A prospective cohort study of biopsychosocial factors associated with childhood urinary incontinence

Mental health problems, stressful life events and new-onset urinary incontinence in primary school-age children: a prospective cohort study

Emotional/behaviour problems and exposure to stressful life events are thought to contribute to new onset of urinary incontinence (UI) amongst children who have attained bladder control. However, very few prospective studies have examined these associations. We assessed whether mental health problems and stressful life events were associated with subsequent new onset in UI using multivariable logistic regression in a prospective UK cohort (n = 6408). Mothers provided information on their child's symptoms of common mental disorders (Development and Wellbeing Assessment, 7 years), stressful life events (7-8 years) and wetting (day and night, 9 years). There was strong evidence that separation anxiety symptoms were associated with new-onset UI in the fully adjusted model (OR (95% CI) = 2.08 (1.39, 3.13), p < 0.001). Social anxiety, attention-deficit hyperactivity disorder and oppositional defiant disorder symptoms were associated with new-onset UI, but these associations attenuated following adjustment for child developmental level and earlier emotional/behaviour problems. There was weak evidence for a sex interaction with stressful life events (p = 0.065), such that females experiencing more stressful life events were at higher risk of new-onset UI (fully adjusted model OR (95% CI) = 1.66 (1.05, 2.61), p = 0.029), but there was no association in males (fully adjusted model OR (95% CI) = 0.87 (0.52, 1.47), p = 0.608). These results suggest that separation anxiety and stressful life events in girls may lead to an increase in UI.

Association Between Maternal Depression and Lower Urinary Tract Symptoms in Their Primary School-Age Daughters: A Birth Cohort Study

PURPOSE

Although maternal depression is associated with adverse outcomes in women and children, its relationship with lower urinary tract symptoms (LUTS) in offspring is less well-characterized. We examined the association between prenatal and postpartum maternal depression and LUTS in primary school-age daughters.

DESIGN

Observational cohort study.

SUBJECTS AND SETTING

The sample comprised 7148 mother-daughter dyads from the Avon Longitudinal Study of Parents and Children.

METHOD

Mothers completed questionnaires about depressive symptoms at 18 and 32 weeks' gestation and 21 months postpartum and their children's LUTS (urinary urgency, nocturia, and daytime and nighttime wetting) at 6, 7, and 9 years of age. Multivariable logistic regression models were used to estimate the association between maternal depression and LUTS in daughters.

RESULTS

Compared to daughters of mothers without depression, those born to mothers with prenatal and postpartum depression had higher odds of LUTS, including urinary urgency (adjusted odds ratio [aOR] range = 1.99-2.50) and nocturia (aOR range = 1.67-1.97) at 6, 7, and 9 years of age. Additionally, daughters born to mothers with prenatal and postpartum depression had higher odds of daytime wetting (aOR range = 1.81-1.99) and nighttime wetting (aOR range = 1.63-1.95) at 6 and 7 years of age. Less consistent associations were observed for depression limited to the prenatal or postpartum periods only.

CONCLUSIONS

Exposure to maternal depression in the prenatal and postpartum periods was associated with an increased likelihood of LUTS in daughters. This association may be an important opportunity for childhood LUTS prevention. Prevention strategies should reflect an understanding of potential biological and environmental mechanisms through which maternal depression may influence childhood LUTS.

Managing children with daytime urinary incontinence: a survey of Dutch general practitioners

BACKGROUND

In the Netherlands, parents of children with daytime urinary incontinence (UI) first consult general practitioners (GPs). However, GPs need more specific guidelines for daytime UI management, resulting in care and referral decisions being made without clear guidance.

OBJECTIVES

We aimed to identify Dutch GP considerations when treating and referring a child with daytime UI.

METHODS

We invited GPs who referred at least one child aged 4-18 years with daytime UI to secondary care. They were asked to complete a questionnaire about the referred child and the management of daytime UI in general.

