Water Over the Bridge

Transcription

1 310 Cedar Street New Haven, CT Water Over the Bridge Marsha Guess MD Alla Vash-Margita MD April 13, 2018 S L I D E 1

2 Disclosures The presenters have no commercial relationships relevant to presentation S L I D E 2

3 Objectives By the end of this lecture participants should be able to: Take targeted and effective comprehensive history in a busy office practice setting Master specifics of physical exam without creating anxiety and fear in children and adolescent girls Learn treatment strategies in care of urinary incontinence and constipation in children and adolescent girls S L I D E 3

4 Water Over the Bridge S L I D E 4

5 Let s have a discussion I m so unhappy! S L I D E 5

6 Case Presentation 1 15 yo G0 young woman presents for evaluation of pelvic pain and urinary urgency She has had urge to void every 30-60min for 3 years, she voids with small amounts of urine, denies hematuria or UTI s She sleeps on the toilet at times due to urge to urinate. She misses school due to this issue No inciting event, she denies any physical or psychologic trauma She c/o constipation, takes Magnesium citrate, but not every day. She has bowel movement almost every day, stool consistency varies from hard to "sometimes" soft stool She drinks about 32 oz of water/day in attempt to regulate bowel movements S L I D E 6

7 Case Presentation 1 Patient reports that she voided 30 min ago and still has an urge to void. She leaves exam room during visit and goes to the bathroom to void She feels that when she is constipated urinary urgency becomes more prominent PGynHx: menarche at age 12. Menses are regular with mild to moderate flow. She has pain during menses, 8/10, minimal relief with Ibuprofen PMedHx: tension headaches PSHx: tonsillectomy Social history: lives at home with parents, attends10 th grade, her grades are B s-c s. She reports heterosexual orientation, has not been sexually active S L I D E 7

8 Case Presentation 1 Physical Exam: PB 105/69, BMI 31.8 Breast Tanner 5 Abdomen: non tender, no masses, no organomegaly Back: no scoliosis, no sacral dimple, no abnormal hair, no skin lesions (lower back), normal anocutaneus fold Neuro: no focal deficits Pelvic: Tanner 4, normal labia majora and minora, normal clitoris, normal prepuce, annular hymen with single opening Anus: orthopically positioned, no fissures, no visible stool Labs: urinalysis and urine culture within normal limits S L I D E 8

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10 Case Presentation 1 Further work up included: Bladder diary: was continued for few days: multiple episodes of urination(>8) with 15-60mL void at a time S L I D E 10

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12 Case Presentation 1 A-P abdominal radiography: moderate fecal load S L I D E 12

13 Terminology Lower Urinary Tract Dysfunction The International Children s Continence Society (I.C.C.I) urinary frequency 8 voids/day decreased frequency as 3 voids/day Reference point is 5 years of age Austin PF at al, The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children's Continence Society, Neurourol Urodyn Apr;35(4): S L I D E 13

14 Urgency Sudden and unexpected experience of an immediate and compelling need to void Incontinence Involuntary leakage of urine; it can be continuous or intermittent Nocturia Terminology Lower Urinary Tract Dysfunction Nocturia - child has to wake at night to void International Children's Continence Society, Neurourol Urodyn 2016 Apr;35(4): S L I D E 14

15 Terminology Lower Urinary Tract Dysfunction Incontinence Continuous Intermittent Day-time Enuresis Monosymptomatic Non-monosymtomatic Primary Secondary Primary Secondary Franco I, Pediatr Clin North Am S L I D E 15

16 Terminology Lower Urinary Tract Dysfunction Voiding Symptoms Hesitancy denotes difficulty in initiating voiding when the child is ready to void Straining: the child complains of needing to make an intense effort to increase intraabdominal pressure (e.g. Valsalva) in order to initiate and maintain voiding Intermittency: micturition that is not continuous but rather has several discrete stop and start spurts Dysuria: is the complaint of burning or discomfort during micturition. The timing of dysuria may be noted during voiding S L I D E 16

17 Terminology Lower Urinary Tract Dysfunction Vaginal reflux Toilet-trained prepubertal girls who wet their underwear This symptom is not associated with other LUTD symptoms It is essential to differentiate this symptom from postvoid dribbling, because the treatment is different S L I D E 17

18 Terminology Lower Urinary Tract Dysfunction Giggle incontinence Giggle incontinence is a rare syndrome in which complete voiding occurs specifically during or immediately after laughing Bladder function is normal when the child is not laughing S L I D E 18

19 History Lower Urinary Tract Dysfunction Other Symptoms Holding Maneuvers: standing on tiptoes forcefully crossing the legs grabbing or pushing on the genitals or abdomen placing pressure on the perineum S L I D E 19

