Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad...

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Dysfunctional Elimination Syndrome

Vincenzo Galati, D.O.Stephen Confer, MD

Ben O. Donovan, MDBrad Kropp, MD

Dominic Frimberger, MD

University of Oklahoma Department of Urology

Section of Pediatric Urology

Objectives

• Normal Elimination

• Dysfunctional Elimination Syndrome

• Non-Neurogenic Neurogenic Bladder

• Biofeedback

• Review of the literature

Development of Urinary Control

• Infancy: Reflex voiding– Detrusor contracts when bladder full

– External urinary sphincter contracts during filling

• Voiding pattern in infants (feeding)• Development of continence

– ↑ capacity and control of striated sphincter

– Control over spinal micturition reflex

Stooling

• Normally– Newborn meconium passes w/in 24 hrs– First few weeks: BMs 6 X q day– By 5 months: BMs 3 X q day– Age 2: BMs bid– Age 4: BM q day

J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

Dysfunctional Elimination

• Unknown etiology

• Abnormal elimination pattern

• Bowel or bladder incontinence

• Withholding maneuvers

Holding Maneuvers

Dysfunctional Elimination

• Prevalence approximately 15% (Hellstrom et al. 1991)

• Overlooked factor in pediatric UTIs

• 40% of toilet trained with 1st UTI

• 80% with recurrent UTI

• Risk factor for VUR and renal scarring

Bad Bladder Habits

• Infrequent visits to bathroom

• Inadequate time in bathroom

• Bad posture

• Poor hygiene

What Happens?

• Infrequent voiding

– Over distended bladder

• Failure to relax pelvic floor

– Voiding against closed sphincter

• ↑ PVR

What Happens?

• Bad posture– Can’t relax

• Bad hygiene or aggressive soaps– Dysuria and incomplete voiding

•Children rated wetting themselves at school as the third most catastrophic event behind losing a parent and going blind.

Ollendick et al, Behav Res Therapy, 1989.Ollendick et al, Behav Res Therapy, 1989.

Functional Bowel Disturbances

• Constipation– Hard BM occurring < 3 X per week

• Most likely to occur in 3 situations• Can induce bladder dysfunction • 50% of dysfunctional voiding have

constipation

Functional Constipation

• Symptoms– Infrequent passage of stool

– Hard stool

– Palpable stool in abdomen or in rectal vault

– Fecal soiling

Functional Constipation

• Management:– Parental education (hydration and fiber)– Many require stool softeners– Visit toilet 30-40 minutes after a meal

• Forward leaning, T&L extension, hip abduction, foot support that allows 90° of hip/knee flexion

Treatment of Day Time Wetting

• 1st line is Behavior Modification– Diary– Bathroom every 2 hrs– Good posture – Ample time– Good hygiene

Treatment of Day Time Wetting

• Treat Constipation

• Biofeedback– Learn to relax pelvic muscles

• Medications – Ditropan ↓ pressure but CONSTIPATES!– ? Role of α-blocker and Botox

Non-neurogenic neurogenic bladder (NNGNGB)

• Nocturnal and diurnal incontinence

• Dribbling, overflow, urge incontinence

• Bowel dysfunction

• Recurrent UTI’s

• Bladder instability

• Voluntary DSD during voiding

NNGNGB

– VCUG large PVR

– Reflux noted in about 50%

NNGNGB - Treatment

– Sterilize Urine– Bladder retraining– Normalize bowel function– Anticholinergics eliminate unstable bladder

contractions– Sympatholytics and diazepam to reduce

outflow resistance– May need CIC

Biofeedback

• Treatment option for children with DSD• Goal: develop control over pelvic floor

muscles during voiding• Visual electromyography feedback• Maintain relaxed pelvic floor with voiding • Success up to child/parent/physician • Problem: can be invasive

Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470-1475.

Modified Biofeedback Program

• Noninvasive UDS• Psychological

techniques– Externalizing voiding

problem

– Empowerment and praise

77 Children Completing Biofeedback Study

No. (%)

Recurrent UTI 59 (76)

Day incontinence 48 (63)

Night incontinence 36 (47)

Anticholinergic tx 38 (49)

VUR 19 (24)

Bowel symptoms 44 (58)

Modified Biofeedback Program

Improvement No. (%)

Subjective:

Pronounced 47 (61)

Moderate 24 (31)

None 6 (8)

Objective:

Pronounced 47 (61)

Moderate 28 (36)

None 2 (3)

• Concluded:– Effective for 92% of

children with DSD

Alpha-blocker therapy be as an alternative to biofeedback for dysfunctional voiding?

• Efficacy of alpha-blocker vs biofeedback

• Prospective study 28 pts (12/16)

• On timed voiding, constipation treatment and anticholinergics for at least 6 mo

• Pts reevaluated at 3 and 6 months– Incontinence episodes, UTIs, mean urinary

flow rates, PVR, and parental satisfaction

Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology, 2005; 174, 1612-1615.

Alpha-blocker therapy be as an alternative to biofeedback for dysfunctional voiding?

• Improved post treatment PVR– NO DIFFERENCE

• Complete improvement in urge incontinence– NO DIFFERENCE

• Combination effective in refractory cases (5/6)

• No side effects reported• Concluded alpha blockers were

a viable alternative

PVR Bio(ml)

PVR AB(ml)

Flow Bio(ml/s)

Flow AB(ml/s)

0 months

3 months

6 months

Botulinum A Toxin Urethral Sphincter injection in Children with NNGNGB

• Prospective (10 children)

• 50-100 units injected • Immediately following

all but 1 voided without catheterization

• PVR ↓ by 89% 0

PVR (ml)

DLPP (cm H2O)

Q max (ml/sec)

Closing Statements

• Best treatment is prevention

• DES diagnosis of exclusion

• Constipation treatment and timed voiding

• Biofeedback

• Adjunctive treatment in refractory cases– Alpha blockers– BOTOX

Vincenzo Galati

Thank YouThank You

Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad...

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