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Abstract
Dysfunctional elimination syndrome (DES) refers to an abnormal pattern of elimination of unknown etiology characterized by bowel and bladder incontinence and withholding. School-aged children with DES had a higher prevalence of previous urinary tract infections and congenital vesicoureteral reflux. Urinary incontinence in children may be caused by a congenital anatomical or neurological abnormality. Many children, however, do not have such an obvious cause for their incontinence and they are referred to as having functional incontinence. Functional urinary incontinence in children may be due to disturbances of the filling phase, the voiding phase or a combination of both. When incontinence is the result of urethral overactivity during voiding the term dysfunctional voiding is used.
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The simultaneous recording of urodynamic parameters and x-ray imaging of the lower urinary tract is the ideal technique for a complex investigation of lower urinary tract function and x-ray morphology. To minimize pain-artefacts by tubes and electrodes, the preparatory measurements, which include the suprapubic insertion of two tubes into the bladder, are done the day before, if necessary, in a short general anaesthesia, the investigation itself is performed the following day without an irritating catheter in the urethra and without pains for the patient (which is especially essential when investigating children). The technical details of a modern videourodynamic system and its advantages for this type of investigation are presented. However, the clinical practice has also revealed some weak points of the system, which need to be improved. The technique together with modern technology guarantees accurate and reproducable information also in childeren.
The symptoms of 128 consecutive patients (mean age 65 years) with benign prostatic hypertrophy were assessed and compared with flowmetry recordings. The 84 patients (65%) with peak flow rates greater than or equal to 2 standard deviations from the mean were considered to have abnormal flowmetry and their symptoms were compared with those of the 44 men with normal peak flows. No significant correlation between peak flow rate and age was found within this group. Symptoms of poor stream, nocturia, post-micturition dribble and nocturnal or full-bladder hesitancy were present in over two-thirds of the whole series. Poor stream, hesitancy and nocturnal or full-bladder hesitancy were found to have significant associations with abnormal flowmetry recordings but also to have a high incidence within the normal flowmetry group. Discriminant analysis was unable to define a symptom complex which would accurately predict those within our group with abnormal peak flows. It was concluded that symptomatology and flowmetry evidence of lower urinary tract obstruction are not associated and subjective and objective evidence must be considered independently in selecting candidates for prostatectomy.
A prospective study was undertaken to delineate the role of spontaneous uroflowmetry as screening procedure for functional infravesical obstruction (detrusor/sphincter dyssynergia). More than 70% of thirty-nine children referred for urinary tract infections and/or enuresis in the absence of neurological deficits underwent a complete diagnostic program including intravenous urography, voiding cystography and cystoscopy as well as spontaneous uroflowmetry, cystometry-emg and pressure-flow-emg study. The incidence of dyssynergia was 22%. However, neither the flow curve pattern nor single flow variables were able to identify children with dyssynergia. Consequently uroflowmetry seems inefficient in the screening for dyssynergia in neurological normal children with voiding disorders in the absence of anatomical bladder outlet obstruction.
Nonintrusive measurement of the hydrodynamic properties of the urinary stream (uroflowmetry) has been included in many adult urological evaluations as an objective diagnostic tool. Measurement and behavioral problems interfere with practical applications in children. We describe a standard procedure for obtaining "impromptu" micturitional flow parameters in clinical pediatric practice. Statistical correlations of these flow parameters in an unselected group of 142 normal boys between 2 and 12 years old are presented. Useful linear regression equations were derived from the sample to assist the clinician in predicting deviations from normal values. Limitations of the methodology are noted.
Persistent daytime incontinence is a fairly uncommon but important problem. Videourodynamic studies were carried out in 215 children presenting with this problem in whom there were no neurological signs and who had not responded to simple measures. Over 90% of symptomatic children were shown to have an abnormality, of which over half had detrusor instability and a fifth had the wide bladder neck anomaly. We consider that it is important that these children are fully assessed as many can be helped.
Voiding function was studied after repair of anterior hypospadias in 44 boys using Duckett's technique of meatoplasty and glanuloplasty. Assessment of the urinary stream was done in 2 ways. At least 6 weeks postoperatively a uroflow measurement using a DISA rotating disk machine was done. Peak flow was compared to previously prepared normal values in a large group of normal boys. Then, a high speed picture of the stream was taken using electronic video photography at the time of peak flow. Of the boys 42 had normal flow rates and 40 had acceptable stream patterns. The only complication was meatal stenosis in 2 cases. There were no fistulas. Although the primary indication for correction of anterior hypospadias is cosmetic, it is essential that function not be sacrificed to achieve this end. This study indicates that voiding function is maintained after hypospadias repair with meatoplasty and glanuloplasty.
