Emotional and behavioral problems in children and adolescents with lower urinary tract dysfunction: a population-based study

Preventing Pediatric Medical Traumatic Stress in a Pediatric Urology Outpatient Setting: Application of the Pediatric Psychosocial Preventative Health Model (PPPHM)

OBJECTIVE

The objectives of this topical review are to (1) increase understanding of pediatric medical traumatic stress (PMTS) in pediatric urology populations through literature review, (2) identify a theoretical model to guide prevention of PMTS in this population, and (3) provide clinical care recommendations based on the model identified. Authors introduce a new term "uropsychology" to describe psychological practice that specializes in the treatment of urology patients.

METHODS

Pediatric uropsychologists from 5 pediatric medical care centers gathered to discuss their experience with treating PMTS in their settings and to review existing literature related to PMTS in pediatric urology, PMTS in other populations, and established models for prevention. Authors provide recommendations based on literature review for preventing PMTS in a pediatric urology population.

RESULTS

Gaps in the evidence base for preventing PMTS in this population are identified. Authors provide a series of clinical care recommendations, utilizing clinical experience, and the Pediatric Psychosocial Preventative Health Model (PPPHM) as a framework.

CONCLUSIONS

While there is limited research on PMTS in pediatric urology populations, urologic interventions can be perceived as invasive, painful, distressing, and traumatic. Application of the PPPHM can guide prevention and intervention efforts. Future research is needed to characterize PMTS in this population, evaluate the efficacy of trauma-informed prevention and intervention practices, and develop screening measures that accurately identify at-risk patients. Authors recommend intradisciplinary collaboration among uropsychologists, urology specialists, and patients and families to create formal standards of care, avenues for other future research, and equitable access to uropsychology care.

The brain, gut, and bladder health nexus: A conceptual model linking stress and mental health disorders to overactive bladder in women

OBJECTIVE

A small, but growing literature links stressors and mental health disorders (MHDs) across the life course to overactive bladder (OAB) and urinary incontinence symptoms. Mechanisms by which stressors and MHDs may impact bladder health are not fully understood, limiting novel prevention and treatment efforts. Moreover, potential biopsychosocial mechanisms involving the brain and gut have not been considered in an integrated, comprehensive fashion.

METHODS

Members of the prevention of lower urinary tract symptoms Research Consortium developed conceptual models to inform research on biopsychosocial mechanisms through which stress and MDHs may impact bladder health among girls and women, focusing on brain and gut physiology.

RESULTS

Two conceptual models were developed-one to explain central (brain-based) and peripheral (gut-based) mechanisms linking stressors and MHDs to OAB and bladder health, and one to highlight bidirectional communication between the brain, gut, and bladder. Traumatic events, chronic stressors, and MHDs may lead to a maladaptive stress response, including dysregulated communication and signaling between the brain, gut, and bladder. Gut bacteria produce molecules and metabolites that alter production of neurotransmitters, amino acids, short-chain fatty acids, and inflammatory immune response molecules that mediate communication between the gut and brain. Microbiota signal neurogenesis, microglia maturation, and synaptic pruning; they also calibrate brain-gut-bladder axis communication through neurotransmission and synaptogenesis, potentially influencing bladder symptom development. Life course trajectories of risk may be prevented or interrupted by central and peripheral resources for neuropsychological resilience.

CONCLUSIONS

Depicted pathways, including brain-gut-bladder communication, have implications for research and development of novel prevention and treatment approaches.

Association between rectal diameter and response to treatment with parasacral transcutaneous electrical nerve stimulation and behavioral changes in children and adolescents with bladder and bowel dysfunction

PURPOSE

Parasacral Transcutaneous Electrical Stimulation (TENS) is one of the treatments for children with Bladder and Bowel Dysfunction (BBD). Some studies showed that children with increased Rectal Diameter (RD) have more Functional Constipation (FC). However, RD prediction in maintenance of BBD after treatment was never evaluated. Our aim is to evaluate the association between RD and response to treatment in children and adolescents with BBD.

