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Dysfunctional Elimination Syndrome, Pediatric

Basics

Description

- 15% of 6-year-olds have abnormal voiding patterns. Children with DES often have - Abnormal renal ultrasounds - Higher rates of urinary tract infections (UTIs) - A decreased ability to resolve vesicoureteral reflux (VUR)

- Urodynamic studies - Tools used to define bladder function if there is a poor response to initial management - Uroflow is used to evaluate bladder outflow. - Cystometry and perineal EMG studies give information about bladder function during filling and voiding.

- Antimuscarinics - Are used for overactive bladders - Work by reducing the frequency and intensity of the bladder contraction - Can be supplied in short-acting and long-acting formulas or transdermally

  • Dysfunctional elimination syndrome (DES) is seen in children with bladder and bowel dysfunction in the setting of normal neurologic findings.
  • We define dysfunctional voiding as tightening the pelvic floor muscles before completely emptying the bladder, which may leave a large amount of urine in the bladder.DES also encompasses the underactive ("flaccid"Ł) bladder, which is seen in children who postpone voiding and only empty a few times a day.Constipation has a major role to play in affecting the bladder's ability to store urine and also affects the bladder's ability to empty completely and in a timely fashion.
  • Patients with DES may also experience daytime and/or nighttime incontinence.

Epidemiology

  • 15% of 6-year-olds have abnormal voiding patterns. Children with DES often haveAbnormal renal ultrasoundsHigher rates of urinary tract infections (UTIs)A decreased ability to resolve vesicoureteral reflux (VUR)
  • 89% of children who are treated for their constipation completely resolve their daytime urinary incontinence, and 63% resolve their nighttime incontinence.

Risk Factors

  • Recurrent UTIs
  • Constipation

Pathophysiology

  • A child who is holding his or her stool and not having regular daily bowel movements has increased stool in the rectal vault.
  • As stool builds up in the rectal vault (constipation), it begins to push on the bladder. This process causes decreased bladder filling.
  • In addition, the rectal vault shares sensory input in the sacral spinal cord with the bladder, and the full rectal vault can be sensed as a full bladder, triggering bladder spasms and leakage and/or incomplete emptying of the bladder.
  • As a child struggles to stay dry in the face of bladder spasms, he or she overcontracts the external sphincter of the bladder, has a hard time relaxing the external sphincter during voiding, and develops increased pressure during voiding. This increased pressure can be transmitted to the kidneys.

Diagnosis

History

  • A child will present after toilet training with symptoms of daytime and/or nighttime incontinence.
  • In addition, he or she may have a history of recurrent UTIs or VUR.
  • Bowel dysfunction may present as encopresis, constipation, or as fecal impaction.

Physical Exam

  • Most commonly, the exam will be normal.
  • Abdomen: palpable bladder or stool in the colon
  • Evaluate the spine for skin discoloration, dimples, or hair patches to rule out occult spinal dysraphism.
  • Evaluate female genitalia and rule out labial adhesions that can trap urine and cause incontinence.
  • Consider possible ectopic ureter if there is vaginal pooling of urine.
  • Evaluate male genitalia and rule out prior hypospadias repair or severe phimosis in which urine trapping can occur.
  • Rectal exam can reveal fecal impaction.

Diagnostic Tests & Interpretation

Lab

  • Urinalysis to rule out bacteriuria or glucosuria
  • First morning urine osmolality to assess renal concentrating ability in nocturnal enuresis

Imaging

  • Radiograph of kidneys, ureters, and bladder (KUB): constipation, normal spine
  • Renal ultrasound: pre- and postvoid images to evaluate the bladder and kidneys

Diagnostic Procedures/Other

  • Voiding/drinkingDiary is a tool used to define the nature of the incontinence.
  • Voiding cystourethrogram (VCUG)Used to evaluate for VUR and to look at the urethra and bladder neck during voiding
  • Urodynamic studiesTools used to define bladder function if there is a poor response to initial managementUroflow is used to evaluate bladder outflow.Cystometry and perineal EMG studies give information about bladder function during filling and voiding.

