Psychosocial Comorbidities and Obesity are Associated with Lower Urinary Tract Symptoms in Children with Voiding Dysfunction

Systematic review and meta-analysis: relationships between attention-deficit/hyperactivity disorder and urinary symptoms in children

Lower urinary tract symptoms (LUTS), e.g., urinary frequency, pressure, urgency, and overactive bladder syndrome, are commonly reported in children with attention-deficit/hyperactivity disorder (ADHD). Understanding the co-occurrence of these conditions has implications regarding clinical approaches, treatments, and improved quality of life. We conducted a systematic review and meta-analysis to examine the relationships between LUTS and ADHD in children. We searched for articles published between January 1990 and July 2019, in PubMed, CENTRAL, and PsycNet. Two authors independently screened all articles and extracted data. We performed random-effect meta-analyses for ADHD with pooled outcomes for LUTS. We identified 119 relevant articles in the literature and 18 articles fulfilled the inclusion criteria for the systematic review, of which, 5 articles had sufficient data for meta-analysis. Examining ADHD among individuals with LUTS, the odds ratio was 2.99 (95% CI 1.13, 7.88, p < 0.001), compared to controls. In multiple studies, the mean overall score for LUTS, using a standardized measure, was significantly higher in patients with ADHD in comparison to controls, and the severity of ADHD was positively associated with the severity of LUTS. Younger age in children was correlated with a higher LUTS score. Different subtypes of urinary incontinence demonstrated differences in behavioral problems and psychiatric comorbidity. Sex differences in LUTS were not consistent across articles. Our results indicate clinically significant associations between ADHD and LUTS in children. Because LUTS and ADHD are common disorders in children, clinicians should be aware of these associations as they inform optimal assessment and treatment strategies.

The Effect of Chronic Psychological Stress on Lower Urinary Tract Function: An Animal Model Perspective

Chronic psychological stress can affect urinary function and exacerbate lower urinary tract (LUT) dysfunction (LUTD), particularly in patients with overactive bladder (OAB) or interstitial cystitis–bladder pain syndrome (IC/BPS). An increasing amount of evidence has highlighted the close relationship between chronic stress and LUTD, while the exact mechanisms underlying it remain unknown. The application of stress-related animal models has provided powerful tools to explore the effect of chronic stress on LUT function. We systematically reviewed recent findings and identified stress-related animal models. Among them, the most widely used was water avoidance stress (WAS), followed by social stress, early life stress (ELS), repeated variable stress (RVS), chronic variable stress (CVS), intermittent restraint stress (IRS), and others. Different types of chronic stress condition the induction of relatively distinguished changes at multiple levels of the micturition pathway. The voiding phenotypes, underlying mechanisms, and possible treatments of stress-induced LUTD were discussed together. The advantages and disadvantages of each stress-related animal model were also summarized to determine the better choice. Through the present review, we hope to expand the current knowledge of the pathophysiological basis of stress-induced LUTD and inspire robust therapies with better outcomes.

Oxidative Stress: A Putative Link Between Lower Urinary Tract Symptoms and Aging and Major Chronic Diseases

Aging and major chronic diseases are risk factors for lower urinary tract symptoms (LUTS). On the other hand, oxidative stress (OS) is one of the fundamental mechanisms of aging and the development of chronic diseases. Therefore, OS might be a candidate mechanism linking these two clinical entities. This article aims to summarize the studies on the prevalence of LUTS, the role of OS in aging and chronic diseases, and the potential mechanisms supporting the putative link. A comprehensive literature search was performed to identify recent reports investigating LUTS and OS in major chronic diseases. In addition, studies on the impact of OS on the lower urinary tract, including bladder, urethra, and prostate, were collected and summarized. Many studies showed LUTS are prevalent in aging and major chronic diseases, including obesity, metabolic syndrome, diabetes, cardiovascular disease, hypertension, obstructive sleep apnea, autoimmune diseases, Alzheimer’s disease, and Parkinson’s disease. At the same time, OS is a key component in the pathogenesis of those chronic diseases and conditions. Recent studies also provided evidence that exacerbated OS can cause functional and/or structural changes in the bladder, urethra, and prostate, leading to LUTS. The reviewed data support the concept that OS is involved in multiple risk factors-associated LUTS, although further studies are needed to confirm the causative relationship. The specific ROS/RNS and corresponding reactions/pathways involved in chronic diseases and associated LUTS should be identified in the future and could serve as therapeutic targets.

