FUNCTIONAL VOIDING FUNCTIONAL VOIDING DISORDERSDISORDERS

NON-NEUROGENIC LOWER NON-NEUROGENIC LOWER URINARY TRACT URINARY TRACT DYSFUVCTIONDYSFUVCTION

Dr. H. Al-Hazmi

DYSFUNCTIONAL DYSFUNCTIONAL ELIMINATION SYNDROMS OF ELIMINATION SYNDROMS OF

CHILDHOODCHILDHOOD[ DES][ DES]

DESDES

• Syndrome with inclusive categorization Syndrome with inclusive categorization of all functional bladder, sphincteric and of all functional bladder, sphincteric and gastrointestinal disorders that gastrointestinal disorders that pathologically affect the pediatric pathologically affect the pediatric urinary tracturinary tract

• TWO GROUP:TWO GROUP:

1-Harmful 1-Harmful 2- harmless 2- harmless

Group 1Group 1

1) Hinmans syndrome1) Hinmans syndrome 2)Unstable bladder 2)Unstable bladder

3) Infrequent voiding 3) Infrequent voiding syndrome syndrome 4) Functional bowel 4) Functional bowel disturbances disturbances

GOUP 2GOUP 2

1) Giggle incontinence1) Giggle incontinence2) Post-void dribbling2) Post-void dribbling

3) Daytime time urinary 3) Daytime time urinary frequency syndrome frequency syndrome4) Nocturnal enuresis4) Nocturnal enuresis

EVALUATION:EVALUATION:

• GoalGoal: to differentiate between : to differentiate between benign disturbances from those benign disturbances from those harmfulharmful

• Include: Include: – HistoryHistory– Physical examinationPhysical examination– Urine analysis,cultureUrine analysis,culture

• UltrasoundUltrasound• MCUGMCUG• UrodynamicUrodynamic• EndoscopyEndoscopy

HINMANS SYNDROMEHINMANS SYNDROME

THE NON-NOEUROGENIC THE NON-NOEUROGENIC NEUROGENIC BLADDER NEUROGENIC BLADDER

• Functional obstruction occur during Functional obstruction occur during voiding to produce severe clinical voiding to produce severe clinical manifestation manifestation

• After toilet training and before After toilet training and before pubertypuberty

• Complex symptomsComplex symptoms• And /Or stressful family And /Or stressful family

environment environment

• Physical and neurologicalPhysical and neurological N N– Apart from palpably large bladderApart from palpably large bladder

• Rectal: good anal tone, +/- fecal Rectal: good anal tone, +/- fecal impactionimpaction

• X- ray and MRI of spine X- ray and MRI of spine N N • Radiographic studies of UT Radiographic studies of UT

abnormalabnormal

• VCUG:VCUG:– Neuropathic bladderNeuropathic bladder– Bladder neck and urethra non obstructingBladder neck and urethra non obstructing– VUR in 50%VUR in 50%

• Ultrasound:dilatation, damageUltrasound:dilatation, damage• Endoscopy:Endoscopy:

– no obstructionno obstruction– bladder : bladder :

trabiculation, saculation,...trabiculation, saculation,...

• Urodynamic:Urodynamic:- DSD with dilatation of - DSD with dilatation of posterior urethra posterior urethra --bladder instability with signs bladder instability with signs of of impaired or obstructed impaired or obstructed bladder emptying in the bladder emptying in the absence of anatomical or absence of anatomical or neurological disease. neurological disease.

Etiology: Etiology:

• Debated Debated • Persistence of pattern of voiding Persistence of pattern of voiding

that is transitional between infant that is transitional between infant and adult typeand adult type

• Developed from overlearnd Developed from overlearnd response to bladder instabilityresponse to bladder instability

Treatment: Treatment:

• Generally follow the lines of Generally follow the lines of treatment NGBtreatment NGB

• Bladder function most be restored Bladder function most be restored to normalto normal

• Bladder retraining program with Bladder retraining program with biofeedback technique:biofeedback technique:

* upper tract not involved* upper tract not involved*excellent result*excellent result

