FUNCTIONAL CONSTIPATION IN CHILDREN

Acute urinary retention in children: causes and the role of bladder catheterization and ultrasonogram

BACKGROUND

Acute urinary retention in children is uncommon and can be related to several causes. The role of abdominal ultrasound and catheterization is controversial. We aimed to identify the most common causes of acute urinary retention in children, focusing, particularly on the role of bladder catheterization and the diagnostic value of acute ultrasound.

METHODS

We retrospectively analyzed all consecutive children admitted to our emergency department with acute urinary retention from 2010 to 2020. Post-operative acute urinary retention, neonatal age, and known urological or neurological disorders were excluded. Diagnostic workup and management were adopted in each patient. Results were compared in patients with more and less than 5 years old.

RESULTS

193 patients were included. Median age was 3 (2-16) years; 53.4% were girls. Ultrasound evaluation was performed in (129/193; 66.8%) patients, more commonly <5-year-old (74% vs. 26%, P<0.01). A previously unknown urological condition was detected in (16/129; 12%). The majority of patients (124/193; 64%) were managed without bladder catheterization. These patients were significantly younger than the remainder (3- vs. 4-year-old, P<0.01) and the most common diagnosis was external genitalia inflammation (53%). Of the remaining patients, (34/69; 49%) restored spontaneous micturition after a single catheterization, whereas 35 required admission. The latter were more commonly males (32%, P=0.01), with higher incidence of abnormal ultrasound (33% vs. 7%, P<0.001).

CONCLUSIONS

Acute urinary retention in commonly due to external genitalia inflammation, particularly in patients <5-year-old, and can be generally managed, without bladder catheterization. Abdominal ultrasound is an important diagnostic tool, that should be performed only in selected cases.

Postoperative Adhesive Small Bowel Obstruction Presenting as Acute Urinary Retention

Postoperative adhesions are commonly seen after most abdominal surgeries. The majority of patients with intra-abdominal adhesions remain asymptomatic; however, some patients may develop symptoms ranging from mild abdominal pain to sometimes life-threatening complications. The most severe complication seen in association with postoperative adhesions is small bowel obstruction (SBO). This complication is rarely seen in the pediatric age-group. Adhesions have the potential to cause bowel obstruction. In addition, they can also affect the normal intestinal motility and transit leading to constipation. Several studies reported in literature show a strong association between constipation and the urinary disorders, such as incontinence and urinary urgency. We herein report a case of a boy who developed adhesive SBO with segmental ileal dilatation leading to constipation, urinary symptoms, and finally presenting to our hospital as acute urinary retention.

Contemporary Management of Urinary Tract Infections in Children

Purpose of Review

Urinary tract infection (UTI) in children is a major source of office visits and healthcare expenditure. Research into the diagnosis, treatment, and prophylaxis of UTI has evolved over the past 10 years. The development of new imaging techniques and UTI screening tools has improved our diagnostic accuracy tremendously. Identifying who to treat is imperative as the increase in multi-drug-resistant organisms has emphasized the need for antibiotic stewardship. This review covers the contemporary management of children with UTI and the data-driven paradigm shifts that have been implemented into clinical practice.

Recent Findings

With recent data illustrating the self-limiting nature and low prevalence of clinically significant vesicoureteral reflux (VUR), investigational imaging in children has become increasingly less frequent. Contrast-enhanced voiding urosonogram (CEVUS) has emerged as a useful diagnostic tool, as it can provide accurate detection of VUR without the need of radiation. The urinary and intestinal microbiomes are being investigated as potential therapeutic drug targets, as children with recurrent UTIs have significant alterations in bacterial proliferation. Use of adjunctive corticosteroids in children with pyelonephritis may decrease the risk of renal scarring and progressive renal insufficiency. The development of a vaccine against an antigen present on Escherichia coli may change the way we treat children with recurrent UTIs.

Summary

The American Academy of Pediatrics defines a UTI as the presence of at least 50,000 CFU/mL of a single uropathogen obtained by bladder catheterization with a dipstick urinalysis positive for leukocyte esterase (LE) or WBC present on urine microscopy. UTIs are more common in females, with uncircumcised males having the highest risk in the first year of life. E. coli is the most frequently cultured organism in UTI diagnoses and multi-drug-resistant strains are becoming more common. Diagnosis should be confirmed with an uncontaminated urine specimen, obtained from mid-stream collection, bladder catheterization, or suprapubic aspiration. Patients meeting criteria for imaging should undergo a renal and bladder ultrasound, with further investigational imaging based on results of ultrasound or clinical history. Continuous antibiotic prophylaxis is controversial; however, evidence shows patients with high-grade VUR and bladder and bowel dysfunction retain the most benefit. Open surgical repair of reflux is the gold standard for patients who fail medical management with endoscopic approaches available for select populations.

