Behavioural problems in children with urge incontinence and voiding postponement: a comparison of a paediatric and child psychiatric sample

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.

Effectiveness of a Practical, At-Home Regimen of Parasacral Transcutaneous Electrical Nerve Stimulation in Pediatric Overactive Bladder

OBJECTIVE

To describe and evaluate efficacy of a more practical, at-home regimen of parasacral transcutaneous electrical nerve stimulation (TENS) for pediatric overactive bladder (OAB).

METHODS

We prospectively enrolled patients with OAB.

INCLUSION CRITERIA

age 5-13 years and willingness to try TENS.

EXCLUSION CRITERIA

urinary tract anatomic abnormalities, current use of OAB medications, neurologic condition, and elevated post-void residual. Patients were instructed to complete 20-minute sessions 2x/day for one month.

RESULTS

We enrolled 21 patients (3 male, 18 female; median age 9.9 years). We had complete VSS data on 17 patients and frequency-volume chart data on 12 patients. Median % of TENS sessions completed was 98%.

CONCLUSION

In our cohort of medically-refractory OAB pediatric patients, nearly half reported subjective improvement with our regimen, despite modest objective improvement. Our compliance rates suggest this regimen is practical but may be best used as an adjunct to other therapies.

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.

Parasacral transcutaneous electrical nerve stimulation in children with overactive bladder: comparison between sessions administered two and three times weekly

Purpose:

This study compares the results achieved following parasacral TENS administered using two different weekly schedules.

Materials and Methods:

Children of at least four years of age with a diagnosis of pure overactive bladder were included in this randomized clinical trial and treated with parasacral TENS (2 versus 3 sessions per week). All the participants also underwent standard urotherapy.

Results:

Sixteen children were included in the twice-weekly group and eighteen in the three times weekly group. There were no statistically significant differences between the two groups with respect to sex; however, there was a difference in age. There were no significant differences regarding complete resolution of urinary symptoms, with 8 children (50%) in the twice-weekly group and 11 children (61%) in the three times weekly group having their symptoms completely resolved (p=0.73). There was a significant difference in the DVSS score in both groups following TENS treatment compared to baseline (p=0.0001 for both groups), but not between groups. Evaluation of the bladder diary showed no difference between the groups before or after treatment.

Conclusion:

For children with overactive bladder who are unable to undergo parasacral TENS treatment three times weekly, the method can be administered successfully at twice-weekly sessions.

Does small voided volume influence uroflowmetry curve patterns in Japanese children with daytime urinary incontinence?

BACKGROUND

A voided volume (VV) of <50% of the expected bladder capacity for age is considered small VV. It was recommended that a VV ≥50% of expected bladder capacity for age is required to assess uroflowmetry (UFM) curves because a small VV causes changes in UFM curve characteristics. However, no clear consensus has been reached on the criterion for evaluating UFM curve patterns.

OBJECTIVE

The aim of the study was to evaluate the reproducibility and characteristics of UFM curve patterns in children with daytime urinary incontinence (DUI) and with a variety of VVs.

METHODS

This study investigated 119 children (79 boys and 40 girls) with primary DUI who underwent UFM 3 times on the same day and were classified into two groups: small VV (<50% of expected bladder capacity for age) in 0-1 of the 3 UFM measurements (group 1; normal VV) or in 2-3 of the 3 UFM measurements (group 2; small VV). The authors then evaluated the agreement of UFM curve patterns among the 3 measurements, classifying complete, partial, or no agreement according to the number of identical curve patterns. The authors also evaluated the most characteristic patterns of UFM curve patterns for each group.

RESULTS

Group 1 comprised 45 children, and group 2 comprised 74 children. Rates of complete agreement (group 1, 24/45; group 2, 30/74), partial agreement (group 1, 19/45; group 2, 35/74), and no agreement (group 1, 2/45; group 2, 9/74) did not differ significantly between groups (p = 0.226). Bell curve patterns were significantly more common in group 1 than in group 2 (p = 0.025). Frequency of the tower pattern was significantly higher in group 2 than in group 1 (p = 0.006) (Summary table).

DISCUSSION

No differences in agreement rates of UFM curve patterns were seen between two groups (small and normal VV). The authors thus suggest that UFM curve patterns can be validly assessed in children with DUI and with small VV. It was found that the bell pattern was significantly more common among children with normal VV, whereas the tower pattern was significantly more common among children with small VV. The tower pattern reflects an overactive bladder. The present results suggest that some children have DUI that is not attributable to urgency.

CONCLUSION

Reproducibility of UFM curve patterns might be properly assessed even in children with DUI and with small VV. This result suggests the presence of various pathological conditions other than the conditions with urgency underlying DUI.

Behavioral disorders and impairment of quality of life in children and adolescents with lower urinary tract dysfunction

BACKGROUND

Lower urinary tract dysfunction (LUTD) is a broad term describing the full spectrum of disorders in any of the stages of bladder function-storage or voiding LUTD is a clinical condition associated with emotional and behavioral disorders in children. This cross-sectional study aimed to investigate the association of emotional and behavioral symptoms and their impact on the quality of life (QoL) in children and adolescents with LUTD.

