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Khondker A, Ahmad I, Rajesh Z, Balkaran S, Aldaqqaq Z, Kim JK, Brownrigg N, Varghese A, Chua M, Rickard M, Lorenzo AJ, Dos Santos J. The Role of Secondary Conservative Management Strategies in Bladder and Bowel Dysfunction: A Systematic Review and Meta-analysis. J Pediatr 2024:114152. [PMID: 38906507 DOI: 10.1016/j.jpeds.2024.114152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/11/2024] [Accepted: 06/11/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE To determine the effect of secondary management strategies in addition to urotherapy on BBD outcomes. STUDY DESIGN The review protocol was prospectively registered (CRD42023422168). MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, Scopus (database initiation until June 2023) were searched. Comparative studies of secondary management strategies versus conventional urotherapy alone were included. Two authors independently screened titles/abstracts and reviewed full-text articles. Two authors extracted data related to study characteristics, methodology, subjects, and results. RESULTS In this systematic review and meta-analysis of 18 studies and 1228 children, secondary management strategies (home-based education, biofeedback, and physical therapy) were associated with reduced symptom burden, fewer recurrent urinary tract infections, and improved uroflowmetry findings than children treated with solely urotherapy for conservative management. CONCLUSIONS While there is significant reporting heterogeneity, secondary conservative management strategies such as home education, biofeedback or cognitive behavioral therapy, and physiotherapy-based education are associated with reduced urinary incontinence, infections, and abnormal uroflowmetry findings.
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Affiliation(s)
- Adree Khondker
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON; Division of Urology, Department of Surgery, University of Toronto, Toronto, ON
| | - Ihtisham Ahmad
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON
| | - Zwetlana Rajesh
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON
| | | | - Zizo Aldaqqaq
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON
| | - Jin K Kim
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON; Division of Urology, Department of Surgery, University of Toronto, Toronto, ON
| | - Natasha Brownrigg
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON
| | - Abby Varghese
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON
| | - Michael Chua
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON; Division of Urology, Department of Surgery, University of Toronto, Toronto, ON
| | - Mandy Rickard
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON
| | - Armando J Lorenzo
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON; Division of Urology, Department of Surgery, University of Toronto, Toronto, ON
| | - Joana Dos Santos
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON.
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Tran DL, Sintusek P. Functional constipation in children: What physicians should know. World J Gastroenterol 2023; 29:1261-1288. [PMID: 36925458 PMCID: PMC10011959 DOI: 10.3748/wjg.v29.i8.1261] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/05/2022] [Accepted: 02/16/2023] [Indexed: 02/28/2023] Open
Abstract
Functional constipation (FC) is considered the most common functional gastrointestinal disorder in children with a pooled global prevalence of 14.4% (95% confidence interval: 11.2-17.6) when diagnosed based on the Rome IV criteria. Its pathophysiological mechanisms are thought be multifactorial and complicated, resulting in difficult management. Currently, the most effective medication, when used in parallel with toilet training, is osmotic laxatives. Children’s adherence to medication and parental concern regarding long-term laxative use are the main contributors to treatment failure. Recently, novel therapies with a high safety profile have been developed, such as probiotics, synbiotics, serotonin 5-hydroxytryptamine 4 receptor agonists, chloride channel activators, and herbal and transitional medicines; nonetheless, well-designed research to support the use of these therapies is needed. This review aims to focus on multiple aspects of FC in children, including global prevalence, pathogenesis, diagnostic criteria, tools, as well as conventional and novel treatment options, such as non-pharmacological management, including adequate fiber and fluid intake, physiotherapy, or neuromodulators. We also report that in very difficult cases, surgical intervention may be required.
