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COL John Roscelli Pediatric Nephrology San Antonio Military Pediatric Center
Perspective
Incontinence is part of transitional phase from infantile to adult lower urinary tract function
Wetting disorders often considered necessary nuisance & tolerated until child lags behind peers Parental concerns about voiding are common & often supersede the child's anxiety
However, voiding dysfunction can be a sign of underlying pathophysiology that needs Rx to prevent Renal/Urologic damage
Agenda
How the Lower Urinary Tract Works Voiding Dysfunction in children with no organic pathology
Definition Presentation modes Evaluation Treatment
Problems with elimination in one usually associated with problems in the other Proper term is Elimination Dysfunction Syndrome
Function of Lower Urinary Tract STORAGE of adequate volumes of urine at low pressure & with no leakage EMPTYING that is
Voluntary Efficient Complete Low pressure
Urethra
Conveys urine from bladder to outside world
Spinal
Sympathetics T10-L1 via hypogastric Nerve S2-S4 Parasympathetic via Pelvic N Somatic via Pudental N
T10L1
S2S4
Outlet obstruction:
Sympathetic E-adrenergic stimulation of bladder neck & posterior urethra from T10-L1 via Hypogastric Nerve Somatic stimulation of External Sphincter from S2-S4 via Pudental Nerve
Bladder Relaxation:
Allows continent storage of significant volumes of urine at < 20 mmHg
F-adrenergic stimulation of bladder fundus from T10-L2 via Hypogastric Nerve decreases bladder tone
Bladder Contraction:
CNS micturition Centers Inhibits F-adrenergic bladder relaxation & stimulates Parasympathetic cholinergic stimulation of bladder fundus from S2-S4 via Pelvic Nerve
Bladder Pressures
Storage (cc)
Voluntary Voiding
Maturation of Voiding
Neonatal voiding
Controlled by sacral spinal cord reflex
Bladder distention sends signals to sacral spinal cord micturition center Spinal cord micturition center sends efferent signals that cause detrusor contraction & relaxation of external sphincter
Maturation of Voiding
Bladder capacity increases & voiding frequency decrease with growth
Bladder capacity in Ounces (30ml) = Age (yrs) +2
1-2 yrs: conscious sensation of bladder fullness develops 2-3 yrs: Ability to initiate or inhibit voiding voluntarily develops 2-4 yrs: Voiding comes under reliable voluntary control
By 4 years of age, most children have achieved an adult pattern of micturition
Maturation of Voiding
By age 4 Micturition spinal reflex fully modulated by CNS micturition center via a spinobulbospinal tact
As bladder fills, desire to empty occurs-child must consciously suppress this desire until he/she can get to toilet With conscious voiding, external sphincter willfully relaxed prior to initiating bladder contraction
Sphincter relaxation & bladder contraction, must occur in coordinated fashion for proper emptying
Maturation of Voiding
Initially child has better control over external sphincter than bladder
Easier to stop urination than start it Voiding inhibition done by contracting external sphincter rather than inhibiting bladder contraction
This pattern may be reinforced during toilet training Persistence of this pattern is bladder sphincter dysnergia
Nocturnal bowel control Daytime bowel control Daytime control of voiding Nocturnal control of voiding
Maturation of Voiding
By 4 most children have adult voiding pattern Brazelton studied 1,170 children & found
26% achieved daytime continence by age 24 months 52.5% by age 27 months 85.3% by age 30 months 98% by age 36 months
Definitions
Incontinence in Children
Definitions
Diurnal enuresis is often interchanged with dysfunctional voiding but they are not the same
Not all dysfunctional voiders are incontinent
Residual Urine
UTI
Incontinence
Social consequences
Urologic Presentation
Signs & Symptoms which suggest voiding dysfunction
Infrequent voiding Frequent voiding Urgency Dysuria Holding maneuvers Straining Poor stream Intermittent stream
Urologic Presentation
It can not be overemphasized to the general pediatrician how important it is that they rule out voiding dysfunction in all their children with recurrent UTIs, VUR or incontinence
GI Presentation