METHODS

Eighty-eight patients and their parents enrolled in an interdisciplinary program for children and adolescents with LUTD were included in the analysis. Child Behavior Checklist (CBCL) was used to estimate the prevalence of behavioral and emotional problems through the assessment of 14 items. Pediatric Quality of Life Inventory (versions for parents and children) was applied in the versions for parents and children to evaluate the QoL. The Pediatric Quality of Life Inventory-PedsQL, version 4.0-was applied separately for parents and patients. The association of clinical variables and aspects related to QoL of patients were evaluated through non-parametric correlations (Spearman) and multiple linear regression analysis.

RESULTS

According to CBCL's clinical scores, 56% of the patients showed total behavioral problems, 55% internalizing, and 38% externalizing. When comparing the conditions of LUTD and the CBCL scores, patients with voiding postponement had the lowest rates of total problems (P = 0.036). Children and adolescents with LUTD who also had enuresis showed a higher frequency of externalizing problems (P = 0.001), especially aggressive behavior (P = 0.013). Scores of patients with LUTD were significantly lower in all domains of QoL than normative data. Presence of behavioral problems was associated with worse QoL in all evaluated aspects. The total QoL was most influenced by the CBCL school competence scale according to the regression model analysis.

CONCLUSIONS

The study findings suggest the relevance of evaluation of behavioral and social repercussions of LUTD to improve the multidisciplinary approach for this condition in pediatric population.

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.

Psychological and Physical Environmental Factors in the Development of Incontinence in Adults and Children: A Comprehensive Review

The aim of this review was to identify etiological environmental factors related to incontinence in children and adults. A variety of etiological environmental factors for the development of incontinence were identified. In children, these encompass stressful life events and trauma, family dysfunction, parental psychopathology, school-related stressors, toilet or "potty" training, fluid consumption habits, housing conditions, and the availability of toilets. In adults, physical exercise, obesity, working conditions, fluid intake, and the availability of toilets play a role. Intervening variables such as hormonal variations due to work shifts have also been identified as influencing the likelihood of incontinence. Current research suggests that environmental factors influence the development of incontinence in children and adults. The interactions between biological factors, the immediate environment, and intervening variables need to be explored in greater detail. Practical solutions to reduce barriers to adequate fluid intake and healthy toileting habits should be implemented in school and work settings.

Voiding postponement in children-a systematic review

Voiding postponement (VP) has been defined as a habitual postponement of micturition using holding maneuvers. VP can represent both a symptom, as well as a condition. As divergent definitions are used internationally, the aim was to review the current state of knowledge on VP and provide recommendations for assessment, diagnosis and treatment. A Scopus and a Pubmed search was conducted, entering the terms 'voiding postponement' without any restrictions or specifications. Other publications relevant to the topic were added. VP can represent a symptom in healthy children. As a condition, VP in combination with nocturnal enuresis (NE) is a subtype of non-monosymptomatic NE. Most studies have focused on daytime urinary incontinence (DUI) with VP, or more aptly termed voiding postponement incontinence (VPI). It is a behaviorally defined syndrome, i.e., by the habitual deferral of micturition and DUI. VPI is associated with a low micturition frequency, urgency and behavioral problems. The most common comorbid disorder is oppositional defiant disorder (ODD). VP as a symptom and VPI as a condition should be differentiated. VPI is a common disorder with many associated problems and disorders. Urotherapy and timed voiding are the main treatment approaches. Due to the high rate of comorbid ODD, other forms of treatment, especially cognitive behavioral therapy, are often needed.

Punishment for bedwetting is associated with child depression and reduced quality of life

This study assessed the relationship between parental punishment and depression as well as quality of life in children with primary monosymptomatic nocturnal enuresis (PMNE). A consecutive sample of 65 children (7-13 years) with PMNE and 40 healthy children, selected as controls (Group III), were included in the study. The children with PMNE were further sub-classified into two groups: Group I, which included children who received parental punishment for enuresis and Group II, which comprised children who were not punished for bedwetting. Depression and health-related quality of life (HRQL) were assessed among the three groups. The number of wet nights per week was significantly increased in Group I compared with Group II (P<.001). In addition, the severity of depressive symptoms increased in Group I as compared to the other two groups (P<.001). Similarly, the psychosocial HRQL lower in Group compared to the control group (Group III) (P<.001). Prior parental discipline, including corporal punishment (B=0.55, P=.008), as well as the frequency (B=0.73, P<.001) and duration of punishment (B=0.33, P=.02) were strong predictors of increased depressive symptom severity. It was also found that prior punishment (B=-0.42, P=.01) and the frequency (B=-0.62, P<.001) and duration of punishment (B=-0.34, P=.02) were strong predictors for poor psychosocial HRQL. Overall, parental punishment has a poor outcome in children with PMNE.

Phantom urinary incontinence in children with bladder-bowel dysfunction

OBJECTIVE

To report a previously undescribed condition in which children present with the sensation of wetness because of presumed urinary incontinence when they are actually completely dry. We have termed this entity "phantom" urinary incontinence (PUI).

