Childhood Enuresis and Voiding Dysfunction

1

• Childhood Enuresis and Voiding Dysfunction
• Betty Ann Thibodeau
• Pediatric Urology Nurse Practitioner
• Stollery Childrens Hospital

2
Neurological Control of Voiding

• Complex neurological control of voiding
• Sympathetic nerves control storage of urine
• Parasympathetic nerves control voiding
• Somatic nerves control contraction relaxation
  of urinary sphincter and pelvic floor muscles
• Infants reflex control void frequently
• Older children adults voluntary control of
  elimination

3
Neurological Control of Voiding

• As the bladder nears capacity a message is sent
  to Pontine micturation center in brain
• The brain then sends a message back to the
  urinary sphincter bladder neck to relax
• The brain also sends a message to the bladder
  muscle to contract
• Complex coordination of relaxation of urethral
  sphincter and bladder neck at the same time as
  contraction of bladder muscle ? expulsion of urine

4
Structural vs Functional Urinary Incontinence

• Structural Urinary Incontinence
• Refers to developmental, iatrogenic, and
  traumatic anatomic abnormalities of the lower
  urinary tract that interfere with storage or
  evacuation of urine (Vemulakonda Jones, 2006)
• Spina Bifida
• Etopic Ureter
• Functional Urinary Incontinence
• Incontinence which is unrelated to any structural
  or neurological abnormality
• Majority of children suffer from functional
  urinary incontinence (Vemulakonda Jones, 2006)

5
Toilet Training

• Sequence of voluntary bowel bladder control
• Bowel control during the day
• Bowel control during the night
• Urine control during the day
• Urine control during the night
• Children learn to hold before they learn to relax
• Some children develop abnormal voiding habits
  during or after toilet training

6
Prevalence of Pediatric Voiding Dysfunction

• Currently 20-30 patients seen in our Pediatric
  Urology Clinics have some form of voiding
  dysfunction
• Australian population based study of 2020 primary
  school children (Sureshkumar, 2001)
• 19.2 of children had urinary incontinence
• Increased incidence in girls with family history
  of daytime wetting or past emotional stress
• Most children were wet 1-2 times in previous 6
  months but 2.7 were wet at least twice / week
• Majority of parents did not seek medical
  attention for their childs incontinence
• Teachers only recognized 3 of children with
  daytime wetting

7
Prevalence of Pediatric Voiding Dysfunction

• Population based study of 6,917 Japanese school
  children 7-12 years of age (Kajiwara, 2004)
• 6.3 daytime urinary incontinence
• 3.6 wet more than once per week 1.2 wet every
  day
• 94.6 suffered from urgency, 23.8 frequency,
  4.5 stress incontinence
• A higher incidence of constipation and UTIs in
  children with daytime urinary incontinence
• Loening-Baucke (2007) US Clinic prevalence study
  (482 children ) - 10.5 had urinary incontinence
  22.6 had constipation
• 13 constipation started prior to 1 year of age

8
Prevalence of Pediatric Voiding Dysfunction

• Hellerstein and Linebarger (2003) review of 226
  charts of children with abnormal voiding patterns
• 76.4 detrusor instability
• 8.7 extraordinary daytime urinary frequency
• 5.7 infrequent voiding
• 31 with detrusor instability suffered from
  constipation
• 72 of children who used posturing maneuvers to
  prevent incontinence developed recurrent UTIs
• Theory obstruction of distal urethra while
  posturing during bladder contractions results in
  bacteria refluxing into the bladder

9
Pediatric Voiding Dysfunction

• Abnormalities in storage or urine micturition
  often associated with urgency, frequency,
  incontinence and/or UTIs
• Dysfunctional Elimination Syndrome children who
  have difficulty with both bowel bladder
• Berry, 2005

10
Psychological Impact of Voiding Dysfunction

• Wetting pants in class was rated as the third
  most stressful of 20 different life events when
  school-age children were asked to grade them in
  terms of severity (Joinson, Heron, VonGontard and
  the ALSPAC study team, 2006, p. 1986)
• Children who have special permission to leave the
  classroom due to urinary or bowel issues are
  often singled out as being "different and are
  teased or bullied (Gerharz, Eiser and Woodhouse,
  2003 Theunis, 2002)
• Self-esteem was significantly lower in children
  with urinary incontinence and the childs
  self-esteem improved once the child became dry
  (Hägglöf et al., 1996)

