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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

Treatments

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

Enuresis

Definitions

• Primary monosymptomatic enuresis: Nocturnal incontinence, in absence of other LUTS, without a prior period of nocturnal dryness
• Secondary monosymptomatic enuresis: Nocturnal incontinence, in absence of other LUTS, with a prior period of noctural dryness (6+ months)
• Non-monosymptomatic enuresis: Noctunral incontinence, with other LUTS present

General Treatment Tips

• The child must be willing/able to participate in treatment otherwise it will not succeed
• Void before bed, avoid fluids before bed
• Do not punish for enuresis (counterproductive)
• Assess family history (may be genetic component)
• May benefit from sleep study if frequent snoring

Enuresis alarm

• Best for motivated families, children with low PVR and without polyuria
• When alarm triggered, the child has to change bedding, reset alarm (active participation)
• Continue until at least 14 consecutive dry nights
• If no improvement after at least 6 weeks, unlikely to improve
• Discontinuation: 30%, skin irritation, bothersome to rest of family, or failure

Desmopressin

• Most effective in nocturnal polyuria (> 130% expected bladder capacity for age) and normal bladder function (max voided volume > 70% expected capacity for age)
• Dosing: 0.2mg 1hr before bedtime, titrate up by 0.2mg to max dose 0.6mg at bedtime
• Reassess within 2 weeks to determine whether improvement present
• Consider using only for certain occasions vs nightly
• Drug holiday for 1 week every 3-6 months to assess whether still warranted

TCAs

• Considered third line therapy
• Dosing: 10-25mg imipramine 1hr before bed, can titrate up by 25mg after 1 week, usual dose 25mg (5-8yo) and 50mg (9+yo), do not exceed 50mg (6-12yo) and 75mg (13+yo)
• Reassess efficacy at 1mo, if no improvement after 3mo then discontinue with taper
• Drug holiday q3-6mo to assess continued need, tapering dose over 2 weeks
• Side effects: less than 5% overall, but can increase suicidal ideations and cardiac complications (risk with overdosing) - obtain personal/family cardiac history

Neuromuscular Dysfunction of LUT

Neural tube defects

• Obtain baseline RUS and VCUG as soon after birth as possible, decide whether to start CIC regimen based on results and PVRs
• Pre-UDS CIC: recommended for high residuals (≥ 30mL), trabeculated bladder, high grade reflux (Grade 5), and high grade hydronephrosis (SFU 3-4)
• Perform UDS within 3mo birth (usually after spinal cord closure)
• UDS findings: bladder/sphincter synergy (26%), dyssyngery (37%), or complete denervation (36%)
• Post-UDS CIC: recommended for DLPP > 40, DSD, or Grade 5 VUR, start oxybutynin 0.2mg/kg TID
• VUR: seen in 3-5% newborns, 30-40% by 5yo if untreated, treat with CIC + anticholinergics
• Occult dysraphisms: if not diagnosed by age 3yo, 92% develop UMN or LMN lesion (tethered cord, lipoma compression)
• Crede voiding: avoid, increases reflux and potential for upper tract damage
• Cystatin C: serum levels provide more accurate estimate of GFR
• Bowel function: managed with laxatives, enemas, frequent BMs, and manual stimulation
• Antegrade continence enema (ACE): administered via appendicostomy or cecostomy, 1-2L fluid 4-7x weekly
• Sexual function: 70-92% can obtain erection, 40-75% can ejaculate, 8-83% men and 23-69% women are sexually active, 70-80% able to achieve pregnancy
• Management of Myelomeningocele Study (MOMS): prenatal surgery reduces fetal/neonatal death or CSF shunting (RR 0.7), but 40% still required shunting and pregnancy complications were higher and had higher risk for spinal cord tethering

Other neuromuscular disorders

• Sacral agenesis: MRI confirms acute cutoff of conus at T12, obtain RUS/VCUG, manage based on UDS findings
• Anorectal malformations: GU abnormalities more likely if supralevator (vs infralevator) fistula insertion, often have DO + DSD, obtain RUS, obtain UDS if bony abnormalities, spinal cord defect, or RUS/VCUG abnormalities
• Post-pelvic surgery: due to splanchnic/hypogastric nerve damage, preop/postop UDS recommended if high risk for injury during surgery
• Cerebral palsy: 16-94% have GU symptoms, mainly incontinence, upper tract injury is rare, manage based on individual picture
• Spinal cord injury: acontractile bladder in acute setting, then may develop DO + DSD, minimal regain of function if cauda equina injured, protect upper tracts
• Transverse myelitis: urinary retention common in acute setting, then develops into DO + DSD, 57-73% require CIC

Management options for NM LUTD

• Goals (in order of priority): protect upper tracts, maintain continence, maintain independence, avoid reconstructive surgery
• Surgical management categories: increase bladder size/compliance, increase bladder outlet resistance, create catheterizable channel
• Most concerning finding is filling pressures > 40, increases risk for upper tract injury
• Anticholinergics: improves capacity/compliance, decreases incontinence and catheterization episodes, side effects (dry mouth, constipation, blurred vision, dizziness, headaches) can lead to decreased compliance, no evidence cognitive impairment in children
• Sympathomimetics: improve urethral resistance, but may cause dizziness, nausea, insomnia, headache, retention
• Botox: 65-87% dryness after failing medical management + CIC, 360U max dose
• Augmentation: for poorly compliant small capacity bladders, 0-29% require continued anticholinergics, 15% develop major complications (SBO, transfusions, perforation, UTI/pyelo), cystography diagnostic for augment perforation, 0.6% cancer risk
• Vesicostomy: used for severe reflux despite CIC, CIC non-compliance, poor augment candidates, complications include prolapse, stenosis, bladder stones
• Artificial urinary sphincter: improves outlet obstruction, continence 63-86%, cuff erosion 16-20%, worse bladder function 4-30%, device lifespan 4.6-12.7yrs
• Bladder slings (fascial and synthetic): improves outlet obstruction, continence 30-93%, new detrusor overactivity 33%
• Bladder neck reconstruction (Young-Dees-Leadbetter): excise and tighten bladder neck to maintain continence
• Catheterizable channels (Mitrofanoff, Yang-Monti): use appendix or intestine to create a continent reservoir to make CIC easier

Bowel Dysfunction

General considerations

• Voluntary control expected by age 3
• Majority have daily BM without straining, ranges from 3x daily to every 3 days
• Functional constipation prevalence: 0.7-29.6%

Evaluation

• HPI: age of onset, inability to toilet train, BM frequency and consistency, growth patterns
• Prior surgeries: GI, GU, and pelvic
• Exam: sacral anomalies, abdominal masses, normal neurologic function
• DRE: not indicated
• KUB: may be helpful to assess stool burden but not required

Management

• Behavioral: increased fluids/fiber, post-meal BMs, flexing thighs to abdomen to optimize abdominal pressure
• Wash-out: miralax 1-1.5 g/kg/day or mineral oil enemas for 3-6 days
• For complex cases, may require NGT + IVF, possible disimpaction under anesthesia
• Miralax maintenance: 0.2-0.8 g/kg/day, titrate up as needed
• Malone antegrade continence enema (MACE): allows for complete colonic emptying for continence, via continent cutaneous bowel access, may allow for greater patient independence