MATERIALS AND METHODS

Twenty children referred to our pediatric urology clinic were diagnosed with PUI between 2009 and 2013. Patient demographics, associated bladder and bowel symptoms, concomitant diagnoses, imaging, management, and treatment outcomes were evaluated.

RESULTS

Twenty children (18 females and 2 males) were diagnosed with PUI over a 5-year interval. Mean age at diagnosis was 6.9 ± 2.5 years (range, 4-12 years). Nineteen patients (95%) had concomitant lower urinary tract symptoms, and all were also diagnosed with constipation. Urgency (75%) and frequency (50%) were the most common associated bladder symptoms. Of the 18 girls, 13 (72%) had associated vaginitis. Fourteen children (70%) carried a parent-reported diagnosis of obsessive-compulsive disorder or obsessive-compulsive disorder personality traits. Patients were managed with timed voiding, dietary modifications, and a bowel regimen. Ninety percent children experienced improvement of bladder-bowel dysfunction and resolution of PUI at a mean follow-up of 14.4 months.

CONCLUSION

Children with PUI have a high incidence of obsessive-compulsive traits. Phantom incontinence as well as associated lower urinary tract symptoms resolve with adherence to a strict bladder-bowel regimen.

Self-esteem in 6- to 16-year-olds with monosymptomatic nocturnal enuresis

AIM

Childhood nocturnal enuresis (NE) and incontinence has been shown to be associated with increased behavioural problems and reduced self-esteem (SE) in Western populations. The impact on Asian children, however, is not known. This study investigates the relationship between SE and monosymptomatic NE in Malaysian children aged 6 to 16 years.

METHOD

Children with wetting frequency of at least 4 out of 14 nights were recruited with controls matched for age, gender and race. SE scores were obtained using the 'I Think I Am' questionnaire for five domains: body image, talents and skills, psychological well-being, relationship with family and relationship with others.

RESULTS

A total of 126 children were recruited; 22 enuretics aged 6-9 years and their matched controls (Group1) and 41 enuretics aged 10-16 years and their matched controls (Group 2). SE scores were similar between the enuretic and controls in Group 1, whereas in Group 2, enuretics had significantly lower scores (P < 0.05) in 'body image', 'relationship with others' and total SE scores. This difference was more pronounced among girls, adolescents and those who wet more than 10/14 nights.

CONCLUSION

The SE of Malaysian children with monosymptomatic NE aged 10 years and above is significantly lower than their peers. This effect is seen particularly among girls, adolescents and those with frequent wetting. In the light of these findings, the 'wait and see' approach by the Malaysian medical profession is no longer appropriate. Treatment should begin before the age of 10 years.

Prevalence of enuresis and daytime urinary incontinence in children and adolescents with sickle cell disease

PURPOSE

There is a known association between sickle cell disease and enuresis. However, the cause of this association is unclear. We tested the hypothesis that children with sickle cell disease would have more symptoms of overactive bladder than a control group.

MATERIALS AND METHODS

Questionnaires were distributed to 155 legal guardians of children and adolescents 5 to 17 years old with sickle cell disease and to 100 legal guardians of a control group of children.

RESULTS

Individuals with and without sickle cell disease were distributed uniformly regarding gender and age. A total of 50 patients (32.3%) in the sickle cell disease group had enuresis vs 5 (5%) in the control group (p = 0.000). Daytime urinary incontinence was observed in 36 individuals with (23.2%) and 11 (11.0%) without sickle cell disease (p = 0.014). A total of 52 patients with sickle cell disease (33.5%) complained of urgency, compared to 10 controls (10%, p = 0.000). A total of 49 patients with sickle cell disease (31.6%) had frequency, compared to 6 controls (6%, p = 0.000). Of all patients who reported enuresis or daytime incontinence only 1 with enuresis had received specific treatment.

CONCLUSIONS

There is a significant association between sickle cell disease and enuresis and overactive bladder symptoms such as daytime incontinence, urgency and frequency. Thus, all children and adolescents with sickle cell disease should be questioned regarding the presence of these symptoms to facilitate treatment for these conditions.

Current state of nerve stimulation technique for lower urinary tract dysfunction in children

PURPOSE

A variety of electrical nerve stimulation methods has been used through the years to treat lower urinary tract dysfunction. Relevant literature was reviewed to analyze techniques and available biomedical devices, technique applicability, indications and usefulness in pediatrics.

MATERIALS AND METHODS

An extensive search was performed on PubMed® and MEDLINE® for scientific publications on intravesical, transcutaneous, sacral spine and root, and tibial nerve stimulation in children with lower urinary tract dysfunction of nonneurogenic and neurogenic origin. Relevant articles and controlled studies in adult patients were also considered. The search covered the period 1990 to 2009 and we found approximately 400 articles, of which 29 related to pediatrics.

RESULTS

Due to feasibility problems with placebo studies the majority of the studies were noncontrolled, some of them clinical trials on acute urodynamic changes during electrical stimulation or experimental research in animals. Overall only a few randomized trials were found. Regarding types of electrostimulation and indications in children the recent literature emphasizes stimulation far from the anal-genital region, such as sacral transcutaneous electrical nerve stimulation, mainly for refractory overactive bladder. Intravesical stimulation is the procedure of choice to enhance sensation in patients with incomplete neurogenic lesions. Percutaneous tibial nerve stimulation is tolerated by children but has been poorly studied. Sacral neuromodulation using implanted devices remains questionable and needs further clarification of its indications. Magnetic stimulation has rarely been used in children to date. More experimental studies are needed to assess the method of action and refine the parameters of stimulation.

