Abstracts
Introduction:
The lower urinary tract dysfunction (LUTD) corresponds to changes in the filling or emptying of urine caused by neurogenic, anatomical and functional alterations.
Objective:
To evaluate the impact of treatment in children and adolescents with LUTD.
Methods:
Historical cohort of 15 year follow-up with the participation of 192 patients (123F, 69M), aged 0.1 to 16.8 years, analyzed at admission (T0) and at final follow-up (T1). Most patients belong to a neurologic bladder dysfunction group (60.4%). The treatment was uroterapy with behavioral and cognitive intervention, timed voiding, oral hydration, laxative diet, biofeedback, sacral nerve stimulation, clean intermittent catheterization (CIC), anticholinergic therapy, rectal enema, treatment of urinary tract infection (UTI) and, in refractory cases, surgical procedures such as continent and incontinent urinary diversion (vesicostomy), bladder augmentation and conduit for performing antegrade colonic enema.
Results:
The main symptoms were daytime urinary incontinence (82.3%), the non-monosymptomatic nocturnal enuresis (78.6%), fecal incontinence (54.2%) and constipation (47.9%). There was a significant reduction of urinary tract infection (p = 0.0027), daytime urinary incontinence (p < 0.001), nocturnal enuresis (p < 0.001), fecal incontinence (p = 0.010) and of vesicoureteral reflux (p = 0.01). There was significant increase in the use of CIC (p = 0.021), of anticholinergic therapy (p < 0.001) and decrease of chemoprophylaxis (p < 0.001).
Conclusion:
This study showed that treatment of LUTD in children must be individualized, and requires constant monitoring of clinical, laboratory and imaging to minimize the risk of kidney damage.
bacteriuria; constipation; enuresis; intermittent urethral catheterization; urinary bladder, overactive; urinary bladder, neurogenic; urinary incontinence
Introdução:
A disfunção do trato urinário inferior (DTUI) corresponde a alterações no enchimento ou esvaziamento de urina de causas neurogênicas, anatômicas e funcionais.
Objetivo:
Avaliar o impacto do tratamento em crianças e adolescentes com DTUI.
Métodos:
Coorte histórica de 15 anos de seguimento com participação de 192 pacientes (123F, 69M) com idade inicial de 0,1 a 16,8 anos, analisados à admissão (T0) e ao final do seguimento (T1). A maioria dos pacientes era do grupo neurológico (60,4%). O tratamento instituído foi a uroterapia com intervenção comportamental e cognitiva, micção de hora marcada, hidratação oral, dieta laxativa, biofeedback, eletroestimulação sacral, cateterismo vesical intermitente limpo (CIL), terapia anticolinérgica, enema retal, tratamento da infecção do trato urinário (ITU) e, nos casos refratários, procedimentos cirúrgicos, tais como a derivação urinária continente e incontinente (vesicostomia), ampliação vesical e conduto para a realização do enema anterógrado cólico.
Resultados:
Os principais sintomas foram incontinência urinária diurna (82,3%), enurese noturna não monossintomática (78,6%), incontinência fecal (54,2%) e constipação intestinal (47,9%). Detectou-se redução significativa da infecção do trato urinário (p = 0,0027), da incontinência urinária diurna (p < 0,001), da enurese noturna (p < 0,001), da incontinência fecal (p = 0,010) e do refluxo vesicoureteral (p = 0,01). Houve aumento significativo no uso do CIL (p = 0,021), da terapia com anticolinérgico (p < 0,001) e diminuição da quimioprofilaxia (p < 0,001).
Conclusão:
Este estudo mostrou que o tratamento da DTUI na criança deve ser individualizado, além de requerer uma monitorização constante dos parâmetros clínicos, laboratoriais e de imagem, para minimizar o risco de lesão renal.
bacteriuria; bexiga urinaria neurogênica; bexiga urinária hiperativa; cateterismo uretral intermitente; constipação intestinal; enurese; incontinência urinária
Introduction
Lower urinary tract dysfunction (LUTD) is an extremely complex condition. It involves
multiple factors and processes that influence the storage or urine and micturition,
including the bladder itself (smooth muscle, urothelium, connective tissue, and
matrix), muscle contraction and the contractile system, humoral and endocrine
messages, and, last but not least, the entire neuraxis from the postganglionic
neurons through to the spinal cord, brain stem, and cerebral cortex.11 Tutlle JB. New tools to study bladder dysfunction. J Urol
2010;183:423-4. DOI: http://dx.doi.org/10.1016/j.juro.2009.11.069
http://dx.doi.org/10.1016/j.juro.2009.11...
In LUTD, bladder filling and emptying may be affected by anatomical, neurological or functional alterations.22 Nørgaard JP, van Gool JD, Hjälmås K, Djurhuus JC, Hellström AL. Standardization and definitions in lower urinary tract dysfunction in children. International Children's Continence Society. Br J Urol 1998;81:1-16. PMID: 9634012 The quality of life of the individuals with this condition may be significantly impaired. Pediatric patients are particularly prone to developing emotional disorders when faced with urinary or fecal incontinence caused by loss of sphincter control. Children with LUTD suffer from low self-esteem, insecurity, anxiety, and decreased socialization, thus affecting their parents and family life.
Congenital malformations of the neural tube such as myelomeningocele, meningocele,
and lipomeningocele are the most frequent causes of neurogenic bladder in
children33 Verpoorten C, Buyse GM. The neurogenic bladder: medical treatment.
