Urinary incontinence and quality of life in children

Learning from the past: How lessons from Hinman syndrome can inform the psychological management of lower urinary tract dysfunction

INTRODUCTION

Pediatric patients with lower urinary tract dysfunction (LUTD) experience a variety of medical and psychosocial concerns that can negatively impact their clinical management and quality of life. When initially described by Drs Hinman and Baumann, patients with a form of severe LUTD, later dubbed Hinman syndrome, were characterized as having a "general attitude of being failures." While this mention was noteworthy as it incorporated an understanding of the interplay between psychological factors and urologic conditions, there have been delays in implementing psychological intervention as a standard of care in patients with LUTD broadly, and perhaps too keen of a focus on youth diagnosed with Hinman syndrome specifically.

METHODS

A non-systematic reviewed of LUTD related to psychological management was performed. Clinical recommendations were developed by a multicenter and multidisciplinary team of care providers with topic expertise.

OBJECTIVE

The aim of this paper is to propose a systems thinking paradigm for how to involve psychology, or psychological principles, across the spectrum of patients with LUTD with the hope of improving attention to specific aspects of care that may improve clinical management.

DISCUSSION

Children across the spectrum of LUTD are likely to benefit from psychological interventions and would benefit from such involvement early on to mitigate the impact of psychosocial concerns on medical outcomes. Pediatric psychologists are well-suited to identify and provide individualized care to patients in greatest need of intervention, such as through pre-procedural preparedness, addressing non-adherence, and with the use of evidence-based, targeted mental health interventions. Psychologists are also apt at implementing interventions while taking into consideration the severity of LUTD, in the context of the patient's psychological, developmental, cultural, familial, and social determinants of health considerations. Youth with severe forms of LUTD, such as Hinman syndrome, likely exemplify the challenges of LUTD that benefit from multidisciplinary intervention.

CONCLUSION

Medical and psychological collaboration are key to ensuring symptom mitigation and emotional support for patients across the entire spectrum of LUTD.

Parental Knowledge, Beliefs, Practices, and Barriers Related to Children's Bladder Health in the School Environment

BACKGROUND

Pediatric lower urinary tract symptoms (LUTS) are a set of common childhood problems. Community-level interventions that target behavioral change among children with LUTS can improve symptoms outside of the clinic environment. Parents, navigating the home and school environments, are key in supporting healthy bladder behaviors. Thus, we asked parents about their perceptions and barriers related to pediatric bladder health.

METHODS

English-speaking parents (n = 30) of children ages 5-10 years with and without LUTS were interviewed. Transcripts were coded iteratively by two independent coders using deductive and inductive approaches that emphasized consensus coding and peer debriefing.

RESULTS

Ninety-three percent of participants were women, 50% were 30-39 years old, and 60% held a graduate degree. Parents identified school-, classroom-, and child-based barriers to bladder health. These included the bathroom environment, restrictive policies for bathroom use, and anxiety on how and when to use the bathroom.

CONCLUSIONS

Addressing school-, classroom-, and child-based barriers is necessary to promote healthy bladder habits among children in the school environment and beyond. Recommended school-based interventions include bathroom use and sanitation policies that support students' voiding needs, teachers' professional development, and school readiness initiatives. Limitations include participation of English-speaking parents only.

Pediatric Lower Urinary Tract Dysfunction: A Comprehensive Exploration of Clinical Implications and Diagnostic Strategies

Lower urinary tract dysfunction is clinically important because it may cause urinary tract infections, mainly due to accumulation of residual urine, and adversely affect renal function. In addition, it may cause urinary incontinence, strongly affecting the child's quality of life. The function of the lower urinary tract is closely associated with function of the bowel because constipation is commonly present with bladder dysfunction. The interplay between the lower urinary tract and bowel function, coupled with common conditions such as detrusor overactivity and voiding dysfunction, requires a nuanced diagnostic approach. Detrusor overactivity, a benign but socially harmful condition, is the principal cause of daytime urinary incontinence in childhood. It needs to be differentiated from more serious conditions such as neurogenic bladder dysfunction or urethral obstruction. Voiding dysfunction, a habitual sphincter contraction during voiding, is common in children with detrusor overactivity and may be self limiting but may also result in residual urine and urinary tract infections. It may resemble, in severe cases, neurogenic bladder dysfunction, most often caused by spinal dysraphism, which very often leads to recurrent urinary tract infections and high intravesical pressures, jeopardizing renal function. A voiding diary is crucial in the initial evaluation of lower urinary tract function in children.

Paediatricians' perspectives in treating lower urinary tract symptoms: a qualitative exploratory needs assessment study

BACKGROUND

Paediatric lower urinary tract symptoms (LUTS) are common experiences among school-aged children, with prevalence rates reaching as high as 20%. Paediatricians are often first-line stakeholders in providing treatment for these bothersome symptoms, yet there is no formal resource to support them with the treatment of LUTS. Evaluating paediatricians' experiences is an important step in informing health promotion efforts to improve health outcomes in children. This study aims to explore paediatricians' knowledge, beliefs, practice patterns, and perceived barriers and facilitators in providing LUTS care.

METHODS

In this qualitative study, we conducted semistructured focus groups of paediatricians within California. Focus groups were conducted via Zoom, and participants were enrolled until thematic saturation was reached. Participants were asked about their current practices, knowledge and beliefs, barriers and facilitators to care, training and education, and responsibility for behaviour and action. Thematic analysis was performed using deductive and inductive approaches; themes were mapped through an iterative, team-based process.

RESULTS

15 paediatricians, aged 30-69 years, with 13 (86.7%) women, were interviewed. Most (11, 73.3%) practised in general outpatient settings. Interviewed paediatricians recognised paediatric LUTS as a common problem that can significantly impact children's well-being. In practice, paediatricians did not actively screen for LUTS beyond the potty-training milestone due to short visit duration and competing healthcare demands. Lack of guidelines, parental mistrust and inadequate clinical education were barriers identified by paediatricians.

CONCLUSIONS

Paediatricians expressed a willingness to help patients but indicated several limitations to providing adequate LUTS care. Future professional development work can emphasise guideline development, early screening strategies to support timely intervention and better education for clinicians.

The effect of methylphenidate for giggle incontinence in children

INTRODUCTION

Giggle incontinence (GI) is a rare form of urinary incontinence that occurs during or immediately after laughing due to involuntary and complete bladder emptying. Few studies in the literature report that methylphenidate can be effective in treatment of this condition.

OBJECTIVE

The aim of this study is to characterize children with GI and evaluate their response to methylphenidate, as well as describe treatment duration, dosage of methylphenidate, relapse rates after discontinuation of medication, and side effects.

METHODS

Medical records and 48-h frequency-volume charts from children treated with methylphenidate for GI in the period January 2011-July 2021 were retrospectively analyzed.

RESULTS

Eighteen children were diagnosed with GI and fulfilled inclusion criteria. Fifteen patients were included in analysis, as 3 out of 18 children decided not to take the methylphenidate that was prescribed. In total, 14 out of the 15 GI patients treated with methylphenidate experienced clinical effect. All patients included in the study had methylphenidate prescribed in a dose range of 5-20 mg daily. Treatment duration ranged from 30 to 1001 days, with a median of 152 days (IQR 114, 243.5). Ten children experienced complete response and two of those reported symptom relapse after discontinuation of the methylphenidate. Only mild and short-lasting side effects were reported by two patients.

DISCUSSION

Our study demonstrates that methylphenidate is an effective treatment in children diagnosed with GI. Side effects are mild and uncommon.

The relationship between maternal psychopathology and offspring incontinence and constipation at school age: A prospective cohort study

BACKGROUND

There is evidence for an association between maternal psychopathology and offspring incontinence and constipation, but it is unclear if there is a critical/sensitive period of exposure to maternal depression and/or anxiety in the antenatal or postnatal period.

METHODS

Mothers from the Avon Longitudinal Study of Parents and Children provided data on their depression and anxiety (antenatal and postnatal) and their child's urinary and faecal incontinence and constipation at age 7 (6489 participants). We used multivariable logistic regression to examine evidence for independent effects of maternal depression/anxiety on offspring incontinence/constipation and to investigate if there was a critical/sensitive period of exposure. We examined evidence for causal intra-uterine effects using a negative control design.

RESULTS

Postnatal maternal psychopathology was associated with an increased risk of offspring incontinence and constipation (e.g. postnatal anxiety and daytime wetting OR: 1.53; 95 % CI: 1.21-1.94). Data were consistent with a postnatal critical period model and there was evidence for an independent effect of maternal anxiety. Antenatal maternal psychopathology was associated with offspring constipation (e.g. antenatal anxiety OR: 1.57; 95 % CI: 1.25-1.98), but there was no evidence for a causal intra-uterine effect.