CONCLUSIONS

Clinical controlled trials vs sham devices and predictable variables for successful response are urgently needed to address an apparently renewed focus on the use of nerve stimulation in the treatment of pediatric lower urinary tract symptoms.

Treatment of non-monosymptomatic nocturnal enuresis by transcutaneous parasacral electrical nerve stimulation

OBJECTIVE

To evaluate the effectiveness of transcutaneous parasacral electrical stimulation (TCPSE) in the treatment of non-monosymptomatic nocturnal enuresis (NMNE). Also, we evaluated possible pretreatment predictors of TCPSE failure.

MATERIALS AND METHODS

Nineteen children diagnosed with NMNE who underwent TCPSE were studied prospectively. There were 6 boys and 13 girls with a mean age of 9.05 ± 3.153 years (range 5-17 years). The sessions were performed three times per week for a maximum of 20 sessions, for 20 min each and at a frequency of 10 Hz.

RESULTS

For eight children (42%) the nocturnal enuresis resolved, four (21%) presented a reduction in nocturnal episodes to less than one a week, six (32%) presented no change and one (5%) had increased frequency of NMNE. Symptoms present before treatment, such as daytime incontinence, frequency, constipation and occurrence of urinary tract infection, were not predictors of failure after TCPSE.

CONCLUSION

TCPSE can be an effective treatment for NMNE, but about a third of patients will need another kind of treatment. No pretreatment factor was determined that predicted TCPSE failure.

Prospective study of transcutaneous parasacral electrical stimulation for overactive bladder in children: long-term results

PURPOSE

We evaluated the long-term success of transcutaneous parasacral electrical stimulation for overactive bladder in children.

MATERIALS AND METHODS

We prospectively evaluated children who underwent transcutaneous parasacral electrical stimulation for overactive bladder. All patients had symptoms of overactive bladder, bell curve in uroflowmetry and low post-void residual urine. The procedure was performed using a frequency of 10 Hz for 20-minute sessions 3 times weekly for a maximum of 20 sessions. Initial and long-term (more than 6 months) success rates were evaluated.

RESULTS

Transcutaneous parasacral electrical stimulation was performed in 36 girls and 13 boys with a mean age of 10.2 years (range 5 to 17). Mean followup was 35.3 months (range 6 to 80). Before treatment urgency, daytime incontinence and urinary tract infection were seen in 100%, 88% and 71% of cases, respectively. Initial success (full response) was demonstrated in 79% of patients for urgency, 76% for incontinence and 77% for all symptoms. Continued success was seen in 84% of patients for urgency, 74% for daytime incontinence and 78% for all symptoms. If the 30 patients with at least 2 years of followup were considered, treatment was successful in 73%. Recurrence of symptoms after a full response was seen in 10% of cases. Two of 33 patients (6%) with urinary tract infection before the procedure still had infection after treatment.

CONCLUSIONS

Transcutaneous parasacral electrical stimulation is well tolerated, and demonstrates short and long-term effectiveness in treating overactive bladder in children. Symptoms eventually will recur in 10% of patients.

Quality of life and self-esteem for children with urinary urge incontinence and voiding postponement

PURPOSE

Urge incontinence and voiding postponement are common subtypes of daytime wetting in children. We analyzed health related quality of life for children with urge incontinence and voiding postponement, and healthy controls at 2 centers.

MATERIALS AND METHODS

We examined a total of 49 consecutive children 5 to 13 years old who presented with urge incontinence (22) or voiding postponement (27), and 32 controls matched for age and sex. Health related and overall quality of life were measured with generic questionnaires, and self-esteem was measured with the Piers-Harris questionnaire.

RESULTS

Health related quality of life was significantly reduced in parent rating but not in child rating in the incontinent vs control group (total mean parent score 73 vs 78, child 76 vs 76). Children with voiding postponement have the lowest health related quality of life. Overall quality of life was significantly reduced in children with incontinence, while self-esteem did not differ. Children with externalizing disorders generally have the lowest health related and overall quality of life.

CONCLUSIONS

Health related and overall quality of life are useful constructs, and are reduced in children with daytime incontinence by parental rating. In comparison, children rate their quality of life as being higher. Quality of life is lowest with externalizing behavioral disorders, as in children with voiding postponement. Due to comorbid behavioral disturbances, children with voiding postponement often need additional assessment, counseling and treatment.

Prospects for the classification of mental disorders of children and adolescents

Suggestions for classification of mental disorders of children and adolescents in DSM-V and ICD-11 have been made, which differ strongly from the current descriptive approach of dimensional classification.

These suggestions even comprise a dichotomized system for health care as well as for scientific purposes.

Nevertheless it is obvious that we are far behind an “etiological” classification, so that trade-offs have necessarily to be made in DSM-V and ICD-11.

Appropriate proposals concern the strict separation of disorders that are typical for children and adolescents as well as for adults.

