Jennifer A. Hagerty, DO
BASICS
DESCRIPTION
• Dysfunctional voiding; various symptoms from mild daytime frequency and postvoid dribbling to daytime and nighttime wetting, urgency, urge incontinence, pelvic holding maneuvers, and urinary tract infections (UTIs)
• Sometimes referred to as bowel bladder dysfunction (BBD).
• Dysfunctional voiding often associated with bowel dysfunction; constipation, encopresis, or fecal impaction (1)[C]
– Constipation and rectal dilation interferes with normal bladder function
– No identifiable neurologic cause
EPIDEMIOLOGY
Incidence
Constipation is present in up to 50% of children with dysfunctional voiding (2)[C]
Prevalence
20–30% school-aged children have dysfunctional voiding (3)[C]
RISK FACTORS
• UTIs
• Sexual abuse
• Attention deficit/hyperactivity disorder
• Stressors during or after toilet training
Genetics
• Ochoa syndrome, a genetic disorder with an autosomal recessive inheritance pattern
– Associated with dysfunctional voiding
PATHOPHYSIOLOGY
• Voiding dysfunction (variable etiologies):
– Small bladder capacity
– Large bladder capacity secondary to urine holding
– Discoordinated voiding with difficulty relaxing the sphincter during voiding
• Often associated with constipation
– Rectum close to posterior wall of bladder
– Large amount stool:
Obstruction by compression of the bladder and bladder neck
Or bladder instability leading to urgency and frequency
ASSOCIATED CONDITIONS
• Vesicoureteral reflux (VUR)
• UTIs
• Encopresis
• Incontinence
• VUR
• Urge syndrome
GENERAL PREVENTION
None have been identified
DIAGNOSIS
HISTORY
• Present typically after toilet training
• Diurnal and/or nocturnal enuresis
• Frequency and urgency
• Hesitancy
• UTIs
• Difficulty stooling, hard or infrequent stools
• Encopresis
PHYSICAL EXAM
• Typically normal physical exam
– Evaluate for neurologic dysfunction
– Examine the external genitalia for anatomic causes of symptoms
– Evaluate for a distended bladder and palpable stool
– Consider rectal exam for fecal retention
DIAGNOSTIC TESTS & INTERPRETATION
Lab
Urinalysis and urine culture; rule out bacteriuria and glucosuria
Imaging
• Renal/bladder ultrasound; evaluate for hydronephrosis, thickened and/or distended bladder, post-void residual, stool in the rectum
• MRI lumbar spine if concern for a neurogenic cause to evaluate for a tethered cord
• Voiding cystourethrogram to evaluate for VUR in patients with febrile UTIs.
– Also information on bladder capacity and emptying, and appearance of the bladder and urethra
– Spinning top urethra; widening of the urethra in females during voiding
Diagnostic Procedures/Surgery
• Voiding and stooling diary to assess frequency and volume of voids and stooling frequency and consistency
• Uroflowmetry; evaluate pattern
– Flow rates different than adults and less reliable; curve more diagnostic
Bell shaped—normal
Tower shaped—overactive bladder
Low flat curve—outlet obstruction
Staccato pattern—sphincter overactivity
Interrupted flow—underactive bladder
• Urodynamics; patients refractory to conventional therapy
– Evaluate the filling and emptying phases of the bladder
– Can be done in conjunction with fluoroscopy
DIFFERENTIAL DIAGNOSIS
• Nonneurogenic neurogenic bladder
• Neurogenic bladder
• Ochoa syndrome
• Overactive bladder
• Giggle Incontinence
TREATMENT
GENERAL MEASURES
• Behavioral modification: Education on voiding patterns
– Timed voiding
– Correct positions to void
– Relaxation techniques
– Proper hydration
• Bowel Management
– Education on correlation between the bladder and bowel activity
– Daily toilet time
– Dietary modifications; high fiber
MEDICATION
First Line
• Treatment of constipation prior to medications for bladder symptoms; disimpaction followed by maintenance therapy
– Initial cleanout with laxatives and enemas
– Maintain soft daily stools with a combination of fiber, fluids, laxatives, and softeners
• Antimuscarinics; overactive bladders
– Reduce the intensity and frequency of bladder contractions
• α-Adrenergic blockers; bladder neck obstruction
– Relaxation of the bladder neck to improve bladder emptying
• Prophylactic antibiotics; prevention of recurrent UTIs until dysfunctional elimination improved
Second Line
• Tricyclic antidepressants for urge incontinence
– Mechanism not known; not FDA approved in children
SURGERY/OTHER PROCEDURES
• Biofeedback
• Transcutaneous electrical nerve stimulation
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
Clean intermittent catheterization with impaired bladder contractility
Complementary & Alternative Therapies
• Acupuncture
– Low utility in children given use of needles
• Probiotics; prevention of UTIs and treatment of constipation
• Cranberry supplements; potential for UTI prevention
ONGOING CARE
PROGNOSIS
Most children have resolution of symptoms in a short period of time with behavioral modifications; however, some children may have persistence requiring more intensive management.
COMPLICATIONS
• UTIs
• Urinary incontinence
• Urinary retention
• Hydronephrosis
FOLLOW-UP
Patient Monitoring
• Voiding/stooling diary
• Uroflowmetry
• Post-void residual monitoring
Patient Resources
• http://kidshealth.org/parent/general/sick/constipation.html
• http://kidshealth.org/parent/medical/kidney/recurrent_uti_infections.html
• http://www.medicine.virginia.edu/clinical/departments/urology/patients/peds-urology/parents/DysfunctionalEliminationSyndrome-page
REFERENCES
1. 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.
2. Chase JW, Homsy Y, Siggaard C, et al Functional constipation in children. J Urol. 2004;171:2641.
3. Lee SD, Sohn DW, Lee JZ, et al. An epidemiological study of enuresis in Korean children. BJU Int. 2000;85:869–873.
ADDITIONAL READING
• Ballek NK, McKenna, PH. Lower urinary tract dysfunction in childhood. Urol Clin North Am. 2010;37:215–228.
• Nijman RJ. Diagnosis and management of urinary incontinence and functional fecal incontinence (encopresis) in children. Gastroenterol Clin North Am. 2008;37:731–748.
See Also (Topic, Algorithm, Media)
• Encopresis, Urologic Considerations
• Enuresis, Pediatric
• Incontinence, Urinary, Pediatric
• Urinary Retention, Pediatric
• Urinary Tract Infection, Pediatric
• Vesicoureteral Reflux, Pediatric
• Dysfunctional Elimination Syndrome Image 
CODES
ICD9
• 599.0 Urinary tract infection, site not specified
• 788.3 Urinary incontinence
• 788.41 Urinary frequency
ICD10
• N39.0 Urinary tract infection, site not specified
• R32 Unspecified urinary incontinence
• R35.0 Frequency of micturition
CLINICAL/SURGICAL PEARLS
• Constipation is often associated with bladder dysfunction in children.
• Treatment of constipation alone may lead to complete resolution of urinary complaints.
• Vesicoureteral reflux may resolve after treatment of voiding dysfunction.
• Education of the correlation between stooling patterns and voiding complaints is a very important part of treatment; if understanding is poor there is often low compliance.