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.

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.

High prevalence of lower urinary tract dysfunction in patients with Prader-Willi syndrome

AIMS

To report the first noninvasive urodynamic screening of lower urinary tract dysfunction (LUTD) in children, adolescents, and young adults with Prader-Willi Syndrome (PWS).

METHODS

We recruited 37 PWS patients with/without lower urinary tract symptoms (LUTS) from our hospital. Uroflowmetry was performed in 36 patients. In addition, 20 patients underwent postvoid residual urine (PVR) measurement by transabdominal ultrasound. LUTD is defined as abnormal uroflow patterns, low peak flow rate (Q_max ), or elevated PVR by age. Videourodynamic study (VUDS) was performed in selected cases.

RESULTS

Mean and median age of the patients were 17.7 ± 7.8 years and 16 years. Male to female ratio was 15/22. Two patients were excluded from the following analysis because of voided volume less than or equal to 50 ml. Of the remaining 34 uroflowmetry examination, normal voiding pattern (bell shape) was observed in 22 (64.7%) patients. Abnormal uroflowmetry pattern were obstructive in 6 (17.6%), staccato in 3 (8.8%), intermittent in 2 (5.8%), tower in 1 (2.9%), and plateau in 0 patients. Ten (29.4%) patients had a Q_max less than 15 ml/s. Of 20 patients undergoing PVR tests 10 (50%) had elevated PVR by age ( > 6% of estimated bladder volume). In all, 17/34 (50.0%) PWS patients had at least one abnormality of the noninvasive tests. Of the three cases undergoing VUDS all showed detrusor sphincter dyssynergia.

CONCLUSIONS

Half of PWS patients with/without LUTS had LUTD. Noninvasive study such as uroflowmetry and postvoid residual urine by ultrasound is recommended to all patients with PWS.

Frequent witnessing to interparental conflict and low parental availability for leisure-time is associated with dysfunctional voiding in primary school children

AIM

Aspects of parenting are an under-investigated topic amongst children with voiding complaints. We aimed to investigate the association between voiding complaints amongst children and two specific parenting-related behaviours: 1) parental availability during the child's leisure time and 2) frequency of witnessing interparental conflict.

MATERIAL AND METHOD

Children aged between 6 and 11 years with their parents were the participants. Two survey forms and informed consent form were sent to potential participants via children's teacher. Voiding dysfunction complaints were evaluated with the Dysfunctional Voiding and Incontinence Symptom Scale (DVISS).

RESULTS

Data analyses were performed with 1101 eligible participants. The mean duration of parental availability during the child's leisure time was below 2 hours per day. Nearly one out of every four children witnessed interparental conflict at least once a month. Age, educational level of the mother, parental availability for the child's leisure time, and frequency of witnessing parental conflicts were found to be significantly associated with DVISS ratings. Adjusting age, socioeconomic level, and educational level of the parents and later adjusting parental availability during the child's leisure time did not change the association of frequency of witnessing interparental conflict with DVISS rates. An increase in the age, educational level of the mother, and parental availability during the child's leisure time was correlated with better scores on DVISS, while an increase in the frequency of witnessing interparental conflict strongly correlated with worse scores.

CONCLUSION

Exposing children to interparental conflicts and shorter togetherness with their leisure time is associated with voiding complaints.