• Normalization of bladder function Normalization of bladder function

• Pharmacologic therapy: Pharmacologic therapy: - According to UD findings - According to UD findings

• Psychological counseling as Psychological counseling as needed needed

• CIC: *bladder de-compensation CIC: *bladder de-compensation *upper tract dilatation and *upper tract dilatation and damagedamage

• Secondary effect as VUR, Secondary effect as VUR, hydronephrosis improve hydronephrosis improve spontaneously after bladder spontaneously after bladder function restored to normalfunction restored to normal

THE UNSTABLE BLADDERTHE UNSTABLE BLADDER

Bladder hyperactivity Bladder hyperactivity occurring during bladder occurring during bladder felling felling

1.1. URGENCY INCONTINECE URGENCY INCONTINECE SYNDROMESYNDROME

2.2. SMALL CAPACITY HYPER SMALL CAPACITY HYPER TONIC SYNDROMTONIC SYNDROM

3.3. CONTINENT BLADDER CONTINENT BLADDER INSTABILITYINSTABILITY

• The most common pattern of The most common pattern of urinary dysfunctional in childhoodurinary dysfunctional in childhood

• 57% of symptomatic children aged 57% of symptomatic children aged 3 to 14 years3 to 14 years

• Does not represent neuropathy Does not represent neuropathy • Either Either persistencepersistence of infant bladder of infant bladder

instability or instability or acquiredacquired

Pathophysiology:Pathophysiology:

• The unstable contraction are The unstable contraction are involuntary and insuppressible involuntary and insuppressible

• The child attempting to maintain The child attempting to maintain continence during contractioncontinence during contraction

DYSSYNERGIADYSSYNERGIA

. NO urodynamic abnormality during . NO urodynamic abnormality during voidingvoiding

Urgency-incontinence Urgency-incontinence Syndrome Syndrome

• 60-70% of affected patients60-70% of affected patients• Bladder instability + weak or Bladder instability + weak or

absent sphincteric responseabsent sphincteric response• HarmlessHarmless• Vincents curtseyVincents curtsey• UD: instability +minimal UD: instability +minimal

dyssynergia or obstructiondyssynergia or obstruction• U/S and MCUG: NORMAL U/S and MCUG: NORMAL

Small-capacity hyper-tonic Small-capacity hyper-tonic bladderbladder

• More prominent urgency and More prominent urgency and incontinenceincontinence

• More obvious bladder –sph. Dyssynrgia More obvious bladder –sph. Dyssynrgia causing obstructioncausing obstruction

• Functional bladder capacity reduced Functional bladder capacity reduced • Due to repetitive functional obstruction Due to repetitive functional obstruction

during unstable contraction during unstable contraction

Continent bladder instabilityContinent bladder instability

• One third of children with instabilityOne third of children with instability• Ability to overcome forceful bladder Ability to overcome forceful bladder

contraction by extemly tight sphincter contraction by extemly tight sphincter constrictionconstriction raised intravesival raised intravesival pressurepressure

• Recurrent UTIRecurrent UTI• MCUG: - trabiculation...…MCUG: - trabiculation...…

- VUR in 50%- VUR in 50%

TREATMENT TREATMENT

• With maturation contraction cease With maturation contraction cease in most children in most children

• GoalGoal : to eliminate unstable : to eliminate unstable contraction without interfering with contraction without interfering with normal voidingnormal voiding

• Anti-cholinergicAnti-cholinergic is the mainstay of is the mainstay of treatment treatment

• Other : fluid Other : fluid restriction,elimination of restriction,elimination of caffeine,frequent voidingscaffeine,frequent voidings

• Treatment of constipationTreatment of constipation

• Successful therapy :Successful therapy :*80% eliminating symptoms*80% eliminating symptoms*complete resolution 2.5 y*complete resolution 2.5 y*eliminate recurrent infection*eliminate recurrent infection*hasten the resolution of *hasten the resolution of refluxreflux