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Affiliation(s)
- Duc Long Tran
- Thailand and Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Bangkok, Thailand
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho City 9000, Viet Nam
| | - Palittiya Sintusek
- Thai Pediatric Gastroenterology, Hepatology and Immunology Research Unit, Division of Gastroenterology, Department of Pediatrics, King Chulalongkorn Memorial Hospital and Thai Red Cross, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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Yang SS, Tsai JD, Kanematsu A, Han CH. Asian guidelines for urinary tract infection in children. J Infect Chemother 2021; 27:1543-1554. [PMID: 34391623 DOI: 10.1016/j.jiac.2021.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/08/2021] [Accepted: 07/11/2021] [Indexed: 11/25/2022]
Abstract
The followings are the level of evidence (LE) and grade of recommendation (GR) on pediatric UTI in Asia. Classification according to the sites of infection (lower versus upper tract), the number of episode (first versus recurrent), the severity (simple versus severe), or the existence of complicating factor (uncomplicated versus complicated) is useful to differentiate children with UTI whether they are at risk of renal damage or not (LE: 2, GR: B). Diagnosis of UTI requires both urinalysis that suggests infection and positive urine culture (LE:3, GR B). For pre-toilet trained children, urine specimen for culture should be collected by urethral catheterization or suprapubic aspiration. For toilet trained children, midstream clean catch urine is reliable (LE: 3, GR: A). Urine culture is considered positive if it demonstrates growth of a single bacterium with the following colony counts: (1) any growth by suprapubic aspiration, (2) >5 × 104 CFU/ml by urethral catheterization, or (3) >105 CFU/ml by midstream clean catch (LE:3, GR: B). For children with febrile UTI, renal and bladder ultrasonography (RBUS) should be routinely performed as soon as possible (LE: 3, GR: C). RBUS should be followed up 6 months later in children with acute pyelonephritis and/or VUR (LE: 3, GR: C). Acute DMSA scan can be performed when severe acute pyelonephritis or congenital hypodysplasia is noted on RBUS or when the diagnosis of UTI is in doubt by the clinical presentation (LE: 3, GR: C). Late DMSA scan (>6 months after the febrile UTI) can be performed in children with severe acute pyelonephritis, high-grade VUR, recurrent febrile UTIs, or abnormal renal parenchyma on the follow-up RBUS (LE: 3, GR: C). Top-down or bottom-up approach for febrile UTI is suggested for the diagnosis of VUR. For top-down approach, VCUG should not be performed routinely for children after the first febrile UTI. VCUG is indicated when abnormalities are apparent on either RBUS or DMSA scan or both (LE: 2, GR: B). VCUG is also suggested after a repeat febrile UTI (LE:2, GR: B). Appropriate antibiotic should be given immediately after urine specimen for culture has been obtained (LE:2, GR: A). Initiating therapy with oral or parenteral antibiotics is equally efficacious for children (>3 months) with uncomplicated UTI (LE: 2: GR: A). The choice of empirical antibiotic agents is guided by the expected pathogen and the local resistance patterns (LE: 2, GR: A). For children with febrile UTI, the total course of antibiotic therapy should be 7-14 days (LE: 2, GR: B). Circumcision may, but not definitively, reduce the risk of febrile UTI in males and breakthrough febrile UTI in males with VUR. Circumcision should be offered to uncircumcised boys with febrile UTI and VUR in countries where circumcision is accepted by the general population (LE: 3, GR: B), while in countries where childhood circumcision is rarely performed, other measures for febrile UTI/VUR should be the preferred choice (LE: 4, GR: C). Bladder bowel dysfunction (BBD) is one of the key factors of progression of renal scarring (LE: 2). Early recognition and management of BBD are important in prevention of UTI recurrence (LE:2, GR: A). Antibiotic prophylaxis to prevent recurrent febrile UTI is indicated in children with moderate to high grade (III-V) VUR (LE: 1b, GR: A). Surgical intervention may be used to treat VUR in the setting of recurrent febrile UTI because it has been shown to decrease the incidence of recurrent pyelonephritis (LE: 2, GR: B).
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Affiliation(s)
- Stephen S Yang
- Division of Urology, Taipei Tzu Chi Hospital, Medical Foundation, New Taipei, Taiwan; Buddhist Tzu Chi University, Hualien, Taiwan.
