Dysfunctional Voiding in Children

1
Dysfunctional Voiding in Children

• Hann-Chorng Kuo
• Department of Urology
• Buddhist Tzu Chi General Hospital

2
Development ofUrethral Sphincter

• Specific striated sphincter muscle closely
  applied to the smooth muscle at membranous
  urethra and mid-urethra
• A ring shape sphincter in early adolescence,
  which account for initial high voiding pressure
  in infancy and early vesicoureteral reflux
• An omega shape shincter in adolescence after
  development of urogenital septum

3
Congenital Abnormalities

• Myelodysplasia
• Lipomeningocele
• Sacral agenesis
• Tethered cord
• Cerebral palsy
• Bladder extrophy
• Posterior urethral valve
• Anorectal malformations

4
Myelomeningocele

• The most common form of NVD in children
• Early detection and folic acid treatment markedly
  decrease spinal defects
• Upper and lower motor bladder dysfunction and
  pelvic floor dysfunction may occur in thoracic or
  sacral lesions
• Early prophylactic treatment of DESD by CIC,
  anticholinergics are beneficial

5
Myelomeningocele, detrusor areflexia and
incontinence
6
Meningomyelocele Bilateral VUR Recurrent UTI
7
Lipomeningocele

• Difficult to identify by physical examination,
  MRI is the best diagnostic method
• Intradural lipoma results in disease and
  presentation
• The most common urodynamic findings are
  consistent with an upper motor neuron lesion
• DESD is less common
• Detrusor hyperreflexia and areflexia can be found
  in this group of lesion

8
Sacral agenesis

• Often discovered at older children with
  incontinence
• Loss of the lower vetebral bodies by X-ray or MRI
• Patients have stable neurological lesion
• Patients may have no signs of denervation,
  hyperreflexia, areflexia, intact sphincter,
  sphincter dyssynergia

9
Tethered cord syndrome

• Most commonly seen in patients after surgery for
  myelomeningocele
• Isolated tethered cord is less common
• Severe bladder dysfunction and refractory
  incontinence may occur
• Surgical division of the filum may improve
  symptoms

10
Cerebral Palsy

• Develops most commonly in premature infant
• Infection and anoxia result in a non-progressive
  brain lesion and muscular disability
• Continence is often delayed to develop but intact
• Uninhibited detrusor contractions without DESD is
  the most commonly urodynamic finding
• Pseudodyssynergia may occur

11
Cerebral palsy with frequency dysuria due to DI
12
Bladder extrophy

• Characterized by extrophic bladder, abdominal
  wall defect, epispadias, pelvic diastasis, VU
  reflux, inguinal hernia
• Staged reconstruction by abdominal wall closure,
  epispadias repair, bladder neck reconstruction
  and correction of VUR
• Improved pelvic floor reconstruction after
  osteotomy has better continence rate
• Bladder augmentation may be indicated

13
Posterior Urethral Valve

• The most common cause of BOO in newborn
• Present with incontinence and recurrent UTI
• Severe PUV may be detected antenatally, mild form
  is found in older children
• Bilateral hydroureter and hydronephrosis may
  develop in severe form of valve disease
• Transurethral ablation of valve resumes normal
  bladder but bladder function depends
• Anticholinergics, CIC and augmentation by ureter
  may be indicated

14
Anorectal Malformations

• Rare congenital lesions of cloaca
• Associated with congenital GU abnormalities in
  20 with low and 60 high lesions,VUR, NVD, renal
  agenesis, renal dysplasia, cryptorchidism
• Urethrorectal fistula may develop at at high,
  intermediate or low level
• Neurogenic voiding dysfunction in 50
• Tethered cord is the main vertebral abnormality,
  which account for NVD

15
Dysfunctional Voiding

• A group of neurologically intact children
  presents with incontinence, dysuria, large
  residual urine, recurrent UTI, unilateral or
  bilateral hydronephrosis
• Urodynamically classified into small capacity
  hypertonic bladder, detrusor hyperreflexia, lazy
  bladder syndrome,non-neurogenic neurogenic
  bladder
• Treatment bases on interaction of bladder and
  external sphincter

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Patient evaluation history

• Antenatal GU abnormalities hydronephrosis,
  enlarged bladder, open spinal cord defect
• Past surgical history detethering procedure, VP
  shunt, urinary diversion
• Occurrence of UTI and antibiotics
• Bowel habit, fecal incontinence, and stool
  softeners
• Catheterization schedule, urine amount
• Medication and adverse effects

17
Physical examination

• Neurological examination gait, discrimination
  of extremities, motor strength, DTR (S1,2), BCR
  (S2-4)
• Sacral dimple, hair patch, lipoma
• Enlarged bladder
• Vincent curtsey
• Anal tone, volitional contraction of pelvic floor
  muscles

