Pediatric voiding dysfunction

Overview

Going to the toilet may appear to be a straightforward task, but there is a complex set of signals that ensure the bladder performs precisely what the brain tells it to do. Children may have difficulty retaining their pee if any of these signals is out of sync (urinary incontinence). If a kid over the age of four experiences urine incontinence and doctors are unable to pinpoint a particular anatomical or neurological reason, the child may be diagnosed with voiding dysfunction.

No one understands what causes voiding disorder, but the illness can have a physical, social, and psychological impact on children. Some kinds of voiding dysfunction, if left untreated, can result in vesicoureteral reflux (VUR) and long-term kidney damage.

 

What is Pediatric voiding dysfunction?

Voiding dysfunction is a prevalent condition in children, accounting for up to 40% of pediatric urology clinic visits. Doctors and nurses use the phrase "voiding dysfunction" to describe when a person's bladder does not empty regularly.

The bladder is like a balloon within your body that fills up with pee. Consider yourself to be clutching an inflated balloon. These fingers are working like a sphincter. Like the bladder muscles, the other hand rests on and around the balloon (called the detrusor muscles). 

To best empty the balloon, relax the fingers that are keeping the balloon's neck shut and squeeze down with the other hand. It takes considerable coordination to relax one hand while squeezing down with the other. When you urinate, the sphincter and bladder behave exactly as they should: the sphincter relaxes while the bladder muscle contracts.

Infants urinate often via detrusor (bladder muscle) contraction, with modest voided volumes and inadequate bladder emptying. The bladder's capacity rises with age. The bladder-sphincter system coordination grows, resulting in improved bladder-emptying ability.

 

Normal Voiding 

When we are newborns, our bladders fill and empty on their own. Our sphincter muscles relax during urinating. This sort of urination is caused by a spinal cord reflex. As we become older, we learn to suppress this response by sending signals to our brain. Our brain discovers that it has the ability to control when the bladder contracts as well as prevent it from contracting. This form of bladder brain control is how children should be toilet trained.

The onset of cerebral control over the bladder in children varies. Most, but not all, youngsters in the United States have achieved this level of control by the age of four. Children who have not yet established cerebral control over their bladder may attempt to keep dry by clenching their sphincter muscles at the same time their bladder attempts to empty. When attempting to hold back urinating, a youngster may cross his or her legs or squat.

It is uncertain why most children establish the tendency of tightening their sphincter muscles at the same time their bladder contracts. Unfortunately, once toddlers develop this habit, it is difficult for them to learn to relax these muscles when attempting to pee. Most children with voiding problems have aberrant sphincter muscle activation.

Lower urinary tract dysfunction in children comprises a wide range of disorders. Urgency, frequency, and incontinence might be temporary, intermittent, or permanent. Transient voiding symptoms are prevalent as a result of a urinary tract infection (UTI), nonspecific urethritis, or periurethral irritation caused by vaginitis. Symptoms may sometimes appear without a known cause. Physical examination of a kid with voiding dysfunction reveals no remarkable abnormalities; nonetheless, a comprehensive examination should be undertaken to rule out alternative causes of voiding symptoms.

 

Constipation as a common cause of Voiding Dysfunction

There is a link between fecal retention and voiding dysfunction. When a kid has a voiding condition, persistent constipation may be the major cause of bladder dysfunction.

Constipation's effects on bladder function may be due to the direct effect of retained fecal material distending the rectosigmoid colon, or it may be due to shared neurological input.

Many children and families are hesitant to talk about their stooling past. Neither the kid nor the parent appears to have appropriate knowledge on the frequency or nature of stooling.

Indicators of constipation include the following:

• Infrequent passage of stools
• Small, hard stools or elongated, wide-bore stools
• Encopresis
• Palpable stool on abdominal examination
• Soiling in the underwear (often misinterpreted as being due to improper or careless wiping)
• Large quantities of stool in the colon, especially the rectosigmoid area as seen on abdominal radiography

 

Types of Voiding Dysfunction and Their Symptoms

Lower urinary tract dysfunction in children comprises a wide range of disorders. Symptoms may sometimes appear without a known cause.

