[Show abstract][Hide abstract] ABSTRACT: We surveyed school nurses on toileting conditions in schools, their level of understanding related to normal toileting patterns in school-age children, and whether they are in need of additional resources to promote healthy toilet habits for their students.
An Institutional Review Board approved web-based survey with 34 questions was employed; 562 nurses completed the survey and 97% were currently employed as school nurses. Participants were invited via email blasts through national school nursing associations and the Iowa Department of Education.
Only 48% and 33% of respondents suspected an underlying health problem in children with frequent urination and bladder or bowel accidents, respectively. Despite 61% reporting never receiving information about children's normal elimination patterns, 43% had been asked to provide such information to teachers. Only 42% felt they had adequate resources to respond to such requests. School nurses requested information about treatment of dysfunctional elimination (67%), health effects of childhood toileting habits (65%), fluid intake guidelines (44%) and improvement of bathroom facilities (39%); 70% were unaware of local providers specially trained to treat children with these problems.
Our survey results suggest that school nurses need additional information and resources in order to promote healthy elimination patterns in school children.
Full-text · Article · Mar 2011 · Journal of pediatric urology
[Show abstract][Hide abstract] ABSTRACT: To examine the outcome of transcutaneous electrical nerve stimulation (TENS) use in children with overactive bladder refractory to behavioral and anticholinergic therapy.
We reviewed the data of 18 children (13 girls and 5 boys; mean age 9 years) with overactive bladder refractory to standard therapy who underwent at-home TENS treatment twice daily for 20 minutes. Symptoms and objective measures (noninvasive uroflowmetry and postvoid residual urine volume) were noted at baseline and after treatment.
Of the 18 children, 15 had pretreatment incontinence and 3 had only increased urgency/frequency. The incontinence group averaged 3.2 +/- 2.1 daytime accidents. The mean length of TENS use was 8 +/- 7 months, and the mean follow-up after starting TENS was 13 +/- 9 months. Of the 15 patients with incontinence, 2 became dry (13%), 9 were significantly improved (60%), and 4 reported no improvement (27%). Of 12 children with marked urinary frequency, 8 had significant symptom improvement. Noninvasive uroflow and postvoid residual urine volume measurements were not significantly different statistically before and after treatment. Pretreatment patient sex, age, and frequency of wetting were not predictive of the outcome. A post-TENS parabolic uroflow curve showed a statistically significant correlation with patients who became dry or improved (P = 0.018).
The results of our study have indicated that TENS use in children with incontinence refractory to pharmacotherapy is safe and well tolerated. The encouraging results of this treatment modality in the refractory patient population warrant additional study of the pediatric overactive bladder.
[Show abstract][Hide abstract] ABSTRACT: To analyze the utility of assessing degree of constipation by abdominal radiograph (KUB) in relation to symptoms and urodynamic data in children with dysfunctional elimination.
A retrospective review of children with concomitant constipation and daytime incontinence was performed. Inclusion required at least two consecutive visits with KUB and noninvasive uroflowmetry. Patients were excluded for anticholinergic medication use or neurogenic or anatomic abnormalities. Rectal fecal quantification and presence of stool throughout the colon was assessed on KUB and categorized as "empty," "normal amount of stool," or "fecal distention of rectum (FDR)."
Twenty-six patients met inclusion requirements (6 boys, 20 girls; average age, 7.7 +/- 2.2 years). The average time between the initial and subsequent visit was 12.5 +/- 7.8 weeks. Initial KUB revealed FDR in 17. No statistical significance was found between FDR on initial or final KUB and outcome of wetting symptoms, nor could a relationship between FDR uroflow parameters at either visit be demonstrated.
No correlation between any uroflowmetry parameter and the presence of FDR at the initial or final visits could be demonstrated. Similarly, no statistical significance between FDR on final or initial KUB and outcome of wetting symptoms was established.
[Show abstract][Hide abstract] ABSTRACT: To analyze the relationship between potential prognostic factors and early success after treatment of childhood daytime urinary incontinence without anticholinergic medication.
A total of 63 patients with daytime urinary incontinence met the inclusion criteria for a retrospective review of the effect of a timed voiding regimen. The severity, duration, and frequency of wetting, along with age, sex, and uroflow parameters, were recorded. Statistical analysis was used to determine the factors predictive of improvement in wetting without anticholinergic treatment.
