Paediatrics 4
Wet child
James Dyer
Amar Mohee
Rosie Blades
Topics covered
• Lecture
– LUT development and physiology
– Assessment
– Nocturnal +/- daytime leakage
• Pathogenesis
• Treatment
• Viva
– When would you perform urodynamics in a child?
– What is the treatment of bedwetting in an 8 year old child?
– What are the causes of haematuria in a child?
• What investigations should you do?
Resources
• Campbell-Walsh Urology 10th Ed.
• NICE guidance CG:111
– http://www.nice.org.uk/guidance/cg111/resources/guidancenocturnal-enuresis-pdf
– http://www.nice.org.uk/resource/CG111/pdf/c/cg111nocturnal-enuresis--the-management-of-bedwetting-inchildren-and-young-people-fullguideline?id=luljkuc7mvszqltghld2lot62y
• ICCS guidelines/standardization document
– Neveus et al. The Standardization of Terminology of Lower
Urinary Tract Function in Children and Adolescents: Report From
the Standardization Committee of the International Children’s
Continence Society (ICCS). 2007 Neurology and Urodynamics
Development of normal adult bladder
function
• Normal pattern dependent upon
– Intact neurological function
– Awareness of social norms
– Changes in bladder physiology
– Maturation of detrusor sphincter coordination
– Progressive development of control of perineal
sphincter complex
• Usually achieved by 3-4 years of age
Development of normal adult bladder
function
• Continence is dependent upon three changes
– Increased bladder capacity
– Maturation of voluntary control of urethral
striated muscle sphincter
– Development of volitional control over the
bladder-sphincteric unit so that the child can
voluntarily initiate or inhibit the micturition reflex
Anatomy
• Bladder easily palpable when full
• External urinary sphincter – cylindrical,
accentuated anteriorly
– Inner smooth muscle and outer striated muscle
• Males – extending from apex of urethra to invest
membranous urethra
• Females – Bladder neck to mid urethra
• Internal sphincter
– Smooth muscle fibres continuing from bladder base
and trigone to traverse bladder neck to proimal
urethra
Bladder Innervation
Changes in bladder functional
parameters
• Voiding frequency
– Increase in bladder volume proportionally greater
than increase in urine production
• 6-12 months – 10-15 times/day
• 2-3 years – 8-10 times/day
• Bladder capacity estimation
– Infants
• 38+2.5 x age(months)
– Holdahl et al. 1996 J urol
– Older children
• 30 x (Age(years)+2)
Changes in bladder functional
parameters
• Emptying efficiency
– Increases
• Voiding detrusor pressure
– Pdetmax higher than in adults (120mmH20 vs. 80
mmH2O)
– Typically falls after 1 year
• No voiding during sleep
– Contradicting belief of no cortical control
• Yeung et al. Br J Urol 1995
Transitory detrusor-sphincter
discoordination - Staccato voiding
Etiologic classification of bladder
dysfunction
Disorders of
detrusor sphincteric muscle
Derangement of
Nervous Control
Structural
Abnormalities
Congenital
Acquired
Congenital
Acquired
Congenital
Acquired
SB
CP
MD
Chronic
bladder
distension
Extrophy
Traumatic
stricture
Tethered
Cord
MS
Spinal cord
injury
Detrusor
fibrosis
Epispadias
Cloacal
abnormality
Developmental
Ureterocele
Mental retardation
PUV
Dysfunctional Voiding
Sphincter
damage
Other Unclassified
Giggle
incontinence
Hinman
Syndrome
Ochoa syndrome
Wet Child - Assessment
• History
• Examination
• Investigations
– Initial assessment aims at establishing diagnosis
• Excluding organic causes
– UTI – Paeds 2
– Neuropathic bladder - Paeds 6
Incontinence: Subdivisions
Children >5 years
All ages
Congenital malformation
Iatrogenic injury
Wet Child - History
• Commencement of symptoms
– Recent onset more indicative of systemic illness
• Previously dry for >6months
– Any triggers
• Pattern of bedwetting
– Nights per week, times per night, time of night, does the
child wake
• Daytime symptoms
• Abnormal voiding frequency
– Useful from attainment of bladder control or 5 years of age
• 4-7 times during daytime hours
History
• Hesitancy
• Urgency
– Older
children/adolescents
• Straining
• Weak stream
• Intermittency
– Physiological until 3 years
• Holding maneuvers
– Relevant from age 5
• Incomplete emptying
– Relevant from
adolescence
• Post-micturition dribble
• LUT pain
• Concurrent
–
–
–
–
Constipation
Learning difficulties
Behavioral problems
Family
problems/safeguarding
issues
Examination
• Inspection
– Congenital abnormalities
• Epispadias
– Spinal abnormalities
• Hairy patch/dimple
• Asymmetric gluteal folds
• Dermovascular malformations
– Muscle wasting
• Palpation
– Bladder
– Enlarged kidneys
• BOO/neuropathic bladder
– Lower limb reflexes
Investigation
• Bladder diary
– Polyuria >2l/m2 body surface area
– Nocturnal polyuria (nappy weights) >130% of EBC
• USS
• Urine flow measurement
– Qmax most useful variable
• Artifacts are common therefore repeated measurements
useful