LIMITATIONS

Attrition and maternal reports without use of diagnostic criteria for incontinence/constipation are potential limitations.

CONCLUSIONS

Children exposed to maternal postnatal psychopathology had a greater risk of incontinence/constipation, and maternal anxiety had stronger associations than depression. Health professionals should be vigilant to effects of maternal psychopathology on child development. Identification of mechanisms linking maternal psychopathology to child incontinence/constipation is required to inform evidence-based support.

Evaluation of the association between asthma and non-neurogenic urinary incontinence in children; a case-control study

BACKGROUND

Asthma is the most common chronic disease in children. Asthma can lead to sleep disorders and psychiatric issues, which are often accompanied by urinary incontinence in children. Furthermore, several studies have shown a relationship between allergic diseases and urinary incontinence. This study aims to examine the association between asthma and non-neurogenic urinary incontinence.

MATERIALS AND METHODS

This case-control study included 314 children over three years old referred to Amir Kabir Hospital; 157 with asthma and 157 without asthma. After explaining each urinary disorder in accordace with the International Children's Continence Society's definitions, parents and children were asked about their presence. The disorders included monosymptomatic nocturnal enuresis(MNE), nonmonosymptomatic nocturnal enuresis (NMNE), vaginal reflux (VR), pollakiuria, infrequent voiding, giggle incontinence (GI), and overactive bladder (OAB). The analysis was performed using Stata 16.

RESULTS

The average age of the children was 8.19 ± 3.15 years. Patients with asthma (p = 0.0001) and GI (p = 0.027) had a considerably lower average age than patients without these disorders. Asthma and urinary incontinence, including NMNE, Infrequent voiding, and OAB, were significantly correlated (p = 0.017, 0.013, and 0.0001, respectively). Moreover, the association between MNE and asthma was significant in males (p = 0.047).

CONCLUSION

Due to the relationship between asthma and urinary incontinence, children with asthma must be evaluated for the presence of urinary disorders and, if present, receive the proper treatment in order to improve their quality of life.

The Prevalence of Bladder and Bowel Dysfunction in Children with Cerebral Palsy and its Association with Motor, Cognitive, and Autonomic Function

PURPOSE

To describe the prevalence of bladder and bowel dysfunction (BBD) in 8-10-year-old children with cerebral palsy and its association with motor, cognitive, and autonomic dysfunction.

METHODS

A cross-sectional, random sample study of parents of 8-10-year-old children with cerebral palsy. Tools: The Enuresis/Urinary Incontinence Parental Questionnaire, the Functional Independence Measure children's version, the autonomic signs questionnaire, and the Gross Motor Function Classification System.

RESULTS

39 out of 59 parents consented to participate, whereas 25.64% reported complete continence. Of the 29 children with BBD, 21 (72.4%) had lower urinary tract symptoms and bowel problems. Only two of the children received conservative and noninvasive treatments. Lastly, motor, cognitive and autonomic impairments were associated with incontinence.

CONCLUSIONS

BBD is common in 8-10-year-old children with cerebral palsy at all levels of functioning. Most having both lower urinary tract symptoms and bowel problems.

Alarm-assisted urotherapy for daytime urinary incontinence in children: A meta-analysis

OBJECTIVES

Wearable alarm systems are frequently used tools added to urotherapy for children with both daytime and nighttime urinary incontinence. For functional daytime incontinence (DUI) specifically, the effect of alarm interventions has not been systematically reviewed. This study systematically evaluates, summarizes, reviews, and analyzes existing evidence about the effect of wearable alarm systems in urotherapy for children with functional DUI.

STUDY DESIGN

We completed a comprehensive literature search in August 2022 using MEDLINE/PUBMED, EMBASE, PsycINFO, Cochrane Library, Web of Science, Google Scholar, conference abstracts, and citation tracking. Clinical controlled trials at controlled-trials.com and clinicaltrials.gov were consulted, as was the National health Service Center For Reviews And Dissemination. Eligible studies including the use of noninvasive wearable alarm systems as (part of) treatment for functional DUI in children were included. The main outcome was continence after treatment. Three independent reviewers extracted data. Risk of bias was assessed using Cochrane and National Heart, Lung and Blood Institute quality assessment tools.

RESULTS

A total of 10 studies out of 1,382 records were included. Meta-analysis revealed a nonsignificant risk ratio of 1.4 (95% CI: 0.8-2.6) for the use of alarm systems. Urotherapy with alarm systems resulted in a 48% (95% CI: 33-62%) continence rate after treatment.

CONCLUSIONS

Alarm systems might be helpful as part of urotherapy for functional DUI in select cases. Adherence is problematic, and the optimal duration of the use of alarm systems is to be determined. Overall, the risk of bias was high in all studies.

Posterior Tibial Nerve Stimulation in Children with Lower Urinary Tract Dysfunction: A Mixed-Methods Analysis of Experiences, Quality of Life and Treatment Effect

Background: Posterior tibial nerve stimulation (PTNS) is one of the treatment modalities for children with therapy-refractory lower urinary tract dysfunction (LUTD). This study used a mixed-methods analysis to gain insight into the experiences of children treated with PTNS and their parents, the effect of treatment on quality of life (QOL) and the effect of PTNS on urinary symptoms. Methods: Quantitative outcomes were assessed through a single-centre retrospective chart analysis of all children treated with PTNS in a group setting between 2016–2021. Voiding parameters and QOL scores before and after treatment were compared. Qualitative outcomes were assessed by an explorative study involving semi-structured interviews transcribed verbatim and inductively analysed using the constant-comparative method. Results: The data of 101 children treated with PTNS were analysed. Overall improvement of LUTD was seen in 42% and complete resolution in 10%. Average and maximum voided volumes significantly increased. QOL improved in both parents and children independent of the actual effect on urinary symptoms. Interviews revealed PTNS to be well-tolerated. Facilitating PTNS in a group setting led to feelings of recognition in both children and parents. Conclusions: PTNS is a good treatment in children with therapy-refractory LUTD and provides valuable opportunities for peer support if given in a group setting.

The effect of vitamin D deficiency in children with overactive bladder related urinary incontinence

Purpose:

Overactive bladder (OAB) is a common syndrome associated with lower urinary tract symptoms (LUTS), especially urinary incontinence in children, which may affect the patient's quality of life (QoL). Vitamin D deficiency has been shown to be associated with OAB syndrome. This study evaluated the relationship between vitamin D status and OAB-related symptoms and QoL in children.

Materials and Methods:

The study included 52 pediatric patients with OAB-related urinary incontinence and 41 healthy children. LUTS were assessed using the Dysfunctional Voiding and Incontinence Symptoms Score (DVISS) questionnaire, and QoL was assessed using the Pediatric Incontinence Questionnaire (PINQ). Oral vitamin D supplementation was given to patients with OAB with vitamin D deficiency. Urinary symptoms and QoL were evaluated before and after vitamin D supplementation.

Results:

Vitamin D deficiency was more common in the OAB group (75%) than in the control group (36.6%). Logistic regression analysis revealed that vitamin D status (<20ng/mL) was a significant predictor of OAB. Both pre-treatment and post-treatment DVISS and PINQ scores showed a positive correlation. After vitamin D supplementation, 8 (23.5%) patients had a complete response and 19 (55.9%) patients had a partial response. Significant improvement in QoL was also achieved.

Conclusions:

Vitamin D deficiency is more common in children with urinary incontinence and OAB than in healthy children. Although vitamin D deficiency is not routinely evaluated for every patient, it should be evaluated in treatment-resistant OAB cases. Vitamin D supplementation may improve urinary symptoms and QoL in patients with OAB.

Urinary incontinence during laughter in children: Is it giggle incontinence?

AIM

Giggle incontinence is a distinct entity of childhood daytime urinary incontinence (DUI), where children wet themselves only when they laugh. The prevalence of true giggle incontinence is unknown, with confusion about the diagnosis of urinary incontinence occurring during laughter and true giggle incontinence. The aim of the study is to improve our understanding of urinary incontinence during laughter by comparing those children with children who have DUI at other times, but not with laughter.

METHODS

We conducted a retrospective medical record review of children with DUI who presented to a tertiary continence service from 2017 to 2018, collecting data on age, gender, associated comorbidities, lower urinary tract symptoms, investigations, provisional diagnosis at first visit and initial treatment responses. Differences between those with DUI occurring during laughter and those with DUI at other times, but not with laughter were compared using standard statistical methods.

RESULTS

Of the 277 new patients seen during the study period, 140 (51%) had DUI, and of these, 72 (51%) had DUI occurring during laughter. Children with incontinence occurring during laughter were more likely to have incontinence associated with other activities. One child had giggle incontinence according to the International Children's Continence Society's definition. Four other children were referred specifically for urinary incontinence associated with laughter, with the term giggle incontinence sometimes used by the referring doctor.

