Dysfunctional Elimination Syndrome
Vincenzo Galati, D.O.
Stephen Confer, MD
Ben O. Donovan, MD
Brad Kropp, MD
Dominic Frimberger, MD
University of Oklahoma
Department of Urology
Section of Pediatric
Urology
Objectives
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Normal Elimination
Dysfunctional Elimination Syndrome
Non-Neurogenic Neurogenic Bladder
Biofeedback
Review of the literature
Development of Urinary Control
• Infancy: Reflex voiding
– Detrusor contracts when bladder full
– External urinary sphincter contracts during filling
• Voiding pattern in infants (feeding)
• Development of continence
– ↑ capacity and control of striated sphincter
– Control over spinal micturition reflex
Stooling
• Normally
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Newborn meconium passes w/in 24 hrs
First few weeks: BMs 6 X q day
By 5 months: BMs 3 X q day
Age 2: BMs bid
Age 4: BM q day
J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.
Dysfunctional Elimination
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Unknown etiology
Abnormal elimination pattern
Bowel or bladder incontinence
Withholding maneuvers
Holding Maneuvers
Dysfunctional Elimination
• Prevalence approximately 15% (Hellstrom
et al. 1991)
• Overlooked factor in pediatric UTIs
• 40% of toilet trained with 1st UTI
• 80% with recurrent UTI
• Risk factor for VUR and renal scarring
Bad Bladder Habits
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Infrequent visits to bathroom
Inadequate time in bathroom
Bad posture
Poor hygiene
What Happens?
• Infrequent voiding
– Over distended bladder
• Failure to relax pelvic floor
– Voiding against closed sphincter
• ↑ PVR
What Happens?
• Bad posture
– Can’t relax
• Bad hygiene or aggressive soaps
– Dysuria and incomplete voiding
•Children rated wetting themselves at
school as the third most catastrophic
event behind losing a parent and going
blind.
Ollendick et al, Behav Res Therapy, 1989.
Functional Bowel Disturbances
• Constipation
– Hard BM occurring < 3 X per week
• Most likely to occur in 3 situations
• Can induce bladder dysfunction
• 50% of dysfunctional voiding have
constipation
J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.
Functional Constipation
• Symptoms
– Infrequent passage of stool
– Hard stool
– Palpable stool in abdomen
or in rectal vault
– Fecal soiling
J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.
Functional Constipation
• Management:
– Parental education (hydration and fiber)
– Many require stool softeners
– Visit toilet 30-40 minutes after a meal
• Forward leaning, T&L extension, hip abduction,
foot support that allows 90° of hip/knee flexion
J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.
Treatment of Day Time Wetting
• 1st line is Behavior Modification
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Diary
Bathroom every 2 hrs
Good posture
Ample time
Good hygiene
Treatment of Day Time Wetting
• Treat Constipation
• Biofeedback
– Learn to relax pelvic muscles
• Medications
– Ditropan ↓ pressure but CONSTIPATES!
– ? Role of α-blocker and Botox
Non-neurogenic neurogenic bladder
(NNGNGB)
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Nocturnal and diurnal incontinence
Dribbling, overflow, urge incontinence
Bowel dysfunction
Recurrent UTI’s
Bladder instability
Voluntary DSD during voiding
NNGNGB
– VCUG large PVR
– Reflux noted in about
50%
NNGNGB - Treatment
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Sterilize Urine
Bladder retraining
Normalize bowel function
Anticholinergics eliminate unstable bladder
contractions
– Sympatholytics and diazepam to reduce
outflow resistance
– May need CIC
Biofeedback
• Treatment option for children with DSD
• Goal: develop control over pelvic floor
muscles during voiding
• Visual electromyography feedback
• Maintain relaxed pelvic floor with voiding
• Success up to child/parent/physician
• Problem: can be invasive
Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 14701475.
Modified Biofeedback Program
• Noninvasive UDS
• Psychological
techniques
– Externalizing voiding
problem
– Empowerment and
praise
77 Children Completing
Biofeedback Study
No. (%)
Recurrent UTI
59 (76)
Day incontinence
48 (63)
Night incontinence
36 (47)
Anticholinergic tx
38 (49)
VUR
19 (24)
Bowel symptoms
44 (58)
Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166,
1470-1475.
Modified Biofeedback Program
Improvement
No. (%)
Subjective:
Pronounced
47 (61)
Moderate
24 (31)
None
6 (8)
• Concluded:
– Effective for 92% of
children with DSD
Objective:
Pronounced
47 (61)
Moderate
28 (36)
None
2 (3)
Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166,
1470-1475.
Alpha-blocker therapy be as an alternative to
biofeedback for dysfunctional voiding?
• Efficacy of alpha-blocker vs biofeedback
• Prospective study 28 pts (12/16)
• On timed voiding, constipation treatment
and anticholinergics for at least 6 mo
• Pts reevaluated at 3 and 6 months
– Incontinence episodes, UTIs, mean urinary
flow rates, PVR, and parental satisfaction
Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology,
2005; 174, 1612-1615.
Alpha-blocker therapy be as an alternative to
biofeedback for dysfunctional voiding?
• Improved post treatment PVR
– NO DIFFERENCE
• Complete improvement in urge
incontinence
– NO DIFFERENCE
• Combination effective in
refractory cases (5/6)
• No side effects reported
• Concluded alpha blockers were
a viable alternative
70
60
50
0 months
40
3 months
30
6 months
20
10
0
PVR Bio PVR AB Flow Bio Flow AB
(ml)
(ml)
(ml/s)
(ml/s)
Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology,
2005; 174, 1612-1615.
Botulinum A Toxin Urethral Sphincter
injection in Children with NNGNGB
400
350
300
250
PVR (ml)
200
DLPP (cm H2O)
150
Q max (ml/sec)
100
50
0
Be
for
e
2W
ks
4W
ks
3M
o
6M
o
• Prospective (10
children)
• 50-100 units injected
• Immediately following
all but 1 voided
without catheterization
• PVR ↓ by 89%
Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology,
2005; 174, 1612-1615.
Closing Statements
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Best treatment is prevention
DES diagnosis of exclusion
Constipation treatment and timed voiding
Biofeedback
Adjunctive treatment in refractory cases
– Alpha blockers
– BOTOX
Thank You
Vincenzo Galati