Andrew J. Combs

Diagnostic Evaluation of Children With Daytime Incontinence

PURPOSEnThis article is one of the standardization documents of the International Childrens Continence Society, and discusses how anatomical/iatrogenic and functional/urodynamic causes of daytime incontinence in children of all ages are to be diagnosed, how neurogenic bladder dysfunction or urinary tract infection is excluded as a cause of the wetting, and how further diagnostic evaluation of children with disturbances such as overactive bladder, voiding postponement and dysfunctional voiding is performed. The roles of history taking (including prenatal and perinatal issues and family history), physical examination, diagnostic bladder diaries, noninvasive urodynamic investigations and radiological imaging are delineated but therapy is not within the scope of this document.nnnMATERIALS AND METHODSnThis document was designed and written by an international panel of authors with a large experience in assessment of children with incontinence.nnnRESULTSnThe best evidence was retrieved from the literature and assembled in a standardization document.nnnCONCLUSIONSnAssessment of children with daytime symptoms is discussed. A noninvasive approach in these children allows us to select patients who will need a more invasive assessment.

Nonneurogenic Voiding Disorders in Children and Adolescents: Clinical and Videourodynamic Findings in 4 Specific Conditions

PURPOSEnWe determined if there were any unique findings regarding specific clinical manifestations and videourodynamics among our patients with nonneurogenic voiding disorders.nnnMATERIALS AND METHODSnA cohort of 237 normal children with lower urinary tract symptoms were evaluated by videourodynamics and uroflow/electromyogram, and divided into 4 groups based on the specific urodynamic findings 1) dysfunctional voiding (active electromyogram during voiding with or without detrusor overactivity), 2) idiopathic detrusor overactivity disorder (detrusor overactivity on urodynamics but quiet electromyogram during voiding), 3) detrusor underutilization disorder (willful infrequent but otherwise normal voiding) and 4) primary bladder neck dysfunction. Association of lower urinary tract symptoms, urinary tract infection, vesicoureteral reflux and abnormal urodynamic parameters within each condition was compared.nnnRESULTSnThe only strong correlation between a particular symptom and a specific condition was between hesitancy and primary bladder neck dysfunction. Urgency was reported to some degree with all 4 conditions. The most common abnormal urodynamic finding was detrusor overactivity, which was seen in 91% of patients with dysfunctional voiding. The highest detrusor pressures were seen in dysfunctional voiding during voiding and in idiopathic detrusor overactivity disorder during detrusor overactivity. Vesicoureteral reflux was seen in a third of children with dysfunctional voiding or idiopathic detrusor overactivity disorder, in all 8 boys with a history of urinary tract infection and in 51% of patients with febrile or recurrent urinary tract infections with lower urinary tract symptoms when not infected. Bilateral vesicoureteral reflux and bowel dysfunction were most common in dysfunctional voiding.nnnCONCLUSIONSnOn objective urodynamic assessment pediatric nonneurogenic voiding dysfunction can essentially be divided into 4 specific conditions. These conditions have distinct urodynamic features that distinguish them from each other, as opposed to their clinical features (particularly lower urinary tract symptoms), which frequently overlap and are not as defining as they are often presumed to be.

Dysfunctional Elimination Syndromes—How Closely Linked are Constipation and Encopresis with Specific Lower Urinary Tract Conditions?

PURPOSEnIt is recognized that there is a strong association between bladder and bowel dysfunction. We determined the association of constipation and/or encopresis with specific lower urinary tract conditions.nnnMATERIALS AND METHODSnWe reviewed our database of children with lower urinary tract dysfunction and divided cases into 3 categories of bowel dysfunction (constipation, encopresis and constipation plus encopresis) and 4 lower urinary tract conditions (dysfunctional voiding, idiopathic detrusor overactivity disorder, detrusor underutilization disorder and primary bladder neck dysfunction). Associations between bowel dysfunction types and each lower urinary tract condition were determined.nnnRESULTSnOf 163 males and 205 females with a mean age of 8.5 years constipation was the most common bowel dysfunction (27%). Although encopresis is generally thought to reflect underlying constipation, only half of children with encopresis in this series had constipation. Dysfunctional voiding was associated with the highest incidence of bowel dysfunction. All but 1 patient with encopresis had associated urgency and detrusor overactivity, and the encopresis resolved in 75% of patients after initiation of anticholinergic therapy. Constipation was significantly more common in girls (27%) than in boys (11%, p <0.01), while encopresis was more common in boys (9%) than in girls (3%, p = 0.02), likely reflecting the higher incidence of dysfunctional voiding in girls and idiopathic detrusor overactivity disorder in boys.nnnCONCLUSIONSnActive bowel dysfunction was seen in half of the children with a lower urinary tract condition. Constipation was more common in patients with dysfunctional voiding, while encopresis was significantly increased in those with idiopathic detrusor overactivity disorder and in those with dysfunctional voiding, severe urgency and detrusor overactivity. Anticholinergics, despite their constipating effect, given for treatment of detrusor overactivity resolved encopresis in most children with this bowel dysfunction.

