Dysfunctional Elimination Syndromes 2

Dysfunctional Elimination Syndrome

Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD

University of Oklahoma Department of Urology Section of Pediatric Urology

Objectives • • • • •

Normal Elimination Dysfunctional Elimination Syndrome Non-Neurogenic Neurogenic Bladder Biofeedback Review of the literature

Development of Urinary Control • Infancy: Reflex voiding – Detrusor contracts when bladder full – External urinary sphincter contracts during filling

• Voiding pattern in infants (feeding) • Development of continence – ↑ capacity and control of striated sphincter – Control over spinal micturition reflex

Stooling • Normally – – – – –

Newborn meconium passes w/in 24 hrs First few weeks: BMs 6 X q day By 5 months: BMs 3 X q day Age 2: BMs bid Age 4: BM q day

J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

Dysfunctional Elimination • • • •

Unknown etiology Abnormal elimination pattern Bowel or bladder incontinence Withholding maneuvers

Holding Maneuvers

Dysfunctional Elimination • Prevalence approximately 15% (Hellstrom et al. 1991) • Overlooked factor in pediatric UTIs • 40% of toilet trained with 1st UTI • 80% with recurrent UTI • Risk factor for VUR and renal scarring

Bad Bladder Habits • • • •

Infrequent visits to bathroom Inadequate time in bathroom Bad posture Poor hygiene

What Happens? • Infrequent voiding – Over distended bladder • Failure to relax pelvic floor – Voiding against closed sphincter • ↑ PVR

What Happens? • Bad posture – Can’t relax

• Bad hygiene or aggressive soaps – Dysuria and incomplete voiding

•Children rated wetting themselves at school as the third most catastrophic event behind losing a parent and going blind.

Ollendick et al, Behav Res Therapy, 1989.

Functional Bowel Disturbances • Constipation – Hard BM occurring < 3 X per week • Most likely to occur in 3 situations • Can induce bladder dysfunction • 50% of dysfunctional voiding have constipation

J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

Functional Constipation • Symptoms – Infrequent passage of stool – Hard stool – Palpable stool in abdomen or in rectal vault – Fecal soiling

J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

Functional Constipation • Management: – Parental education (hydration and fiber) – Many require stool softeners – Visit toilet 30-40 minutes after a meal • Forward leaning, T&L extension, hip abduction, foot support that allows 90° of hip/knee flexion

J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

Treatment of Day Time Wetting • 1st line is Behavior Modification – – – – –

Diary Bathroom every 2 hrs Good posture Ample time Good hygiene

Treatment of Day Time Wetting • Treat Constipation • Biofeedback – Learn to relax pelvic muscles

• Medications – Ditropan ↓ pressure but CONSTIPATES! – ? Role of α-blocker and Botox

Non-neurogenic neurogenic bladder (NNGNGB) • • • • • •

Nocturnal and diurnal incontinence Dribbling, overflow, urge incontinence Bowel dysfunction Recurrent UTI’s Bladder instability Voluntary DSD during voiding

NNGNGB – VCUG large PVR – Reflux noted in about 50%

NNGNGB - Treatment – – – –

Sterilize Urine Bladder retraining Normalize bowel function Anticholinergics eliminate unstable bladder contractions – Sympatholytics and diazepam to reduce outflow resistance – May need CIC

Biofeedback • Treatment option for children with DSD • Goal: develop control over pelvic floor muscles during voiding • Visual electromyography feedback • Maintain relaxed pelvic floor with voiding • Success up to child/parent/physician • Problem: can be invasive Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 14701475.

Modified Biofeedback Program • Noninvasive UDS • Psychological techniques – Externalizing voiding problem – Empowerment and praise

77 Children Completing Biofeedback Study

No. (%)

Recurrent UTI

59 (76)

Day incontinence

48 (63)

Night incontinence

36 (47)

Anticholinergic tx

38 (49)

VUR

19 (24)

Bowel symptoms

44 (58)

Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470-1475.

Modified Biofeedback Program Improvement

No. (%)

Subjective: Pronounced

47 (61)

Moderate

24 (31)

None

6 (8)

• Concluded: – Effective for 92% of children with DSD

Objective: Pronounced

47 (61)

Moderate

28 (36)

None

2 (3)

Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470-1475.

Alpha-blocker therapy be as an alternative to biofeedback for dysfunctional voiding? • Efficacy of alpha-blocker vs biofeedback • Prospective study 28 pts (12/16) • On timed voiding, constipation treatment and anticholinergics for at least 6 mo • Pts reevaluated at 3 and 6 months – Incontinence episodes, UTIs, mean urinary flow rates, PVR, and parental satisfaction Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology, 2005; 174, 1612-1615.

Alpha-blocker therapy be as an alternative to biofeedback for dysfunctional voiding? • Improved post treatment PVR – NO DIFFERENCE

• Complete improvement in urge incontinence – NO DIFFERENCE

• Combination effective in refractory cases (5/6) • No side effects reported • Concluded alpha blockers were a viable alternative

70 60 50 0 months

40

3 months 30

6 months

20 10 0 PVR Bio PVR AB Flow Bio Flow AB (ml) (ml) (ml/s) (ml/s)

Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology, 2005; 174, 1612-1615.

Botulinum A Toxin Urethral Sphincter injection in Children with NNGNGB 400 350 300 250

PVR (ml)

200

DLPP (cm H2O)

150

Q max (ml/sec)

100 50 0 Be for e 2W ks 4W ks 3M o 6M o

• Prospective (10 children) • 50-100 units injected • Immediately following all but 1 voided without catheterization • PVR ↓ by 89%

Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology, 2005; 174, 1612-1615.

Closing Statements • • • • •

Best treatment is prevention DES diagnosis of exclusion Constipation treatment and timed voiding Biofeedback Adjunctive treatment in refractory cases – Alpha blockers – BOTOX

Thank You

Vincenzo Galati