Pediatr Nephrol 2008;23:717-25. DOI:
http://dx.doi.org/10.1007/s00467-007-0691-z
http://dx.doi.org/10.1007/s00467-007-069...
and predispose patients to
injuries of the upper urinary tract due to increased bladder pressure,
detrusor-sphincter dyssynergia, post-void residual urine, and urinary tract infection
with or without vesicoureteral reflux.44 Thorup J, Biering-Sorensen F, Cortes D. Urological outcome after
myelomeningocele: 20 years of follow-up. BJU Int 2011;107:994-9. DOI:
http://dx.doi.org/10.1111/j.1464-410X.2010.09681.x
http://dx.doi.org/10.1111/j.1464-410X.20...
Thirty
to 40% of the children with myelomeningocele develop some degree of renal
dysfunction. This complication can be prevented or attenuated with appropriate
treatment aimed at reducing bladder pressure and treating post-void residual
urine.55 Müller T, Arbeiter K, Aufricht C. Renal function in meningomyelocele:
risk factors, chronic renal failure, renal replacement therapy and transplantation.
Curr Opin Urol 2002;12:479-84. DOI:
http://dx.doi.org/10.1097/00042307-200211000-00006
http://dx.doi.org/10.1097/00042307-20021...
Children with untreated detrusor-sphincter dyssynergia develop upper urinary tract
lesions, which may in some cases be present as early as in fetal life.66 Bauer SB, Austin PF, Rawashdeh YF, de Jong TP, Franco I, Siggard C, et
al. International Children's Continence Society's recommendations for initial
diagnostic evaluation and follow-up in congenital neuropathic bladder and bowel
dysfunction in children. Neurourol Urodyn 2012;31:610-4. DOI:
http://dx.doi.org/10.1002/nau.22247
http://dx.doi.org/10.1002/nau.22247...
Children with neurogenic bladders must be
followed in an outpatient regime since their first year of life, in order to detect
the early signs of kidney involvement that may trigger the progression of chronic
kidney disease.77 Dik P, Klijn AJ, van Gool JD, de Jong-de Vos van Steenwijk CC, de Jong
TP. Early start to therapy preserves kidney function in spina bifida patients. Euro
Urol 2006;49:908-13. DOI:
http://dx.doi.org/10.1016/j.eururo.2005.12.056
http://dx.doi.org/10.1016/j.eururo.2005....
,88 Olandoski KP, Koch V, Trigo-Rocha FE. Renal function in children with
congenital neurogenic bladder. Clinics (Sao Paulo) 2011;66:189-95. DOI:
http://dx.doi.org/10.1590/S1807-59322011000200002
http://dx.doi.org/10.1590/S1807-59322011...
When LUTD has no neurological or anatomical cause, it is called urinary tract
functional disorder, a condition believed to be related to genetic factors,
neurological immaturity, inadequate sphincter training and voiding habits,99 Meneses RP. Atualização em nefrologia pediátrica: distúrbios funcionais
na infância. J Bras Nefrol 2000;22:95-102.
10 Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W, et al.
The standardization of terminology of lower urinary tract function in children and
adolescents: report from the Standardisation Committee of the International
Children's Continence Society. J Urol 2006;176:314-24. PMID: 16753432 DOI:
http://dx.doi.org/10.1016/S0022-5347(06)00305-3
http://dx.doi.org/10.1016/S0022-5347(06)...
-1111 Ellsworth P, Caldamone A. Pediatric voiding dysfunction: current
evaluation and management. Urol Nurs 2008;28:249-57. emotional problems, stress, sexual abuse, or unknown causes.1111 Ellsworth P, Caldamone A. Pediatric voiding dysfunction: current
evaluation and management. Urol Nurs 2008;28:249-57.
The type of lower urinary tract dysfunction must be clearly identified before patients can be offered specific treatment. Interdisciplinary treatment should be directed to the preservation of renal function and improvement of urinary continence.1212 Borzyskowski M. Neuropathic bladder: identification, investigation, and management. In: Webb N, Postlethwaite R, eds. Clinical paediatric nephrology. 3rd ed. Oxford: Oxford University Press; 2003. p.179-94.
This study aimed to assess the impact of treatment on patients treated at the LUTD Clinic followed up for 15 years.
Methods
This is a retrospective longitudinal observational epidemiological cohort study. The Research Ethics Committee of the institution approved the design of the study. Patients or their caregivers were asked to give informed consent before joining the study.
One hundred and ninety-two patients with LUTD of neurological and non-neurological causes submitted to workup were included in the study. Seventy-three were excluded for not meeting the enrollment criteria.
Clinically stable patients were scheduled to return to the LUTD Clinic every four or six months or within shorter time intervals when needed. The workup defined in the study protocol consisted of the following:
• Assessment of renal function on admission, annual urinalysis, and urine culture on every visit to the clinic.
• Renal ultrasound and voiding dynamics annually.1313 Filgueiras MF, Lima EM, Sanchez TM, Goulart EM, Menezes AC, Pires CR. Bladder dysfunction: diagnosis with dynamic US. Radiology 2003;227:340-4. PMID: 12676967 DOI: http://dx.doi.org/10.1148/radiol.2272011872
http://dx.doi.org/10.1148/radiol.2272011...• Voiding cystourethrography or radioisotope cystography and urodynamic test on admission for patients with neurological etiology LUTD and based on patient clinical evolution.
