Functional Defecation Disorders in Children with Lower Urinary Tract Symptoms

Translation, cross-cultural adaptation, and psychometric properties of the Spanish version of the dysfunctional voiding score symptoms (DVSS-Sp) questionnaire in a pediatric chilean sample

BACKGROUND

The Dysfunctional Voiding Score Symptoms (DVSS) questionnaire is commonly used to evaluate dysfunctional voiding and incontinence (DVI).

OBJECTIVES

To translate and culturally adapt the DVSS questionnaire into Spanish (DVSS-Sp) in pediatric population and to assess its psychometric properties.

METHODS

The process of translation and cultural validation were done. To obtain evidence of validity and reliability, we evaluated the fit of different factor models and calculated internal consistency coefficients. Also, the diagnostic capacity of the DVSS-Sp scale was assessed through a logistic regression analysis and a receiver operating characteristic (ROC) curve. Accordingly, a total sample of 248 participants was recruited (204 with a diagnosis of DVIs and 44 with no medical problems).

RESULTS

The cross-cultural adaptation showed an adequate correspondence with the original version. The DVSS-Sp was configured with 2 factors: Overactive Bladder (OB) symptoms (items 1, 2, 6, and 7) and Dysfunctional Elimination (DE) symptoms (items 3, 4, 8, and 9), showing excellent goodness-of-fit indices. The relationship between the factors OB and DE was low. The reliability of the OB factor was α = 0.68, ω = 0.71, and the DE factor was α = 0.56, ω = 0.57. A logistic regression analysis suggests a good diagnostic capacity of the DVSS-Sp scale. Additionally, ROC analysis showed a cut-off score of 3.5 on the DVSS-Sp scale, where the specificity was 0.907, and the sensitivity was 0.636.

CONCLUSION

The results of this study support the use of the DVSS-Sp for assessing DVIs in Spanish-speaking children.

Scoring system to evaluate meaningful fecal impaction in patients with lower urinary tract dysfunction with simple radiography (KUB)

PURPOSE

The management of bowel bladder disorder (BBD) has only been indicated for subjective constipation without objective evidence. We attempted to highlight the radiological findings in patients with BBD and construct a scoring system to identify patients with BBD prior to treatment.

MATERIALS AND METHODS

Forty-five patients with lower urinary tract dysfunction (LUTD) received polyethylene glycol for 2 months before bladder medication for LUTD. Based on partial response to LUTD following treatment, we divided the patients into LUTD-fecal impaction (FI) and LUTD not attributed to FI (LUTD-NFI) groups. Pre/post-treatment kidney, ureter, and bladder (KUB) were compared with respect to several radiographic parameters. Items with significant changes after treatment were included in the scoring system. The accuracy and inter-rater agreement were also evaluated.

RESULTS

Cecal dilation, descending colon dilation, fecal quality, and overall haziness were found to undergo significant changes after laxative treatment. We assigned 0 to 2 points for each item, with a total score of 8. Receiver operating characteristic curve analysis revealed a cutoff value of 5 between LUTD-FI and LUTD-NFI, with 79% sensitivity and 88% specificity. The scoring system was instructed to six doctors who were unaware of it and was then tested on previous patients, which showed a substantial concordance rate (κ=0.79, p<0.05).

CONCLUSIONS

Fecal scoring system based on KUB was beneficial in identifying children with LUTD attributed to FI. This may provide an opportunity to obtain objective FI data as an alternative to subjective assessment of constipation.

The ten "hard" questions in pediatric functional constipation

Functional constipation is a common problem in childhood and has a great impact on social, physical, and emotional functioning of affected children and their caregivers. No organic cause of the constipation can be found in approximately 95% of children, defining the "so-called" chronic functional constipation. Its prevalence has been reported to range from 0.7 to 29.6%, with a median of 12%. The diagnosis of functional constipation is exclusively clinical based on the pediatric diagnostic Rome criteria for functional gastrointestinal disorders and does not routinely require laboratory and/or radiological investigations. In case of alarm signs and symptoms that may suggest organic diseases, further investigations can be required. The therapeutic management is based on non-pharmacological and pharmacological approaches. Education, demystification of constipation and reward-based toilet training represent the cornerstones of nonpharmacological management. Disimpaction, maintenance treatment and weaning of medication are all elements of pharmacological treatment. Osmotic laxatives, mainly polyethylene glycol (PEG), are considered the first-choice laxative for both disimpaction and maintenance treatment. The aim of this review is to provide pediatric gastroenterologists with a practical tool to support the clinical and therapeutic management of children and adolescents affected by chronic functional constipation.

Cross-cultural adaptation and validation of the constipation scoring system for the pediatric population: A new tool to be used for constipated children

BACKGROUND

The Rome IV criteria are used to characterize constipation and its subtypes, but not its severity. Conversely, the constipation scoring system (CSS) is a tool designed to assess the level of constipation severity and assist clinicians in selecting suitable therapeutic strategies. Although validated for adults, this score has yet to be validated for children.

OBJECTIVE

To adapt and validate the CSS for the pediatric population.

METHODS

Children and adolescents of 4-17 years of age with no morphological or neurological abnormalities of the gastrointestinal system were randomly selected during general consultation with a pediatrician and evaluated between November 2021 to April 2022. The Rome IV criteria were considered the gold-standard detection method. The adapted version was initially assessed on 30 children to assess comprehension and then administered to another 100 children. The internal consistency of the adapted questionnaire was assessed in a test-retest procedure with a two-week interval.

RESULTS

One hundred patients with a mean age of 8.61 ± 3.25 years were assessed. Of these, 51 (51 %) were male. Most children (n = 91) received a score of 1-10 (the total CSS score can range from 0 to 30 points). The correlation between the pediatric version of the CSS and the Rome IV criteria was substantial, as shown by a positive Spearman correlation (r2) of 0.553 (p < 0.001). Cronbach's alpha between the test-retest responses was 0.97. When each item of the questionnaire was assessed individually, a greater level of internal consistency was found, indicating adequate internal reliability.

DISCUSSION

The current study broadens the horizon with the emergence of new diagnostic aid for FC in Brazilian children and adolescents. In addition, this study provides the cornerstone for future research to determine the diagnostic accuracy of the CSS and its prognostic value for monitoring the treatment. The loss of a follow-up rate (26 %) during the telephone "test-retest" phase was a limitation. Using a subjective questionnaire such as the Rome IV criteria as the gold standard method may also represent a limitation. Further research is required on the use of objective diagnostic tools for FC including colonic transit time, anal manometry, cine-defecography, and electromyography.

CONCLUSION

The CSS was successfully adapted for use with the pediatric population and was well accepted, confirming its language and psychometric validity in aiding the diagnosis of functional constipation. This was the first step towards validating the use of this score in other countries and cultures to assess the severity of constipation in children.

Does KUB play a role in the diagnosis of bladder bowel dysfunction?

INTRODUCTION

Kidney ureter bladder radiography (KUB) is widely used for the evaluation of constipation in children with bladder and bowel dysfunction (BBD); however, there is varying evidence to support its routine diagnostic use. One drawback to KUB is radiation exposure. The dangers of radiation in children are well-documented, and per As Low As Reasonably Achievable, non-beneficial radiation should be avoided. This risk is especially high in children who undergo repeated imaging in the follow up of constipation treatment.

OBJECTIVE

We sought to assess the utility of KUB in diagnosing children with BBD by comparing it to four diagnostic tests and/or validated instruments: the Dysfunctional Voiding Symptom Score (DVSS), Rome IV criteria, rectal diameter on ultrasound (RD), and the Bristol Stool Form Score (BSFS).