– Qmax2 > vol likely to be normal
» Szabo 1995 Br J Urol
– Used to screen for requirement for CMG
Bladder diary
ICCS expected information
Flow rates - EMQ
Investigation
• Bladder diary
– Polyuria >2l/m2 body surface area
– Nocturnal polyuria (nappy weights) >130% of EBC
• USS
• Urine flow measurement
– Qmax most useful variable
• Artifacts are common therefore repeated measurements useful
– Qmax2 > vol likely to be normal
» Szabo 1995 Br J Urol
– Used to screen for requirement for CMG
– Normal – bell shaped curve
•
•
•
•
BOO – low amplitude
OAB – explosive voiding contraction
Interrupted – detrusor failure
Staccato – sphincter overactivity
Post void residual volume
• Normal infants/toddlers empty to completion
once every 4 hours
• Older children
– Incomplete emptying is abnormal
• <5mls normal
• 5-20 mls equivocal - repeat examination
• >20 mls abnormal
Cystometry
• Paediatric adaptations
– Suprapubic route
• >6 hours post insertion
– Small diameter urethral catheter
– Physiological filling
• Weight (kg)/4 = mls/min
• Expected bladder capacity/20 per minute
• Filling phase
– Sensation
– Detrusor activity
• any activity during filling is pathological
– Compliance (ml/cm H20)
• Less reliable owing to changing bladder capcity
– Capacity
Cystometry – cont.
• Urethral function assessed by EMG
– Skin/needle electrodes
• Voiding phase
– BOO
– Prolonged voiding phase
• Detrusor under activity/ lazy bladder
– Dysfunctional voiding
• Involuntary striated muscle contraction of sphincter
– DSD
Cystometry alternatives
• Natural fill urodynamics
• Ambulatory urodynamics
• Four hour voiding observation
– Alternative to cystometry in infancy
– Serial nappy weights and post void scans
Nocturnal Enuresis and Bedwetting
• Nocturnal enuresis as an involuntary voiding of urine during sleep, with a
severity of at least twice a week, in children aged >5 years in the absence
of congenital or acquired defects of the central nervous system
– DSM IV
• Infrequent bedwetting < 2/week.
– NICE guidance
– Butler et al 2005 BJUI
• Enuresis is defined as intermittent incontinence of urine when sleeping
– ICCS
• Mono symptomatic enuresis – nigh time symptoms alone
• Non-mono symptomatic enuresis – both daytime and nocturnal symptoms
• At least one episode per month for at least 3 months
Epidemiology
• Bedwetting
– 21% at 4 years 6 months
– 8% at 9 years 7 months
• Nocturnal Enuresis
– 8% 4 years 6 months
– 1.5% at 9 years 7 months
• Butler RJ 2008 Scan J Urol
– Parents affected 20-40%
– Siblings affected 60-70%
– Spontaneous remission rate of 15% per year
Pathophysiology
• Complex involving combinations of
– Impaired arousal from sleep
– Polyuria
• More likely to respond to desmopressin
– Bladder dysfunction
• Low capacity or detrusor over activity
• More likely to respond to anticholinergics
– Persson-Junemann et al 1993 Eur Urol
• Genetic predisposition
– Autosomal dominant inheritance pattern 4p16
• Eiberg et al 2001 J Urol
• ADHD
– Linked to arousal difficulty
Enuresis – Conservative treatment
• Advise adequate fluid intake
• Avoid caffeinated drinks
• Regular visits to the toilet during the day
– Aiming for 4-7 times
• Trial without nappies for those who are continent
during the day
• Lifting not advised
• Waking only for short term solution
– Holidays
Enuresis – conservative management
• Reward systems/star charts
– Drinking recommended fluid levels
– Using toilet prior to sleep
– Engaging in management
• No system that penalize or remove gained
rewards
Enuresis – initial treatment
• Alarm systems
– First line for children who have not responded to
conservative measures
• Inappropriate if enuresis is infrequent (<1-2/week)
– Assess response by 4 weeks +/- continue
Enuresis - Desmopressin
• Consider in absence of improvement or partial improvement with
alarm system
– +/- continue with alarm
• Initial dose
– 200mcg Desmotabs or 120mg DesmoMelts
– Double dose if not completely dry at 1-2 weeks
• Assess response at 4 weeks +/- continue for 3 months if signs of
response
• Fluid restriction
– 1 hour before until 8 hours after taking
• Caution
– Sickle cell disease – withdraw at times of crisis
• Counseling
– Most children will relapse but repeated doses can be used
Enuresis – second line
• Anticholinergics
– In combination with desmopressin
– Oxybutynin
• 2.5-3mg BD increasing to 5mg 2-3 times/day
• Imipramine
– 6-8 years 25mg
– 8-11 years 25-50mg
– >11 years 50-75mg
– Withdraw gradually following 3 month course
History – symptoms EMQ
Historical Feature
Indication
Ans
Large volume of urine in the first few hours of
night
A
Bedwetting is defined as secondary
D
Variable volume of urine, often more than
once a night
B
Any of these may indicate the presence of a bladder disorder such as
overactive bladder or more rarely (when symptoms are very severe and
persistent) an underlying urological disease.
