Vaginal reflux and enuresis

Pediatric urethrovaginal reflux: an underestimated cause of urinary incontinence and its successful management

INTRODUCTION AND HYPOTHESIS

Urethrovaginal reflux (UVR) secondary to vaginal urine entrapment is an unnoticed cause of daytime urinary leakage in toilet-trained girls. Our aim is to emphasize the diagnosis of UVR as a cause of urinary incontinence, its predisposing factors, early detection, and treatment.

METHODS

A total of 25 girls aged between 9 and 14 years presented with mixed daytime urinary incontinence from 2019 to 2021. They were evaluated by detailed history, vaginal examination, focused neurological examination, bladder diaries, urine analysis, uroflowmetry, and residual urine assessment. Micturating cystourethrography was also performed in those girls who did not show improvement with a conservative line of management.

RESULTS

The parents of these girls were educated about the cause of leakage. They were treated with behavioral modifications, urotherapy, correcting toilet postures, and reverse sitting on the commode. Urethrovaginal reflux was found in 6 of the 25 girls (24%). Their ages were 9, 10, 10, 11, 12, and 14 years respectively. Two girls (10 and 14 years old) had a body mass index more than 25. They all had a typical history of a small quantity of urine leakage 5-10 min (post-micturition dribble) after every void. At follow-up after 12 months, all of them were free from urinary incontinence.

CONCLUSIONS

Urethrovaginal reflux should be considered in the differential diagnoses of girls with day-time incontinence. The key to diagnosis is an appropriate and detailed history as it is common for parents or girls to ignore symptoms or fail to report them. Proper voiding instructions and behavioral therapy often resolve the problem.

Urethro-vaginal reflux during micturition: An underestimated cause of urinary incontinence in adult women

AIMS

To evaluate if urethrovaginal reflux (UVR) is an underestimated cause of insensible or postmicturition incontinence in adult women.

METHODS

An observational and retrospective study was carried out on the computerized records of a neuro-urology department. Female patients who had insensible or postmicturition incontinence were investigated. Retrograde and voiding urethrocystography (UCG), urodynamic evaluation, urethral pressure profilometry, and anamnestic and clinical examination had to be available.

RESULTS

Among the 79 adult female patients with insensible or postmicturition incontinence in whom the whole set of required evaluations was achieved, 16 had a UVR (mean age 47 ± 15 years). There were no urethral diverticula, urethrocele, vesicovaginal, or urethrovaginal fistula on their UCG. All of them also had a cystoscopy and a CT urography which did not establish any abnormality.

CONCLUSIONS

UVR is not an exclusive pathology of children. This mechanism seems to be an underestimated cause of urinary incontinence in adult women. Retrograde and voiding UCG appears to be the gold standard to confirm the intravaginal reflux.

Day wetting

About 1% of healthy children over the age of 5 years have troublesome daytime wetting. Two-thirds of those who wet by day are reliably dry at night. The problem is more common in girls and is usually the result of urge incontinence. Although the wetting may be exacerbated by giggling and/or stress, pure giggle micturition and isolated stress incontinence are both rare. There is a strong association with bacteriuria (50% prevalence) in girls who wet by day. A potentially important relationship exists between day wetting, infection, reflux and upper tract damage, which is expressed in an extreme form in the syndromes of incoordinated voiding and progressive renal damage. Most children who wet by day have unstable bladders. Many of them adopt characteristic "holding" postures. There is an increased incidence of emotional disorder compared with children who merely wet the bed. Between 10% and 15% of children who wet by day become dry during the next 12 months. The acquisition of dryness is accelerated by eradication of bacteriuria and a sympathetic and energetic management regime, which should place responsibility on the child and result in the child voiding more frequently and completely. Reminder alarms and other behaviour therapies have proved effective. There is no satisfactory evidence for the efficacy of drugs. More complex behavioural training regimes including biofeedback are valuable for severe cases.

Enuresis: principles of management and result of treatment

We studied 115 consecutive cases of primary enuresis. Excretory urography, urodynamic testing and endoscopy are needed only in children with enuresis and concomitant urinary infection. A detailed urologic history was the most important factor in deciding upon a treatment program. Children with diurnal and nocturnal enuresis or nocturnal enuresis and daytime urgency and frequency of urination are started on anticholinergic medication. Girls with enuresis and urinary infection also are started on anticholinergic medication. Significant improvement occurs in up to 90% of the patients. Children with only nocturnal enuresis and no other symptoms are started on imipramine with a 70% improvement rate.