Phantom urinary incontinence in children with bladder-bowel dysfunction

Comorbidity of Obsessive-Compulsive Symptomatology and Bowel and Bladder Dysfunction in a Tertiary Children's Hospital: A Case Series

OBJECTIVE

To improve understanding of co-occurring obsessive-compulsive disorder (OCD) and bowel and bladder dysfunction (BBD) in an outpatient pediatric urology clinic setting. To provide a series of clinical care recommendations to enhance the identification and integrated medical and behavioral health treatment of these disorders.

METHODS

Authors participated in a series of discussions to define the patient population and specific aims for the study. Efforts were made to select index patients of diverse background despite limited sample availability. Three patients were ultimately selected for the study.

RESULTS

The case studies highlight the connection between urinary issues and underlying OCD symptoms. All patients were initially seen for medical treatment of urological symptoms, then referred for psychological evaluation, and were diagnosed with and received treatment for OCD. Similarities among the cases, including experience of phantom urinary incontinence, stressors present that contributed to symptoms, and obsessive fears of incontinence that led to compulsive behavior, were discussed. Differences between the cases, including patient age, sex, and compulsive behavior demonstrated (ie, urinary frequency, excessive wiping) were also reviewed.

CONCLUSION

Access to a behavioral health provider can enhance the identification of comorbid psychological disorders and can reduce duration of symptoms through appropriate psychological treatment. Authors provide recommendations for screening measures and reinforce importance of including basic education on psychiatric diagnoses and impact on urological symptoms in urology and pediatric fellowship training programs. Future research exploring prevalence of comorbid psychiatric conditions and efficacy of treatment interventions in a pediatric urology population would be beneficial.

Bowel and Bladder Dysfunction Is Associated with Psychiatric Comorbidities and Functional Impairment in Pediatric Obsessive-Compulsive Disorder

Objective: Neuropsychiatric disorders are common in children with bowel and bladder dysfunction (BBD), a syndrome associated with urinary frequency, urgency, holding, incontinence, and constipation. We evaluated BBD symptom severity in children and youth attending a tertiary care obsessive-compulsive disorder (OCD) clinic. Methods: Consecutive patients attending initial OCD assessments between 2016 and 2020 were invited to participate in a registry study. Diagnosis of OCD and comorbidities was established by structured clinical interview. OCD severity and impact were assessed with the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) and the Child Obsessive Compulsive Impact Scale (COIS-R; self-report), respectively. BBD symptoms were quantified with the Vancouver Symptom Score (VSS), a validated self-report measure. Results: One hundred twelve participants completed the VSS (mean age 13.5 ± 3.3, range 7-20). Based on a cutoff score of 11 corresponding to pediatric urologist-diagnosed BBD, 30.4% of participants screened positive, including more females than males (39.3% vs. 21.4%; p = 0.04). Daytime urinary incontinence was present in a greater proportion of participants with OCD forbidden thoughts (34.8% vs. 8.2%, p = 0.002), major depressive disorder (MDD; 38.5% vs. 6.8%, p = 0.001), and somatization disorder (60% vs. 9%, p = 0.001) compared with those without. A regression model including CY-BOCS, COIS-R, psychiatric comorbidities, medications, age, and gender explained 52.2% of the variance in VSS; COIS-R, tic disorder, and MDD were significant predictors. Conclusion: BBD symptoms are common and associated with high OCD-related impairment and psychiatric comorbidities. Standardized assessment may facilitate identification of BBD symptoms in this population and is critical to mitigating long-term physical and mental health impacts. Further studies are required to assess the relationship between BBD and OCD treatment outcomes.

Obsessive-Compulsive Disorders and Functional Urinary Disorders: A Fortuitous Association?

Although psychological factors are known to affect bladder and bowel control, the occurrence of functional urinary disorders in patients with psychiatric disorders has not been well-studied or described. A higher prevalence of functional lower urinary tract disorders have also been reported amongst patients with obsessive-compulsive (OC) disorders. A systematic literature search of PubMed, EMBASE, OVID Medline, PsycINFO, Clinical Trials Register of the Cochrane Collaboration Depression, Anxiety and Neurosis Group (CCDANTR), Clinicaltrials.gov and Google Scholar databases found five observational studies on the topic. Unfortunately, as only one study had a (healthy) control group, a meta-analytic approach was not possible. Overall, patients with OC symptoms appeared to have increased occurrence of functional urinary symptoms, e.g., overactive bladder, increase in urgency, frequency, incontinence and enuresis. This was even more common amongst patients with Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) or Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) as opposed to patients with OCD alone. Several biological and behavioural mechanisms and treatment approaches were discussed. However, as the current evidence base was significantly limited and had moderate to serious risk of bias, no strong inferences could be drawn. Further well-designed cohort studies are necessary to better elucidate the observed associations and their management.

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.

Prospective evaluation of the management of bowel dysfunction in children with neuropathic lower urinary tract dysfunction and its effect on bladder dynamics

INTRODUCTION AND AIM

Children with neuropathic lower urinary tract dysfunction usually suffer from associated bowel dysfunction, urinary tract infection and vesicoureteral reflux. This work aimed to highlight the impact of bowel management on bladder dynamics.

PATIENTS AND METHODS

In the period from January 2011 to January 2013, 30 patients, 21 girls and 9 boys with neuropathic lower urinary tract dysfunction were studied. All suffered from urinary tract and bowel dysfunctions. All children were on urological treatment. They had their bowel managed by assurance and psychological support, dietary modification, retrograde or antegrade enemas and maintenance therapy. They were evaluated initially and on follow up by history, physical examination, ultrasound, urodynamics, Wexener score and bowel control chart.

RESULTS

Mean age was 8.3 ± 3.47 years (range from 4 to 18). There was a significant decrease in bowel dysfunction (Wexener score decreased from 12.67 ± 1.54 to 10.17 ± 1.76, p = 0.00), rectal diameter (decreased from 34.83 ± 5.91 to 27.90 ± 5.32 mm, p = 0.00), and frequency of UTI (p = 0.00). Detrusor leak point pressure decreased from 37.33 ± 24.95 to 30 ± 17.35 cmH2O, (p = 0.42). The cystometric capacity increased from 136.63 ± 45.69 to 155.17 ± 39.29 ml. (p = 0.001). Reflux and kidney function improved but was not statistically significant (p = 0.25 and p = 0.066 respectively).

CONCLUSION

Management of bowel dysfunction is of utmost importance in the treatment of children with neuropathic bladder dysfunction. It has a positive effect on lower urinary tract function and decreasing the incidence of complications. This is a LEVEL III prospective study.