MATERIALS AND METHODS

This study evaluated patients from 5-17 years old with BBD. Dysfunctional Voiding Scoring System (DVSS), Rome IV criteria, and the Constipation Score were used. RD was measured using abdominal ultrasound before treatment according to the technique established by Klijn et al. and was considered enlarged when >3cm. No laxatives were used during treatment. Descriptive analysis and binary regression were performed and the area under the ROC curve was calculated.

RESULTS

Forty children were included (mean age 8.4±2.8 years, 52.5% male). Before treatment, RD was enlarged in 15 children (37.5%) (mean diameter 3.84±0.6cm), with FC persisting post-treatment in 11/15(73.3%). Those patients also required more laxatives following treatment and had more severe FC. Binary regression showed pretreatment RD to be an independent predictor of the persistence of FC post-treatment (OR=9.56; 95%CI:2.05-44.60). In ROC curve analysis, the sensitivity was 100% (95%CI: 0.49-1.0) and specificity 77.14% (95%CI:0.60-0.90) for rectal diameter >3 cm. The likelihood ratio was 4.38 (95%CI:2.40-8.0) for the persistence of BBD following treatment.

CONCLUSION

RD appears to be relevant in the evaluation of children with BBD, not only as a diagnostic tool but also as a predictor of treatment outcome.

Personalized Pre-clinic Nursing Telemedicine Visit: An Efficient and Efficacious Approach for Bowel and Bladder Dysfunction in Children

OBJECTIVES

To evaluate the effectiveness and efficacy of a Registered Nurse (RN) led educational pre-clinic telephone call on compliance and outcomes in children with bowel and bladder dysfunction (BBD).

METHODS

A retrospective chart review of a prospectively applied protocol in a single academic institution was performed for children aged 4-17 presenting with BBD. All children underwent a pre-clinic RN telemedicine visit where they were educated on pathophysiology of BBD, provided personalized urotherapy and bowel recommendations and instructed to complete pre-clinic questionnaires and voiding diaries. Patients were evaluated by a provider 4weeks following RN call. Data collected included compliance with forms, bowel management and need for imaging/testing, medications, and biofeedback. Patients were considered to improve with urotherapy alone if they were discharged from urology without the need for medications and/or biofeedback.

RESULTS

In total, 277 patients completed an RN call and 224 patients attended a provider visit between December 2020 and June 2022. Mean age was 9.4years (3:1 Female to Male ratio). During the RN call, 154 (56%) patients had bowel management initiated. Of the 224 patients seen by a provider, 69% (n = 154) had symptom improvement or resolution with urotherapy alone. Thirty-eight patients (17%) enrolled in biofeedback with 7 (3%) completing all 8 sessions. Thirty-two patients (14%) required medication for daytime bladder symptoms.

CONCLUSION

Our novel RN-led pre-clinic telemedicine visit demonstrates excellent compliance and patient outcomes for children with BBD and can reduce the use of unnecessary imaging, medications, and time-consuming treatments such as biofeedback.

Effects of electroacupuncture on pediatric chronic urinary retention: a case-series study

Objectives

This study aims to preliminarily evaluate the effect and safety of electroacupuncture (EA) in treating pediatric chronic urinary retention (CUR) following lumbosacral surgeries, with treatment duration evaluated.

Methods

This prospective case-series study was performed from August 5, 2017, to July 31, 2022. Pediatric patients diagnosed with CUR following lumbosacral surgeries were included and treated by EA for 2-16 weeks. Responders were defined as participants achieving a reduction of 50% or more in post void residuals (PVR) from baseline. Time-to-event analysis was applied to explore the association between EA treatment duration and response rate. Adverse event was recorded.

Results

Totally 14 participants (mean [SD] age, 12 [4] years) completed EA treatment. Response rate was 71% (10/14) at the 12th week. 50% (7/14) of participants removed catheters at the 12th week, and none of them experienced re-catheterization in the 24-week follow-up. No serious adverse event was reported. Time-to-event analysis estimated that over 50% patients could respond to EA of more than 8 weeks. Subgroup analysis showed that participants with baseline PVR ≥300 ml and CUR duration ≥12 months experienced longer EA duration to reach the response rate of 50%, compared with those whose PVR <300 ml and CUR duration <12 months (median value: 12 weeks vs. 8 weeks, 12 weeks vs. 4 weeks, respectively).