| | - Jeng-Daw Tsai
- Department of Medicine, Mackay Medical College, Taiwan; Department of Pediatric Nephrology, MacKay Children's Hospital, Taiwan; Department of Pediatrics, Taipei Medical University Hospital, Taipei, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
| | | | - Chang-Hee Han
- Department of Urology, Uijeongbu ST. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Republic of Korea
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Sjöström S, Sillén U, Bachelard M, Johansson E, Brandström P, Hellström AL, Abrahamsson K. Bladder/bowel dysfunction in pre-school children following febrile urinary tract infection in infancy. Pediatr Nephrol 2021; 36:1489-1497. [PMID: 33274398 PMCID: PMC8084797 DOI: 10.1007/s00467-020-04853-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 09/22/2020] [Accepted: 11/06/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND An association between bladder-bowel dysfunction (BBD) and urinary tract infection (UTI) is well-known. However, a question less explored is whether children with UTI early in life also have increased prevalence of BBD after they are toilet-trained. In this study, consecutively selected children with pyelonephritis during their first year of life were assessed for BBD at pre-school age. METHODS Ninety-two children (51 boys) hospitalized due to pyelonephritis during their first year of life were assessed for BBD at median age 5.4 years. A validated BBD questionnaire, along with urine flow and residual volume measurements, was used for diagnosing BBD. During follow-up, the group was well-characterized regarding renal status, vesicoureteral reflux (VUR), and recurrent UTI. RESULTS BBD was diagnosed in 35/92 (38%), of which the majority was sub-diagnosed with dysfunctional voiding (DV). There was a strong association between BBD and recurrent UTI during follow-up (p < 0.0001), but only a slight association with VUR status at presentation. Nevertheless, in the group with both BBD and VUR, recurrent UTI was four times higher (12/13, 92%) than in children who had neither VUR nor BBD (23%), (p = 0.0008). BBD was also associated with kidney damage (p = 0.017). CONCLUSION In children with pyelonephritis during the first year of life, 38% had BBD at pre-school age, regardless of whether they had VUR or not. The study shows an important association between BBD and recurrent UTI, so an assessment of BBD is therefore recommended for pre-school children with UTI, especially when they have history of pyelonephritis during infancy.
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Affiliation(s)
- Sofia Sjöström
- The Pediatric UroNephrology Center, The Queen Silvia Children’s Hospital, The Sahlgrenska Academy at the University of Gothenburg, 416 85 Gothenburg, Sweden
| | - Ulla Sillén
- The Pediatric UroNephrology Center, The Queen Silvia Children's Hospital, The Sahlgrenska Academy at the University of Gothenburg, 416 85, Gothenburg, Sweden.
| | - Marc Bachelard
- The Pediatric UroNephrology Center, The Queen Silvia Children’s Hospital, The Sahlgrenska Academy at the University of Gothenburg, 416 85 Gothenburg, Sweden
| | - Ewa Johansson
- The Pediatric UroNephrology Center, The Queen Silvia Children’s Hospital, The Sahlgrenska Academy at the University of Gothenburg, 416 85 Gothenburg, Sweden
| | - Per Brandström
- The Pediatric UroNephrology Center, The Queen Silvia Children’s Hospital, The Sahlgrenska Academy at the University of Gothenburg, 416 85 Gothenburg, Sweden
| | - Anna-Lena Hellström
- The Pediatric UroNephrology Center, The Queen Silvia Children’s Hospital, The Sahlgrenska Academy at the University of Gothenburg, 416 85 Gothenburg, Sweden
| | - Kate Abrahamsson
- The Pediatric UroNephrology Center, The Queen Silvia Children’s Hospital, The Sahlgrenska Academy at the University of Gothenburg, 416 85 Gothenburg, Sweden
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Yang S, Chua ME, Bauer S, Wright A, Brandström P, Hoebeke P, Rittig S, De Gennaro M, Jackson E, Fonseca E, Nieuwhof-Leppink A, Austin P. Diagnosis and management of bladder bowel dysfunction in children with urinary tract infections: a position statement from the International Children's Continence Society. Pediatr Nephrol 2018; 33:2207-2219. [PMID: 28975420 DOI: 10.1007/s00467-017-3799-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/04/2017] [Accepted: 08/08/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND We present a consensus view from the International Children's Continence Society (ICCS) on the evaluation and management of bladder bowel dysfunction (BBD) in children with urinary tract infection (UTI). The statement aims to highlight the importance of BBD in the development and recurrence of childhood UTI and its management to reduce its associated morbidity and sequelae. METHODS A systematic literature search was done on PubMed, Embase, and Scopus databases until August 15, 2016. Relevant publications concerning BBD and its relationship with UTI among children were reviewed and aggregated for statements of recommendation. Discussion by the ICCS Board and a multi-disciplinary core group of authors resulted in a document available on its website for all ICCS members to review. Insights and feedback were considered with consensus and agreement reached to finalize this position statement. RESULTS BBD in children with UTI is summarized. Details regarding epidemiology, pathophysiology, and recommendations for general and family practitioners and pediatricians relating to the evaluation and management of this condition are presented. CONCLUSIONS This document serves as the position statement from ICCS, based on literature review and expert opinion providing our current understanding of BBD in children with UTI.
