The evaluation of combined standard urotherapy, abdominal and pelvic floor retraining in children with dysfunctional voiding

[Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment]

Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment Abstract: Objective: Enuresis and daytime urinary incontinence are common disorders in children and adolescents and are associated with incapacitation and a high rate of comorbid psychological disorders. This interdisciplinary guideline summarizes the current state of knowledge regarding somatic and psychiatric assessment and treatment. We formulate consensus-based, practical recommendations. Methods: The members of this guideline commission consisted of 18 professional associations. The guideline results from current literature searches, several online surveys, and consensus conferences based on standard procedures. Results: According to the International Children's Continence Society (ICCS), there are four different subtypes of nocturnal enuresis and nine subtypes of daytime urinary incontinence. Organic factors first have to be excluded. Clinical and noninvasive assessment is sufficient in most cases. Standard urotherapy is the mainstay of treatment. If indicated, one can add specific urotherapy and pharmacotherapy. Medication can be useful, especially in enuresis and urge incontinence. Psychological and somatic comorbid disorders must also be addressed. Conclusions: The recommendations of this guideline were passed with a high consensus. Interdisciplinary cooperation is especially important, as somatic factors and comorbid psychological disorders and symptoms need to be considered. More research is required especially regarding functional (nonorganic) daytime urinary incontinence.

Pediatric Psychology in a Urology Division: Unifying Complex Medical and Mental Health Treatment

PURPOSE OF REVIEW

Although pediatric psychology is heavily involved in many medical divisions, its involvement in a urology division is still relatively new and its role continuously evolving and growing.

RECENT FINDINGS

This article reviews the limited research on the use of psychology in a urology division, including psychosocial struggles across urology diagnoses, dysfunctional voiding, and anxiety surrounding medical procedures and surgery. Urinary diagnoses and presenting problems seen by pediatric psychologists and medical providers at an urban children's hospital are also included. Based on the complex conditions and varied presenting concerns in a urology division, potential assessments and future research are suggested to help gather data for this population moving forward and expand the literature on urology psychology.

Pelvic Floor Muscle Resting Tone in Children With Dysfunctional Voiding Symptomology Following Simple Gross Motor Exercises

PURPOSE

The study aimed to understand the effects of a set of simple gross motor exercises on pelvic floor muscle (PFM) resting tone (RT) in children with dysfunctional voiding symptomology.

METHODS

The study compared PFM RT for a single-sample before and after 2 protocols: exercise versus relaxation (metric standard).

RESULTS

Participants included 27 children ages 5.00 to 10.92 years. Preintervention PFM RT was similar between the interventions: 63% (exercise) and 78% (relaxation) of children decreased PFM RT following intervention. Between-intervention post-minus-prechanges in PFM RT were compared. Between-intervention differences were similar.

CONCLUSIONS

Exercise and relaxation protocols were comparable in lowering PFM RT in children with voiding dysfunction. Findings are clinically worthy in that either exercises or relaxation prior to toileting may assist with more complete emptying in children with symptoms.

EAU-ESPU guidelines recommendations for daytime lower urinary tract conditions in children