Of 315 children evaluated with daytime incontinence, only 24% were treated with nonanticholinergic methods. At the first follow-up visit, 6.3% of patients treated without anticholinergics became dry, 38.1% showed significant improvement, 36.5% were slightly improved, and 19.0% were unchanged. Age, sex, duration or severity of wetting, constipation, bladder capacity, and uroflow pattern and parameters were not predictive of early improvement with timed voiding. Patients with good compliance with timed voiding were significantly more likely to improve than those with poor compliance (P = 0.014).
The results of our study have indicated that anticholinergic therapy appears to be overused as a first-line treatment for children with daytime urinary incontinence in our clinic population. The lack of reliable predictive factors regarding the response to nonanticholinergic treatment suggests a trial of timed voiding should be used as an initial treatment for all children with daytime urinary incontinence. Almost 45% of our patients had significant improvement in the frequency of wetting within 4 months without anticholinergics.
[Show abstract][Hide abstract] ABSTRACT: To examine the variables relative to the response of oxybutynin treatment in children with daytime urinary incontinence.
The records of patients seen for voiding problems between 1999 and 2003 were reviewed. Patients taking oxybutynin for 3 months or longer were included in the study. Patients with structural or neurologic bladder abnormalities and those taking oxybutynin at the initial visit were excluded. Age, sex, uroflowmetry findings, postvoid residual urine volume, duration and severity of symptoms before oxybutynin, urinary tract infection history, constipation, and the duration, dosage, and adverse effects of oxybutynin treatment were evaluated. Data were analyzed using Fisher's exact test for categorical variables, the two-sample t test or Wilcoxon rank-sum test for continuous and ordinal variables, and the linear mixed model analysis for uroflow data.
Eighty-one patients met the inclusion criteria. After an average follow-up of 1.2 years, 31 (38.3%) were dry, 25 (30.9%) had experienced significant improvement, 19 (23.5%) had experienced slight improvement, and 6 (7.4%) were unchanged. No significant differences were detected between those who became dry and those with little to no improvement with respect to age, sex, duration of symptoms, follow-up, uroflow pattern, postvoid residual urine volume, or bladder capacity. Those children presenting with decreased frequency of wetting episodes were significantly more likely to obtain daytime continence. The most common side effects were constipation (18.5%), dry mouth (17.3%), and flushing (13.6%).
Children with daytime incontinence presenting with the lowest frequency of wetting were most likely to achieve continence. The frequency of wetting should be considered a significant prognostic variable when assessing the results of therapeutic intervention trials.
[Show abstract][Hide abstract] ABSTRACT: We evaluated pediatric patients who were treated with biofeedback for dysfunctional voiding with respect to clinical outcome and objective changes in uroflow parameters and post-void residual.
We retrospectively reviewed 81 patients treated for dysfunctional voiding and/or urinary tract infections with biofeedback. Conservative management had previously failed in all patients. Uroflow data and symptoms were reviewed, and clinical outcomes were recorded. For analysis, patients were stratified by symptoms of incontinence or presence of urinary tract infections.
Of 73 patients with incontinence 22 (30%) became dry, 36 (49%) had improvement and 15 (21%) reported no change following biofeedback. In 39 (78%) of 50 patients with recurrent urinary tract infections resolved. Overall, there was a significant (p <0.002) increase in peak flow and average flow rate, and a significant decrease in post-void residual and post-void residual as a percent of predicted bladder capacity. There was no significant change in voided volume following biofeedback. Overall, there was no significant difference in uroflow parameters and post-void residual following biofeedback between patients with incontinence or infections, except for a higher maximum flow rate in patients who continued to have infections.
Treatment of children with pelvic floor muscle biofeedback is associated with improved urinary continence and decreased urinary tract infections in the majority. It results in improvement in uroflow curves and parameters, and a decreased post-void residual. Posttreatment results of these parameters did not correlate with improvement in continence and urinary tract infections.
No preview · Article · Oct 2004 · The Journal of Urology
[Show abstract][Hide abstract] ABSTRACT: Dysfunctional voiding in children may partly be learned, and constitutes a significant percentage of pediatric urological referrals. Half of a child's waking hours are spent at school, suggesting a significant potential impact on learned toileting behaviors. Nonetheless, data on teacher perception and practice regarding pediatric voiding are lacking.
