排尿障礙治療中心版權所有 dysfunctional voiding in children hann-chorng kuo department...

排尿障礙治療中心版權所有

Dysfunctional Voiding in Children

Hann-Chorng KuoDepartment of Urology

Buddhist Tzu Chi General Hospital


Development ofUrethral Sphincter Specific striated sphincter muscle closely a

pplied to the smooth muscle at membranous urethra and mid-urethra

A ring shape sphincter in early adolescence, which account for initial high voiding pressure in infancy and early vesicoureteral reflux

An omega shape shincter in adolescence after development of urogenital septum


Congenital Abnormalities Myelodysplasia Lipomeningocele Sacral agenesis Tethered cord Cerebral palsy Bladder extrophy Posterior urethral valve Anorectal malformations


Myelomeningocele The most common form of NVD in children Early detection and folic acid treatment ma

rkedly decrease spinal defects Upper and lower motor bladder dysfunctio

n and pelvic floor dysfunction may occur in thoracic or sacral lesions

Early prophylactic treatment of DESD by CIC, anticholinergics are beneficial


Myelomeningocele, detrusor areflexia and incontinence


Meningomyelocele & Bilateral VUR & Recurrent UTI


Lipomeningocele Difficult to identify by physical examination,

MRI is the best diagnostic method Intradural lipoma results in disease and pre

sentation The most common urodynamic findings are

consistent with an upper motor neuron lesion

DESD is less common Detrusor hyperreflexia and areflexia can be

found in this group of lesion


Sacral agenesis Often discovered at older children with

incontinence Loss of the lower vetebral bodies by X-r

ay or MRI Patients have stable neurological lesio

n Patients may have no signs of denervat

ion, hyperreflexia, areflexia, intact sphincter, sphincter dyssynergia


Tethered cord syndrome Most commonly seen in patients after

surgery for myelomeningocele Isolated tethered cord is less common Severe bladder dysfunction and refrac

tory incontinence may occur Surgical division of the filum may imp

rove symptoms


Cerebral Palsy Develops most commonly in premature infa

nt Infection and anoxia result in a non-progres

sive brain lesion and muscular disability Continence is often delayed to develop but

intact Uninhibited detrusor contractions without

DESD is the most commonly urodynamic finding

Pseudodyssynergia may occur


Cerebral palsy with frequency dysuria due to DI


Bladder extrophy Characterized by extrophic bladder, abdom

inal wall defect, epispadias, pelvic diastasis, VU reflux, inguinal hernia

Staged reconstruction by abdominal wall closure, epispadias repair, bladder neck reconstruction and correction of VUR

Improved pelvic floor reconstruction after osteotomy has better continence rate

Bladder augmentation may be indicated


Posterior Urethral Valve The most common cause of BOO in newborn Present with incontinence and recurrent UTI Severe PUV may be detected antenatally, mild

form is found in older children Bilateral hydroureter and hydronephrosis may

develop in severe form of valve disease Transurethral ablation of valve resumes norm

al bladder but bladder function depends Anticholinergics, CIC and augmentation by ure

ter may be indicated


Anorectal Malformations Rare congenital lesions of cloaca Associated with congenital GU abnormalitie

s in 20% with low and 60% high lesions,VUR, NVD, renal agenesis, renal dysplasia, cryptorchidism

Urethrorectal fistula may develop at at high, intermediate or low level

Neurogenic voiding dysfunction in 50% Tethered cord is the main vertebral abnorm

ality, which account for NVD


Dysfunctional Voiding A group of neurologically intact children pre

sents with incontinence, dysuria, large residual urine, recurrent UTI, unilateral or bilateral hydronephrosis

Urodynamically classified into small capacity hypertonic bladder, detrusor hyperreflexia, lazy bladder syndrome,non-neurogenic neurogenic bladder

Treatment bases on interaction of bladder and external sphincter


Patient evaluation – history Antenatal GU abnormalities – hydronephrosi

s, enlarged bladder, open spinal cord defect Past surgical history – detethering procedure,

VP shunt, urinary diversion Occurrence of UTI and antibiotics Bowel habit, fecal incontinence, and stool so

fteners Catheterization schedule, urine amount Medication and adverse effects


Physical examination Neurological examination – gait, discr

imination of extremities, motor strength, DTR (S1,2), BCR (S2-4)