• Static renal scintigraphy on admission, repeated in the presence of changes in the initial examination.
• Dynamic renal scintigraphy upon signs of urinary obstruction.
Based on workup results, the treatment offered to LUTD patients consisted of the following:
Conservative treatment: anticholinergics, alpha-blockers, prophylactic chemotherapy, intestinal modulators, and clean intermittent catheterization (CIC).
Urotherapy and behavioral therapy including timed voiding, two-stage voiding, adequate fluid intake, laxative diet, voiding posture, voiding map, pelvic floor training using biofeedback or sacral nerve stimulation.
Surgery: incontinent (vesicostomy) or continent urinary diversion, bladder augmentation, and placement of an antegrade colonic conduit to allow rectal enemas to be carried out.
Patient clinical, workup, and imaging data were collected from their medical records. Patients were examined on admission (start time - T0) and on their last visit (finish time - T1).
The following parameters were assessed: daytime wetting, non-monosymptomatic nocturnal enuresis, constipation, fecal incontinence, urinary tract infection, asymptomatic bacteriuria, thickening of the bladder wall, involuntary detrusor contractions, pelvic and/ or calicial dilation, ureteral dilation, trabeculated bladder, bladder diverticulum, post-void residual urine, vesicoureteral reflux, and renal scarring.
Descriptive statistical analysis resorted to median, minimum and maximum values, and percent distribution of categorical variables to characterize the collected data. The results of the interventions performed in the LUTD Clinic were assessed. Clinical data and imaging parameters (ultrasound, radiology, and nuclear medicine images) captured on admission and at the end of follow-up were compared. The odds ratios of an event occurring at two different times (on admission and at the end of follow-up) were calculated. Statistical significance was attributed to differences between variables with a p < 0.05.
Results
The study included 192 patients (123 ♀, 69 ♂) with a median age of 6.6 (0.1 to 6.8) years followed up for a median of 4.9 (0.6 to 15.1) years.
The etiology of LUTD was mostly neurological (n = 16; 60.4%), with myelomeningocele (MMC) as the main diagnosis at baseline (n = 90; 77.6%) followed by sacral agenesis (n = 5; 4.3%), spine cord tumors (n = 4; 3.4%), and others. Most patients with MMC (70%) had hydrocephalus treated with ventriculoperitoneal (VP) shunts.
With respect to non-neurological etiologies, functional disorder (n = 46; 60.5%) and vesicoureteral reflux (VUR, n = 20; 26.3%) were the most prevalent causes of LUTD. Many of the patients with reflux had been diagnosed before they came to the Clinic. Renal function was normal in patients with LUTD regardless of etiology, with a median creatinine clearance of 138 (36.0 to 456.5) ml/min/1.73 m2.
Table 1 shows that on admission the majority of the patients had daytime urinary incontinence and non-monosymptomatic nocturnal enuresis. Approximately half of the patients had constipation and fecal incontinence. Urinary tract infection occurred in 15% of the patients, whereas asymptomatic bacteriuria was more prevalent, affecting approximately a third of the enrolled individuals.
Imaging findings (Table 1) revealed that most patients had involuntary detrusor contractions and about half had ureteral dilation and post-void residual urine.
In terms of bladder emptying methods, 49 (25.5%) patients used clean intermittent catheterization, 93 (48.4%) resorted to chemoprophylaxis, and 139 (72.4%) did not take anticholinergics.
When surgery was considered, 14 patients (7.3%) had undergone incontinent urinary diversion procedures, three (1.6%) continent urinary diversion procedures, two (1.0%) had been submitted to bladder augmentation, and one (0.5%) had performed an antegrade colonic conduit procedure at T0. At T1, only eight patients (4.2%) had undergone incontinent urinary diversion, 11 (5.7%) continent urinary diversion, seven (3.6%) bladder augmentation, and four (2.1%) antegrade colonic conduit procedures.
Significant reductions in daytime urinary incontinence, non-monosymptomatic nocturnal enuresis, fecal incontinence, UTI, and VUR were observed at T1. Significant decreases were also seen in the use of chemoprophylaxis (OR = 0.20; p < 0.001), along with a significant increase in the use of anticholinergics (OR = 2.31; p < 0.001) and increased use of clean intermittent catheterization (OR = 1.67; p = 0.021). Pyelocaliceal and ureteral dilatation increased significantly. No alterations were seen in asymptomatic bacteriuria (Table 1).
Discussion
Analyzing the impact of treatment on patients is a way of understanding and evaluating whether the procedures adopted by the interdisciplinary team in the care of these patients are being effective or if they need to be replaced or complemented with other interventions.
Diurnal and nocturnal urinary incontinence are common clinical entities in pediatric
urology, with prevalence ranging between 2% and 7% in children aged around seven
years.1414 Lee SD, Sohn DW, Lee JZ, Park NC, Chung MK. An epidemiological study of
enuresis in Korean children. BJU Int 2000;85:869-73. PMID: 10792168 DOI:
http://dx.doi.org/10.1046/j.1464-410x.2000.00617.x
http://dx.doi.org/10.1046/j.1464-410x.20...
