Dysfunctional voiding The importance of assessment, diagnosis and treatment of dysfunctional voiding and its role in recurrent UTI Dr Dean Wallace Consultant Paediatric Nephrologist RMCH
Objectives Development of normal voiding Derailing normal voiding and continence development Think about risk factors associated with recurrent UTIs Understand the methods of clinical assessment and merits of various investigations incl. Uroflowometry and Video- Urodynamics Be aware of the treatment methods available Understand the gains in VUR/Rec UTI to be made by addressing DV
Normal Voiding 1 STORAGE Phase: T10-L2 hypogastric nerve plexus (sympathetic +) relaxation of detrusor and (-) of sphincteric complex bladder wall compliance allows storage at low pressures VOIDING Phase: Parasympathetic (+) sacral micturition centre (S2-4) (+) detrusor contraction (-) internal sphincteric relaxation PLUS somatic input from pudendal nerve (-) external sphincter
Normal Voiding 2 Bladder unusual autonomic viscera with voluntary somatic interface control (rectum is similar) IMMATURE VOIDING: frequent small volumes 1-2hrly interrupted dysco-ordinated voiding with PVR MATURE VOIDING: by toilet training, complete emptying, mastering of voluntary aspect 5 years should be continent day/night with EBC (Age+1) 30 Frequency 4-7 times daily
Dysfunctional voiding ICCS definition Child habitually contracts the urethral sphincter or pelvic floor during voiding and demonstrates a staccato pattern on repeated uroflowometry when EMG activity is concomitantly recorded. This is a term associated with a neurologically intact patient.
Lower Urinary Tract dysfunction and VUR 506 children with VUR prospectively followed 4 features emerged predictive of VUR resolution Non-white race Mild grade of VUR Absence of renal damage Absence of Dysfunctional voiding AAP recommends children > 1with VUR having assessment to identify and treat BBD incl DV as part of VUR therapy VUR with associated LUTD has been shown to resolve with Rx LUTD in 45% cases Patients with DV had greatest improvement in VUR grade/sx
What causes it? Congenital Pons micturition centre damage? Down syndrome and Ochoa syndrome little known Persistence of immature voiding style? Nappy use, delayed toilet training > 24 months (Avon, Swedish and Vietnamese studies) Acquired behaviours: difficult toilet training, painful voiding, constipation, UTI, bladder irritation, vulvitis, balanitis, fear unclean toilets, sound-proof area, CNS delay, CSA, OAB can evolve High association with constipation (63% DVs fulfil criteria) High association with VUR and its persistence
How do you diagnose it? Rec UTI (persistence of dip stick NIT/LEUC positivity large PVR) DUI and NE Urethral-suprapubic pain Urinary hesitancy, interrupted stream, abdominal massage Sensation of incomplete voiding/strangury Urinary odour Constipation history Extreme end, severe bilateral VUR, ESRF, trabeculated, thick bladder Secondary storage symptoms Urgency, frequency, incontinence, holding manoeuvres, Often had +++++course oral antibiotics and unconvincing MC+S
Examination May be normal exclude lumbosacral lesions Palpable bladder? Faecal loading Evidence of chronic vulvo-vaginitis/balanitis Observed interrupted-staccato flow Observed abnormal straining to void Stigmata CKD proteinuria - hypertension
Radiology - USS Bladder wall thickening> 3mm Pre-post void volumes and PVR Ureteric dilatation Upper tract dilatation
Uroflowometry Time: Flow study 2-3 relaxed voids >50 < 115% bladder capacity voided Immediate post void residuals Tells us nothing about intravesical/detrusor pressures
Classical patterns A Bell-shaped Curve B Tower shaped curve (OAB) C Staccato curve (DV, constipation, technical) D Interrupted (underactive detrusor and straining) E Plateau (functional/anatomical obsruction PUV, stricture, underactive detrusor)
Shei Dei Yang, S; Tzu-Shi, E; Chang SJ. Tzu-Chi nomograms for uroflowometry, PVR urine and lower urinary tract function. Tzu chi medical journal 26 (2014) 10-14.
Pelvic EMG
So, who needs video-urodynamics? Diagnostic uncertainty Refractory symptoms despite treatment Evidence of scarring, renal impairment and upper tract dilatation Concerns about compliance and intravesical pressures Transplant planning in bladder disease VUR and DV (highest risk of decompensation) VUD can inform further therapies BOTOX, ALPHA BLOCKADE and CIC
CIC Urodynamic investigation and assessment of kidney status Botox bladder neck Alpha - blockade Uroflow - Biofeedback (+/- anticholinergic) TENS CIC Urotherapy and timed double- Voiding Positioning Constipation management Management of UTI
80% sustained effect at 4 years
Take home points Dysfunctional voiding an important cause of recurrent UTI Diagnosed obstructed voiding - uroflow with EMG activity Biofeedback and urotherapy are the mainstay treatments Treat any constipation aggressively and first Get assessment of voiding in patients with recurrent UTI and symptoms of LUTD These are the patients who benefit most from urinary prophylaxis (up to 80% UTI reduction RIVUR study)