Furthermore a differentiation of diagnosis for infants, toddlers and preschool children is required in both classification systems. As far as it is relevant for treatment, combined diagnosis in DSM-V and subthreshold diagnosis as well as coding-possibilities for findings in molecular biology should be permitted.

As personality disorders should only be diagnosed after the age of 16, it is recommended to dimensionally classify personality traits that are pathognomonic for specific symptom patterns and of prognostic relevance.

DSM-V and ICD-11 should allow age-specific information on axis-IV. The article discusses the general question of how relational disorders respectively disturbances should be classified and include furthermore special recommendations concerning ICD and DSM categories.

Diagnosis and management of urinary incontinence and functional fecal incontinence (encopresis) in children

The ability to maintain normal continence for urine and stools is not achievable in all children by a certain age. Gaining control of urinary and fecal continence is a complex process, and not all steps and factors involved are fully understood. While normal development of anatomy and physiology are prerequisites to becoming fully continent, anatomic abnormalities, such as bladder exstrophy, epispadias, ectopic ureters, and neurogenic disturbances that can usually be recognized at birth and cause incontinence, will require specialist treatment, not only to restore continence but also to preserve renal function. Most forms of urinary incontinence are not caused by an anatomic or physiologic abnormality and, hence, are more difficult to diagnose and their management requires a sound knowledge of bladder and bowel function.

Behavior profiles in children with functional urinary incontinence before and after incontinence treatment

OBJECTIVE

The purpose of this work was to analyze prospectively the prevalence of behavioral disorders in children with urinary incontinence because of nonneuropathic bladder-sphincter dysfunction before and after treatment for incontinence.

METHODS

A total of 202 children with nonneuropathic bladder-sphincter dysfunction were enrolled in the European Bladder Dysfunction Study, in branches for urge syndrome (branch 1) and dysfunctional voiding (branch 2); 188 filled out Achenbach's Child Behavior Checklist before treatment and 111 after treatment. Child Behavior Checklist scales for total behavior problems were used along with subscales for externalizing problems and internalizing problems.

RESULTS

After European Bladder Dysfunction Study treatment, the total behavior problem score dropped from 19% to 11%, the same prevalence as in the normative population; in branch 1 the score dropped from 14% to 13%, and in branch 2 it dropped from 23% to 8%. The prevalence of externalizing problems dropped too, from 12% to 8%: in branch 1 it was unchanged at 10%, and in branch 2 it dropped from 14% to 7%. The decrease in prevalence of internalizing problems after treatment, from 16% to 14%, was not significant.

CONCLUSION

More behavioral problems were found in dysfunctional voiding than in urge syndrome, but none of the abnormal scores related to the outcome of European Bladder Dysfunction Study treatment for incontinence. With such treatment, both the total behavior problem score and the score for externalizing problems returned to normal, but the score for internalizing problems did not change. The drops in prevalence are statistically significant only in dysfunctional voiding.

Prevalence and behavioural correlates of enuresis in young children

OBJECTIVES

Previous studies based on clinical samples report that enuresis in children is associated with behavioural problems and reduced self-esteem, but the relationship between behavioural problems and enuresis remains controversial. This population-based study investigated the prevalence and behavioural correlates of enuresis in a group of preparatory school children.

METHODS

This cross-sectional survey involved 356 parents and their children aged 5-7 years, all residents of Istanbul, Turkey. Parents completed the Child Behaviour Checklist and socio-demographic data form (response rate: 90%). Fifty-three children with enuresis were compared with 303 non-symptomatic children. Differences in the mean scores and the percentages of children falling beyond pre-selected clinical thresholds were compared between the groups.

RESULTS

The prevalence of enuresis was 14.9%, and enuresis was more frequent among boys. Children with enuresis were reported by their parents to have greater social problems and higher total problem scores than control children (P = 0.019, P = 0.048, respectively). However, there were no differences in the percentages of children falling beyond pre-selected clinical thresholds between the groups.

CONCLUSIONS

Children with enuresis had higher mean scores for total and social behavioural problems than controls; however, clinically relevant behavioural problems did not show differences between the groups. Given the inconsistent research findings across studies, longitudinal research and outcome studies could help determine whether there is a causal relationship between psychopathology and enuresis.

Emotional and behavioural difficulties of children and young people at entry into care

Emotional and behavioural difficulties of a sample of children and young people were identified at the point of entry to local authority care by analysis of social work case files. The files indicated high levels of need, including that in children aged under 5. Bedwetting was identified as an important issue related to the physical health and emotional well-being of looked-after children. There was an association between bedwetting and emotional and behavioural problems. Analysis of placement types at entry to care showed that significantly more boys than girls were first placed in residential care.