Observation on the Efficacy of Shouhui Tongbian Capsule in the Treatment of Functional Constipation and Study on Its Regulatory Effect on Intestinal Flora

Functional constipation is relatively common in both adults and children, exhibiting similar symptoms. However, there are significant differences in the epidemiology, symptomatology, pathophysiology, diagnostic tests, and treatment management of functional constipation by age. The treatment of functional constipation is generally based on lifestyle interventions, pelvic floor interventions, and pharmacotherapy. Pharmacological treatment is popular as the most direct and effective modality, especially the herbal preparations (e.g., Shouhui Tongbian capsule), which are popular for their lower toxic side effects and less physiological reactions. In our clinical study, patients with functional constipation who took Shouhui Tongbian capsules for a longer period of time showed significantly better improvement than those who took them for a shorter period of time (P < 0.001). Relative to the duration of the disease, the improvement effect was higher in patients with short duration of the disease than in patients with long duration of the disease (P < 0.001). What's more, Shouhui Tongbian capsule had a regulating effect on intestinal flora, and the regulating effect was stronger in patients with a shorter disease duration.

Influence of constipation on enuresis

INTRODUCTION

Constipation has classically been considered as a risk factor of enuresis, although there are increasingly more publications that report a similar prevalence of constipation in both enuretics and non-enuretics.

OBJECTIVE

To determine the influence of constipation in monosymptomatic and non-monosymptomatic enuresis, and to find out the prevalence of the three disorders, as well as the lower urinary tract dysfunction and bladder-bowel dysfunction in the population.

MATERIAL AND METHOD

A cross-sectional observational prevalence study on a representative population sample of 5-9 year-old school boys and girls of Galicia, Spain. A questionnaire was completed in the schools on urinary and bowel habits, which included questions from the Paediatric Lower Urinary Tract Scoring System (PLUTSS) diagnostic questionnaire and grading of the lower urinary tract dysfunctions. The enuresis was diagnosed using the International Children's Continence Society (ICSS), and if it was also associated with diurnal symptoms, it was also classified as non-monosymptomatic enuresis. The constipation was evaluated using the Rome III criteria and the adapted Bristol stool scale.

RESULTS

A total of 772 questionnaires were included in the study. The prevalence of constipation was 20% and that of enuresis was 9.1% (62.9% monosymptomatic enuresis and 37.1% non-monosymptomatic), with the prevalence of bladder-bowel dysfunction being 5.2%. It was observed that constipation had no influence on the presence of monosymptomatic enuresis, but it did have an influence on non-monosymptomatic enuresis and lower urinary tract dysfunctions, where it was a significant risk factor.

CONCLUSIONS

The differential diagnosis between monosymptomatic and non-monosymptomatic enuresis is essential in the initial evaluation of the patient with enuresis, since the therapeutic management and the characteristics of both disorders are different, with constipation only being a risk factor in cases of non-monosymptomatic enuresis.

Transanal irrigation (TAI) in the paediatric population: Literature review and consensus of an Italian multicentre working group

Constipation and fecal incontinence in pediatric patients are conditions due to either functional or organic bowel dysfunction and may represent a challenging situation both for parents, pediatricians, and pediatric surgeons. Different treatments have been proposed throughout the past decades with partial and alternant results and, among all proposed techniques, in the adult population the Transanal Irrigation (TAI) has become popular. However, little is known about its efficacy in children. Therefore, a group of Italian pediatric surgeons from different centers, all experts in bowel management, performed a literature review and discussed the best-practice for the use of TAI in the pediatric population. This article suggests some tips, such as the careful patients' selection, a structured training with expert in pediatric colorectal diseases, and a continuous follow-up, that are considered crucial for the full success of treatment.

The complex relationship between urinary and defecatory disorders in young and adolescent girls

PURPOSE OF REVIEW

Scientific advancements have led to enhanced clarity about the interrelationship between urinary tract pathology and functional bowel disturbances. The present article will review the current literature regarding the cause, pathophysiology, diagnosis, and treatment of lower urinary tract dysfunction and abnormal bowel habits in young and adolescent girls.

RECENT FINDINGS

Complex neurological, physiological mechanisms and functional behaviors exist that contribute to the development of coexisting urinary symptoms and defecatory disorders in young and adolescent girls. Bladder bowel dysfunction (BBD) in childhood and adolescence is carried into adulthood creating a lifetime health burden.

SUMMARY

Practitioners should be aware and actively screen for conditions mimicking BBD with time-efficient and effective history-taking and physical exams that reduce anxiety and fear. The present review provides guide to comprehensive treatment strategies for managing complex pelvic floor disorders including urinary incontinence, defecatory disorders, pelvic and perineal pain, and constipation. More research is needed to elucidate pathophysiology and optimal treatment strategies of the BBD.