Leonardo et
al.1515 Leonardo CR, Filgueiras MF, Vasconcelos MM, Vasconcelos R, Marino VP,
Pires C, et al. Risk factors for renal scarring in children and adolescents with
lower urinary tract dysfunction. Pediatr Nephrol 2007;22:1891-6. DOI:
http://dx.doi.org/10.1007/s00467-007-0564-5
http://dx.doi.org/10.1007/s00467-007-056...
studied children and
adolescents with LUTD and reported daytime urinary incontinence rates of 88% among
patients in the neurological group and 73.6% in the non-neurological etiology group.
In another study, daytime urinary incontinence was reported to have occurred in 60.9%
of the patients with open and hidden spina bifida.1616 Verhoef M, Lurvink M, Barf HA, Post MW, van Asbeck FW, Gooskens RH, et
al. High prevalence of incontinence among young adults with spina bifida:
description, prediction and problem perception. Spinal Cord 2005;43:331-40. PMID:
15685262 DOI: http://dx.doi.org/10.1038/sj.sc.3101705
http://dx.doi.org/10.1038/sj.sc.3101705...
Vasconcelos et al.1717 Vasconcelos M, Lima E, Caiafa L, Noronha A, Cangussu R, Gomes S, et al.
Voiding dysfunction in children. Pelvic-floor exercises or biofeedback therapy: a
randomized study. Pediatr Nephrol 2006;21:1858-64. DOI:
http://dx.doi.org/10.1007/s00467-006-0277-1
http://dx.doi.org/10.1007/s00467-006-027...
studied
patients with refractory functional LUTD treated conventionally and found that 75% of
the enrolled subjects had daytime urinary incontinence and 53.3% had
non-monosymptomatic nocturnal enuresis, confirming the high frequency of occurrence
of these symptoms.
Patients with LUTD are more exposed to the risks of having urinary tract infections
due to the presence of post-void residual urine in their bladders and other
urodynamic alterations. Transmural inflammation and fibrosis may further deteriorate
the status of the bladder. LUTD has been associated high intravesical pressure and/or
VUR and may cause acute pyelonephritis and renal injury. Patients with persistent
relapsing UTI with fever - infants in particular - are more likely to develop renal
scarring.1818 Jakobsson B, Jacobson SH, Hjalmås K. Vesico-ureteric reflux and other
risk factors for renal damage: identification of high- and low-risk children. Acta
Paediatr Suppl 1999;88:31-9. PMID: 10588269 DOI:
http://dx.doi.org/10.1111/j.1651-2227.1999.tb01316.x
http://dx.doi.org/10.1111/j.1651-2227.19...
,1919 Orellana P, Baquedano P, Rangarajan V, Zhao JH, Eng ND, Fettich J, et
al. Relationship between acute pyelonephritis, renal scarring, and vesicoureteral
reflux. Results of a coordinated research project. Pediatr Nephrol
2004;19:1122-6. Therefore, UTI requires early aggressive
treatment, as renal injury and failure are among its most serious complications.
Early diagnosis and prompt treatment of UTI are part of the protocol in effect at our
clinic designed to preserve patient renal function.
Since most patients in this study had neurogenic bladders accompanied by more complex
urodynamic conditions and post-void residual urine volumes greater than 20 ml, the
use of CIC was significantly increased (p = 0.021). The procedure -
performed every three or four hours - may have contributed to significant reductions
in the occurrence of UTI, daytime urinary incontinence, non-monosymptomatic nocturnal
enuresis, and VUR. Other studies also reinforce the use of CIC in cases of incomplete
voiding with significant levels of post-void residual urine22 Nørgaard JP, van Gool JD, Hjälmås K, Djurhuus JC, Hellström AL.
Standardization and definitions in lower urinary tract dysfunction in children.
International Children's Continence Society. Br J Urol 1998;81:1-16. PMID:
9634012,1010 Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W, et al.
The standardization of terminology of lower urinary tract function in children and
adolescents: report from the Standardisation Committee of the International
Children's Continence Society. J Urol 2006;176:314-24. PMID: 16753432 DOI:
http://dx.doi.org/10.1016/S0022-5347(06)00305-3
http://dx.doi.org/10.1016/S0022-5347(06)...
and
neurogenic bladder.2020 Coward RJ, Saleem MA. The neuropathic bladder of childhood. Curr Pediatr
2001;11:135-42. DOI: http://dx.doi.org/10.1054/cupe.2000.0161
http://dx.doi.org/10.1054/cupe.2000.0161...
A study carried out
previously in our Clinic with patients on CIC described it as an effective procedure
in promoting bladder emptying, reducing the occurrence of urinary infections even
when the catheter was reused, and improving urinary continence despite the increase
in cases of asymptomatic bacteriuria,2121 Azevedo RVM. Fatores de risco para infecção do trato urinário em
crianças e adolescentes portadores de disfunção vesical que realizam o cateterismo
vesical intermitente limpo [Dissertação de mestrado]. Belo Horizonte: Universidade
Federal de Minas Gerais; 1999. as
described by other authors.88 Olandoski KP, Koch V, Trigo-Rocha FE. Renal function in children with
congenital neurogenic bladder. Clinics (Sao Paulo) 2011;66:189-95. DOI:
http://dx.doi.org/10.1590/S1807-59322011000200002
http://dx.doi.org/10.1590/S1807-59322011...
,2222 Lapides J, Diokno AC, Silber SJ, Lowe BS. Clean, intermittent
self-catheterization in the treatment of urinary tract disease. J Urol
1972;107:458-61. PMID: 5010715 Many patients on CIC were able to be socially
continent, without experiencing urine leakages between catheterizations. CIC training
can be performed with the patient's caregiver - in most cases the subject's mother -
or the child himself, when he shows interest in self-care and has no physical or
cognitive limitations.
