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von Gontard A, Niemczyk J, Wagner C, Equit M. Voiding postponement in children-a systematic review. Eur Child Adolesc Psychiatry 2016; 25:809-20. [PMID: 26781489 DOI: 10.1007/s00787-015-0814-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/21/2015] [Indexed: 01/19/2023]
Abstract
Voiding postponement (VP) has been defined as a habitual postponement of micturition using holding maneuvers. VP can represent both a symptom, as well as a condition. As divergent definitions are used internationally, the aim was to review the current state of knowledge on VP and provide recommendations for assessment, diagnosis and treatment. A Scopus and a Pubmed search was conducted, entering the terms 'voiding postponement' without any restrictions or specifications. Other publications relevant to the topic were added. VP can represent a symptom in healthy children. As a condition, VP in combination with nocturnal enuresis (NE) is a subtype of non-monosymptomatic NE. Most studies have focused on daytime urinary incontinence (DUI) with VP, or more aptly termed voiding postponement incontinence (VPI). It is a behaviorally defined syndrome, i.e., by the habitual deferral of micturition and DUI. VPI is associated with a low micturition frequency, urgency and behavioral problems. The most common comorbid disorder is oppositional defiant disorder (ODD). VP as a symptom and VPI as a condition should be differentiated. VPI is a common disorder with many associated problems and disorders. Urotherapy and timed voiding are the main treatment approaches. Due to the high rate of comorbid ODD, other forms of treatment, especially cognitive behavioral therapy, are often needed.
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Affiliation(s)
- Alexander von Gontard
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, 66421, Homburg, Germany.
| | - Justine Niemczyk
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, 66421, Homburg, Germany
| | - Catharina Wagner
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, 66421, Homburg, Germany
| | - Monika Equit
- Department of Clinical Psychology, Saarland University, Saarbrücken, Germany
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Faasse MA, Nosnik IP, Diaz-Saldano D, Hodgkins KS, Liu DB, Schreiber J, Yerkes EB. Uroflowmetry with pelvic floor electromyography: inter-rater agreement on diagnosis of pediatric non-neurogenic voiding disorders. J Pediatr Urol 2015; 11:198.e1-6. [PMID: 26159493 DOI: 10.1016/j.jpurol.2015.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 05/27/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Uroflowmetry with electromyography (uroflow-EMG) is commonly used for evaluation of lower urinary tract (LUT) function in children. Diagnostic criteria based largely on uroflow-EMG findings have previously been proposed for several conditions collectively termed non-neurogenic voiding disorders (NNVDs). These include dysfunctional voiding (DV), idiopathic detrusor overactivity disorder (IDOD), detrusor underutilization disorder (DUD), and primary bladder neck dysfunction (PBND). It is unknown whether practitioners with varying levels of training and experience can apply the diagnostic criteria for these conditions with a high level of consistency. OBJECTIVE To assess inter-rater agreement on diagnosis of NNVDs using uroflow-EMG studies. STUDY DESIGN Six raters performed post hoc evaluation of 84 uroflow-EMG studies and associated clinical data from children with symptoms of LUT dysfunction and no evidence of neurologic or anatomic abnormalities. Each rater was asked to categorize the uroflow-EMG studies as being consistent with DV, IDOD, DUD, PBND, or normal/unclassifiable. A consensus diagnosis was noted for studies on which at least four raters agreed. Inter-rater agreement was assessed via calculation of unweighted Fleiss' kappa statistics. RESULTS Overall inter-rater agreement on NNVD diagnoses was moderate (kappa 0.46, 95% CI 0.38-0.54). Agreement between individual raters ranged from 0.33 (fair) to 0.74 (substantial) (Figure). There was no consensus on diagnosis for 20 patients (24%). DISCUSSION Several factors may contribute to inter-rater disagreement on diagnosis of NNVDs. These include instances where patients satisfy one criterion for a particular diagnosis while missing others - or have findings consistent with more than one diagnosis. Strategies to address this may involve simplifying the diagnostic criteria, developing a clear algorithm that prioritizes certain criteria, and/or allowing assignment of multiple diagnoses. Practitioners could also benefit from standardized education regarding the diagnostic criteria for NNVDs. Potential limitations of this analysis included the use of just one uroflow-EMG study per patient in almost all cases. Also, the raters had variable levels of previous experience using the diagnostic criteria for NNVDs, and it is possible that they were not always applied as originally intended. If this were the case, it would support development of a standardized education tool to facilitate practitioner understanding and application of the criteria. CONCLUSIONS Uroflow-EMG has shown promise for improving clinical management of NNVDs associated with pediatric LUT dysfunction. However, inter-rater agreement on NNVD diagnoses using current criteria is suboptimal. Various mechanisms should be explored to improve consistency in practitioners' diagnosis of NNVDs.