• Overactive Bladder (OAB). Children with OAB have an intense desire to urinate even if their bladder is not full, and they may go to the bathroom more than 10 times a day, or approximately every hour. Most children with OAB will experience urine incontinence and urinary tract infections (UTIs), and these symptoms may persist even after the UTI has been treated. Some youngsters may attempt (in vain) to "hold it" by crossing their legs or engaging in other physical actions. OAB is the most frequent kind of voiding disorder, affecting around 22% of children aged 5 to 7 years.
• Dysfunctional Voiding. The muscles that govern the flow of urine out of the body do not entirely relax in this form of malfunction, and the bladder never completely empties. This results in a variety of symptoms including daytime wetness, nighttime wetting, the sensation that the bladder is always full, urgency, and straining to pee. Children with severe cases of dysfunctional voiding may acquire symptoms similar to those of a neurogenic bladder (a bladder that does not function owing to an underlying neurological reason) and are more likely to develop problems such as kidney infection and disease.
• Underactive Bladder. Children with an underactive bladder pee less than three times per day or can spend more than 12 hours without urinating. Because the bladder muscle is "weak" and does not respond to the brain's signal that it is time to go, these youngsters must strain to urinate. The bladder becomes excessively full and overflows, resulting in accidental wetting with an underactive bladder.

 

How is Voiding Dysfunction Diagnosed?

If your kid exhibits the symptoms indicated above, he will almost certainly be sent to a pediatric urologist for assessment. The urologist will most likely ask you to keep a voiding diary and will collect a history of your child's voiding patterns. This is possibly the most crucial aspect of appropriately detecting a faulty voiding pattern.

A comprehensive physical examination, urinalysis, and urine culture are routinely performed after this. A radiologic and urodynamic evaluation (a complete examination of bladder function) may be performed to establish the diagnosis of a dysfunctional voiding pattern as well as to record its aftereffects.

The intensity and nature of your child's symptoms will require further urinary tract investigation. The following tests may be recommended by your child's doctor:

• Voiding cystourethrogram (VCUG) — A specific x-ray that examines well your child’s urinary tract. The images will show if there is any reverse flow of urine into the ureters and kidneys.
• Radionuclide cystogram (RNC) — An RNC is similar to a VCUG except a different fluid is used to highlight well your child’s urinary tract.
• Renal ultrasound — The test is used to determine the size and shape of well your child’s kidney, and to detect a mass, kidney stone, cyst, or other obstruction or abnormalities.
• Intravenous pyelogram (IVP) — An IVP reveals the rate and path of urine flow through the urinary tract.
• Blood tests — To see how well your child’s kidneys are working.

 

How is Voiding Dysfunction Treated?

Most treatments begin with a scheduled voiding regimen in which you will urge your child to use the restroom as soon as he wakes up, every two to three hours afterwards, and before going to bed at night.

It is also critical that your youngster relax totally when peeing. These minor adjustments are frequently sufficient to assist your youngster in resolving the issue. However, in certain children, medication may be required to reduce bladder hyperactivity sufficiently to allow for attempted improvements in voiding patterns.

Extensive reconstructive surgery, such as bladder augmentation which involves adding a section of the intestine or stomach to the bladder to improve bladder capacity, may be required in rare cases.

If your kid also has vesicoureteral reflux, that problem may improve on its own. If it does not, it may require surgical treatment. See our article on vesicoureteral reflux for a more detailed explanation. All disorders can be successfully treated with drugs, bladder "training," or both, depending on the kind of voiding dysfunction.

1. Overactive Bladder (OAB): 

If your kid is young and has no other urinary tract issues, we may prescribe a wait-and-see strategy in the hopes that the condition may resolve itself. Some lifestyle modifications, such as having your kid avoid coffee, urging him or her not to postpone urinating, and addressing constipation if it happens, may assist with the symptoms. If the condition persists, pharmaceutical therapy may be a possibility. Ditropan and Detrol are the most often prescribed medicines for hyperactive bladder in children.

These drugs are used one to three times each day to assist lessen bladder spasms, allowing the bladder to fill more completely without having to empty it. Red face, dry mouth, diarrhea, tiredness, decreased perspiration, impaired eyesight, and personality changes are all possible side effects.

Most children accept these drugs without major complications, but if your kid develops adverse effects, you should call his or her doctor. Your child's doctor may advise lowering the dose or discontinuing the drug entirely. If the meds work, we usually recommend continuing them for 6 months, after which you can discontinue them and observe how your kid fares without them.

2. Dysfunctional Voiding: 

Most therapies for dysfunctional urination concentrate on retraining the brain and relaxing the bladder. Children are taught that regular urinating does not include pressing the abdominal muscles, but rather releasing pelvic and bladder muscles. A scheduled voiding program is an essential component of bladder retraining. Biofeedback and Kegel exercises (pelvic floor relaxation and contraction) can also be useful in managing dysfunctional urination. The doctor may also prescribe medication to help the bladder relax.