The Focal Play Therapy: A Clinical Approach to Promote Child Health and Family Well-being

Eating and evacuation disorders can cause serious health problems for children. Early recognition and early treatment require a multifactor intervention based on a collaborative relationship between pediatricians, psychotherapists and other health professionals. In this context the Focal Play Therapy (FPT) with children and parents is a psychodynamic model of intervention that improves parental ability to cope with child's difficulties. Parental engagement in child interventions allows to understand child's symptoms within family dynamics and to build an alliance with parents that represents a crucial variable of an effective psychological support for children and families. In the present study data were collected from 17 parental couples and their preschool children at two time points (1st and 6th FPT sessions) marking the first phase of this intervention. This phase was aimed to the assessment of child's symptoms within family relationships and to the promotion of the alliance with parents. Families were in treatment at the Psychological Consultation Center for Children and Parents located at the Department of Psychology of the University of Bologna (Italy). This Center provides health assessment and intervention services to children and their families. We investigated the alliance from both parents and therapist points of view along with other parental and child outcome variables implied in clinical works with children and families. Alliance scores were obtained through the Working Alliance Inventory and the System for Observing Family Therapy Alliances, two measures used in individual and family settings, respectively. Parenting stress and parent-child interactions were investigated using the Parenting Stress Index and the Emotional Availability Scales. Furthermore, paired t-tests were run to detect changes on parental and child variables. Findings advise that special attention should be paid to the building of an early alliance with parents. In this regard the FPT is specifically designed to promote the parent-therapist alliance in the context of child health and family well-being.

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.

Measuring the Transrectal Diameter on Point-of-Care Ultrasound to Diagnose Constipation in Children

OBJECTIVES

The aim of the study was to determine the test performance characteristics for point-of-care ultrasound in diagnosing constipation, through measuring the transrectal diameter (TRD). We sought to develop a sonographic numeric cutoff value for diagnosing constipation. Secondary objectives included whether certain patient characteristics would affect the TRD measurement and the accuracy of the TRD in comparison with abdominal radiographs.

METHODS

We conducted a prospective, cohort study of pediatric patients between the age of 4 and 17 years, presenting with abdominal pain to a pediatric emergency department. A point-of-care ultrasound was performed with a phased array transducer (5-1 MHz). In addition to a thorough history and physical examination, each patient was administered with the Rome III questionnaire, which served as the criterion standard for the diagnosis of constipation. Radiographs and enema treatments were performed at the discretion of the treating attending physician. When enemas were administered, a postenema TRD measurement was obtained.

RESULTS

Fifty subjects were "constipated" or "nonconstipated," as determined by the Rome III questionnaire. A TRD cutoff of 3.8 cm or greater correlated with the diagnoses of constipation (P < 0.001). Ultrasound-diagnosed constipation had a sensitivity of 86% (95% confidence interval, 69%-96%), specificity of 71% (95% CI, 53%-85%), negative predictive value of 0.87 (95% CI, 0.68-0.95), and positive predictive value of 0.70 (95% CI, 0.52-0.84). The TRD measurement was not affected by patient physical characteristics or bladder fullness. In 7 patients, an enema was administered. There was an overall mean (SD) decrease of 1.22 (1.62) cm; this difference was not statistically significant (P = 0.093). Abdominal radiographs were performed in 25 patients. When compared with abdominal radiographs, ultrasound had a higher specificity of 71% (95% CI, 53%-85%), but this difference was not statistically significant. Ultrasound performed similarly to abdominal radiographs with regard to sensitivity 86% (95% CI, 67%-95%), positive predictive value of 0.70 (95% CI, 0.52-0.84), and negative predictive value of 0.87 (0.68-0.95). In 22 of 25 patients who received radiographs, the ultrasound diagnosis was the same as the radiologist read of the radiographs. Potentially, 88% of radiographs could have been avoided in these patients.

CONCLUSIONS

In pediatric patients with abdominal pain, there is a strong correlation of an enlarged TRD with constipation. Our results suggest that point-of-care ultrasound is a useful adjunct for diagnosing constipation and has the potential to replace the use of abdominal radiographs.

Constipation and Lower Urinary Tract Dysfunction in Children and Adolescents: A Population-Based Study

OBJECTIVE

To evaluate the correlation between constipation and lower urinary tract dysfunction (LUTD) and nocturnal enuresis in a population-based study.

MATERIAL AND METHODS

This is a cross-sectional study. The criteria for inclusion were children and adolescents of between 5 and 17 years and who agreed to sign the informed consent form. The study excluded students with neurological problems or who had documented abnormalities of the urinary tract. To identify the presence and severity of LUTD, we used the Voiding Dysfunction Symptom Score (DVSS). To evaluate the presence of constipation, Rome III questionnaire was used.

RESULTS

We interviewed 829 children and adolescents, of which 416 (50.18%) were male. The mean (SD) age was 9.1 (±2.9) years. The overall prevalence of LUTD was 9.1%, predominantly in girls (15 versus 3.1%, p < 0.001). Constipation was found in 9.4% of boys and 12.4% of girls (p = 0.169). Constipated children were 6.8 times more likely to have LUTD than those not constipated (p < 0.001, coefficient and correlation of 0.411). Constipation was found in 8.2% of children without LUTD and in 35.2% of children with LUTD. We performed multivariate analysis to identify urinary symptoms that are independent predictors of the presence of constipation. The presence of infrequent urination (p = 0.004) and holding maneuvers (p < 0.001) were independent predictors. It was noted also noted that constipated children, according to the Rome III criteria, possess a worse DVSS (p < 0.001). Regarding the presence of nocturnal enuresis, 12.6% of children and adolescents had constipation in association with this symptom. However, this relationship was not statistically significant (p = 0.483).

