anticholinergic medication. Follow-up averaged 3.2 years.¹ The study reported symptom resolution or improvement in 91% of children with daytime urinary incontinence, and 56% of those with UTI stopped having infections.
  • In an attempt to define predictive factors that affect the continence outcome in children with daytime wetting, a study evaluated 81 children treated with oxybutynin for an average of 1.2 years; at the last visit while taking oxybutynin, 38% of patients were dry, 31% of patients were significantly improved, 24% of patients were slightly improved, and 7% of patients were unchanged in their symptoms.¹¹ The only variable significantly associated with improvement in daytime wetting with oxybutynin was the frequency of wetting episodes; those who presented with fewer wetting episodes were more likely to become dry.
• An extended-release formulation of oxybutynin (Ditropan XL) is taken once per day.
• • One study reviewed 27 children who were changed from immediate-release oxybutynin to extended-release.¹² All patients had persistent incontinence while taking regular oxybutynin. Of children with persistent wetting, 48% became dry or had significant improvement in the frequency of wetting by the next visit after changing to the extended-release formulation. Voided volume and bladder capacity were also improved.
  • Studies of oxybutynin extended-release reported fewer adverse effects.¹³

Drug Category: Anticholinergic agents

These drugs inhibit the binding of acetylcholine to the cholinergic receptor, thereby suppressing involuntary bladder contraction of any etiology. In addition, they increase the volume of the first involuntary bladder contraction, decrease the amplitude of the involuntary bladder contraction, and, possibly, increase bladder capacity.

Drug Category: Alpha1-adrenergic antagonists

These agents are used to decrease smooth muscle tone in the bladder outlet.

One study of doxazosin in dysfunctional voiding associated with urinary retention showed an 88% reduction in residual urine, whereas a placebo-controlled trial did not show an objective benefit.¹⁴

Drug Category: Laxatives

These agents are useful when treating constipation and detrusor instability.

FOLLOW-UP

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Further Outpatient Care

• Ongoing follow-up is usually needed to monitor progress.
• Parents and children should pay attention to maintenance of the recommended voiding interventions and to bowel function with regard to constipation.

Complications

• Persistence of daytime wetting may markedly disrupt the social lives of older children. Daytime wetting can negatively affect self-esteem and is a major stressor in school-age children. One study of 2000 children reported that wetting in school ranked behind only parental death and going blind as potential perceived stressful events.
• Skin irritation and rashes may result from chronic wetness. Children should be monitored for skin breakdown.
• Detrusor instability with pelvic withholding maneuvers may foster recurrent UTIs or persistence of VUR. One study reported recurrent UTIs were identified in as many as 60% of children with voiding dysfunction. In one study of children with VUR, as many as 43% had voiding dysfunction, and VUR has been identified on video-urodynamics in 16-20% of children with voiding dysfunction. The time to reflux resolution was 1.6 years longer in children with dysfunctional elimination syndrome in one study.
• In rare cases, this results in dilatation of the upper urinary tract (hydronephrosis) and kidney damage.

Prognosis

• The prognosis for complete or partial resolution of a functional voiding disorder is excellent for children with daytime urinary incontinence and detrusor instability. The spontaneous resolution rate has been estimated to be 14% per year.
• Children with voiding dysfunction appear to be more likely to have adult overactive bladder or voiding dysfunction. One study reported that childhood incontinence in girls was a risk factor for urge symptoms and severe incontinence as middle-aged women.¹⁵
• The prognosis is good for children with giggle incontinence, who tend to outgrow it during adolescence, and for those with underactive bladder syndrome, who respond to intervention.
• The prognosis is guarded for those few children with dysfunctional voiding whose condition does not respond to intervention.

Patient Education

• Patients and parents should be educated about voiding retraining.
• • This is the foundation of the treatment of children with functional voiding disorders.
  • Effective biofeedback training is especially helpful for management of dysfunctional voiding.
• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center and Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Constipation in Children, Bladder Control Problems, and Understanding Bladder Control Medications.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

1. Hellerstein S, Zguta AA. Outcome of overactive bladder in children. Clin Pediatr (Phila). Jul-Aug 2003;42(6):553-6. [Medline].
2. Hellstrom AL, Hanson E, Hansson S, Hjalmas K, Jodal U. Micturition habits and incontinence in 7-year-old Swedish school entrants. Eur J Pediatr. Mar 1990;149(6):434-7. [Medline].
3. Neveus T, von Gontard A, Hoebeke P, et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. J Urol. Jul 2006;176(1):314-24. [Medline].
4. Chandra M, Saharia R, Shi Q, et al. Giggle incontinence in children: a manifestation of detrusor instability. J Urol. Nov 2002;168(5):2184-7; discussion 2187. [Medline].
5. Ellsworth PI, Merguerian PA, Copening ME. Sexual abuse: another causative factor in dysfunctional voiding. J Urol. Mar 1995;153(3 Pt 1):773-6. [Medline].
6. Allen HA, Austin JC, Boyt MA, et al. Initial trial of timed voiding is warranted for all children with daytime incontinence. Urology. May 2007;69(5):962-5. [Medline].
7. Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics. Aug 1997;100(2 Pt 1):228-32. [Medline].
8. Erickson BA, Austin JC, Cooper CS, et al. Polyethylene glycol 3350 for constipation in children with dysfunctional elimination. J Urol. Oct 2003;170(4 Pt 2):1518-20. [Medline].
9. Sher PK, Reinberg Y. Successful treatment of giggle incontinence with methylphenidate. J Urol. Aug 1996;156(2 Pt 2):656-8. [Medline].
10. Sureshkumar P, Bower W, Craig JC, et al. Treatment of daytime urinary incontinence in children: a systematic review of randomized controlled trials. J Urol. Jul 2003;170(1):196-200; discussion 200. [Medline].
11. Van Arendonk KJ, Austin JC, Boyt MA, et al. Frequency of wetting is predictive of response to anticholinergic treatment in children with overactive bladder. Urology. May 2006;67(5):1049-53; discussion 1053-4. [Medline].
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Article Last Updated: Jun 24, 2008