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Urodynamic study

• Estimated bladder capacity (age2)x30 ml
• Infusion rate 10 of capacity
• Catheter lt6Fr intraurethral dual channel
  catheter, suprapubic catheter is preferable for
  pressure flow study
• Abdominal pressure by rectal catheter
• Pelvic floor EMG surface or needle
• Measuring bladder compliance, detrusor pressure,
  and EMG activities coordination

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Detrusor external sphincter dyssynergia (DESD)

• Type 1 Onset of EMG activity with initiation of
  voiding
• Type 2 intermittent inappropriate external
  sphincter contraction during voiding,which causes
  a reflex inhibition of detrusor contraction
• Type 3 Persistent increased EMG activity during
  filling and voiding phases, which causes large
  residual urine and incontinence
• Pseudodyssynergia presence of urodynamic DESD in
  neurologically intact patient

20
Leak-point pressures

• Detrusor leak-point pressure (DLPP) The detrusor
  pressure causing urinary leakage per urethrum in
  the absence of detrusor contractions
• A DLPP of more than 40 cm water has a risk of
  upper tract deterioration
• Valsalvar LPP (VLPP) Assessing urethral
  resistance by abdominal straining, a VLPP lt60 cm
  water indicates intrinsic sphincter deficiency

21
Indications for urodynamic study in children

• Spinal dysraphisms
• Spinal cord injury
• Cerebral palsy with voiding dysfunction
• Sacral agenesis
• Imperforated anus
• Diurnal enuresis
• Suspicious voiding dysfunction and UTI
• Dysfunctional voiding

22
Urodynamic studies in children with dysfunctional
voiding

• Uroflowmetry with surface EMG
• Cystometry with abdominal pressure and EMG
• Pressure flow study recording Pves,Pabd, Pdet,
  EMG activity, and uroflowmetry
• Videourodynamic study by suprapubic catheter or
  intra-urethral catheter

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Uroflowmetry flat flow pattern with
non-relaxing ES
24
Uroflowmetry Staccato pattern and poor relaxing
ES
25
Videourodynamics via cystostomy pressure flow
study
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Dysfunctional Voiding

• Associated with the followings
• Diurnal enuresis
• Urinary urgency
• Urinary frequency
• Constipation
• Urinary tract infection
• Vesicoureteral reflux

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Pathogenesis of dysfunctional voiding

• Increased voiding pressure during voiding with
  contraction of the urethral sphincter
• Dysfunctional bowel evacuation and constipation
• Treatment directed at urodynamic abnormalities
  reduce the incidence of breakthrough UTI and
  increase resolution of vesicoureteral reflux

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Typical spinning top voiding cystourethrography
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Development of dysfunctional voiding

• Long-standing pelvic floor dysfunction results in
  paradoxical sphincter contraction
• Pelvic laxity
• Inappropriate stimulation of guarding reflex
  results in inhibition of detrusor contraction

30
Detrusor instability without dyssynergic external
sphincter
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Dysfunctional voiding and Urinary tract infection

• Elevated postvoid residual urine
• Host resistance ability of bladder to wash out
  pathogens
• Well hydration, void with strong stream, and
  complete voiding are important in prevention of
  UTI
• Treatment aims at relaxation of the pelvic floor
  rather than the bladder

32
Recurrent UTI in siblings with Dysfunctional
voiding
33
Non-neurogenic neurogenic bladder Hinman syndrome

• The severest form of dysfunctional voiding
• Symptom complex including nocturnal enuresis,
  diurnal enuresis, constipation, encopresis, UTI,
  and upper tract dilatation
• Uninhibited detrusor contractions and dyssynergic
  external sphincter

34
Treatment of non-neurogenic neurogenic bladder

• Voiding retraining
• Biofeedback
• Anticholinergic therapy
• Hypnosis
• Psychotherapy
• Management of constipation
• Antibiotics
• Clean intermittent catheterization

35
Dysfunctional voiding and Vesicoureteral reflux

• Play a major role in etiology of congenital VUR
• Important in development of VUR in older child
  without congenital VUR
• Responsible for reflux exacerbation and renal
  scarring
• Therapy to VUR should aim at correction of
  dysfunctional voiding

36
Bilateral VUR in a girl with Dysfunctional voiding
37
Right VUR and DI without dysfunctional voiding
38
Resolution of VUR after Anticholinergic therapy
39
Urodynamic studies in infants

• High voiding pressures (160cm water) with low
  bladder capacity in infant with gross dilating
  reflux
• Voiding pressure in infant without reflux is 80
  cm water
• By age 2 years, voiding pressure diminished (70
  cm water) and capacity increased, but unstable
  detrusor remain

40
High voiding pressures in infancy

• Transient functional bladder outlet obstruction
• Boys with high grade reflux have dilated
  posterior urethra
• Higher voiding pressure is seen in children with
  grades IV and V reflux
• Normalization of voiding pressures explains high
  rate of reflux resolution in childhood