Enuresis and daytime wetting as a biopsychosocial problem: a review

Enuresis is considered to be the most prevalent of all childhood problems with important psychosocial consequences. Thorough research by both medical and psychological disciplines has resulted in a lack of agreement concerning definitions and terminology. Psychiatric classification systems stress phenomenological aspects such as age, frequency and duration of wetting episodes, but are not based on pathophysiologic aspects, whereas the International Children's Continence Society recommend distinguishing between monosymptomatic enuresis and complex/non-monosymptomatic enuresis depending on the absence or presence of bladder dysfunctions. Several epidemiological and cross-sectional studies show higher scores for behavioral problems in children with enuresis. Parental reports suggest more externalizing problems, attention/hyperactive problems and anxious/withdrawn behavior, however, no difference has been demonstrated in children's self-report concerning internalizing problems. Four different viewpoints relating to the association between enuresis and psychopathology are described, including their clinical implications. In conclusion, enuresis and daytime wetting is seen as a 'biopsychosocial' problem with evidence for pathophysiologic causes and is often associated psychiatric/psychological problems.

Lower urinary tract dysfunction in children. What do pre-school teachers know about it?

OBJECTIVE

To evaluate the basic knowledge of pre-school teachers who deal with children between the ages of 4 and 7 years, who present signs of lower urinary tract dysfunction (LUTD).

MATERIALS AND METHODS

We performed a survey with 50 teachers from 9 private schools working with pre-school children. The criteria for selection were if teachers were certified or non-certified elementary school teachers - NCEST and the amount of professional experience.

RESULTS

Thirty-three teachers considered that the normal daily urinary frequency should be from 4 to 7 times. Two of the 50 teachers considered it normal to urinate less than 4 times per day and 15 teachers considered more than 7 times per day as normal. There was no difference between the 2 categories of certified or NCEST nor between those with more or less than five years of professional experience. Thirty-three percent believed that to urinate more than 4 times during a class period (4-5 hours) could indicate a urinary problem. There was a statistically significant difference among the certified and NCEST but not in terms of time of professional experience. If during this period the child would not ask to urinate, only 18% considered that as an indication of urinary problem. When asked about the symptoms that would indicate urinary urgency and urge incontinence, only 24% of the teachers connected it with urinary problem. There was no difference in terms of professional background or professional experience in these 2 last analyses.

CONCLUSION

Our data shows evidences that private pre-schools teachers are not well informed of the clinical manifestation of LUTD.

Psychological problems in children with daytime wetting

OBJECTIVE

This population-based study investigated the psychological problems associated with daytime wetting in children.

METHODS

A sample of 8213 children (age range: 7 years 6 months to 9 years 3 months) who were enrolled in the population-based Avon Longitudinal Study of Parents and Children participated in this study. Parents completed a postal questionnaire asking about their children's toileting behavior and assessing psychological problems, including childhood emotional and behavioral problems (99% completed the questionnaire by the time their child was 8 years 3 months of age). The rate of psychological problems was compared in children with daytime wetting and in those with no daytime wetting. Analyses adjusted for developmental delay, gender, sociodemographic background, stressful life events, and soiling.

RESULTS

Chi2 tests of association and multivariable logistic regression indicate that children with daytime wetting have a higher rate of parent-reported psychological problems than children who have no daytime wetting. It is particularly notable that the reported rates of attention and activity problems, oppositional behavior, and conduct problems in daytime wetting children were around twice the rates reported in children with no daytime wetting.

CONCLUSIONS

The increased vulnerability to psychological problems in children as young as 7 years of age with daytime wetting highlights the importance of parents seeking early intervention for the condition to help prevent later psychological problems. Although treatment in a pediatric setting is often successful, clinicians should be aware of the increased risk of disorders, such as attention-deficit/hyperactivity disorder, in children with daytime wetting, because this is likely to interfere with treatment.

Nonpharmacological treatment of lower urinary tract dysfunction using biofeedback and transcutaneous electrical stimulation: a pilot study

OBJECTIVE

To report a series of children with lower urinary tract dysfunction (LUTD) whose urge syndrome was treated by electrical stimulation, and their voiding dysfunction by biofeedback; none of the children were using anticholinergic drugs during treatment.

PATIENTS AND METHODS

In all, 36 children who presented with symptoms of urinary urgency and/or daily incontinence completed the treatment and were prospectively evaluated. The mean (range) follow-up was 13.8 (4-24) months, and their mean age 7 (3-14) years, 17 children were aged <5 years. The children were divided into two groups: group 1, with urge syndrome treated with superficial parasacral electrical stimulation, and group 2, with voiding dysfunction, treated with biofeedback.

RESULTS

In group 1, the mean (range) number of electrical stimulation sessions was 13.1 (4-20). Of the 19 children treated, 12 had a complete clinical improvement, six a significant improvement, and one a mild improvement. In group 2, the mean (range) number of biofeedback sessions was 6 (4-14). Of the 17 children treated, there was complete improvement of symptoms in 10, significant improvement in two and mild improvement in five. Six children who had no resolution of symptoms after biofeedback had salvage therapy with electrical stimulation, after which four had complete improvement of symptoms, and two a 90% and 40% improvement, respectively. Taking the two groups together, after treatment, four children developed isolated episodes of urinary tract infection. Of 21 children with nocturnal enuresis, bed-wetting continued in 13 (62%) after treatment.

CONCLUSION

In this short-term follow-up, the nonpharmacological treatment of voiding dysfunction using biofeedback, and of urge syndrome by electrical stimulation, was effective for treating LUTD in children.