Conclusions

EA could reduce PVR for pediatric patients suffering from CUR following lumbosacral surgeries, with long-term efficacy and safety. EA treatment of more than 8 weeks was reasonable. Further study of a larger sample and controlling is needed.

Clinical Trial Registration

www.chictr.org.cn, identifier, ChiCTR1800020222.

Sexual Health Behaviors by Age 17 and Lower Urinary Tract Symptoms at Age 19: PLUS Research Consortium Analysis of ALSPAC Data

PURPOSE

We examined how antecedent sexual health factors affect lower urinary tract symptoms (LUTS) in adolescent women.

METHODS

We analyzed 1,941 adolescent women from the Avon Longitudinal Study of Parents and Children at age 19. At ages 15 and 17, participants reported use of oral contraceptives (OCs), history of sexual intercourse, number of sexual partners, and condom use. At age 19, The Bristol Female Lower Urinary Tract Symptoms questionnaire quantified the frequency over the past month: stress incontinence, any incontinence, urgency, sensation of incomplete emptying, bladder pain, and urinary tract infection. Multivariable regression models examined associations between sexual health behaviors reported at ages 15 and 17 and six LUTS reported at age 19, after controlling for covariates.

RESULTS

Commonly reported LUTS at age 19 were past-month stress incontinence (26.8%), bladder pain (26.3%), any urine leakage (22.1%), and urinary tract infection (15.4%). OC use by age 17 was associated with urgency (odds ratio [OR] = 1.62, 95% confidence interval [CI] 1.19-2.20), incomplete emptying (OR = 1.62, 95% CI = 1.17-2.26), bladder pain (OR = 1.45, 95% CI = 1.15-1.83), and urinary tract infections (OR = 1.68, 95% CI = 1.28-2.21) at age 19 after adjustment for covariates. However, associations were attenuated after adjustment for condom use and number of sexual partners. Sexual intercourse by age 17 was associated with 1.53-2.65 increased odds of LUTs categories except incontinence, with lower confidence interval boundaries > 1.0. Associations were stronger among women with ≥ 3 sexual partners (vs. 0) by age 17.

DISCUSSION

We found longitudinally assessed associations between OC use, sexual intercourse, and number of sexual partners during adolescence and LUTS at age 19.

Validation of the International Consultation on Incontinence Questionnaire-Pediatric Lower Urinary Tract Symptoms (ICIQ-CLUTS) for Spanish-speaking children

The International Consultation on Incontinence Questionnaire-Pediatric Lower Urinary Tract Symptoms (ICIQ-CLUTS) is a 12-item self-administered tool to screen lower urinary tract symptoms (LUTS) in children. The aim of this study is to translate and validate the ICIQ-CLUTS into Spanish (ICIQ-CLUTS-Sp) and to study its psychometric properties. The cross-cultural adaptation of the ICIQ-CLUTS was performed following international recommendations. The psychometric analysis of the ICIQ-CLUTS-Sp was carried out to determine the reliability, validity, and diagnostic accuracy in a sample of 155 children and parents who completed the Spanish version ICIQ-CLUTS. The reliability indicators for the ICIQ-CLUTS-Sp were excellent (Cronbach's alpha was > 0.8 and ICC > 0.9 both for children's and parents' versions). There was a high Pearson r > 0.6 and a high agreement level between children's and parents' answers (ICC > 0.6), except in 4 items. For parents, the standard error of measurement (SEm) was 0.41, and the minimal detectable change (MDC) was 1.14 points. In children, these results were 0.42 and 1.16 points, respectively. Cut-off points greater than 15 points in the parent version or 16 points in the children version have the highest sensitivity and specificity for detecting LUTS.  Conclusion: The Spanish version of the ICIQ-CLUTS questionnaire is a valid, reliable, and diagnostically accurate instrument to identify cases of children with LUTS. Therefore, it can be used to screen for lower urinary tract symptoms in Spanish speaking children and/or parents, as well as to monitor the effects of interventions. What is Known: • Lower urinary tract symptoms in children should be assessed multimodally using minimally invasive diagnostic procedures. One way to do this is to use the questionnaire to differentiate these cases in paediatric patients. • A cross-cultural adaptation of the ICIQ-CLUTS questionnaire to Spanish has not yet been done. What is New: • Based on a comprehensive validation methodology, this study highlights that the ICIQ-CLUTSSp questionnaire has good psychometric properties.