E
Bedwetting every night
C
Typical pattern for children and young people who have bedwetting and
daytime symptoms with possible underlying overactive bladder.
A
Previously dry for more than 6 months
D
A common comorbidity that can cause bedwetting and requires treatment
F
Daytime frequency, Daytime urgency,
Daytime wetting, Abdominal straining or poor
urinary stream or Pain passing urine
E
usually secondary to underlying faecal impaction and constipation which
may have been unrecognised
G
Constipation
F
Typical pattern for bedwetting only
A
Soiling
G
Severe bedwetting, which is less likely to resolve spontaneously than
infrequent bedwetting
C
Inadequate fluid intake
H
These may be a cause or a consequence of bedwetting. Treatment may
need to be tailored to the specific requirements of each child or young
person and family.
J
Family problems
I
A difficult or 'stressful' environment may be a trigger for bedwetting. These
factors should be addressed alongside the management of bedwetting.
I
Behavioral and emotional problems
J
May mask an underlying bladder problem, such as overactive bladder
disorder, and may impede the development of an adequate bladder
capacity.
H
Daytime Conditions
• OAB +/- urge incontinence
– More prevalent in females
– Associated with holding maneuvers
• Vincent curtsy
– Voluntary pelvic floor contraction to compress urethra
– Commonly associates with constipation
– Incontinence most frequently occurs during
distraction
• Play
– Anticholinergics first line pharmacotherapy
Daytime Conditions
• Voiding postponement
– Holding manoeuvres
– Low urinary frequency
– Associated with behavioural/psychological
problems
Daytime conditions
• Underactive bladder and infrequent voiding
– Spectrum of same condition
– End point of long standing dysfunctional voiding
– Gradual deterioration in detrusor contractility
– Abdominal straining required to void
– Progressive increase in residual volume
• UTI – often first presentation
• Incontinence
– May require CISC
Daytime conditions
• Dysfunctional voiding
– Habitual sphincteric contraction during voiding
– Absence of neurological abnormality
• Stress incontinence
– Rare in neurologically normal children
• Vaginal reflux
– Toilet trained prepubertal girls
– Occurs within 10 minutes after normal void
– Treatment with thigh abduction and leaning forward
after voiding
Daytime conditions
• Giggle incontinence
– Rare syndrome, usually in girls
– Complete voiding during or shortly after laughter
– Normal bladder function when not laughing
– More common to have combination of
• OAB
• Voiding postponement
• Underactive bladder
– Treatment is difficult – mainstay anticholinergics
Daytime conditions
• Extraordinary daytime urinary frequency
– Void at least once/hour
– Volumes <50% expected bladder capacity
– Nocturnal bladder function is normal
Daytime Conditions
• Hinman Syndrome
– Non-neurogenic neurogenic bladder
• Bladder-sphincter dysfunction leading to
–
–
–
–
Bladder decompensation +/- upper tract compromise
Incontinence
Poor emptying
UTI
– Features consistent with neuropathic bladder in the
absence of defined cause
– Treat as neuropathic bladder
• Minimize risks to upper tracts
• Address infections
Management of functional
incontinence
• Urotherapy
– Child and parental education on normal
• Voiding mechanisms
– Sitting and standing positions
• Fluid intake
• Timed voiding
• Pelvic floor relaxation
• Biofeedback/Pelvic floor rehabilitation
– Ambulatory urodynamics with real time
uroflowmetry/EMG
• Neuromodulation
• Accupuncture
Ochoa syndrome/urofacial syndrome