RESULTS

Of 244 distributed questionnaires, 118 (48.4%) were returned by 94 GPs. Most reported taking a history and performing basic diagnostic tests like urine tests (61.0%) and physical examinations (49.2%) before referral. Treatment mostly involved lifestyle advice, with only 17.8% starting medication. Referrals were usually at the explicit wish of the child/parent (44.9%) or because of symptom persistence despite treatment (39.0%). GPs usually referred children to a paediatrician (n = 99, 83.9%), only referring to a urologist in specific situations. Almost half (41.4%) of the GPs did not feel competent to treat children with daytime UI and more than half (55.7%) wanted a clinical practice guideline. In the discussion, we explore the generalisability of our findings to other countries.

CONCLUSION

GPs usually refer children with daytime UI to a paediatrician after a basic diagnostic assessment, usually without offering treatment. Parental or child demand is the primary stimulus for referral.

Continence Problems and Mental Health in Adolescents from a UK Cohort

BACKGROUND

Adolescents with continence problems experience unique threats to their psychological well-being, but long-term mental health sequelae are unknown.

OBJECTIVE

To examine prospective relationships between incontinence/lower urinary tract symptoms (LUTS) and mental health problems in young people.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort study of young people (n = 7332: 3639 males and 3693 females) from a population-based sample was conducted.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We estimated the association between incontinence/LUTS and mental health outcomes using multivariable regression models adjusted for sex, socioeconomic position, developmental level, intelligence quotient, stressful life events, maternal psychopathology, body mass index, and emotional/behavioural problems.

RESULTS AND LIMITATIONS

Daytime wetting and voiding postponement showed the greatest number of associations with mental health problems. All incontinence subtypes/LUTS were associated with increased odds of generalised anxiety disorder (eg, odds ratio for daytime wetting = 3.01, 95% confidence interval [1.78, 5.09], p < 0.001) and/or higher anxiety scores. There was also evidence of associations with common mental disorder (eg, voiding postponement: 1.88 [1.46, 2.41], p < 0.001), depression (eg, urgency: 1.94 [1.19, 3.14], p = 0.008), depressive symptoms (eg, daytime wetting: 1.70 [1.13, 2.56], p = 0.01), self-harm thoughts (eg, voiding postponement: 1.52 [1.16, 1.99], p = 0.003), and disordered eating (eg, nocturia 1.72 [1.27, 2.34], p = 0.001). We are unable to generalise our results to minority ethnic groups, less affluent populations, and non-UK samples.

CONCLUSIONS

Young people with incontinence/LUTS are at an increased risk of mental health problems. Further research is needed to establish the direction of causality.

PATIENT SUMMARY

We looked at the association between continence problems and mental health outcomes in young people from a large population-based cohort. Young people with continence problems at the age of 14 yr were more likely to suffer from a range of mental health problems at the age of 18 yr, including common mental disorder, depression, anxiety, self-harm thoughts, and disordered eating. Paediatric continence clinics should address the mental health needs of young people and provide clear and effective care pathways to child and adolescent mental health services.

The relationship between maternal psychopathology and offspring incontinence and constipation at school age: A prospective cohort study

BACKGROUND

There is evidence for an association between maternal psychopathology and offspring incontinence and constipation, but it is unclear if there is a critical/sensitive period of exposure to maternal depression and/or anxiety in the antenatal or postnatal period.

METHODS

Mothers from the Avon Longitudinal Study of Parents and Children provided data on their depression and anxiety (antenatal and postnatal) and their child's urinary and faecal incontinence and constipation at age 7 (6489 participants). We used multivariable logistic regression to examine evidence for independent effects of maternal depression/anxiety on offspring incontinence/constipation and to investigate if there was a critical/sensitive period of exposure. We examined evidence for causal intra-uterine effects using a negative control design.

RESULTS

Postnatal maternal psychopathology was associated with an increased risk of offspring incontinence and constipation (e.g. postnatal anxiety and daytime wetting OR: 1.53; 95 % CI: 1.21-1.94). Data were consistent with a postnatal critical period model and there was evidence for an independent effect of maternal anxiety. Antenatal maternal psychopathology was associated with offspring constipation (e.g. antenatal anxiety OR: 1.57; 95 % CI: 1.25-1.98), but there was no evidence for a causal intra-uterine effect.

