Voiding dysfunction in children

The effect of biofeedback treatment for children with non-neurogenic voiding dysfunction: A systematic review and meta-analysis

BACKGROUND

Children's non-neurogenic voiding dysfunction (NVD) is a syndrome characterized by lower urinary tract symptoms (LUTs) because of the inability to relax the external sphincter. Patients with NVD always suffer from urinary tract infections (UTI), incontinence, constipation. The aim of this study is to assess the efficacy of biofeedback treatment for children's NVD.

METHODS

PubMed, Embase, Cochrane library database were searched for all relevant studies. Two independent reviewers decided whether to include the study, conducted quality evaluation, and extracted article data. A random-effects model was used to calculate overall effect sizes. Risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI) served as the summary statistics for meta-analysis. And sensitivity analysis was subsequently performed.

RESULTS

Fifteen studies and 1274 patients were included in the systemic review, seven RCTs and 539 patients were included in meta-analysis. Meta-analysis showed efficacy of biofeedback treatment in following aspects, (1) relieving UTI (RR: 1.71, 95% CI: 1.11 to 2.64), (2) reducing PVR (MD: 9.51, 95% CI: 2.03 to 16.98), (3) increasing maximum urine flow rate (MD: 4.28, 95% CI: 2.14 to 6.42) and average urine flow rate (MD: 1.49, 95% CI: 0.53 to 2.46), (4) relieving constipation (RR: 1.59, 95% CI: 1.12 to 2.26)，(5) improving abnormal voiding pattern (RR: 1.75, 95% CI: 1.30 to 2.36) and abnormal EMG during voiding (RR: 1.55, 95% CI: 1.25 to 1.91). The improvement of UTI symptoms, maximum urine flow rate and average urine flow rate took a longer time (12 months). In terms of daytime incontinence (RR: 1.20, 95% CI [0.96, 1.50], p = 0.11), nighttime incontinence (RR: 1.20, 95% CI [0.62, 2.32], p = 0.58), no significant difference was found between biofeedback treatment and standard urotherapy. The qualitative analysis showed that biofeedback treatment was beneficial for NVD.

CONCLUSION

Compared with standard urotherapy, biofeedback treatment is effective for some symptoms, such as UTI and constipation, and can improve some uroflowmetric parameters, such as PVR. Biofeedback treatment seems to have a better long-term effect.