Asymptomatic bacteriuria was not a very prevalent condition in the two groups of
patients at the time of admission, but it increased slightly at the end of the
follow-up period (Table 1). This may be
explained by the fact that CIC - often associated with asymptomatic bacteriuria - was
prescribed at length for patients with post-void residual urine in their bladders.
Patients on CIC are expected to have asymptomatic bacteriuria. As the procedure is
clean but not sterile, inoculation of bacteria into the bladder is inevitable as the
catheter is inserted.2323 Dilks SA, Schlager T, Kopco JA, Lohr JA, Gressard RP, Hendley JO, et al.
Frequency and correlates of bacteriuria among children with neurogenic bladder. South
Med J 1993;86:1372-5. PMID: 8272914
24 Schlager TA, Anderson S, Trudell J, Hendley JO. Nitrofurantoin
prophylaxis for bacteriuria and urinary tract infection in children with neurogenic
bladder on intermittent catheterization. J Pediatr 1998;132:704-8. PMID: 9580774 DOI:
http://dx.doi.org/10.1016/S0022-3476(98)70364-6
http://dx.doi.org/10.1016/S0022-3476(98)...
25 Seki N, Masuda K, Kinukawa N, Senoh K, Naito S. Risk factors for febrile
urinary tract infection in children with myelodysplasia treated by clean intermittent
catheterization. Int J Urol 2004;11:973-7. DOI:
http://dx.doi.org/10.1111/j.1442-2042.2004.00943.x
http://dx.doi.org/10.1111/j.1442-2042.20...
26 Guidoni EB, Dalpra VA, Figueiredo PM, da Silva Leite D, Mímica LM, Yano
T, et al. E. coli virulence factors in children with neurogenic bladder associated
with bacteriuria. Pediatr Nephrol 2006;21:376-81. DOI:
http://dx.doi.org/10.1007/s00467-005-2133-0
http://dx.doi.org/10.1007/s00467-005-213...
-2727 Rawashdeh YF, Austin P, Siggaard C, Bauer SB, Franco I, de Jong TP, et
al.; International Children's Continence Society. International Children's Continence
Society's recommendations for therapeutic intervention in congenital neuropathic
bladder and bowel dysfunction in children. Neurourol Urodyn 2012;31:615-20. DOI:
http://dx.doi.org/10.1002/nau.22248
http://dx.doi.org/10.1002/nau.22248...
Previous studies indicate that asymptomatic
bacteriuria does not cause kidney injury,1515 Leonardo CR, Filgueiras MF, Vasconcelos MM, Vasconcelos R, Marino VP,
Pires C, et al. Risk factors for renal scarring in children and adolescents with
lower urinary tract dysfunction. Pediatr Nephrol 2007;22:1891-6. DOI:
http://dx.doi.org/10.1007/s00467-007-0564-5
http://dx.doi.org/10.1007/s00467-007-056...
,2828 Linshaw MA. Asymptomatic bacteriuria and vesicoureteral reflux in
children. Kidney Int 1996;50:312-29. DOI:
http://dx.doi.org/10.1038/ki.1996.317
http://dx.doi.org/10.1038/ki.1996.317...
29 Bakke A, Vollset SE. Risk factors for bacteriuria and clinical urinary
tract infection in patients treated with clean intermittent catheterization. J Urol
1993;149:527-31. PMID: 8437255-3030 Zegers B, Uiterwaal C, Kimpen J, van Gool J, de Jong T, Winkler-Seinstra
P, et al. Antibiotic prophylaxis for urinary tract infections in children with spina
bifida on intermittent catheterization. J Urol 2011;186:2365-70. PMID: 22019031 DOI:
http://dx.doi.org/10.1016/j.juro.2011.07.108
http://dx.doi.org/10.1016/j.juro.2011.07...
and that antibiotics should not be prescribed
to treat it, as such therapy could favor the selection of more pathogenic bacteria
that could cause antimicrobial agent-resistant UTI.2424 Schlager TA, Anderson S, Trudell J, Hendley JO. Nitrofurantoin
prophylaxis for bacteriuria and urinary tract infection in children with neurogenic
bladder on intermittent catheterization. J Pediatr 1998;132:704-8. PMID: 9580774 DOI:
http://dx.doi.org/10.1016/S0022-3476(98)70364-6
http://dx.doi.org/10.1016/S0022-3476(98)...
,2727 Rawashdeh YF, Austin P, Siggaard C, Bauer SB, Franco I, de Jong TP, et
al.; International Children's Continence Society. International Children's Continence
Society's recommendations for therapeutic intervention in congenital neuropathic
bladder and bowel dysfunction in children. Neurourol Urodyn 2012;31:615-20. DOI:
http://dx.doi.org/10.1002/nau.22248
http://dx.doi.org/10.1002/nau.22248...
,2828 Linshaw MA. Asymptomatic bacteriuria and vesicoureteral reflux in
children. Kidney Int 1996;50:312-29. DOI:
http://dx.doi.org/10.1038/ki.1996.317
http://dx.doi.org/10.1038/ki.1996.317...
In this study, chemoprophylaxis at baseline was used by almost half of the patients.