Comparative analysis of the frequency of lower urinary tract dysfunction among institutionalised and non-institutionalised children

OBJECTIVES

To evaluate the level of symptoms of lower urinary tract dysfunction (LUTD) in orphans in institutions, and compare these data with schoolchildren of the same age group who were not institutionalised, as LUTD in children is related to factors such as social isolation and low self-esteem, with other psychological changes also being cited, although it is unknown whether these problems are primary or secondary to the symptoms of LUTD.

PATIENTS AND METHODS

Children institutionalised in orphanages with no parental presence and who are isolated from a family environment are probably more sensitive to psychological disturbances. Psychological changes have been associated with symptoms of urgency and urinary incontinence. Thus 89 orphans were compared with 143 schoolchildren not in institutions. A questionnaire was devised and completed by the care-taking staff in the orphanage, while for the schoolchildren the parents completed the questionnaire. The mean age in the institutionalised children was 7.9 years and that of the control group 7.8 years (P = 0.32). Thirty-nine (44%) of the orphans were boys, vs 74 (54%) of the control group (P = 0.17).

RESULTS

The incidence of urgency, diurnal urinary incontinence, nocturnal enuresis and constipation in the orphans and in the control group were: 45 (51%) and 57 (40) (P = 0.17), 36 (40%) and 19 (13%) (P < 0.001), 39 (47%) and 38 (27%) (P = 0.002), and 27 (30%) and 43 (30%) (P = 0.76), respectively.

CONCLUSION

Children living in orphanages have a significantly higher level of diurnal urinary incontinence and nocturnal enuresis than those not in an institution.

An approach to daytime wetting in children

Daytime wetting is a common problem with various causes that can usually be identified through a careful history, thorough physical examination, and urinalysis. Conservative approaches to therapy have a successful outcome in most children. Invasive diagnostic imaging studies and pharmacologic or surgical intervention are necessary only for carefully selected children.

Comparative analysis of the symptomatology of children with lower urinary tract dysfunction in relation to objective data

OBJECTIVES

To assess the clinical presentation of children with lower urinary tract dysfunction (LUTD) relating to objective examination data.

MATERIALS AND METHODS

Forty-four children (36 girls and 8 boys with mean age of 6.8 years) with LUTD were prospectively assessed through a specific questionnaire that analyzed clinical presentation of those patients. These data were then compared to objective data, such as micturition diary and uroflowmetry with electromyography.

RESULTS

A urinary tract infection (UTI) antecedent was observed in 31 cases (70.5%), and of those, 24 cases of UTI were accompanied by fever. All children presented micturition urgency. Daily urinary incontinence was observed in 33 cases (75%) and nocturnal enuresis in 23 (52.3%). As for micturition frequency, 15 (34.1%) had normal frequency 19 (43.2%) presented more than 10 daily micturition episodes and 10 (22.7%) thought they urinated less than 5 times a day. In the uroflowmetry and electromyography examination, 14 (31.8%) experienced lack of coordination during micturition. Of 10 children with infrequent micturition, 5 confirmed this in their micturition diaries and 2 listed more than 5 micturition episodes per day in the diary. Of 19 patients presenting polaciuria, only 5 confirmed this in their micturition diaries, while 7 had less than 10 micturition episodes per day.

CONCLUSION

Most children with LUTD presented a previous UTI, and daily incontinence was verified in around 75% of the patients. Complaints of polaciuria or infrequent micturition are not noted completely in the micturition diaries and there is no parameter in the clinical history that offers good sensitivity or specificity for the diagnosis of lack of perineal coordination.

TOLTERODINE TREATMENT FOR CHILDREN WITH SYMPTOMS OF URINARY URGE INCONTINENCE SUGGESTIVE OF DETRUSOR OVERACTIVITY: RESULTS FROM 2 RANDOMIZED, PLACEBO CONTROLLED TRIALS

PURPOSE

We report the results of the first 2 large randomized controlled trials designed to evaluate the efficacy and safety of tolterodine extended release in children 5 to 10 years old with symptoms of urinary urge incontinence suggestive of detrusor overactivity.

MATERIALS AND METHODS

Two double-blind, placebo controlled trials were conducted sequentially. Children 5 to 10 years old with incontinence suggestive of detrusor overactivity (1 or more diurnal incontinence episodes per 24 hours) were randomized to tolterodine (2 mg daily) or placebo for 12 weeks. The primary end point was the change from baseline to week 12 in the number of incontinence episodes per week. Changes from baseline in the number of voids per 24 hours and volume of urine per void were also evaluated. Exploratory analyses were conducted to determine whether particular subsets of patients showed differential responses to treatment.

RESULTS

A total of 224 and 487 children (mean age 8 years) were randomized to placebo and tolterodine, respectively. Differences in the number of incontinence episodes per week, voids per 24 hours, and volume of urine per void between tolterodine and placebo did not reach statistical significance. This finding may be explained by a high placebo response and under dosage of tolterodine among children with greater body weight. Tolterodine was well tolerated.

