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Initial Evaluation

History

• Assess symptoms and degree of bother
• Voiding frequency (daytime/nighttime)
• Male voiding symptoms: deviated/narrow stream, prolonged urination, straining, dysuria, postvoid dribbling
• Female voiding symptoms: postvoid dribbling, posture
• Presence of incontinence
• Diet and fluid intake
• Bowel function, frequency, incontinence, consistency (discuss Bristol stool scale)
• UTI history: assess fever/symptoms, asymptomatic bacteruria in 1% girls and 0.03% boys
• Medical history (including congenital and neuromuscular disorders)
• Family history voiding issues
• Pediatric milestones

Physical

• Lower extremity function, sensation, and gait should be assessed
• Assess for spinal abnormalities, to consider spina bifida workup
• Abdominal exam for masses and suprapubic tenderness/fullness
• Genital exam to assess for abnormalities
• Assess upper extremity function if needing to consider future catheterization

Adjunct Tests

• 7-day voiding diary (tracks timing only), or 48hr frequency/volume chart
• Expected bladder capacity: weight x 7 (if < 1yo) or (age + 2) x 30 (if > 1yo)
• Questionnaires: can be used but not required
• Urinalysis: consider if patient reports dysuria, urgency, or frequency
• Blood tests and urine culture usually not warranted
• Spinal US: can be used up to 6mo age (spine ossification), otherwise use lumbar/sacral MRI
• Uroflow: assess voided volume, flow curve, Qmax, Qavg
• Post-Void Residual: considered elevated (per Chang 2013) if > 30mL or 21% total capacity (if 4-6yo) or > 20mL or 15% total capacity (if 7+yo)
• Bladder wall thickening: > 5mm when empty or 3mm when full as seen on US
• Urodynamics: consider if LUTS if findings will alter management, fill rate of 5-10% bladder capacity per minute

Management

Conservative therapies

• Toilet posture: sit backwards on toilet to prevent squeezing legs together and contracting pelvic floor muscles
• Timed voiding: start with q2hr, and space out as able
• Biofeedback: works better with dysfunctional voiding

Bowel management

• Daily fiber intake: age (years) + 15-20g, while maintaining fluid intake
• Can titrate miralax to daily stool frequency
• "Magic Mousse": 1 cup ice cream + 1 cup pudding + 6oz mineral oil, mixed and frozen then given 60ml (< 6yo) or 120mL (> 6yo) BID, supplement with tap water enemas

Medications

• Anticholinergics: consider with OAB, small capacity, complete voiding
• A-blockers: consider if EMG lag time associated with impaired bladder neck opening
• Methylphenidate: rarely used for refractory giggle incontinence

Invasive Therapies

• Botox: inject in detrusor (OAB/NGB) or external sphincter (dysfunctional voiding)
• Neuromodulation: can consider for refractory OAB or NGB

Overly Specific Diagnoses of Pediatric Voiding Dysfunction (and their managements)

• Giggle incontinence: large volume incontinence triggered by laughter alone, diagnosis of exclusion, treat with biofeedback or stimulants
• Benign urinary frequency (pollakiuria): extremely high daytime frequency, no nocturia/enuresis, usually secondary to traumatic event, usually self-limited (3mo) but requires ruling out other conditions
• Underactive (lazy) bladder: rule out other causes, manage with timed/double voiding and/or CIC
• Vaginal voiding: incontinence after voiding in absence of other symptoms, may have labial adhesions, can treat with postural modifications when voiding