Signs & Symptoms which suggest voiding dysfunction
Fecal staining of undergarments Fecal incontinence Constipation Encopresis Obstipation (i.e., severe constipation causing obstruction) Abdominal pains
Lower back abnormalities such as nevus, dermal sinus, or dimple Pain in the lower back during stretching of the lower extremities Gait abnormalities Worsening symptoms during growth spurts Severe stool incontinence Complex enuresis refractory to routine Rx
Major Voiding Dysfunctional Disorders Hinman syndromenon neruogenic neurogenic bladder Ochoa (urofacial) syndrome
Hinman syndrome with Autosomal dominant inheritance & facial grimace when smiling
Filling
Multiple uninhibited detrusor contractions with increased EMG activity and expressions of urgency
Filling
Usually normal
Variable
Filling
Abnormally capacious bladder with little or no expression of urge
Purpose of evaluation
Characterize the Elimination problems to direct treatment
Storage problem Emptying problem Continence problem
History
To characterize the Problem
History
To characterize the Problem
Holding Maneuvers
Ectopic Ureter
3 Day Elimination DiaryYour most powerful diagnostic tool & its CHEAP & BENIGN
Determines BM problems Characterizes voiding Frequency of voids Volume of voids Accidents Associated symptoms Allows Characterization voiding disorder Storage Emptying Continence
History
Irritable Bladder
Urgency & frequency as Cerebral cortex unable to inhibit reflex bladder contractions triggered during filling
Parents need to know where every bathroom is at mall etc
When they void, void normally although usually have a small bladder capacity Exhibit behaviors to avoid leakage: Dancing, squatting, holding & posturing
Classic sign of bladder instability is "Vincent's curtsy- squatting posture in girls in which the heel compresses the perineum and thereby obstructs the urethra to prevent urinary leakage
If unsuccessful get urge incontinence of small amount of urine
History
Infrequent Voider
Typically school girls with recurrent UTI & often with history of intermittent enuresis Postpone voiding as long as possible
Dont like to void in public bathrooms Use holding maneuvers to fight urge to void
If holding maneuvers fail get incontinence- Suzy waits till the last minute to void & then its to late
Develop large capacity bladders- void 2-3 times per day & often dont have to void on awakening
When they void voluntarily it is large volumes, prolonged & requires straining
Often dont take time to completely empty
History
Infrequent Voider
Physician must uncover that the child with a wetting problem actually has abnormally few voids & a weak bladder
May wait at least an hour after waking to void May void only 2-3 to three times daily, often not at all during school Straining during urination common because detrusor is large-capacity & capable of only weak contractions
History
To Identify underlying treatable Pathology
Physical Examination
1st step is growth, general health & vital signs including BP 2nd step is to inspect the child's underwear for evidence of wetness or soiling 3rd step is to observe or at least listen to voiding for evidence of weak, slow or intermittent stream 4th step is focused physical exam
Physical Examination
Abdomen
Physical Examination
Perineum & Genitalia
Dampness at beginning of exam & with straining Signs of erythema or irritation may be indicative of vaginal voiding Meatal stenosis in boys & presence of labial adhesions in girls Signs of trauma suggestive of sexual abuse Careful examination of the introitus for an ectopic ureter Location of anus
NERVE ROOTS & THEIR ASSOCIATED SENSORY & MOTOR FUNCTIONS Level
L1 L2 L3 L4 L5 S1 S2 S3, 4
Sensation
Inguinal area Anterior/medial thigh Knees, lateral thigh Anterior/medial tibia Lateral tibia Sole of the foot Heel of the foot Perineal
Motor
Thigh extension/flexion Thigh extension/flexion Lower leg flexion Lower leg extension Dorsiflexion of foot (cannot walk on heels) Plantar flexion of foot (cannot walk on toes) Dorsiflexion of big toe Plantar flexion of big toe
Nerve Root S1 S2 S3
Routine Labs
Urine tests best obtained on 1st AM specimen after overnight NPO
UA
