Pediatric urinary incontinence: Classification, evaluation, and management

A Bladder Sensor for Adults With Urinary Incontinence

INTRODUCTION

Urinary incontinence (UI) is a very common hygiene and health problem in adults which has an enormous impact on quality of life (QoL). Noninvasive treatment options are the first line of treatment. It would be beneficial to know when the bladder reaches its maximum capacity, to enable to prompt going to the bathroom on time and thereby potentially prevent an UI event. Recently, a wearable bladder sensor was developed, the TENA SmartCare Bladder Sensor (Bladder Sensor), which is intended to support children ( ≥ 6 years) and adults (BMI ≤ 25 kg/m2). The Bladder Sensor tracks the bladder filling status and notifies the user when it is time to go to the bathroom by a vibration of the device and/or a notification in an app on a mobile device (e.g., smartphone and/or Apple Watch®). The primary objective of this first pivotal study was to demonstrate that the Bladder Sensor can detect the bladder before urination among adult intended users. The secondary objectives were to collect real-life data to evaluate performance, safety, usability, and subject satisfaction with the device as well as impact on QoL. The primary hypothesis was to evaluate if the median bladder detection rate in the evaluated population is greater than the threshold of 85% (H0: ≤ 0.85, H1: > 0.85, p-value < 0.05).

PATIENTS & METHODS

Adults ( ≥ 18 years) suffering from UI during day and/or night tested the Bladder Sensor independently at home for 1 week. Device performance, safety, usability, user satisfaction and self-reported disease specific information, and QoL were assessed at pre-defined times. Intra-individual results were compared. Any episodes of urination and/or urine loss were documented by subjects in a paper diary. Raw data of the Bladder Sensor was analyzed to evaluate the bladder detection rate and full bladder notification rate(s).

RESULTS

30 adults (female/male: 67%/33%; median age: 53 years (Interquartile range (IQR) 32-61 years); median BMI of 22.6 kg/m2 (IQR 20.7-23.8 kg/m2)) completed the study testing the Bladder Sensor at home for 6.9 days on average. The median bladder detection rate was 89.8% (IQR 82.6-95.3%) in a sample without statistically and clinically identified outliers (n = 28). The null hypothesis was rejected among those (z = 69, p < 0.05). The median actual full bladder notification rate was 63.1% (IQR 50.0-71.4%), and the median perceived full bladder notification rate was 94.4% (IQR 87.0-105.6%). The device showed to have a positive effect on subjects' UI problems (e.g., 67% reduced number of unwanted leakages) and QoL.

CONCLUSION

It was demonstrated that the Bladder Sensor can detect the bladder under real-life conditions among its intended users and can support in the prevention of UI. This seemed dependent on anatomical limitations (e.g., BMI and body shape), bladder volume (low bladder detection rate < 100 mL), and/or proper fixation. The device had a positive effect on the subject's urinary incontinence, their Qo,L and overall well-being while testing it for 1 week. It is assumed that this effect will be strengthened when users incorporate the use of the device into their daily life. Long-term benefits of the Bladder Sensor as an adjunct tool in continence care management needs to be investigated.

TRIAL REGISTRATION

Registration number is NL81246.000.22.

Bladder and Bowel Dysfunction Rehabilitation in Children with Acquired Brain Injury

Objective: To evaluate neurogenic bladder and bowel dysfunction (NBBD) in children with cerebral palsy (CP) and acquired brain injury (ABI), a condition considered less frequent in those patients than in children with spinal cord injury (SCI), and to study the relationship between NBBD and disability grade in this population. Study Design: We retrospectively reviewed the clinical data of all patients (aged 3-18 years old) admitted during a three-month observation in our neurorehabilitation department. Data collected were as follows: demographic parameters; disability status (Wee-FIM Scale, Gross Motor Function Classification System (GMFCS) and the Communication Function Classification System); and gastrointestinal and urological symptoms (diaries, Bristol scale, Pad Test and International Consultation on Incontinence Modular Questionnaire). Results: Sixty patients were enrolled (31 females, 29 males): 30 CP, 17 ABI, 3 SCI, and 10 others with neurological diseases. All presented urinary incontinence without gender differences. CP and ABI had major incidences of bowel dysfunction (50% and 64.7%, respectively) and SCI of urinary tract infections (66.6%) and enuresis (100%). A major incidence of symptoms was recorded in patients with higher GMFCS levels (level 3-4-5). Conclusions: NBBD has a high frequency in children with CP and ABI, as in SCI. More attention is needed from pediatricians and pediatric urologists for this clinical entity. Further studies are needed to better understand clinical relevance and, therefore, to establish specific management.

The Prevalence of Bladder and Bowel Dysfunction in Children with Cerebral Palsy and its Association with Motor, Cognitive, and Autonomic Function

PURPOSE

To describe the prevalence of bladder and bowel dysfunction (BBD) in 8-10-year-old children with cerebral palsy and its association with motor, cognitive, and autonomic dysfunction.

METHODS

A cross-sectional, random sample study of parents of 8-10-year-old children with cerebral palsy. Tools: The Enuresis/Urinary Incontinence Parental Questionnaire, the Functional Independence Measure children's version, the autonomic signs questionnaire, and the Gross Motor Function Classification System.

RESULTS

39 out of 59 parents consented to participate, whereas 25.64% reported complete continence. Of the 29 children with BBD, 21 (72.4%) had lower urinary tract symptoms and bowel problems. Only two of the children received conservative and noninvasive treatments. Lastly, motor, cognitive and autonomic impairments were associated with incontinence.

CONCLUSIONS

BBD is common in 8-10-year-old children with cerebral palsy at all levels of functioning. Most having both lower urinary tract symptoms and bowel problems.