Association Between Obesity and Lower Urinary Tract Symptoms Among Children and Adolescents: A Community-Based Study

Introduction: Obesity is associated with lower urinary tract symptoms (LUTSs) and dysfunction in adults while its impact on children and adolescents remains unknown. This study aimed to explore the impact of obesity on LUTSs among children and adolescents through a large-scale community-based study. Methods: From July 2004 to April 2017, children and adolescents aged 5-15 years-old in Xin-Dian District, New Taipei City were invited to participate in our study. The exclusion criteria were a history of congenital genitourinary tract anomalies, neurological anomalies, or a presence of urinary tract infection. After providing informed consent the participant completed a questionnaire, which included their baseline characteristics and dysfunctional voiding symptom score (DVSS); a parent completed the questionnaire with the younger children. Urgency and daytime incontinence were defined as having positive statement for DVSS questions 7 and 1, respectively. Multivariate regression analysis was used to evaluate the predictors of urgency, daytime incontinence and enuresis. A p-value of <0.05 was considered statistically significant. Results: A total of 2,371 participants were enrolled in the study, and 1,599 were ultimately eligible for analysis. The prevalence of urgency, daytime incontinence, constipation, and enuresis were 37.6, 6.4, 26.1, and 7.7%, respectively. Multivariate analysis revealed that younger age (p = 0.01) and obesity (p = 0.04) were independent predictors for urgency. Younger age (p < 0.01) and constipation (p = 0.04) were independent predictors for daytime incontinence but obesity was not. Younger children were more likely to have nocturnal enuresis (95% CI = 0.77-0.88) and obesity did not have a significant impact on enuresis. Conclusion: Obesity was significantly associated with urgency but it was not significantly associated with daytime incontinence and enuresis in community dwelling children and adolescents.

Incontinence and constipation in adolescent patients with anorexia nervosa-Results of a multicenter study from a German web-based registry for children and adolescents with anorexia nervosa

OBJECTIVE

Nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI) are common disorders in childhood and are frequently accompanied by comorbid psychiatric disorders. Despite a high association between urinary and fecal incontinence with psychiatric and neurodevelopmental disorders, research on comorbidity between incontinence and anorexia nervosa (AN) remains scarce. Yet, it is well known that somatic consequences of AN include metabolic and gastrointestinal disorders. The study sought to assess the prevalence of incontinence and constipation in children and adolescents with AN and to examine associations of these two symptoms with body weight at admission and with BMI changes during inpatient treatment.

METHODS

Data collected between 2015 and 2017 by a multicenter German web-based registry for AN were analyzed. Three hundred and forty-eight patients with AN (96.3% female, mean age = 15.1 ± 1.8 years) were assessed regarding AN subtype, psychiatric comorbidity, body weight, incontinence, and constipation.

RESULTS

Overall, 27.6% of patients had constipation, 1.8% had NE and 1.8% DUI. Prevalence of constipation did not significantly differ between AN subtypes. Constipation did not lead to any significant differences in weight/BMI changes during inpatient treatment.

DISCUSSION

This is the largest study of incontinence and constipation in patients with AN, so far. Our results indicate that constipation is highly prevalent in adolescent patients with AN and reflects a clinically relevant condition. Despite, patients with AN do not have an increased prevalence of incontinence compared with the general population. Future studies should include medical examinations like ultrasound and physical examination of the lower abdomen to evaluate the severity of constipation.

Prevalence of nocturia and fecal and urinary incontinence and the association to childhood obesity: a study of 6803 Danish school children

INTRODUCTION

Fecal and urinary incontinence are common disorders in children. Obesity and its associated comorbidities have become increasingly common, and a relation between obesity, nocturia, incontinence, and nocturnal enuresis has been suggested.

OBJECTIVE

This large scale population study aims to determine the prevalence of fecal incontinence (FI), daytime urinary incontinence (DUI), nocturnal enuresis (NE), and nocturia in children at school entry and in adolescence and to clarify whether obesity is associated to any of the aforementioned symptoms.

STUDY DESIGN

First-grade children and their parents and adolescents in the seventh to ninth grades were interviewed in relation to school nurse visits. The interview included questions on whether incontinence or nocturia were experienced at least once per month. The participants' age was recorded, and weight and height were measured. Body mass index (BMI) was calculated and age standardized by the use of BMI-standard deviation score (SDS), with reference to World Health Organization normative BMI data. Obesity was defined as BMI-SDS >2. Associations between obesity and incontinence and nocturia were quantified by odds ratio (OR).