At the end of follow-up, the use of this therapy had significantly decreased. This
finding can be clearly explained by the change in the approach adopted by the medical
team treating the patients. The protocol currently in use at the LUTD Clinic is based
on the literature and recommends chemoprophylaxis only for infants suffering from VUR
or individuals with recurrent UTI for whom other causes of sustained infection have
been ruled out.3030 Zegers B, Uiterwaal C, Kimpen J, van Gool J, de Jong T, Winkler-Seinstra
P, et al. Antibiotic prophylaxis for urinary tract infections in children with spina
bifida on intermittent catheterization. J Urol 2011;186:2365-70. PMID: 22019031 DOI:
http://dx.doi.org/10.1016/j.juro.2011.07.108
http://dx.doi.org/10.1016/j.juro.2011.07...
According to Zegers
et al.,3030 Zegers B, Uiterwaal C, Kimpen J, van Gool J, de Jong T, Winkler-Seinstra
P, et al. Antibiotic prophylaxis for urinary tract infections in children with spina
bifida on intermittent catheterization. J Urol 2011;186:2365-70. PMID: 22019031 DOI:
http://dx.doi.org/10.1016/j.juro.2011.07.108
http://dx.doi.org/10.1016/j.juro.2011.07...
discontinuation
of chemoprophylaxis in patients with neurogenic bladders and detrusor-sphincter
dyssynergia on clean intermittent catheterization does not significantly increase the
number of cases of UTI, showing that it should be discontinued as soon as specific
treatment is instituted.
The reduction of vesicoureteral reflux may have been favored by a significant
increase in the use of CIC in combination with anticholinergics (p =
0.0024), a drug class known to promote relaxation of the detrusor and produce bladder
pressure decreases and increases in the compliance and capacity of the bladder.2727 Rawashdeh YF, Austin P, Siggaard C, Bauer SB, Franco I, de Jong TP, et
al.; International Children's Continence Society. International Children's Continence
Society's recommendations for therapeutic intervention in congenital neuropathic
bladder and bowel dysfunction in children. Neurourol Urodyn 2012;31:615-20. DOI:
http://dx.doi.org/10.1002/nau.22248
http://dx.doi.org/10.1002/nau.22248...
Oxybutynin was the most frequently used
anticholinergic drug in this study. It is an affordable medication - a characteristic
that may increase compliance to treatment. Nevertheless, some patients experienced
side effects previously reported in the literature,2020 Coward RJ, Saleem MA. The neuropathic bladder of childhood. Curr Pediatr
2001;11:135-42. DOI: http://dx.doi.org/10.1054/cupe.2000.0161
http://dx.doi.org/10.1054/cupe.2000.0161...
the most common of which were flushing, dry mouth, dizziness, blurred
vision. Patients with intolerance to oral oxybutynin on CIC were administered the
drug through intravesical instillation, with satisfactory response. Bauer et
al.66 Bauer SB, Austin PF, Rawashdeh YF, de Jong TP, Franco I, Siggard C, et
al. International Children's Continence Society's recommendations for initial
diagnostic evaluation and follow-up in congenital neuropathic bladder and bowel
dysfunction in children. Neurourol Urodyn 2012;31:610-4. DOI:
http://dx.doi.org/10.1002/nau.22247
http://dx.doi.org/10.1002/nau.22247...
reported oral oxybutynin side
effect incidences ranging from 6% to 57%; intravesical instillation of the drug
decreased the incidence of side effects to nine percent. Other drugs were
administered to non-catheterized patients.
CIC was not prescribed in the treatment of children with non-neurological etiology
LUTD and post-void urine residues as their urethral sensitivity was preserved, thus
hindering the acceptance of catheterization. The treatment of choice in these cases
was urotherapy and behavioral therapy, with timed voiding and guidance on urination.
Biofeedback and transcutaneous electrical nerve stimulation may also reduce
incontinence in patients with functional lower urinary tract disorders. In a study
also carried out in the LUTD Clinic, Vasconcelos et al.1717 Vasconcelos M, Lima E, Caiafa L, Noronha A, Cangussu R, Gomes S, et al.
Voiding dysfunction in children. Pelvic-floor exercises or biofeedback therapy: a
randomized study. Pediatr Nephrol 2006;21:1858-64. DOI:
http://dx.doi.org/10.1007/s00467-006-0277-1
http://dx.doi.org/10.1007/s00467-006-027...
used kinesiotherapy and biofeedback to reduce
diurnal and nocturnal urinary symptoms. However, only patients undergoing biofeedback
showed a significant reduction in post-void urine residues, probably due to improved
relaxation of the pelvic floor muscles. Further corroborating this idea, Robson &
Leung3131 Robson LM, Leung AK. Urotherapy recommendations for bedwetting. J Natl
Med Assoc 2002;94:577-80. PMID: 12126283 prescribed urotherapy as the
initial non-pharmacological intervention of choice particularly for patients with
non-neurological conditions associated with urinary incontinence. This therapy takes
three to six months and requires encouragement from parents, a motivated patient, and
a caring family.