Can the combined treatment of solifenacin and imipramine has a role in desmopressin refractory monosymptomatic nocturnal enuresis? A prospective double-blind randomized placebo-controlled study

BACKGROUND

Nocturnal enuresis is a common disease of childhood. It can be classified into monosymptomatic nocturnal enuresis (MNE) or nonmonosymptomatic nocturnal enuresis (NMNE). Imipramine is a tricyclic antidepressant used to treat enuresis with initial success rates are high as 50% but some studies record a high relapse rate and it has a cardiotoxic effect when overdosed. Anticholinergics may be effective in the treatment of children with bladder storage dysfunction, including daytime incontinence. However, anticholinergics monotherapy is not effective in treating MNE. In our study, we used a low dose (25 mg) of imipramine in order to avoid its potential side effects and combined it with the synergistic anticholinergic action of solifenacin. Our objective was to evaluate the efficacy and safety of the combination of solifenacin and imipramine compared with placebo in the treatment of desmopressin refractory MNE.

METHODS

One hundred children aged 6 years or more with primary MNE unresponsive to desmopressin treatment were included. The children were randomly divided into two equal groups. Group A received imipramine 25 mg and solifenacin 5-10 mg oral tablets and group B received placebo once 1 h before bedtime for 3 months. The primary end point was to investigate the efficacy of the combined treatment of solifenacin and imipramine and the secondary end point was the safety of the drugs.

RESULTS

Our study showed that the mean post treatment wet nights per month was significantly lesser in the treatment group than placebo group (p < 0.001) and cure rate was significantly higher in treatment group than placebo group (p < 0.001). The relapse rate was statistically significantly lower in treatment group than placebo group (p = 0.032). No significant side effects related to the drugs were reported.

CONCLUSION

The combination treatment of solifenacin and imipramine is a useful and safe treatment for nocturnal enuresis after failure of everything else.

Uroflowmetry in Non-Monosymptomatic Nocturnal Enuresis in Children of Coastal Region of Croatia

PURPOSE

The aim of the study was to describe clinical characteristics and bladder assessment in children with Non-Monosymptomatic Nocturnal Enuresis (NMNE) in coastal region of Croatia.

MATERIALS AND METHODS

Records on 85 patients with NMNE were retrospectively reviewed. Bladder assessments were performed in all children. In this research we: (i) compare clinical characteristics and features of bladder assessment: uroflowmetry, post void residuals (PVR) and bladder wall thickness between boys and girls with NMNE and we compare (ii) clinical characteristics and bladder assessment between children with primary and secondary NMNE.

RESULTS

There were 46 girls and 39 boys. The total of 59 children had primary NMNE and 26 children had secondary NMNE. Uroflow pattern was abnormal in 42% of all children with NMNE. Abnormal uroflow pattern in children with NMNE was more often in girls than in boys (P < 0.05) and in children with secondary than in children with primary NMNE (P < 0.05). Ultrasound evidence of bladder wall thickness was more frequent in boys than in girls. Girls were more likely to have dysfunctional voiding and larger residual urinary volume than boys.

CONCLUSIONS

Abnormal uroflow pattern in children with NMNE was more often in girls than boys and in children with secondary than in children with primary NMNE.

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.

SENS-U: validation of a wearable ultrasonic bladder monitor in children during urodynamic studies

PURPOSE

Urinary incontinence is a common problem in school-age children. Because many children remain unaware of a full-bladder sensation, the SENS-U^™ Bladder Sensor was developed. The SENS-U is a small, wearable ultrasound sensor, which is positioned on the lower abdomen using a skin-friendly adhesive. The sensor continuously estimates the bladder filling status and informs the user when it is time to go to the toilet. In this study, the clinical performance of the SENS-U is evaluated in children during (video) urodynamics.

MATERIAL AND METHODS

In this study, 30 children (6-12 years) were included who were scheduled for a (video) urodynamic study. During urodynamics, the SENS-U determined the average anterior-posterior (A-P) bladder dimension (every 30 s) to estimate the filling status. The correlation between the average A-P bladder dimension and the infused volume is analyzed by Spearman's correlation.

RESULTS

Thirty patients (boys/girls: 15/15; mean age: 7.9 ± 1.4 years) were included, in whom the SENS-U detected the full bladder before voiding in 90% of the patients (27/30). In the other patients, the bladder was outside the detection area due to either erroneous sensor placement (n = 1) or an (relative) obese abdomen in the upright position (n = 2). There was a strong correlation (median r_s = 0.94) between the average A-P bladder dimension and the infused volume. The detectable maximum bladder volume ranged between 71 and 463 ml.

CONCLUSION

The SENS-U is able to detect a full bladder with a success rate of 90%. When excluding erroneous data due to sensor misplacement or an (relative) obese abdomen, the detection rate may even be higher. Future research will focus on investigating the effect of theSENS-U in incontinence training.

Prevalence of Pelvic Incontinence in Patients With Cystic Fibrosis

Cystic fibrosis (CF) patients are at risk for developing pelvic (urinary and/or fecal) incontinence due to progressive weakness of pelvic floor muscles secondary to recurrent episodes of coughing and respiratory infections. Many patients do not bring these symptoms to the attention of their health care providers because of social embarrassment and lack of knowledge of available effective treatment. Several studies have identified the prevalence of incontinence in CF adults and adolescents. However, few studies identified the problem in children with CF. Our study aims are to identify the prevalence of pelvic incontinence in CF patients aged 6 to 21 years, to identify the correlation between incontinence and severity of lung disease, and to help develop treatment strategy in collaboration with physical therapy to address these issues.