RACP

Office NephrologyOffice Nephrology

Chair: Paul RoyChair: Paul Roy

RACP

UTI & Dysfunctional Voiding DisordersUTI & Dysfunctional Voiding Disorders

Steven McTaggart

Chair: Paul RoyChair: Paul Roy

Voiding Disorders in Children

Dr Steven McTaggart

Queensland Child & Adolescent Renal Service

Royal Children’s and Mater Children’s Hospitals

Brisbane.

•Children rated wetting themselves at school as the third most catastrophic event behind losing a parent and going blind.• Ollendick et al, Behav Res Therapy, 1989.

Outline• Definitions• Classification• Pathogenesis• Evaluation

– History– Physical examination– Investigations

• Overview of Specific Disorders

Definitions

• International Children’s Continence Society (1997)

• Enuresis– Normal voiding that occurs at an inappropriate or

socially-unacceptable time or place– nocturnal or diurnal– diurnal enuresis vs dysfunctional voiding

• neuropathic & nonneuropathic

• Incontinence– Involuntary loss of urine, objectively demonstrable, and

constituting a social or hygienic problem

Classification - Voiding Disorders

• Minor– Extreme daytime urinary frequency syndrome– Stress/giggle incontinence– Postvoid dribbling

• Moderate – Staccato/fractionated voiding Lazy Bladder syndrome

(Dysfunctional voiding)– Urge syndrome (Overactive bladder/Detrusor instability/Unstable

bladder)

• Major– Hinman syndrome (non-neurogenic, neurogenic bladder)– Ochoa syndrome (Urofacial syndrome)– Myogenic detrusor failure

Pathogenesis of Bladder Dysfunction

• Neonate - bladder emptying via sacral spinal cord reflex• ~ 2 yr age develop conscious sensation of bladder fullness spinal

reflex gradually modified and inhibited by pontine micturition centre in brain stem

• Between 2-4 years child develops ability to control voiding - conscious voiding requires relaxation of the external sphincter just prior to detrusor contraction

• Balance between “inhibiting voiding” and “initiating voiding” not fully mastered until ~ 4yrs age

• Note that ethnic,cultural,economic and individual family differences exist in relation to toilet training and the perception that daytime incontinence is abnormal

Pathogenesis of Bladder Dysfunction

• “Bad” bladder behaviours

• Adoption of holding manoeuvres to suppress desire to void

– - leads to overactive detrusor with uninhibited bladder contractions

• develop volitional control over contraction of the external sphincter - external sphincter is used as ‘on-off’ switch for bladder

• - difficulty relaxing sphincter when attempting to void voluntarily (detrusor sphincter discoordination)

–

Pathophysiology of Dysfunctional Voiding

C e ntra l fa ilure to inhib it b la d d e r c o ntra c tio ns

Ho ld ing m a no e uvre s

Dissip a tio n o f d e truso r c o ntra c tio n

Inc o m p le te re la xa tio n o r o ve ra c tivity o f p e lvic flo o r m usc le s d uring m ic turitio n

De truso r-sp hinc te r d ysc o o rd ina tio n

Func tio na l b la d d e r o utflo w o b struc tio n

Sta q c c a to vo id ing

Fra c tio na te d vo id ing

La zy Bla d d e r synd ro m e

Inc o ntine nc e

Se nsa tio n o f Urg e nc y

Urg e Synd ro m e

De truso r C o ntra c tio n d uring Bla d d e r Filling

Pe lvic flo o r use d a s “e m e rg e nc y b ra ke ”

+

Bladder Dysfunction - Associated Problems

VUR

UTI

Dysfunc tio na l vo id ing

“M ilk-b a c k” o f infe c te d urineEffe c ts o n lo c a l d e fe nc e m e c ha nism

sInc re a se d Po st-vo id re sid ua l

C ha ng e in b la d d e r se nsa tio n

Evaluation - History

• Current symptoms and signs– voiding pattern - stream/volume/frequency (diary)

– dysuria/frequency/urgency

– holding manoeuvres

– perineal hygiene - vulvovaginitis/balanitis

– UTI’s

– constipation

• Specific problems in infancy• Age and pattern of toilet training

– primary vs secondary

– longest dry periods

• Family history of urological problems• Social history - think about CSA

Voiding Diary

Holding Maneuvers

Evaluation - Physical Exam

• Exclude structural lesions– Abdominal examination– Genital examination

• labial adhesions/meatal stenosis

• bifid clitoris

• Exclude occult neurological disorders– examine back for signs of occult spina bifida– DTR’s lower limbs– gait– anal wink

Ectopic Ureter

Evaluation - Investigations

• Urinalysis - dipstick, M/C/S, (urine osmolality)• Ultrasound (IVP if suspect ectopic ureter)

– estimate functional bladder capacity & residual

• MCU if abnormal USS• Spinal Imaging• Urodynamics

“Spinning top” urethra

Hinman Syndrome

Evaluation - Role of Spinal Imaging

• Wraige E & Borzyskowski M, Arch Dis Child, 2002• retrospective study - 48 children with voiding dysfunction • closed spina bifida present in 5 patients - only 1 had no cutaneous,

neuro-orthopaedic or lumbosacral spine abnormalities.