The urinary flow was studied in 216 boys and 180 girls, aged 3 days to 16 years. the individual flow pattern was fairly constant. There were considerable variations between different individuals. the ranges of different flow variables at different micturition volumes are given. With increased micturition volume the flow curve showed a plateau in the age group 4-13 years. This plateau seems to be characteristic for children. the maximum flow was positively correlated to the volume of voided urine, as in adults. in girls no difference between age groups could be demonstrated as regards increase in maximum flow with volume. in boys 0-4 years the increase of maximum flow with volume was more pronounced than in boys aged 4-16 years. Girls 4-16 years showed a more pronounced increase of maximum flow with volume than boys of the same age group—above 70 ml volume their mean maximum flow was on a higher level. An attempt was made to correlate the maximum flow with height, weight, body surface and age, respectively. the coefficients of correlation were small and about the same for all the parameters. Thus, growth seems to have little influence on maximum urinary flow, which is mainly related to the voided volume. There is a slight tendency for maximum flow to increase during growth to reach a level just below the values reported for adults. Psychic factors seemed to have surprisingly little influence on micturition provided attention was paid to the specific demands of the paediatric age group. Abdominal straining was not used during micturition by normal children.
The problems in the evaluation of children with suspected infravesical obstruction are shortly reviewed. Based upon literature studies it is concluded, that an isolated urinary flow measurement determining the Qmax is a suitable procedure of screening. Due to different shortcomings of earlier published normal materials, we investigated the spontaneous urination of 205 normal children aged 3 to 13 years in their normal environment. The mictiograph was installed in the toilet of two kindergartens and one school, enabling the children freely to void into the machine upon desire. From the flow curves the following parameters were calculated: Q1 sec, Qmax, Qmax time, and the micturition time, all of them being related to the square root of the voided volume. The data were non-parametrically statistically processed, and the limits of normal values (2 1/2% and 97 1/2% percentiles) are defined for different groups of age and sex. Furthermore, the different flow curve patterns are described, and it is found, that in 90% of the cases they are identical to the adult pattern.
Micturition patterns in 33 males, aged 15 to 34 years, were investigated after hypospadias repair in childhood. Spraying of the urinary stream was the most common complaint (13 patients). Urinary flow was low in five patients as compared with controls, but in only one of these patients was an obstruction found that required treatment. Five patients had persistent curvature of the penis. One of them was unable to perform sexual intercourse.
Uroflow parameter nomograms determined by nonparametric tolerance limits were established from measurements in 1,014 children. Percentile nomograms for maximum and average flow rates were based on body surface area, volume voided and sex.
Summary— The findings of the videourodynamic (VUD) assessment of the vesicourethral dysfunction of 103 children with neurological disease are described. Detrusor-sphincter dyssynergia was the main determinant of voiding efficiency and the most important cause of impaired renal function. Storage efficiency was mainly determined by the behaviour of the bladder neck during the filling phase. The response to treatment of the child's incontinence was largely determined by the detrusor compliance.
Detrusor contractility was found to be of 2 types distinguishable by several physical and functional characteristics rather than by amplitude alone. This may be of more than just academic and semantic importance.
VUD studies are essential if conservative treatment modalities are to be rationally and selectively employed.
The aim of this study was to assess the relationship between bladder dysfunction and impaired cardiovascular reflexes in diabetic children with no clinical symptoms of autonomic neuropathy. After 15 ml/kg of water intake, the time to first sensation to void, the voiding volume, the voiding time, the average and maximum urinary flows, and the time to maximum urinary flow were estimated by sonography and uroflowmetry in diabetic children with and without cardiovascular autonomic dysfunction (CAD), and in a healthy control group. The three groups of children were matched for age, weight and height. CAD was considered to be present if the results of cardiovascular tests were more than 2SD from the mean of healthy controls. Diabetic children with and without CAD had increased time to first sensation to void, voiding volume, and average urinary flow when compared with healthy children. Voiding volume and average and maximum urinary flows were higher in diabetic children with CAD than in those without CAD. Diabetic children with CAD had also a higher maximum urinary flow than diabetic children without CAD and healthy children. Diabetic children with CAD had a longer diabetes duration and a higher mean fructosamine level during the preceding 3 years than those without CAD. These findings suggest that diabetic children may have diminished sensation of bladder filling independent of impaired cardiovascular reflexes, however, the degree of bladder dysfunction parallels with CAD, both depending on diabetes duration and long-term glycaemic control.
Videourodynamic evaluation that incorporates radiographic imaging with simultaneous measurement of bladder and urethral pressure is the most precise method available for diagnosing complex incontinence and voiding disorders. In addition, videourodynamics has been instrumental to the development of our present knowledge about urethral and bladder function including the concepts of detrusor and abdominal leak point pressures. Although these studies are more expensive and time consuming, the authors have found videourodynamic evaluation indispensable when the diagnosis remains in question after simple urodynamics and when the studies and clinical scenario do not agree.