The objective is to review the literature related to lower urinary tract (LUT) conditions in children to conceptualize general practice guidelines for the general practitioner, pediatrician, pediatric urologist, and urologist. PubMed was searched for the last 15-year literature by the committee. All articles in peer-review journal-related LUT conditions (343) have been retrieved and 76 have been reviewed extensively. Prospective trials were few and the level of evidence was low. Most of the recommendations have been done by committee consensus after extensive discussion of literature reports. History taking is an integral part of evaluation assessing day- and nighttime urine and bowel control, urgency, and frequency symptoms. Exclusion of any neurogenic and organic cause is essential. Uroflowmetry and residual urine determination are recommended in all patients to evaluate bladder emptying. Urodynamic studies are reserved for refractory or complicated cases. Urotherapy that aims to educate the child and family about bladder and bowel function and guides them to achieve normal voiding and bowel habits should initially be employed in all cases except those who have urinary tract infections (UTI) and constipation. Specific medical treatment is added in the case of refractory overactive bladder symptoms and recurrent UTIs.Conclusion: Producing recommendations for managing LUTS in children based on high-quality studies is not possible. LUTS in children should be evaluated in a multimodal way by minimal invasive diagnostic procedures. Urotherapy is the mainstay of treatment and specific medical treatment is added in refractory cases.What is Known:• Symptoms of the lower urinary tract may have significant social consequences and sometimes clinical morbidities like urinary tract infections and vesicoureteral reflux. In many children, however, there is no such obvious cause for the incontinence, and they are referred to as having functional bladder problems.What is New:• This review aims to construct a practical recommendation strategy for the general practitioner, pediatrician, pediatric urologist, and urologist for LUTS in children. Producing recommendations for managing LUTS in children based on high-quality studies is not possible. LUTS in children should be evaluated in a multimodal way by minimal invasive diagnostic procedures. Urotherapy is the mainstay of treatment and specific medical treatment is added in refractory cases.

Does biofeedback therapy improve quality of life in children with lower urinary tract dysfunction: parents' perspective

INTRODUCTION

Lower urinary tract dysfunction (LUTD) is a situation that often disrupts the quality of life (QoL) of both the child and the family with daytime and nighttime incontinence. Although the first-line treatment option for children with LUTD is standard urotherapy, biofeedback therapy can be performed in children in which standard urotherapy failed.

OBJECTIVE

We studied the biofeedback success in children with LUTD according to parents' expressions.

METHODS

We retrospectively analyzed our hospital records of children who were diagnosed with LUTD between 2005 and 2017. In total, 281 patients, refractory to standard urotherapy were included into the study and directed to biofeedback treatment. Their parents completed the dysfunctional voiding symptom scores (DVSS) before and after biofeedback therapy.

RESULTS

At the end of the six-month follow-up period, all voiding disorders and voiding patterns were evaluated. According to DVSS, QoL tools before biofeedback treatment 48 (17%) parents appraised that LUTD caused no effect in their children's daily life, 104 (37.8%) expressed little effect, 89 (31%) moderate effect, and 40 (14.2%) serious effect. And, 120 (43%) parents expressed no effect, 95 (34%) little effect, 51 (18%) moderate effect, and 15 (5%) serious effect (P = 0.001) after biofeedback therapy. Biofeedback therapy affected positively the daily life of LUTD's family. The less serious the effect of LUTD on these children's family, the more success rate of biofeedback therapy. The effect of biofeedback therapy was less successful in moderated and serious affected families.

CONCLUSIONS

Biofeedback treatment is a non-invasive and effective treatment modality for improving the QoL for LUTD families who were less suffered from LUTD.

Urotherapy in the treatment of children and adolescents with bladder and bowel dysfunction: a systematic review

OBJECTIVE

To identify and describe the protocols and clinical outcomes of urotherapy interventions in children and adolescents with bladder bowel dysfunction.

METHOD

Systematic review carried out in June 2018 on Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL),Excerpta Medica dataBASE (EMBASE), Scientific Electronic Library Online (SciELO), Cochrane Library, and PsycInfo databases. Clinical trials and quasi-experimental studies carried out in the last ten years in children and/or adolescents with bladder and bowel symptoms and application of at least one component of urotherapy were included.

RESULTS

Thirteen clinical trials and one quasi-experimental study were included, with moderate methodological quality. The heterogeneity of the samples and of the methodological design of the articles prevented the performance of a meta-analysis. The descriptive analysis through simple percentages showed symptom reduction and improvement of uroflowmetry parameters. The identified urotherapy components were: educational guidance, water intake, caffeine reduction, adequate voiding position, pelvic floor training, programmed urination, and constipation control/management.

CONCLUSION

This review indicates positive results in terms of symptom reduction and uroflowmetry parameter improvement with standard urotherapy as the first line of treatment for children and adolescents with bladder bowel dysfunction. It is recommended that future studies bring contributions regarding the frequency, number, and time of urotherapy consultations.