20 Lower Urinary Tract Dysfunction Genital and LUT pain Bladder pain: Complaint of suprapubic pain or pressure or discomfort related to the bladder Urethral pain: Complaint of pain felt in the urethra Genital pain: This refers to pain in the genital area In girls, vaginal pain and vaginal itching are seen with localized irritation from incontinence S L I D E 20

21 Constipation Constipation: Infrequent, hard defecation, often painful defecation and involuntary loss of feces in the underwear S L I D E 21

22 Constipation Organic causes(<10%) Anorectal malformation Hirschsprung s disease Neurological abnormality Endocrine or metabolic disorder No organic cause is found(>90%): Functional constipation Hutson JM, et al. Slow-transit constipation in children: our experience. Pediatr Surg Int 2009 S L I D E 22

23 Functional Constipation S L I D E 23

24 Functional Constipation Functional constipation (FC) and lower urinary tract symptoms are common problems in children The reported prevalence of childhood constipation varies from 0.7% to 29.6% Up to 50% of children seen for lower urinary tract dysfunction (LUTD) report symptoms of constipation Burgers R at al, Functional defecation disorders in children with lower urinary tract symptoms, J Urol, 2013 Chase JWet al: Functional constipation in children. J Urol 2004 Mugie SM at al, Epidemiology of constipation in children and adults: a systematic review. Best Pract Res Clin Gastroenterol 2011 S L I D E 24

25 Constipation and Lower Urinary Tract Dysfunction Bladder Bowel Dysfunction BBD Lower Urinary Tract Dysfunction Overactive bladder syndrome (OAB) Voiding postponement Stress/giggle incontinence Dysfunctional voiding Bowel Dysfunction Functional constipation Overflow incontinence International Children's Continence Society, Neurourol Urodyn April 2016 S L I D E 25

26 Constipation, faecal and urinary incontinence in children The prevalence rate: Urinary incontinence % (chronic conditions excluded) 3.3% daytime only 1.8% daytime with night-time 5.4% night-time urinary incontinence Constipation 22.6% (similar in boys and girls) Fecal incontinence - 4.4% Fecal and urinary incontinence were significantly more commonly observed in children with constipation than in children without constipation- 21.8% vs 7.3% (p<0.001) Loening-Baucke V, Prevalence rates for constipation and faecal and urinary incontinence, Arch Dis Child S L I D E 26

27 Prevalence of constipation in children with isolated overactive bladder (IOAB) 51 children with IOAB, control group of 74 children (ages of 4-14, Rome III criteria for constipation) The urinary symptoms were urge incontinence, frequency, enuresis, nocturia and holding maneuvers IOAB - urgency with or without daytime incontinence or frequency, a bell-shaped uroflow, and no post-residual urine History of urinary tract infection (UTI) was also noted Children with neurological or anatomical abnormalities were excluded Viega ML at al, Constipation in children with isolated overactive bladders, J Pediatr Urol Dec;9(6 Pt A):945-9, Feb 2013 S L I D E 27

28 Prevalence of constipation in children with isolated overactive bladder (IOAB) Mean patient ages were 7 and 8 years in the OAB and control group, respectively (p = 0.54) Girls - 28 (54.9%) of the OAB group and 34 (45.9%) in the control group (p = 0.32) More of the children with IOAB had constipation than those without urinary symptoms (54.9% vs. 29.7% p = 0.005) Girls with OAB presented more frequently with UTI than boys (18 vs. 10, p = 0.13) Viega ML at al, Constipation in children with isolated overactive bladders, J Pediatr Urol Dec;9(6 Pt A):945-9, Feb 2013 S L I D E 28

29 Pelvis: close neighbors Large massive bowel movements are an indicator of infrequent bowel movements The rectal mucosa absorbs water from the fecal mass, retained stools become progressively harder and more difficult to evacuate S L I D E 29

30 Evaluation of Constipation S L I D E 30

31 Bladder Bowel Innervation S L I D E 31

32 Bladder Bowel Dysfunction Hypotheses: 1. Rectal distention BBD Direct pressure on the posterior bladder wall The postvoid residual volume increased Stool in the rectum Bladder s ability to empty is impaired 2. Prolonged external anal sphincter contraction in the presence of large amount of stool Inappropriate pelvic floor of muscle contractility and consequently urethral sphincter nonrelaxation Ambrosiana L at al, Neurogastroenterol Motil Jun;28(6): S L I D E 32