CONCLUSION

Children with DUI commonly experience incontinence during laughter, but true giggle incontinence is rare. Correct diagnosis is essential as it directs treatment.

The effect of meatal correction on daytime urinary incontinence in girls with an anterior deflected urinary stream

INTRODUCTION

Girls with an anterior deflected urinary stream (ADUS) are known to wet the toilet rim and their buttocks while voiding. This deviation may prevent adopting an ideal toileting position and can thus develop into a functional voiding disorder. Although surgical correction of the urinary stream by a meatotomy is part of standard care in girls with ADUS and lower urinary tract symptoms (LUTS) at our center, little is known about the effect of this procedure on daytime urinary incontinence (DUI).

OBJECTIVE

To assess the effect of meatal correction on incontinence in girls with ADUS and DUI, and to find predictors for therapy success.

STUDY DESIGN

A retrospective chart study including all girls with ADUS and DUI who underwent a dorsally directed meatal correction at our tertiary referral center between 2005 and 2018 (n = 274). The main outcome measurement was continence according to the International Children's Continence Society criteria, expressed as the percentage of children that were continent at post-surgical follow-up (complete response). Multivariate logistic regression was used to identify predictors of continence.

RESULTS

In 93% of girls, the direction of the urinary stream was no longer anterior deflected. 29% (n=79) of all girls were continent at post-surgical follow-up. We could not find a convincing predicting factor for achieving continence.

DISCUSSION

Although meatal correction is successful on normalizing the direction of the urinary stream, less than one-third of girls became continent. In addition, we were unable to indicate which girls will profit from this procedure in terms of continence. Since not every girl with ADUS develops incontinence complaints, it may also be questionable whether ADUS and incontinence are directly related. Since other, less invasive and more effective treatment options for DUI are available, meatal correction should therefore be considered a last-resort option in the treatment of pediatric DUI in girls with ADUS.

CONCLUSION

Of the 274 girls with ADUS and DUI, 29% did benefit from a meatotomy. No convincing indicator for therapy success could however be found. Therefore, we discourage a meatotomy as standard treatment in girls with ADUS and DUI.

Parental perceptions of bladder dysfunction in children with symptomatic joint hypermobility

Children with symptomatic joint hypermobility (SJH) report chronic pain, fatigue, and joint instability as their main symptoms. Symptoms can extend beyond musculoskeletal and include lower urinary tract dysfunction (LUTD). There are no studies exploring parent-perceived quality of life (QoL) in children with LUTD, or strategies used to manage symptoms in this population. Our online cross-sectional survey assessed parents of 6-18-year-olds via two UK charitable organizations. It included the Pediatric Incontinence Questionnaire (PinQ), the Dysfunctional Voiding Symptom Score, and questions exploring treatments and efficacy. Sixty-seven parental questionnaires were analyzed. The majority of children were white females (95%, n = 64). Urgency (97%, n = 65) and enuresis (41.7%, n = 28) were the most frequently reported symptoms. The PinQ questionnaire showed that children were emotionally distressed by LUTD. Twenty-nine parents (43%, n = 29) reported pharmacotherapy as the most effective treatment. Few had accessed other treatments such as physiotherapy (16%, n = 18). Most parents reported that overall treatment did not meet their expectations. This study highlights that parents perceive LUTD as having a great impact on their child's QoL. There is need for education among clinicians about LUTD and hypermobility-related disorders, and for development and evaluation of treatments.

A prospective survey study of lower urinary tract dysfunction in childhood cancer survivors after vincristine and/or doxorubicin chemotherapy

BACKGROUND

Two chemotherapeutic agents used widely in pediatric oncology are vincristine (VCR) and doxorubicin (DOX), which may cause neuropathy and myopathy, respectively. The study hypothesis is that neurotoxic effects of VCR and/or myotoxic effects of DOX affect bladder physiology and manifest clinically as lower urinary tract dysfunction (LUTD).

PROCEDURE

Based on a priori power analysis, 161 children divided evenly by gender were recruited. Children aged 5-10 years completed the dysfunctional voiding scoring system (DVSS) survey. The study cohort comprised cancer survivors treated with VCR and/or DOX. Healthy controls were recruited from well-child clinic visits. Exclusion criteria included pelvic-based malignancy, pelvic irradiation, pre-existing LUTD, neurologic abnormalities, and treatment with cyclophosphamide/ifosfamide. DVSS scores and presence of LUTD, defined as DVSS scores above gender-specific thresholds (males ≥9, females ≥6), were compared across cohorts.

RESULTS

Median DVSS scores were higher in the study cohort (6 vs. 4, p = .003). Moreover, children in the study cohort were more likely to exceed threshold scores for LUTD (38.8% vs. 21%, p = .014; OR 1.8). Subanalysis by gender revealed female cancer survivors are more likely to report LUTD than controls (57.5% vs. 30%, p = .013, OR 1.9). This did not hold true for males (20% vs. 12.2%, p = .339).

CONCLUSIONS

Childhood cancer survivors who received VCR and/or DOX reported higher rates of LUTD than controls. Female cancer survivors appear more likely to suffer from LUTD than males. Further study with a positive control cohort of cancer survivors who received non-VCR, non-DOX chemotherapy is underway to elucidate the contribution of a cancer diagnosis to LUTD.

Effect of education given to children with enuresis on quality of life

INTRODUCTION

The quality of life of children diagnosed with enuresis is affected negatively compared with that of healthy children.

OBJECTIVES

This study aimed to evaluate the effect of the education program given within the framework of nursing activities on the quality of life of children diagnosed with enuresis.

STUDY DESIGN

The study was conducted on 60 children aged 7-12 years who applied to the urology clinic of a hospital in Turkey and were diagnosed with enuresis. Data were collected using the Pediatric Incontinence Questionnaire (PINQ). Children who met the study criteria were divided into two groups, control and experimental, using the random draw method. Participants in the experimental group were educated by the researcher with using the Enuresis Education Booklet.

RESULTS

Of the 60 children, 43.3% were aged 7-8 years and 63.3% were male. At baseline, the children in the control group revealed a total mean PINQ score of 45.00 ± 11.52, and the total mean PINQ score was 45.80 ± 12.05 at 1 month. At baseline, the children in the experimental group revealed a total mean PINQ score of 47.00 ± 11.88, and the total mean PINQ score of was 32.404 ± 8.62 at 1 month. A measurement carried out in the education and control groups 1 month later showed a statistically significant difference in the total mean PINQ scores (P < 0.001).

CONCLUSION

Explaining the disease thoroughly to a child created a positive effect on the child's quality of life.

Systematic review and meta-analysis identify significant relationships between clinical anxiety and lower urinary tract symptoms

BACKGROUND

Lower urinary tract symptoms (LUTS), such as voiding symptoms, overactive bladder, and interstitial cystitis, and anxiety disorders are often comorbid conditions in patients. However, the existing evidence regarding the rates and nature of the co-occurrence of these conditions has not been systematically evaluated. The aim of this study was to examine these relationships.

METHODS

We conducted a systematic review and meta-analysis to examine the relationship between LUTS and anxiety. We searched for articles published from January 1990 to July 2019 in PubMed, CENTRAL, PsycINFO, and Google Scholar. Outcomes were anxiety-related disorders and symptoms (clinically significant anxiety) and LUTS. We performed random-effects meta-analyses, inspected funnel plots, and applied the Egger's test to evaluate publication bias. We followed PRISMA guidelines and recorded our protocol on PROSPERO (ID = CRD42019118607).

RESULTS

We identified 814 articles, of which 94 fulfilled inclusion criteria, and 23 had sufficient data for meta-analysis. The odds ratio (OR) for clinically significant anxiety among individuals with LUTS was 2.87 (95% CI: 2.38,3.46, p < .001). The OR for LUTS among individuals with clinically significant anxiety was 2.87 (95% CI: 1.07,7.74, p < .001), although very few studies examined this relationship. A large value of I² index suggests high heterogeneity between studies.

CONCLUSION

The results demonstrate a significant association between clinically significant anxiety and LUTS in both females and males. There were limited studies on younger individuals and on individuals ascertained for clinically significant anxiety, which should motivate further study in these areas. Understanding the co-occurrence of these conditions will lead to better prevention and interventions to ameliorate the progression of the symptoms and improve the quality of life. A thorough assessment of anxiety may provide more optimal care for LUTS patients.

Integrative review and evaluation of quality of life related instruments in pediatric urology

INTRODUCTION

While most paediatric urologists consider patients' quality of life (QOL) important, few actually measure this outcome. Our goal was to assess instruments used in the pediatric urology QOL literature, specifically looking at whether they captured QOL.