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Affiliation(s)
- M A Faasse
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA.
| | - I P Nosnik
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA.
| | - D Diaz-Saldano
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA.
| | - K S Hodgkins
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA; Division of Kidney Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA.
| | - D B Liu
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA.
| | - J Schreiber
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA.
| | - E B Yerkes
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA.
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Alazab RS, Saqan RS, Abu Shamma F. Advanced Uropathy in a Child With Underactive Bladder: Unusual Presentation, Treatment, and Long-term Follow Up. Urol Case Rep 2015; 3:37-9. [PMID: 26793494 PMCID: PMC4714257 DOI: 10.1016/j.eucr.2014.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 12/11/2014] [Accepted: 12/12/2014] [Indexed: 11/24/2022] Open
Abstract
Underactive bladder in children is characterized by low voiding frequency; straining, hypotonic high capacity bladder, and significant residual urine. The usual presentation is recurrent urinary tract infections. Accurate evidence-based diagnosis and treatment is crucial. Subjective and objective improvement and regain of normal voiding can be achieved in response to bladder rehabilitation program and correction of serious complications.
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Van Batavia JP, Fast AM, Combs AJ, Glassberg KI. The bladder of willful infrequent voiders: underactive or underutilized? J Pediatr Urol 2014; 10:517-21. [PMID: 24360923 DOI: 10.1016/j.jpurol.2013.10.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 10/29/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We previously described a lower urinary tract (LUT) condition (detrusor underutilization disorder, DUD) characterized by chronic or episodic willful deferment of voiding resulting in an expanded capacity in patients with LUT symptoms. We now further characterize these DUD patients. MATERIALS AND METHODS We reviewed our database identifying neurologically/anatomically normal children diagnosed with DUD. Bladder capacity had to be at least >125% EBC for age to be included. LUTS, diaries and uroflow/EMG findings were analyzed. RESULTS Fifty-five children (mean age 10.5 years, range 3.7-20.2; 34F, 19M) with LUTS were diagnosed with DUD. The most common reasons for presentation included incontinence (43.6%), history of urinary tract infection (UTI) (49.1%), and urgency (30.9%). Mean percent estimated bladder capacity for age was 1.67 and following treatment mean %EBC decreased to 1.10. CONCLUSIONS DUD patients typically present with infrequent voiding, incontinence, urgency, and UTIs. They have less bowel dysfunction and frequency, and larger bladder capacities than typically found in children with overactive bladder and dysfunctional voiding. Although the symptoms associated with DUD overlap in part with those considered by the International Children's Continence Society to be typical for "underactive bladder" and "voiding postponement", DUD, we feel, is a stand-alone diagnosis.
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Affiliation(s)
- Jason P Van Batavia
- Division of Pediatric Urology, Morgan Stanley Children's Hospital of New York - Presbyterian, Columbia University, College of Physicians and Surgeons, New York, NY, USA.
| | - Angela M Fast
- Division of Pediatric Urology, Morgan Stanley Children's Hospital of New York - Presbyterian, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Andrew J Combs
- Division of Pediatric Urology, Morgan Stanley Children's Hospital of New York - Presbyterian, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Kenneth I Glassberg
- Division of Pediatric Urology, Morgan Stanley Children's Hospital of New York - Presbyterian, Columbia University, College of Physicians and Surgeons, New York, NY, USA.