Asian guidelines for urinary tract infection in children

The followings are the level of evidence (LE) and grade of recommendation (GR) on pediatric UTI in Asia. Classification according to the sites of infection (lower versus upper tract), the number of episode (first versus recurrent), the severity (simple versus severe), or the existence of complicating factor (uncomplicated versus complicated) is useful to differentiate children with UTI whether they are at risk of renal damage or not (LE: 2, GR: B). Diagnosis of UTI requires both urinalysis that suggests infection and positive urine culture (LE:3, GR B). For pre-toilet trained children, urine specimen for culture should be collected by urethral catheterization or suprapubic aspiration. For toilet trained children, midstream clean catch urine is reliable (LE: 3, GR: A). Urine culture is considered positive if it demonstrates growth of a single bacterium with the following colony counts: (1) any growth by suprapubic aspiration, (2) >5 × 104 CFU/ml by urethral catheterization, or (3) >105 CFU/ml by midstream clean catch (LE:3, GR: B). For children with febrile UTI, renal and bladder ultrasonography (RBUS) should be routinely performed as soon as possible (LE: 3, GR: C). RBUS should be followed up 6 months later in children with acute pyelonephritis and/or VUR (LE: 3, GR: C). Acute DMSA scan can be performed when severe acute pyelonephritis or congenital hypodysplasia is noted on RBUS or when the diagnosis of UTI is in doubt by the clinical presentation (LE: 3, GR: C). Late DMSA scan (>6 months after the febrile UTI) can be performed in children with severe acute pyelonephritis, high-grade VUR, recurrent febrile UTIs, or abnormal renal parenchyma on the follow-up RBUS (LE: 3, GR: C). Top-down or bottom-up approach for febrile UTI is suggested for the diagnosis of VUR. For top-down approach, VCUG should not be performed routinely for children after the first febrile UTI. VCUG is indicated when abnormalities are apparent on either RBUS or DMSA scan or both (LE: 2, GR: B). VCUG is also suggested after a repeat febrile UTI (LE:2, GR: B). Appropriate antibiotic should be given immediately after urine specimen for culture has been obtained (LE:2, GR: A). Initiating therapy with oral or parenteral antibiotics is equally efficacious for children (>3 months) with uncomplicated UTI (LE: 2: GR: A). The choice of empirical antibiotic agents is guided by the expected pathogen and the local resistance patterns (LE: 2, GR: A). For children with febrile UTI, the total course of antibiotic therapy should be 7-14 days (LE: 2, GR: B). Circumcision may, but not definitively, reduce the risk of febrile UTI in males and breakthrough febrile UTI in males with VUR. Circumcision should be offered to uncircumcised boys with febrile UTI and VUR in countries where circumcision is accepted by the general population (LE: 3, GR: B), while in countries where childhood circumcision is rarely performed, other measures for febrile UTI/VUR should be the preferred choice (LE: 4, GR: C). Bladder bowel dysfunction (BBD) is one of the key factors of progression of renal scarring (LE: 2). Early recognition and management of BBD are important in prevention of UTI recurrence (LE:2, GR: A). Antibiotic prophylaxis to prevent recurrent febrile UTI is indicated in children with moderate to high grade (III-V) VUR (LE: 1b, GR: A). Surgical intervention may be used to treat VUR in the setting of recurrent febrile UTI because it has been shown to decrease the incidence of recurrent pyelonephritis (LE: 2, GR: B).

Prevalence of Bladder and Bowel Dysfunction in the Outpatient Clinic of Pediatric Urology and Nephrology

Objective Bladder and bowel dysfunction (BBD) is defined as the presence of functional alterations in both organs. The correct diagnosis and treatment prevent the exposure of patients to multiple antibiotic treatments, invasive procedures and radiological studies. The aim of the present study was to estimate the prevalence of BBD in the outpatient clinic of pediatric urology and nephrology.

Methods A prospective cohort composed of 334 patients aged between 5 and 18 years was evaluated. The Pediatric Lower Urinary Tract Symptom Score (PLUTSS) was applied. A score higher than 8 was considered as significant urinary symptomatology. Moreover, the Bristol Stool Scale and the Rome IV Criteria for functional constipation and fecal incontinence were used. Patients with organic pathologies were excluded. The risk factors were evaluated using logistic regression models.

Results The median age was 9 years old (interquartile range [IQR]: 6–13). The PLUTSS questionnaire was significant in 16.5% of the kids, constipation was found in 31.9%, and fecal incontinence, in 4%. The prevalence of BBD was of 27.8%. The female gender (odds ratio [OR]: 2.47; p = 0.002) and psychological disorders (OR: 4.637; p = 0.024) were considered risk factors. The evaluation of the PLUTSS questionnaire showed relevance regarding incontinence (OR: 3.059; p = 0.038), enuresis (OR: 8.532; p < 0.001); intermittent flow (OR: 9.211; p = 0.004), frequency (OR: 6.73; p = 0.005), and constipation (OR: 34.46; p < 0.001).

Conclusions The prevalence of BBD is of 27.8% in the outpatient clinic. It is important to prevent associated complications and the exposure to multiple antibiotic treatments, as well as invasive and imaging procedures, which also generate high costs to the health system.

Relationship of Urinary Tract Infection to Lower Urinary Tract Dysfunction and Kidney Scar Formation in Children

Background:

Urinary tract infection (UTI) is the most common infection during childhood. Lower urinary tract dysfunction (LUTD) is a broad term that indicates an abnormal voiding pattern in a child without anatomical and neurological impairment. The purpose of this study was to determine the relationship between UTI and LUTD.

