Lower Urinary Tract Dysfunction

Overview

More than 10% of kids have lower urinary tract dysfunction, which frequently necessitates contact with the healthcare system. It is critical to provide therapy since the condition is socially restrictive as well as intellectually and physically demanding for children and their parents.

Lower Urinary Tract Dysfunction, commonly known as dysfunctional voiding, is a disorder that affects many children. It is not a major problem, but it is certainly unpleasant. Dysfunctional voiding is thought to be caused by a lack of coordination between the bladder and the bladder outlet. Because to bladder muscle stiffness, the bladder will not empty completely.

Multiple signs and symptoms may arise, and no single pattern stands out: Urinary incontinence/leakage, painful voiding (Dysuria), frequency, infrequent voiding, urinary tract infections, urgency, incomplete emptying, and constipation are all symptoms of urinary incontinence/leakage. All of these signs and symptoms point to ineffective or disorganized bladder and bowel emptying.

The purpose of addressing dysfunctional voiding is to determine which characteristics are most common. The treatment for dysfunctional urination then focuses on increasing bladder and bowel elimination.

Definitions & Symptoms

The International Continence in Children Society (ICCS) has modified the standard definitions of widely used terms to characterize lower urinary tract function abnormalities in children as follows:

1. Frequency: The frequency can be raised or reduced. In a kid above the age of 5, increased frequency means 8 or more voids per day, and decreasing frequency means 3 or less voids per day.
2. Incontinence: It is defined as uncontrolled urine leaking that can be either continuous or intermittent. Continuous urine leakage is present almost exclusively in congenital defects, whereas intermittent pee leakage is prevalent in children above the age of five.
3. Enuresis: It describes intermittent incontinence at night and refers to any discrete leakage of urine at night. The term "diurnal enuresis" is no longer used; instead, "diurnal incontinence" or "daytime incontinence" is used to describe incontinence that occurs throughout the day.
4. Nocturia: It is defined as awakening to emptiness as opposed to waking as a result of enuresis. The sudden and unexpected need to urinate is referred to as urgency.
5. Voiding dysfunction: It has been used as a catch-all phrase to explain LUTD, however it is no longer an appropriate term.
6. Dysfunctional voiding: It depicts habitual urethral sphincter contraction and has been utilized when a uroflow pattern of staccato voiding is seen or validated by urodynamics. The ICCS has issued terminology for DV that widen the criteria to encompass cases of urodynamically confirmed muscle dysfunction associated with low flow.

Classifications of LUTD

The bladder cycle can be used to classify disturbances in lower urinary tract function in neurologically normal children. Overactive bladder syndrome, functional urinary incontinence, and laugh incontinence are all symptoms of the filling phase. DV, slow bladder syndrome, Hinman syndrome, and post-void dribbling are all examples of emptying phase disturbances.

These syndromes can be difficult to distinguish since they might exist as a single entity or in combination, and they can progress.

1. Overactive bladder (OAB): This condition is characterized by involuntary detrusor contractions and urethral instability. In the ICCS definitions, OAB has replaced "unstable bladder of childhood." This condition is present in one-third of children who have VUR with recurrent UTIs. OAB in children is caused by a sudden and overpowering need to urinate, which necessitates quick urethral compression by the pelvic floor or external procedures such as the Vincent curtsy. Constipation may arise from persistent pelvic musculature contraction in this illness. OAB syndrome can be diagnosed based on a history of incontinence linked to urgency and does not need urodynamic evidence of unrestrained detrusor activity.
2. Functional urine incontinence: it is the failure of the sphincteric system to maintain continence in physically normal children. True stress urinary incontinence, defined as an anatomic inadequacy of the sphincteric system to retain urine during transmission of abdominal pressures to the bladder, is uncommon in children.
3. Giggle incontinence: it is an uncommon disease in which large-volume incontinence occurs with laughter. This disorder may be a kind of cataplexy, as methylphenidate has been proven to ameliorate some of the symptoms. Recently, PFMR has been found to be a potential therapy approach.
4. Dysfunctional voiding (DV): is defined as an aberrant contraction of the voluntary sphincter mechanism during voiding, which is regarded to be an acquired condition that can lead to full bladder function loss. Uroflow investigations reveal staccato and fractionated voiding in these children. Constipation is prevalent in these children due to aberrant pelvic floor contractions. The term dysfunctional elimination syndrome (DES) is frequently used to characterize this condition since it accounts for the relationship between problems voiding and defecation caused by aberrant pelvic floor contraction.
5. Lazy bladder syndrome: It is characterized by a decrease of detrusor activity that necessitates the Valsalva maneuver to completely empty the bladder. Long-term fractionated voiding, which results in lack of normal detrusor function, is considered to be the etiology of this condition. Urodynamics may demonstrate significant bladder capacity with low detrusor pressures and high abdominal pressures during voiding in children who have a history of rare big voids.
6. Hinman syndrome: also known as occult neuropathic bladder, is a complete decompensation of the voiding mechanism. Children will appear with incontinence both during the day and at night, as well as persistent UTIs and constipation. Uninhibited detrusor activity during filling, high filling pressures, large post-void residual (PVR) volumes, and aberrant pelvic floor musculature activity after voiding are all common findings in urodynamic tests. The findings of imaging examinations are typically aberrant, with hydroureteronephrosis related to VUR being prevalent.
7. Post-void dribbling: It is a condition in which urine incontinence occurs shortly after micturition. This syndrome is more frequent in women and is considered to be caused by trapped pee in the vagina that leaks after standing. This condition is typically regarded as innocuous and disappears with age. It is best addressed by having the patient sit backward on the toilet with their legs spread far apart. When the child is able to void with a clean stream in this posture, he or she can void normally.