Simplifying the diagnosis of 4 common voiding conditions using uroflow/electromyography, electromyography lag time and voiding history.

PURPOSEnNoninvasive uroflowmetry with simultaneous electromyography is useful to triage cases of lower urinary tract symptoms into 4 urodynamically defined conditions, especially when incorporating short and long electromyography lag times in the analysis. We determined the prevalence of these 4 conditions at a single referral institution and the usefulness of uroflowmetry with simultaneous electromyography and electromyography lag time to confirm the diagnosis, guide treatment and monitor response.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of 100 consecutive normal children who presented with persistent lower urinary tract symptoms, underwent uroflowmetry with electromyography as part of the initial evaluation and were diagnosed with 1 of 4 conditions based on certain uroflowmetry/electromyography features. The conditions included 1) dysfunctional voiding--active pelvic floor electromyography during voiding with or without staccato flow, 2a) idiopathic detrusor overactivity disorder-A--a quiet pelvic floor during voiding and shortened lag time (less than 2 seconds), 2b) idiopathic detrusor overactivity disorder-B--a quiet pelvic floor with a normal lag time, 3) detrusor underutilization disorder--volitionally deferred voiding with expanded bladder capacity but a quiet pelvic floor, and 4) primary bladder neck dysfunction--prolonged lag time (greater than 6 seconds) and a depressed, right shifted uroflowmetry curve with a quiet pelvic floor during voiding. Treatment was tailored to the underlying condition in each patient.nnnRESULTSnThe group consisted of 50 males and 50 females with a mean age of 8 years (range 3 to 18). Dysfunctional voiding was more common in females (p <0.05) while idiopathic detrusor overactivity disorder-B and primary bladder neck dysfunction were more common in males (p <0.01). With treatment uroflowmetry parameters normalized for all types. Electromyography lag time increased in idiopathic detrusor overactivity disorder-A cases and decreased in primary bladder neck dysfunction cases.nnnCONCLUSIONSnNoninvasive uroflowmetry with simultaneous electromyography offers an excellent alternative to invasive urodynamics to diagnose 4 urodynamically defined conditions. It identifies the most appropriate therapy for the specific condition and objectively monitors the treatment response.

Myogenic Failure in Posterior Urethral Valve Disease: Real or Imagined?

PURPOSEnIt has been suggested that hypocontractility or myogenic failure develops in older boys with a history of 9 posterior urethral valved as the hyperactive, poorly compliant bladders decompensate with age. Also a much higher prevalence of myogenic failure has been reported than we have observed. We determine the prevalence of myogenic failure in boys with a posterior urethral valve and whether myogenic failure was a consequence of earlier detrusor instability or diminished compliance.nnnMATERIALS AND METHODSnWe retrospectively reviewed the urodynamic findings of 51 boys after transurethral ablation of a posterior urethral valve. Group 1 (longitudinal group) consisted of 11 boys 12 to 19 years old who had undergone at least 1 serial urodynamic study before and 1 after age 10 years. Group 2 (younger group) included 33 boys whose urodynamic testing was performed before age 10 years. Group 3 (older group) comprised 7 previously treated boys whose initial urodynamic study was done after age 12 years.nnnRESULTSnOverall, myogenic failure was noted in 3 (all group 1) of 51 (5.9%) patients. Each of the 3 boys initially had a hypocompliant bladder, and myogenic failure developed only after institution of anticholinergic therapy and resolved once anticholinergics were discontinued. An additional 34 boys treated with anticholinergics did not have myogenic failure. No tendency towards myogenic failure or marked increase in bladder capacity for age was noted in the older boys.nnnCONCLUSIONSnIn our experience myogenic failure is uncommon and more likely secondary to anticholinergic therapy than a preordained consequence of valve disease. We postulate that our proactive, early aggressive use of urodynamic studies and pharmacotherapy to identify and manage the secondary effects of valve disease reduces the incidence of myogenic failure.