CONCLUSION

Constipated children were 6.8 times more likely to have LUTD than those not constipated. Among the urinary symptoms, infrequent voiding and holding maneuvers are independent factors of urinary expressions in constipated children. Children with more severe constipation have more prominent urinary symptoms. The presence of enuresis was not associated with constipation.

[Acute urinary retention in a pre-school girl with constipation]

OBJECTIVE

To report a case of a preschool girl who developed acute urinary retention associated with constipation.

CASE DESCRIPTION

A girl aged six years old presented a 24 hour history of inability to urinate. She was went twice to the emergency room during this period. In the first admission, 12 hours after the onset of the symptoms, she presented abdominal pain and acute urinary retention. After the drainage by urinary catheterization of 300 mL of clear urine, she presented relief of the symptoms and, as urinalysis had no change, the patient was discharged home. Twelve hours after the first visit, she returned to the emergency room complaining about the same symptoms. At physical examination, there was only a palpable and distended bladder up to the umbilicus with no other abnormalities. Again, a urinary catheterization was performed, which drained 450 mL of clear urine, with immediate relief of the symptoms. Urinalysis and urine culture had no abnormalities. During the anamnesis, the diagnosis of constipation was considered and a plain abdominal radiography was performed, which identified large amount of feces throughout the colon (fecal retention). An enema with a 12% glycerin solution was prescribed for three days. During follow-up, the child used laxatives and dietary modifications, this contributed to the resolution of the constipation. There were no other episodes of urinary retention after 6 months of follow-up.

COMMENTS

Acute urinary retention in children is a rare phenomenon and constipation should be considered as a cause.

Diagnosis of constipation does not correlate with trans-abdominal ultrasound of rectal distention

INTRODUCTION

Constipation has been shown to have a significant impact on lower urinary tract symptoms (LUTS) in children, and treatment of constipation in children with bowel bladder dysfunction (BBD) has been shown to improve or completely resolve LUTS in many cases. Recent studies utilizing trans-abdominal ultrasound (US) to assess stool burden have correlated diagnosis of constipation with US appearance of rectal stool. An US scoring tool was published in 2008 to assess stool burden, showing linear correlation with constipation severity by symptom questionnaire in an outpatient pediatric constipation clinic population. We hypothesized that this US scoring tool would correlate with constipation symptoms in our outpatient pediatric urology population.

METHODS

In 2010, our pediatric urology outpatient clinic began administering a previously published validated BBD questionnaire to new toilet-trained patients, containing three questions addressing bowel function. Patients in our clinic undergoing trans-abdominal US of the bladder also have assessment of their stool burden by the previously published US scoring tool. We retrospectively reviewed patient charts beginning in June 2013 who had undergone trans-abdominal US of the bladder, gathering data on the first 100 patients with a complete BBD questionnaire and a completed stool burden US scoring tool.

RESULTS

Chart review of 272 consecutive patients was required to enroll 100 patients with a completed US scoring of stool burden and a completed BBD questionnaire. Of these 272 patients, 225 (82%) had a complete scoring of stool burden during their US examination. BBD questionnaires were complete in 107 of 272 patients (39%). Median patient age was 8.2 years, with 69% of patients being female. The most common diagnosis was incontinence or bladder dysfunction (41%). Only one patient (1%) had constipation as the primary diagnosis for their visit. Linear regression analysis showed no correlation of US score to patient reported frequency of bowel movement, frequency of hard stool, frequency of fecal incontinence, or all three symptoms combined. When investigating the subgroup of patients who had diagnoses of BBD/incontinence, this group was seen to have higher mean symptom scores than the entire cohort as a whole, but US scores were still widely variable and again did not correlate with symptom scores.

CONCLUSION

US examination has previously been shown to correlate with symptom severity for children with chronic constipation in a pediatric constipation clinic setting. However, in a pediatric urology outpatient clinic setting at our institution, US examination did not correlate with patient reported symptoms.

Evaluation and management of recurrent urinary tract infections in children: state of the art

Urinary tract infections (UTIs) represent an important cause of febrile illness in young children and can lead to renal scarring and kidney failure. However, diagnosis and treatment of recurrent UTI in children is an area of some controversy. Guidelines from the American Academy of Pediatrics, National Institute for Health and Clinical Excellence and European Society of Paediatric Radiology differ from each other in terms of the diagnostic algorithm to be followed. Treatment of vesicoureteral reflux and antibiotic prophylaxis for prevention of recurrent UTI are also areas of considerable debate. In this review, we collate and appraise recently published literature in order to formulate evidence-based guidance for the diagnosis and treatment of recurrent UTI in children.

