Urination Disorders

In other words, voiding dysfunction refers to voiding disorders that occur as a result of neurological disorders or incorrectly acquired voiding habits during the toilet training period. Clinical findings in these children vary according to the type of dysfunction. These are serious clinical findings such as daytime and nighttime urinary incontinence, frequent urination, urgent urge to urinate, vesicoureteral reflux.

In children with voiding dysfunction, this clinic may sometimes be accompanied by constipation and fecal incontinence (Incontinence). When these clinical findings are associated with bladder instability, frequent or infrequent voiding, costipation and frequent urinary tract infections, it is called dysfunctional elimination syndrome.

Only nocturnal enuresis (nocturnal enuresis) is not considered as voiding dysfunction.

In this article, a wide spectrum of voiding disorders will be discussed. The article will talk about the physiology of voiding, a brief description of voiding dysfunctions and nocturnal enuresis in order. Nocturnal Urinary Incontinence and Urge Incontinence will be mentioned under separate headings.

 

Before talking about voiding disorders and their treatment in children, we think that it would be more effective in understanding the subject to talk about voiding physiology. Therefore, the physiology of voiding will be mentioned first.

Urine is made in the kidneys and then transferred to the bladder (urine bag) through the renal pelvis and ureters. The urine stored here is emptied by the bladder through the urethra at the appropriate time and place with the control of the muscle and nerve mechanism especially in the bladder neck and the brain and spinal cord. As it can be understood from here, the retention, storage and emptying of urine is under the control of the brain, spinal cord, bladder and bladder neck. These structures must work perfectly and coordinated, that is, their relations with each other must work in harmony.

A normal urination cycle takes place in two stages: storage and emptying (urination) function of the bladder (urine bag). These two functions are under the control of the autonomic nervous system and occur reflexively. For urinary continence, bladder storage, which is under the control of the Sympathetic nervous system, and emptying, which is under the control of the Parasympathetic nervous system.

The reflex center of voiding is located in the Sacral (lower) 2nd and 4th Segments of the spinal cord. Nerve impulses from the brainstem and spinal cord ensure the regularity of the filling and emptying cycle.

What is Adult Type Voiding Control?

In a normal adult, during the filling of the bladder, the detrusor (bladder muscle) relaxes, that is, it does not contract, while the sphincter, which is a special muscle structure located in the bladder neck, contracts. The functioning of these two structures is in harmony and reflexively under the control of the spinal cord and consciously under the control of the brain. When the bladder is full, the detrusor starts to contract reflexively, and the sphincter contracts when the time and place are not suitable for emptying urine. This process is controlled by the brain. When the place and time are appropriate, the brain is controlled (consciously), then the detrusor contracts reflexively, the sphincter relaxes voluntarily and voiding occurs. These processes are under the control of the sympathetic and parasympathetic nervous system. Thus, with the synergistic (simultaneous) operation of the detrusor and sphincter, low-pressure voiding occurs in which no urine is left behind in the bladder (no residual urine).

How is the development of urinary control (continence) in children?

In the newborn, voiding occurs reflexively. There is no synergy between the detrusor and the sphincter. Urine remains in the bladder after voiding, that is, the residue is positive. In the first 1 year of life, babies urinate 20 times a day on average. During this time, bladder capacity increases and the amount of urine decreases according to daily weight. Around 2.5 - 3 years of age, the child urinates an average of 10 times a day, and the habit of stopping urine, which first starts by contracting the sphincter, then becomes the habit of initiating voluntary urination. Around 4 - 5 years of age, adult-type voiding is acquired. Therefore, urinary incontinence under 4 - 5 years of age is considered normal.

Between the ages of 1 and 2, children feel that the bladder is full, and between the ages of 2 and 3, they gain the ability to voluntarily start and finish urination. Therefore, toilet training should be given at this age.

What are continence and incontinence in children?

Continence is the ability to hold urine or poop in a way that is socially appropriate, to urinate or defecate at the appropriate time, in the appropriate place and voluntarily. Loss of this ability for any reason is called Incontinence.

What is the Developmental Sequence of Continence in Children?

The order of development of continence in children is as follows; Daytime Poop Control, Nighttime Poop Control, Daytime Urine Control, Nighttime Urine Control.

Around 90% of children around 4-5 years of age have developed day and night urine control.

What is Enuresis and Urinary Incontinence?