METHODS

We searched MEDLINE and EMBASE for articles with a self-described primary outcome of measuring QOL. All validated QOL instruments in the papers were analyzed by QOL instrument content experts. Instruments were classified as focusing on: Functioning or QOL (Table). The term Functioning focuses on performing activities. QOL captures person's perceptions about their position in life, informed by circumstances, functioning and conditions. QOL instruments were further subdivided into generic QOL, health-related QOL (HRQOL) and disease-specific HRQOL. Only direct patient self-reported QOL instruments were then assessed, since they are the most clinically useful, reliably assessing patients' own perception of their QOL.

RESULTS

Forty-three publications met inclusion criteria (published 1999-2019). Most common conditions included urinary incontinence (16, 37.2%) and kidney transplantation (12, 27.9%). Overall, 22 unique instruments purporting to measure QOL were identified. Looking at the concepts measured by each instrument, nine instruments (40.9%) assessed Functioning. Nine instruments (40.9%) measured a combination of Functioning and QOL. Only the remaining 4 instruments (18.2%) assessed strictly QOL. The 13 instruments assessing any QOL focused on generic QOL (n = 4), HRQOL (n = 3) and disease-specific HRQOL (n = 6). Of the subset of four instruments assessing strictly QOL, and not Functioning, all had patient self-reported versions available: two generic QOL instruments (KINDL, KIDSCREEN), one generic HRQOL (DISABKIDS), and one disease-specific HRQOL (QUALAS). Thirteen of 43 studies (30.2%) employed more than one instrument. Thirty-eight studies (88.4%) used an instrument measuring Functioning, with 19 (44.1%) measuring only Functioning, not QOL at all. Twenty-four studies (55.8%) used an instrument measuring actual QOL, although 17 (39.5%) used a combined Functioning/QOL instrument. Only nine (20.9%) used a strictly QOL instrument (strictly HRQOL instruments: 4.7%).

DISCUSSION

We present encouraging evidence of sustained interest in QOL research in pediatric urology and identify areas needing improvement. Selecting appropriate QOL tools requires a working knowledge of their various underlying meanings and purposes. Whether it adequately assess QOL must be considered. We discuss strengths and weaknesses of instruments and a practical approach to QOL instrument selection.

CONCLUSION

Much of pediatric urology is grounded in improving QOL. Unfortunately, most studies published to date focus on Functioning, rather than young people's perception-based QOL. Future QOL studies should ideally employ validated instruments capturing patient-reported QOL.

Effectiveness of standard urotherapy (basic bladder advice) and combination therapies in managing bladder dysfunction in children with treated behavioral disorders: Results of a prospective cohort (DABBED) study

AIMS

We evaluated the efficacy of standard urotherapy and combination therapies in treatment of bladder dysfunction in children with treated behavioral disorders.

METHODS

Prospective study of children (6-16 years) with bladder dysfunction and behavioral disorders was conducted between March 2018-2020. Eligible children were initially offered standard urotherapy and those with no response at 3 months were offered combination therapies. Symptomatic response, changes in Akbal score and PinQ score were reported at 6 months and outcomes were correlated to behavioral diagnoses and medications.

RESULTS

Thirty-nine consecutive children (male = 27, mean age [SD] 10.3 [±2.0] years) were recruited, of whom 29 completed the study (five lost to follow-up, three non-compliant to treatment, two excluded). Thirty-four (87%) children had attention deficit/hyperactivity disorder. Monosymptomatic nocturnal enuresis (n = 11) and non-monosymptomatic enuresis (n = 17) were the commonest diagnoses. Following 3-month review, 14 (38%) children continued to receive standard urotherapy, while 15 (41%) children were transitioned to combination therapy. At 6-month review, complete/partial response was seen in 62% (23/37) and no response in 16% (6/37); with 32% (12/37) responding to standard urotherapy alone. Akbal symptom scores (15.9-11.5; P < 0.01) and PinQ scores (26.0-19.5; P = 0.008) improved significantly at 6-month follow-up. Type of underlying behavioral disorder(s) or medications for behavioral disorder did not influence the outcomes.

CONCLUSION

This study confirms that children with underlying behavioral disorders are able to have a good response to the appropriate therapy for their bladder dysfunction with a third of children responding to standard urotherapy alone.

Bladder and Bowel Dysfunction Network: Improving the Management of Pediatric Bladder and Bowel Dysfunction

Lower urinary tract symptoms with constipation characterize bladder and bowel dysfunction (BBD). Due to high referral volumes to hospital pediatric urology clinics and time-consuming appointments, wait times are prolonged. Initial management consists of behavioral modification strategies that could be accomplished by community pediatricians. We aimed to create a network of community pediatricians trained in BBD (BBDN) management and assess its impact on care.

METHODS

We distributed a survey to pediatricians, and those interested attended training consisting of lectures and clinical shadowing. Patients referred to a hospital pediatric urology clinic were triaged to the BBDN and completed the dysfunctional voiding symptom score and satisfaction surveys at baseline and follow-up. The Bristol stool chart was used to assess constipation. Results were compared between BBDN and hospital clinic patients.

RESULTS

Surveyed pediatricians (n = 100) most commonly managed BBD with PEG3350 and dietary changes and were less likely to recommend bladder retraining strategies. Baseline characteristics were similar in BBDN (n = 100) and hospital clinic patients (n = 23). Both groups had similar improvements in dysfunctional voiding symptom score from baseline to follow-up (10.1 ± 4.2 to 5.6 ± 3.3, P = 0.01, versus 10.1 ± 4.2 to 7.8 ± 4.5, P = 0.02). BBDN patients waited less time for their follow-up visit with 56 (28-70) days versus 94.5 (85-109) days for hospital clinic patients (P < 0.001). Both groups demonstrated high familial satisfaction.

CONCLUSIONS

Community pediatricians may require more knowledge of management strategies for BBD. Our pilot study demonstrates that implementing a BBDN is feasible, results in shorter wait times, and similar improvement in symptoms and patient satisfaction than a hospital pediatric urology clinic.

Children's experience with daytime and nighttime urinary incontinence - A qualitative exploration

BACKGROUND

Much of our knowledge about the impact of urinary incontinence (UI) on children is derived from surveys. While these studies provide an overview of the UI experience, personal interviews may offer additional nuances and a more detailed perspective of what the experience of UI is for children. Objective To conduct interviews and use qualitative analysis to explore the experiences of children with UI, with a particular focus on (1) the impact of UI on participants' lives, (2) which coping strategies children with UI use, and (3) the emotional effects of UI.

STUDY DESIGN

Semi-structured interviews of children with non-neurogenic and non-anatomic UI recruited from a pediatric urology clinic were audio recorded and verbatim transcribed. Eligibility included: age 8-17 years, history of UI, English fluency, and being able to participate in a 30 min interview. Conventional content analysis was performed to identify themes directly from the transcripts. Coders independently and iteratively coded transcripts (intercoder reliability >0.85) until inductive thematic saturation was achieved.

RESULTS

There were substantial practical and emotional impacts on the 30 (14 males, 16 females) children (median age 11.5 years) with UI. Participants relayed significant interference with social activities like sports and sleepovers, which often lead to avoidant behavior of these activities. By contrast, most stated that UI did not impair school performance. The most strongly and consistently expressed emotions were embarrassment and anxiety. Nevertheless, children described a wide variety of adaptations, including behavioral and cognitive, to manage their incontinence and its effects on their lives (Summary Table).

DISCUSSION

This is the first qualitative study that describes the experiences and perspectives of children with UI. Surveys of this population suggest a lower health-related quality of life, particularly in emotional well-being, self-esteem and relationships. This work augments this body of literature and shows how UI interferes with their daily life and is a major source of embarrassment and anxiety. Despite this, children with UI display strong resilience and adapt to their condition. The study was limited in that the sample was biased to those presenting to a urology clinic and was not designed to compare differences in UI experience between ages, genders, or treatment types.

CONCLUSION

This study, the first qualitative exploration of the emotional responses and coping behaviors of children with UI, shows significant social impact and negative emotional responses but marked resiliency. These findings should be considered when developing a comprehensive treatment strategy for children with UI.

[Voiding dysfunction and access to toilets among elementary school children: A Toulouse school district study]

Not urinating regularly, voluntarily restraining oneself at school promotes the occurrence of voiding disorders.

AIM

To determine the prevalence of such disorders in elementary schools (students from 1st to 5th grade) and analyze the role of access to school toilets on voiding habits.

METHOD

Observational, descriptive epidemiological study during the 2017-2018 school year by electronic questionnaire with parents of pupils attending elementary school.