33 Defecation Maintenance of defecation Defecation S L I D E 33

34 The interrelationship between bowel, bladder and CNS Franco I, Pediatr Clin North Am S L I D E 34

35 Why does this matter? Childhood daytime incontinence and nocturnal enuresis Population based cohort study 2,109 women age >2-fold adult urge incontinence History of childhood urinary tract infections (UTIs) increased rate of adult UTIs (p<0.001) Fitzgerald MP at al, Reproductive Risks for Incontinence Study at Kaiser Research Group Childhood urinary symptoms predict adult overactive bladder symptoms, J Urol S L I D E 35

36 Why does this matter? 267 cases (120 stress, 37 urge, 98 mixed, and 12 other UI), 107 controls 56% of cases (48% stress, 65% urge, and 62% mixed UI) had a prevalence of childhood dysfunctional voiding compared to 40% controls, p =0.06 Women with adult UI had a 2-fold increased odds (P = 0.006) of childhood dysfunctional voiding compared with controls The highest prevalence of dysfunctional voiding was urge UI (OR = 4.4, 95% CI = ) mixed UI (OR = 2.7, 95% CI = ) stress UI (OR = 1.4, 95% CI = ) Minassian VA, Dysfunctional voiding is differentially associated with urinary incontinence subtypes in women, World J Urol Feb S L I D E 36

37 Evaluation of Child with Lower Urinary Tract Symptoms History: Obtain from the child as feasible # of times to void Voiding and bowel diaries are of utmost importance S L I D E 37

38 Pertinent History Interaction between the child and parent (child and the physician): excessive anxiety inappropriate fear is this type of behavior is commonly present at home or during other stressful situations? Family history: anxiety phobias attention-deficit disorder/attention-deficit/hyperactivity disorder (ADHD) depression S L I D E 38

39 History and Physical Exam Ask specific questions: Do you leak after you finished peeing? Postvoid dribble incomplete relaxation of the external sphincter Does it hurt when you pee? Dysuria - in the absence of infection signifies dyssynergic voiding S L I D E 39

40 Tools of Investigation complete bladder diary 7-night recording of incontinence episodes nighttime urine volume measurements to evaluate enuresis 48 hours daytime frequency and volume chart S L I D E 40

41 Bladder Voiding Diary S L I D E 41

42 History and Physical Exam Ask specific questions: Bowel habits of the patient should be obtained from the patient directly How often do you poop? Is you poop soft like ripe banana or hard like pebbles? Do you have any pain or have any blood when pooping? Any life altering events? death in the family birth of a sibling school problems sexual abuse S L I D E 42

43 Evaluation of Constipation S L I D E 43

44 Evaluation of Constipation List of medication: Diuretics Iron Antihypertensives Antipsychotics Aluminium and calcium containing antacids Anticholinergics Anticonvulsants Opioid analgesics Ganglionic blockers S L I D E 44

45 Evaluation of Constipation Bowel movement: abdominal pain loss of appetite nausea, vomiting weight loss or poor weight gain neuromuscular development psychological or behavioral problems Timing of the 1st bowel movement -??Hirschsprung s disease S L I D E 45

46 Tools of Investigation: Bowel Diary S L I D E 46

47 Functional Constipation changes in routine or diet genetic predisposition stressful events perianal irritation parental divorce unavailability or dislike of toilets intercurrent illness entering or changing school S L I D E 47

48 Functional Constipation BBD (bladderbowel dysfunction) Behavioral issues: autism spectrum disorder, ADHD, anxiety and depressive symptoms 20% to 40% of children with urinary incontinence and/or constipation are affected by comorbid behavioral disorders S L I D E 48

49 Functional Constipation Higher prevalence of FC in children with: low consumption of fiber cow's milk protein allergy low physical activity level living in a highly densely populated community low parental education level Mugie SM at al, Epidemiology of constipation in children and adults: a systematic review. Best Pract Res Clin Gastroenterol 2011 S L I D E 49

50 Functional Constipation Cross-sectional study surveyed mothers in the US: evaluated children s (age 0-18) GI symptoms using online tool (Rome IV criteria) Functional constipation (FC) was present in 14.1% of children older than 4 years Functional abdominal pain - not otherwise specified was more prevalent in female (4.2%) than male subjects (1.8%), P =.04 Robin SG at al, Prevalence of Pediatric Functional Gastrointestinal Disorders Utilizing the Rome IV Criteria, J Pediatr, February 2018 S L I D E 50

51 Evaluation of Child with Bladder Bowel Dysfunction Abdomen: Fecal mass in the LLQ Lower back: lumbosacral spine abnormality sacral agenesis spinal dysgraphism (tethered cord syndrome) Lower extremities: strength length mass and sensation may also uncover an occult spinal dysraphism S L I D E 51