Abnormal voiding parameters in children with severe idiopathic constipation

OBJECTIVE

It is suggested that idiopathic constipation may associate with abnormal voiding parameters. In this study, we investigate the voiding parameters in children with constipation.

METHODS

Since 2010, seventeen consecutive children (12 boys, 5 girls) aged 5-17 (median = 14) with significant constipation according to Rome III criteria and who were not responding to conventional treatment (diet, laxatives & bowel training) for over 6 months were recruited. The rectal diameter (RD) was measured by transpubic ultrasonography (USG), RD >3.5 cm was considered as dilated. Each patient had uroflow measurement and bladder USG done to measure the maximal flow rate (Vmax), voided volume (VV), and post-void residual urine (PVR). Abnormal voiding parameters were defined as Vmax <12 ml/sec, VV <65 or >150% of age-adjusted expected bladder capacity (EBC) and/or PVR >20 ml.

RESULTS

Rectal diameter ranged from 1.7 to 8.2 cm (median = 3 cm) and was abnormally dilated in eight children. Vmax was normal in all children (median = 23.7 ml/sec). Voided volume ranged from 30 to 289% of EBC and was abnormal in six children (35.5%). Post-void residual urine varied from 0 to 85 ml and was abnormal in six (35.5 %) children. Three children (17.6 %) had both abnormal VV and PVR. On the whole, the prevalence of abnormal voiding parameters in constipated children was 52.9 %. Mean RD in normal and abnormal parameters groups was 2.8 and 4.7 cm, respectively. Rectal dilation was associated with abnormal voiding parameters (p = 0.015).

CONCLUSION

Abnormal voiding parameters including voided volume and post-void residual urine are prevalent in constipated children. Dilated rectum is associated with abnormal voiding parameters.

Positioning irrigation of contrast cystography for diagnosis of occult vesicoureteric reflux: association with technetium-99m dimercaptosuccinic acid scans

OBJECTIVE

Positioning irrigation of contrast (PIC) cystography identifies occult or PIC vesicoureteral reflux (PIC-VUR) in children with recurrent febrile urinary tract infections (UTI) but no vesicoureteric reflux (VUR) on standard voiding cystourethrogram (VCUG). We sought to identify the relationship between PIC-VUR and renal scarring in technetium-99m dimercaptosuccinic acid (DMSA) scans.

PATIENTS AND METHODS

We retrospectively analysed PIC cystograms and DMSA scans for 154 kidneys in 81 children (65 girls; 16 boys; median age, 4.7 years; range, 0.9-15.2). Renal scarring was graded on a scale of 0-3. DMSA scans were pathologic in 66 patients (81%). Children had experienced mean 3.8 febrile UTI (range 1-25). Forty-seven (58%) children had a history of reflux, including 15 (19%) with previous anti-reflux operations. Indications for PIC cystography were recurrence of febrile UTI after either bilateral negative VCUG (66 children) or unilateral VUR (15 children) with contralateral/bilateral scarring or reflux that had changed sides in subsequent VCUGs.

RESULTS

PIC-VUR was bilateral in 63, unilateral in 12, and absent in 6 children. Statistically significant associations between PIC-VUR grade and severity of renal scarring were identified in inter-individual (n = 77, p = 0.017) and intra-individual (refluxing vs. nonrefluxing kidney; n = 12, p = 0.008) analyses. After excluding patients with history of VUR, statistical significance was maintained in inter-individual analysis (n = 49; p = 0.018).

CONCLUSION

The data suggest an association between PIC-VUR and severity of renal scarring, and legitimise the use of PIC cystography in children with renal scarring due to recurrent febrile UTI but negative findings on VCUG.

Constipation in children with isolated overactive bladders

OBJECTIVE

To evaluate the prevalence of constipation in children with isolated overactive bladder (IOAB) and no micturition complaints.

MATERIALS AND METHODS

A questionnaire was used to evaluate constipation in 51 children with IOAB, as well as in a control group of 74 children between the ages of 4 and 14 years. The Rome III criteria for children were used to assess constipation. IOAB was defined as the presence of symptoms such as urgency with or without daytime incontinence or frequency, a bell-shaped uroflow, and no post-residual urine.

RESULTS

Mean patient ages were 7.94 (±2.8) and 8.28 (±3.4) years in the OAB and control group, respectively (p = 0.54). Twenty-eight (54.9%) of the OAB group were girls, and 34 (45.9%) were girls in the control group (p = 0.32). More of the children with IOAB had constipation than those without urinary symptoms (54.9% vs. 29.7%, p = 0.005; or 2.87, 95% CI: 1.3-6.0). The results were statistically significant regarding the following Rome III criteria: "history of stool retention", "presence of painful or hard bowel movements", "the presence of a large fecal mass in the rectum" and "large diameter stools which may obstruct the toilet". Within the group with OAB, constipation was more common among males (p = 0.05). There was no association between the type of OAB symptoms and constipation. The average dysfunctional voiding symptom score was 9.76 (±4.1). Eleven children (21.6%) presented alterations on ultrasound. Girls with OAB presented more frequently with UTI than boys (18 vs. 10, p = 0.13).