RESULTS

2119 questionnaires were analyzed. The graders sex ratio was 1.07 (1087 boys). 410 families (19%) were classified as "popular" class. First, second and third graders represented 60% of the enrollment (N = 1273). Overall use of school toilets was 87% and 69% of students had appropriate use for urine. The main obstacles to their use were lack of hygiene and comfort (51%), lack of security or privacy (33%), limited accessibility (28%). The overall prevalence of urinary elimination disorders was 9%. Girls had more inappropriate use of the toilet for urine (36% vs 27%, OR 1.5, P = 0.0004). The factors associated with urinary elimination disorders were: not using the toilet (13% vs 9 %, OR 1.5, P = 0.04), being a girl (14% vs 5%, OR 3.5, P &lt; 0.0001), belonging to the working class (14% vs 8% OR 1.8, P = 0.0008).

CONCLUSION

This situation, which is a long-denounced major public health problem, mainly affects girls and also reveals social inequalities in the use of school toilets.

The role of bladder function in the pathogenesis and treatment of urinary tract infections in toilet-trained children

Urinary tract infections (UTIs) are a common reason for referral to pediatric specialists and the risk profile of these children is influenced by age, sex, and underlying urinary tract abnormalities. UTIs in toilet-trained children represent a different entity than confirmed, febrile UTIs that occur in infants, impacted by suboptimal bladder habits, bladder dysfunction, constipation, or a combination of these factors. A comprehensive literature search was conducted using PubMed and MEDLINE and search terms included recurrent UTI, VUR, bladder and bowel dysfunction (BBD), constipation, lower urinary tract symptoms, and voiding dysfunction. Common presenting symptoms of UTI in children include fever (> 38 °C) with or without "traditional" lower urinary tract symptoms (LUTS) such as dysuria, malodorous urine, frequency, urgency, and incontinence. However, many infections in older children are afebrile episodes-consisting primarily of LUTS-which may or may not be confirmed with biochemical and/or microbiological evidence. Therefore, when evaluating toilet-trained children with recurrent UTIs, it is paramount to consider dysfunctional elimination as an underlying cause, diagnose, and treat it prior to indicating surgical options, even in the presence of VUR or other anatomical abnormalities. Although the impact of bladder function on the risk of infections is important, so is the accurate diagnosis and initial evaluation. This review article will focus on an often overlooked yet critical factor: the impact of bladder function, particularly for toilet-trained children, as well as the importance of implementing bladder training strategies, aggressive management of constipation, and pharmacological management as necessary.

Bladder and bowel control in a population-based sample: Associations to quality of life and behavioral problems of 4-6-year-old children participating in the German Health Interview and Examination Survey (KiGGS)

BACKGROUND

Prevalence rates for psychiatric comorbidities are high in incontinent children. We analyzed data from the KiGGS survey in order to assess the rate of preschool children with delayed or regular continence, the mean age of gaining continence, psychiatric problems, and quality of life in a nation-wide, representative sample.

METHODS

Parental questionnaire data of 3875 preschool children (4-6 years) were analyzed. Percentages of children with daytime, nighttime, and complete continence, and mean ages of gaining continence were calculated. Psychological and behavioral problems (SDQ), as well as Quality of life (KINDL-R), were assessed.

RESULTS

16.9% showed delayed gaining of continence. Percentages of children with nighttime bladder continence were lower for boys (76.3%) than for girls (80.6%), and lower for children without (78.2%) than those with a migration status (79.2%). Complete continence was gained by more girls (83.9%) than boys (78.2%), more children from the former East Germany (82.4%) than former West Germany (81.1%), and by more migrants (82.7%) than nonmigrants (81.9%). Girls, children living in the former East of Germany, and migrants achieved continence consistently at an earlier age. Children with incontinence or continence ≥4 years showed significantly more psychological problems, less prosocial behavior and low quality of life.

CONCLUSION

The age at gaining continence is moderated by gender, German region, and migration status. Delayed achievement of continence is associated with more psychological problems and a lower quality of life. The importance of effective treatment of incontinence is emphasized by the results of this study.

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.

Complete resolution of urinary incontinence with treatment improved the health-related quality of life of children with functional daytime urinary incontinence: a prospective study

Background

To assess the health-related quality of life (HRQOL) of children with daytime urinary incontinence (DUI) based on pre- and post-treatment self-reports and parent proxy-reports.

Methods

The study population comprised 117 children with at least one episode of DUI per week and their caregivers as well as 999 healthy children (control group). The Pediatric Quality of Life Inventory 4.0 (PedsQL) questionnaire was administered to assess the HRQOL of children. To assess the degree of improvement in HRQOL, we categorized children into two groups: group A achieved complete response (CR) to treatment within 12 months and group B did not achieve CR within 12 months. CR was defined as the complete resolution of symptoms or alleviation of symptoms to < 1 DUI episode/month.

Results

Valid responses were collected from 84 children [53 boys and 31 girls; mean age: 7.9 ± 1.5 years (range, 6–12)]. Sixty-two patients (73.8%) were classified into group A and 22 (26.1%) into group B. Based on self-reports, significant post-treatment improvement was observed in the scores of all PedsQL items (mean total score: 82.2 ± 11.3 vs. 87.2 ± 9.8; P = 0.003). Group A showed significant improvement in the scores of all PedsQL items after achievement of CR based on child self-reports; however, this was improvement not observed in group B.

Conclusions

To the best of our knowledge, this is the first study to demonstrate the complete resolution of DUI with treatment for improving the HRQOL of these children.

Assessment of Needs in Children Suffering From Refractory Non-neurogenic Urinary and Fecal Incontinence and Their Caregivers' Needs and Attitudes Toward Alternative Therapies (SNM, TENS)

Background: Non-neurogenic urinary and fecal incontinence (UI, FI) affects approximately 6% of North American children with 1% of cases becoming refractory (nonresponsive to standard therapies). Incontinence has major potential long-term physiological and psychological implications for patients and their families. While Sacral Neuromodulation (SNM) and Transcutaneous Nerve Stimulation (TENS) are alternative therapies available for the treatment of refractory UI/FI, these are not approved for use in children in Canada. The present study assessed participants' perception of current treatments, incontinence burden, and attitudes toward novel therapies in a single pediatric institution. Methods: Multiple validated questionnaires including Dysfunctional Voiding Scoring System (DVSS), Bristol Stool Chart (BSC), Pediatric Incontinence measurement (PinQ), and Time-Driven Activity Based Costing were used to perform a needs assessment for patients with non-neurogenic refractory incontinence, and to determine patients' and caregivers' attitudes toward alternative therapies. Results: 75% of patients and 89% of caregivers reported a moderate to severe impact of incontinence on QoL with diminished social interactions among the primary concerns. Caregivers were frustrated with current treatments and were open to trying alternative therapies (SNM and TENS), which, at least in the case of SNM, seems to be less expensive, possibly less burdensome and more effective than current surgical options. Conclusion: Pediatric refractory UI/FI has a large impact on patients' and caregivers' QoL and alternative therapies with the potential to improve QoL of patients and caregivers should be further investigated as a substitute for surgery.

Bladder and Bowel Dysfunction in Korean Children with Down Syndrome and Parental Quality of Life

PURPOSE

Children with Down syndrome (DS) are more likely to experience bladder bowel dysfunction (BBD) than typically developing children, which could in turn have a serious effect on children with DS and on their parents and other family members. This study aimed to explore the prevalence of BBD in Korean children with DS and its effect on parental quality of life (QOL).

DESIGN AND METHODS

To assess BBD and parental QOL, we used self-administered questionnaires (Dysfunctional Voiding Symptom Score [DVSS], Rome IV criteria, and World Health Organization Quality of Life scale [WHOQOL-BREF]) for parents of children with DS. We collected data from 86 parents between September and October 2017 through an online community website.

RESULTS

DVSS was elevated in 26.7% of the children with DS. Specifically, 14% had daytime urinary incontinence, and 33.7% had functional constipation. Moreover, 18.6% of children had BBD according to the DVSS and Rome IV criteria. The sensitivity and specificity of DVSS to functional constipation was 55.17% and 87.72%, respectively. The BBD score and total parental QOL score were statistically correlated (r = 0.291, p = 0.007).

CONCLUSIONS

Although children with DS are a high-risk group for BBD, their BBD symptoms are often overlooked because of their intellectual disability. Consequently, this could negatively affect children's and family's health and QOL in the long term.

PRACTICE IMPLICATIONS

Health-care providers should reconsider a routine check-up of BBD in children with DS. If a child has BBD, health-care providers should consult a urologist to determine the appropriate diagnosis and intervention.

Does a serious game increase intrinsic motivation in children receiving urotherapy?