52 Evaluation of Child with Bladder Bowel Dysfunction Perianal inspection: position of the anus gluteal cleft deviation perianal feces fissures hemorrhoids scars (sequelae of sexual abuse) vaginal irritation caused by wetting is rarely if ever lead to fungal infections lichen sclerosis is also an indicator that there is chronic irritation of the perineum due to wet underwear green or foul smelling vulvar discharge with erythema indicator of vulvitis collect vulvar culture S L I D E 52

53 Evaluation of Child with Lower Urinary Tract Symptoms Urinalysis Hematuria is common in dyssynergic voiding WBC s/nitrates will help to rule out infection Uroflow/EMG 4 classic curves: normal bell curve the hypervoider curve staccato curve plateau curve S L I D E 53

54 Evaluation of Child with Lower Urinary Tract Symptoms VCUG Assessment of the dynamics of voiding The bladder neck can be seen The external sphincter can be seen as it opens and closes The presence of the spinning top urethra is a classic example of external sphincter dyssynergia Spinning top urethra with bilateral reflux Franco I, 2012 S L I D E 54

55 Evaluation of Child with Bladder Bowel Dysfunction Lumbosacral Films Kidney ureter bladder (KUB) may not be adequate to evaluate the spine R/o sacral dysraphism Spina bifida occulta is rarely associated with incontinence Sacral anteroposterior film showing the full Sacrum, Franco I, 2012 S L I D E 55

56 Constipation Work Up The additional costs of care of functional constipation in children are estimated at $3.9 billion in the US alone (Liem at al, 2009) DO NOT SCREEN for hypothyroidism, celiac disease, and hypercalcemia in the absence of alarm symptoms Abdominal radiography not recommended Sensitivity 60-80% Specificity 43-90% Order only if suspect fecal rectal mass AND unable to do rectal Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence- Based Recommendations From ESPGHAN and NASPGHAN, February 2014 S L I D E 56

57 Evaluation of Child with Bladder Bowel Dysfunction Colonic Transit Time (CCT) Results: normal colonic transit colonic inertia (also known as slow-transit constipation with slow propagation throughout all colonic segments) outlet obstruction (delay is mainly in the rectosigmoidal region) Evidence does not support the routine use of colonic transit studies to diagnose functional constipation Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN, February 2014 S L I D E 57

58 Evaluation of Child with Bladder Bowel Dysfunction Anorectal manometry Anorectal manometry is only indicated if there is strong suspicion of Hirschsprung disease It is aimed to demonstrate absent recto anal inhibitory reflex If recto anal inhibitory reflex is absent biopsy of the rectum is indicated Biopsy absence of ganglion cells in the submucosal and myenteric plexus increase in acetylcholinesterase activity in the parasympathetic nerve fibers (c/w the diagnosis of Hirschsprung disease) S L I D E 58

59 Evaluation of Child with Bladder Bowel Dysfunction Abdominal Ultrasonography assessment of stool retention size of rectum and colon A rectal diameter larger than 30 mm is considered as enlarged Evidence does not support the routine use of rectal ultrasound to diagnose functional constipation Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN S L I D E 59

60 MRI Evaluation of Child with Bladder Bowel Dysfunction Indicated in children with neurologic symptoms or physical findings suggestive of occult spine involvement: shortened gluteal cleft, cutaneous manifestations(hair patch, dimple, subcutaneous mass) lower extremities weakness or asymmetry Spinal abnormality was found in: 2 out of 42 (5%) children with normal sacral examination 7 of 19 (37%) children with an abnormal sacral findings (Tarcan at al, 2012) S L I D E 60

61 Case Presentation 1 15 yo nulligravid young woman presents for evaluation of pelvic pain and urinary urgency She has had urge to void every 30-60min for 3 years, she voids with small amounts of urine, denies hematuria or UTI s She sleeps on the toilet at times due to urge to urinate. She misses school due to this issue No inciting event, she denies any physical or psychologic trauma She also c/o constipation, takes Magnesium citrate, but not every day. She has bowel movement almost every day, stool consistency varies from hard to "sometimes" soft stool She drinks about 32 oz of water/day in attempt to regulate bowel movements S L I D E 61

62 Case Presentation 1 A-P abdominal radiography: moderate fecal load S L I D E 62

63 Case Presentation 1 Further work up included: Bladder diary was continued for few days: showed multiple episodes of urination (>8) with 15-60mL void at a time Negative UA/UC&S Normal EMG Normal pelvic ultrasound S L I D E 63

64 Case 1 Treatment of constipation Do not use suppositories or enemas These children are exquisitely sensitive about their bottoms, and inserting suppositories or enemas will only add to their concern Rewarding Few rules to follow: 1. The adolescent has to be able to do what is expected of her 2. The rewards have to be reasonable 3. Know when to stop S L I D E 64