11
Constipation

• Major contributor to voiding dysfunction is
  unrecognized constipation
• Constipation results from the tightening of the
  pelvic floor muscles which in turn tightens the
  anus and rectum preventing fecal evacuation
  (Hellerstein and Linebarger, 2003)
• Excess stool in the rectum applies pressure to
  the bladder to prevent proper bladder filling and
  emptying (Robson and Leung, 2006)
• Impacted stool in the rectum compresses the
  bladder, reduces the capacity of the bladder and
  provokes an earlier voiding sensation (Halachmi
  Farhat, 2008)

12
Constipation

• Treating constipation resolved or decreased the
  frequency of urinary tract infections in 80 of
  their patients (Neumann, 1973)
• In a study of 234 children ? treatment of
  constipation ? 52 of children improved daytime
  urinary incontinence by 89, nocturnal enuresis
  by 63 and UTIs by 100 (Loening-Baucke, 1997)
• Children with daytime wetting and recurrent UTIs
  have a significantly higher rate of constipation
  than those with children with just daytime
  wetting (Kodman-Jones, Hawkins and Schulman,
  2001)
• Children with constipation and/or rectal
  impaction had significantly larger rectal
  diameters on transabdominal rectal ultrasound
  (Joensson et. al., 2008)

13
Constipation

• Constipation often not recognized by parents
  unless child has significant problems ? once
  child is toilet trained parents do not monitor
  elimination habits
• Australian prevalence study 36.1 of children
  were constipated by clinical assessment compared
  to parental reporting of 14.1 (McGrath, Caldwell
  Jones, 2008)
• Children with urinary symptoms treated for
  constipation ? 63 no urinary symptoms, 35
  symptoms were partially resolved only 1 had no
  change ? 26 parents reported normal BMs, 16 no
  idea of childs bowel habits (Akyol et al, 2007)
• 47 girls with recurrent UTIs, bladder
  instability, enuresis and signs of constipation ?
  treatment resulted in improvement despite parents
  of 21 subjects denying constipation (ORegan,
  Yazbeck Schick, 1985)

14
2006 ICCS LUTS Standardized Terminology

• Overactive Bladder (OAB) Urge Incontinence
• Voiding Postponement
• Underactive Bladder
• Obstruction
• Stress Incontinence
• Vaginal Reflux
• Giggle Incontinence
• Extraordinary Daytime Urinary Frequency
• Enuresis (refers to nocturnal enuresis /
  bedwetting)
• Dysfunctional Voiding (Detrusor Sphincter
  Dysenergia - DSD)
• Children may suffer from one or more at a time

15
2006 ICCS LUTS Standardized Terminology

• Overactive Bladder (OAB) Urge Incontinence
• Urgency increased voiding frequency (gt 8/day) ?
  may be associated with incontinence
• Voiding Postponement
• Children who habitually postpone voiding
  utilizing posturing maneuvers ? often associated
  with decreased voiding frequency (lt3/day)
  urgency from full bladder
• Underactive Bladder
• Children with low voiding frequency ? typically
  uses increased abdominal pressure to initiate,
  maintain or complete voiding
• Obstruction
• Children with mechanical or functional
  obstruction preventing urine flow from the bladder

16
2006 ICCS LUTS Standardized Terminology

• Stress Incontinence
• Leakage of small amount of urine with exertion or
  ? abdominal pressure (cough, sneeze, laugh,
  exercise)
• Vaginal Reflux
• As the girl voids, urine refluxes up into the
  vaginal vault ? leaks out when standing
• Giggle Incontinence
• Complete voiding during or immediately after
  laughing
• Extraordinary Daytime Urinary Frequency
• Void small amounts frequently during the day only
  (at least hourly 50 of expected bladder
  capacity)
• Enuresis (Nocturnal Enuresis or Bedwetting)

17
2006 ICCS LUTS Standardized Terminology

• Dysfunctional Voiding (Detrusor Sphincter
  Dysenergia - DSD)
• Children who contract their urethra sphincter
  while voiding (contracts pelvic floor at the same
  time as the bladder contracts resulting in a
  functional obstruction)
• Hinman Syndrome (Non-neurogenic Neurogenic
  Bladder) ? Severe form of DSD which results in
  severe urinary retention, bladder dysfunction,
  hydronephrosis and renal impairment (Feldman
  Bauer, 2003)

18
Posturing Maneuvers to Prevent Incontinence

• Children attempt to prevent incontinence during a
  strong detrusor contraction by posturing
• Tightening of pelvic-floor muscles
• Applying pressure to urethra with hands (boys
  pinching glans)
• Vincent Curtsy crossing legs and bending
  forward at the waist
• Squatting on the floor pressing heel of foot into
  perineum against urethra
• Hellerstein and Linebarger (2003) - obstruction
  of distal urethra while posturing during bladder
  contractions results in bacteria refluxing into
  the bladder
• Contraction of pelvic floor muscles while voiding
  also results in milking bacteria from the distal
  urethra back into the bladder (Ellsworth
  Caldamone, 2008)