STUDY DESIGN

We prospectively enrolled a cohort of patients presenting to an academic pediatric urology practice with symptoms of BBD. Severity of stool burden on KUB (mild, moderate, or severe), RD on ultrasound (≥3.4 cm), DVSS, Rome IV, and BSFS were obtained for each patient. All imaging was interpreted by a pediatric radiologist and pediatric urologist. Primary outcomes were the association between the four diagnostic tests and KUB stool burden. Bivariate analysis of all individual variables versus KUB was performed, as well as multivariate regressions to determine if multiple measures were predictive of KUB stool burden when combined.

RESULTS

Between October 2020 and May 2022, 50 patients were enrolled. All children were under the age of 18, with a median age of 8 years (IQR 3-13). 38 % were male. Median BMI-for-age-percentile was 80.8 (IQR 50.3-98.3). When comparing individual variables to KUB in bivariate analyses, it was found that RD on ultrasound is predictive of significant stool burden on KUB (p = 0.03). No other individual variables were predictive. In the multivariate analyses, no combination of tests was found to be predictive of KUB.

DISCUSSION

We compared the effectiveness of four commonly used diagnostic tests in children with BBD to validate the use of KUB. In conclusion, our results support the use of RD on ultrasound as a non-radiating alternative to KUB to assess stool burden. Data also suggest that KUB for fecal load does not correlate with urinary (DVSS) or bowel (Rome IV, BSFS) symptoms in BBD, and that symptoms scores should still be used independently for diagnosis and monitoring of treatment response.

CONCLUSION

In conclusion, KUB has a limited role in the diagnosis of BBD.

Measurement properties of the childhood bladder and bowel dysfunction questionnaire

OBJECTIVES

The childhood bladder and bowel dysfunction questionnaire (CBBDQ) was previously found feasible, structurally valid, with good internal consistency. The purpose of this study was to evaluate the remaining measurement properties according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN).

METHODS

A prospective cohort study among parents of children aged 5-12 years was conducted. Calculated were the area under the curve (AUC) (criterion validity, responsiveness, interpretability) and intra-class correlation coefficients (ICCagreement ) (construct validity and test-retest reliability).

RESULTS

One hundred and seventy-two parents were included from March 2019 to April 2021. Correlating the bladder subscales of the CBBDQ with the Vancouver symptom score for dysfunctional elimination (VSSDES) and proxy-reported pediatric incontinence quality of life (p-PinQ) showed convergent validity (ICCsagreement : 0.76 and 0.74). Divergent validity was found when correlating the bowel subscales of the CBBDQ with the VSSDES (ICCagreement : 0.52). Excellent criterion validity (AUC: 0.98); excellent test-retest reliability (ICCagreement : 0.94) and, at 6 months, fair responsiveness (AUC: 0.74) were found. The minimal important change was 4.5, with cut-off value of 11.

CONCLUSION

The CBBDQ has been developed according to COSMIN standards. The items were defined using the consensus-based ICCS standards and Rome-III criteria. The measurement properties were identified using enough participants. Although interpretability is not considered a measurement property, interpretability aspects are reported here as they refer to what instrument scores mean. The 18-item-CBBDQ met the measurement properties of validity, reliability, and responsiveness, as defined by COSMIN. The CBBDQ is suitable for self-administration by parents, and completion takes little time.

Association between rectal diameter and response to treatment with parasacral transcutaneous electrical nerve stimulation and behavioral changes in children and adolescents with bladder and bowel dysfunction

PURPOSE

Parasacral Transcutaneous Electrical Stimulation (TENS) is one of the treatments for children with Bladder and Bowel Dysfunction (BBD). Some studies showed that children with increased Rectal Diameter (RD) have more Functional Constipation (FC). However, RD prediction in maintenance of BBD after treatment was never evaluated. Our aim is to evaluate the association between RD and response to treatment in children and adolescents with BBD.

MATERIALS AND METHODS

This study evaluated patients from 5-17 years old with BBD. Dysfunctional Voiding Scoring System (DVSS), Rome IV criteria, and the Constipation Score were used. RD was measured using abdominal ultrasound before treatment according to the technique established by Klijn et al. and was considered enlarged when >3cm. No laxatives were used during treatment. Descriptive analysis and binary regression were performed and the area under the ROC curve was calculated.

RESULTS

Forty children were included (mean age 8.4±2.8 years, 52.5% male). Before treatment, RD was enlarged in 15 children (37.5%) (mean diameter 3.84±0.6cm), with FC persisting post-treatment in 11/15(73.3%). Those patients also required more laxatives following treatment and had more severe FC. Binary regression showed pretreatment RD to be an independent predictor of the persistence of FC post-treatment (OR=9.56; 95%CI:2.05-44.60). In ROC curve analysis, the sensitivity was 100% (95%CI: 0.49-1.0) and specificity 77.14% (95%CI:0.60-0.90) for rectal diameter >3 cm. The likelihood ratio was 4.38 (95%CI:2.40-8.0) for the persistence of BBD following treatment.

CONCLUSION

RD appears to be relevant in the evaluation of children with BBD, not only as a diagnostic tool but also as a predictor of treatment outcome.

Improvement in bladder function in children with functional constipation after a bowel management program

PURPOSE

We sought to determine if children with functional constipation (FC) would have an improvement in bladder function with treatment of constipation with a bowel management program (BMP).

METHODS

A single-institution review was performed in children aged 3-18 with FC who underwent a BMP from 2014 to 2020. Clinical characteristics, bowel management details, and the Vancouver Symptom Score for Dysfunctional Elimination Syndrome (VSS), Baylor Continence Scale (BCS), and Cleveland Clinic Constipation Score (CCCS) were collected. Data were analyzed using linear mixed effect modeling with random intercept.

RESULTS

241 patients were included with a median age of 9 years. Most were White 81 and 47% were female. Univariate tests showed improvement in VSS (- 3.6, P < 0.0001), BCS (- 11.96, P < 0.0001), and CCCS (- 1.9, P < 0.0001) among patients having undergone one BMP. Improvement was noted in VSS and CCCS among those with more than one BMP (VSS: - 1.66, P = 0.023; CCCS: - 2.69, P < 0.0001). Multivariate tests indicated undergoing a BMP does result in significant improvement in VSS, BCS, and CCCS (P < 0.0001).

CONCLUSIONS

There is significant improvement in bladder function in children with FC who undergo a BMP. For patients with bowel and bladder dysfunction and FC, a BMP is a reasonable treatment strategy for lower urinary tract symptoms.

Problems with enuresis management-A personal view

Much has happened since the end of the era when enuresis was blamed on the parents or the children themselves. Still, there are large gaps in our knowledge and large parts of modern enuresis management guidelines are (still) not based on firm evidence. In this review I will question the following commonly made assumptions regarding enuresis evaluation and treatment: •It is important to subdivide enuresis according to the presence of daytime symptoms•Voiding charts are crucial in the primary evaluation of the enuretic child•All children with enuresis need to be screened for behavioral or psychiatric issues•Concomittant daytime incontinence needs to be successfully treated before addressing the enuresis•Concomittant constipation needs to be successfully treated before addressing the enuresis•Urotherapy is a first-line treatment against enuresis In this review I will argue that much of what we do with these children is based more on experience and well-meant but poorly supported assumptions than on evidence. Some advice and therapies are probably ineffective whereas for other treatments we lack reliable predictors of treatment response. More research is obviously needed, but awaiting new results enuresis management could be substantially simplified.