Methods:

This study was conducted at the Children Medical Center Hospital in 2014–2016. The inclusion criteria of this study were at least one UTI confirmed by a positive urine culture and active urine analysis in children who were well toilet-trained previously. Complete physical examination of the genitourinary and skeletal systems was performed to identify patients with anomalies in these systems. The patients with genitourinary system anomalies and obvious and prediagnosed neurological defects of the urinary system such as neurogenic bladder were excluded from the study. To confirm the presence of LUTD, the scoring system of Akbal et al. was applied.

Results:

A total of 260 patients including 9.2% of males and 90.8% of females were included in this study. The prevalence of LUTD was 63.8% (166 cases) in these patients. In this study, the prevalence of LUTD in patients with a single episode of UTI was 50.5%, while in patients with recurrence of UTI it was 88.9%. In patients with unilateral kidney scar formation, 90.9% had a recurrence of UTI (P = 0.003) which shows a strong correlation of unilateral scar formation with recurrence of UTI.

Conclusions:

These data suggest that there is a significant relationship between UTI and LUTD in children, so evaluation of voiding dysfunction is necessary in this group. With early diagnosis and appropriate treatment, we can reduce the possible serious and permanent sequels of LUTD in patients with UTIs.

Urogenital tract disorders in children suspected of being sexually abused

INTRODUCTION

Child sexual abuse (CSA) is generally defined as child exploitation that leads to achievement of sexual satisfaction. According to data from European countries, sexual abuse of children affects 10-40% of girls and 5-20% of boys.

MATERIAL AND METHODS

The Medline, and Web of Science databases were searched with no date limitation on May 2015 using the terms 'child abuse' in conjunction with 'urinary tract', 'urologist', 'urological dysfunction', 'urologic symptoms', 'LUTS' or 'urinary infection'.

RESULTS

Awareness of the CSA problem among paediatricians and urologists is very important, because they are often the only physicians who are able to recognize the problem. CSA diagnosis is possible only through the proper collection of a medical history and a thorough physical examination. Urologists have to remember that children exposed to sexual abuse rarely exhibit abnormal genital findings. In fact, absence of genital findings is the rule rather than the exception. In most cases, the final diagnosis of sexual abuse is based on the child's history and behavior, along with the onset and exacerbation of urologic symptoms.

CONCLUSIONS

In this article, we present a review of studies and literature concerning urinary symptoms in sexually abused children to clarify the problem for a broad group of urologists. We present common symptoms and premises that can point to the right diagnosis and basic guidelines of proceeding after suspicion of abuse.

Generalized joint hypermobility and voiding dysfunction in children: is there any relationship?

Voiding dysfunction is a common entity in pediatric urology. It is believed to have a multifactorial etiology. The aim of this study was to investigate whether there is an increased prevalence of generalized joint hypermobility (GJH) in children with voiding dysfunction compared to normal children. Moreover, the prevalence of voiding complaints in patients with and without GJH was assessed. A total of 226 children--aged 5 to 14 years--including 113 patients diagnosed with voiding dysfunction and 113 sex/age/body mass index-matched normal children were recruited. GJH was evaluated in both groups using the Beighton score (4 or more= hypermobile). In the patient’s group, GJH was significantly more frequent than in controls: 51/113 (45 %) versus 19/113 (17 %) (P=0.001). In addition, in both groups, GJH was more prominent in girls than boys (P<0.05). Urinary tract infection was the most frequent features in children with voiding dysfunction (64 %). In the subgroup of positive GJH, urinary tract infection remained the most common manifestation among the girls (P=0.003), while constipation was the most prevalent manifestation among the boys (P=0.001).

CONCLUSION

Our findings suggest that children with voiding dysfunction have significantly higher prevalence of GJH compared to normal children. Further studies are needed to determine the cause and effect of these two common presentations and will help to develop a multidisciplinary approach in understanding and management of voiding dysfunction in children.

