Voiding Dysfunction Treatment & Management

Updated: Oct 22, 2021
  • Author: Christopher S Cooper, MD, FACS, FAAP; Chief Editor: Marc Cendron, MD  more...
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Treatment

Approach Considerations

Behavioral modification is the foundation of treatment for children with functional voiding disorders. Effective biofeedback training is especially helpful for management of dysfunctional voiding, primarily by decreasing outlet resistance during voiding. Children younger than 5 years are often incapable of doing biofeedback on a regular basis. [28] Animated biofeedback has been shown to effectively treat dysfunctional voiding in the pediatric population. [29, 30]

One study of children with daytime incontinence reported that as many as 76% of these patients never had an adequate trial of preliminary nonpharmacologic measures. [18]

Sacral nerve stimulation is being studied as a means of treating refractory lower urinary tract dysfunction in children. [31]  Some evidence suggests that it may be as effective as biofeedback for treating nonneurogenic voiding dysfunction. [32]

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Overactive Bladder

In the treatment of overactive bladder (OAB), the goal is to foster development of cerebral inhibition of detrusor contractions during bladder filling so that urgency and urge incontinence do not occur. No known medication or procedure has been shown to accomplish this; however, certain interventions appear to help.

A voiding retraining program is an essential component of management. In most instances, such retraining should be tried for 1-2 months before an anticholinergic medication is introduced.

One study evaluated the response to treatment in 63 children with daytime incontinence initially treated with nonanticholinergic methods; by the second visit, 6% of patients were dry, 38% showed significant improvement, and 37% showed slight improvement. [18]

Guidelines for voiding retraining with behavioral modifications

Children should have a footstool or other solid surface placed in front of the commode so that their feet are on a solid surface. The child should remove the underpants or lower them to the ankles to permit relaxed separation of the thighs. During voiding, the child should be comfortable and relaxed and should not be rushed to void (eg, during a television commercial).

Boys should be instructed to free the penis before voiding. The zipper or buttons should be completely opened. If the underwear constricts the penis, this should be corrected. Boys should be relaxed and take sufficient time to empty the bladder completely.

Successful management requires ongoing support, instruction, and education. Children should be taught to understand that normal urination is the result of relaxing the sphincters and permitting the bladder muscle to expel the urine, not a matter of forced voiding using the abdominal muscles.

A timed voiding schedule, to be used when the child is awake, is an essential component of bladder retraining, even in patients with urinary frequency. Children should be encouraged to void before a sense of urgency is present in order to develop a regular voiding pattern. Timed voiding is instituted with bladder evacuation every 2-3 hours “by the clock” when the child is awake.

Writing letters to a school nurse, teacher, or principal to carry out this program is necessary and of value. In a survey of school nurses, 47% of respondents reported being involved in setting voiding schedules for children, and the majority allowed free access with a physician’s note. [33]

Introduce calendars to keep records of voiding patterns and bowel movements. The latter is important, even in a child with no history of constipation, particularly if an anticholinergic medication is introduced.

Pharmacologic treatment

Prophylactic antibacterial therapy should be considered in children with recurrent urinary tract infections (UTIs) and in those with vesicoureteral reflux (VUR).

Anticholinergic medications (eg, oxybutynin [34] ) are frequently helpful in children who do not respond to conservative measures. However, these medications are meant to help the child develop a normal voiding pattern and are not long-term solutions. Ultimately, the child must develop the ability to use cerebral mechanisms to inhibit detrusor contractions.

Parasacral trancutaneous electrical nerve stimulation

Various reports have suggested that parasacral trancutaneous electrical nerve stimulation (TENS) can be useful in treating OAB. It appears to be more effective than oxybutynin, with fewer adverse side effects. [34] Its usefulness does not appear to be affected by sex, age, daytime incontinence, nocturia, previous UTI, constipation, or holding maneuvers; however, it may be less likely to be effective in the presence of nocturnal enuresis. [35, 36]

Constipation and overactive bladder

Prevalence figures for constipation in the pediatric population have ranged from 0.7% to 29.6%. [37] When constipation is diagnosed in a child with voiding dysfunction, it is important to treat the constipation so as to determine whether it is the cause of the bladder symptoms. In one study of the relation between constipation and incontinence, resolution of constipation was associated with 89% resolution of concomitant urinary incontinence. [38]

Treatment of chronic constipation includes a high-fiber diet, sometimes with the addition of laxative medication. One option is treatment with MiraLAX, which is prepared by diluting the powder and administering it at least once a day. This therapy has gained widespread use for constipation. A study of 46 children with urinary incontinence and constipation treated with MiraLAX found that 39% of patients became dry, 56% of patients had improvement in their wetting, and 5% of the children had no improvement. [39]

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Dysfunctional Voiding

Dysfunctional voiding is the most worrisome functional voiding disorder in children because in rare cases it progresses in a pattern similar to a neurogenic bladder or outlet obstruction. In the infrequent instances in which severe bladder dysfunction occurs, the condition has been termed nonneurogenic neurogenic bladder (Hinman-Allen syndrome).