LIMITATIONS

Attrition and maternal reports without use of diagnostic criteria for incontinence/constipation are potential limitations.

CONCLUSIONS

Children exposed to maternal postnatal psychopathology had a greater risk of incontinence/constipation, and maternal anxiety had stronger associations than depression. Health professionals should be vigilant to effects of maternal psychopathology on child development. Identification of mechanisms linking maternal psychopathology to child incontinence/constipation is required to inform evidence-based support.

Relationship between toilet training process and primary nocturnal enuresis in children and adolescents - A systematic review

INTRODUCTION

Primary nocturnal enuresis (PNE) affects the quality of life of children and families and may lead to low self-esteem and social isolation. The pathophysiology of enuresis is multifactorial. This systematic review aimed to investigate the relationship between toilet training (TT) and PNE in children and adolescents.

METHODS

We searched for articles about TT and PNE in MEDLINE (via PubMed), SCOPUS and WEB of SCIENCE databases. The Preferred Reporting Items for Systematic Reviews (PRISMA) statement was used to guide the systematic review. Prior to the study, the review protocol was registered and approved in PROSPERO under the protocol CRD42021270976. The Risk of Bias in Non-Randomized Studies of Exposures (ROBINS-E) was used to analyze the biases of the select studies.

RESULTS

A total of 570 studies were initially selected. Of these, eight articles were included in this systematic review, with a total number of 5990 participants aged between 5 and 18 years diagnosed with PNE. Seven of the eight articles reported that prolonged use of disposable diapers for more than one-year, late initiation of the TT process or non-acceptance of the Assisted Infant TT or Elimination Communication approach, use of coercive approaches, and complete of TT after 24 months of age increase the risk of enuresis. Only one of the selected studies did not find an association between the start of TT after 24 months of age and the presence of isolated PNE. Three studies did not mention the approach used in the TT process.

CONCLUSION

Most of the articles reviewed showed that prolonged diaper use, delay in the start or completion of the TT and use of coercive approaches increase the risk of enuresis. On the other hand, one study showed no relationship between the start of TT after 24 months of age and the presence of isolated enuresis.

Relationship between primary monosymptomatic enuresis and process toilet training: a case-control

OBJECTIVE

Primary monosymptomatic nocturnal enuresis (PMNE) is a prevalent condition in childhood, and the pathophysiology is multifactorial. This study investigated the relationship between the toilet training process (TT) and PMNE in children and adolescents.

PATIENTS AND METHODS

A case-control study was carried out from 2015 to 2020. The presence of PMNE was identified according to International Children's Continence Society criteria. A semi-structured questionnaire was applied to assess TT.

RESULTS

The study included 103 children and adolescents with PMNE and 269 participants with normal psychomotor development without PMNE (control group [CG]). Readiness signals were more remembered and less frequent in participants with PMNE (p=0.001) when compared to control group. No differences were found between the groups regarding the onset age of the daytime TT (p= 0.10), the nocturnal TT (p=0.08), the acquisition of daytime continence (p=0.06), and the type of equipment used for the TT (p=0.99). The use of Child-Oriented approach in group of children with enuresis was lower than in controls [87.4% (90/103) versus 94% (250/266)], respectively (OR= 0.44, 95% CI 0.21-0.94, p = 0.039).

CONCLUSIONS

The age of onset of TT, acquisition of daytime continence, and the type of equipment were not associated with higher occurrence of PMNE. On the other hand, the Child-Oriented approach was a protective factor for the occurrence of PMNE.