It is very important to know and differentiate these two medical terms in order to understand, diagnose and treat voiding disorders.

Enuresis is normal physiologic voiding at an unwanted place and time. This is a clinical finding rather than a disease. It can be divided into Primary (children who have never been dry since birth) and Secondary (children who have been dry for a period of at least 6 months but then start urinary incontinence again). It is also divided into two as Monosymptomatic and Diurnal Enuresis.

Monosymptomatic Nocturnal Enuresis or Nocturnal Urinary Incontinence or Bedwetting;

It can be more appropriately called urinary incontinence during sleep. Sick children do not have any other clinical complaints and do not have any anatomical and physiologic problems. If urinary incontinence occurs during the daytime, an underlying disease should be sought. If this picture is seen before 4-5 years of age, it should not be considered as a disease. However, if it occurs after the age of 5 years, it should be considered pathologic and treated as it may cause psychological problems. In most of these children, knowing the history, physical examination and how normal urinary continence develops allows the problem to disappear in a short time.

Daytime Enuresis: It means urinary incontinence only during the daytime and is a rare condition.

If nocturnal enuresis is present, daytime incontinence should be treated first, because normally, daytime urinary incontinence develops first, followed by nocturnal enuresis. It usually occurs as a result of attention-deficit and hyperactivity syndrome and child psychiatrist should be asked for help in treatment.

Incontinence defines all urinary incontinence problems except enuresis. These can be grouped in three main groups; urination problems due to neurological damage, urination problems due to non-neurological detrusor and sphincter dysfunctions and urination problems due to anatomical structural disorders. The main diseases in this group are myelomeningocele, spina bifida, sacral agenesis, sacral teratoma, hinman syndrome, ocha syndrome, bladder exstrosis, cloaca anomaly.

How should children with enuresis be investigated?

First of all, a good history and physical examination provides a great understanding of the event.

The conditions that should be questioned when taking a history in children with urinary incontinence are as follows; Questioning the pattern of urination and incontinence, questioning the pattern of pooping and poop incontinence, frequency of urination, behavioral characteristics of the child, psychomotor development should be questioned.

The following questions should be asked;

• Does she urinate frequently during the day, or how many times?
• Is the incontinence continuous or intermittent?
• How many times a week does he/she wet the bed?
• Is he/she still in diapers during the day or at night?
• Does he/she engage in any behavior to avoid leakage when he/she urinates?
• Does he/she have urinary tract infections?
• Has he/she been incontinent since he/she was a baby or has he/she started incontinence after a certain period of time?
• Has there been any change in the life of the child or the family (such as separation of parents, siblings, change of school and caregiver or even teacher)?
• How is the pooping pattern?
• How is the menstrual pattern in young girls?

The first step is to take a detailed history, what questions can be asked at this stage?

• Age of onset of urinary incontinence?
• Is there increased or decreased frequency of voiding (less than 4, more than 8)?
• Is there urgency, hesitation, straining?
• Is there weak stream during urination, intermittent urination, dripping after urination?
• Is there uncontrollable urine leakage?
• Is there a feeling of incomplete ejaculation?
• Sudden feeling of urgency, urgent urge to urinate? Is there urinary incontinence when squeezed or suddenly?
• Is the urine stream regular when urinating? Or intermittent?
• Is there pain when urinating?
• Does he/she make special movements, urine retention maneuvers to hold urine?
• How are bowel habits? Is there constipation, fecal incontinence?

What are the Conditions to be Considered in Physical Examination in Children with Urinary Incontinence?

Especially psychomotor development should be evaluated. Perineal sensory examination, genital area, back and coccyx examination should be performed well to exclude neuropathic and anatomical causes. The coccyx should be well evaluated for anatomical defects, masses, hair growth and color changes. Gluteal cleft asymmetry is important. The lower extremities, especially the feet, should be evaluated well in terms of deformity and gait disorders should be evaluated. Abdominal examination should be evaluated for large bladder and intestines and hard stools. Voiding should be observed and lumbosacral reflex evaluation should be performed.

What are the tests that should be performed after history and physical examination in children with enuresis?

Whether there is an underlying disease is important in determining these tests. The tests to be performed here are determined according to the patient. These; Urine test, culture if necessary, urinary system ultrasound, voiding cystogram, urodynamics, magnetic resonance imaging tests are performed.

