Functional lower urinary tract problems, bladder and bowel problems, or dysfunctional elimination syndrome are all terms that describe the common array of symptoms that include overactive bladder syndrome, voiding postponement, stress incontinence, giggle incontinence, and dysfunctional voiding in children. This article discusses the nomenclature and looks at the pathophysiology of functional bladder disorders from a different perspective than has been the norm in the past. Some standard medical treatments as well as some newer forms of treatment are outlined. Treatment algorithms for urinary frequency and urinary incontinence have been created to help the practitioner manage the patient.
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The hallmark of treatment of bladder and bowel problems is the been the use of a bowel program and timed voiding regimen. The use of biofeedback has helped many other children correct their errant voiding patterns.
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The use of drugs to treat OAB shows increased promise and it seems that the sensory limb of the voiding reflex is the primary target for continued pharmacologic treatment.
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Numerous other treatment modalities are available for patients who have failed pharmacologic therapy, therefore no one need go untreated.
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The continued use of stimulation modalities whether peripheral or central needs continued exploration in the future.
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The relationship between neuropsychiatric disorders and OAB is significant, therefore a thorough family history is essential in the initial evaluation to properly treat the patient.
Introduction
Functional lower urinary tract (LUT) problems, bladder and bowel problems (BBD) or dysfunctional elimination syndrome are all terms that describe the common array of symptoms that include overactive bladder syndrome (OAB), voiding postponement, stress incontinence, giggle incontinence. and dysfunctional voiding. The most common is OAB, which seems to have a peak incidence between 5 and 7 years of age. Ruarte and Quesada and found an incidence of 57.4% in a group of 383 incontinent children ranging in age from 3 to 14 years of age. The group consisted of 38.9% boys and 60.1% girls. Daytime wetting is estimated to affect 5 to 7 million children in the United States aged 6 years or older. The impact of daytime wetting in children can be profound. It can affect their life socially, emotionally, and behaviorally and also affects the everyday life of their family. From our understanding of OAB, we know that if it continues over a prolonged period, the bladder wall thickens, which can have an impact in adulthood. As patients become older, its consequences become more profound and require more of an effort to correct.
From a pediatric urologist perspective, the child who has OAB has a good chance of becoming an adult who continues to have problems with OAB. This correlation has been reported in 2 published studies. In the first study, Fitzgerald and colleagues revealed that OAB in childhood correlated with adult OAB symptoms. These investigators found that frequent daytime voiding in childhood correlated with adult urgency. A correlation existed between childhood nocturia and adult nocturia. Childhood daytime incontinence and nocturnal enuresis were associated with a more than 2-fold increased association with adult urge incontinence. Also a history of childhood urinary tract infections (UTIs) correlated with a history of adult UTIs. Another study by Minassian and colleagues involving 170 adult women found that there was a higher prevalence of childhood voiding dysfunction in women who had urinary frequency, urgency, stress incontinence, and urge incontinence. These investigators also noted that there was a greater likelihood of their symptomatic patients having a higher body mass index, calculated as weight in kilograms divided by the square of height in meters.
In another study by Stone and colleagues, there was about a one in three chance if patients were wetting by 9 to 10 years of age that they would continue to have OAB-type symptoms by 18 years of age. In this study, all patients were evaluated with urodynamics and magnetic resonance imaging (MRI) of the lumbosacral spine. No lesions were found in the spine to indicate that a spinal problem was the source of the BBD. The implications of these findings underscore the importance of childhood OAB and its potential impact in adulthood. The trend over the years has been to tell parents that these problems are self-limiting and that they will resolve in due time as the child matures. It seems that this theory may not be the case and that some children as they mature are just better at compensating for their problems and eventually drop off the radar screen (our offices) either because of frustration with our inability to treat their problems or because they have developed coping strategies that satisfy their needs for the interim. A better understanding of the potential causes of childhood OAB could prevent undue problems in adulthood and make many children happier, along with their parents and teachers.
This article discusses the updated nomenclature and looks at the pathophysiology of functional bladder disorders from a different perspective than has been the norm in the past. Some standard medical treatments as well as some newer forms of treatment are also outlined. Treatment algorithms for urinary frequency ( Fig. 1 ) and urinary incontinence ( Fig. 2 ) have been created to help the practitioner manage the patient.
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