A total of 1,000, 21-question surveys were mailed to randomly selected Iowa public elementary school teachers, of which 467 were returned and analyzed.
Eighty percent of respondents reported set times for student bathroom breaks. More than half requested all children go to the bathroom at the set times. One-third asked a child requesting a break in the middle of class to wait. Thirty-five percent and 48%, respectively, reported the boys and girls bathrooms were always sanitary. Forty-seven percent and 36% believed bathroom sanitation was progressively worse during the day for boys and girls bathrooms, respectively. Forty-two percent and 34% noticed bullying and lack of supervision, respectively, in the boys bathrooms. Seventeen percent, 16% and 15% suspect an underlying health problem in children who urinate more frequently than normal, or wet or defecate in their pants, respectively. More experienced teachers are significantly more likely to report these suspicions to the school nurse. Only 18% of respondents reported receiving information about abnormal voiding or stooling. Only 8% were aware of specialists trained to treat children with these problems.
Teachers report suboptimal toileting conditions for many children at public schools. These conditions appear to become significantly worse following kindergarten. Teachers have the potential to have a significant impact on dysfunctional voiding but are infrequently informed regarding these issues.
Full-text · Article · Oct 2003 · The Journal of Urology
[Show abstract][Hide abstract] ABSTRACT: Children with daytime wetting often have constipation, and treatment of constipation helps children become dry. Polyethylene glycol 3350 (Miralax, Braintree Laboratories, Braintree, Massachusetts) is a nonaddictive, tasteless powder that can be mixed with any liquid for treatment of constipation.
We review our use of polyethylene glycol 3350 in 35 girls and 11 boys with dysfunctional elimination. Noninvasive urodynamic studies and post-void residual measurement were performed before and during treatment.
A significant increase in frequency of bowel movements occurred while taking polyethylene glycol 3350 (p = 0.0001). Average final dose was 0.63 gm/kg. The only reported adverse effect was diarrhea (9 patients). Of the children 18 became dry, 26 had decreased wetting and 2 had no improvement. Voided volume increased (146 vs 210 ml, p <0.0001) and post-void residual decreased significantly (92 vs 48 ml, p <0.0001) while on polyethylene glycol 3350. Ten children were still considered constipated including both patients who experienced no change in wetting. Average final dose in this group (0.69 gm/kg) did not differ significantly from those in whom constipation resolved (0.61 gm/kg). Patients in whom constipation resolved had a significantly lower post-void residual than those who remained constipated (11.8% vs 30.6%, p <0.01) and were significantly more likely to become dry or improved (p = 0.045).
The efficacy, compliance and lack of significant side effects make polyethylene glycol 3350 an ideal substance for treatment of constipation in children with dysfunctional elimination. Persistent constipation was associated with decreased resolution of voiding symptoms and significantly increased post-void residuals.
Full-text · Article · Oct 2003 · The Journal of Urology
[Show abstract][Hide abstract] ABSTRACT: We designed a survey to assess the microwave sterilization technique practiced by patients at our clinic who perform clean intermittent catheterization.
A 23-question survey addressing urinary catheter use and home sterilization techniques was mailed to 129 patients. A followup survey was mailed to 47 respondents who reported using a microwave oven to sterilize the catheters to assess the microwave technique further.
Of the 129 initial surveys 84 (64%) were returned, while 40 (85%) of the 47 followup questionnaires on microwave sterilization were returned. All patients surveyed have used clean intermittent catheterization for at least 1 year and 75% have used it more than 5 years. Of the respondents 80% perform clean intermittent catheterization 4 to 5 times daily, although sterilization frequency varies from daily to less than once weekly. Of the respondents 71% reported no difficulty with microwave sterilization, although 31 (63%) reported a history of catheter melting during microwaving. Of the respondents 35% reported using a rotation table, all used a heat sink containing 1/2 to 4 cups of water, 39% used 500 to 1,000 W., 37% used greater than 1,000 W., 73% set the microwave for 6 minutes, others set it for 3 to 30 minutes and 98% used a power setting described as high, full, 10 or 100%.
Significant variation exists in the cleaning and sterilizing techniques used by our patients, although they were given uniform written and verbal instructions. It is unclear from the data in the literature how this variation affects sterilization.
No preview · Article · Sep 2002 · The Journal of Urology