Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
Levels of evidence (1a-4) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Definition
Daytime lower urinary tract (LUT) conditions are conditions that present with LUT symptoms (LUTS), including urge, incontinence, weak stream, hesitancy, frequency and urinary tract infections, but without overt uropathy or neuropathy.
Normal bladder storage and voiding involves low pressure and adequate bladder volume filling. This is then followed by a continuous detrusor contraction, which results in complete bladder emptying, associated with an adequate relaxation of the sphincter complex.
Normal urine storage by the bladder and evacuation are controlled by a complex interaction between the spinal cord, brain stem, midbrain and higher cortical structures, associated with a complex integration of sympathetic, parasympathetic and somatic innervations.
It is understandable that this complex control mechanism is likely to be susceptible to developing different types of dysfunction. Various functional disorders of the detrusor-sphincter complex may occur during the sophisticated early development of normal mechanisms of micturition control. Voiding dysfunction is therefore thought to be the expression of incomplete or delayed maturation of the bladder sphincter complex.
Normal daytime control of bladder function matures between 2 and 3 years of age, while night-time control is normally achieved between 3 and 7 years of age.
There are two main groups of voiding dysfunction, namely, filling-phase dysfunctions and voiding-phase dysfunctions.
Filling-phase Dysfunctions
In filling-phase dysfunctions, the detrusor can be overactive, as in overactive bladder (OAB) and urge syndrome, or underactive, as in underactive or highly compliant bladder (formerly known as 'lazy bladder'). Furthermore, some children habitually postpone micturition leading to voiding postponement.
Voiding-phase (Emptying) Dysfunctions
In voiding-phase (emptying) dysfunctions, interference with the sphincter and pelvic floor during detrusor contraction is the main dysfunction. The general term for this condition is dysfunctional voiding. Different degrees of dysfunction are described, depending on the strength of interference with the sphincter and pelvic floor. Weak interference results in staccato voiding, while stronger interference results in interrupted voiding and straining, due to an inability to relax during voiding.
Bladder sphincter dysfunction is often associated with bowel dysfunction such as obstipation and soiling. Sometimes, secondary anatomical changes are observed, such as trabeculation, diverticulae and vesicoureteral reflux.
Diagnosis
A non-invasive screening, consisting of history-taking, clinical examination, uroflow, ultrasound and voiding diary, is essential to reach a diagnosis.
In the paediatric age group, where the history is taken from both the parents and child together, a structured approach is recommended using a questionnaire. Many signs and symptoms related to voiding and wetting will be unknown to the parents and should be specifically requested, using the questionnaire as a checklist. A voiding diary is mandatory to determine the child's voiding frequency and voided volumes as well as the child's drinking habits. History-taking should also include assessment of bowel function. Some dysfunctional voiding scores have recently been developed and validated.
Upon clinical examination, genital inspection and observation of the lumbosacral spine and the lower extremities is necessary to exclude obvious uropathy and neuropathy. Uroflow with post-void residual evaluates the emptying ability, while an upper urinary tract ultrasound screens for secondary anatomical changes. A voiding diary provides information about storage function and incontinence frequency, while a pad test can help to quantify the urine loss.
In the case of resistance to initial treatment, or in the case of former failed treatment, re-evaluation is warranted and further video-urodynamic studies may be considered. Sometimes, there are minor, underlying, urological or neurological problems, which can only be suspected using video-urodynamics.
In the case of anatomical problems, such as urethral valve problems, syringocoeles, congenital obstructive posterior urethral membrane (COPUM) or Moormann's ring, it may be necessary to perform further cystoscopy with treatment. If neuropathic disease is suspected, magnetic resonance imaging (MRI) of the lumbosacral spine and medulla can help to exclude tethered cord, lipoma or other rare conditions.
Psychological screening may be useful for children or families with major psychological problems associated with the voiding dysfunction.
Treatment
Treatment of voiding dysfunction consists of lower urinary tract rehabilitation, mostly referred to as urotherapy. Urotherapy means non-surgical, non-pharmacological, treatment of LUT function. It is a very broad therapy field, incorporating many treatments used by urotherapists and other healthcare professionals. Urotherapy can be divided into standard therapy and specific interventions.
Standard Therapy
Standard urotherapy, which is defined as non-surgical, non-pharmacological, treatment for LUT malfunction, includes the following components:
- Information and demystification, which includes explanation about normal LUT function and how a particular child deviates from normal function
- Instruction about what to do about the problem, i.e., regular voiding habits, sound voiding posture, avoiding holding manoeuvres, etc.
- Lifestyle advice, regarding fluid intake, prevention of constipation, etc.
- Registration of symptoms and voiding habits using bladder diaries or frequency-volume charts
- Support and encouragement via regular follow-up by the caregiver
Most studies on the effect of urotherapy programmes are retrospective. Independent of the elements of a urotherapy programme, a success rate of 80% has been described. The evidence level is low as most studies are retrospective and non-controlled.
Specific Interventions
As well as urotherapy, there are some specific interventions, including physiotherapy (e.g., pelvic floor exercises), biofeedback, alarm therapy and neurostimulation. Although good results with these treatment modalities have been reported, there have been no randomized controlled treatment trials (RCTs), so that the level of evidence is low.
In some cases, pharmacotherapy may be added. Antispasmodics and anticholinergics have been shown to be effective. However, even for these pharmacological interventions, no RCTs have been published, so that the level of evidence is low. Although alpha-blocking agents are used occasionally, a recent RCT showed no benefit. More recently, newer drugs have become available and have been tested in children. Even botulinum toxin injection seems to be promising.
However, the evidence currently available suggests that a good outcome is simply related to the fact that training is being given and attention is being paid to the child's incontinence problem rather than a specific kind and/or amount of training being required.
Definitions:
Levels of Evidence
1a Evidence obtained from meta-analysis of randomized trials
1b Evidence obtained from at least one randomized trial
2a Evidence obtained from at least one well-designed controlled study without randomization
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendation
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical studies
- Made despite the absence of directly applicable clinical studies of good quality