65 Case 1 Treatment of constipation Senna based laxative - Generic: Senna-S (Natural Vegetable Laxative) 1 tablet daily Magnesium 500mg daily works as an osmotic laxative to help put water back into the stool allowing for it to pass easier Helpful Tip: Have your child sit on the toilet at least once a day to promote daily bowel movements S L I D E 65

66 Case 1 Treatment of constipation To maximize the body s natural ability to pass stool, the gastrocolic reflex, it is important to sit 20 minutes after eating for minutes Try a stool for proper positioning on the toilet (squatty potty ) No electronic devices should be allowed during this time as they are distracting Try books, magazines, or listening to music to help promote relaxation S L I D E 66

67 Defecation Maintenance of defecation Defecation S L I D E 67

68 Sitting position - relaxing puborectal muscle Sitting as usual Sitting with feet support(squatting) S L I D E 68

69 Bowel regimen Vegetables: peas, carrots, asparagus, corn, broccoli, artichokes, spinach, all beans, cauliflower, beets, brussel sprouts, cooked cabbage, cooked celery, eggplant, string beans, parsnip, potatoes, sweet potato (yam), turnip, squash (zucchini) Cereals: Raisin Bran, Frosted Mini Wheats, Cracklin Oat Bran, Smart Start Healthy Heart, Puffins Cereal, Kashi Go Lean Crunch or Heart to Heart (cereal should have at least 5g of Dietary Fiber/ serving) 100% Whole Wheat Bread and Whole Wheat Pasta. Brown rice or long grain wild rice Fluids 64oz (2 liters) water minimum everyday if you give juice always mix with water (at least ¾ water with ¼ juice) Limit soda for only special occasions S L I D E 69

70 Case Presentation 1 15 yo nulligravid young woman with pelvic pain and urinary urgency After 8 weeks of bowel regimen she reported daily bowel movements Bristol type IV Her urinary urgency diminished to 2-3 episodes per week, dysmenorrhea significantly improved She was continued on maintenance bowel regimen S L I D E 70

71 Case presentation 2 17 y.o. female G0 who has had recurrent UTI for 2 years 6 UTI s within last year, never associated with fever burning and pain, increased urgency and frequency She has pelvic pressure, urgency and vaginal discomfort for 12 months Pressure is worse around her menses She voids 3-4x/day She reports that in school she holds urine entire day She drinks 32oz of water a day, denies loss of urine BM daily stools lumpy, denies pain denies straining. Diet is poor She had seen Gyn few times and has had multiple exams and testing all negative, except she has been treated for yeast PMHx: anxiety and depression Social: 11 th grade, not sexually active, heterosexual orientation, denies abuse, admits to peer pressure Meds: Fluoxetine, Bupropion S L I D E 71

72 Case presentation 2 BP 121/78 BMI kg/m2 General: no distress Abdomen: soft, non tender, no masses, stool palpable: up to LUQ RLQ Bladder: not palpable, non tender Back: straight spine, no sacral dimple, normal anocutaneous folds Anus: normal position, no fissures noted, no hemorrhoids Neurologic: she is walking without difficulty, moving all four extremities, good muscle tone Underwear: clean and no odor External Genitalia : Tanner 5, normal labia majora and minora, normal clitoris and prepuce, normal external urethral meatus Urinalysis and urine culture within normal limits S L I D E 72

73 S L I D E 73

74 Bowel regimen Senna based laxative - Generic: Senna-S (Natural Vegetable Laxative) 1 tablet daily Magnesium 500mg daily - osmotic laxative S L I D E 74

75 Bowel regimen The American Academy of Pediatrics & the American Heart Association recommends that children receive fiber daily: 9 years and older have grams of fiber a day 3 fruits and vegetables daily, the foods listed below are higher in fiber, at least 3g/serving, example: grapes are not on the list; they are not constipating but only have 1g/serving Fruits: dried apricots, prunes, figs, dates, all berries, watermelon, clementines, peach, plums, kiwi, mango, coconut, avocado, navel oranges, tangerines, (only if the pulp is eaten and not just the liquid), apples and pears (only with the skin, otherwise they are low in fiber) S L I D E 75

76 Case presentation 2 She is taking Senna-S daily and bowel movements are improved but urinary complaints are unchanged S L I D E 76

77 S L I D E 77

78 Case presentation 2 - Uroflow Findings c/w external sphincter dyssynergia (ESD) Recommendations: biofeedback retraining S L I D E 78

