VOIDING DYSFUNCTION IN CHILDREN
Natalie Barganski, RN, CPNP
Objectives
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The learner will be familiar with the presentation of
voiding dysfunction
The learner will be familiar with the evaluation of
voiding dysfunction
The learner will be familiar with different treatment
options for voiding dysfunction
Physiology of micturition
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Muscles of the bladder and the internal urinary
sphincter are innervated by autonomic nerves,
sympathetic and parasympathetic
These nerves are integrated at various sites in the
spinal cord, brain stem, midbrain, and higher
cortical centers
Physiology of micturition
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Two major functional
roles of the bladder,
storage and
elimination of urine
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Filling Phase
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Storage
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Voiding Phase
Micturition continued
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It evolves from involuntary bladder emptying during
infancy to daytime urinary continence, usually
around 4 years of age, then night time incontinence
usually by 5 -7 years of age
It is usually achieved after successful nighttime
daytime bowel continence
Voiding Dysfunction
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General term to
describe abnormalities
in either the filling
and/or emptying of
the bladder
It constitutes ~ 40% of
the Pediatric Urology
Clinic
International Children’s Continence Society
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Global multidisciplinary organization of clinicians
involved in the care of children with lower urinary
tract dysfunction
Standardized definitions for voiding dysfunction
symptoms and disorders
These definitions mostly apply to children who are
five or more years of age
ICCS Definitions
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Daytime frequency
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Incontinence
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Urgency
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Hesitancy
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Straining
ICCS Definitions continued
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Weak stream
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Intermittent stream
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Holding maneuvers
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Post-micturition dribbling
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Residual urine
Categories
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Nocturnal enuresis or nighttime
incontinence
Continuous or intermittent daytime
urinary incontinence – these disorders
are generally applied to children at
least 5 years of age or older
Nocturnal enuresis
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Monosymptomatic enuresis (MNE)
Nonmonosymptomatic enuresis (NMNE)– occurs in
children with enuresis who also describe other LUT
symptoms
Primary or secondary enuresis- 85% of all cases of
childhood enuresis in primary
Nocturnal enuresis cont.
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Both MNE and NMNE
are often hereditary
INCIDENCE
Three major causes:
 Nocturnal polyuria
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Detrusor overactivity
No family history
15%
One enuretic patient
44%
Two enuretic parent
77%
Increased arousal
thresholds
Nevéus, T, et. al. ICCS MNE Standardization 2008
Daytime Urinary Incontinence
Due to underlying abnormalities of bladder function
 Overactive bladder
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Voiding postponement and underactive bladder
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Dysfunctional voiding
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Other conditions- giggle incontinence, vaginal
voiding, primary bladder neck dysfunction
Etiology
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Neurogenic causes
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Anatomic causes
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Functional causes
Prevalence
Nocturnal enuresis- 15% - 20% of 5 year olds,
decreases with increasing age
 Daytime urinary incontinence
Four – six year olds – up to 20% have daytime
urinary incontinence
Decreases with age
Five – Six year old children – 10 %
Six – Twelve year old children- 5 %
Twelve – Eighteen year old children- 4 %
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Categories based on risk
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Minor
Daytime frequency
Giggle incontinence
Stress incontinence
Post void-dribbling
Nocturnal enuresis
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Moderate
Underactive bladder
Overactive bladder
Dysfunctional
elimination syndrome
Severe
Hinman
Ochoa
Myogenic failure
Associated conditions
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Urinary tract infection
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Vesicoureteral reflux
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Constipation and dysfunctional elimination syndrome
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Behavioral and neurodevelopmental issues
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Bladder extrophy, epispadias, ectopic ureter,
neurogenic bladder
Assessment of urinary incontinence
Main goals:
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Find those that are at risk for upper tract
deterioration in order to prevent of renal
impairment
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Establish the cause of incontinence
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Improve quality of life
History & Physical
History is the KEY in determining the type of disorder
 Birth history
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Child’s medical history
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Family medical history
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Developmental history
Voiding History
Toilet training history
 Voiding schedule
 Symptoms of voiding dysfunction
 Diet intake, including fluid intake (caffeinated)
 Bowel habits
 Family conflict or stress, behavior, peer
relations
 Sleep
 Treatment strategies
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Clinical Tools- Voiding Questionnaire
Tools- Bladder (Voiding) Diary
Tools- Bristol Stool Chart
Physical Examination
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Focus is on detecting neurologic and urologic
abnormalities
Height/weight
Blood pressure
Abdominal palpation
Lower back
Neurologic exam
Genital examination
Investigations
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UA, culture
Nocturnal urine
production
Bladder scanUroflow with or w/o EMG
RUS
VCUG
MRI
Urodynamic studies
Dynamic renal imaging
Management
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FIRST- Treatment of Constipation
40% of children with LUT symptoms have
constipation
Large retrospective study of 234 patients showed a
resolution of constipation was associated with
elimination of wetting in 89% and 63 % of children
with daytime or nighttime urinary incontinence, and
prevention of UTIs
Loening-Baucke, V. Pediatrics 1997; 100-228
Management
When to start treatment?
When the child is
ready!
 Nonpharmacolgic or
conservative
treatment- Voiding
Behavior Modification
 A partial response
with > 50% reduction
of incontinent episodes
Allen, et al. Urology 2007; 69:962
Weiner, et al. J Urol 2000; 164-786
Management
If conservative treatment fails to relieve symptoms
treatment is condition specific
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NE- desmopressin, alarm, maybe anticholinergics,
imipramine
OAB- anticholinergic medication can be beneficial
Management
Underactive bladder- timed voiding is
important, avoid anticholinergics, alpha
adrenergic blockade has been helpful in
relaxing bladder outlet
 Non-neurogenic dysfunctional voiding- concern
for upper urinary tract deterioration, may
need urodynamics, pelvic floor relaxation
techniques, biofeedback, or an alpha
antagonist
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Dysfunctional voiding
Compensatory detrusor hypertrophy and
hyperplasia
Small capacity trabeculated bladder
that may elevate bladder pressures
Vesicoureteral reflux and
resultant upper tract renal
damage
Detrusor
decompensation
and
hypocontractility
May need CIC
or surgery
Management
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Biofeedback- therapy teaches children how to
identify and control the muscle groups involved in
voiding
Reserved for children with detrusor sphincter
dyssynergia contributing to daytime incontinence
despite behavior modifications/pharmacotherapy
Helpful in children with significant post void
residuals who have recurrent UTI and constipation
THANK YOU!! QUESTIONS?