CONCLUSION

This was the first comparative study with respect to constipation in children with IOAB and without urinary symptoms. Children with IOAB have a greater risk of having constipation compared to those with no urinary symptoms.

Evaluation of constipation after parasacral transcutaneous electrical nerve stimulation in children with lower urinary tract dysfunction--a pilot study

OBJECTIVE

To evaluate the efficacy of parasacral transcutaneous electrical nerve stimulation (TENS) for the treatment of constipation in children with lower urinary tract dysfunction (LUTD).

MATERIALS AND METHODS

We treated 9 boys and 5 girls with a mean age of 8.07 ± 2.72 years. 10 (71.4%) had overactive bladder and 4 (28.6%) had voiding dysfunction. A total of 20 parasacral TENS sessions, 20 min each (10 Hz), were performed 3 times per week. The criteria used to assess constipation were the Rome III criteria for children, the Bristol Stool Chart, and a visual analog scale (pain from 0 to 10). The children were reassessed immediately after treatment. No specific treatment of constipation was performed.

RESULTS

After treatment, 85.7% (p < 0.001) of the children's constipation symptoms had improved following the Rome III criteria. Parasacral TENS significantly impacted the following symptoms: "the presence of at least one episode of fecal incontinence per week", "history of stool retention", and "the presence of a large fecal mass in the rectum." There was no significant change in the Bristol Stool Chart evaluation (p < 0.25), but there was a significant improving trend in level of pain before and after treatment (p < 0.063). All urinary symptoms evaluated showed improvement after TENS treatment. There was a decrease in post-void residual urine.

CONCLUSION

In this first study to evaluate the results of parasacral TENS on constipation in children with LUTD, satisfactory results were obtained for both complaints.

Bladder and bowel dysfunction and the resolution of urinary incontinence with successful management of bowel symptoms in children

AIM

To investigate the effect of treating defecation problems on urinary incontinence in children suffering from combined urinary bladder and bowel dysfunction (BBD).

METHODS

We established a clinical database from medical records of all children referred to the urinary incontinence and gastroenterology outpatient clinics with BBD. The following variables were extracted: symptoms of constipation, faecal incontinence, urinary incontinence, age at onset of symptoms, treatment, including duration and response. All children went through the same treatment protocol. Faecal disorders were treated primarily and once relieved, the daytime incontinence was managed and followed by intervention for nocturnal enuresis.

RESULTS

In total, 73 children were included in the study. The treatment regimen resulted in resolution of the defecation disorder in 96% of the patients. Of the children with daytime urinary incontinence, 68% had at least a 50% reduction in number of daytime incontinence episodes by successful relief of bowel dysfunction and 27% became completely continent during daytime. Only 17% of the children suffering from enuresis had a significant reduction in number of wet nights after relief of their faecal problem.

CONCLUSION

The empirical treatment approach of managing bowel symptoms before intervening for bladder dysfunction in children with BBD is found to be appropriate.

Management of functional constipation in children with lower urinary tract symptoms: report from the Standardization Committee of the International Children's Continence Society

PURPOSE

We present a consensus view of members of the International Children's Continence Society (ICCS) together with pediatric gastroenterologists, experts in the field of functional gastrointestinal disorders, on the management of functional constipation in children with lower urinary tract symptoms.

MATERIALS AND METHODS

Discussions were held by the board of the ICCS and a multidisciplinary core group of authors was appointed. The draft document review process was open to all ICCS members via the website. Feedback was considered by the core authors and, by agreement, amendments were made as necessary.

RESULTS

Guidelines on the assessment, and pharmacological and nonpharmacological management of functional constipation in children with lower urinary tract symptoms are outlined.

CONCLUSIONS

The final document is not a systematic literature review. It includes relevant research when available, as well as expert opinion on the current understanding of functional constipation in children with lower urinary tract symptoms. The document is intended to be clinically useful in primary, secondary and tertiary care settings.

[Voiding disorders in childhood: from symptoms to diagnosis]

The new definitions of voiding disorders in children should be used in clinical practice. Two major kinds of voiding disorders are identified: 1) isolated primary enuresis as a disorder occurring exclusively during sleep with no daytime leakage; 2) urinary dysfunctions that include uninhibited detrusor contraction, sphincter hypertonicity, and urethral instability. These dysfunctions may be primary or secondary. Constipation as an underlying cause is frequent and usually underestimated. The diagnostic process requires one (or more) long consultations. After ruling out a urine leak without a voiding disorder and secondary causes (constipation, inadequate hydration, poor voiding hygiene, crystalluria, etc.), the aim is to distinguish isolated sleep-time disorders (primary enuresis) from daytime ± sleep-time symptoms (primary urinary dysfunctions). Anamnesis, long and accurate, can be sensitized by a questionnaire completed at home. The physical examination focuses on the exclusion of anatomic abnormalities and local inflammation (vulvitis, balanitis, etc.). Diagnostic tests are rarely required at the beginning. Urodynamic exploration may be indicated, never at the first consultation, in case of primary urinary dysfunction. This diagnostic approach provides an appropriate therapeutic decision.

