Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma.
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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
J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.
Functional Constipation
• Symptoms– Infrequent passage of stool
– Hard stool
– Palpable stool in abdomen or in rectal vault
– Fecal soiling
J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.
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
J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.
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
Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470-1475.
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
Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470-1475.
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
0
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PVR Bio(ml)
PVR AB(ml)
Flow Bio(ml/s)
Flow AB(ml/s)
0 months
3 months
6 months
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.
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
50
100
150
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350
400
PVR (ml)
DLPP (cm H2O)
Q max (ml/sec)
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.
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
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