Maternal Anxiety Associated with Nocturnal Childhood Enuresis

Introduction: Nocturnal enuresis is a common problem affecting 20% of 5-year-old children; its prevalence decreases with age. Nocturnal bedwetting in children younger than 5 is generally accepted by parents and society, but the expectation of parents is that children will achieve a higher degree of responsibility and increased control with age. Some studies have identified maternal distress as a factor associated with childhood urinary incontinence; specifically, maternal stress, maternal depression, and maternal anxiety. The aim of this study was to compare the degree of anxiety (trait and state) among mothers of children with nocturnal enuresis and mothers of healthy children. Methods: This was a prospective, cross-sectional, comparative study including two groups: a control group of 25 mothers of healthy children from open population, and an enuresis group of 25 mothers of children with nocturnal enuresis of the pediatric urology clinic of a third-level Mexican Hospital. STAI-T and STAI-S tests were performed and assessed blindly. Quantitative variables were compared using the Mann−Whitney U test, and qualitative determinations using a chi-square test or Fischer’s exact test. Results: The STAI-S and STAI-T tests results identified 14 (56%) mothers of enuretic children with moderate-to-severe trait anxiety versus 4 (16%) mothers from the control group and moderate-to-severe state anxiety in 23 (92%) of the mothers of enuretic children compared to 7 (28%) control-group mothers. The anxiety scores were significantly higher for the enuresis group for both tests: STAI-T: 53.00 ± 8.39 versus 41.52 ± 9.61 (p < 0.001) and STAI-S: 56.48 ± 6.83 versus 43.84 ± 10.57 (p < 0.001). Conclusion: Mothers of children with nocturnal enuresis present state anxiety ranging from moderate to severe. In clinical practice, our results indicate that the transitory emotion experienced by mothers of enuretic children cannot be neglected in an enuresis treatment program, state anxiety needs to be evaluated, and psychological interventions need to be implemented.

Animal Abuse as an Indicator of Domestic Violence: One Health, One Welfare Approach

For years now, the importance of animal cruelty has been gaining recognition in the industrialized cities of the West. Animal cruelty encompasses any act that causes a non-human animal unnecessary pain or suffering, including negligence, abandonment, abuse, torture, bestiality, and even theriocide. This represents a red flag for society as a whole because people who commit such acts can escalate violence and direct it to other individuals. Animal cruelty and interpersonal violence—as well as other socially undesirable conduct such as bullying, antisocial personality disorder, rape, and serial murder—are closely related, so timely diagnoses of either one can help prevent acts of aggression. It is necessary, therefore, to analyze and try to understand whether there are early indicators that may help identify potentially violent individuals. It is well known that kids from homes with actual violence in their homes show a high tendency to reproduce such behaviors with both animals and other people. In conclusion, much research and rethinking of the importance of the veterinarian in detecting animal abuse and cruelty is needed to help detect and prevent cases of interpersonal violence that may arise over time.

Limitation of developmental test to measure functional independence of children: Relationship between the Japanese version of WeeFIM II® and KSPD

PURPOSE

The purpose of the study was to explore whether a developmental test provides enough information to estimate a child's functional independence. The strength of the relationship between developmental level and functional independence of different skills was investigated.

METHODS

The participants were 397 children (age 0-7 years) who were referred to NCCHD for suspected developmental delay. The participants' developmental level was measured with the Kyoto Scale of Psychological Development (KSPD) and their functional independence was assessed through a Japanese version of the WeeFIM II®. To calculate the strengths of the relationship between developmental age (DA) in different domains of the KSPD and WeeFIM II item scores, partial correlation analyses were conducted, controlling for chronological age.

RESULTS

Partial correlation coefficients between the score of each of the 18 WeeFIM II items and each of the three KSPD domain DAs (controlling chronological age) fell in the ranges of r = 0.169-0.581 (Posture-Motor; P-M), r = 0.377-0.627 (Cognitive-Adaptive; C-A), and r = 0.332-0.655 (Language-Social; L-S). When the participants were divided into three age groups, the correlations ranged from -0.095 to 0.552 for the youngest group (mean age = 14.21 months), from 0.283 to 0.653 for the middle group (mean age = 32.98 months), and from 0.345-0.692 for the oldest group (mean age = 57.48 months), depending on the combinations of the WeeFIM II items/developmental domains of the KSPD. The results indicated that for most of the daily living skills, its functional independence was only partially explained by the scores of a developmental test, once chronological age was controlled.