INFREQUENT VOIDINF INFREQUENT VOIDINF SYNDROMESYNDROME

• More common in girlsMore common in girls• Simple voiding infrequentlySimple voiding infrequently to bladder to bladder

decomensationdecomensation• History is the mainstay of diagnosisHistory is the mainstay of diagnosis• Cause Cause

megacystismegacystis behavioralbehavioral psychogenicpsychogenic– ? End stage after bladder instability ? End stage after bladder instability

• Diagnostic study usually normalDiagnostic study usually normal• UD: - normal except large capacity UD: - normal except large capacity

bladderbladder

Management: Management:

-Patient education -Patient education - Bladder retraining with timed Bladder retraining with timed

voidingvoiding- Correction of fecal retentionCorrection of fecal retention- CIC: *severe infrequent voidingCIC: *severe infrequent voiding

*bladder decompensation*bladder decompensation

*urine retention *urine retention

FUNCTIONAL BOWEL FUNCTIONAL BOWEL DISTURBANCESDISTURBANCES

• Long, historical relationship exist in Long, historical relationship exist in children among bladder dysfunction, UTI children among bladder dysfunction, UTI and functional GIT disorders and functional GIT disorders

• When constipation treated recurrent UTI When constipation treated recurrent UTI reduced to 20% (88%)reduced to 20% (88%)

• Bladder instability could be produced by Bladder instability could be produced by constipation constipation

• Diagnosis of constipation:Diagnosis of constipation:

- infrequent passage of stools- infrequent passage of stools

- small, hard stools - small, hard stools

- elongated ,wide-bore stools- elongated ,wide-bore stools

- skids mark in the underwear- skids mark in the underwear

- encopresis- encopresis

- palpable stool on abdominal exam.- palpable stool on abdominal exam.

- abdomial x-ray- abdomial x-ray

Treatment:Treatment:

• Initial clean-out with laxatives and Initial clean-out with laxatives and enemas, followed by maintenance enemas, followed by maintenance program that combine oral laxative program that combine oral laxative and/or stool softeners with dietary and/or stool softeners with dietary manipulation manipulation

GIGGLE INCONTINENCE GIGGLE INCONTINENCE

• Common in girlsCommon in girls• Laughter is the most common Laughter is the most common

precipitating eventsprecipitating events• Cause unknown Cause unknown • UD: detruosr hyper-reflexia or UD: detruosr hyper-reflexia or

tetanic detrusor contraction during tetanic detrusor contraction during laughter laughter

• Completely normal voiding habits Completely normal voiding habits aside from incontinence aside from incontinence

• Treatment:Treatment:

- frequent voiding- frequent voiding

- anticholinergic medication- anticholinergic medication

Post-void Dribbling Post-void Dribbling

• Occurs in normal girls after toilet Occurs in normal girls after toilet trainingtraining

• Viding normal and dry night Viding normal and dry night • Result from vaginal refluxResult from vaginal reflux• Observed during MCUGObserved during MCUG• Improves with ageImproves with age

• Treated by two simple measureTreated by two simple measure

(1) Voiding by facing the back of (1) Voiding by facing the back of commodecommode

(2) After voiding and while (2) After voiding and while setting setting the child leans the child leans forward to touch forward to touch her toes her toes with her hands with her hands

Daytime urinary frequency Daytime urinary frequency syndrome syndrome

• Relatively commonRelatively common• Sudden,severe,and often dramatic Sudden,severe,and often dramatic

daytime urinary frequency without daytime urinary frequency without incontinence in healthy young incontinence in healthy young childrenchildren

• Stop with sleepStop with sleep• Natural history:Natural history: spontaneous spontaneous

resolution after several months resolution after several months

• Cause unknownCause unknown

- Seasonal variation- Seasonal variation

- psychosocial stresses- psychosocial stresses

- hyper calciuria (30%)- hyper calciuria (30%)

. Diagnosis by exclusion. Diagnosis by exclusion

. No known therapy. No known therapy

. Reassurance of family . Reassurance of family

ENURISISENURISIS

• Involuntary discharge of urineInvoluntary discharge of urine• Nocturnal - Diurnal – MixedNocturnal - Diurnal – Mixed• Primary – SecondaryPrimary – Secondary• Mono-symptomatic – Polysympt. Mono-symptomatic – Polysympt.