19
Indications of Voiding Dysfunction

• Thick walled bladder on ultrasound
• Large capacity bladder for age
• Expected (age 2) x 30ml
• Inability to empty bladder
• Trabeculated bladder with VCUG
• Use of posturing maneuvers
• Vincent curtsy
• Squatting
• Holding self
• Recurrent UTIs

• Infrequent voiding
• (less than 3 times/day)
• Constipation
• Incontinence
• Spinning top urethra with VCUG ? indicates
  contraction of the external sphincter while
  voiding

20
Tests

• Standard Tests
• Bladder Scan (pre post void residual)
• Uroflow with EMG (voiding pattern, contraction of
  perineal muscles with voiding)
• Voiding stooling diaries

• Other Tests
• KUB (fecal loading, sacral agenesis)
• Urinalysis Urine for c/s if suspect current
  infection
• Renal Ultrasound (pre post void views, bladder
  shape, bladder wall thickness, hydronephrosis)
• VCUG (posterior urethral valves, reflux)
• DMSA Scan
• Urodynamics

21
Bladder Testing

• Bladder scanning pre and post void residual
• Uroflow - Non invasive measurement of voiding
• Provides a graphic representation of the childs
  voiding
• Measures duration and rate of voiding
• EMG leads show relaxation or contraction of
  pelvic floor while voiding

22
Urodynamics

• An invasive test which measures the bladder
  pressures during filling, bladder contractions
  and voiding
• Also measures bladder capacity and demonstrates
  when or if leaking occurs
• Used in conjunction with MRI of spine to rule out
  spinal cord pathology in children who fail
  conservative management or suspect tethered cord

23
Standard Therapy for Voiding Dysfunction

• Standard Management
• Timed voiding voiding every 2-3 hours
  (discourage holding)
• Adequate hydration (20-30ml/kg) especially
  increased water intake
• Avoiding bladder irritants (carbonated drinks,
  caffeine, citrus)
• High fiber diet
• Treat constipation
• Proper positioning on the toilet
• Encourage child to take time on the toilet to
  empty completely
• If unresponsive to above therapies
• Antibiotic prophylaxis (recurrent UTIs)
• Biofeedback
• Psychological counseling

24
Medications

• Overactive Bladder (Anticholinergic)
• Ditropan 0.2 mg/kg/day divided q8h (max of 15
  mg/day)
• Ditropan XL 5-10 mg/day (max 20 mg/day)
• Detrol LA 4 mg/day (risk of long QT syndrome with
  higher doses)
• Bedwetting
• DDAVP
• DDAVP Tabs 0.2 mg ? 1 to max of 3 tabs at bedtime
• DDAVP Melts 120mcg ? 1 to 3 tabs at bedtime
• DDAVP Nasal spray is no longer used in Bedwetting
• Ditropan 0.2 mg/kg/day divided q8h (max of 15
  mg/day)
• Imipramine (10-25 mg at bedtime ?? by 25 mg/day
  if no response after 1 week of treatment to
  maximum 2.5 mg/kg/day or 50 mg if 6-12 years of
  age or 75 mg if 12 years of age)

25
Medications

• UTIs Antibiotic prophylaxis
• Septra 2 mg/kg/day at bedtime
• Nitrofurantion 1-2 mg/kg/day at bedtime
• Constipation
• PEG 3350 1 gram/kg/day to maximum of 17 grams/day
  
• 7-17 g/day (1 tsp - 1 tbsp/day)
• Lactulose 7.5 ml/day in children 15-30ml/day to
  maximum of 60ml/day in adults

26
Biofeedback

• Teaches children how to relax their pelvic floor
  muscles through the use of visual stimuli
• Electrodes are attached to the abdomen and around
  the anal sphincter
• Children play computer games with their pelvic
  floor muscles while trying not to use their
  abdominal muscles
• Used to teach children how to relax their pelvic
  floor muscles so that they can void correctly

27
Enuresis / Bedwetting

• Prevalence
• 15-20 of 5 year olds
• 4-8 of 12 year olds
• 1-2 of 15 year olds wet the bed
• More common in boys than girls
• Familial history
• 44 chance if one parent wet the bed
• 77 chance if both parents wet the bed
• Approximately 15 of children will out grow
  bedwetting each year
• Association with sleep apnea