Constipation & LUTD

Constipation is described by the North American Society for Pediatric Gastroenterology and Nutrition (NASPGN) as "a delay or difficulty in defecation that has been present for 2 weeks or longer and is causing considerable concern to the patient."

Constipation is a cofactor in PFD that leads to voiding symptoms and should be included in therapeutic plans. The embryologic development of the pelvic floor, where both organs empty, and common innervations of sacral spinal nerves demonstrate the intimate relationship between bladder and bowel function. This relationship may be overlooked by physicians and parents of children with wetting issues.

In one research of children with enuresis, more than one-third of patients experienced constipation, despite only 14% of parents reporting any stooling issues. Children with constipation may appear with DV, large residual volumes, and reflux owing to intestinal distention that inhibits proper contraction. Constipation alleviation has been established as an independent risk factor in the treatment of VUR.

Treatment of constipation reduces UTIs, most likely through altering the intestinal flora. Constipation and rectal vault distention can cause urethral blockage, which may explain why constipation therapy lowers remaining urine volumes.

Evaluation of LUTD

DV symptoms generally appear immediately after toilet training in children. Children frequently continue to suffer incontinence during the day, at night, or both. The first examination of the patient history should focus on important questions about frequency, daily patterns of voiding, volume of voids, and sensations of urgency. Data on fluid intake, including caffeine use, may be obtained.

Birth history, developmental milestones, age of toilet training, toilet training difficulties, and behavioral or mental deficits should all be covered in the developmental history. A history of urinary tract infection and vesicoureteral reflux is also important. Any new stresses, such as a recent transfer, disruption in home life, recent separation from loved ones, or school performance, should be examined in the social history. Questions about constipation, soiling, and encopresis should be evaluated.

Parents are often unaware of their child’s bowel habits, including abdominal pain or anxiety associated with defecation. Voiding diaries are useful to accurately record fluid intake, frequency, urgency symptoms, incontinence episodes, voiding patterns, and voiding volumes. 

A careful physical examination should be performed to rule out any evidence of neurologic abnormalities. Examine the back for evidence of spinal dysraphism or sacral agenesis. A neurologic examination to measure limb strength and reflexes, gait, perineal sensation, rectal tone, and bulbocavernosal reflex is helpful in revealing any neurologic deficiency. An abdominal examination may indicate impacted stool in the colon. To guarantee patency, a genitourinary examination should focus on the urethral meatus. Perineal soiling or excoriation of the skin, as well as fecal staining of undergarments, may occur.

During the initial visit, a urinalysis with cultures and sensitivities should be performed. Ultrasonography of the kidneys and bladder with pre- or post-void volumes should be done on children with LUTD and recurrent febrile UTIs. Ultrasonography can detect thicker bladder walls, obstructive uropathy, and ureterocele. In individuals with proven UTIs, a voiding cystourethrogram (VCUG) is recommended. Spinning top deformity in females with DV, keyhole sign in boys with posterior urethral valves, VUR, ureterocele, and bladder trabeculation are all significant findings.

Full urodynamic investigations are considered invasive and should be reserved for children with neurogenic bladder dysfunction, severe DV, or symptoms that do not improve with treatment. Less intrusive uroflowmetry, perineal electromyography, and PVR are the recommended screening and monitoring modalities at the authors' institution. Before the flow study, bladder ultrasonography is done to assess appropriate volume and to eliminate individuals with overdistention of the bladder. 

Overdistention of the bladder can conceal findings, giving a false elevation in PVR volumes in normal children. A common uroflow pattern in children with DV is a staccato pattern with a low sustained flow rate. Children with detrusor underactivity have modest interrupted flows, abdominal straining, and big voided volumes.

Anatomic anomalies must be evaluated in the examination of males with OAB symptoms before starting treatment. Male patients may appear with complaints of frequency, urgency, or dysuria, as well as a flattened curve and no pelvic floor activity during flow investigations. A recent study from the authors' institution found that approximately half of these individuals had correctable surgical defects such as posterior urethral valves, strictures, or anterior urethral valves. Although the CNS has a role in OAB syndrome, these findings call into question the assumption that the CNS is the only cause of OAB.