• 15% of children still wet at night at 15% of children still wet at night at age 5 yearsage 5 years

• 50% common in boys50% common in boys• 15% resolution rate per year15% resolution rate per year• 80% only at night and no other 80% only at night and no other

abnormalities abnormalities MNE MNE

NOCTURNAL ENURESISNOCTURNAL ENURESIS

Etiology:Etiology:

• MNE symptoms rather than a MNE symptoms rather than a diseasedisease

• Multiple theories but no single Multiple theories but no single explanationexplanation

• Multiple factors may operate in Multiple factors may operate in each individual each individual

Theories :Theories :

• 1- sleep factors:1- sleep factors:

* NE not related to sleep * NE not related to sleep pattern, depth of sleep, or pattern, depth of sleep, or sleep arousal pattern sleep arousal pattern

2- Alteration in vasopressin secretion 2- Alteration in vasopressin secretion ::

- lack of circadian rhythm- lack of circadian rhythm

- Bladder fullness - Bladder fullness stimulate AVP stimulate AVP

- Developmental delay - Developmental delay

• 3- Developmental delay.3- Developmental delay.• 4 - hereditary factors4 - hereditary factors

* if both parents: 77% child NE* if both parents: 77% child NE

* IF one parent : 44% child NE * IF one parent : 44% child NE

. 5 - Organic UT disease . 5 - Organic UT disease

. 6 - Miscellaneous factors . 6 - Miscellaneous factors

Evaluation Evaluation

• History, P/E, Urinalysis + C/SHistory, P/E, Urinalysis + C/S• Radiographic studies are not Radiographic studies are not

indicated when the screening indicated when the screening evaluation is evaluation is negativenegative

Characteristics of a negative Characteristics of a negative screening evaluation for NE screening evaluation for NE

• Age prepubertalAge prepubertal• Enuresis has been lifelongEnuresis has been lifelong• Wetting occurs only at nightWetting occurs only at night• No daytime symptomsNo daytime symptoms• No history of UTINo history of UTI• Negative U/A and C/SNegative U/A and C/S• Normal P/E Normal P/E

Urodynamic :Urodynamic :

• Reduced functional bladder Reduced functional bladder capacitycapacity

• Unstable bladder contraction noted Unstable bladder contraction noted in15-20% with pure MNEin15-20% with pure MNE

• Unstable bladder contraction are Unstable bladder contraction are not the cause for sleeping wetting not the cause for sleeping wetting in MNEin MNE

TRATEMENT TRATEMENT

• Started after 7 years of ageStarted after 7 years of age• GeneralGeneral

1- Maintain a voiding diary1- Maintain a voiding diary2- D/C fluid intake 2h before 2- D/C fluid intake 2h before sleepsleep

3- Void before sleep3- Void before sleep

A-pharmacologic therapyA-pharmacologic therapy

• 1- Anticholinergic (oxybutynin)1- Anticholinergic (oxybutynin)* no role in management of * no role in management of

MNE MNE. 2- Desmopresin (DDAVP). 2- Desmopresin (DDAVP) * more effective in reducing * more effective in reducing the the

number of wet nights per number of wet nights per week week than at curing than at curing bedwetting bedwetting

. 3- imipramine . 3- imipramine

B- Behavioral modification:B- Behavioral modification:

1- Bladder retraining: 1- Bladder retraining:

* retention control training* retention control training

* to reverse functional * to reverse functional bladder capacity bladder capacity

2- Responsibility reinforcement 2- Responsibility reinforcement

*required motivated child, *required motivated child, conscientious parents and conscientious parents and close close rapport between the rapport between the physician physician and familyand family

* Gold star chart* Gold star chart

3- conditioning therapy3- conditioning therapy– using the urinary alarm is using the urinary alarm is

the most effective of the most effective of eliminating bedwettingeliminating bedwetting

– cure rate : 60-100%cure rate : 60-100%– Relapse : 24%Relapse : 24%

THANK YOUTHANK YOU