Examinations to be performed in a child with urinary incontinence; The physician should decide which of these examinations will be performed on which patient.

Urine examination: Absolute must be done. Urinary tract infection should be investigated. Urine culture is also taken from necessary cases.

Urination frequency chart: Also called a voiding diary. The family records in milliliters (ml) the time and amount of all fluids the patient has taken in over 24 hours and the time and amount of each urination in milliliters (ml) over 24 hours. Incontinence, separate from voiding, is also noted. These objective data are used to determine how many times a day the patient voids, what is the average volume of voiding, what is the maximum and minimum volume voided, how many times a day the patient incontinences urine, what is the daily urine volume and what is the daily fluid intake.

Ultrasonography: Ultrasonography is an indispensable diagnostic tool in the evaluation of a child with urinary incontinence. On ultrasonography, normal kidneys, ureters and bladder (no hydronephrosis, bladder wall thickening or post-void residue) almost completely exclude an anatomical abnormality.

In ultrasonography, the diameter of the last part of the large intestine (rectum) should also be measured and evaluated.

Urodynamics: It is a very specific research method based on physical and mathematical models related to pressure, flow and force in the urinary system. It gives the maximum capacity of the bladder, the contraction strength of the bladder, the coordination between the contraction of the bladder and the opening of the bladder neck, the leak point pressure (LPP) of the bladder, abnormal contractions of the bladder, urinary sensation (first urine sensation, normal urine sensation, feeling of incontinence), pathologies in the contraction and relaxation of the sphincters, the ability of the person to voluntarily start and stop urination.

Uroflowmetry: It is a test to measure the micturition rate. It can be used alone or in combination with cystometry.

After this part of our article, the main topics of Incontinence and Enuresis will be briefly mentioned.

1- Incontinence due to Structural or Anatomical Causes; In this group, there are a number of underlying neurological and anatomical diseases, often incontinence may be the only symptom of this group of diseases.

Neurological Diseases; Meningomyelocele, Hydrocephalus, Sacral Trauma and Tumors. Structural Diseases; Bladder Exstrophy, Epispadi, Cloacal anomaly, Ectopic ureter, Posterior Urethral Valve, Purune Belly syndrome.

2- Non-Neurological Bladder Sphincter Dysfunctions;

Diseases that need to be evaluated in this group; Urge Incontinence, urinary incontinence during giggling, less active bladder (lazy bladder), Staccato urination, freaxione urination, Urinary tract infection-related urination disorder, Hinman syndrome, Ochoa Syndrome.

Voiding dysfunction (dysfunctional voiding) is a bladder sphincter dysfunction related to the emptying phase of the bladder (voiding phase). An important issue to emphasize here is non-neurological bladder sphincter dysfunctions, as in Ochoa and Hinmean syndrome. Here, there is no neurologic damage but the clinic behaves as if there is the same neurologic damage.

On the other hand, recurrent urinary tract infection and vesicourteral reflux are clinical conditions that frequently accompany bladder-sphincter dysfunction without neuropathy. Bladder-sphincter dyssynergia is responsible for approximately 10% of vesicoureteral reflux and recurrent urinary tract infections, especially in school-age girls.

a - Overactive (Active) Bladder (Urge-compression syndrome); One of the most common causes of urinary incontinence in children, especially in girls, is overactive bladder. It has three typical features.

• Recurrent urinary tract infection,
• Bladder-sphincter dysfunction (feeling of squeezing),
• Vesicoureteral reflux.

The cause is not known exactly, the bladder behaves like the fetal bladder and cannot switch to adult bladder behavior. Since there is no central inhibition here, the detrusor starts to contract when the bladder volume reaches a certain level. Reflexively, the sphincter relaxes and the child voluntarily tightens the sphincter to prevent this, but it provides this to a certain extent, eventually the contractions overcome this obstacle and urine leakage occurs.

The clinical symptoms of urge incontinence are not the same in every child. In general, these children rise on tiptoe, cross their legs, squat, move their buttocks on the floor while watching television, clench their fists, hold their penises in boys, and run to the toilet immediately realizing that they will leak urine, but often cannot reach the toilet and leak urine, urine is small and enough to wet the panties, the child goes to the toilet frequently and urinates in small amounts. If this condition is not treated, it causes vesicoureteral reflux because it causes increased intra-bladder pressure.