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Affiliation(s)
- Stephen Yang
- Department of Urology, Taipei Tzu-Chi Hospital, and Buddhist Tzu Chi University, Taipei, Taiwan.
| | - Michael E Chua
- Department of Urology, Taipei Tzu-Chi Hospital, and Buddhist Tzu Chi University, Taipei, Taiwan
- Department of Urology, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Urology, St. Luke's Medical Center, Quezon City, Philippines
| | - Stuart Bauer
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Anne Wright
- Department of Paediatric Nephrourology, Evelina Children's Hospital, London, UK
| | - Per Brandström
- Department of Pediatrics, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Piet Hoebeke
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Søren Rittig
- Department of Pediatrics, Aarhus University, Aarhus, Denmark
| | - Mario De Gennaro
- Department of Urology, Bambino Gesù Children's Hospital of Rome, Rome, Italy
| | - Elizabeth Jackson
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eliane Fonseca
- Department of Pediatrics, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | | | - Paul Austin
- Department of Urology, St Louis Children's Hospital, St. Louis, MO, USA
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Idiopathic constipation: A challenging but manageable problem. J Pediatr Surg 2018; 53:1742-1747. [PMID: 29079312 DOI: 10.1016/j.jpedsurg.2017.09.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/19/2017] [Accepted: 09/20/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE A protocol to treat idiopathic constipation is presented. METHODS A contrast enema is performed in every patient and, when indicated, patients are initially submitted to a "clean out" protocol. All patients are started on a Senna-based laxative. The initial dosage is empirically determined and adjusted daily, during a one week period, based on history and abdominal radiographs, until the amount of Senna that empties the colon is reached. The management is considered successful when patients empty their colon daily and stop soiling. If the laxatives dose provokes abdominal cramping, distension, and vomiting, without producing bowel movements, patients are considered nonmanageable. RESULTS From 2005 to 2012, 215 patients were treated. 121 (56%) were males. The average age was 8.2years (range: 1-20). 160 patients (74%) presented encopresis. 67 patients (32%) needed a clean out. After one week, 181 patients (84%) achieved successful management, with an average Senna dose of 67mg (range: 5-175mg). In 34 patients (16%) the treatment was unsuccessful: 19 were nonmanageable, 3 noncompliant, and 12 continued soiling. At a later follow-up (median: 329days) the success rate for 174 patients was 81%. CONCLUSION We designed a successful protocol to manage idiopathic constipation. The key points are clean out before starting laxatives, individual adjustments of laxative, and radiological monitoring of colonic emptying. TREATMENT STUDY Level IV.
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Definition of Reliable, Objective Criteria by Abdominal Radiography to Identify Occult Constipation in Children with Lower Urinary Tract Symptoms. J Urol 2013; 189:1519-23. [DOI: 10.1016/j.juro.2012.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 11/20/2022]
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Yang SSD, Chiang IN, Lin CD, Chang SJ. Advances in non-surgical treatments for urinary tract infections in children. World J Urol 2011; 30:69-75. [PMID: 21614468 DOI: 10.1007/s00345-011-0700-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 05/07/2011] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE With growing antibiotics failure due to emerging resistance of bacteria, non-surgical management of pediatric UTI plays a more important role because of its non-invasive characteristics and little adverse effects. METHODS We searched the Pubmed for management of UTI in children other than surgical correction and antibiotics using terms: risk factor, prepuce/phimosis, steroid cream/steroid, behavioral therapy, urotherapy, biofeedback/pelvic floor exercise, adrenergic antagonist, anticholinergics, diet/dietary, dysfunctional voiding/dysfunctional elimination syndrome, constipation, dietary, clean intermittent catheterization, probiotics/lactobacillus, cranberry, vitamin supplement, breastfeeding, breast milk, with infant/child/children/pediatrics/pediatrics and urinary tract infection. RESULTS The proposed non-surgical management of pediatric UTI included behavioral modification (timed voiding and adequate fluids intake), topical steroid for phimosis, nutrient supplements (breast milk, cranberry, probiotics, and vitamin A), biofeedback training for dysfunctional voiding, anticholinergics for reducing intravesical pressure, alpha-blockers in dysfunctional voiding and neurogenic bladder, and intermittent catheterization for children with large PVR. CONCLUSION The published reports usually included small number of patients and were lacking of randomization and controlled group. Further well-designed studies are warranted to support the concepts of non-operative management for pediatric UTI.