Risk factors for breakthrough urinary tract infection in children with vesicoureteral reflux receiving continuous antibiotic prophylaxis

BACKGROUND

To investigate the risk factors for breakthrough urinary tract infection (BT-UTI) in children with vesicoureteral reflux (VUR) receiving continuous antibiotic prophylaxis (CAP).

METHODS

This was a single-centre cohort study (January 2016 to December 2019). The clinical data of 256 children with grade I-V VUR receiving CAP were analysed. In this study, exposure variables were sex, younger age at the initial diagnosis of UTI ≤12 months, high-grade VUR, bilateral VUR, aetiology, presence of renal scarring at the initial diagnosis, presence of renal function impairment at the initial diagnosis, ultrasound abnormalities, antibiotic used and bladder and bowel dysfunction (BBD). Outcome was BT-UTI.

RESULTS

BT-UTI occurred in 81 out of 256 children with grade I-V VUR who received CAP, an incidence of 31.64%. Univariate analysis showed that younger age at the initial diagnosis of UTI (≤12 months), bilateral VUR, renal scarring on the dimercaptosuccinic acid (DMSA) scan at the initial diagnosis of UTI and BBD were correlated with the occurrence of BT-UTI. Multivariate analysis showed that younger age at the initial diagnosis of UTI (≤12 months) [hazard ratio (HR): 4.629; 95% confidence interval (CI): 1.302-16.462], bilateral VUR (HR: 2.078; 95% CI: 1.084-4.022) and BBD (HR: 3.194; 95% CI: 1.243-8.206) were independent risk factors for the occurrence of BT-UTI.

CONCLUSIONS

For VUR children receiving CAP, younger age at the initial diagnosis of UTI (≤12 months), bilateral VUR, and BBD were independent risk factors for the occurrence of BT-UTI.

Evaluation of bladder and bowel functions in children with microcephaly and congenital zika syndrome

INTRODUCTION

Children with Congenital Zika Syndrome (CZS) present structural cortical changes that may compromise the integrity of their connections with urinary and digestive systems, causing bowel and bladder dysfunctions.

OBJECTIVE

To evaluate bladder and bowel dysfunction (BBD) in children with CZS.

STUDY DESIGN

This is an observational cross-sectional study of a series of CZS cases. Urinary tracts were investigated using a bladder function protocol consisting of clinical history, detailed physical examination, laboratory tests, ultrasound of the lower and upper urinary tracts, and urodynamic evaluation. The bowel function protocol expanded anamnesis with questions related to signs and symptoms of functional disorders, Bristol scale, and ultrasound of the rectal ampoule.

RESULTS

Forty children with CZS, aged between one and five years were included. The majority (80%) had bladder and bowel dysfunction (BBD), 12.5% had bladder dysfunction only, and 7.5% only bowel dysfunction. A reduced bladder capacity was confirmed in 36 patients (90%), while 15 (40%) presented postvoid residual greater than 20% of their cystometric capacity. Thirty-five patients (87.5%) presented four signs/symptoms of functional bowel disorders and the rectal ampoule ultrasound was >2.9 cm in 21 (52.5%). Moreover, 19 (47.5%) presented urinary tract infection, while 5 (12.5%) developed pyelonephritis and required hospitalization. Renal ultrasound showed nephrolithiasis in three (7.5%), one (2.5%) presented horseshoe kidney, and a duplicated collecting system was found in three patients. Cryptorchidism was presented in eight (34%).

DISCUSSION

Our study confirmed the presence of BBD in 80% of the children with CZS studied in this series. This is the first time that bowel dysfunction is confirmed in the settings of CZS. This recognition will facilitate early identification and appropriate therapies in an attempt to reduce complications. One limitation of the study is the absence of a control group. Due to the new aspects of CZS, it has been difficult to find a suitable group of patients with neurological disorders to compare and performing urodynamic studies in children without neurological or non-neurological voiding dysfunction is unethical. Appropriate control groups for future studies may be children with microcephaly due to other causes or older children with CZS who were not yet investigated or treated. Another limitation is the lack of a standard quantitative evaluation of bowel dysfunction in children with neurological disorders.

CONCLUSION

Bladder and bowel dysfunction was confirmed in 80% of the children with CZS. This is a new Zika virus-associated neuromuscular disorder that needs to be further investigated.

Prevalence of Bladder and Bowel Dysfunction in Duchenne Muscular Dystrophy Using the Childhood Bladder and Bowel Dysfunction Questionnaire

Introduction: Lower urinary tract symptoms (LUTS) and gastrointestinal (GI) problems are common in Duchenne muscular dystrophy (DMD), but not systematically assessed in regular care. We aimed to determine the prevalence of bladder and bowel dysfunction (BBD) in DMD patients compared with healthy controls (HC). Methods: The Childhood Bladder and Bowel Dysfunction Questionnaire (CBBDQ) based on the International Rome III criteria and the International Children’s Continence Society was filled out by 57 DMD patients and 56 HC. Additionally, possible associations of BBD with, for example, medication use or quality of life were evaluated in an additional questionnaire developed by experts. Results: In 74% of patients versus 56% of HC ≥ 1 LUTS (n.s.) were reported, 68% of patients versus 39% of HC reported ≥1 bowel symptom (p = 0.002) and 53% of patients versus 30% of HC reported combined LUTS and bowel symptoms (p = 0.019). A negative impact of BBD on daily life functioning was reported by 42% of patients. Conclusions: These data underscore that standard screening for BBD is needed and that the CBBDQ could be of added value to optimize DMD care.

Influence of constipation on enuresis

INTRODUCTION

Constipation has classically been considered as a risk factor of enuresis, although there are increasingly more publications that report a similar prevalence of constipation in both enuretics and non-enuretics.

OBJECTIVE

To determine the influence of constipation in monosymptomatic and non-monosymptomatic enuresis, and to find out the prevalence of the three disorders, as well as the lower urinary tract dysfunction and bladder-bowel dysfunction in the population.

MATERIAL AND METHOD

A cross-sectional observational prevalence study on a representative population sample of 5-9 year-old school boys and girls of Galicia, Spain. A questionnaire was completed in the schools on urinary and bowel habits, which included questions from the Paediatric Lower Urinary Tract Scoring System (PLUTSS) diagnostic questionnaire and grading of the lower urinary tract dysfunctions. The enuresis was diagnosed using the International Children's Continence Society (ICSS), and if it was also associated with diurnal symptoms, it was also classified as non-monosymptomatic enuresis. The constipation was evaluated using the Rome III criteria and the adapted Bristol stool scale.

RESULTS

A total of 772 questionnaires were included in the study. The prevalence of constipation was 20% and that of enuresis was 9.1% (62.9% monosymptomatic enuresis and 37.1% non-monosymptomatic), with the prevalence of bladder-bowel dysfunction being 5.2%. It was observed that constipation had no influence on the presence of monosymptomatic enuresis, but it did have an influence on non-monosymptomatic enuresis and lower urinary tract dysfunctions, where it was a significant risk factor.

CONCLUSIONS

The differential diagnosis between monosymptomatic and non-monosymptomatic enuresis is essential in the initial evaluation of the patient with enuresis, since the therapeutic management and the characteristics of both disorders are different, with constipation only being a risk factor in cases of non-monosymptomatic enuresis.

Frequent witnessing to interparental conflict and low parental availability for leisure-time is associated with dysfunctional voiding in primary school children

AIM

Aspects of parenting are an under-investigated topic amongst children with voiding complaints. We aimed to investigate the association between voiding complaints amongst children and two specific parenting-related behaviours: 1) parental availability during the child's leisure time and 2) frequency of witnessing interparental conflict.