CONCLUSIONS

Analysis of the primary efficacy outcome did not reveal a statistically significant effect of treatment. However, secondary analyses demonstrated that tolterodine was well tolerated among 5 to 10-year-old children with diurnal incontinence. Exploratory analyses also showed that children weighing 35 kg or less with detrusor overactivity characterized by incontinence and/or frequent voiding benefited most from tolterodine treatment, suggesting that a weight adjusted dosing regimen may be required for optimal response among older and heavier children.

Childhood nocturnal enuresis: Developing a conceptual framework

Nocturnal enuresis has been described as the most prevalent and chronic of all childhood problems. The experience, particularly for the older child, can be extremely distressing and limiting. It is now thought that psychological distress (emotional, behavioural, and self-esteem) arises as a consequence of bedwetting, and reaches clinical importance in only a minority who are vulnerable. Many aetiological theories have been proposed with the cause of nocturnal enuresis now regarded as heterogeneous. Based on empirical findings, a new model, termed 'the three systems,' has facilitated a greater clinical understanding of the problem and identification of the appropriate intervention. The model proposes bedwetting results from excessive nocturnal urine production and/or nocturnal bladder overactivity coupled with an inability to arouse to bladder sensations. Effective treatment arises from identification of the child's particular need and application of the appropriate psychological and pharmacological approach. Treatment methods are reviewed in terms of the new model, the mode of action, effectiveness, and application in combination.

Toilet training children with learning difficulties: what the literature tells us

Nurses and health visitors are the professional group most likely to be involved in advising and supporting parents of children with disabilities (Bliss and Watson, 1992). Little research has been done into assessing and treating urinary continence difficulties of children with learning difficulties and many questions remain unanswered: what is the extent of the problem; what specific intervention do children with learning difficulties require to attain toileting skills; what expectation can the parent and clinician have that children with learning difficulties can be toilet trained and who is best placed to promote toileting skills? The main findings from the literature will support health and education professionals and carers who are involved in toilet training children with learning difficulties.

Self-image and performance in children with nocturnal enuresis

OBJECTIVE

To study the self-image of children between 8 and 12 years with nocturnal enuresis, and to correlate the findings with age, sex, clinical symptoms, primary versus secondary enuresis and treatment failures.

METHODS

The study-group embraced 50 university hospital, and therefore selected therapy-resistant nocturnal enuresis-children, 27 boys and 23 girls. The mean age was 9.8, which means children aged between 8 and 12 years. Children were classified into two age groups: I=8-9 years and II=9-12 years. A total of 41 out of 50 had primary nocturnal enuresis. The mean number of treatments before intake was 5.6, A=1-4, B=5-8, C=9-12. Seventy-seven children without nocturnal enuresis were included in the control group, 31 boys and 46 girls. The method we used to measure the perceived competence of the children on specific domains of their life was the Dutch translation and also validation of the "Self-Perception Profile for Children" by Harter. The testing was performed before and after therapy.

RESULTS

Children with nocturnal enuresis have a significantly lower perceived competence than children without nocturnal enuresis, concerning physical appearance (p<0.05) and global self-esteem (p<0.01). There is a main effect of gender (p<0.01) and age (p<0.05) concerning scholastic skills. There is a correlation with the number of treatment failures. The more treatment failures, the lower the self-esteem. After successful treatment, there is an improvement of 'athletic competence' and 'global self-esteem', but it is not significant.

CONCLUSION

Nocturnal enuresis has important negative effects on the self-image and performance of children. Perceived competence was lower in girls than in boys with enuresis, and it was significantly lower in the higher age than in the lower. Children with day-time and night-time incontinence have a significantly decreased perceived competence on scholastic skills compared to children with nocturnal problems only. Successful treatment tended to increase athletic competence and global self-esteem.

Bedwetting, behaviour and self-esteem: a review of the literature

AIM

The aim of this review was to examine the empirical evidence on the impact of bedwetting and its treatment on a child's self-esteem and behaviour.

INCLUSION CRITERIA

The inclusion criteria for this review were empirical studies conducted on children, aged 5-16 years old, with primary nocturnal enuresis using measures of self-esteem or behaviour. Studies utilizing psychological measurement scales completed by children were the main focus although those that used scales completed by parents were also included.

SEARCH STRATEGIES

The electronic databases from 1981 to 1999 were searched, and hand searching of the literature dating back to 1973 was conducted using the reference lists of key papers.

RESEARCH FINDINGS

Fifteen empirical studies matched the inclusion criteria. There was only one randomised-controlled trial and the rest of the studies were cohort, case-control or cross-sectional design. Evidence of sample bias predominantly due to the use hospital-based and/or 'volunteer' subjects was found in five studies. A further five studies used birth cohort data, which excludes important variables such as the impact of treatment. Four studies used single parent-reported measures, which may under or over-estimate the problem. No large cohort studies were available which compare the self-esteem of bedwetting children with matched controls. The most interesting line of enquiry is pursued by studies looking at whether self-esteem improves with successful treatment. However, the use of self-selected subject groups does not make the current evidence convincing and more work is required to determine outcomes for all children. There is empirical evidence for increased behavioural problems in bedwetting children. Studies conducted on younger children report less behavioural problems with more reported in studies conducted on older children with complex wetting disorders. This may point towards wetting being the primary problem, but more work is needed, as causation in any direction is difficult to ascertain from the literature.