INTRODUCTION

Urotherapy is considered the treatment of choice for children suffering daytime urinary incontinence (DUI). Urotherapy intends to improve bladder dysfunction for children with DUI. For children with refractory DUI, an intensive inpatient bladder training program exists, which focuses on relearning, concentration on, and awareness of the bladder. Children's motivation and adherence are key determinants of a successful training outcome. It is hypothesized that motivation endurance throughout the treatment process may be enhanced by a serious game training tool, which could make the training more appealing and rewarding.

OBJECTIVE

The study explores intrinsic motivation in children receiving bladder training for DUI and whether using a serious game improves their intrinsic motivation.

STUDY DESIGN

In this pragmatic study, 50 children were allowed to choose among receiving bladder training with (intervention group) or without the application of a serious game (control group). At 4, 8, and 12 weeks of training, children and parents were asked to complete the Intrinsic Motivation Inventory (IMI). Children also completed the Pediatric Urinary Incontinence Quality of Life Tool (PinQ) before the start of the training and 6 months thereafter. At 6-month follow-up, patients were ask to participate in two focus groups, wherein the children discussed how they used the serious game and which improvements they would prefer.

RESULTS

Children who received standard bladder training with the addition of a serious game did not differ in terms of intrinsic motivation from children who underwent standard bladder training only. Training results were equal in both the groups, with 80% good or improved. Incontinence-related quality of life (QoL) improved accordingly.

DISCUSSION

In contrast to the study expectations, this game did not increase intrinsic motivation. Findings on training and QoL results are consistent with those of previous studies in both interventions. Although a randomized design could have yielded more valid results than this preference-based approach, the latter is more congruent with clinical practice. In contrast to existing bladder diary apps, this game offers a combination of child-friendly instructions, explanation of bladder (dys)function, and keeping a bladder diary. Mobile devices are playing an increasingly important role in health care; therefore, an urotherapy app can be a complementary therapeutic tool.

CONCLUSION

Most children find it attractive to combine bladder training with a serious game. However, no added value was found regarding intrinsic motivation and training results. All children with persistent DUI in this cohort were highly motivated to complete an intensive bladder training program.

Pediatric sacral nerve stimulator explanation due to complications or cure: a survival analysis

INTRODUCTION

Historically, there have been few treatment options for children with severe refractory bladder and bowel dysfunction (BBD). Sacral neuromodulation (SNM) continues to show promising results in this challenging pediatric population with recalcitrant lower urinary tract symptoms. At the authors institution, they have begun offering explantation to those with persistent improvement after >6 months of having device turned off. The authors hypothesized that (1) SNM explantation for cure increases with extended follow-up and (2) those explanted for cure would have improved symptoms and quality of life when compared to those explanted for complication.

MATERIALS & METHODS

The authors retrospectively reviewed all consecutive patients aged <18 years who underwent SNM placements at their institution (2012-2017). They excluded those without the second stage procedure. Reasons for device explantation were categorized as cure (resolution of symptoms with the device turned off for at least 6 months) or a complication (e.g. infection, need for magnetic resonance imaging, or pain). Non-parametric tests and survival analysis were used for analysis to account for differential follow-up time. Of those explanted, surveys were electronically sent to assess BBD severity and overall quality of life.

RESULTS

Of 67 children who underwent a first stage procedure, 62 (92.5%) underwent a second stage procedure. 61 met inclusion criteria (68.9% female, 29.5% with previous filum section, median age at implantation 10.3 years). During follow-up (median 2.3 years), 12 patients (19.7%) had the SNM exchanged/revised because of lead fracture/breakage and return of urinary symptoms. To date, 50 patients remain with their SNM implanted, and 11 have been explanted. Adjusting for follow-up time, the risk of explantation was 6.5% at 2 years (2.2% for cure, 4.3% for complications) (Figure 1). Explantation increased to 24.5% at 3 years (16.5% for cure, 8.0% for complications) and 40.4% at 4 years (32.4% for cure, 8.0% for complications). Questionnaires were collected on patients after explant (median 2.2 years), with improvement in those explanted for cure compared to complication (Figure 2).

DISCUSSION

Sacral neuromodulation explantation for cure is a novel concept previously not described in the literature. Limitations of this study include the relatively small numbers and lack of objective data in the cohort that remains with SNM device implanted.

CONCLUSION

Sacral neuromodulation is a safe, viable option for the pediatric patient with refractory bladder dysfunction. Furthermore, SNM explantation for cure is an option with increasing likelihood after 2 years.

The impact of bowel and bladder problems on children's quality of life and their parents: A scoping review

BACKGROUND

Functional bladder and bowel problems are common in children and have a serious psychological as well as physical impact. The objective of this scoping review was to synthesise evidence on the impact of such conditions both on children's quality of life (QOL) and their parents.

METHODS

The scoping review followed Arksey and O'Malley's framework. Relevant studies were identified by a comprehensive search of scientific databases. Inclusion criteria focused on children with bladder and bowel dysfunction, their QOL, and impact on parents. Studies were analysed for aims, study populations, measures, and results.

RESULTS

A total of 783 records were retrieved with 30 meeting the criteria. Most studies found that QOL was reduced in children with nocturnal enuresis, day bladder dysfunction, bowel dysfunction, and combined bladder and bowel dysfunction. Parents' QOL and social-emotional functioning were also negatively affected.

CONCLUSIONS

Functional bladder and bowel problems should be identified and treated as early as possible to minimise negative impacts on QOL of children and their carers. Future research should focus on how to best provide early and effective intervention in the most accessible manner.

SENS-U: validation of a wearable ultrasonic bladder monitor in children during urodynamic studies

PURPOSE

Urinary incontinence is a common problem in school-age children. Because many children remain unaware of a full-bladder sensation, the SENS-U^™ Bladder Sensor was developed. The SENS-U is a small, wearable ultrasound sensor, which is positioned on the lower abdomen using a skin-friendly adhesive. The sensor continuously estimates the bladder filling status and informs the user when it is time to go to the toilet. In this study, the clinical performance of the SENS-U is evaluated in children during (video) urodynamics.

MATERIAL AND METHODS

In this study, 30 children (6-12 years) were included who were scheduled for a (video) urodynamic study. During urodynamics, the SENS-U determined the average anterior-posterior (A-P) bladder dimension (every 30 s) to estimate the filling status. The correlation between the average A-P bladder dimension and the infused volume is analyzed by Spearman's correlation.

RESULTS

Thirty patients (boys/girls: 15/15; mean age: 7.9 ± 1.4 years) were included, in whom the SENS-U detected the full bladder before voiding in 90% of the patients (27/30). In the other patients, the bladder was outside the detection area due to either erroneous sensor placement (n = 1) or an (relative) obese abdomen in the upright position (n = 2). There was a strong correlation (median r_s = 0.94) between the average A-P bladder dimension and the infused volume. The detectable maximum bladder volume ranged between 71 and 463 ml.

CONCLUSION

The SENS-U is able to detect a full bladder with a success rate of 90%. When excluding erroneous data due to sensor misplacement or an (relative) obese abdomen, the detection rate may even be higher. Future research will focus on investigating the effect of theSENS-U in incontinence training.

Imipramine for refractory daytime incontinence in the pediatric population

INTRODUCTION AND OBJECTIVE

Lower urinary tract (LUT) and voiding dysfunction constitute a large percentage of pediatric urology referrals. Children with urinary incontinence unresponsive to behavioral modifications and traditional pharmacotherapy including anticholinergics and alpha blockers remain a challenge. We evaluated the impact of imipramine on treatment outcomes in children with refractory incontinence.

STUDY DESIGN

Children ≤18 years of age with refractory non-neurogenic daytime incontinence prescribed imipramine were identified. Patient demographics and baseline testing were assessed, as well as medication dosing and side effects of all patients. The Vancouver Symptom Score (VSS) was completed at the initial consultation and each subsequent clinic visit. The questionnaire was self-administered and completed by patients and/or parents. Treatment success was defined as per the International Children's Continence Society (ICCS).

RESULTS

One hundred and three patients (55 males and 48 females) met the inclusion criteria. The intention-to-treat response rate was 65% (complete 44, partial response 23). Sixteen (15.6%) patients were non-responders and 20 (19.4%) were lost to follow-up. There was no statistical difference between all groups with regards to age, baseline VSS, and dose. Of those children with complete follow-up (n = 83), 44 (53%) experienced complete treatment response. Pre- and post-VSS were statistically different in both complete and partial response groups (complete 19.5-9.5; p < 0.0001; partial 19.7-13; p = 0.0002) (Table). Side effects were reported by 11 out of 83 (13.3%) patients; partial responders experienced a higher likelihood of side effects (26.1%; p = 0.03).