79 Urodynamic study S L I D E 79

80 Case presentation 2 Follow up visit: She is taking Senna and Magnesium and notes an improvement in her urgency and constipation She notes no change in her pelvic pain S L I D E 80

81 S L I D E 81

82 Case presentation 2 Psychotherapy started along with adjustment of her Bupropion and Fluoxetine Biofeedback training continued In 12 weeks she reports that vaginal pain improved dramatically: she has 1-2 episodes of pain per week (daily pain prior to treatment) She continued with bowel regimen and continued to have daily soft BM s S L I D E 82

83 Management of Lower Urinary Tract Symptoms and Functional Constipation Medical history and physical examination Criteria for functional constipation (Rome IV) Bowel diary for 7 days (Bristol stool score)- if + treat accordingly Urine analysis(urine culture if + treat accordingly) Ultrasound to measure: Postvoid residual if elevated treat FC first then try urotherapy and a-blockers Rectal diameter- if >30mm, treat FC Bladder wall thickness if rectal diameter >6mm(empty rectum) and >3mm (full rectum) then treat FC LUTS and FC improve -> maintenance therapy for 3-6 months Burgers RE at al, Management of functional constipation in children with lower urinary tract symptoms: report from the Standardization Committee of the International Children's Continence Society, J Urol July S L I D E 83

84 Management of Lower Urinary Tract Symptoms and Functional Constipation FC improves but persistent LUTS-> Flow/EMG = treat accordingly: urotherapy->anticholinergics or Botox or biofeedback or transcutaneous electrical neuromodulation LUTS improves but persistent FC-> ensure compliance and/or intensify toilet training and treat with PEG+/- enemas, try biofeedback or transcutaneous electrical neuromodulation no improvement FC calls for thorough work up by Peds GI: colonic transit measurement, spinal MRI, defecography, anorectal/colonmanometry Burgers RE at al, Management of functional constipation in children with lower urinary tract symptoms: report from the Standardization Committee of the International Children's Continence Society, J Urol July S L I D E 84

85 Treatment of Bladder Bowel Dysfunction Education and demystification Explain bowel function and the physiology of the anorectum Remove blame, as many children are often teased before medical attention is sought Describe the coexistence of bowel and bladder problems in children Explore whether stress is present (home, school, society) and address Eliminate negative attitude regarding stools S L I D E 85

86 Treatment of Bladder Bowel Dysfunction Toilet Training and Behavioral Therapy Use the toilet regularly usually after each major meal (30 to 40 min) The proper seating method (upright posture) to bring the anorectum to the correct angle to facilitate the passage of stools Proper positioning of legs and relaxing them with the pelvic floor This process needs to be a regular practice and could be encouraged with a reward system S L I D E 86

87 Treatment of Functional Constipation High Fiber Diet: Although widely believed, a high-fiber diet does not relieve constipation Several trials including different types of fibers did not show any clinically meaningful therapeutic benefit in children (Kokke FT, 2008, Castillejo G, 2006) Current evidence does not support the use of fiber supplements in the treatment of functional constipation Tabbers MM, Boluyt N, Berger MY, et al. Nonpharmacologic treatments for childhood constipation: systematic review. Pediatrics 2011; 128: S L I D E 87

88 Treatment of Functional Constipation Probiotics: 5 RCTs with a total of 377 subjects (194 in the experimental group and 183 in the control group) Children (2 RCTs, n = 111, aged 2-16) with constipation: L. casei rhamnosus Lcr35, but not L. rhamnosus GG, showed a beneficial effect No sufficient scientific evidence to support a general recommendation about the use of probiotics in the treatment of FC Use of probiotics for this condition should be considered investigational Chmielewska A and Szajewska H: Systematic review of randomized controlled trials: probiotics for functional constipation. World J Gastroenterol 2010 S L I D E 88

89 Treatment of Functional Constipation Disimpaction: % of children with constipation have a large rock-hard fecal mass in the rectum (Wessel S, 2013) After evacuation of the fecal mass children are more likely to respond to maintenance therapy Oral polyethylene glycol (PEG) is both successful and cost-effective in the majority of children with fecal impaction S L I D E 89

90 Treatment of Functional Constipation Osmotic Lactulose 1-3ml/kg 1-2times per day Magnesium hydroxide 1-3ml/kg of 400 mg/5ml PEG gm/day Lubricant Mineral oil <1year- not recommended Flatulence, abdominal discomfort Hypermagnes emia Loose stool, bad taste, abdominal distension, nausea Bad taste, anal leakage Adapted from Mugie et al, 2011 S L I D E 90