3. Underactive Bladder: 

The primary treatment for overactive bladder is behavioral. Children are put on a scheduled toilet schedule and are required to use it whether or not they have the desire to urinate. Medications that relax the bladder can be beneficial as well. Children with extremely big bladders who are unable to pee may require brief catheterization. Transcutaneous Electrical Nerve Stimulation (TENS) has also been demonstrated to benefit these youngsters.

Another important aspect of successful therapy is addressing any constipation the kid may have. According to studies, practically all children with voiding disorder also experience constipation. Many children's bladder problems may improve or disappear after the constipation is addressed.

 

Follow-up

Your kid's doctor will want to check in with you and your child to ensure that everything is well. Preventing urinary tract infections is critical, as is ensuring that any other related issues, such as vesicoureteral reflux, bladder dysfunction, or kidney difficulties, are properly managed.

The key to preventing voiding dysfunction is to detect it early, correct it, and limit the detrimental impact it may have on your child's urinary system.

 

Frequency-urgency syndrome of Childhood

Frequency-urgency syndrome can strike unexpectedly, and children suffering from it may need to use the restroom every 10 minutes. Most children had no voiding issues previous to developing the urge to urinate regularly, and they can normally sleep through the night without wetting the bed or waking up to use the toilet. This condition normally resolves itself, although it might linger for months, a year, or longer. Children with this condition are normally normal in every manner except that they have a strong need to pee even when there is no or very little urine in their bladder.

We visit some youngsters because they have urinary tract infections and their caregivers note that they only use the restroom two or three times a day. Holding urine for extended periods of time might allow bacteria to enter the bladder and cause illness. Urination aids in infection prevention by flushing germs from the bladder. Even if they do not feel the need to go, children should urinate at least six times every day.

 

Prognosis

For children with daytime urine incontinence and detrusor instability, the prognosis for total or partial remission of a functional voiding problem is favorable.

Adult OAB or voiding dysfunction appears to be more common in children with voiding disorder. Several studies have found that female childhood incontinence is a risk factor for urge symptoms and severe incontinence in adulthood.

Children with giggle incontinence (involuntary total bladder evacuation caused by laughter) usually outgrow it throughout puberty. In children with this illness who were treated for detrusor instability, a resolution rate of 89 % was recorded. Children with underactive bladder syndrome have a decent prognosis as well. However, the outlook is bleak for the few children with defective voiding whose condition does not respond to treatments.

 

Complications

Children who wet their pants throughout the day had a greater risk of parent-reported psychological difficulties than children who do not wet their pants during the day. This has been observed in youngsters as early as seven years old.

Daytime wetness can significantly interrupt the social lives of older children. Daytime wetness may have a detrimental impact on self-esteem and is a major source of stress in school-age children. At a survey of 2000 youngsters, peeing in school was ranked third only to parental death and turning blind in terms of probable stressful occurrences.

Chronic dampness can cause skin irritation and rashes. Skin deterioration in children should be checked. Tinea patients may potentially benefit from topical antifungal medication. Recurrent infections can induce dilatation of the upper urinary tract (hydronephrosis) and kidney injury in rare circumstances. High storage pressures cause dilatation of the upper tract. This pressure has the potential to cause additional reflux. Kidney damage is caused by high blood pressure and kidney infections.

A few children with functional voiding disease have significantly defective voiding and may sustain considerable kidney injury. The usual pathophysiology is inappropriate constriction of the external urinary sphincter during voiding and consequent rise of the intravesical pressure. The most common clinical characteristics are daytime or nighttime wetness, recurrent UTI, constipation, and increased postvoid residual urine volume in the absence of a neurologic impairment.

 

Conclusion 

Going to the restroom isn't always as straightforward as it appears. Urinating, in reality, necessitates a sequence of synchronized signals and reactions from the brain and the lower urinary tract. A number of voiding issues can arise in youngsters. This collection of illnesses characterized by difficulties urinating is referred to as dysfunctional voiding.

Voiding dysfunction is a wide term that refers to a variety of diseases that disrupt muscular coordination in the lower urinary tract. The symptoms of voiding dysfunction might vary depending on the issue your child has. It is most commonly diagnosed in children over the age of four who have a definite anatomical or neurological diagnosis of frequent urination or urine incontinence. There are several treatments and therapies that may assist your child in regaining bladder control. Based on your child's diagnosis and treatment objectives, the care team will go through each therapy choice with you.