CONCLUSION

This study showed the limitation of a developmental test as a tool to measure the functional independence of children and the necessity of using an independent tool, such as WeeFIM II, to evaluate the level of required support for each daily living skill.

Determinants of bedwetting trajectories between 4 and 7 years - A birth cohort analysis

INTRODUCTION

Enuresis is frequent in school-aged children and results from a complex interaction between genetics, biological and psychosocial factors. This study aims to analyze bedwetting trajectories between 4 and 7 years of age and to evaluate the impact of biological and developmental characteristics of the child and sociodemographic factors in those bedwetting trajectories.

METHODS

Data from 5433 children from the Generation XXI population-based birth cohort was analyzed. Four bedwetting trajectories were defined: normative (acquired nighttime bladder control at 4 years and no enuresis at 7 years); delayed (no nighttime bladder control at 4 years and no enuresis at 7 years); enuresis (no nighttime bladder control at 4 years and enuresis at 7 years); and secondary enuresis (acquired nighttime bladder control at 4 years and enuresis at 7 years). Multinomial logistic regression models were fitted to test the association between biological and developmental characteristics of the child and sociodemographic factors with bedwetting trajectories.

RESULTS

At the age of 4 years, 36.5% of children had bedwetting (8.1% infrequently and 28.4% frequently) and at the age of 7 years, 11.0% had enuresis (5.8% infrequently and 5.2% frequently). Of the 4-year-old children who were infrequent bedwetters, 14.0% had enuresis at 7 years, while among frequent bedwetters, 30.2% had enuresis at 7 years. Regarding bedwetting trajectories, 26.8% of children were classified in the delayed trajectory, 9.7% in the enuresis trajectory and 1.3% were in the secondary enuresis trajectory. Children with developmental disorders presented an increased risk of being in enuresis trajectory (OR = 1.47, 95% CI 1.15-1.88) than children without developmental disorders. Living in overcrowded houses (OR = 1.60, 95% CI 1.12-2.30), growing up in families with low household income (OR = 1.27, 95% CI 1.03-1.57) and an orphan of one parent (OR = 3.19, 95% CI 1.18-8.64) presented higher odds of being in the enuresis trajectory than in the normative trajectory. Having a sibling both before the age of 4 years and between the ages of 4 and 7 years was associated with delayed trajectory (OR = 1.55, 95% CI 1.16-2.07) and with enuresis (OR = 1.53, 95% CI 1.01-2.33), when compared with children without siblings born at that time.

CONCLUSION

Both developmental disorders and sociodemographic factors seem to be important determinants of bedwetting trajectories. Further studies are needed to better characterize the impact of biological and environmental determinants, on the nighttime bladder control acquisition, to enable timely medical interventions that improve the quality of life of enuretic children.

The evaluation of urinary incontinence in secondary school children and risk factors: An epidemiological study

AIM

Urinary incontinence is an important problem that can arise due to neurogenic or functional reasons and negatively affect the psychological, social and personality development of children. This study was conducted on secondary school students to determine the prevalence and risk factors of urinary incontinence at night and/or in the daytime.

METHODS

The study universe included all secondary school students attending public elementary schools in the city centre of Eskişehir (N = 34 000). Ethics Committee and Provincial Directorate of National Education approvals were obtained before conducting the study. A data collection form prepared by the researchers and a consent form were delivered in a sealed envelope to the parents via the students. The study data were collected over the period 09 May 2018-30 May 2018. A total of 6957 questionnaires that were fully completed among the 7370 surveys were taken into consideration. The statistical analysis was carried out using the SPSS software package.

RESULTS

The number of children found to have urinary incontinence was 215 (3.1%). It was seen that 33 children had urinary incontinence only in the daytime, 61 children experienced it both at night and during the day and 121 children at night. It was observed that 56% of the children suffering from urinary incontinence had not applied to any health facility for treatment prior to the study. It was found that among the risk factors for urinary incontinence were young age, late start of toilet training and presence of a family history of urinary incontinence.