MATERIAL AND METHOD

Children aged between 6 and 11 years with their parents were the participants. Two survey forms and informed consent form were sent to potential participants via children's teacher. Voiding dysfunction complaints were evaluated with the Dysfunctional Voiding and Incontinence Symptom Scale (DVISS).

RESULTS

Data analyses were performed with 1101 eligible participants. The mean duration of parental availability during the child's leisure time was below 2 hours per day. Nearly one out of every four children witnessed interparental conflict at least once a month. Age, educational level of the mother, parental availability for the child's leisure time, and frequency of witnessing parental conflicts were found to be significantly associated with DVISS ratings. Adjusting age, socioeconomic level, and educational level of the parents and later adjusting parental availability during the child's leisure time did not change the association of frequency of witnessing interparental conflict with DVISS rates. An increase in the age, educational level of the mother, and parental availability during the child's leisure time was correlated with better scores on DVISS, while an increase in the frequency of witnessing interparental conflict strongly correlated with worse scores.

CONCLUSION

Exposing children to interparental conflicts and shorter togetherness with their leisure time is associated with voiding complaints.

Prevalence of Bladder and Bowel Dysfunction in the Outpatient Clinic of Pediatric Urology and Nephrology

Objective Bladder and bowel dysfunction (BBD) is defined as the presence of functional alterations in both organs. The correct diagnosis and treatment prevent the exposure of patients to multiple antibiotic treatments, invasive procedures and radiological studies. The aim of the present study was to estimate the prevalence of BBD in the outpatient clinic of pediatric urology and nephrology.

Methods A prospective cohort composed of 334 patients aged between 5 and 18 years was evaluated. The Pediatric Lower Urinary Tract Symptom Score (PLUTSS) was applied. A score higher than 8 was considered as significant urinary symptomatology. Moreover, the Bristol Stool Scale and the Rome IV Criteria for functional constipation and fecal incontinence were used. Patients with organic pathologies were excluded. The risk factors were evaluated using logistic regression models.

Results The median age was 9 years old (interquartile range [IQR]: 6–13). The PLUTSS questionnaire was significant in 16.5% of the kids, constipation was found in 31.9%, and fecal incontinence, in 4%. The prevalence of BBD was of 27.8%. The female gender (odds ratio [OR]: 2.47; p = 0.002) and psychological disorders (OR: 4.637; p = 0.024) were considered risk factors. The evaluation of the PLUTSS questionnaire showed relevance regarding incontinence (OR: 3.059; p = 0.038), enuresis (OR: 8.532; p < 0.001); intermittent flow (OR: 9.211; p = 0.004), frequency (OR: 6.73; p = 0.005), and constipation (OR: 34.46; p < 0.001).

Conclusions The prevalence of BBD is of 27.8% in the outpatient clinic. It is important to prevent associated complications and the exposure to multiple antibiotic treatments, as well as invasive and imaging procedures, which also generate high costs to the health system.

Prospective evaluation of the management of bowel dysfunction in children with neuropathic lower urinary tract dysfunction and its effect on bladder dynamics

INTRODUCTION AND AIM

Children with neuropathic lower urinary tract dysfunction usually suffer from associated bowel dysfunction, urinary tract infection and vesicoureteral reflux. This work aimed to highlight the impact of bowel management on bladder dynamics.

PATIENTS AND METHODS

In the period from January 2011 to January 2013, 30 patients, 21 girls and 9 boys with neuropathic lower urinary tract dysfunction were studied. All suffered from urinary tract and bowel dysfunctions. All children were on urological treatment. They had their bowel managed by assurance and psychological support, dietary modification, retrograde or antegrade enemas and maintenance therapy. They were evaluated initially and on follow up by history, physical examination, ultrasound, urodynamics, Wexener score and bowel control chart.

RESULTS

Mean age was 8.3 ± 3.47 years (range from 4 to 18). There was a significant decrease in bowel dysfunction (Wexener score decreased from 12.67 ± 1.54 to 10.17 ± 1.76, p = 0.00), rectal diameter (decreased from 34.83 ± 5.91 to 27.90 ± 5.32 mm, p = 0.00), and frequency of UTI (p = 0.00). Detrusor leak point pressure decreased from 37.33 ± 24.95 to 30 ± 17.35 cmH2O, (p = 0.42). The cystometric capacity increased from 136.63 ± 45.69 to 155.17 ± 39.29 ml. (p = 0.001). Reflux and kidney function improved but was not statistically significant (p = 0.25 and p = 0.066 respectively).

CONCLUSION

Management of bowel dysfunction is of utmost importance in the treatment of children with neuropathic bladder dysfunction. It has a positive effect on lower urinary tract function and decreasing the incidence of complications. This is a LEVEL III prospective study.

Diagnosis and management of bladder bowel dysfunction in children with urinary tract infections: a position statement from the International Children's Continence Society

BACKGROUND

We present a consensus view from the International Children's Continence Society (ICCS) on the evaluation and management of bladder bowel dysfunction (BBD) in children with urinary tract infection (UTI). The statement aims to highlight the importance of BBD in the development and recurrence of childhood UTI and its management to reduce its associated morbidity and sequelae.

METHODS

A systematic literature search was done on PubMed, Embase, and Scopus databases until August 15, 2016. Relevant publications concerning BBD and its relationship with UTI among children were reviewed and aggregated for statements of recommendation. Discussion by the ICCS Board and a multi-disciplinary core group of authors resulted in a document available on its website for all ICCS members to review. Insights and feedback were considered with consensus and agreement reached to finalize this position statement.

RESULTS

BBD in children with UTI is summarized. Details regarding epidemiology, pathophysiology, and recommendations for general and family practitioners and pediatricians relating to the evaluation and management of this condition are presented.

CONCLUSIONS

This document serves as the position statement from ICCS, based on literature review and expert opinion providing our current understanding of BBD in children with UTI.

Assessment of pediatric bowel and bladder dysfunction: a critical appraisal of the literature

OBJECTIVE

Bowel and bladder dysfunction (BBD) is a clinical syndrome defined by the coexistence of constipation and lower urinary tract symptoms. Although BBD is a common condition in pediatric urology and can cause significant stress to patients/parents, clinical diagnosis of BBD has not been standardized. Bowel and bladder dysfunction instruments have gained popularity over the past decade to aid in diagnosis. In this review, the currently published BBD symptom questionnaires were summarized and an analysis on their psychometric validation process was provided.

SUBJECTS/PATIENTS

PubMed was searched for articles on BBD symptom questionnaires/instruments/surveys since 2000. Two investigators (R.Y.J. & M.S.K.) conducted the search in duplicate. The search was limited to English language. The included search terms were 'dysfunctional elimination syndrome', 'bowel and bladder dysfunction', 'dysfunctional voiding', 'voiding dysfunction symptom score', and 'dysfunctional voiding symptom scale'. Reference lists of included studies were screened for missed studies. Unpublished abstracts presented at the following scientific meetings were also manually searched for: the American Urological Association, the Society for Pediatric Urology, and the American Academy of Pediatrics Section on Urology. Exclusion criteria included articles in languages other than English, articles not related to BBD questionnaires, and articles not pertaining to pediatric patients.

RESULTS

After initial search, a total of 54 articles were obtained. Of the seven questionnaires reviewed, only one did not measure sensitivity or specificity. Almost all questionnaires showed excellent discriminative property with an Area under the curve (AUC) >0.85. Criterion validity was not reported in any of the questionnaires. Known-group validation was used as a common method to evaluate construct validity. Internal consistency was reported in 2 studies, and only 1 study measured questionnaire responsiveness during initial validation.