Sacral dimple, hair patch, lipoma Enlarged bladder Vincent curtsey Anal tone, volitional contraction of pe

lvic floor muscles


Urodynamic study Estimated bladder capacity: (age+2)x30 ml Infusion rate: 10% of capacity Catheter: <6Fr intraurethral dual channel ca

theter, suprapubic catheter is preferable for pressure flow study

Abdominal pressure by rectal catheter Pelvic floor EMG – surface or needle Measuring bladder compliance, detrusor pr

essure, and EMG activities coordination


Detrusor external sphincter dyssynergia (DESD) Type 1: Onset of EMG activity with initiation o

f voiding Type 2: intermittent inappropriate external sp

hincter contraction during voiding,which causes a reflex inhibition of detrusor contraction

Type 3: Persistent increased EMG activity during filling and voiding phases, which causes large residual urine and incontinence

Pseudodyssynergia: presence of urodynamic DESD in neurologically intact patient


Leak-point pressures Detrusor leak-point pressure (DLPP): The de

trusor pressure causing urinary leakage per urethrum in the absence of detrusor contractions

A DLPP of more than 40 cm water has a risk of upper tract deterioration

Valsalvar LPP (VLPP): Assessing urethral resistance by abdominal straining, a VLPP <60 cm water indicates intrinsic sphincter deficiency


Indications for urodynamic study in children Spinal dysraphisms Spinal cord injury Cerebral palsy with voiding dysfunction Sacral agenesis Imperforated anus Diurnal enuresis Suspicious voiding dysfunction and UTI Dysfunctional voiding

排尿障礙治療中心版權所有Urodynamic studies in children with dysfunctional voiding Uroflowmetry with surface EMG Cystometry with abdominal pressure

and EMG Pressure flow study recording Pves,Pa

bd, Pdet, EMG activity, and uroflowmetry

Videourodynamic study by suprapubic catheter or intra-urethral catheter


Uroflowmetry – flat flow pattern with non-relaxing ES


Uroflowmetry – Staccato pattern and poor relaxing ES


Videourodynamics via cystostomy pressure flow study


Dysfunctional VoidingAssociated with the followings Diurnal enuresis Urinary urgency Urinary frequency Constipation Urinary tract infection Vesicoureteral reflux


Pathogenesis of dysfunctional voiding Increased voiding pressure during voiding

with contraction of the urethral sphincter Dysfunctional bowel evacuation and consti

pation Treatment directed at urodynamic abnorm

alities reduce the incidence of breakthrough UTI and increase resolution of vesicoureteral reflux


Typical spinning top voiding cystourethrography


Development of dysfunctional voiding Long-standing pelvic floor dysfunctio

n results in paradoxical sphincter contraction

Pelvic laxity Inappropriate stimulation of guarding

reflex results in inhibition of detrusor contraction


Dysfunctional voiding and Urinary tract infection Elevated postvoid residual urine Host resistance – ability of bladder to

wash out pathogens Well hydration, void with strong strea

m, and complete voiding are important in prevention of UTI

Treatment aims at relaxation of the pelvic floor rather than the bladder


Recurrent UTI in siblings with Dysfunctional voiding


Non-neurogenic neurogenic bladder– Hinman syndrome The severest form of dysfunctional voi

ding Symptom complex including nocturn

al enuresis, diurnal enuresis, constipation, encopresis, UTI, and upper tract dilatation

Uninhibited detrusor contractions and dyssynergic external sphincter


Treatment of non-neurogenic neurogenic bladder Voiding retraining Biofeedback Anticholinergic therapy Hypnosis Psychotherapy Management of constipation Antibiotics Clean intermittent catheterization


Dysfunctional voiding and Vesicoureteral reflux Play a major role in etiology of

congenital VUR Important in development of VUR in

older child without congenital VUR Responsible for reflux exacerbation

and renal scarring Therapy to VUR should aim at

correction of dysfunctional voiding


Bilateral VUR in a girl with Dysfunctional voiding


Right VUR and DI without dysfunctional voiding


Resolution of VUR after Anticholinergic therapy


Urodynamic studies in infants High voiding pressures (160cm water)

with low bladder capacity in infant with gross dilating reflux

Voiding pressure in infant without reflux is 80 cm water

By age 2 years, voiding pressure diminished (70 cm water) and capacity increased, but unstable detrusor remain