Long-term prospective evaluation of an inpatient voiding reeducation program for lower urinary tract conditions in children

PURPOSE

Our aim was to evaluate the efficacy of our treatment program for children with lower urinary tract conditions, developed at the Department of Pediatric Nephrology of the University Children's Hospital in Ljubljana.

METHODS

Sixty-four patients with lower urinary tract conditions were randomly allocated to two groups. Group A received treatment immediately, whereas patients of group B received no treatment for a period of 3 months-the amount of time it takes to complete our program. No child in group B experienced spontaneous regression of their symptoms in the 3-month delay period, while the patients of group A were already being treated and were achieving results. Thus, all the patients of group B then entered the program in exactly the same way as patients of group A.

RESULTS

The final success rate in both groups did not differ significantly (p = 0.706-1.000) and ranged from 86.2 % for group A and 86.7 to 90 % for group B. Long-term follow-up showed statistically identical success rates (p = 1.000).

CONCLUSION

This prospective controlled study with long-term follow-up (48 months) shows that our treatment program, applied as an inpatient voiding school program, is an effective method, with durable results.

Loss of dicer exacerbates cyclophosphamide-induced bladder overactivity by enhancing purinergic signaling

microRNAs (miRNAs) have regulated the expression and function of genes implicated in many pathological settings, but their impact on the pathoetiological characteristics of overactive bladder (OAB) largely remains unknown. We have generated a mouse model in which adult mice can be induced for detrusor deletion of Dicer, an enzyme essential for miRNA processing. Targeted deletion of Dicer did not lead to a significant change for detrusor functionality under physiological conditions; however, loss of Dicer exacerbated cyclophosphamide-induced OAB, manifested by the higher severity of altered detrusor contractile force and sensitivity, abnormal urodynamics, and enhanced macrophage infiltration. Mechanistic studies revealed that loss of Dicer may impair the expression of miRNAs that are capable of targeting P2x mRNAs. As a result, mice deficient in Dicer manifest enhanced P2X expression in the detrusor on cyclophosphamide treatment, predisposing to the increased risk for OAB development. More important, studies using bladder biopsy samples of patients with OAB also demonstrated similar results as those found in animals. Taken together, our results suggest that miRNAs modulate OAB susceptibility by regulating purinergic signaling, in which the pathogenic insult induces the expression of miRNAs capable of targeting P2X mRNAs to suppress OAB symptoms.

Management of daytime urinary incontinence and lower urinary tract symptoms in children

Lower urinary tract symptoms, particularly urgency, frequency and incontinence are common in school-aged children but are often overlooked. They may cause considerable physical, social and psychological difficulties to children and their families, and usually are manifestations of underlying non-neurogenic voiding disorders. The differential diagnoses include overactive bladder syndrome, dysfunctional voiding and vaginal reflux as well as less common conditions like giggle incontinence, voiding postponement, pollakiuria and diabetes insipidus. In this paper, we discuss an evidence-based approach to the management of conditions causing daytime urinary incontinence and lower urinary tract symptoms in children from a general paediatrician's perspective.

Loss-of-function mutations in HPSE2 cause the autosomal recessive urofacial syndrome

Previously, we localized the defective gene for the urofacial syndrome (UFS) to a region on chromosome 10q24 by homozygosity mapping. We now report evidence that Heparanse 2 (HPSE2) is the culprit gene for the syndrome. Mutations with a loss of function in the Heparanase 2 (HPSE2) gene were identified in all UFS patients originating from Colombia, the United States, and France. HPSE2 encodes a 592 aa protein that contains a domain showing sequence homology to the glycosyl hydrolase motif in the heparanase (HPSE) gene, but its exact biological function has not yet been characterized. Complete loss of HPSE2 function in UFS patients suggests that HPSE2 may be important for the synergic action of muscles implicated in facial expression and urine voiding.