Pelvic floor rehabilitation in children with functional LUTD: does it improve outcome?

INTRODUCTION

If children do not experience satisfactory relief of lower urinary tract dysfunction (LUTD) complaints after standard urotherapy is provided, other treatment options need to be explored. To date, little is known about the clinical value of pelvic floor rehabilitation in the treatment of functional voiding disorders.

OBJECTIVE

Therefore, we compared pelvic floor rehabilitation by biofeedback with anal balloon expulsion (BABE) to intensive urotherapy in the treatment of children with inadequate pelvic floor control and functional LUTD.

STUDY DESIGN

A retrospective chart study was conducted on children with functional incontinence and inadequate pelvic floor control. All children referred for both intensive inpatient urotherapy and pelvic floor rehabilitation between 2010 and 2018 were considered for inclusion. A total of 52 patients were eligible with 25 children in the group who received BABE before inpatient urotherapy, and 27 children in the group who received BABE subsequently to urotherapy. Main outcome measurement was treatment success according to International Children's Continence Society criteria measured after treatment rounds and follow-up.

RESULTS

Baseline characteristics demonstrate no major differences between the BABE and control group. There was a significant difference in improvement between BABE and inpatient urotherapy after the first and second round of treatment (round 1: BABE vs urotherapy; 12% vs 70%, respectively, round 2: urotherapy vs BABE; 92% vs 34%, respectively, both P < .001). In both cases, the urotherapy group obtained greater results (Fig. 1). When the additional effect of BABE on urotherapy treatment is assessed, no significant difference is found (P = .355) in the children who received BABE; 30 (58%) showed improvement on pelvic floor control.

DISCUSSION

Our findings imply that training pelvic floor control in combination with inpatient urotherapy does not influence treatment effectiveness on incontinence. Intensive urotherapy contains biofeedback by real-time uroflowmetry; children receive direct feedback on their voiding behaviour. Attention offered to the child and achieving cognitive maturity with corresponding behaviour is of paramount importance. It is known that combining several kinds of biofeedback does not enhance the outcome. However, our results do not provide a conclusive answer to the effectiveness of pelvic floor physical therapy in the treatment of children with LUTD because we specifically investigated BABE.

CONCLUSION

In this study, we could not prove that pelvic floor rehabilitation by BABE has an additional effect on inpatient urotherapy on incontinence outcomes. Considering the invasive nature of BABE, the use of BABE to obtain continence should therefore be discouraged.

Conservative interventions for treating functional daytime urinary incontinence in children

BACKGROUND

In children, functional daytime urinary incontinence is the term used to describe any leakage of urine while awake that is not the result of a known underlying neurological or congenital anatomic cause (such as conditions or injuries that affect the nerves that control the bladder or problems with the way the urinary system is formed). It can result in practical difficulties for both the child and their family and can have detrimental effects on a child's well-being, education and social engagement.

OBJECTIVES

To assess the effects of conservative interventions for treating functional daytime urinary incontinence in children.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains studies identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 11 September 2018). We also searched Chinese language bibliographic databases: Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), and Wanfang. No language restrictions were imposed.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised, multi-arm studies, cross-over studies and cluster-randomised studies that included children aged between 5 and 18 years with functional daytime urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened records and determined the eligibility of studies for inclusion according to predefined criteria. Where data from the study were not provided, we contacted the study authors to request further information. Two review authors assessed risk of bias and processed included study data as described in the Cochrane Handbook for Systematic Reviews of Interventions. Where meta-analysis was possible, we applied random-effects meta-analysis using the Mantel-Haenszel method for dichotomous outcomes.