DISCUSSION

The mainstay of LUT dysfunction management in children is implementation of a bowel program and timed voiding regimen, with additional treatment modalities and pharmacotherapy added depending upon prevailing symptomatology. Daytime incontinence refractory urotherapy, anticholinergics, and/or non-selective alpha blockers can be difficult to treat, and can be unresponsive to parasacral transcutaneous electrical nerve stimulation (TENS) and percutaneous tibial nerve stimulation (PTNS). We observed that over half of children with refractory daytime incontinence reported complete resolution of daytime accidents with imipramine. Limitations of the study include the retrospective nature, relatively small sample size and lack of control group.

CONCLUSIONS

Two-thirds of children with refractory daytime incontinence experienced treatment response to imipramine, adding a valuable tool to the pediatric urologist's armamentarium in managing select, challenging patients.

Renal Transplant in Abnormal Bladder: Treatment Options and Their Effects on Graft Outcome

OBJECTIVES

Correction of structural urologic disorders and optimization of emptying and storage function of the bladder should be achieved before renal transplant in patients with abnormal urinary bladders to protect the new transplanted kidney. The aim of this study was to determine the outcomes of renal transplant among the differently treated abnormal bladder patients.

MATERIALS AND METHODS

This was a retrospective study of 30 renal transplant recipients with abnormal bladders who were divided into 2 groups based on abnormal bladder management. Group A included 12 patients who required surgical procedures for their bladder, including 6 with augmentation cystoplasty, 1 with Mitrofanoff procedure, 2 with ileal conduit, 1 with vesicostomy, and 2 who required artificial urinary sphincter. Group B included 18 patients who were treated with oral anticholinergics or beta-3 sympathomimetic drugs, clean intermittent catheterization, suprapubic catheterization, or a combination of these options. Graft function, survival, and complications were compared between both groups.

RESULTS

Mean estimated glomerular filtration rates at 1, 3, and 5 years were higher in group A than in group B but not statistically significant. We also found no significant differences in graft survival between the 2 groups. Among all postoperative complications, only incidence of wound infection was significantly higher in group A than in group B (33% vs 5%; P = .04).

CONCLUSIONS

The options of abnormal bladder treatment (either by surgical procedures or other methods of treatment) did not have an impact on graft outcome after renal transplant as long as a safe and suitable bladder was achieved.

The impact of a bladder training video versus standard urotherapy on quality of life of children with bladder and bowel dysfunction: A randomized controlled trial

INTRODUCTION

Bladder and bowel dysfunction (BBD) can negatively impact the quality of life (QoL) of children. Urotherapy is an accepted treatment option for BBD; however, literature that examines the impact of management options on QoL in this population is scarce.

OBJECTIVE

To determine whether a bladder training video (BTV) is non-inferior to standard urotherapy (SU) in improving QoL in children with BBD.

METHODS

Children aged 5-10 years and who scored ≥11 on the Vancouver Non-Neurogenic Lower Urinary Tract Dysfunction/Dysfunctional Elimination Syndrome Questionnaire (NLUTD/DES) were recruited from a pediatric tertiary care center. Children were excluded with known vesicoureteral reflux; spinal dysraphism; learning disabilities; recent urotherapy; and primary nocturnal enuresis. Quality of life was evaluated using the Pediatric Incontinence Quality-of-Life questionnaire (PinQ). Questionnaires were administered at the baseline and 3-month follow-up clinic visits. Following centralized electronic blocked randomization schemes to guarantee allocation concealment, patients were assigned to receive SU or BTV during their regular clinic visits. An intention-to-treat protocol was followed. Between-group baseline and follow-up QoL scores were compared using paired and unpaired t-tests, and linear regression analysis.

RESULTS

Of the 539 BBD patients who were screened, 173 (32%) were eligible, and 150 (87%) were randomized. Of these, 143 (96%) completed the study, five (3%) were lost to follow-up, and two (1%) withdrew. In total, 140/143 (97%) completed the QoL questionnaire at baseline and follow-up. Mean follow-up time was 3.5 ± 1.1 months for BTV patients and 3.7 ± 1.6 months for SU. At baseline, BTV and SU patients had a mean QoL score of 26.6 ± 13 and 23.8 ± 12, respectively (P = 0.17). Between-group mean change in PinQ scores from baseline was not statistically significant (BTV: 6.25 ± 12.5 vs SU: 3.75 ± 12.2; P = 0.23; Summary Fig.). Significant predictors of positive change in QoL were: higher symptomatology score, with a correlation coefficient of 0.5 (95% CI: 0.2-0.9; P = 0.003), and worse baseline QoL score, with a correlation coefficient of 0.5 (95% CI: 0.4-0.7; P < 0.001). Overall, most patients had improved symptomatology and QoL scores.

CONCLUSION

Significant and similar QoL changes from baseline to follow-up were observed in both the BTV and SU groups, suggesting that BTV was non-inferior to SU in improving QoL in children with BBD. Quality of life assessment should be considered when evaluating interventions for BBD, as it appears to be an important clinical outcome with which to determine urotherapy success.

Nocturnal enuresis impaired children's quality of life and friendships

AIM

There have not been any continence-specific measurement tools in Swedish that have allowed clinicians to investigate the quality of life (QoL) in children with bladder dysfunction. This study evaluated the QoL in Swedish children with nocturnal enuresis and tested the reliability of a Swedish translation of the Paediatric Incontinence Questionnaire (PinQ).

METHODS

This prospective study comprised 46 children aged six to 18 years with nocturnal enuresis, who completed the PinQ after it was translated into Swedish. It was completed twice by 33 patients, and these responses were included in the test-retest evaluation.

RESULTS

The self-reported mean sum score for the whole group was 26.3 ± 13.37 (range: 5-58), and the most affected domains were social relations with peers and self-esteem. The highest individual scores were four, three or two for 71.7%, 17.4% and 10.9% of the study population, respectively. Cronbach's alpha was 0.87 for the whole questionnaire, indicating good internal consistency. The test-retest stability was excellent, with an intra-class correlation coefficient of 0.76.

CONCLUSION

Children with nocturnal enuresis had impaired self-esteem, and their impaired QoL affected their relationships with friends. The Swedish version of the PinQ proved to be a reliable tool that will be used in further studies.

Effects of urinary incontinence on psychosocial outcomes in adolescence

To examine whether daytime wetting and bedwetting urinary incontinence (UI) in childhood and adolescence are associated with psychosocial problems in adolescence. We used data from the Avon Longitudinal Study of Parents and Children to examine the association between trajectories of UI from 4 to 9 years and self-reported psychosocial problems in adolescence (13-14 years) including depressive symptoms, peer victimisation, poor self-image and school experiences (negative perception of school and teachers, problems with peer relationships). Sample sizes ranged from 5162 (perception of teachers) to 5887 (self-image). We also examined associations between self-reported UI at 14 years and psychosocial problems. Relative to normative development, adolescents who experienced delayed development of bladder control had poorer self-image [standardised mean difference = 0.18 (95% CI 0.04, 0.32)], more negative perceptions of school [0.18 (0.02, 0.34)] and more problems with peer relationships at school [0.25 (0.10, 0.40)]. Persistent wetting (bedwetting with daytime wetting) in childhood was associated with increased problems with peer relationships in adolescence [0.19 (0.03, 0.34)]. The strongest associations between adolescent UI and psychosocial problems were found for daytime wetting (reference = no UI at 14 years): depressive symptoms [OR = 3.04 (95% CI 1.91-4.84)], peer victimisation [2.14 (1.48-3.10)], poor self-image (t = -8.49, p < 0.001) and problems with peer relationships (t = -4.69, p < 0.001). Children with delayed development of bladder control and persistent wetting have increased psychosocial problems in adolescence. Adolescents with UI reported a range of psychosocial problems and clinicians should be aware that they might require support from psychological services.

Lower urinary tract symptoms in children with anorectal malformations with rectoperineal fistulas

AIM

The aim was to describe the frequency of lower urinary tract symptoms (LUTS) in children with anorectal malformations with rectoperineal fistulas (ARM-P), as compared with healthy controls based on gender.

METHOD

LUTS were defined using the 2014 definitions of the International Children's Continence Society. Data were collected at 2 tertiary pediatric surgery centers in 2 countries from all children aged 4-12years who had undergone an operation for ARM-P.

RESULTS

A total of 24 girls and 33 boys, with a median age of 8 (4-12)years, were eligible and compared with 165 controls. Of the patient group, 4 (17%) girls had 8 urinary tract anomalies (UTA), and 8 (24%) boys had 13 UTA. There were no gender differences in LUTS among the patients. The frequency of urinary tract infections was higher among the patients (5/24 girls and 7/55 boys) than the controls (1/55 and 4/110) (p=0.009). More patients (5/24 girls and 5/33 boys) than controls (1/55 and 2/110) used daily urinary medications (p=0.009 and p=0.007, respectively). Patients with UTA reported urinary infections more frequently (3/4 girls and 4/8 boys) than those without UTA (2/20 girls and 0/25 boys) (p=0.018 and p=0.002, respectively).