Quality of life and psychological aspects in children with overactive bladder treated with parasacral transcutaneous electrical nerve stimulation - A prospective multicenter study

OBJECTIVE

To assess the impact of parasacral transcutaneous electrical nerve stimulation (parasacral TENS) on quality of life (QoL) and psychological aspects in children treated for overactive bladder (OAB).

METHODS

This international, multicenter, prospective cohort study involved individuals of 6-16 years of age under TENS treatment for OAB. The study was conducted between June 2016 and December 2019 in four participating centers: two in Australia, one in Germany and one in Brazil. Patients with anatomical and/or neurological abnormalities of the urinary tract were excluded. Questionnaires were applied before and after parasacral TENS treatment: the Dysfunctional Voiding Symptom Score (DVSS), used in Brazil, or the International Consultation on Incontinence Questionnaire - Pediatric Lower Urinary Tract Symptoms (ICIQ-CLUTS), used in Germany and Australia, to analyze urinary symptoms; the Strengths and Difficulties Questionnaire (SDQ) to assess emotional and behavioral aspects; and the Pediatric Incontinence Questionnaire (PinQ) for bladder-specific Qol.

RESULTS

Fifty-three patients (28 girls and 25 boys) with a mean age of 8.64 ± 2.63 years were included. Median DVSS was 11 (range 6-13.5) and 3 (range 0-7), (p < 0.001), and median ICIQ-CLUTS was 12 (range 9-14) and 9 (range 5.7-12), (p < 0.001), before and after treatment, respectively. Median PinQ score decreased from 47.8 (range 38.9-59.7) to 39 (range 29-53.15) following treatment (p = 0.04). Median total SDQ score before and after treatment was 17 (range 13.5-21) and 15 (range 12-21), respectively (p = 0.939).

CONCLUSION

Parasacral TENS was associated with a significant improvement in urinary symptoms and QoL; however, there was no change in psychological symptoms, as measured using the SDQ.

A Prospective Comparative Study of Mobile Acoustic Uroflowmetry and Conventional Uroflowmetry

PURPOSE

The aim of this study was to assess the performance of a mobile acoustic Uroflowmetry (UFM) application compared with standard UFM in the pediatric population.

METHODS

A mobile acoustic UFM application represents a noninvasive method to estimate the urine flow rate by recording voiding sounds with a smartphone. Male pediatric patients who were undergoing UFM testing were prospectively recruited, and the voiding sounds were recorded and analyzed. The intraclass correlation coefficient (ICC) was used to compare the maximum flow rate (Qmax), average flow rate (Qavg), voiding time (VT), and voiding volume (VV) as estimated by acoustic UFM with those calculated by standard UFM. Differences in Qmax, Qavg, VT, and VV between the 2 UFM tests were determined using 95% Bland-Altman limits of agreement.

RESULTS

A total of 16 male patients were evaluated. Their median age was 9 years. With standard UFM, the median Qmax, Qavg, VT, and VV were 18.7 mL/sec, 11.1 mL/sec, 15.2 seconds, and 157.8 mL, respectively. Strong correlations were observed between the 2 methods for Qmax (ICC=0.755, P=0.005), VT (ICC=0.974, P<0.001), and VV (ICC=0.930, P<0.001), but not for Qavg (ICC=0.442, P=0.135). The Bland-Altman plot showed good agreement between the 2 UFM tests. Flow patterns recorded by acoustic UFM and conventional UFM showed good visual correlations.

CONCLUSION

Acoustic UFM was comparable to standard UFM for male pediatric patients. Further validation of its performance in different toilet settings is necessary for broader use.