Constipation and/or fecal incontinence are often seen in patients with LUTD. Koff
et al.3232 Koff SA, Wagner TT, Jayanthi VR. The relationship among dysfunctional
elimination syndromes, primary vesicoureteral reflux and urinary tract infections in
children. J Urol 1998;160:1019-22. DOI:
http://dx.doi.org/10.1016/S0022-5347(01)62686-7
http://dx.doi.org/10.1016/S0022-5347(01)...
named the
association between gastrointestinal and urinary disorders dysfunctional elimination
syndrome (DES). Treatment of constipation is critical to the successful management of
LUTD, although other authors have reported difficulties in achieving complete
resolution of the gastrointestinal disorder.3333 Franco I. Overactive bladder in children. Part 2: Management. J Urol
2007;178:769-74. DOI: http://dx.doi.org/10.1016/j.juro.2007.05.076
http://dx.doi.org/10.1016/j.juro.2007.05...
,3434 Chung JM, Lee SD, Kang DI, Kwon DD, Kim KS, Kim SY, et al.; Korean
Enuresis Association. Prevalence and associated factors of overactive bladder in
Korean children 5-13 years old: a nationwide multicenter study. Urology 2009;73:63-7.
DOI: http://dx.doi.org/10.1016/j.urology.2008.06.063
http://dx.doi.org/10.1016/j.urology.2008...
In this study, approximately half of the patients had fecal incontinence and
constipation on admission (Table 1) - a pair
of symptoms often described in the literature.1717 Vasconcelos M, Lima E, Caiafa L, Noronha A, Cangussu R, Gomes S, et al.
Voiding dysfunction in children. Pelvic-floor exercises or biofeedback therapy: a
randomized study. Pediatr Nephrol 2006;21:1858-64. DOI:
http://dx.doi.org/10.1007/s00467-006-0277-1
http://dx.doi.org/10.1007/s00467-006-027...
,3535 Loening-Baucke V. Urinary incontinence and urinary tract infection and
their resolution with treatment of chronic constipation of childhood. Pediatrics
1997;100:228-32. PMID: 9240804 DOI:
http://dx.doi.org/10.1542/peds.100.2.228
http://dx.doi.org/10.1542/peds.100.2.228...
Fecal incontinence
was significantly reduced at the end of the follow-up period. The gastrocolic reflex
associated with the Valsalva maneuver may be used after bigger meals in an attempt to
promote the elimination of feces in a toilet or potty, thus minimizing the
inconveniences of the patient soiling himself. Other strategies are: laxative diets,
increased water intake, proper posture during defecation with use of a footrest to
ensure relaxation of the pelvic floor and aid in bladder and bowel emptying. Oral
laxatives such as mineral oil, magnesium hydroxide, polyethylene glycol (PEG) without
electrolytes, and lactulose3636 Bigélli RHM, Fernandes MIM, Galvão LC. Constipação intestinal na
criança. Medicina (Ribeirão Preto) 2004;37:65-75. are introduced
when these measures do not produce the desired result. Pashankar et
al.3737 Pashankar DS, Bishop WP, Loening-Baucke V. Long-term efficacy of
polyethylene glycol 3350 for the treatment of chronic constipation in children with
and without encopresis. Clin Pediatr (Phila) 2003;42:815-9. DOI:
http://dx.doi.org/10.1177/000992280304200907
http://dx.doi.org/10.1177/00099228030420...
reported that 93% of the
children treated with PEG went on to have normal bowel habits and 52% ceased to
suffer from encopresis.
Although reductions were seen in fecal incontinence, the same did not occur with
constipation. Caregivers and school age/teenage patients fear that laxatives may
decrease stool consistency and increase the occurrence of episodes of fecal
incontinence. The potential exposure to embarrassing situations leads them to abandon
treatment and deal with the troubles of hard and dry stool. Another point to be
considered is that the diagnosis of constipation is often difficult, as it relies on
information relayed by the caregiver and on the presence of a skilled interviewer.
Although PEG without electrolytes has had excellent outcomes in the management of
constipation,1111 Ellsworth P, Caldamone A. Pediatric voiding dysfunction: current
evaluation and management. Urol Nurs 2008;28:249-57.,3838 Ballek NK, McKenna PH. Lower urinary tract dysfunction in childhood.
Urol Clin North Am 2010;37:215-28. DOI:
http://dx.doi.org/10.1016/j.ucl.2010.03.001
http://dx.doi.org/10.1016/j.ucl.2010.03....
the high cost of the treatment has limited its
use to a smaller number of patients.
Loening-Baucke3535 Loening-Baucke V. Urinary incontinence and urinary tract infection and
their resolution with treatment of chronic constipation of childhood. Pediatrics
1997;100:228-32. PMID: 9240804 DOI:
http://dx.doi.org/10.1542/peds.100.2.228
http://dx.doi.org/10.1542/peds.100.2.228...
confirmed the association
between constipation and daytime urinary incontinence. The author reported a
constipation resolution rate of 52% for patients enrolled in the study after the
introduction of an aggressive treatment protocol. Improvements in daytime urinary
incontinence were described for 89% of the individuals; 63% improved from nocturnal
enuresis; and no more outbreaks of UTI were recorded.
In the LUTD Clinic, cases of chronic constipation refractory to behavioral or drug
therapy, patients failing to comply with the prescribed treatment, and individuals
with fecal incontinence are offered more aggressive therapies such as rectal enema.
Patients with indication for bladder augmentation surgery are also offered antegrade
colonic conduits to allow for enemas lasting 30 to 45 minutes with saline solution or
tap water every two or three days to help empty their bowels.2020 Coward RJ, Saleem MA. The neuropathic bladder of childhood. Curr Pediatr
2001;11:135-42. DOI: http://dx.doi.org/10.1054/cupe.2000.0161
http://dx.doi.org/10.1054/cupe.2000.0161...