RESULTS

Completed interview questionnaires and measurements were obtained from 4002 children (95.1%) in the child population and 2801 adolescents (84.4%) in the adolescent population. The mean age of children was 6.45 ± 0.39 years, and 4.4% were obese. Overall 11.2% reported FI, 21.8% DUI, 16.8% NE, and 31.4% experienced nocturia. Obesity was associated with FI in first-grade boys (OR 1.86 compared with normal weight). Mean age of adolescents was 13.9 ± 0.85 years, and 7.6% of adolescent boys and 5.5% of the girls were obese. Fecal incontinence was reported by 2.1% of the adolescents, 4.5% had DUI, 1.0% stated to have NE, and 32.3% reported nocturia. Obesity was significantly associated with nocturia in adolescents (OR 1.74-2.01).

DISCUSSION

The prevalence of nocturia seems constant throughout childhood and adolescent life; this has not previously been documented. Incontinence is very common at school entry, with DUI reported more frequently than enuresis by both children and adolescents. Obesity is associated with nocturia in adolescents and FI in first-grade boys, but no significant association between obesity and NE or DUI is found. Strength of this study is the very high participation rates, but the study does not reveal information on previous treatment, subtype, or severity of symptoms.

CONCLUSIONS

Incontinence is very common in children. One-third of both children and adolescents experience nocturia. Obesity is associated with FI in first-grade boys and nocturia in adolescents.

Assessment of pediatric bowel and bladder dysfunction: a critical appraisal of the literature

OBJECTIVE

Bowel and bladder dysfunction (BBD) is a clinical syndrome defined by the coexistence of constipation and lower urinary tract symptoms. Although BBD is a common condition in pediatric urology and can cause significant stress to patients/parents, clinical diagnosis of BBD has not been standardized. Bowel and bladder dysfunction instruments have gained popularity over the past decade to aid in diagnosis. In this review, the currently published BBD symptom questionnaires were summarized and an analysis on their psychometric validation process was provided.

SUBJECTS/PATIENTS

PubMed was searched for articles on BBD symptom questionnaires/instruments/surveys since 2000. Two investigators (R.Y.J. & M.S.K.) conducted the search in duplicate. The search was limited to English language. The included search terms were 'dysfunctional elimination syndrome', 'bowel and bladder dysfunction', 'dysfunctional voiding', 'voiding dysfunction symptom score', and 'dysfunctional voiding symptom scale'. Reference lists of included studies were screened for missed studies. Unpublished abstracts presented at the following scientific meetings were also manually searched for: the American Urological Association, the Society for Pediatric Urology, and the American Academy of Pediatrics Section on Urology. Exclusion criteria included articles in languages other than English, articles not related to BBD questionnaires, and articles not pertaining to pediatric patients.

RESULTS

After initial search, a total of 54 articles were obtained. Of the seven questionnaires reviewed, only one did not measure sensitivity or specificity. Almost all questionnaires showed excellent discriminative property with an Area under the curve (AUC) >0.85. Criterion validity was not reported in any of the questionnaires. Known-group validation was used as a common method to evaluate construct validity. Internal consistency was reported in 2 studies, and only 1 study measured questionnaire responsiveness during initial validation.

CONCLUSIONS

Although BBD is a common pediatric urology condition; a large amount of heterogeneity exists in the questionnaires' psychometric testing and validation process. To further improve the diagnosis and management of BBD in pediatric patients, there is a need for consensus on the gold standard questionnaire measure.

Angiotensin II, a stress-related neuropeptide in the CNS, facilitates micturition reflex in rats

BACKGROUND AND PURPOSE

We investigated the effects of centrally administered stress-related neuropeptide, angiotensin II, on the micturition reflex and the downstream signalling pathways in rats.

EXPERIMENTAL APPROACH

Male Wistar rats were anaesthetized with urethane for cystometry before and after i.c.v. administration of vehicle or angiotensin II (30 pmol). Muscimol (a GABA_A receptor agonist) or baclofen (a GABA_B receptor agonist) was i.c.v. administered 30 min before or 15 min after central angiotensin II administration. Telmisartan [an angiotensin II type 1 (AT₁ ) receptor antagonist], valsartan (an AT₁ receptor antagonist), PD123319 (an AT₂ receptor antagonist), U-73122 (a PLC inhibitor), chelerythrine chloride (a PKC inhibitor), apocynin (a NADPH oxidase inhibitor) or tempol (an antioxidant) was centrally administered 30 min before central angiotensin II administration.

