Basics
Description
- 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 have
- Abnormal renal ultrasounds
- Higher 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/drinking
- Diary 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 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.
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 management
- Goal: full clean out
- Clean 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 management
- Goal: 1-2 soft bowel movements daily
- Polyethylene glycol 3350 (MiraLax)/lactulose daily dosing and/or mineral oil help for daily maintenance.
- 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
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.