Primary Bladder Neck Dysfunction in Children and Adolescents III: Results of Long-Term α-Blocker Therapy

PURPOSEnPrimary bladder neck dysfunction is a nonneurogenic voiding disorder frequently overlooked in pediatrics. The diagnosis classically is made by videourodynamics but can also be made with noninvasive uroflow studies with pelvic floor electromyography. We report our long-term results using alpha-blocker therapy in patients with primary bladder neck dysfunction.nnnMATERIALS AND METHODSnWe reviewed 51 neurologically normal children (mean age 11.6 years, range 3.5 to 17.8) meeting criteria for primary bladder neck dysfunction who underwent alpha-blocker therapy for at least 1 year. All patients were symptomatic with abnormal flow parameters and an electromyogram lag time of 6 seconds or more on initial uroflow/electromyography. Pretreatment and on-treatment uroflow/electromyogram studies were performed in all patients. Average and maximum uroflow rates, electromyogram lag times and post-void residual volumes were compared.nnnRESULTSnAfter a mean followup of 46.2 months (range 12 to 124) mean average and maximum uroflow rates improved from 7.0 to 12.4 cc per second and from 12.4 to 20.3 cc per second, respectively, while mean electromyogram lag time decreased from 30.8 to 5.8 seconds (all p <0.01). Of the patients 85% reported subjective symptomatic relief. A total of 15 patients (29%) stopped alpha-blocker therapy for various reasons, none related to side effects. Repeat off-treatment uroflow/electromyogram studies showed that measured parameters reverted to pretreatment values (all p <0.05). Eight of these 15 patients eventually resumed alpha-blocker therapy, while only 3 remained asymptomatic off of the alpha-blocker.nnnCONCLUSIONSnalpha-Blocker therapy continues to benefit children with primary bladder neck dysfunction even after 3 years of treatment. Few patients can come off of alpha-blocker therapy without returning to their pretreatment state, suggesting the condition is likely chronic in most patients.

Prevalence of Urinary Tract Infection and Vesicoureteral Reflux in Children with Lower Urinary Tract Dysfunction

PURPOSEnLower urinary tract dysfunction is a common pediatric urological problem that is often associated with urinary tract infection. We determined the prevalence of a urinary tract infection history in children with lower urinary tract dysfunction and its association, if any, with gender, bowel dysfunction, vesicoureteral reflux and specific lower urinary tract conditions.nnnMATERIALS AND METHODSnWe retrospectively reviewed the charts of children diagnosed with and treated for lower urinary tract dysfunction, noting a history of urinary tract infection with or without fever, gender, bowel dysfunction and vesicoureteral reflux in association with specific lower urinary tract conditions.nnnRESULTSnOf the 257 boys and 366 girls with a mean age of 9.1 years 207 (33%) had a urinary tract infection history, including 88 with at least 1 febrile infection. A total of 64 patients underwent voiding cystourethrogram/videourodynamics, which revealed reflux in 44 (69%). In 119 of the 207 patients all infections were afebrile and 18 underwent voiding cystourethrogram/videourodynamics, which revealed reflux in 5 (28%). A urinary tract infection history was noted in 53% of girls but only 5% of boys (p <0.001). Patients with detrusor underutilization disorder were statistically more likely to present with an infection history than patients with idiopathic detrusor overactivity disorder or primary bladder neck dysfunction (each p <0.01).nnnCONCLUSIONSnFemales with lower urinary tract dysfunction have a much higher urinary tract infection incidence than males. This association was most often noted for lower urinary tract conditions in which urinary stasis occurs, including detrusor underutilization disorder and dysfunctional voiding. Reflux was found in most girls with a history of febrile infections. Since reflux was identified in more than a quarter of girls with only afebrile infections who were evaluated for reflux, it may be reasonable to perform voiding cystourethrogram or videourodynamics in some of them to identify reflux.

Can Staccato and Interrupted/Fractionated Uroflow Patterns Alone Correctly Identify the Underlying Lower Urinary Tract Condition?