KEY RESULTS

Centrally administered angiotensin II significantly shortened the intercontraction interval and decreased the voided volume and bladder capacity without altering the maximum voiding pressure, post-voiding residual urine volume or voiding efficacy. Muscimol, baclofen, telmisartan, valsartan, U-73122, chelerythrine chloride, apocynin or tempol pretreatment significantly suppressed the reduction in intercontraction interval induced by central angiotensin II. Post-treatment with muscimol or baclofen also ameliorated the decrease in intercontraction interval induced by central angiotensin II.

CONCLUSIONS AND IMPLICATIONS

Angiotensin II in the CNS facilitates micturition reflex by inhibiting central GABAergic activity and activating the AT₁ receptor/PLC/PKC/NADPH oxidase/superoxide anion pathway.

Dysfunctional voiding: Challenges of disease transition from childhood to adulthood

N/A

Role of body mass index in school-aged children with lower urinary tract dysfunction: Does weight classification predict treatment outcome?

INTRODUCTION

Lower urinary tract (LUT) dysfunction comprises a large percentage of pediatric urology referrals. Childhood obesity is a major health concern, and has been associated with voiding symptoms. We assessed the impact of body mass index (BMI) on treatment outcomes of children presenting with LUT or bladder-bowel dysfunction (BBD).

STUDY DESIGN

Children aged 5-17 years diagnosed with non-neurogenic LUT dysfunction and no prior urologic diagnoses were identified. Patient demographics including BMI, lower urinary tract symptoms, constipation, medical and psychologic comorbidities, imaging, and treatment outcomes were evaluated. BMI was normalized by age and gender according to percentiles: underweight < 5th, healthy 5th to <85th, overweight 85th to <95th, and obese > 95th percentile. Uni- and multivariate analyses were performed to identify predictors of treatment response.

RESULTS

During an 18-month period, 100 children (54 girls, 46 boys) met the inclusion criteria. The mean age at diagnosis was 7.7 ± 2.4 years, and mean length of follow-up 15.3 ± 13.1 months. Sixty-nine patients were a normal weight, 22 were overweight, and nine were obese. Fifteen percent of the children had complete treatment response, 63% partial response, and 22% non-response. On univariate analysis, children with elevated BMI (p = 0.04) or history of urinary tract infection (p = 0.01) were statistically more likely to not respond to treatment. Controlling for all other variables, children with BMI > 85th percentile had 3.1 times (95% CI 1.11-8.64; p = 0.03) increased odds of treatment failure (Table).

DISCUSSION

BBD management includes implementation of a bowel program and timed voiding regimen, with additional treatment modalities tailored on the basis of the prevailing symptoms. We observed that school-aged children with a BMI ≥ 85th percentile were over three times more likely to experience treatment failure when controlling for all other patient characteristics including constipation and a history of urinary tract infection. Limitations of the study include the relatively small sample size, lack of uroflow with electromyography to confirm the presence or the absence of detrusor sphincter dyssynergia, and inconsistent anticholinergic dosing.

CONCLUSIONS

Nearly one-third of school-aged children presenting to our institution with LUT or BBD were overweight or obese when normalized for age and gender. Children with LUT dysfunction and elevated BMI are significantly less likely to experience treatment response.

Obesity and lower urinary tract dysfunction in children and adolescents: Further research into new relationships

INTRODUCTION

Lower urinary tract dysfunction (LUTD) involves faults in the filling and emptying phases of bladder function in toilet-trained children with no previous infection or any other obvious pathology. Lower urinary tract dysfunction is associated with conditions such as vesicoureteral reflux, recurrent urinary infection, behavioral alterations and decreased quality of life. The literature suggests an association between LUTD and obesity; however, the association between each individual symptom and obesity has yet to be evaluated.

OBJECTIVE

To evaluate the association between excess weight and LUTD in children and adolescents in a community-based sample.

STUDY DESIGN

This cross-sectional study included 423 children and adolescents aged 5-17 years, and randomly selected in public places and schools between May and July 2015. The participants and their mothers completed the Dysfunctional Voiding Scoring System (DVSS) questionnaire, except for the questions on constipation and with the addition of a question on enuresis. They also completed the Rome III questionnaire, in which two positive responses defined the presence of constipation. Participants were classified as being of normal weight, overweight or obese, which was based on the BMI-for-age indicator.