91 Treatment of Functional Constipation Stimulants Bisacodyl oral 5mg every other day 10mg daily Abdominal cramps, pain, diarrhea Bisacodyl rectal 5mg every other daydaily suppositories Abdominal cramps anal irritation Senna 2-6 yo: ml/day 6-12yo: 5-15ml/day Abdominal pain, melanosis coli Adapted from Mugie et al, 2011 S L I D E 91

92 Treatment of Bladder Bowel Dysfunction Continue bowel regimen for 4 to 6 weeks, adjust doses to maintenance dosing It is imperative to keep the patient on the bowel regimen throughout the treatment course Anticholinergics will tend to constipate the children if started as first-line therapy KUB will convince parents about constipation as many argue that child is not constipated S L I D E 92

93 Treatment of Functional Constipation After successful treatment of constipation: Decrease in the occurrence of UTIs Decrease in urinary incontinence episodes Resolved intermittent/staccato flow patterns Improvement of detrusor overactivity S L I D E 93

94 Treatment of Bladder Bowel Dysfunction Standard Urotherapy: Timed voiding regimen void every 2 hours during the day Positive reinforcement Voiding dairy Use vibratory watch is a good option Voiding position Drinking habits, quality of beverages S L I D E 94

95 Treatment of Bladder Bowel Dysfunction Internal and external sphincter dyssynergia treatment with α-blockers as well as biofeedback each session lasts approximately 45 minutes, with a trained nurse performing the biofeedback therapy S L I D E 95

96 Treatment of Bladder Bowel Dysfunction Biofeedback therapy Indicated for children who failed the initial treatment with management of their constipation and showed signs of external sphincter dyssynergia (ESD) Initial biofeedback therapy: simple relaxation and contraction exercises while the oscilloscopic activity of the perineum is monitored Computerized system with a game-like interactive setting: child attempts to move an icon of their choice (ie, dolphin, car, or bird) within the predetermined ranges S L I D E 96

97 Treatment of Bladder Bowel Dysfunction: Medications α-blockers Bladder neck dysfunction and urinary retention as well as ameliorating the symptoms of urgency and urge incontinence Terazosin is the 1st line drug for urgency and frequency because of its nonselective properties Nonselective α-blockers postural hypotension, need to gradually titrate the dose Selective α-blockers (tamusolin and alfuzosin) are better suited for management of bladder neck dysfunction S L I D E 97

98 Treatment of Bladder Bowel Dysfunction Parasacral Stimulation with Transcutaneous Electrical Nerve Stimulation (TENS) Study by Hoebeke(2001) home parasacral TENS in 15 girls and 26 boys with refractory OAB Current frequency 2 Hz Parents performed the stimulation for 2 hours every day, for a period of 6 months After 1 year, the rate of complete resolution of daytime incontinence was 51.2% P. Hoebeke et al, Transcutaneous neuromodulation for the urge syndrome in children: a pilot study, J Urol, 166 (2001) S L I D E 98

99 Treatment of Bladder Bowel Dysfunction: Medications Anticholinergics 5 antimuscarinics are approved in the United States for the treatment of OAB: darifenacin, oxybutynin, solifenacin, tolterodine, and trospium Propiverine is available in Europe Studies of these agents have shown similar efficacy (70% 75%) for decreasing urge incontinence episodes Oxybutinin is FDA approved for use in children Oxybutynin: children >5 years and adolescents: Initial: 5 mg twice daily, increase as necessary up to 5 mg 3 times daily Tolterodine: experimental in children S L I D E 99

100 What we learned Bladder Bowel Dysfunction is highly prevalent and costly medical condition that requires multidisciplinary approach Childhood Bladder Bowel Dysfunction carries risk of adulthood urinary incontinence, UTI s, depression and anxiety Targeted and sensitive history is key to the diagnosis Treatment is highly successful with minimally invasive approach S L I D E 100

101 THANK YOU: Israel Franco MD, Pediatric Urology Oz Harmanli MD, Urogynecology Kaitlyn Murphy, NPRN Pediatric Urology Amy Chmiel S L I D E 101

102 THANK YOU! S L I D E 102

103 References Chase JW, Homsy Y, Siggaard C, Sit F, Bower WF, Functional constipation in children, J Urol Jun;171: Dhroove G, Chogle A, Saps M. A million-dollar work-up for abdominal pain: is it worth it? Gastroenterology 2010;51: Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, Rittig S, Walle JV, von Gontard A, Wright A, Yang SS, Nevéus T The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children's Continence Society, Neurourol Urodyn, 2016 Apr;35(4): Burgers R, Liem O, Canon S, Mousa H, Benninga MA, Di Lorenzo C, Koff SA, Effect of rectal distention on lower urinary tract function in children, J Urol Oct;184(4 Suppl): Mugie SM, Benninga MA and Di Lorenzo C: Epidemiology of constipation in children and adults: a systematic review. Best Pract Res Clin Gastroenterol 2011; 25: 3 S.M. Mugie, C. Di Lorenzo, M.A. Benninga, Constipation in childhood, Nat Rev Gastroenterol Hepatol, 8 (2011), p. 502 S L I D E 103