The prevalence and therapeutic effect of constipation in pediatric overactive bladder

PURPOSE

Overactive bladder (OAB) is a manifestation of urgency, regardless of urge incontinence, due to involuntary bladder contraction during the storage period. There is a close association between constipation and OAB, but constipation cannot be readily diagnosed. The aims of this study were to evaluate the prevalence of constipation in OAB and the consequent therapeutic effects according to the diagnostic criteria for constipation.

METHODS

We collected clinical data from 40 children (mean age, 71±22 months) with chief complaints of urgency, frequency, and incontinence. A voiding questionnaire and a 2-day voiding diary were collected, and urinalysis, the Bristol stool scale, and plain abdominal radiography were performed. Constipation was defined as conditions satisfying at least one of the following criteria: Rome III diagnostic criteria, Bristol stool scale types I/II, or a Leech score higher than 8 points as determined by plain radiography. Lower urinary tract symptoms, defecation symptoms, and the bladder volume of patients were examined, and the therapeutic outcomes by constipation diagnostic criteria were evaluated.

RESULTS

Of the 40 OAB patients, 25 had constipation. Among them, 6 had reduced functional bladder capacity (24%; P>0.05). Regarding treatment, in patients who satisfied only one diagnostic criterion, the symptoms improved in 76.9%, 76.9%, and 69.6% of patients meeting the Rome III criteria, Bristol stool scale, and Leech score, respectively (P<0.05). Among the 8 patients satisfying all three criteria, 75% responded to treatment (P<0.05).

CONCLUSIONS

The prevalence of constipation in OAB is high. Constipated patients recruited by use of the Rome III criteria, Bristol scale, and Leech score alone and together showed similar outcomes on OAB improvement after the treatment of constipation, which implies that each criterion has the same strength and can be applied comprehensively and generally.

Constipation and LUTS - how do they affect each other?

CONTEXT

Urinary bladder and rectum share a common embryological origin. Their autonomic and somatic innervations have close similarities. Moreover, the close proximity of these two organ systems could suggest that dysfunction in one may influence, also mechanically, the function of the other. Therefore, it is not surprising that defecation problems and lower urinary tract symptoms (LUTS) occur together, as reported in the literature.

OBJECTIVE

To study the relationship between constipation and LUTS focusing on what is evidence-based.

EVIDENCE ACQUISITION

We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE) database in February 2010 to retrieve English language studies (from 1997 to 2009) and the 2005, 2006 and 2007 abstract volumes of the European Association of Urology (EAU), American Urological Association (AUA) and International Continence Society (ICS).

EVIDENCE SYNTHESIS

We present the findings according to the studied population in four groups: (a) children, (b) middle-aged women, (c) elderly and (d) neuropathic patients. Most published studies that correlated rectal and bladder dysfunction were carried out in children or in young women. On the other hand, there are few studies regarding the association between constipation and LUTS in the elderly and in neuropathic patients.

CONCLUSIONS

Several studies in children documented that constipation is linked to urinary tract problems, including infections, enuresis, vesicoureteral reflux and upper renal tract dilatation. The underlying pathophysiology of these findings has not yet been clearly defined. Studies in middle-aged women also support a high prevalence of constipation among patients suffering from urinary tract dysfunction. Furthermore, an association between constipation and urinary incontinence, as well as between constipation and pelvic organ prolapse, has been suggested. The only prospective study in constipated elderly with concomitant LUTS demonstrates that the medical relief of constipation also significantly improves LUTS. Finally, the available data on neuropathic patients suggest that stool impaction in the rectum may mechanically impede bladder emptying. However, most of the studies only include a small number of patients, are not prospective and are uncontrolled. Therefore, there is a need for large-scale, controlled studies to further improve evidence and to provide a valid recommendation for all groups, especially for the elderly and neuropathic patients.

Update on childhood urinary tract infection and vesicoureteral reflux

Urinary tract infection (UTI) is a leading cause of serious bacterial infection in young children. Vesicoureteral reflux (VUR), a common pediatric urologic disorder, is believed to predispose to UTI, and both are associated with renal scarring. The complex interaction of bacterial virulence factors and host defense mechanisms influence renal damage. However, some renal parenchymal abnormalities associated with VUR are noninfectious in origin. Long-term, renal parenchymal injury may be associated with hypertension, pregnancy complications, proteinuria, and renal insufficiency. Optimal management of VUR and UTI is controversial because of the paucity of appropriate randomized controlled trials; there is a need for well-designed studies. The recently launched Randomized Intervention for children with VesicoUreteral Reflux (RIVUR) study hopefully will provide insight into the role of antimicrobial prophylaxis of UTI in children with VUR.