High voiding pressures in infancy Transient functional bladder outlet

obstruction Boys with high grade reflux have dilated

posterior urethra Higher voiding pressure is seen in

children with grades IV and V reflux Normalization of voiding pressures

explains high rate of reflux resolution in childhood


Urodynamic studies in older children Up to 60% of children with reflux have

urodynamic abnormality Detrusor overactivity and sphincter d

yscoordination Primary sphincter overactivity is more

associated with high grade reflux and renal scarring

Bladder instability improves over time


Pitfalls in urodynamic study in infants and children Poor cooperation of patient Appropriate size of intra-urethral cathet

er – 3 Fr, 5 Fr, 7 Fr? Frequent increased abdominal pressure Different infusion rate and compliance i

n different age Differential diagnosis of volitional voidi

ng and detrusor overactivity


Urodynamics and Clinical course of VUR Treatment of detrusor overactivity with anti

cholinergics improves resolution or improvement in VUR than stable bladders

A higher surgery rate in stable bladder with VUR

Controversy remains in correlation of urodynamic abnormalities with grades of VUR and anticholinergic treatment with resolution rate of VUR


Resolution of VUR and improved DI after anticholinergic and CIC in myelomeningocele


Dysfunctional elimination syndromes (DES) Children are both infrequent voiders and co

nstipated Associated with an increased risk of urinary

tract infection With or without reflux Incontinent day and night with fecal soiling Observed to engage in holding maneuver to

avoid urination and defecation


DES – A learned habit A learned habit acquired during

toilet training Most often occur in girls Recurrent cystitis due to short

urethra and bladder colonization Congenital VUR or secondary VUR

due to these aberrant toilet training habits


Breakthrough UTI and Dysfunctional voiding Girls with history of voiding dysfuncti

on have higher rates of breakthrough UTI (4 times more common in DES)

Unsuccessful surgical outcome was seen in children with DES

Adequate hydration, timed voiding, stool softeners, laxatives, as well as anticholinergics may be helpful


Voiding dysfunction without UTI Children with mono-symptomatic enuresis

have a very low urodynamic abnormality VUR has been found in child with frequency

urgency and urinary incontinence without history of UTI

15% of children had positive urodynamic findings and 16% had renal scarring

排尿障礙治療中心版權所有Treatment of Dysfunctional voiding in Children Adequate hydration and timed voiding Stool softeners and laxatives Anticholinergics – Ditropan, tolterodine Biofeedback – pelvic floor relaxation, c

omputerized game Intermittent catheterization Antibiotics for recurrent UTI


Adequate hydration Provide adequate urine production an

d wash out effect of bladder Prevent constipation and reduce colo

nization of pathogen in perineum Reduce detrusor instability through di

lution of urine and decrease urine permeability into urothelium

Time voiding is required


Medication for dysfunctional voiding Oxybutynin – effective in reducing detrusor

overactivity, side effects of mucosal dryness & constipation

Ditropan XL – elimination of peak drug effect and reduce adverse effects

Tolterodine – M3 anticholinergic Alpha-adrenergic blocker to reduce urethral

resistance Phenylpropanolamine, pseudoephedrine –

in ISD with incontinence ready for CIC


Pelvic floor rehabilitation Identification of pelvic floor muscles Regular pelvic floor muscle exercises

provide adequate relaxation of pelvic floor including urethral sphincter

A synergistic voiding pattern can be achieved after rehabilitation

Combined with fluid and anticholinergic therapy

排尿障礙治療中心版權所有Biofeedback for pelvic floor muscle relaxation Correcting paradoxical contractions of pelvi

c floor and urinary sphincter muscles with voiding

Success relies on motivation of children Uroflow- surface EMG integrated biofeedback

Cystometry biofeedback to inhibit detrusor overactivity in patients with DI

Visual or audio biofeedback may be more successful than verbal biofeedback


Electrical stimulation to inhibit detrusor overactivity


CMG biofeedback to inhibit Detrusor overactivty

排尿障礙治療中心版權所有Urethral injection of Botulinum A toxin in dysfunctional voiding New technique in reducing urethral re

sistance by paralyzing striated urethral sphincter

Intra-detrusor injection to reduce detrusor overactivity and increase bladder capacity

Restoration of normal voiding pattern Repeat injection may be necessary


Botulinum A toxin (Botox)


Reduction of MUCP after Botulinum A toxin injection


Reduction of voiding pressure after Botulinum A toxin

排尿障礙治療中心 版權所有 dysfunctional voiding in children hann-chorng kuo department...

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排尿障礙治療中心版權所有 dysfunctional voiding in children hann-chorng kuo department...