RESULTS

Mean age was 9.7 years (SD 2.9), with girls comprising 50.6% of the sample and adolescents 52.5%. The prevalence of LUTD was 7.1%, with 13.5% of participants being overweight and 12.1% obese (Figure). Constipation was present in 5.9% of participants and enuresis in 10.8%. In the multivariate analysis, three factors were independently and significantly associated with a positive DVSS: age <10 years (β = 0.76; 95% CI: 0.34-1.18), constipation (β = 1.79; 95% CI: 0.88-2.70) and obesity (β = 0.89; 95% CI: 0.25-1.52).

DISCUSSION

Only bladder filling symptoms were associated with obesity. This may be explained by the fact that both obese individuals and those with emptying symptoms were shown to have activation alterations in the same brain regions. One limitation of this study was the use of questionnaires alone to diagnose LUTD and constipation.

CONCLUSION

Only the bladder-emptying symptoms of LUTD appear to be associated with obesity. This hypothesis may serve as a basis for future studies.

Urinary tract infections in children and adolescents with acute psychosis

OBJECTIVE

Schizophrenia is associated with increased infections. We previously found an association between urinary tract infection (UTI) and acute psychosis in adults. The aims of this study were to 1) evaluate the prevalence of UTI at the time of admission in children and adolescents with non-affective psychosis and psychotic depression versus those with non-psychotic major depressive disorder, and 2) compare demographic and clinical features between children and adolescents with acute psychosis with and without comorbid UTI.

METHOD

We performed a retrospective chart review of 227 subjects ages 10-18 who were hospitalized between 2005 and 2014 for an acute episode of DSM-IV non-affective psychosis (schizophrenia, schizoaffective disorder, psychosis NOS, or delusional disorder; n=80), major depressive disorder (MDD) with psychotic features (n=47); or MDD without psychotic features (n=100).

RESULTS

The prevalence of UTI was 20% in non-affective psychosis, 9% in MDD with psychotic features, and 13% in non-psychotic MDD. After controlling for potential confounders, UTI was 3.5 times more likely in subjects with non-affective psychosis than non-psychotic MDD (OR=3.5, 95% CI 1.3-9.2, p=0.01). Subjects with UTI had a higher prevalence of manic symptoms, but otherwise there were no associations between clinical characteristics and UTI in acute psychosis.

CONCLUSIONS

We found an association between UTIs and children and adolescents with acute non-affective psychosis. The results highlight the potential importance of screening for comorbid UTI in patients with acute psychosis.

Overactive bladder in children

Overactive bladder (OAB) is a ubiquitous syndrome that is defined by urinary urgency with, or without urinary incontinence. OAB is observed in all parts of the world, with a prevalence of 5-12% in children (5-10 years of age) and a prevalence of 0.5% in older adolescents (16-18 years of age). Published data indicate that around a third of children with OAB are likely to become adults with similar complaints. Studies in children and in adults with OAB indicate that these individuals are more likely to also have anxiety, depression and attention deficit problems, and that appropriate treatment of these comorbidities can often improve the patient's OAB symptoms. Furthermore, data from twin studies and familial surveys seem to indicate a genetic component of OAB. Pharmacological treatments of OAB in children have improved in the past 5 years, moving beyond anticholinergic agents and including the off-label use of α-blockers, β3-agonists and intravesical botulinum toxin. Use of several different electrical stimulation techniques is also effective, both as first-line treatments, and for patients with treatment-refractory symptoms. Overall the outlook of children with OAB seems to be improving, with a greater understanding of the pathophysiology of this syndrome. Treatment modalities that target the source of the underlying problem, especially in children, are likely to provide the best patient outcomes.

Interactions Between Depression and Lower Urinary Tract Symptoms: The Role of Adverse Life Events and Inflammatory Mechanisms. Results From the European Male Ageing Study

OBJECTIVES

Depression and lower urinary tract symptoms (LUTSs) have been found to co-occur among aging men. The present study attempted to clarify the nature of this relationship, considering adverse life events as potential moderators and the inflammation as an underlying biological mechanism.