In this cross-sectional epidemiological questionnaire survey of 7-8-y-old Danish school entrants with focus on voiding habits, 29% were found to have symptoms that could suggest that bladder control was not fully developed. The frequency of day wetting, urgency, emptying difficulties, nocturnal enuresis, nocturia and encopresis, and the median frequency of voidings are presented. Furthermore, the relationship between urinary tract infections, day wetting, encopresis and voiding habits is investigated. There was an association between previous urinary tract infection in girls and current voiding symptoms, suggesting bladder dysfunction as a predisposing factor to infections. In particular, focus should be placed on girls with squatting on urge and/or emptying difficulties.
Aim:
To analyse the number of urinary tract infections, uroflowmetry, behavioural symptoms and intrafamilial interaction in two groups of daytime wetting children in a paediatric and a child psychiatric unit.
Methods:
Ninety-four children with either voiding postponement (52) or urge incontinence (42) were examined prospectively for history of urinary tract infections (UTIs), uroflowmetry, the syndrome scales of the Child Behaviour Checklist (CBCL 4/18-Achenbach) and the Family Adaptability and Cohesion Evaluation Scales (FACES-III) (Olson) questionnaire.
Results:
Children with urge incontinence had a significantly higher rate of previous urinary tract infections (50%) than children with voiding postponement (19.2%; p < 0.001), who showed a high rate of plateau (12.2%) and staccato (20.4%) curves and were characterized by a wide variety of behavioural symptoms, including withdrawn (11.6%), aggressive (11.8%), delinquent (19.6%) behaviour and attention problems (13.7%). Clinically relevant behavioural scores were 4-10 times higher for the voiding postponers, and 2-3 times higher for children with urge incontinence. Furthermore, families of voiding postponers had significantly fewer balanced types of intrafamilial function (FACES-III). Problematic "rigid/disengaged" and "rigid/separated" types predominated.
Conclusion:
Urge incontinence is characterized by a higher rate of UTIs, a lower urine volume in uroflowmetry, a lower rate of behavioural scores in the clinical range and well-functioning families. Voiding postponement children, on the other hand, have a higher, though not significant, rate of abnormal uroflow curves, a wide variety of clinically relevant behavioural symptoms, which were significantly higher for attention and delinquent problems. Conduct problems predominated; only 13.7% of the children had attention problems in the clinical range. The findings lend empirical support to the entity of voiding postponement as an acquired or behavioural syndrome characterized by wetting in association with a delay of micturition and other externalizing conduct problems.
The overactive bladder (OAB) in children is defined as both involuntary detrusor contractions and urethral instability. The development of urinary control plays a key role in its incidence and in our understanding of its pathogenesis. It is seen in a number of conditions but by far is most common among patients with dysfunctional voiding. Urinary infection can be both a cause and an effect of OAB. In some instances, vesicoureteral reflux may result from detrusor overactivity because its successful resolution has been shown to depend on abolition of the hyperactivity. Early diagnosis and appropriate treatment can affect upper urinary tract function and drainage and ultimate bladder function. Recognition is noted via a thorough history and careful physical examination. Urodynamic assessment is indicated in neurologically normal children >5 years old and is combined with a voiding cystourethrogram in boys and a radionuclide cystogram in girls who have a history of recurrent urinary infection. Treatment consists of prophylactic use of anticholinergic agents in patients with neurologic dysfunction, as an early adjunctive measure in boys after ablation of posterior urethral valves, and in children with vesicoureteral reflux. The dose must be carefully titrated in children with cerebral palsy to prevent the appearance of elevated residual urine. Behavioral therapy and biofeedback techniques are effective alternatives to anticholinergic agents for children with dysfunctional voiding.
Urinary bladder dysfunction is a frequent complication of diabetes mellitus in adults. The aim of this study is to determine the early disturbances of the detrusor contractility in children, and adolescents with type 1 diabetes.
The bladder urine flow parameters were investigated in 37 children with type 1 diabetes, 10/37 with cardiovascular autonomic dysfunction (CAD) voided 482 +/- 128 mils (Group A), 27/37 without CAD voided 258 +/- 52 mils (Group B). From an earlier uroflow screening study 20 healthy children formed group control A, who had voided 488 +/- 94 mils, and another 30 healthy children formed group control B, who had voided 260 +/- 50 mils. The compared groups were matched for voided volume, age, weight, and height. There was no evidence of urinary tract abnormalities in any of the children.
Time to maximum flow was longer in both diabetic groups as compared with controls (P < 0.01), and the acceleration (the ratio of maximum flow and the time to maximum flow) of diabetics was significantly lower (P < 0.01). Bladder emptying was complete in each subject. Bladder wall disturbances were not seen by ultrasound.
The decreased acceleration of detrusor muscle contraction may be interpreted as an early sign of autonomic neuropathy in children and adolescent with type 1 diabetes, even in patients without CAD. Clinicians may be able to determine autonomic neuropathy by using uroflowmetry that is easy to perform, sensitive, reproducible, and needs only a child's minimal cooperation.