MAIN RESULTS

The review included 27 RCTs involving 1803 children. Of these, six were multi-arm and one was also a cross-over study. Most studies were small, with numbers randomised ranging from 16 to 202. A total of 19 studies were at high risk of bias for at least one domain. Few studies reported data suitable for pooling due to heterogeneity in interventions, outcomes and measurements.Individual conservative interventions (lifestyle, behavioural or physical) versus no treatmentTranscutaneous electrical nerve stimulation (TENS) versus sham (placebo) TENS. More children receiving active TENS may achieve continence (risk ratio (RR) 4.89, 95% confidence interval (CI) 1.68 to 14.21; 3 studies; n = 93; low-certainty evidence).One individual conservative intervention versus another individual or combined conservative interventionPelvic floor muscle training (PFMT) with urotherapy versus urotherapy alone. We are uncertain whether more children receiving PFMT with urotherapy achieve continence (RR 2.36, 95% CI 0.65 to 8.53, 95% CI 25 to 100; 3 studies; n = 91; very low-certainty evidence).Voiding education with uroflowmetry feedback and urotherapy versus urotherapy alone. Slightly more children receiving voiding education with uroflow feedback and urotherapy may achieve continence (RR 1.13, 95% CI 0.87 to 1.45; 3 studies; n = 151; low-certainty evidence).Urotherapy with timer watch versus urotherapy alone. We are uncertain whether urotherapy plus timer watch increases the number of children achieving continence compared to urotherapy alone (RR 1.42, 95% CI 1.12 to 1.80; 1 study; n = 58; very low-certainty evidence).Combined conservative interventions versus other combined conservative interventionsTENS and standard urotherapy versus PFMT with electromyographic biofeedback and standard urotherapy. We are uncertain whether there is any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 1.11, 95% CI 0.73 to 1.68; 1 study; n = 78; very low-certainty evidence).PFMT with electromyography biofeedback and standard urotherapy versus PFMT without feedback but with standard urotherapy. We are uncertain whether there is any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 1.05, 95% CI 0.72 to 1.52; 1 study; n = 41; very low-certainty evidence).Individual conservative interventions versus non-conservative interventions (pharmacological or invasive, combined or not with any conservative interventions)PFMT versus anticholinergics. We are uncertain whether more children receiving PFMT than anticholinergics achieve continence (RR 1.92, 95% CI 1.17 to 3.15; equivalent to an increase from 33 to 64 per 100 children; 2 studies; n = 86; very low-certainty evidence).TENS versus anticholinergics. We are uncertain whether there was any evidence of a difference between treatment groups in the proportions of children achieving continence (RR 0.81, 95% CI 0.05 to 12.50; 2 studies; n = 72; very low-certainty evidence).Combined conservative interventions versus non-conservative interventions (pharmacological or invasive, combined or not with any conservative interventions)Voiding education with uroflowmetry feedback versus anticholinergics. We are uncertain whether there was any evidence of a difference between treatment groups in the proportion of children achieving continence (RR 1.02, 95% CI 0.58 to 1.78; 1 study; n = 64; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The review found little reliable evidence that can help affected children, their carers and the clinicians working with them to make evidence-based treatment decisions. In this scenario, the clinical experience of individual clinicians and the support of carers may be the most valuable resources. More well-designed research, with well-defined interventions and consistent outcome measurement, is needed.

Traditional Biofeedback vs. Pelvic Floor Physical Therapy-Is One Clearly Superior?

PURPOSE OF REVIEW

Pelvic floor physical therapy is a worldwide accepted therapy that has been exclusively used to manage many pelvic floor disorders in adults and children. The aim of this review is to suggest to clinicians an updated understanding of this therapeutic approach in management of children with non-neuropathic voiding dysfunction.

RECENT FINDINGS

Today, pelvic floor muscle training through biofeedback is widely used as a part of a voiding retraining program aiming to help children with voiding dysfunction which is caused by pelvic floor overactivity. Biofeedback on its own, without a pelvic floor training component, is not an effective treatment. Biofeedback is an adjunct to the pelvic floor training. In the current review, we develop the role of pelvic floor physical therapy in management of children with non-neuropathic voiding dysfunction and compare it with biofeedback therapy alone.

Is urotherapy alone as effective as a combination of urotherapy and biofeedback in children with dysfunctional voiding?