METHODS

The relationship between depression and LUTS was evaluated using data from the European Male Ageing Study, the largest multicenter population-based study of aging in European men. The sample included 3369 men who were assessed by means of several self-reported questionnaires, including the Beck Depression Inventory-II, the International Prostate Symptom Score, and the Adverse Life Events Scale. Participants were asked to provide information regarding general health and life-style, and medical comorbidities. Biological measures including prostate-specific antigen, testosterone, and C-reactive protein were measured.

RESULTS

LUTS and depressive symptoms were correlated (R = 0.32, β = .10, p < .001), even after adjusting for life-style, psychological, and medical variables. A history of adverse life events was associated with both higher LUTS and Beck Depression Inventory scores. Furthermore, adverse life events moderated the LUTS-depression association (F = 22.62, b = 0.061, p < .001), which increased as a function of the number of life events. C-reactive protein was found to mediate the LUTS-depression association. This mediation effect was moderated by number of adverse life events.

CONCLUSIONS

Participants with a history of adverse life events represent a vulnerable population in whom the association between somatic and depressive symptoms is stronger. One of the biological mechanisms underlying this association could be an activation of the central inflammatory signaling pathways.

Clinical course of a cohort of children with non-neurogenic daytime urinary incontinence symptoms followed at a tertiary center

OBJECTIVE

To characterize a cohort of children with non-neurogenic daytime urinary incontinence followed-up in a tertiary center.

METHODS

Retrospective analysis of 50 medical records of children who had attained bladder control or minimum age of 5 years, using a structured protocol that included lower urinary tract dysfunction symptoms, comorbidities, associated manifestations, physical examination, voiding diary, complementary tests, therapeutic options, and clinical outcome, in accordance with the 2006 and 2014 International Children's Continence Society standardizations.

RESULTS

Female patients represented 86.0% of this sample. Mean age was 7.9 years and mean follow-up was 4.7 years. Urgency (56.0%), urgency incontinence (56.0%), urinary retention (8.0%), nocturnal enuresis (70.0%), urinary tract infections (62.0%), constipation (62.0%), and fecal incontinence (16.0%) were the most prevalent symptoms and comorbidities. Ultrasound examinations showed alterations in 53.0% of the cases; the urodynamic study showed alterations in 94.7%. At the last follow-up, 32.0% of patients persisted with urinary incontinence. When assessing the diagnostic methods, 85% concordance was observed between the predictive diagnosis of overactive bladder attained through medical history plus non-invasive exams and the diagnosis of detrusor overactivity achieved through the invasive urodynamic study.

CONCLUSIONS

This subgroup of patients with clinical characteristics of an overactive bladder, with no history of urinary tract infection, and normal urinary tract ultrasound and uroflowmetry, could start treatment without invasive studies even at a tertiary center. Approximately one-third of the patients treated at the tertiary level remained refractory to treatment.

Angiotensin II centrally induces frequent detrusor contractility of the bladder by acting on brain angiotensin II type 1 receptors in rats

Angiotensin (Ang) II plays an important role in the brain as a neurotransmitter and is involved in psychological stress reactions, for example through activation of the sympatho-adrenomedullary system. We investigated the effects of centrally administered Ang II on the micturition reflex, which is potentially affected by the sympatho-adrenomedullary system, and brain Ang II receptors in urethane-anesthetized (1.0 g/kg, intraperitoneally) male rats. Central administration of Ang II (0.01, 0.02, and 0.07 nmol per rat, intracerebroventricularly, icv) but not vehicle rapidly and dose-dependently decreased the urinary bladder intercontraction interval, without altering the bladder detrusor pressure. Central administration of antagonists of Ang II type 1 but not type 2 receptors inhibited the Ang II-induced shortening of intercontraction intervals. Administration of the highest dose of Ang II (0.07 nmol per rat, icv) but not lower doses (0.01 and 0.02 nmol per rat, icv) elevated the plasma concentration of adrenaline. Bilateral adrenalectomy reduced Ang II-induced elevation in adrenaline, but had no effect on the Ang II-induced shortening of the intercontraction interval. These data suggest that central administration of Ang II increases urinary frequency by acting on brain Ang II type 1 receptors, independent of activation of the sympatho-adrenomedullary system.