Specific gravity- over 1.020 rules out significant concentrating defect pH Glucose Blood Protein Microscopic
UC
Other Studies that can be obtained prior to referral Post void residual urine by catheter Abdominal radiograph (KUB)
Identifies lumbar-sacral anomalies, bowel gas patterns & amount of stool
Sonography
Upper tract
Size, contour, echogenicity Hydro-nephrosis Lower tract
Assess bladder wall thickness (nl <3mm when full; 5 mm when empty) Post void residual > 2 mL/kg is abnormal
Excellent correlation between residual urine by direct urethral instrumentation & noninvasive sonography
Other Studies that can be obtained prior to referral Nuclear Medicine renal scan
Cortical scan to RO scars or difference in function Functional SCAN with/without lasix to RO obstruction
Voiding cystourethrography
History of UTIs Family history of VUR
Management of Voiding Dysfunction in Children with no treatable Neruologic, Urologic or other organic etiology
Timed voiding is the easiest & most effective Rx & it works for irritable bladder & infrequent voider
Regular by the clock voids q 2-3 hours during day
Anticholinergic
Used for irritable bladder especially with urgency, frequency & urge incontinence
Oxybutinin 0.1-0.15 mg/kg per dose 3 x day
Dry mouth, constipation, drowsiness & heat intolerance
Imipramine used primarily for nocturnal enuresis Low dose UTI prophylaxis
Strong association between the 3 Treat voiding dysfunction Treat stooling dysfunction
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Summary
We have reviewed
Function (continent storage & voluntary emptying at low pressures) & how the lower GU tract works & how it matures
Relationship with lower GI tract
Spinal cord injury (SCI) produces profound alterations in lower urinary tract function
Focus is on 2 issues
Preservation of Renal function
Maintaining normal bladder pressures during filling & voiding Minimizing UTIs
Continence
Not an issue in first couple of years of life
Evaluation of Newborn with Neurogenic Bladder Assess lower tract for evidence of increased voiding pressure
Bladder US for bladder hypertrophy & post void residual- obtain in newborn period VCUG for VUR & bladder hypertrophy Urodynamics for LPP & compliance
Prevention
Folic Acid- 0.4 mg per day start prior to pregnancy
Flaccid bladder unable to empty- CIC Hyperreflexic &/or non compliant bladder- CIC with anticholinergics
Oxybutynin 0.1 mgk/Kg per dose 3 X per day
CIC is key- s bladder pressures, improves continence & eliminates residual urine
CIC in newborns
done every 3 hours NO CREDE If upper tracts deteriorate- vesicostomy
In older children CIC can be made easier with Continent Catheterizable stomas
Especially valuable in males who still have perineal sensation or children with poor coordination
Metroffanof uses appendix as conduit
Improving Continence
Continent Catherizable Stomas
Appendix (Mitrofanoff), section of ileum or colon placed from umbilicus to bladder & tunneled into bladder to prevent reflux Indicated in
Wheel-chair bound patients with severe scoliosis lordosis Poor upper extremity function Males with intact urethral sensation
Bladder Augmentation
Indicated when medical therapy fails to achieve adequate low-pressure capacity with continence Variety of substances and surgical techniques used each with problems
Use of intestinal tract allows absorption or secretion of electrolytes from or into urine
Bladder Augmentation
Variety of Methods Ileum & colon
Hyperchloremic hypokalemia acidosis, mucous
Stomach
Less mucous Can cause hyperkalemic metabolic aklalosis Can cause hematuria and dysuria due to acid
Rx with H2 blockers
Surgical techniques
Periurethral injections Bladder neck suspension & Sling procedures Artificial urinary sphincter
Summary
We have reviewed
Function (storage & voluntary emptying at low pressures) & how the lower GU tract works & how it matures
Relationship with lower GI tract
Evaluation & Rx of children with neurogenic bladder- focus on preserving upper tract & continence
References
Pediatric Clinics N America 48; Dec 01 1489-1503 & 1505-1518 Fernandes; The Unstable Bladder in children; Journal Peds; 118; 1991; 831 Pediatrics in Review; Volume 21 Number 10 October 2000; 336-341