Objective:

To compare standard urotherapy with a combination of urotherapy and biofeedback sessions and to determine the changes that these therapies promote in children with dysfunctional voiding.

Patients and Methods:

The data of 45 patients who participated in the study from January 2010 to March 2013 were evaluated. All patients underwent urinary system ultrasonography to determine post-void residual urine volumes and urinary system anomalies. All patients were diagnosed using uroflowmetry - electromyography (EMG). The flow pattern, maximum flow rate, and urethral sphincter activity were evaluated in all patients using uroflowmetry - EMG. Each patient underwent standard urotherapy, and the results were recorded. Subsequently, biofeedback sessions were added for all patients, and the changes in the results were recorded and statistically compared.

Results:

A total of forty - five patients were included, of which 34 were female and 11 were male and the average age of the patients was 8.4 ± 2.44 years (range: 5 - 15 years). After the standard urotherapy plus biofeedback sessions, the post-void residual urine volumes, incontinence rates and infection rates of patients were significantly lower than those with the standard urotherapy (p < 0.05). A statistically significant improvement in voiding symptoms was observed after the addition of biofeedback sessions to the standard urotherapy compared with the standard urotherapy alone (p < 0.05).

Conclusions:

Our study showed that a combination of urotherapy and biofeedback was more effective in decreasing urinary incontinence rates, infection rates and post - void residual urine volumes in children with dysfunctional voiding than standard urotherapy alone, and it also showed that this combination therapy corrected voiding patterns significantly and objectively.

Standard urotherapy as first-line intervention for daytime incontinence: a meta-analysis

According to the International Children's Continence Society (ICCS) guidelines for the treatment of daytime urinary incontinence (DUI) in children and adolescents, the first-line intervention for all types of DUI is standard urotherapy (SU). Despite this recommendation there is still no meta-analysis available on the effectiveness of SU. The aim of this study is to provide a meta-analytic evaluation of the intervention. This meta-analysis is based on Odds Ratios (OR) and consists of 26 patient samples out of 19 studies (N = 1609), collected from well-established medical databases. Remission rates after SU are compared to spontaneous remission rates, which are matched to the individual follow-up period. The meta-analysis shows that SU is an effective treatment of DUI. Compared to a spontaneous remission rate of 15.40% per year, urotherapy increases the probability to recover by a factor of 7.27 (6.57 if corrected for publication bias). After exclusion of three outlying samples this effect can be generalized for all types of SU and all patient populations. Moderator analyses cannot identify variables which significantly influence the variance of effect sizes. However, RCTs seem to be associated with lower effects, even when the control group is not considered for effect size calculation. Based on the present meta-analysis, SU is an effective intervention for treating DUI in children and adolescents. Of 100 patients in 1 year, approximately 56 patients (54 if corrected for publication bias) remit after being treated with SU, while only 15 out of 100 remit spontaneously. However, to further quantify the effect size of SU in comparison to spontaneous remission rates and other treatments, additional RCTs are still needed.

Are Interferential Electrical Stimulation and Diaphragmatic Breathing Exercises Beneficial in Children With Bladder and Bowel Dysfunction?

OBJECTIVE

To evaluate the effects of interferential current (IC) stimulation and diaphragmatic breathing exercises (DBEs) in children with bladder and bowel dysfunction.

PATIENTS AND METHODS

Seventy-nine children with dysfunctional voiding and chronic constipation who were failures of primary care interventions were included in the prospective clinical study. All the children were checked for their medical history regarding lower urinary tract symptoms and bowel habits. Physical examination, including abdominal and anorectal digital examination, was performed. Children kept a bladder and bowel diary, and underwent urinalyses and urine culture, ultrasound examination of bladder and kidneys, and uroflowmetry with pelvic floor electromyography. Eligible children were divided into 3 groups (A, B, and C). All groups were assigned education and behavioral modifications. Additionally, group A underwent DBEs and IC stimulation, whereas group B received only DBEs. The treatment was conducted for 2 weeks in the clinic in all 3 groups,. The behavioral modifications and DBEs were continued at home for 1 month. Clinical manifestations, uroflowmetry parameters, and postvoided residual urine were analyzed before and after 6 weeks of therapy.