How is Urge Incontinence Diagnosed?

It is diagnosed by history, physical examination and voiding frequency chart. Urodynamics can be performed if the diagnosis is not sure, and ultrasound can be used for differential diagnosis.

 

How to Treat Urge Incontinence?

The main thing in treatment is to explain the event very well to the family and the child and to motivate them. Explaining how and when to urinate and keeping a schedule of urination, treatment of constipation and urinary tract infection, if any, and antimuscarinic drug treatment. In recent years, electric stimulation therapy and Botulinum applications are also used in patients who are resistant to this treatment.

b - Voiding Dysfunction; It is characterized by incomplete relaxation or overactivity of the pelvic floor muscles during voiding. It is seen alone or in combination with an overactive bladder. Here, the clinical findings depend on the intensity of detrusor contraction and bladder outlet resistance.

Clinical findings are sudden urination, straining, intermittent urination and recurrent urinary tract infections.

1- Staccato Urination; Despite the contraction of the detrusor, regular urine flow cannot be achieved, the child urinates one after the other, intermittently and in spurts. The reason for this is that the activity of the pelvic floor muscles shows periodic and sudden ups and downs.

In these children, the duration of urination is longer than normal and there is residual urine in the bladder (urine remaining in the bladder after urination), which causes urinary tract infection.

2- Fractionated voiding; These children urinate both normally and infrequently. In addition, the bladder cannot be emptied completely because the detrusor does not contract enough. The child who realizes that he/she cannot empty the bladder completely urinates by pushing but still has a residue. Bladder acapacity is higher than normal in these children.

Treatment of voiding dysfunction; The disease should be explained in detail to the family and the child, how and when to urinate, constipation and urinary tract infection, if any, should be treated, and a voiding diary should be kept.

Urotherapy and antimuscarinic drug treatment may be given if there is accompanying detrusor hyperactivity. In urotherapy, patients are taught how to relax the sphincter during voiding by visual and auditory methods. Drugs used in the treatment of hypertension may be used in this group of patients.

 

c - Underactive Bladder Syndrome (Lazy Bladder); It is also known as lazy bladder. It is considered as an advanced form of overactive bladder. Due to the high bladder outlet pressure, the ability of detrusor contraction decreases over time, the child urinates by pushing to contribute to detrusor pressure, but still remains residual after urination. These patients can hold their urine throughout the day and urinate at long intervals. The bladder volume is very increased. There are frequent urinary tract infections. The detrusor contracts little or not at all.

Diagnosis is based on History, Physical Examination, Ultrasound and Urodynamics

In treatment; regular voiding is taught, Clean Interval Catheterization may be required in children who do not comply.

d- Hinman Syndrome; Other name is non-neurogenic neurogenic bladder. In this disease, there is no neurologic problem but the bladder behaves as if there is a neurologic problem. The bladder wall is thick and trabeculated and there is advanced vesicoureteral reflux. Early diagnosis and treatment is important.

Diagnosis is based on history, physical examination, ultrasound, urodynamics and magnetic resonance imaging.

Treatment is determined according to the patient. The prognosis is determined by the function of the kidneys.

e - Ochoa Syndrome; This disease is considered a genetic form of Hinman syndrome. It has severe renal pathology, constipation and facial anomalies. Most of these children are in renal failure at the time of diagnosis. They do not smile much, when they do, their face becomes tearful.

Diagnosis is based on history and physical examination,

Treatment; Clean Intermittent Catheterization is applied.

f- Giggle (Laughter) Incontinence; Urinary incontinence while awake and only during laughter, also known as giggle incontinence. In these patients, there is no problem in day and night urine control, only when the patient laughs, especially when he laughs, urine incontinence occurs. The bladder is completely emptied, one of the most important differences from urge incontinence is that in urge incontinence, the bladder is completely emptied while in giggle incontinence, only the panties get wet. This condition is rarely associated with urinary infection or structural abnormalities. In this condition, which occurs almost exclusively in girls, the bladder empties suddenly and completely during laughter. The cause is not clear. Anticholinergic treatment may be beneficial in this condition. Spontaneous recovery is expected in these cases over time. General treatment principles The most important step in patients with dysfunctional voiding syndrome is to decrease the increased pelvic floor muscle activity. If the child has a habit of waiting, this must be tried to be broken. It is very important to teach the habit of timed urination (once every 2 hours).

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