CONCLUSIONS

Children with urinary incontinence and their families need medical information and support to reach the root of the problem and seek solutions. Accompanying pathologies in detected cases can be determined in the early period by means of school screenings, and medical evaluation and support can prevent adverse effects on children's psychosocial and personality development.

State and trait anxiety in children with incontinence and their parents

BACKGROUND

Maternal anxiety increases the risk for incontinence in children. The aim was to analyze anxiety in children with incontinence and their parents before (t1) and after 6 months of incontinence treatment (t2).

METHODS

40 children with incontinence and 40 controls completed the State-trait Anxiety Inventory for Children, their parents the Child Behavior Checklist (CBCL) and the State-trait Anxiety Inventory at baseline (t1) and 6 months later (follow-up, t2). Psychiatric disorders were assessed by a standardized parental diagnostic interview (Kinder-DIPS), IQ was tested by a one-dimensional test. All children were neurologically examined. Children with incontinence underwent a guideline-based treatment during the 6 months.

RESULTS

At baseline, child and parental state and trait anxiety scores, as well as all CBCL scores were significantly higher in the patient group compared to the control group. At t2, parental anxiety, CBCL scores, and child trait anxiety were significantly higher in patients versus controls, whereas child state anxiety decreased, and parental state anxiety increased from t1 to t2.

CONCLUSIONS

Incontinence and anxiety are associated. While state anxiety decreases, trait anxiety can remain stable over time. Higher levels of anxiety can influence incontinence treatment and should be assessed in every patient.

Urgency in children with overactive bladder or voiding postponement: What's the difference?

INTRODUCTION

Overactive bladder (OAB) and voiding postponement (VP) can share the same symptom of urgency, but with different pathophysiology, including the cerebral interpretation of bladder filling. The objective of the present study was to compare the clinical, psychological and sociodemographic features of children with urgency for OAB with those who presented urgency for VP (UrVP).

METHODS

A retrospective cross-sectional study with an analytical component was conducted with patients of 5-14 years of age with urinary urgency between January, 2014, and January, 2019. Urinary symptoms were evaluated using the Dysfunctional Voiding Scoring System (DVSS) questionnaire, constipation using the Rome IV criteria and psychological symptoms using the Strengths and Difficulties Questionnaire (SDQ). All the patients had bell-shaped or tower-shaped curves at uroflowmetry and no significant post-void residual volume at ultrasonography. Patients were classified as having OAB or UrVP depending on whether they voided >3 or ≤3 times/day, respectively.

RESULTS

Median age of the 101 children/adolescents included was 9 years, with no significant difference between the groups. The prevalence of OAB was 60.4%. Girls constituted 57.4% of the sample but 67.5% of the postponement group, although no independent association was found between sex and diagnosis. The prevalence of constipation was 75.2%, with no difference between the groups. The children with OAB had higher behavioral hyperactivity scores and more intense externalizing symptoms, although there was no significant difference between the groups for the SDQ total difficulties score. In the multivariate analysis, the independent clinical factors associated with a diagnosis of OAB were behavioral hyperactivity (OR = 5.134), urge incontinence (OR = 4.694) and MVV/EBC (%) (OR = 0.983).

CONCLUSION

More behavioral problems, particularly hyperactivity, were found in children with OAB compared to those with UrVP. No statistically significant difference was found between the groups evaluated insofar as their sociodemographic characteristics are concerned. Furthermore, as expected, there was a strong association between the symptom of urge incontinence and lower MVV/EBC in the children and adolescents with OAB compared to those with voiding postponement.

Delayed in toilet training association with pediatric lower urinary tract dysfunction: A systematic review and meta-analysis

BACKGROUND

Globally, attitudes and practices towards toilet training have changed several decades ago and children are completing toilet training at a later age compared to previous generations. Concurrently, there has been an increase in the incidence of pediatric bladder bowel dysfunction (BBD), including lower urinary tract dysfunction (LUTD). Whether the fact of delayed toilet training may negatively impact the ability of children to obtain bladder and bowel control and cause LUT dysfunction remains controversial.