RESULTS

After the treatment, significant improvement in defecation frequency and fecal incontinence was noticed only in group A (P < .001 and P < .05, respectively). These children demonstrated significant improvement in lower urinary tract symptoms and postvoided residual urine (P < .001 and P < .05, respectively). Bell-shaped uroflowmetry curve was observed in 73.3% of group A patients (P < .001).

CONCLUSION

IC stimulation and DBEs are beneficial in chronically constipated dysfunctional voiders. Further trials are needed to define the long-term effects of this program.

Scintigraphy evaluation of the types of functional constipation in children with bowel bladder dysfunction

PURPOSE

To evaluate the types of constipation according to colonic transit time in chronically constipated children with dysfunctional voiding (bowel bladder dysfunction, BBD group) and to compare the results with transit type in children with chronic functional constipation without urinary symptoms (constipation group) and children with normal bowel habits, but with lower urinary tract symptoms (control group).

PATIENTS AND METHODS

One-hundred and one children were included and their medical histories were obtained. The BBD group kept a voiding diary, and underwent urinalyses and urine culture, ultrasound examination of bladder and kidneys and uroflowmetry with pelvic floor electromyography. Radionuclear transit scintigraphy was performed in all children according to a standardized protocol. Patients were categorized as having either slow-transit (ST), functional fecal retention (FFR) or normal transit.

RESULTS

FFR was diagnosed in 31 out of 38 children with BBD, and 34 out of 43 children in the constipation group. ST was found in seven children with BBD, compared with nine children in the constipation group. The control group children demonstrated normal colonic transit. Urgency, daily urinary incontinence and nocturnal enuresis were noted only in children with FFR. Both children with ST constipation and FFR complained of difficulties during voiding, voiding postponement and urinary tract infections.

CONCLUSIONS

FFR is the most common form of constipation in children with dysfunctional voiding. However, some children might suffer from ST constipation. Differentiation between these two types of constipation is clinically significant because they require different treatment. Future studies with larger numbers of patients are needed to confirm the noted differences in urological symptoms in these two groups of constipated children..

The influence of positioning in urination: an electromyographic and uroflowmetric evaluation

PURPOSE

We conducted a cross-sectional study to evaluate whether the different positions during urination influence the electrical activity of the abdominal and perineal musculature, as well as the uroflowmetric parameters of children with lower urinary tract dysfunction (LUTD).

MATERIALS AND METHODS

Ninety-four children between the ages of 3 and 14 years with symptoms of LUTD were evaluated. All underwent uroflowmetry and electromyography tests (abdominal and perineal) in two different positions: oriented position (trunk bent slightly forward and feet flat) and atypical position (standing on toes for boys and buttocks not in contact with the lavatory seat and legs flexed in girls). We excluded nine patients due to suspicions of outside interference or elements complicating the analysis of charts.

RESULTS

Among patients evaluated 55 (64.7%) were girls and 30 (35.3%) were boys with an average age of 8.5 years. Children urinating in atypical position showed higher levels of perineal electrical activity than when they were in normal position (p=0.018). However, there was no difference in the pattern of the curve if normal or abnormal when comparing the two groups (p=0.824). When evaluated separately, the boys demonstrated no difference between positions, in relation to perineal electrical activity (p=0.412) or abdominal electrical activity (p=0.202).

CONCLUSIONS

The electrical activity of the pelvic floor musculature is decreased in the oriented position when compared to atypical positions in female children. Our data suggest that special attention should be given to adopting an adequate posture during urination for girls with LUTD.