28
Enuresis / Bedwetting

• Monosymptomatic Enuresis only bedwetting (no
  daytime symptoms)
• Nonmonosymptomatic Enuresis bedwetting other
  daytime symptoms (urgency, frequency, daytime
  incontinence)
• Primary Enuresis have never been dry overnight
• Secondary Enuresis have had a dry period of 6
  months or more prior to the start of bedwetting
• Children may have one or more of the following
• Difficulty arousing from sleep
• Small bladder capacity
• Nocturnal polyuria

29
Enuresis / Bedwetting Treatment

• Behavioural therapy
• Encourage healthy bladder habits (timed voiding,
  taking time to void)
• Voiding immediately upon rising in morning and
  before bed
• Discourage holding of urine during the day
• Limiting fluids after supper but drink liberally
  in morning early afternoon
• Proper positioning on toilet
• Treat constipation
• Encourage physical activity discourage sitting
  in front of TV computer for prolonged periods
  of time
• Tend to be more aggressive if bedwetting is
  bothering child

30
Enuresis / Bedwetting Treatment

• Bedwetting Alarm (60 - 70 effective but labor
  intensive)
• Moisture sensor and alarm which rings when child
  wets
• Conditioning ? teaches child to wake to a full
  bladder before wetting
• Encourage healthy bladder habits
• May be used in combination with DDAVP and/or
  Ditropan

31
Enuresis / Bedwetting Treatment

• Medications
• DDAVP - Desmopressin (reduces noctural polyuria)
• Ditropan (increases bladder capacity and reduces
  detrusor overactivity)
• Imipramine (mechanism unknown use as third line
  only as many serious side effects)

32
Preliminary Results from the Pediatric Voiding
Dysfunction Study

• Voiding dysfunction does have a significant
  impact on the child, family dynamics and peer
  relations

• Parental themes
• Worry about the impact on the childs feelings
  and self-esteem
• Anger frustration regarding the childs wetting
• Being prepared
• Increased laundry
• Schools teacher reactions

• Child themes
• Embarrassment frustration
• Worry that others would notice
• Missing out on doing things
• Teasing

33
References

• Alyol, I., Adayener, C., Senkul, T., Baykal, K.,
  Iseri, C. (2007). An important issue in the
  management of elimination dysfunction in
  children Parental awareness of constipation.
  Clinical Pediatrics, 46(7), 601- 603.
• Berry, A. (2005). Helping children with
  dysfunctional voiding. Urologic Nursing, 25(3),
  193-200.
• Ellsworth, P. Caldamone, A. (2008). Pediatric
  voiding dysfunction Current evaluation and
  management. Urologic Nursing, 28(4), 249-258.
• Feldman, A., Bauer, S. B. (2006). Diagnosis
  and management of dysfunctional voiding. Current
  Opinions in Pediatrics, 18(2), 139-147.
• Gerharz, E. W., Eiser, C., Woodhouse, C. R. J.
  (2003). Current approaches to assessing the
  quality of life in children and adolescents.
  British Journal of Urology International, 91(2),
  150-154.

34
References

• Hägglöf, B., Andrén, O., Bergström, E., Marklund,
  L., Wendelius, M. (1997). Self-esteem before
  and after treatment in children with nocturnal
  enuresis and urinary incontinence. Scandinavian
  Journal of Urology and Nephrology, 183, 79-82.
• Halachmi, S. Farhat, W. (2008). The impact of
  constipation on the urinary tract system.
  International Journal of Adolescent Medicine and
  Health, 20(1), 17-22.
• Hellerstein, S. Linebarger, J. S.(2003).
  Voiding dysfunction in pediatric patients.
  Clinical Pediatrics, 42(1), 43-49.
• Joinson, C., Heron, J., Von Gontard, A., the
  ALSPAC Study Team (2006). Psychological problems
  in children with daytime wetting. Pediatrics,
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• Kajiwara, M., Inoue, K., Usui, A., Kurihara, M.,
  Usui, T. (2004). The micturation habits and
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35
References

• Loening-Baucke, V. (2007). Prevalence rates for
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• Neveus, T., Von Gontard, A., Hoebeke, P.,
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  M., Rittig, S., Vande Walle, J., Yeung, C.,
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• Robson, W. L. M. (2008). Current management of
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36
References

• Schulman, S. L. Berry, A. K. (2007). A simple,
  step-wise approach to the child with daytime
  wetting. Contemporary Urology, 19(1), 19-29.
• Sureshkumar, P., Craig, J. C., Roy, L.P.,
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• Vemulakonda, V. M. Jones, E. A. (2006).
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