CONCLUSION

Children with ARM-P had more LUTS than controls, and patients with concomitant UTA had more LUTS than patients without UTA. Therefore, children with ARM-P are suggested to have routine follow-up for both UTA and LUTS.

Simultaneous urodynamic and anorectal manometry studies in children: insights into the relationship between the lower gastrointestinal and lower urinary tracts

BACKGROUND

Children with urinary incontinence (UI) have associated functional constipation (FC) and fecal incontinence (FI). The physiology between lower urinary tract (LUT) and anorectum in children has not been elucidated.

AIMS

Observe the effect of rectal distention (RD) on LUT function, and bladder filling and voiding on anorectal function.

METHODS

Children with voiding dysfunction referred to Boston Children's Hospital were prospectively enrolled in combined urodynamic (UDS) and anorectal manometry (ARM). Anorectal and urodynamic parameters were simultaneously measured. Patients underwent two micturition cycles, first with rectal balloon deflated and second with it inflated (RD). Lower urinary tract and anorectal parameters were compared between cycles.

KEY RESULTS

Ten children (seven UI, four recurrent UTIs, nine FC ± FI) were enrolled. Postvoid residual (PVR) increased (p = 0.02) with RD. No differences were observed in percent of bladder filling to expected bladder capacity, sensation, and bladder compliance with and without RD. Bladder and abdominal pressures increased at voiding with RD (p < 0.05). Intra-anal pressures decreased at voiding (p < 0.05), at 25% (p = 0.03) and 50% (p = 0.06) of total volume of bladder filling.

CONCLUSIONS & INFERENCES

The PVR volume increased with RD. Stool in the rectum does not alter filling cystometric capacity but decreases the bladder's ability to empty predisposing patients with fecal retention to UI and UTIs. Bladder and abdominal pressures increased during voiding, demonstrating a physiological correlate of voiding dysfunction. Intra-anal pressures decreased during bladder filling and voiding. This is the first time intra-anal relaxation during bladder filling and voiding has been described.

Pathophysiological and Therapeutic Considerations for Non-Neurogenic Lower Urinary Tract Dysfunction in Children

Non-neurogenic lower urinary tract dysfunction (LUTD) in children is very common in clinical practice and is important as an underlying cause of lower urinary tract symptoms, urinary tract infection and vesicoureteral reflux in affected children. LUTD in children is caused by multiple factors and might be related with a delay in functional maturation of the lower urinary tract. Behavioral and psychological problems often co-exist in children with LUTD and bowel dysfunction. Recent findings in functional brain imaging suggest that bladder bowel dysfunction and behavioral and psychiatric disorders in children might share common pathophysiological factors in the brain. Children with suspected LUTD should be evaluated properly by detailed history taking, validated questionnaire on voiding and defecation, voiding and bowel diary, urinalysis, screening ultrasound, uroflowmetry and post-void residual measurement. Invasive urodynamic study such as videourodynamics should be reserved for children in whom standard treatment fails. Initial treatment of non-neurogenic LUTD is standard urotherapy comprising education of the child and family, regular optimal voiding regimens and bowel programs. Pelvic floor muscle awareness, biofeedback and neuromodulation can be used as a supplementary purpose. Antimuscarinics and α-blockers are safely used for overactive bladder and dysfunctional voiding, respectively. For refractory cases, botulinum toxin A injection is a viable treatment option. Prudent use of urotherapy and pharmacotherapy for non-neurogenic LUTD should have a better chance to cure various problems and improve self-esteem and quality of life in affected children.

Non-biological determinants of paediatric bladder bowel dysfunction: A pilot study

OBJECTIVES

Children with bladder and bowel dysfunction (BBD) constitute a significant proportion of referrals at paediatric urology clinics worldwide, presenting with a wide range of symptom severity that may significantly affect quality of life. Non-biological factors may play a key role in triggering BBD severity, but these underpinning causes of BBD during childhood are still unknown. The aim of this study was to identify the effects of personal, family related and environmental variables on the severity of BBD symptoms in school-aged children.

STUDY DESIGN

A pilot, prospective, observational study was conducted on 53 children diagnosed with BBD, and their legal guardian(s), on their first referred visit to a paediatric BBD clinic led by nurse practitioners. Upon receiving consent, patients and their legal guardian(s) completed three study questionnaires, with the guidance of research coordinators. The first questionnaire was the Dysfunctional Voiding Scoring System (DVSS); the second, a three-part questionnaire used to collect demographic information and data on the patient, their family and environmental characteristics; and the third gathered a detailed history of the child's lifestyle regimen, focusing on their bowel and bladder function.

RESULTS

Most of the children were female (66%), with an average age of 8.35 years. Most children attended public schools (74%) and none reported failing a grade. The mean parental age was 41.4 years (SD = 4.9 years), 62% of the families had two children and 53% were Caucasian. The mean DVSS score for this sample was 9.9 (SD = 4.2, range 2-21). Daycare attendance, school problems and unplanned pregnancy showed statistically significant influences on the severity of BBD and were associated with higher DVSS scores according to the Table below.

CONCLUSIONS

Children with BBD attending urology outpatient clinics as new referrals had more severe symptoms when they were born from an unplanned pregnancy, attended daycare and/or had school problems. These findings suggest that interventions aimed at decreasing BBD severity, or preventing its onset in school-aged children, should focus on the environment surrounding them, specifically on the interaction between personal, familial and environmental factors. These factors seem to have an important effect on paediatric continence, as children grow and develop under numerous societal influences and social interactions.

Lower Urinary Tract Dysfunction in Elementary School Children: Results of a Cross-Sectional Teacher Survey

PURPOSE

Lower urinary tract dysfunction in school-aged children is common and yet data are lacking on current teacher practice regarding bathroom use and daytime incontinence during classroom hours. We determined the prevalence of elementary school teachers who promote lower urinary tract health and identified predictors for and against such behavioral promotion.

MATERIALS AND METHODS

We performed an electronic cross-sectional survey among self-identified teachers using targeted social media advertisement during a 1-week period in July 2014. The empirical survey tool consisted of 27 questions and collected data on 5 principal domains, including 1) teacher demographics, 2) rules and regulations on water intake and bathroom use during classroom hours, 3) characteristics of school bathrooms in terms of safety, supervision and suitability for use, 4) experience with and management of students with daytime incontinence and 5) training on the topic of lower urinary tract health. Predictors for promoting lower urinary tract health were identified by multivariable logistic regression.

RESULTS

Of the 4,166 teachers who completed the survey 88% indicated that they encourage students to hold urine. Despite strict bathroom protocols 81% of teachers allowed children unlimited access to water. Of the teachers 82% reported never having undergone any professional development on bathroom regulations for children. Overall only 24% of surveyed teachers met criteria for promoting lower urinary tract health. The odds of promoting lower urinary tract health decreased with ascending grade level (OR 0.80, 95% CI 0.76-0.84). Conversely it increased if teaching experience was greater than 5 years (OR 1.66, 95% CI 1.39-1.98) or professional development on the subject had been received (OR 1.42, 95% CI 1.18-1.70).

CONCLUSIONS

Of elementary school teachers 76% are not promoting lower urinary tract health in school-aged children. Professional development training on the topics of lower urinary tract dysfunction and/or lower urinary tract health may be beneficial, particularly for educators who teach higher grades and those with less teaching experience.

The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children's Continence Society

AIM

The impact of the original International Children's Continence Society (ICCS) terminology document on lower urinary tract (LUT) function resulted in the global establishment of uniformity and clarity in the characterization of LUT function and dysfunction in children across multiple healthcare disciplines. The present document serves as a stand-alone terminology update reflecting refinement and current advancement of knowledge on pediatric LUT function.

METHODS

A variety of worldwide experts from multiple disciplines within the ICCS leadership who care for children with LUT dysfunction were assembled as part of the standardization committee. A critical review of the previous ICCS terminology document and the current literature was performed. Additionally, contributions and feedback from the multidisciplinary ICCS membership were solicited.

RESULTS

Following a review of the literature over the last 7 years, the ICCS experts assembled a new terminology document reflecting current understanding of bladder function and LUT dysfunction in children using the resources from the literature review, expert opinion and ICCS member feedback.

CONCLUSIONS

The present ICCS terminology document provides a current and consensus update to the evolving terminology and understanding of LUT function in children. Neurourol. Urodynam. 35:471-481, 2016. © 2015 Wiley Periodicals, Inc.