Treatment of this voiding disorder, which has been described as a disharmony between the detrusor and sphincters, consists of a voiding retraining program with emphasis on good voiding technique and suppressive antibacterial agents for patients prone to UTIs. Anticholinergic medication is not useful to treat sphincter dysfunction. Botulinum toxin A has been reported to achieve satisfactory results in selected children with refractory voiding dysfunction. [40]

When the upper urinary tract is normal, management should focus on the development of effective, relaxed voiding using the interventions described for OAB. Biofeedback training for carrying out Kegel exercises (pelvic floor relaxation and contraction) has been successful in many centers. [41] Animated biofeedback has also been reported to effectively manage dysfunctional voiding. [29, 30, 40]

Giggle incontinence

Treatment results for giggle incontinence are difficult to assess because of the high rate of spontaneous resolution with maturity. Patients may need to accommodate the problem by trying to avoid situations that cause laughter when in public places. If incontinence frequently occurs, a trial of a timed voiding schedule with the addition of an anticholinergic agent may be warranted, and high rates of success have been reported.

An uncontrolled study of seven children with giggle incontinence reported success with methylphenidate. The report’s authors suggested that the condition responded to a stimulant because, possibly, giggle incontinence shares pathophysiologic features with narcolepsy/cataplexy syndrome. [42]  Biofeedback and bladder training have been advocated by those who place more emphasis on urologic dysfunction than on neurologic origin as an explanation for giggle incontinence. [43]  

Incontinence upon laughter may have symptoms similar to those of OAB, and a treatment regimen including anticholinergics has been described as yielding a success rate of 89%. [11]

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Underactive Bladder

Not all patients with detrusor underutilization are found to have detrusor underactivity or overactivity, with the majority of patients generating a normal sustained voiding contraction that empties the bladder completely and in synergy with the sphincter. [44]

Chronic or episodic willful deferring of voiding by patients can occur. Children who void as infrequently as two or three times every 24 hours should be encouraged to undertake more frequent voiding to avoid potential problems at a later age. They are at risk for UTIs because prolonged bladder incubation of urine compromises the protective effect of regular bladder emptying, which clears bacteria that gain access to the bladder during voiding.

Children with large-capacity, hypotonic urinary bladders who are unwilling or unable to comply with an improved voiding schedule can benefit from clean intermittent catheterization (CIC).

A randomized clinical study of 36 children with nonneuropathic underactive bladder found that the combination of transcutaneous interferential electrical stimulation (IFES) and urotherapy was safe and effective in the management of pediatric patients with this condition. [45]  A review of 11 studies assessing transcutaneous IFES for lower urinary tract dysfunction and urinary incontinence cited success rates ranging from 61% to 90%. [46]

 

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Other Sources of Incontinence

Wetting secondary to vaginal reflux may be resolved by teaching the child proper voiding technique. The child may void in a reverse sitting position on the commode, which causes the thighs to be abducted and the labia majora to separate. If this is unsuccessful, the child may assume an upright position over the commode immediately after voiding to empty the vagina.

Labial adhesions have been attributed to local inflammation and a hypoestrogenic state in a preadolescent child. The labial skin can become so excoriated and denuded that during the healing process, the labial edges fuse together. Symptoms, if present, are usually vulvar irritation or soreness. The child may also present with “incontinence,” when dribbling of urine occurs as a result of urine being trapped in the vagina.

Recommended treatment of labial adhesions consists of conservative observation, application of a topical estrogen cream to only the fused area, or physician lysis of adhesions. After the adhesions have separated, a bland petroleum jelly should be applied to the medial surfaces of the labia minora once daily for 1-2 months.

If no specific diagnostic etiology is found, management of persistent and otherwise asymptomatic daytime urinary incontinence is primarily supportive.

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Consultations

Reasons to have a patient's condition evaluated by a urologist include the following:

  • Suspicion of neurologic or anatomic etiology
  • Lack of familiarity or training in diagnosis and treatment of children with voiding dysfunction
  • Symptoms that are not responsive to behavioral modification
  • Constant, continuous incontinence
  • Frequent UTIs
  • VUR
  • Suspected renal involvement (elevated creatinine levels, hydronephrosis)
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