CONCLUSIONS

Although BBD is a common pediatric urology condition; a large amount of heterogeneity exists in the questionnaires' psychometric testing and validation process. To further improve the diagnosis and management of BBD in pediatric patients, there is a need for consensus on the gold standard questionnaire measure.

Bladder Symptoms in Children With Functional Constipation: A Systematic Review

OBJECTIVE

The aim of the review is to perform a systematic review of the literature examining the prevalence of bladder symptoms in children with functional constipation (FC) and to compare the prevalence of those symptoms between children with and without FC.

METHODS

In this systematic review 4 databases were searched to July 2018. Studies investigating the prevalence of bladder symptoms in children aged 4 to 17 years with FC were included. There was no language restriction. Two reviewers independently extracted data and assessed study quality. Clinical heterogeneity between studies was investigated. Prevalence rates of bladder symptoms in children with FC were calculated. Relative risks were calculated to compare the prevalence of bladder symptoms between children with and without FC.

RESULTS

Among 23 studies of children with FC, 22 reported the prevalence bladder symptoms (12,281 children) and 7 reported the prevalence of urinary tract infections (UTIs) (687 children). The prevalence rates of single bladder symptoms, lower urinary tract symptoms (LUTS), and UTI varied between 2% to 47%, 37% to 64%, and 6% to 53%. The relative risks were 1.24 to 6.73 for 20 single bladder symptoms (12 studies) and 2.18 to 6.55 for UTI (2 studies). The 95% confidence intervals indicated significance in 14 of 20 single bladder symptoms.

CONCLUSIONS

Bladder symptoms seem common in children with FC, but the reported prevalence varies greatly. Children with FC are more likely to have bladder symptoms than children without FC. We recommend that clinicians be aware of concomitant bladder symptoms in children presenting with FC.

Rectal diameter assessment in enuretic children-exploring the association between constipation and bladder function

OBJECTIVES

Detrusor overactivity and constipation often co-exist in children with enuresis. Constipation is known to be linked to detrusor overactivity. The voiding chart is the best non-invasive way to investigate bladder function, whereas the ultrasonographical detection of rectal dilatation is the best way to objectify constipation. We wanted to investigate a possible relationship between the rectal diameter and voiding chart data in enuretic children.

METHODS

Children with therapy-resistant enuresis were retrospectively evaluated. All had completed a voiding chart for at least 48 h. The rectal diameter was assessed ultrasonographically. The cutoff for rectal dilatation was set at 30 mm.

RESULTS

We evaluated 74 patients (12 girls) aged 10.2 ± 2.8 years, 35 of whom had rectal dilatation. No significant differences in voiding chart parameters were found between children with normal versus dilated rectum. Neither did urgency or a history of daytime incontinence differ between the groups. Boys were more likely to have rectal dilatation than girls (p = 0.02).

CONCLUSIONS

The absence of differences regarding voiding chart data may be explained as two mechanisms neutralizing each other: behavioral factors may make the constipated children void seldom and with large volumes, whereas detrusor overactivity caused by rectal compression of the bladder may have the opposite effect. Another option may be that the voiding chart is too blunt an instrument to detect detrusor overactivity. Constipation, and thus presumably bladder dysfunction, seems to be more important in enuretic boys than girls.

Clinical management of nocturnal enuresis

Nocturnal enuresis (NE) is a common health problem. Approximately 10% of 7-year-old children wet the bed regularly during sleep. Enuresis can be categorized into monosymptomatic (MEN) and nonmonosymptomatic (NMEN) forms. MEN occurs without any other symptoms of bladder dysfunction. NMEN is associated with dysfunction of the lower urinary tract with or without daytime incontinence. The rate of comorbid gastrointestinal, behavioral, and emotional disorders is elevated depending upon the subtype of NE. A careful clinical history is fundamental to the evaluation of enuresis. Diagnostic procedures include medical history and psychological screening with questionnaires, bladder and bowel diary, physical examination, urinalysis, ultrasound, and examination of residual urine. The mainstay of treatment is urotherapy with information and psychoeducation about normal lower urinary tract function, the underlying cause of MEN, disturbed bladder dysfunction in the child with NMEN and instructions about therapeutic strategies. Alarm therapy and the use of desmopressin have been shown to be effective in randomized trials. Children with NMEN first need treatment of the underlying daytime functional bladder problem before treatment of nocturnal enuresis. In patients with findings of overactive bladder, besides urotherapy, anticholinergic drugs may be useful.

Risks of irritable bowel syndrome in children with infantile urinary tract infection: a 13-year nationwide cohort study

Early life events play a crucial role in the development of irritable bowel syndrome (IBS). Some evidence suggests the phenomenon of cross-organ sensitization between bladder and colon. Whether urinary tract infection (UTI) during infancy is a risk factor of childhood IBS remains to be elucidated. In this retrospective cohort study, we selected 31 788 infants who had UTI between 2000 and 2011 as a UTI cohort and selected 127 152 infants without UTI as a comparison cohort, matched by age, sex and level of urbanization of living area. Incidence density and HRs with CIs of IBS between UTI and non-UTI cohorts were calculated by the end of 2012. The incidence density of IBS during the study period was 1.52-fold higher in the UTI cohort (95% CI 1.38 to 1.67) compared with the non-UTI cohort (2.05 vs 1.32 per 10 000 person-years). The HR of IBS was slightly higher for boys (1.53; 95% CI 1.34 to 1.73) than for girls (1.50; 95% CI 1.29 to 1.73). The HRs for IBS in children with UTI were greater for those with more UTI-related medical visits/per year (>5 visits, HR 61.3; 95% CI 51.8 to 72.6), with longer length of stay of hospitalization (>7 days, HR 1.75; 95% CI 1.36 to 2.24) and with vesicoureteral reflux (VUR) (HR 1.73; 95% CI 1.35 to 2.22) (p<0.0001, the trend test). Infants with UTI had higher risks of childhood IBS and the risks elevated further with recurrent UTI or UTI with concurrent VUR.

Childhood Bladder and Bowel Dysfunction Questionnaire: Development, Feasibility, and Aspects of Validity and Reliability

OBJECTIVES

The aim of the study was to develop a questionnaire evaluating the frequency of symptoms over time of concomitant childhood bladder and bowel dysfunctions (CBBDs) in 5- to 12-year-old children and to assess its feasibility and aspects of validity and reliability.

METHODS

The Childhood Bladder and Bowel Dysfunction Questionnaire (CBBDQ) was developed in phases according to COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) in cooperation with epidemiologists, pediatricians, physiotherapists (phases 1 and 5), and professional translators (phase 5): selection of items (Delphi-method), content validity (pilot), feasibility (interviews), structural validity and internal consistency (field testing), and guideline-based translation (Dutch-English). Participants were parents of children, ages 5 to 12 years (phases 2-4).

RESULTS

Parents of 1333 children (mean age 7.8 years [standard deviation 2.1]) were included. Most common were urinary incontinence (35.9%), enuresis (29.7%), and constipation/fecal incontinence (30.1%). Concomitant CBBD was seen in 74.2% of 1229 children. Originally, a 27-item CBBDQ was developed. After the pilot (48 parents) a 23-item version remained for evaluation of feasibility aspects by interviewing 56 parents. Based on 1229 completed questionnaires during field testing, the CBBDQ reduced to 18 items. Cronbach α values were 0.74 and 0.71 for bladder and bowel subscales, respectively. Feasibility and aspects of validity and reliability were satisfactory. A definitive and accepted English version of the CBBDQ is available.