OBJECTIVES

To investigate the association between age at initiation of toilet training or approach to toilet training and the risks of lower urinary tract (LUT) dysfunction.

METHODS

A comprehensive search of the CENTRAL, EMBASE and MEDLINE via Ovid SP, and CINAHL via EBSCO databases was conducted to identify RCTs, cohort or case-control studies investigating the association between age at initiation of toilet training, approach used for toilet training, and pediatric LUT dysfunction.

RESULTS

A total of 10 studies with 24,121 participants (aged 5-17) were included for pooled analysis. Overall, the odds ratio (OR) with 95% confidence interval (95%CI) of LUT dysfunction in children who initiated toilet training at a younger age when compared to those who initiated toilet training at an older age, was 0.71 (0.63-0.81), P < 0.001), irrespective of the approach used for toilet training (Table). Subgroup analysis for day-time incontinence (persistent daytime wetting) was 0.77 (0.62-0.95), P = 0.014; although the outcomes for enuresis fluctuated, favorable results were still observed in the earlier training group (OR:0.63, 95%CI:0.43-0.94, P = 0.023). Subgroup analysis for age at initiating toilet training vs LUT dysfunction also showed favorable results in children who were trained earlier, i.e., before 24 months (OR:0.77, 95% CI 0.63-0.94, P = 0.009). Sensitivity analysis confirmed that the results were robust.

DISCUSSION

Although the definition about the age of initial toilet training varied greatly in studies, findings from the current study suggested that the optimal time for initiating toilet training may be prior to the age of 24 months; if toilet training was initiated after 24 months or later, it may result in increased prevalence of LUT dysfunction. Since no RCTs studies were included in the current meta-analysis, well-designed longitudinal studies with larger sample size and from different cultural background are needed to confirm these results.

CONCLUSION

This meta-analysis presents preliminary findings that show the incidence of LUTD may be decreased by initiating toilet training in children at a younger age.

Early life stress: update on neurophysiologic effects and treatment

PURPOSE OF REVIEW

Recent research on childhood trauma has focused on the effects of in-utero and early life stress (ELS) as well as improving access to care. This review includes the previous year's clinically relevant research with attention to gaps that require further research that should improve patient care.

RECENT FINDINGS

The current article focuses on the latest understanding of ELS effects on the neuroendocrine, inflammatory, immune, and neurologic systems, as well as epigenetic effects with a focus on research examining sex-specific differences. Resilience and innovative treatment delivery models are reviewed with emphasis on integrated care models and technology-based treatments.

SUMMARY

The findings reviewed point toward clinically relevant research avenues. The call for more and better treatment options can only be realized with a better understanding of ELS effects. There is a specific need for more in depth exploration and application of sex-specific differences as well as an examination of the effects of age of onset and chronicity of stressors. New developments in the delivery of interventions and treatment allow the potential to provide broader early access to care.

The complex relationship between urinary and defecatory disorders in young and adolescent girls

PURPOSE OF REVIEW

Scientific advancements have led to enhanced clarity about the interrelationship between urinary tract pathology and functional bowel disturbances. The present article will review the current literature regarding the cause, pathophysiology, diagnosis, and treatment of lower urinary tract dysfunction and abnormal bowel habits in young and adolescent girls.

RECENT FINDINGS

Complex neurological, physiological mechanisms and functional behaviors exist that contribute to the development of coexisting urinary symptoms and defecatory disorders in young and adolescent girls. Bladder bowel dysfunction (BBD) in childhood and adolescence is carried into adulthood creating a lifetime health burden.

SUMMARY

Practitioners should be aware and actively screen for conditions mimicking BBD with time-efficient and effective history-taking and physical exams that reduce anxiety and fear. The present review provides guide to comprehensive treatment strategies for managing complex pelvic floor disorders including urinary incontinence, defecatory disorders, pelvic and perineal pain, and constipation. More research is needed to elucidate pathophysiology and optimal treatment strategies of the BBD.