School Nurse Interventions in Managing Functional Urinary Incontinence in School-Age Children

Uncomplicated urinary incontinence (UI) in school-age children is a prevalent yet underrecognized problem that has remained in the shadow of other concerns commonly perceived as more prominent or urgent. There is good evidence that functional UI in children can be treated and managed effectively. When there is no structural or neurologic abnormality and the underlying cause of the UI is related to either the storage or voiding phase of the bladder cycle then it is considered functional. School nurses are in an ideal position to identify, manage, and help children with functional UI cope effectively while maintaining healthy psychosocial well-being and educational success.

Dysfunctional elimination behaviors and associated complications in school-age children

Lack of privacy, risk of bullying, limited access, lack of essential products for good hygiene, and dirty bathrooms can all contribute to encouraging a child to withhold urine and stool while in school. Withholding behaviors over time can create a condition known as dysfunctional elimination syndrome (DES). DES is any pattern of voiding or stooling that varies from the developmental norm. These abnormal patterns of elimination can eventually lead to complications of urinary tract infection, vesicoureteral reflux, and incontinence of urine and/or stool. School officials (teachers, school nurses, and school administrators) can help in the prevention of learned behaviors that lead to DES in school-age children. School officials need to realize children are individuals and should not be expected to empty their bowels and bladders according to a set, rigid schedule. In addition, school officials should not expect children to use dirty, unsafe bathrooms that they themselves would not tolerate. School nurses can be a powerful force in protecting children's health by participating in research and developing evidence-based guidelines to improve bathroom access and conditions.

Primary school children: access to toilets

AIM

Most children are continent of urine by the time they are in primary school. Balanced micturition and paradoxically dysfunctional voiding (DV) are acquired behaviour. Children need easy access to toilets at school, to comply with timed voiding which is part of the treatment for DV. This study investigated children's access to primary school toilets in Auckland.

METHODS

A questionnaire was sent to 97 primary schools listed on the New Zealand ministry of education (MoE) website for the Auckland region. Information regarding the school decile rating, population, rota, toilet facilities and toilet policy was requested. Six randomly selected schools were visited to verify the facilities available there.

RESULTS

Eighty-four percent of the schools in our sample complied with the prescribed statutory minimum for both boys and girls toilets. There was a median ratio of 11 children per facility. The median duration to use a facility during the first recess was 2 min.

CONCLUSION

In general, the toilet facilities and utilization ratios in primary schools in the Auckland region appear to provide a healthy environment for urination. Schools must be encouraged to draft and adhere to a toilet policy to ensure a uniform toilet environment.

Quantifying demographic, urological and behavioral characteristics of children with lower urinary tract symptoms

OBJECTIVE

This project examines the voiding and behavioral characteristics of children referred to a specialty voiding clinic, including the impact of incontinence on the child and family.

PATIENTS AND METHODS

A total of 351 new patients (aged 5-17 years) referred to our specialty voiding clinic completed background information, including demographics and medical history, a standardized voiding questionnaire, school history, and questions about child and family quality of life, prior to their first appointment.

RESULTS

Patients are primarily female (53%) and Caucasian (70%) with a mean age of 9.5 years (range 5-17; SD=3.5). Of the patients, 25% were diagnosed with a mental or behavioral health problem. Mean urological symptom score was 12 (range 0-29). Higher symptom scores are associated with younger age, ethnic minority status, a mental health diagnosis, being on psychotropic medications, and a poor child and family quality of life. Families of children who are wet day and night reported a poorer quality of life as compared to the families of children who were daytime wetters or bedwetters only.

CONCLUSION

Symptom scores are associated with type of incontinence, social and quality of life variables. Collecting this baseline data will enable ongoing monitoring of progress for these complex patients.