,2727 Rawashdeh YF, Austin P, Siggaard C, Bauer SB, Franco I, de Jong TP, et
al.; International Children's Continence Society. International Children's Continence
Society's recommendations for therapeutic intervention in congenital neuropathic
bladder and bowel dysfunction in children. Neurourol Urodyn 2012;31:615-20. DOI:
http://dx.doi.org/10.1002/nau.22248
http://dx.doi.org/10.1002/nau.22248...
During the follow-up period only six patients underwent this procedure. All had neurogenic bladders and five were females; all acquired fecal continence. Another study with a seven-year follow-up reported this procedure was offered to six patients, all of whom with neurogenic bladders. The results were favorable, as fecal continence was achieved for five subjects and improvements in chronic constipation observed in all patients.3939 Orozco LMA, Gómez LGJM. Técnica de Malone para el enema anterógrado continente en niños con afección neurógena intestinal y urinaria. Rev Mex Urol 2009;69:268-72.
Other surgical procedures are available when urotherapy and drug therapy cannot
preserve renal function, prevent urinary infection, or maintain urinary continence.
Incontinent urinary diversion has been indicated for patients unable to perform
self-catheterization due to physical or mental limitations, for infants to whom
urinary continence was not a social requirement, or when CIC could no longer be
performed by the caregiver - usually the mother.4040 Stein R, Schröder A, Thüroff JW. Bladder augmentation and urinary
diversion in patients with neurogenic bladder: surgical considerations. J Pediatr
Urol 2012;8:153-61. DOI:
http://dx.doi.org/10.1016/j.jpurol.2011.11.014
http://dx.doi.org/10.1016/j.jpurol.2011....
Another option is continent urinary diversion, in which the child or
the caregiver empties the bladder by clean intermittent catheterization through a
stoma reaching from the bladder to the anterior abdominal wall.2020 Coward RJ, Saleem MA. The neuropathic bladder of childhood. Curr Pediatr
2001;11:135-42. DOI: http://dx.doi.org/10.1054/cupe.2000.0161
http://dx.doi.org/10.1054/cupe.2000.0161...
Bladder augmentation was recommended for patients with
neurogenic bladders associated with detrusor hyperactivity, reduced bladder capacity,
low bladder compliance, and high intravesical pressure not responding to conservative
treatment and at imminent risk of injury to the upper urinary tract, with the purpose
of enhancing bladder storage and decreasing intravesical pressure.4040 Stein R, Schröder A, Thüroff JW. Bladder augmentation and urinary
diversion in patients with neurogenic bladder: surgical considerations. J Pediatr
Urol 2012;8:153-61. DOI:
http://dx.doi.org/10.1016/j.jpurol.2011.11.014
http://dx.doi.org/10.1016/j.jpurol.2011....
Pyelocaliceal and ureter dilation were not quantified - they were considered as either present or absent - although they were mild in many patients. As the presence of pyelocaliceal and ureter dilation was associated with the development of renal scarring, we believe that detecting, quantifying, and controlling it is key to improve the management of kidney disease progression in our patients. Therefore, a more detailed categorization is needed, including mild, moderate, and severe levels of involvement.
Conclusions
Early detection of LUTD and diagnostic investigation with constant monitoring of clinical, workup, and imaging parameters are essential in preventing or minimizing alterations of the upper urinary tract and promoting urinary continence. Treatment must be individualized and delivered at an interdisciplinary specialized care center.
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32Koff SA, Wagner TT, Jayanthi VR. The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children. J Urol 1998;160:1019-22. DOI: http://dx.doi.org/10.1016/S0022-5347(01)62686-7
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35Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics 1997;100:228-32. PMID: 9240804 DOI: http://dx.doi.org/10.1542/peds.100.2.228
» http://dx.doi.org/10.1542/peds.100.2.228 -
36Bigélli RHM, Fernandes MIM, Galvão LC. Constipação intestinal na criança. Medicina (Ribeirão Preto) 2004;37:65-75.
-
37Pashankar DS, Bishop WP, Loening-Baucke V. Long-term efficacy of polyethylene glycol 3350 for the treatment of chronic constipation in children with and without encopresis. Clin Pediatr (Phila) 2003;42:815-9. DOI: http://dx.doi.org/10.1177/000992280304200907
» http://dx.doi.org/10.1177/000992280304200907 -
38Ballek NK, McKenna PH. Lower urinary tract dysfunction in childhood. Urol Clin North Am 2010;37:215-28. DOI: http://dx.doi.org/10.1016/j.ucl.2010.03.001
» http://dx.doi.org/10.1016/j.ucl.2010.03.001 -
39Orozco LMA, Gómez LGJM. Técnica de Malone para el enema anterógrado continente en niños con afección neurógena intestinal y urinaria. Rev Mex Urol 2009;69:268-72.
-
40Stein R, Schröder A, Thüroff JW. Bladder augmentation and urinary diversion in patients with neurogenic bladder: surgical considerations. J Pediatr Urol 2012;8:153-61. DOI: http://dx.doi.org/10.1016/j.jpurol.2011.11.014
» http://dx.doi.org/10.1016/j.jpurol.2011.11.014
Publication Dates
-
Publication in this collection
Oct-Dec 2014
History
-
Received
11 Dec 2013 -
Accepted
07 Apr 2014