Differential Diagnosis

  • Ectopic ureter to the vagina
  • Spinal cord abnormalities (tethered cord)
  • Brain tumors

Treatment

Behavior Modification

  • Educate proper voiding mechanics.
  • Timed voiding every 2 hours; may use a watch with a repeating alarm
  • Correct sitting and standing positions during voiding
  • Modify drinking and voiding habits based on diaries to attain frequent voiding and regular stooling.
  • Encourage plenty of water intake; fiber for management of constipation
  • Time set aside to attempt regular morning bowel movements

Medication

  • Bowel managementGoal: full clean outClean out usually lasts 3 days.Use polyethylene glycol 3350 (MiraLax)/ lactulose and enemas and/or mineral oil.If severe, can use KUB to confirm clean out is complete
  • Daily managementGoal: 1-2 soft bowel movements dailyPolyethylene glycol 3350 (MiraLax)/lactulose daily dosing and/or mineral oil help for daily maintenance.
  • AntimuscarinicsAre used for overactive bladdersWork by reducing the frequency and intensity of the bladder contractionCan be supplied in short-acting and long-acting formulas or transdermally

Alert

Make sure the patient has truly had a good bowel clean out and is focusing first on 1-2 daily soft bowel movements before adding medications to treat the bladder symptoms. á

Additional Therapies

  • Biofeedback
  • Acupuncture
  • Neuromodulation

General Measures

  • When a provider is treating a child with bladder and bowel dysfunction, it is imperative that the focus begins with daytime management first, specifically focusing on soft daily bowel movements and timed voiding.
  • The nighttime wetting will not improve until the daytime wetting and the constipation have been properly managed.

Ongoing Care

Follow-up Recommendations

  • Children with recurrent febrile UTIs should be referred to pediatric urology.
  • Children with abnormal renal ultrasound should be referred to pediatric urology.
  • Children who don't resolve their incontinence after initial management of the bowel dysfunction should be referred to pediatric urology.

Prognosis

  • 80% of children are able to resolve their symptoms, with attention given to their bowel function and timed voiding.
  • Because this treatment predominantly involves making behavioral changes, this process does not occur quickly. Time and patience are required by both the parents and the children.

Additional Reading

  • Dohil áR, Roberts áE, Jones áKV, et al. Constipation and reversible urinary tract abnormalities. Arch Dis Child. 1994;70(1):56-57. á[View Abstract]
  • Issenman áRM, Filmer áRB, Gorski áPA. A review of bowel and bladder control development in children: how gastrointestinal and urologic conditions relate to problems in toilet training. Pediatrics. 1999;103(6, Pt 2):1346-1352. á[View Abstract]
  • Koff áSA, Wagner áTT, Jayanthi áVR. The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children. J Urol. 1998;160(3, Pt 2):1019-1022. á[View Abstract]
  • Loening-Bauke áV. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics. 1997;100(2, Pt 1):228-232. á[View Abstract]

Codes

ICD09

  • 788.30 Urinary incontinence, unspecified
  • 564.00 Constipation, unspecified
  • 787.60 Full incontinence of feces

ICD10

  • R32 Unspecified urinary incontinence
  • K59.00 Constipation, unspecified
  • R15.9 Full incontinence of feces

SNOMED

  • 252030006 Dysfunctional voiding of urine (finding)
  • 14760008 Constipation (disorder)
  • 72042002 Incontinence of feces (finding)
  • 236657002 dysfunctional voiding (disorder)

FAQ

  • Q: Should children with DES have urodynamic evaluation?
  • A: Rarely. A patient should undergo standard therapy with timed voiding and treatment of constipation as the 1st-line therapy. If that fails, then a referral to pediatric urology is appropriate, and the need for further testing will be assessed.