Surgical management of the tethered spinal cord--walking the fine line

The tethered spinal cord is a fascinating yet controversial condition seen frequently in neurosurgical practice. Treatment decision making is made difficult by the variety of lesions and clinical presentations comprised by this condition and the absence of high-quality clinical outcome data to provide guidance. Clinical presentations may be divided into four general categories or typical scenarios: 1) significant dysraphic abnormality, clear clinical deterioration; 2) significant dysraphic abnormality, normal examination results or stable deficit; 3) incidentally discovered abnormality, other problem; and 4) tethered spinal cord symptomatology, normal imaging. The author provides case examples to illustrate potential treatment approaches and suggests balancing the risks and benefits for each general category. Clearer diagnostic and treatment strategies for the tethered spinal cord will only result from high-quality clinical and basic research. Until the results of such research are available, surgeons should endeavor to maximize benefit and reduce risk for patients who may have a tethered spinal cord, walking the fine line between over- and undertreatment.

Initial Trial of Timed Voiding Is Warranted for All Children with Daytime Incontinence

OBJECTIVES

To analyze the relationship between potential prognostic factors and early success after treatment of childhood daytime urinary incontinence without anticholinergic medication.

METHODS

A total of 63 patients with daytime urinary incontinence met the inclusion criteria for a retrospective review of the effect of a timed voiding regimen. The severity, duration, and frequency of wetting, along with age, sex, and uroflow parameters, were recorded. Statistical analysis was used to determine the factors predictive of improvement in wetting without anticholinergic treatment.

RESULTS

Of 315 children evaluated with daytime incontinence, only 24% were treated with nonanticholinergic methods. At the first follow-up visit, 6.3% of patients treated without anticholinergics became dry, 38.1% showed significant improvement, 36.5% were slightly improved, and 19.0% were unchanged. Age, sex, duration or severity of wetting, constipation, bladder capacity, and uroflow pattern and parameters were not predictive of early improvement with timed voiding. Patients with good compliance with timed voiding were significantly more likely to improve than those with poor compliance (P = 0.014).

CONCLUSIONS

The results of our study have indicated that anticholinergic therapy appears to be overused as a first-line treatment for children with daytime urinary incontinence in our clinic population. The lack of reliable predictive factors regarding the response to nonanticholinergic treatment suggests a trial of timed voiding should be used as an initial treatment for all children with daytime urinary incontinence. Almost 45% of our patients had significant improvement in the frequency of wetting within 4 months without anticholinergics.

Evaluation of Constipation by Abdominal Radiographs Correlated with Treatment Outcome in Children with Dysfunctional Elimination

OBJECTIVES

To analyze the utility of assessing degree of constipation by abdominal radiograph (KUB) in relation to symptoms and urodynamic data in children with dysfunctional elimination.

METHODS

A retrospective review of children with concomitant constipation and daytime incontinence was performed. Inclusion required at least two consecutive visits with KUB and noninvasive uroflowmetry. Patients were excluded for anticholinergic medication use or neurogenic or anatomic abnormalities. Rectal fecal quantification and presence of stool throughout the colon was assessed on KUB and categorized as "empty," "normal amount of stool," or "fecal distention of rectum (FDR)."

RESULTS

Twenty-six patients met inclusion requirements (6 boys, 20 girls; average age, 7.7 +/- 2.2 years). The average time between the initial and subsequent visit was 12.5 +/- 7.8 weeks. Initial KUB revealed FDR in 17. No statistical significance was found between FDR on initial or final KUB and outcome of wetting symptoms, nor could a relationship between FDR uroflow parameters at either visit be demonstrated.

CONCLUSIONS

No correlation between any uroflowmetry parameter and the presence of FDR at the initial or final visits could be demonstrated. Similarly, no statistical significance between FDR on final or initial KUB and outcome of wetting symptoms was established.