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Van Batavia JP, Combs AJ, Glassberg KI. Short pelvic floor EMG lag time II: use in management and follow-up of children treated for detrusor overactivity. J Pediatr Urol 2014; 10:255-61. [PMID: 24291249 DOI: 10.1016/j.jpurol.2013.10.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 10/11/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine utility of short pelvic floor electromyography (EMG) lag time in monitoring therapeutic response in children with idiopathic detrusor overactivity (DO) and quiet EMG during voiding (idiopathic detrusor overactivity disorder, IDOD). PATIENTS AND METHODS 162 consecutive normal children (77M, 85F) diagnosed with IDOD and short EMG lag time were reviewed. All were treated with combined standard urotherapy and anticholinergics. Pre-treatment uroflow/EMG parameters were compared with on-treatment parameters. RESULTS Median age at evaluation was 6.8 years and median EMG lag time was 0 s; 110 children had repeat uroflow/EMG studies while on anticholinergic therapy. With a median follow-up of 18.7 months, mean EMG lag time increased from 0.7 to 2.2 s and % expected bladder capacity for age (EBC) increased from 0.68 to 0.98 (both p < 0.01). EMG lag time increased in all patients while on therapy and normalized in 83 patients (75%). CONCLUSION A short EMG lag time on noninvasive uroflow/EMG in a patient with urgency can be a surrogate for urodynamics study (UDS) in diagnosing DO and objectively monitoring response to therapy. When effectively treated, children with DO have amelioration of their lower urinary tract symptoms (LUTS) and normalization of both EMG lag time and bladder capacity.
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Affiliation(s)
- Jason P Van Batavia
- Division of Pediatric Urology, Morgan Stanley Children's Hospital of New York-Presbyterian, Department of Urology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Andrew J Combs
- Division of Pediatric Urology, Morgan Stanley Children's Hospital of New York-Presbyterian, Department of Urology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Kenneth I Glassberg
- Division of Pediatric Urology, Morgan Stanley Children's Hospital of New York-Presbyterian, Department of Urology, Columbia University, College of Physicians and Surgeons, New York, NY, USA.
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Dysfunctional Elimination Syndromes—How Closely Linked are Constipation and Encopresis with Specific Lower Urinary Tract Conditions? J Urol 2013; 190:1015-20. [DOI: 10.1016/j.juro.2013.03.111] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2013] [Indexed: 11/22/2022]
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Combs AJ, Van Batavia JP, Horowitz M, Glassberg KI. Short Pelvic Floor Electromyographic Lag Time: A Novel Noninvasive Approach to Document Detrusor Overactivity in Children with Lower Urinary Tract Symptoms. J Urol 2013; 189:2282-6. [DOI: 10.1016/j.juro.2013.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Andrew J. Combs
- Division of Pediatric Urology, Morgan Stanley Children's Hospital of New York–Presbyterian, Columbia University Medical Center and Division of Pediatric Urology, State University of New York Downstate Medical Center (MH), New York, New York
| | - Jason P. Van Batavia
- Division of Pediatric Urology, Morgan Stanley Children's Hospital of New York–Presbyterian, Columbia University Medical Center and Division of Pediatric Urology, State University of New York Downstate Medical Center (MH), New York, New York
| | - Mark Horowitz
- Division of Pediatric Urology, Morgan Stanley Children's Hospital of New York–Presbyterian, Columbia University Medical Center and Division of Pediatric Urology, State University of New York Downstate Medical Center (MH), New York, New York
| | - Kenneth I. Glassberg
- Division of Pediatric Urology, Morgan Stanley Children's Hospital of New York–Presbyterian, Columbia University Medical Center and Division of Pediatric Urology, State University of New York Downstate Medical Center (MH), New York, New York
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