41
Urodynamic studies in older children

• Up to 60 of children with reflux have urodynamic
  abnormality
• Detrusor overactivity and sphincter
  dyscoordination
• Primary sphincter overactivity is more associated
  with high grade reflux and renal scarring
• Bladder instability improves over time

42
Pitfalls in urodynamic study in infants and
children

• Poor cooperation of patient
• Appropriate size of intra-urethral catheter 3
  Fr, 5 Fr, 7 Fr?
• Frequent increased abdominal pressure
• Different infusion rate and compliance in
  different age
• Differential diagnosis of volitional voiding and
  detrusor overactivity

43
Urodynamics and Clinical course of VUR

• Treatment of detrusor overactivity with
  anticholinergics improves resolution or
  improvement in VUR than stable bladders
• A higher surgery rate in stable bladder with VUR
• Controversy remains in correlation of urodynamic
  abnormalities with grades of VUR and
  anticholinergic treatment with resolution rate of
  VUR

44
Resolution of VUR and improved DI after
anticholinergic and CIC in myelomeningocele
45
Dysfunctional elimination syndromes (DES)

• Children are both infrequent voiders and
  constipated
• Associated with an increased risk of urinary
  tract infection
• With or without reflux
• Incontinent day and night with fecal soiling
• Observed to engage in holding maneuver to avoid
  urination and defecation

46
DES A learned habit

• A learned habit acquired during toilet training
• Most often occur in girls
• Recurrent cystitis due to short urethra and
  bladder colonization
• Congenital VUR or secondary VUR due to these
  aberrant toilet training habits

47
Breakthrough UTI and Dysfunctional voiding

• Girls with history of voiding dysfunction have
  higher rates of breakthrough UTI (4 times more
  common in DES)
• Unsuccessful surgical outcome was seen in
  children with DES
• Adequate hydration, timed voiding, stool
  softeners, laxatives, as well as anticholinergics
  may be helpful

48
Voiding dysfunction without UTI

• Children with mono-symptomatic enuresis have a
  very low urodynamic abnormality
• VUR has been found in child with frequency
  urgency and urinary incontinence without history
  of UTI
• 15 of children had positive urodynamic findings
  and 16 had renal scarring

49
Diurnal incontinence due to pelvic floor
hypertonicity DI
50
Urge incontinence in a girl with dysfunctional
voiding DI
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Treatment of Dysfunctional voiding in Children

• Adequate hydration and timed voiding
• Stool softeners and laxatives
• Anticholinergics Ditropan, tolterodine
• Biofeedback pelvic floor relaxation,
  computerized game
• Intermittent catheterization
• Antibiotics for recurrent UTI

52
Improved bladder compliance and DI after ditropan
therapy in myelomeningocele
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Adequate hydration

• Provide adequate urine production and wash out
  effect of bladder
• Prevent constipation and reduce colonization of
  pathogen in perineum
• Reduce detrusor instability through dilution of
  urine and decrease urine permeability into
  urothelium
• Time voiding is required

54
Medication for dysfunctional voiding

• Oxybutynin effective in reducing detrusor
  overactivity, side effects of mucosal dryness
  constipation
• Ditropan XL elimination of peak drug effect and
  reduce adverse effects
• Tolterodine M3 anticholinergic
• Alpha-adrenergic blocker to reduce urethral
  resistance
• Phenylpropanolamine, pseudoephedrine in ISD
  with incontinence ready for CIC

55
Pelvic floor rehabilitation

• Identification of pelvic floor muscles
• Regular pelvic floor muscle exercises provide
  adequate relaxation of pelvic floor including
  urethral sphincter
• A synergistic voiding pattern can be achieved
  after rehabilitation
• Combined with fluid and anticholinergic therapy

56
Biofeedback for pelvic floor muscle relaxation

• Correcting paradoxical contractions of pelvic
  floor and urinary sphincter muscles with voiding
• Success relies on motivation of children Uroflow-
  surface EMG integrated biofeedback
• Cystometry biofeedback to inhibit detrusor
  overactivity in patients with DI
• Visual or audio biofeedback may be more
  successful than verbal biofeedback

57
Biofeedback Pelvic floor muscle retraining
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Electrical stimulation to inhibit detrusor
overactivity
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CMG biofeedback to inhibit Detrusor overactivty
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Urethral injection of Botulinum A toxin in
dysfunctional voiding

• New technique in reducing urethral resistance by
  paralyzing striated urethral sphincter
• Intra-detrusor injection to reduce detrusor
  overactivity and increase bladder capacity
• Restoration of normal voiding pattern
• Repeat injection may be necessary

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Botulinum A toxin (Botox)
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Reduction of MUCP after Botulinum A toxin
injection
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Reduction of voiding pressure after Botulinum A
toxin