Combined functional pelvic floor muscle exercises with Swiss ball and urotherapy for management of dysfunctional voiding in children: a randomized clinical trial

We report the clinical results of two types of urotherapy programs in children with dysfunctional voiding (DV). Sixty children with a median age of 8 (range, 5-14) diagnosed with DV were randomly allocated to one of two groups, each made up of 30 patients. Patients in group A underwent behavioral urotherapy (hydration, scheduled voiding, toilet training, and high-fiber diet) combined with pelvic floor muscle (PFM) exercises, whereas group B only received behavioral urotherapy. All parents completed a voiding and bowel habit diary chart. Uroflowmetry with pelvic floor surface electromyography (EMG) and bladder ultrasound were performed on all patients at the beginning and the end of the 1-year study. Abnormal voiding pattern normalized to a bell shape in 21/30 of patients in group A and 8/30 of patients in group B (P < 0.000). EMG activity during voiding disappeared significantly in 23/30 patients in group A compared to 15/30 patients in group B (P < 0.02). Episodes of urgency resolved in 12/14 of patients in group A and 3/11 of patients in group B (P < 0.01). Daytime wetting improved in 15/17 and 4/11 of patients in groups A and B, respectively. In addition, reduction in post-void residue (PVR) was significant in group A (P < 0.003).

CONCLUSION

Functional PFM exercises with Swiss ball combined with behavioral urotherapy proved as a safe and effective therapeutic modality, reducing the frequency of urinary incontinence, PVR, and the severity of constipation in children with DV.

The effect of breathing exercises on the nocturnal enuresis in the children with the sleep-disordered breathing

BACKGROUND

The nocturnal enuresis is one of the most common complaints of childhood. Upper airway obstruction and nocturnal snoring affect the nocturnal enuresis in children.

OBJECTIVES

The aim of this study was to investigate the effects of breathing exercises on the nocturnal enuresis in the children with the sleep-disordered breathing.

PATIENTS AND METHODS

This study was conducted in year of 2011 by a semi-experimental design with the control group among 40 children, aged 6 - 12 years, who had the nocturnal enuresis. Participants were examined based on the criteria of nocturnal enuresis, oral breathing, and nocturnal snoring. Subsequently, they were randomly assigned to the case and control groups. In the case group, the breathing exercises were performed for 45 minutes, and were pursued for four weeks in the morning following and prior to sleeping, and subsequently the arterial blood gases were measured and the frequency of enuresis and the respiratory rates (RR) were recorded.

RESULTS

After intervention the means of PaCO2 and RR in the control group were significantly higher than the case group (P < 0.0001). Likewise, O2sat, PaO2 in the case group were higher than the control group (P < 0.0001). The nocturnal enuresis decreased significantly in the case group, compared to the control group (P < 0.0001).

CONCLUSIONS

This study suggests that the breathing exercises may reduce the frequency of nocturnal enuresis in the patients with the oral breathing and nocturnal snore. The clinical implications of these findings should be verified in the future longitudinal studies.

Evaluation of functional lower urinary tract dysfunction in children: are the physicians complying with the current guidelines?

OBJECTIVE

To elucidate whether the diagnostic and treatment approaches of the physicians for functional lower urinary tract dysfunction (LUTD) in children is complying with the current guidelines.

MATERIAL AND METHODS

We have conducted an internet-based national survey for the physicians from different departments randomly sampled from the database of Turkish Paediatric Urology Society. Participants were asked to answer two-page questionnaire consisting of 4 main sections: "demography," "working conditions," "daily practice," and "scientific knowledge." Kruskal Wallis and multiple logistic regression were used for statistical analyses.

RESULTS

Of the 117 departments a total of 93 have completed the survey (n: 58 urology; n: 35 paediatric nephrology). Routine use of a questionnaire with validated symptom scoring system was found to be 13.9%. Of the participants, only 38.7% were asking all of the patients to fill the bladder diary. During treatment, only 24.7% were applying standard urotherapy for every patient. Almost half of the clinicians (45.1%) believed that they were personally insufficient during the evaluation of those children. Finally, 86% reported that children with LUTD were not adequately approached.

CONCLUSIONS

Evaluation of LUTD in children is not complying with the current guidelines. General approach for those children needs to be revisited by the clinicians.