CONCLUSIONS

When completed by parents, the 18-item evaluative CBBDQ appears feasible, content, and structurally valid with good internal consistency for the bladder and bowel subscales. The Dutch and English versions will be introduced clinically and subjected to further psychometric evaluation.

Encopresis in Children: An Overview of Recent Findings

The term ‘encopresis’, derived from ancient Greek ἐγκόπρησις / egkóprēsis, which means stool, was first introduced in 1926 by Weissenberg to describe the loss of stool in underwear as the faecal equivalent of enuresis. The soiling of underwear is defined as the accidental passage of very small amounts of faeces into underpants. Quantitatively, the content of stool between encopresis and soiling is difficult to determine, and it is especially difficult for parents assess it. Therefore, a new term was adopted – faecal incontinence – that encompasses both encopresis and soiling.

Faecal incontinence is defined as the discharge of faeces in socially awkward situations at least once per month in children ≥ 4 years old. In approximately 95% of cases, faecal incontinence in children is not organic in origin, but instead appears as a functional gastrointestinal disorder. In 80% of children with functional faecal incontinence, the symptoms are associated with functional constipation. The remaining 20% of the cases involve no signs of faecal retention and are defined as non-retentive functional faecal incontinence.

This paper aims to present the latest findings within this area of paediatric gastroenterology.

Refractory Urinary Incontinence in Girls: The Role of the Bladder Neck

BACKGROUND

Prevalence of lower urinary tract dysfunction (LUTD) in children is between 6 and 9% with urinary incontinence (UI) being one of the most common symptom.

VARIOUS ASPECTS OF LOWER URINARY TRACT SYMPTOMS LUTS

Anatomical anomalies of the urinary tract as well as neurogenic underlying pathology can results in LUTS. Comorbidities and long-term consequences of the LUTD for the female patients as well as genetic issues are also briefly discussed.

THE ROLE OF THE BLADDER NECK

Thanks to urodynamics, we have learnt a lot about the lower urinary tract function, but the role of the bladder neck in the pathophysiology of LUTS in children is not clear. Secondary bladder neck hypertrophy is a well-described pathology, but there is no standardized treatment for this phenomenon. Primary bladder neck dysfunction has already been defined by the International Children's Continence Society.

REFRACTORY UI IN GIRLS

Uniform diagnostic protocols are used in these girls with UI. Treatment consists of standard urotherapy, additional interventions, and pharmacotherapy in selected cases. Those with refractory UI require careful reassessment to look for the unrecognized disorders. Invasive urodynamics should be done in those patients. Ultrasound of the bladder neck region and the pelvic floor can be helpful, but its interpretation is very subjective. In a small group bladder neck insufficiency can be found and those might benefit from a surgical intervention.

FUTURE PERSPECTIVE

Strict criteria of the bladder neck insufficiency in children must be defined. Early surgical intervention in girls with bladder neck insufficiency might reduce the long period of intensive conservative treatment.

Bladder and bowel dysfunctions in 1748 children referred to pelvic physiotherapy: clinical characteristics and locomotor problems in primary, secondary, and tertiary healthcare settings

The aims of this study are to evaluate in a pragmatic cross-sectional study, the clinical characteristics of childhood bladder and/or bowel dysfunctions (CBBD) and locomotor problems in the primary through tertiary health care setting. It was hypothesized that problems would increase, going from primary to tertiary healthcare. Data were retrieved from patient-records of children (1-16 years) presenting with CBBD and visiting pelvic physiotherapists. Prevalence's of dysfunctions were compared between healthcare settings and gender using ANOVA and chi-square test. Agreement between physicians' diagnoses and parent-reported symptoms was evaluated (Cohen's Kappa). One thousand seventy hundred forty-eight children (mean age 7.7 years [SD 2.9], 48.9% boys) were included. Daytime urinary incontinence (P = 0.039) and enuresis (P < 0.001) were more diagnosed in primary healthcare, whereas constipation (P < 0.001) and abdominal pain (P = 0.009) increased from primary to tertiary healthcare. All parent-reported symptoms occurred more frequently than indicated by the physicians. Poor agreement between physicians' diagnoses and parent-reported symptoms was found (k = 0.16). Locomotor problems prevailed in all healthcare settings, motor skills (P = 0.041) and core stability (P = 0.015) significantly more in tertiary healthcare.

CONCLUSIONS

Constipation and abdominal pain (physicians' diagnoses) and the parent-reported symptoms hard stools and bloating increased from primary to tertiary healthcare. Discrepancies exist between the prevalence's of physicians' diagnoses and parent-reported symptoms. Locomotor problems predominate in all healthcare settings. What is Known: • Childhood bladder and/or bowel dysfunctions (CCBD) are common. • Particularly tertiary healthcare characteristics of CBBD are available What is New: • Characteristics of CBBD referred to pelvic physiotherapy are comparable in primary, secondary, and tertiary healthcare settings. • Concomitant CBBD appeared to be more prevalent than earlier reported. • Discrepancies exist between referring physicians' diagnoses and parent-reported symptoms.

Does central sensitization help explain idiopathic overactive bladder?

The pathophysiological mechanisms underlying overactive bladder syndrome (OAB) can include dysfunction of sensory pathways of the peripheral and central nervous systems, resulting in bladder hypersensitivity. Central sensitization describes an induced state of spinal hypersensitivity that is associated with a variety of chronic pain disorders that share many attributes with OAB, albeit without the presence of pain. As such, the concept of central sensitization might be relevant to understanding the mechanisms and clinical manifestations of OAB syndrome. An understanding of the pathophysiology and clinical manifestations of central sensitization, and the evidence that supports a role of central sensitization in OAB, including the potential implications of mechanisms of central sensitization for the treatment of patients with OAB could provide a novel approach to the treatment of patients with this disease. Such an approach would be especially relevant to those patients with central sensitization-related comorbidities, and has the potential to improve the outcomes of these patients in particular.

Simultaneous urodynamic and anorectal manometry studies in children: insights into the relationship between the lower gastrointestinal and lower urinary tracts

BACKGROUND

Children with urinary incontinence (UI) have associated functional constipation (FC) and fecal incontinence (FI). The physiology between lower urinary tract (LUT) and anorectum in children has not been elucidated.

AIMS

Observe the effect of rectal distention (RD) on LUT function, and bladder filling and voiding on anorectal function.

METHODS

Children with voiding dysfunction referred to Boston Children's Hospital were prospectively enrolled in combined urodynamic (UDS) and anorectal manometry (ARM). Anorectal and urodynamic parameters were simultaneously measured. Patients underwent two micturition cycles, first with rectal balloon deflated and second with it inflated (RD). Lower urinary tract and anorectal parameters were compared between cycles.

KEY RESULTS

Ten children (seven UI, four recurrent UTIs, nine FC ± FI) were enrolled. Postvoid residual (PVR) increased (p = 0.02) with RD. No differences were observed in percent of bladder filling to expected bladder capacity, sensation, and bladder compliance with and without RD. Bladder and abdominal pressures increased at voiding with RD (p < 0.05). Intra-anal pressures decreased at voiding (p < 0.05), at 25% (p = 0.03) and 50% (p = 0.06) of total volume of bladder filling.

CONCLUSIONS & INFERENCES

The PVR volume increased with RD. Stool in the rectum does not alter filling cystometric capacity but decreases the bladder's ability to empty predisposing patients with fecal retention to UI and UTIs. Bladder and abdominal pressures increased during voiding, demonstrating a physiological correlate of voiding dysfunction. Intra-anal pressures decreased during bladder filling and voiding. This is the first time intra-anal relaxation during bladder filling and voiding has been described.