An abdominal examination may be done to assess constipation, although rectal examinations are normally not conducted owing to the child's emotional disturbance. Constipation may be diagnosed and quantified using abdominal ultrasonography. In rare circumstances, an enlarged rectal diameter may suggest impaction.

Treatment of LUTD

The most effective treatment programs employ an increasing treatment program that begins with education and lifestyle modification and progresses to PFMR and pharmaceutical therapy. Conservative care is the first line of treatment for children who arrive with the primary symptom of incontinence or UTI and no anatomic abnormalities. Prior to more intrusive testing or treatment techniques, the focus should be on changing the child's urine and bowel habits in an attempt to alleviate incontinence and avoid UTI.

Bowel function management in the treatment of LUTD is one of the main goals in managing voiding symptoms, VUR, and UTIs. Many conservative treatment programs implement bowel management as a treatment strategy to manage LUTD. Programs differ in exact protocol; however, most emphasize education, increased hydration, timed voiding, correction of constipation, and proper hygiene. 

Education is a key component of the initial management for LUTD for voiding habits and hygiene. In one prospective study, education emphasizing timed voiding, fluid management, and pelvic floor exercises had a large impact of daytime incontinence, with nearly 60% of patients having improvement at the end of 5 years of treatment. In addition, education concerning proper posture during voiding should be emphasized to minimize abdominal musculature straining. Research has shown the link between abdominal musculature contraction and concomitant pelvic floor contraction. Proper sitting technique with buttock and foot support and comfortable hip position is necessary to enable voiding without recruitment of the abdominal muscles.

Education about hygiene is also helpful for limiting local skin irritation, which can lead to holding maneuvers and DV. Coordinated voiding with a relaxed pelvic floor can therefore be facilitated at the start of treatment. Constipation has been highlighted as an important component in the conservative approach to DV control. Constipation treatment alone has been found to alleviate lower urinary tract problems. Enuresis was treated in 63 percent of patients with constipation and incontinence in one trial by Loening-Baucke, while daytime incontinence was resolved in 89 percent. Resolving constipation also cured recurring UTIs in the same research. If fecal impaction is evident, the NASPGN recommends vigorous therapy with laxatives, stool softeners, and enemas.

Oral medications such as mineral oil or polyethylene glycol are effective. Phosphate soda, saline, or mineral oil enemas are recommended because they do not have the potential risk of toxicity that soap suds, tap water, or magnesium enemas carry. Oral and invasive rectal treatments are equally effective, although enemas have a faster resolution of impaction.

To be effective, fecal impaction must be addressed prior to starting maintenance medication. To maintain a target of one bulky bowel movement per day, a balanced diet, fiber supplements, and laxatives are advised. After conservative treatments have been tried, PFMR with biofeedback therapy is the next step. The goals of biofeedback therapy vary depending on the kind of LUTD, but the basic goal in each instance is to increase pelvic floor awareness in order to change the patient's voiding behaviors.

Biofeedback therapy focuses on relaxing and restoring normal flow in children with overactive pelvic floor. Using the guarding response of the pelvic floor musculature to preserve continence during unrestrained contractions can help children with overactive bladder and incontinence. Furthermore, biofeedback can educate young children how to empty properly and prevent decompensation of the detrusor muscle, which is common in lazy bladder syndrome.

There is no standard methodology for teaching biofeedback correctly, although there are two techniques in general. The first modifies flow by combining real-time flow rates observed by the patient with pelvic floor exercises. This approach is suggested for children who have pelvic floor hyperactivity but no OAB symptoms.

The procedure necessitates the use of a sophisticated flowmeter with immediate feedback. In some individuals, this sort of biofeedback may result in symptom relief in fewer sessions. The second approach employs pelvic and abdominal surface electromyography (EMG) to monitor activity and offer feedback to the patient on how these muscle groups are being used. The benefit of utilizing this strategy is that it can teach a guarding response in addition to pelvic floor relaxation during voiding. This form of biofeedback therapy may aid children with mixed DV more.

Follow-up

Close monitoring is essential for the effective treatment of pediatric urine incontinence. Children should be followed up with in the primary healthcare service once or twice a month to ensure that the family understands the therapy and that motivation levels are maintained. 

To allow the therapy to be assessed, a diary should be maintained to record pertinent information (e.g., wet/dry nights, daytime leaking, frequency of bowel movements). If therapy does not result in improvement over time, the child may be sent to a specialist in accordance with the priority-setting standards of the Directorate of Health.

Conclusion

LUTD is a prevalent condition that parents and clinicians may underreport. Although the prognosis is generally favourable, significant long-term consequences, such as renal failure, can occur.

A thorough history, physical examination, and step-by-step evaluation will establish the best therapy options. Advances in knowledge of the underlying pathophysiology of this widespread condition have resulted in a paradigm shift in care, shifting away from costly and possibly hazardous drugs and operations and toward non-invasive, successful behavioural adjustments.