Encopresis, soiling and constipation in children and adults with developmental disability

Children and adults with developmental disabilities are more likely to evince encopresis, soiling and constipation than the general population. This set of related behaviors can produce a great deal of stress and can be a major restriction in independent living. This paper provides a review of the current state of knowledge on the prevalence, etiology, assessment and treatment of this co-occurring set of disorders. These problems are more common in persons with developmental disabilities then the general population. Furthermore, classical and operant treatment methods appear to be the best supported interventions for most cases. Strengths and weaknesses of the current research base are discussed along with potential avenues for future research.

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.

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.

Medical management of vesicoureteral reflux--quiz within the article. Don't overlook placebos

Vesicoureteral reflux (VUR) in children is associated with increased risk of urinary tract infection (UTI). Recurrent UTI in the presence of the VUR is believed to cause renal scarring, which carries a risk of subsequent hypertension, toxemia of pregnancy, and significant renal damage, including end-stage renal disease. The natural history of VUR is to improve or resolve completely with time in most of the patients. The traditional management consists of prompt treatment of UTI, long-term anti-microbial prophylaxis until the VUR resolves, or surgical intervention in those with persistent high grade VUR, recurrent UTI in spite of prophylaxis with anti-microbial agent, allergy to anti-microbial agents, and patient/parent non-compliance with the medical management. Voiding dysfunction and constipation play an important role, and their diagnosis and appropriate management helps reduce the frequency of UTI and promote the resolution of the VUR. Patients with renal scarring need to be monitored for potential complications such as hypertension, proteinuria, and progression of the renal damage. In patients with hypertension and/or proteinuria, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are the drugs of choice, because of their reno-protective properties. Recent studies have revealed that there is no convincing evidence that UTI in the presence of VUR predicts renal injury or that the use of long-term anti-microbial prophylaxis or surgical intervention prevents renal scarring or its progression. However, until proven otherwise by a prospective, placebo-controlled, randomized study, it is advisable to err on the side of caution and consider VUR and UTI risk factors for renal scarring and treat each patient on individual basis.

Symptom score for lower urinary tract dysfunction in pediatric urology

Lower urinary tract dysfunction is a common component of virtually every pediatric urologist's practice. Although lower urinary tract dysfunction should be considered more of a social nuisance than a true medical condition, if left unchecked, real comorbidities may occur. A thorough history, physical examination, voiding diary, and noninvasive urodynamic studies, such as flow rate or flow rate with electromyography, generally are used to make an accurate diagnosis. Once the diagnosis is established, a wide range of therapies are available and their use may be based on the age of the child, duration of symptoms, etiology of the lower urinary tract dysfunction and associated urologic disease, and physician or family preferences. Symptom scoring systems have been devised to confirm diagnosis of lower urinary tract dysfunction, classify its severity, and serve as a monitoring instrument to determine response to treatment.

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.

Voiding dysfunction: outcome in infants with congenital vesicoureteral reflux

OBJECTIVES

To assess the rate of development of voiding dysfunction as an outcome in patients with congenital vesicoureteral reflux.

METHODS

A computerized database was used to review the medical records of all patients with congenital reflux diagnosed before 6 months of age from 1988 to 2002. Only those infants with reflux who were followed up for at least 6 months past the age of toilet training were included. The parameters tabulated in this group included the presence of frequency, daytime wetting, urge incontinence, and infrequent voiding. The variables were summarized using contingency tables, and associations were evaluated using chi-square analysis and Fisher's exact test.

RESULTS

Of 342 patients (145 boys and 197 girls) with reflux, 67 (19.6%) developed voiding dysfunction (17.9% boys and 20.8% girls). No statistically significant difference was found between high grade (IV and V) and low grade (I and II) or grade III reflux, or between unilateral and bilateral reflux for the development of voiding dysfunction. Of the patients with reflux who had renal damage on dimercaptosuccinic acid scan, 24.3% of girls and 30.4% of boys developed voiding dysfunction, which was not significantly different from those without renal damage.

CONCLUSIONS

Approximately 20% of patients with vesicoureteral reflux diagnosed before 6 months of age demonstrated dysfunctional voiding after the age of toilet training. Voiding dysfunction occurred independent of sex, laterality, or severity of vesicoureteral reflux. Infants with renal damage on dimercaptosuccinic acid scan developed dysfunctional voiding only at a slightly greater, but not significantly different, rate than those with normal kidneys.

Chronic constipation in children: organic disorders are a major cause

Diagnostic tools for paediatric chronic constipation have been limited, leading to over 90% of patients with treatment-resistant constipation being diagnosed with chronic idiopathic constipation, with no discernible organic cause. Work in our institution suggests that a number of children with intractable symptoms actually have slow colonic transit leading to slow transit constipation. This paper reviews recent data suggesting that a significant number of the children with chronic treatment-resistant constipation may have organic causes (slow colonic transit and outlet obstruction) and suggests new approaches to the management of children with chronic treatment-resistant constipation.