• Ritchey et al,J Urol 1994• 127 children - 17 (38%) bony spina bifida occulta• 10/48 underwent MRI - 1 had lipoma requiring resection

• Recommendations for Screening– neurological /neuro-orthopaedic abnormality– secondary enuresis or deterioration in primary enuresis– significant associated bowel abnormality– ?urodynamic study suggesting neurogenic bladder– ?failure to respond to conventional treatment

Evaluation - Urodynamic Studies

• Not required for majority of children• Indicated if;

– evidence of/at risk of upper tract deterioration• hydroureteronephrosis• high grade VUR• recurrent episodes of pyelonephritis

– suspicion or evidence of neurological abnormality

– significant daytime enuresis that fails to respond to conventional treatment

– (unexplained secondary enuresis - cystoscopy is preferable)

UrgeSyndrome

Staccato Voiding ‘Lazy Bladder’

General Principles of Treatment

VUR

UTI

Dysfunc tio na l vo id ing

“M ilk-b a c k” o f infe c te d urineEffe c ts o n lo c a l d e fe nc e m e c ha nism

sInc re a se d Po st-vo id re sid ua l

C ha ng e in b la d d e r se nsa tio n

C o nstip a tio n

General Principles of Treatment

• Treat constipation• Ensure adequate fluid intake• Bladder retraining

– Timed voiding schedule

– Double voiding if large post-void residual

– Physiotherapy - pelvic floor retraining

– Biofeedback

• Medications– Antibiotic prophylaxis if UTI

– Anticholinergics eg propantheline, oxybutinin

Minor Voiding Disorders

• Extreme Daytime Urinary Frequency– Sudden onset daytime urinary urgency/frequency

– No dysuria or incontinence

– Exclude idiopathic hypercalciuria

– Reassurance

• Stress/Giggle Incontinence– Mostly self-limiting

– Trial anticholinergics if troublesome

• Postvoid Dribbling (Vaginal voiding)– Related to posture during voiding

– Toilet retraining

Lazy Bladder Syndrome

• Characterised by;– Large capacity, hypotonic bladder

– Infrequent voiding

– Poor urinary stream

– Abdominal straining to void

• Incontinence between voiding due to overflow• Decreased sensation of bladder fullness• Incomplete emptying predisposes to UTI• Mx - Timed voiding / Double voiding

• - Treat constipation if present • - Antibiotics for UTI

• - Physio / Biofeedback

Urge Syndrome

• Most common voiding dysfunction• Peak ages 5-7 years• Characterised by;

– urgency, frequency

– holding manoeuvres eg squatting

– usually normal bladder emptying

• UTI’s and constipation common• Mx - Treat constipation

• - Increase fluid intake• - Timed voiding• - Anticholinergics

Urge Syndrome Lazy Bladder Diurnal Enuresis

Other names Detrusor instability Dysfunctional voiding

Pathogenesis Uninhibited bladdercontractions during filling

Bladder-sphincterdiscoordination

Unclear

Symptoms ‘Minor’ wettingUrgencyFrequencyHolding manoeuvres

‘Minor’ wettingSometimes urgency

Uncontrolled voidingNo/deny urgeComplete bladder emptying

Voiding Pattern Small volumeFrequent voiding

Large volumesInfrequent voidingLarge post-void residual

Normal voiding

AssociatedProblems

UTIConstipation

UTIConstipation

Behavioural problemsEncoporesis(UTI)

Management Treat constipationIncrease fluid intakeTimed voidingAnticholinergics

Treat constipationTimed voidingDouble voiding

Psychosocial assessmentBehavioural program

Voiding Disorders - Summary

Long Term Outcome

• Kuh et al, 1999.– Longitudinal study of 1333 women with urinary

incontinence (mean age 48 years)– 50% reported stress incontinence– 22% reported urge incontinence– 8% had severe symptoms– women who had daytime wetting as a child were

more likely to have severe symptoms

The End