Pathophysiological and Therapeutic Considerations for Non-Neurogenic Lower Urinary Tract Dysfunction in Children

Non-neurogenic lower urinary tract dysfunction (LUTD) in children is very common in clinical practice and is important as an underlying cause of lower urinary tract symptoms, urinary tract infection and vesicoureteral reflux in affected children. LUTD in children is caused by multiple factors and might be related with a delay in functional maturation of the lower urinary tract. Behavioral and psychological problems often co-exist in children with LUTD and bowel dysfunction. Recent findings in functional brain imaging suggest that bladder bowel dysfunction and behavioral and psychiatric disorders in children might share common pathophysiological factors in the brain. Children with suspected LUTD should be evaluated properly by detailed history taking, validated questionnaire on voiding and defecation, voiding and bowel diary, urinalysis, screening ultrasound, uroflowmetry and post-void residual measurement. Invasive urodynamic study such as videourodynamics should be reserved for children in whom standard treatment fails. Initial treatment of non-neurogenic LUTD is standard urotherapy comprising education of the child and family, regular optimal voiding regimens and bowel programs. Pelvic floor muscle awareness, biofeedback and neuromodulation can be used as a supplementary purpose. Antimuscarinics and α-blockers are safely used for overactive bladder and dysfunctional voiding, respectively. For refractory cases, botulinum toxin A injection is a viable treatment option. Prudent use of urotherapy and pharmacotherapy for non-neurogenic LUTD should have a better chance to cure various problems and improve self-esteem and quality of life in affected children.

Management of functional nonretentive fecal incontinence in children: Recommendations from the International Children's Continence Society

BACKGROUND

Fecal incontinence (FI) in children is frequently encountered in pediatric practice, and often occurs in combination with urinary incontinence. In most cases, FI is constipation-associated, but in 20% of children presenting with FI, no constipation or other underlying cause can be found - these children suffer from functional nonretentive fecal incontinence (FNRFI).

OBJECTIVE

To summarize the evidence-based recommendations of the International Children's Continence Society for the evaluation and management of children with FNRFI.

RECOMMENDATIONS

Functional nonretentive fecal incontinence is a clinical diagnosis based on medical history and physical examination. Except for determining colonic transit time, additional investigations are seldom indicated in the workup of FNRFI. Treatment should consist of education, a nonaccusatory approach, and a toileting program encompassing a daily bowel diary and a reward system. Special attention should be paid to psychosocial or behavioral problems, since these frequently occur in affected children. Functional nonretentive fecal incontinence is often difficult to treat, requiring prolonged therapies with incremental improvement on treatment and frequent relapses.

Constipation and Lower Urinary Tract Dysfunction in Children and Adolescents: A Population-Based Study

OBJECTIVE

To evaluate the correlation between constipation and lower urinary tract dysfunction (LUTD) and nocturnal enuresis in a population-based study.

MATERIAL AND METHODS

This is a cross-sectional study. The criteria for inclusion were children and adolescents of between 5 and 17 years and who agreed to sign the informed consent form. The study excluded students with neurological problems or who had documented abnormalities of the urinary tract. To identify the presence and severity of LUTD, we used the Voiding Dysfunction Symptom Score (DVSS). To evaluate the presence of constipation, Rome III questionnaire was used.

RESULTS

We interviewed 829 children and adolescents, of which 416 (50.18%) were male. The mean (SD) age was 9.1 (±2.9) years. The overall prevalence of LUTD was 9.1%, predominantly in girls (15 versus 3.1%, p < 0.001). Constipation was found in 9.4% of boys and 12.4% of girls (p = 0.169). Constipated children were 6.8 times more likely to have LUTD than those not constipated (p < 0.001, coefficient and correlation of 0.411). Constipation was found in 8.2% of children without LUTD and in 35.2% of children with LUTD. We performed multivariate analysis to identify urinary symptoms that are independent predictors of the presence of constipation. The presence of infrequent urination (p = 0.004) and holding maneuvers (p < 0.001) were independent predictors. It was noted also noted that constipated children, according to the Rome III criteria, possess a worse DVSS (p < 0.001). Regarding the presence of nocturnal enuresis, 12.6% of children and adolescents had constipation in association with this symptom. However, this relationship was not statistically significant (p = 0.483).

CONCLUSION

Constipated children were 6.8 times more likely to have LUTD than those not constipated. Among the urinary symptoms, infrequent voiding and holding maneuvers are independent factors of urinary expressions in constipated children. Children with more severe constipation have more prominent urinary symptoms. The presence of enuresis was not associated with constipation.

Comparison of uroflow parameters in children with pure constipation versus constipation plus lower urinary tract symptoms

OBJECTIVE

The aim of this study was to compare uroflow parameters of patients with pure constipation against those with constipation plus lower urinary tract symptoms (LUTS) and a control group (no constipation).

MATERIALS AND METHODS

During August 2012 to March 2014 three groups of patients were enrolled into the study: group C (constipation only), group CL (LUTS plus constipation) and group N (control: no constipation or LUTS). Dysfunctional elimination syndrome (DES) scores, uroflowmetry/electromyography (uroflow-EMG) findings, postvoiding residual urine (PVR) and rectal diameter were measured and compared between groups.

RESULTS

Groups C, CL and N comprised 80, 100 and 30 patients, respectively. Average DES scores were 12.6, 18.7 and 4.9, respectively. Voided volume (as a percentage of expected bladder capacity) was 104%, 89% and 101%; and average maximum flow rate was 21.1 ml/s, 36.4 ml/s and 28.1 ml/s, respectively. Pelvic floor muscle activity during voiding was seen in 40.0%, 42.0% and 6.7% of patients in groups C, CL and N, respectively; and pathological PVR was seen in 26.3%, 55.0% and 3.3% of patients in the respective groups. Average rectal diameter was measured as 38.6 mm, 36.4 mm and 28.1 mm in groups C, CL and N, respectively.

CONCLUSION

This study found that abnormal voiding parameters are present in patients with constipation even if LUTS are not present. Therefore, it is important that all patients presenting with constipation have their voiding function evaluated.

Transabdominal ultrasound measurement of rectal diameter is dependent on time to defecation in constipated children

AIM

To study whether diurnal variations and time in relation to defecation has to be taken into account when measurements of rectal diameter are used to determine faecal impaction in constipated children.

METHODS

Repeated ultrasound measures of rectal diameter were performed in 28 children (14 constipated/14 healthy, aged between 4 and 12 years) every third hour during 24 h. After defecation, three additional scans were performed at 1-h intervals.

RESULTS

No diurnal variation in rectal diameter was found in the healthy group. In the constipated group, mean rectal diameter was significantly larger at 2 pm (P = 0.038) and 5 pm (P = 0.006). There were significant differences between rectal diameter in the healthy group and the constipated group at 2 pm (P = 0.016) and 5 pm (P = 0.027). When we omitted the rectal diameter of five constipated children who had their first bowel movement after 5 pm, there were no difference between groups (2 pm (P = 0.103)/5 pm (P = 0.644) ). Only in the constipated group, rectal diameter exceeded 3 cm without the patients feeling the urge to defecate.

CONCLUSION

We found no independent daily variation in either group without relation to defecation. There was a relation between defecation and changes in rectal diameter in both healthy children and constipated children during maintenance treatment.Asking for defecation signals before scanning should be considered a routine question, and a positive answer should cause postponement of the scan.