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Affiliation(s)
- Stephen Shei-Dei Yang
- Division of Urology, Buddhist Tzu Chi General Hospital, Taipei Branch, No. 289 Chienkuo Road, Xindian City, Taipei, 231, Taiwan
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Silva JAF, Alvares RA, Barboza AL, Monteiro RTM. Lower urinary tract dysfunction in children with cerebral palsy. Neurourol Urodyn 2009; 28:959-63. [DOI: 10.1002/nau.20714] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Yerkes EB. Urologic Issues in the Pediatric and Adolescent Gynecology Patient. Obstet Gynecol Clin North Am 2009; 36:69-84. [PMID: 19344848 DOI: 10.1016/j.ogc.2008.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Elizabeth B Yerkes
- Northwestern University's Feinberg School of Medicine, Division of Urology, Children's Memorial Hospital, 2300 Children's Plaza #24, Chicago, IL 60614, USA.
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Allen HA, Austin JC, Boyt MA, Hawtrey CE, Cooper CS. Evaluation of Constipation by Abdominal Radiographs Correlated with Treatment Outcome in Children with Dysfunctional Elimination. Urology 2007; 69:966-9. [PMID: 17482944 DOI: 10.1016/j.urology.2007.01.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2006] [Revised: 11/06/2006] [Accepted: 01/21/2007] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To analyze the utility of assessing degree of constipation by abdominal radiograph (KUB) in relation to symptoms and urodynamic data in children with dysfunctional elimination. METHODS A retrospective review of children with concomitant constipation and daytime incontinence was performed. Inclusion required at least two consecutive visits with KUB and noninvasive uroflowmetry. Patients were excluded for anticholinergic medication use or neurogenic or anatomic abnormalities. Rectal fecal quantification and presence of stool throughout the colon was assessed on KUB and categorized as "empty," "normal amount of stool," or "fecal distention of rectum (FDR)." RESULTS Twenty-six patients met inclusion requirements (6 boys, 20 girls; average age, 7.7 +/- 2.2 years). The average time between the initial and subsequent visit was 12.5 +/- 7.8 weeks. Initial KUB revealed FDR in 17. No statistical significance was found between FDR on initial or final KUB and outcome of wetting symptoms, nor could a relationship between FDR uroflow parameters at either visit be demonstrated. CONCLUSIONS No correlation between any uroflowmetry parameter and the presence of FDR at the initial or final visits could be demonstrated. Similarly, no statistical significance between FDR on final or initial KUB and outcome of wetting symptoms was established.
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Affiliation(s)
- Heidi A Allen
- Division of Pediatric Urology, Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242-1089, USA
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Abstract
Urinary incontinence is a common primary care problem. With the proper understanding of normal and abnormal bladder function, pediatricians can create a protocol that will benefit most children seen with this condition. Emphasis should be placed on primary therapy: establishing healthy dietary habits, treating constipation, maintaining appropriate hygiene, and developing a regular voiding pattern. When the initial evaluation identifies an anatomic abnormality or when primary therapy fails, referral to a pediatric urologist is warranted.
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Affiliation(s)
- C D Anthony Herndon
- Section of Pediatric Urology, Division of Urology, Department of Surgery, University of Alabama at Birmingham, Children's Hospital, 1600 7th Avenue S, Birmingham, AL 35233-1711, USA.
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