104 References Vriesman MH, Velasco-Benitez CA, Ramirez CR, Benninga MA, Di Lorenzo C, Saps M, Assessing Children's Report of Stool Consistency: Agreement Between the Pediatric Rome III Questionnaire and the Bristol Stool Scale, J Pediatr Nov;190:69-73 Liem O, Harman J, Benninga M, Kelleher K, Mousa H, Di Lorenzo C Health utilization and cost impact of childhood constipation in the United States, J Pediatr Feb;154(2): Robin SG, Keller C, Zwiener R, Hyman PE, Nurko S, Saps M, Di Lorenzo C, Shulman RJ, Hyams JS, Palsson O, van Tilburg MAL, Prevalence of Pediatric Functional Gastrointestinal Disorders Utilizing the Rome IV Criteria, J Pediatr Feb 2. [Epub ahead of print] S L I D E 104

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106 References Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, Rittig S, Walle JV, von Gontard A, Wright A, Yang SS, Nevéus T, The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children's Continence Society, Neurourol Urodyn Apr;35(4): Borowitz SM, Cox DJ, Tam A, et al: Precipitants of constipation during early childhood. J Am Board Fam Pract 2003; 16: pp Wyllie, Robert, Hyams, Jeffrey S, Kay, Marsha, Pediatric gastrointestinal and liver disease, 2015 Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition, North American Society for Pediatric Gastroenterology, Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN, J Pediatr Gastroenterol Nutr Feb;58(2): S L I D E 106

107 References Minassian VA, Langroudi MH, Parekh M, Poplawsky D, Lester Kirchner H, Sartorius J, Dysfunctional voiding is differentially associated with urinary incontinence subtypes in women, World J Urol Feb;30(1):111-5 Franco I, Functional bladder problems in children: pathophysiology, diagnosis, and treatment, Pediatr Clin North Am Aug;59(4): Kern MK, Shaker R, Cerebral cortical registration of subliminal visceral stimulation, Gastroenterology Feb;122(2):290-8 Loening-Baucke V, Prevalence rates for constipation and faecal and urinary incontinence, Arch Dis Child Jun;92(6):486-9 Tarcan T, Tinay I, Temiz Y, Alpay H, Ozek M, Simsek F, The value of sacral skin lesions in predicting occult spinal dysraphism in children with voiding dysfunction and normal neurological examination, J Pediatr Urol Feb;8(1):55-8 Wessel S, Benninga MA. Diagnostic testing of defecation disorders. Nunez R, Fabbro A, Chronic constipation in children: diagnosis and treatment. New York: Nova Science Publishers Inc.; pp S L I D E 107

108 References Kokke FT, Scholtens PA, Alles MS, Decates TS, Fiselier TJ, Tolboom JJ, et al. A dietary fiber mixture versus lactulose in the treatment of childhood constipation: a double-blind randomized controlled trial. J Pediatr Gastroenterol Nutr. 2008;47(5):592 7 Castillejo G, Bullo M, Anguera A, Escribano J, Salas-Salvado J, A controlled, randomized, double-blind trial to evaluate the effect of a supplement of cocoa husk that is rich in dietary fiber on colonic transit in constipated pediatric patients. Pediatrics, 2006;118(3):e641 8 Franco I. Overactive bladder in children. Part 1: pathophysiology, J Urol 2007;178:761 Kern MK, Arndorfer RC, Hyde JS, Shaker R. Cerebral cortical representation of external anal sphincter contraction: effect of effort. Am J Physiol Gastrointest Liver Physiol 2004;286:304e11 Blok BF, Groen J, Bosch R, Veltman DJ, Lammertsma AA. Different brain effects during chronic and acute sacral neuromodulation in urge incontinent patients with implanted neurostimulators. BJU Int 2006;98:1238e43 S L I D E 108

109 References I.K. Walsh, R.S. Johnston, P.F. Keane, Transcutaneous sacral neurostimulation for irritative voiding dysfunction, Eur Urol, 35 (1999), pp P. Hoebeke et al, Transcutaneous neuromodulation for the urge syndrome in children: a pilot study, J Urol, 166 (2001), pp Constipation, Withholding and Your Child : A Family Guide to Soiling and Wetting, edited by Anthony Cohn, Jessica Kingsley Publishers, 2006 S L I D E 109