Urinary tract infection in infancy is a risk factor for chronic abdominal pain in childhood

OBJECTIVE

Adverse early life events are key factors for development of functional gastrointestinal disorders (FGIDs). Urinary tract infection (UTI) is associated with chronic pelvic pain in adults, a finding that has been recapitulated in murine models, but the relation between UTI and chronic pelvic and abdominal pain has not been studied in children. We hypothesized that UTI in infancy increases the risk of FGIDs and chronic abdominal pain (CAP) in childhood.

METHODS

The present study included children, ages 4 to 18 years, with a single UTI in the first year of life and their siblings with no history of UTI. Parents completed the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III Version (QPGS-III) by telephone. Children meeting QPGS-III criteria for FGIDs but with pain less than once weekly were considered to have CAP.

RESULTS

A total of 57 patients with UTI and 58 sibling controls were identified. Mean age at UTI was 4.8 months, and mean time since UTI was 9.3 years. At the time of survey, mean age of patients was 9.7 years (5-16 years, 40% boys) and that of controls was 9.6 years (range 4-17 years, 57% boys). FGIDs were diagnosed in 6 of 57 (11%) patients, and 1 of 58 (2%) controls (P = 0.06). CAP was identified in 10 of 57 (18%) patients and 2 of 58 (3%) controls (P = 0.02). Predominant sex (female), infecting organism (E coli), and treatment (third-generation cephalosporin) were similar in patients with UTI with and without CAP.

CONCLUSIONS

We show for the first time that UTI is associated with CAP in childhood. We speculate that pelvic organ sensory convergence explains our findings.

Scintigraphy evaluation of the types of functional constipation in children with bowel bladder dysfunction

PURPOSE

To evaluate the types of constipation according to colonic transit time in chronically constipated children with dysfunctional voiding (bowel bladder dysfunction, BBD group) and to compare the results with transit type in children with chronic functional constipation without urinary symptoms (constipation group) and children with normal bowel habits, but with lower urinary tract symptoms (control group).

PATIENTS AND METHODS

One-hundred and one children were included and their medical histories were obtained. The BBD group kept a voiding diary, and underwent urinalyses and urine culture, ultrasound examination of bladder and kidneys and uroflowmetry with pelvic floor electromyography. Radionuclear transit scintigraphy was performed in all children according to a standardized protocol. Patients were categorized as having either slow-transit (ST), functional fecal retention (FFR) or normal transit.

RESULTS

FFR was diagnosed in 31 out of 38 children with BBD, and 34 out of 43 children in the constipation group. ST was found in seven children with BBD, compared with nine children in the constipation group. The control group children demonstrated normal colonic transit. Urgency, daily urinary incontinence and nocturnal enuresis were noted only in children with FFR. Both children with ST constipation and FFR complained of difficulties during voiding, voiding postponement and urinary tract infections.

CONCLUSIONS

FFR is the most common form of constipation in children with dysfunctional voiding. However, some children might suffer from ST constipation. Differentiation between these two types of constipation is clinically significant because they require different treatment. Future studies with larger numbers of patients are needed to confirm the noted differences in urological symptoms in these two groups of constipated children..

Independence does not come with the method--treatment of neurogenic bowel dysfunction in children with myelomeningocele

AIM

The aim was to evaluate and compare different bowel regimes with regard to satisfaction, faecal incontinence and independence, and the relationship to quality of life among children with myelomeningocele (MMC).

METHODS

A questionnaire, including the health-related quality of life instrument PedsQL 4.0™, was sent to all children aged seven to 16 years (n = 172) with MMC, treated at two centres in Sweden and one in Norway. The three centres cover a third of the population in the two countries. The response rate was 62%.

RESULTS

Parents of children (30%) using antegrade colonic enemas (ACE) reported higher satisfaction (p = 0.01) than the parents of those (47%) using transanal irrigation (TAI). The children reported no significant difference. Children and parents in the ACE group reported more complete evacuation of the bowels than the TAI group. No significant difference was found in faecal incontinence or independent toileting. The children (40%) who emptied their bowels independently reported a higher quality of life. Children using TAI or ACE spent around one hour on the toilet at every bowel emptying.

CONCLUSION

TAI and ACE are effective treatments, but time-consuming and difficult to perform independently. Higher parental satisfaction is obtained with ACE. Irrespective of method the children who can use the toilet independently report a higher quality of life, which makes efforts to support independence valuable.

Prevalence of lower urinary tract symptoms in individuals with Down syndrome

OBJECTIVES

Down syndrome (DS), which is caused by the trisomy of chromosome 21, is the most frequent of all genetic syndromes. The current study aims to estimate the prevalence of lower urinary tract symptoms (LUTS) in individuals with DS buy using the Dysfunctional Voiding Symptom Score (DVSS) and correlate with functional constipation, age, and gender, as well as determine the most sensitive and specific factors associated with LUTS.

METHODS

LUTS was assessed in individuals with DS using a cross-sectional study through the application of a validated and adapted version of the DVSS for the Brazilian population. The presence of functional constipation was evaluated according to the Rome III criteria.

RESULTS

Of the 114 individuals assessed, 84 were included in the study (median age 16 ± 5.0 years, 66.7% female). The prevalence of LUTS was 27.3%. The symptoms were more frequent in males (OR 3.0, 95% CI 1.1-8.3, p = 0.03) and in individuals younger than 10 years of age (OR 5.2, 95% CI 1.8-14, p = 0.001). Functional constipation was observed in 50% of subjects. It was detected in 95.65% of the individuals with LUTS and 32.78% without LUTS (OR 45.1, 95% CI 5.66-301, p = 0.001). The symptom listed in question 8 ("push to pee") was the most specific indicator. When present, this symptom indicated a higher probability of LUTS (LR+ = 6.3), while the symptom listed in question 4 ("push for bowel movements to come out") showed high sensitivity and, when absent, indicated a lower probability of LUTS (LR- = 0.1).

CONCLUSIONS

LUTS was more prevalent in young males with DS and appeared to improve with age. Functional constipation was strongly associated with LUTS. These findings will contribute to raising the awareness of professionals involved in the follow-up of individuals with DS regarding the clinical manifestations and the need for a standardized investigation of LUTS.

Bladder and bowel dysfunction: evidence for multidisciplinary care

PURPOSE

We examined the symptoms of bladder-bowel dysfunction (ie severity of voiding dysfunction and stool consistency) and psychosocial difficulties in children presenting to the pediatric urology clinic for voiding dysfunction and to the pediatric gastroenterology clinic for functional constipation.

MATERIALS AND METHODS

Parents of children seen at the gastroenterology clinic were recruited during the outpatient clinic appointment, and parents of children seen at the urology clinic were randomly selected from the research database and matched to the gastroenterology sample based on age and gender of the child. All parents completed the Dysfunctional Voiding Scoring System, Bristol Stool Form Scale, Pediatric Symptom Checklist and Parenting Stress Index™-Short Form, which assessed severity of voiding dysfunction, stool consistency, level of psychosocial difficulties and level of parenting stress, respectively.

RESULTS

Children seen at the urology and gastroenterology clinics did not differ significantly on any of the measures, indicating that the severity of their bladder-bowel dysfunction is similar. However, they had significantly more severe voiding dysfunction, more constipated stool and more psychosocial difficulties than historical healthy controls. Additionally, level of parenting stress was significantly correlated with patient level of psychosocial difficulties and severity of voiding dysfunction.

CONCLUSIONS

Patients with bladder and bowel dysfunction represent a homogeneous group that would potentially benefit from a multidisciplinary treatment approach involving urology, gastroenterology and psychology professionals.