Long-term functional and psychosocial outcome in adolescents and young adults treated for lower urinary tract dysfunction in childhood

BACKGROUND

Lower urinary tract dysfunction (LUTD) in childhood might affect lower urinary tract function and psychological wellbeing later in life. This study presents long-term functional outcome, psychological outcome and quality of life (QOL) of adolescents and young adults treated for childhood LUTD compared to healthy age-matched controls. In addition, association with past treatment outcomes is evaluated.

STUDY DESIGN

A single-centre cross-sectional study of former patients treated in childhood (currently 16-26 years old) was conducted. Participants completed a survey composed from validated questionnaires: the Overactive Bladder Questionnaire, the Hospital Anxiety and Depression Scale, the Pediatric Quality of Life Inventory and the Short Form 36 Health Survey.

RESULTS

Fifty-two former patients (out of 133) agreed to participate and returned the survey (mean age 21 ± 4.1 years). Sixty-nine control subjects were included (mean age 21 ± 2.9 years). Urinary tract symptoms were more common in former patients than controls. Storage symptoms more frequently reported were (urge) urinary incontinence, stress urinary incontinence (SUI) and nocturia. Voiding symptoms more frequently reported were intermittency and feeling of incomplete emptying, Fig. 1. There were no differences in urinary tract symptoms or urinary incontinence subdivided by childhood treatment outcome (complete response, partial response or no response), respectively p = 0.17 and p = 0.58. Results of the overactive bladder questionnaire revealed higher urinary symptom bother scores (score 14 versus 5 p < 0.01) and lower disease-specific QOL (score 95 versus 98 p = 0.02) in former patients compared to controls. General QOL and psychosocial wellbeing were not significantly different between the two groups. A childhood treatment duration extending 2,5 years was an independent prognostic factor for subsequent urinary tract symptoms later in life (OR = 1.5, 95% CI 1.1-2.0). Psychological comorbidity was more often present in former patients (35%) versus controls (10%), p < 0.01.

CONCLUSION

Adolescents and young adults treated for childhood LUTD are more prone to report urinary tract symptoms later in life, especially if treatment duration was extensive. However general QOL and psychosocial wellbeing later in life are not or only mildly affected.

Factors Correlating with the Emotional and Behavioral Problems among Adolescents with Legal Problems

BACKGROUND: The prevalence of emotional and behavioral problems (EBP) among adolescents (12–18 years) in Indonesia is 28.4%. These problems are related to age, sex, family economic level, father’s education, peer relationships, psychosocial skills, and family mental health status. However, factors related to EBPs among adolescents who are dealing with law cases have not been widely reported. AIM: The purpose of this study is to find out factors correlating with the EBPs among adolescents with legal problems. MATERIALS AND METHODS: A cross-sectional design was used in this study. Fifty-nine adolescents with legal problems who were sheltered at the Social Protection and Rehabilitation Centre for Adolescents (SPRCA) and the Guidance Institution for Children (GIC) served respondents. Strengths and Difficulties Questionnaires were used to measure the EBP among adolescents. The Pearson Product Moment and linear regressions were used to analyze the data. RESULTS: The prevalence of the EBP among adolescents with legal problems at SPRCA and GIC is 67.8%. The correlations of emotional problems, behavioral problems, hyperactivity, and peer problems with the EBP among adolescents with legal problems are 67.8%, 64.4%, 13.6%, and 57.6%, respectively. Age and psychosocial skills have an effect of 15.7% on the EBP among adolescents. CONCLUSION: Age and psychosocial skills correlate with the EBP among adolescents with legal problems at the SPRCA and GIC.

Urgency in children with overactive bladder or voiding postponement: What's the difference?

INTRODUCTION

Overactive bladder (OAB) and voiding postponement (VP) can share the same symptom of urgency, but with different pathophysiology, including the cerebral interpretation of bladder filling. The objective of the present study was to compare the clinical, psychological and sociodemographic features of children with urgency for OAB with those who presented urgency for VP (UrVP).

METHODS

A retrospective cross-sectional study with an analytical component was conducted with patients of 5-14 years of age with urinary urgency between January, 2014, and January, 2019. Urinary symptoms were evaluated using the Dysfunctional Voiding Scoring System (DVSS) questionnaire, constipation using the Rome IV criteria and psychological symptoms using the Strengths and Difficulties Questionnaire (SDQ). All the patients had bell-shaped or tower-shaped curves at uroflowmetry and no significant post-void residual volume at ultrasonography. Patients were classified as having OAB or UrVP depending on whether they voided >3 or ≤3 times/day, respectively.