(Poly)acrylonitrile-based hydrogel as a therapeutic bulking agent in urology

Vesicoureteral reflux and urinary incontinence can be treated by endoscopic injection. Injectables such as collagen and hyaluronic acid-dextranomer are commonly used, however are not offering optimal therapeutic effect yet. In the present study a novel application for poly(acrylonitrile)-based hydrogel (Hypan), already tested in other clinical indications, has been investigated for its aptitude as an injectable bulking agent. This non-degradable, extremely hydrophilic hydrogel has the capacity of a 6-fold swelling once implanted into the body, assuring the bulking effect. Deposits of this bulking agent have been implanted into the submucosal space of the bladder of 6 minipigs and the histological reaction, as well as the physical implant behavior have been studied over a time period of 6 months. The implants have developed the desired bulking effect by the above-described hydrophilic swelling. They have been enclosed into a fine fibrous tissue capsule and provoked a very limited inflammatory reaction. This study has showed that poly(acrylonitrile)-based hydrogel implants injected into the bladder are well tolerated and, due to their defined bulking ability, feasible for the treatment of vesico-ureteral reflux and urinary incontinence. To determine the therapeutic efficiency of this treatment the implants will be studied in a vesicoureteral reflux and urinary incontinence animal model.

Occult tethered cord syndrome: not an indication for surgery

OBJECT

The author describes the paucity of information known about occult tethered cord syndrome and summarizes the argument for using a nonsurgical approach in these cases.

METHODS

A review of what we do and do not know about this syndrome is provided. Surgical procedures to divide the terminal filum in patients with symptoms of tethered spinal cord without the imaging correlates are said to result in clinical improvement, yet there is little physiological evidence to support the surgical release of the filum in the absence of other anatomical lesions. Validated diagnostic and outcome measures are also lacking, which makes the interpretation of reported results exceedingly difficult. Finally, reports used to support surgical intervention are limited by small size, the absence of control groups, and observer bias.

CONCLUSIONS

Without conclusive clinical evidence, the arguments supporting surgery for occult tethered cord syndrome must be viewed cautiously.

Diagnosis and management of dysfunctional voiding

PURPOSE OF REVIEW

This review will focus on the diagnosis and management of voiding dysfunction in neurologically and anatomically normal children. The discussion will highlight recent developments and research in the clinical approach as well as the etiology and classification of these disorders.

RECENT FINDINGS

Voiding dysfunction in children encompasses a wide spectrum of clinical entities, recently classified collectively as dysfunctional elimination syndromes. Voiding dysfunction typically presents after toilet training and may originate from behavioral issues that arise around this time in childhood development. The spectrum of disorders includes urge syndrome, dysfunctional voiding with an uncoordination between the detrusor and urinary sphincter, and enuresis. Clinical symptoms may vary from mild incontinence to severe disorders with endpoints of irreversible bladder dysfunction with vesicoureteral reflux, urinary tract infection and resulting nephropathy. Diagnosis relies heavily on a good history and physical examination, but also includes radiologic and urodynamic evaluation. Treatment generally consists of medical therapy, primarily with anticholinergics as well as behavioral therapy to modify learned voiding patterns that contribute to the voiding dysfunction.

SUMMARY

This overview of voiding dysfunction in children outlines the established approaches to its diagnosis and treatment and highlights the most recent developments in the field.

Teachers' knowledge of normal and abnormal elimination patterns in elementary school children

Dysfunctional elimination may be learned, to some degree. Because children spend nearly half of their waking hours at school, there is the potential for school to have a significant impact on their elimination patterns. Surveys were mailed to 1,000 randomly selected Iowa public elementary school teachers; 467 of the surveys were returned. Findings indicate that most elementary school teachers are unaware of the potential health problems of elimination dysfunction. One third of respondents indicated that they ask children to wait to go to the bathroom. Suboptimal conditions exist in most of the school bathrooms, with only 35% of the boys' restrooms and 48% of the girls' restrooms reported as "always clean." Those teachers with more experience were more likely to report information about abnormal elimination to the school nurse. Very few teachers (18% of respondents) reported having received information about abnormal elimination and even fewer (8% of respondents) were aware of specialists trained to treat children with these problems. School nurses can have a significant impact on the development of healthy bladder habits in children. Teachers need information about normal and abnormal elimination patterns in children.