Chronic social defeat, but not restraint stress, alters bladder function in mice

BACKGROUND

Voiding disorders in humans, particularly in children are associated with increased incidence of behavioral issues as well as past history of childhood abuse. We hypothesized that creating stress in mice, utilizing either a chronic social defeat model (SD) or restraint stress in shallow water model (RSSW) would engender changes in bladder function, morphology, and behavior, thereby enabling us to study the resultant voiding dysfunction.

METHODS

For SD stress (14 days), C57BL/6 male mice were exposed daily to a larger aggressive CD-1 male for 10 min, followed by sensory exposure in a barrier cage for 24h. Control mice were similarly housed with no exposure. For RSSW (21 days), C57BL/6 mice were put in a perforated conical tube with feet immersed in water daily for 4h, then returned to single housing cages. Control mice were also in single housing. After the stress period, voiding patterns were obtained on filter paper, followed by behavioral tests. At necropsy, blood was taken for corticosterone analysis, and bladder and body weights measured. Bladder cryosections were stained with hematoxylin and eosin (H&E) for morphological assessment. Sequential sections were immunostained with antibodies to Ki-67 as a proliferation marker, CD31 (endothelial cell marker), and uroplakin-II. ImageJ software was used to measure bladder wall thickness on blinded H&E photomicrographs as well as quantitate CD31 staining. Both Ki-67-positive and -negative nuclei were counted with Imaris software to obtain a proliferation index.

RESULTS

Only SD mice had a single large void pattern. Bladder-to-body weight ratios increased in SD mice (p≤0.02) but not in RSSW mice. Plasma corticosterone levels were elevated in all stressed mice. SD mice exhibited lower levels of locomotor activity compared with controls; RSSW mice were hyperactive. In SD mice, bladder wall thickness was increased (p ≤ 0.003) but no change was seen in Ki-67 proliferation index, consistent with hypertrophy. No difference with control mice was seen in vascularity as visualized by CD31 staining. Uniform uroplakin-II staining lined the urothelium of both SD and control mice.

CONCLUSIONS

Mice exposed to repeated SD (14 days) respond with altered voiding indicative of urine retention, and exhibit bladder wall changes consistent with hypertrophy while the urothelial barrier is maintained. These changes were not observed with repeated RSSW. SD, in contrast to RSSW, provides a model of psychological stress to further study the interplay of behavior and bladder dysfunction, enabling an improved understanding of voiding dysfunction, and the ability to create innovative and more effective management pathways for children who present with voiding dysfunction.

Voiding dysfunction related to adverse childhood experiences and neuropsychiatric disorders

OBJECTIVE

Research has demonstrated the effect of adverse childhood experiences (ACEs) on later physiologic function and illness development. In the urologic literature, the relationship between bladder dysfunction and neuropsychiatric disorders is well documented. Observations in pediatric urology clinical practice suggest that a blend of these two areas of research can inform care of patients with voiding dysfunction.

METHODS

Retrospective review of 216 patients seen in a single pediatric urology clinic by a single provider over a 24-month period. A descriptive, correlational study design was used to assess the extent to which ACEs and neuropsychiatric disorders affected resolution of symptoms when patients were treated with a bowel and bladder retraining program. Patients were selected using diagnostic codes related to voiding dysfunction and a retrospective chart review was conducted.

RESULTS

A majority of patients who were seen for voiding dysfunction (60%) had at least one psychosocial factor. There is a greater prevalence of ACEs (51%) than neuropsychiatric disorders (25%). Children with either ACEs or neuropsychiatric disorders dropped out of treatment at a higher rate than those with neither. When factors were looked at separately, neuropsychiatric disorders were more likely to impede treatment progress than ACEs.

CONCLUSIONS

ACEs and neuropsychiatric disorders affect patients' ability to make progress with bowel and bladder retraining and to stay in treatment. Efforts specifically aimed at maintaining therapeutic relationships with patients who have ACEs are needed to fully treat this group, which typically has a high drop-out rate but high rate of resolution if they are able to stay involved in treatment.