RESULTS

Median age of the 101 children/adolescents included was 9 years, with no significant difference between the groups. The prevalence of OAB was 60.4%. Girls constituted 57.4% of the sample but 67.5% of the postponement group, although no independent association was found between sex and diagnosis. The prevalence of constipation was 75.2%, with no difference between the groups. The children with OAB had higher behavioral hyperactivity scores and more intense externalizing symptoms, although there was no significant difference between the groups for the SDQ total difficulties score. In the multivariate analysis, the independent clinical factors associated with a diagnosis of OAB were behavioral hyperactivity (OR = 5.134), urge incontinence (OR = 4.694) and MVV/EBC (%) (OR = 0.983).

CONCLUSION

More behavioral problems, particularly hyperactivity, were found in children with OAB compared to those with UrVP. No statistically significant difference was found between the groups evaluated insofar as their sociodemographic characteristics are concerned. Furthermore, as expected, there was a strong association between the symptom of urge incontinence and lower MVV/EBC in the children and adolescents with OAB compared to those with voiding postponement.

Neurodevelopmental and psychiatric disorders in pediatric bladder and bowel dysfunction

BACKGROUND

Bladder and bowel dysfunction (BBD) is a common pediatric problem that describes a constellation of lower urinary tract symptoms associated with constipation and/or encopresis. Its association with neurodevelopmental and psychiatric (NDP) problems is not well understood.

OBJECTIVES

Our primary aim was to identify pre-existing NDP disorders in children with BBD. Secondarily, we aimed to screen for new behavioral problems and evaluate the association between bladder or bowel symptoms and behaviors symptoms.

METHODS

A cross sectional study was conducted in urology clinics. New patients referred for BBD between 4 and 17 years old were recruited and completed: a demographics survey, Dysfunctional Voiding Score System questionnaire, assessment of bowel movements with the Bristol Stool Scale, and Strength and Difficulties questionnaire (SDQ). Those with known spinal dysraphism were excluded. SDQ scores were evaluated for abnormal screens in different subscales and total difficulties scores. Pearson correlation analyses were conducted for association.

RESULTS

We included 61 participants (age 9.5 ± 4.1 years), including 33 females and 28 males. One or more pre-existing NDP disorder(s) was reported in 14 (23%) children; most commonly being learning disability (43%) and attention deficit hyperactivity disorder (29%). This cohort had more severe BBD symptoms as reflected in DVSS scores. SDQ scores demonstrated that 12 patients without pre-existing NDP diagnoses scored in the clinical range, with hyperactivity as the most common difficulty (6/12; 50%).

CONCLUSIONS

A significant proportion of children with BBD have a comorbid NDP disorder and present with more severe symptomatology. The SDQ can be used as a behavioral screening tool this population for the identification of children who may benefit from formal developmental pediatrics assessment.

Delayed elimination communication on the prevalence of children's bladder and bowel dysfunction

To determine the prevalence of bladder and bowel dysfunction (BBD) and its relationship with delayed elimination communication (EC) in children. A cross-sectional study was carried out in kindergartens and primary schools in mainland China. A total of 10,166 children ranging from 4 to 10 years old were included. A total of 10,166 valid questionnaires were collected, and 409 children were diagnosed with BBD. The overall prevalence was 4.02% (409/10,166) and decreased with age, from 6.19% at age 4 to 1.96% at age 10. With the prolonged use of disposable diapers (DDs), the commencement of usage of EC in a child was significantly put off or delayed by parents, and the prevalence of BBD amongst these children increased (P < 0.001). The prevalence of BBD among children who stopped using DDs within the first 12 months and after more than 24 months was 2.79% and 4.38% respectively. Additionally, the prevalence among children who started EC within 12 months after birth and those who never engaged in EC was 1.36% and 15.71% respectively. Early introduction of EC and weaning of DD usage has a positive correlation with lower prevalence of BBD in children in China.