PURPOSEnWorldwide, uroflowmetry without simultaneous electromyography is often the only testing performed during the initial assessment of children with lower urinary tract symptoms. Various alterations in uroflow pattern are thought to indicate particular types of lower urinary tract conditions, specifically staccato uroflow indicating dysfunctional voiding and intermittent/fractionated uroflow indicating detrusor underactivity. We determined how reliable uroflow pattern alone is as a surrogate for simultaneously measured pelvic floor electromyography activity during voiding, and how well staccato and interrupted uroflow actually correlate with the diagnoses they are presumed to represent.nnnMATERIALS AND METHODSnWe reviewed uroflow/electromyography studies performed during the initial evaluation of 388 consecutive neurologically and anatomically normal patients with persistent lower urinary tract symptoms. We identified those with staccato, interrupted/fractionated and mixed uroflow based on current International Childrens Continence Society guidelines.nnnRESULTSnA total of 69 girls (58.5%) and 49 boys (41.5%) met inclusion criteria. Staccato uroflow was noted in 60 patients, interrupted/fractionated uroflow in 28 and a combination in 30. An active electromyography during voiding confirmed the diagnosis of dysfunctional voiding in 33.3% of patients with staccato, 46.4% with interrupted/fractionated and 50% with mixed uroflow patterns.nnnCONCLUSIONSnDiagnoses based on uroflow pattern appearance without simultaneous electromyography to support them can be misleading, and reliance on uroflow pattern alone can lead to overdiagnoses of dysfunctional voiding and detrusor underactivity. When assessing patients with uroflow, an accompanying simultaneous pelvic floor electromyography is of utmost importance for improving diagnostic accuracy and thereby allowing for the most appropriate therapy.

Short Pelvic Floor Electromyographic Lag Time: A Novel Noninvasive Approach to Document Detrusor Overactivity in Children with Lower Urinary Tract Symptoms

PURPOSEnNoninvasive uroflow with simultaneous electromyography can measure electromyographic lag time, ie the interval between the start of pelvic floor relaxation and the start of urine flow (normally 2 to 6 seconds). Intuitively one would expect that in patients experiencing urgency secondary to detrusor overactivity the lag time would be short or even a negative value. We studied whether short electromyographic lag time on uroflow with electromyography actually correlates with documented detrusor overactivity on urodynamics.nnnMATERIALS AND METHODSnWe reviewed 2 separate and distinct cohorts of 50 neurologically and anatomically normal children with persistent lower urinary tract symptoms who were evaluated by uroflow with simultaneous electromyography and videourodynamics. Group 1 consisted of 30 boys and 20 girls (mean age 7.8 years, range 4 to 19) selected based on electromyographic lag time of 0 seconds or less on screening uroflow with electromyography who subsequently underwent videourodynamics. Group 2 consisted of 14 boys and 36 girls (median age 8.4 years, range 5 to 18) selected based on the presence of detrusor overactivity on videourodynamics whose screening uroflow with electromyography was then reviewed. Correlations between short electromyographic lag time and videourodynamically proved detrusor overactivity were analyzed.nnnRESULTSnFor group 1 urodynamics confirmed the presence of detrusor overactivity in all patients with an electromyographic lag time of 0 seconds or less. For group 2 mean ± SD electromyographic lag time was 0.1 ± 1.7 seconds, and 35 patients (70%) with urodynamically proved detrusor overactivity had a lag time of 0 seconds or less.nnnCONCLUSIONSnIn patients with lower urinary tract symptoms an electromyographic lag time of 0 seconds or less is 100% predictive of detrusor overactivity. This short electromyographic lag time has 100% specificity and 70% sensitivity for diagnosing detrusor overactivity (88% if less than 2 seconds). Thus, diagnosing the presence or absence of detrusor overactivity in most children with lower urinary tract symptoms and a quiet pelvic floor during voiding can be done reliably via uroflow with simultaneous electromyography.

Analysis of uroflow patterns in children with dysfunctional voiding

OBJECTIVEnAlthough a staccato uroflow pattern is considered representative of dysfunctional voiding (DV), we recently found that only a third of children with staccato flow had an active pelvic floor electromyography (EMG) during voiding. Here, we analyzed the reverse, that is, how often a staccato flow pattern occurs in children with documented DV. In addition, we reviewed what other flow patterns are prevalent in this condition.nnnMATERIALS AND METHODSnWe reviewed our LUT dysfunction registry for children with EMG-confirmed DV. Uroflow patterns were categorized as staccato, interrupted, mixed (i.e., staccato and interrupted patterns), or grossly normal.nnnRESULTSnOf 596 children who underwent a uroflow/EMG examination, 121 had an active pelvic floor EMG during voiding, that is a finding consistent with the diagnosis of DV. The flow patterns identified in those diagnosed with DV were staccato in 70 (58%), interrupted in 22 (19%), mixed in 12 (10%), and a bell-shaped or depressed curve in 17 (14%). Staccato pattern became normal in 96% following successful treatment with biofeedback.nnnCONCLUSIONSnWhile a staccato uroflow pattern was the most common pattern seen in children diagnosed with DV by a uroflow/EMG, nearly a third had an interrupted or mixed flow pattern underscoring the importance of performing simultaneous pelvic floor EMG during a uroflow study, especially when trying to rule out DV. Failure of the staccato flow pattern to normalize after therapy strongly suggests either inadequate therapy or an incorrect diagnosis.