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Lower Urinary Tract Dysfunction in Childhood: What’s Really Wrong with These Children?

  • Hot Topic–Pediatric Bladder Functions
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Abstract

Lower urinary tract dysfunction, in otherwise neurologically and anatomically normal children, encompasses a variety of LUT conditions that are often diagnostically challenging. Currently, the most common diagnostic approach has been the one advocated by the ICCS in which the primary focus is on symptomatology, clinical history, and various uroflow patterns, and results are judged on the basis of symptomatic improvement. For example, the “daytime conditions” of OAB and voiding postponement are a compilation of symptoms and presumptions and do not represent true, urodynamically defined conditions. Our approach differs in that while symptoms and clinical history are taken into account, we routinely incorporate uroflow with simultaneous pelvic floor EMG in their assessment and define the various LUT conditions on the basis of specific uroflow/EMG criteria. We focus on the driving forces responsible for those symptoms and have found that most children with LUT dysfunction have one of four conditions: (1) dysfunctional voiding (active pelvic floor EMG during voiding, +/−DO); (2) idiopathic detrusor overactivity disorder, similar to OAB but with DO documented by a short EMG lag time and a quiet EMG during voiding; (3) detrusor underutilization disorder, willful postponement of urination resulting in an expansive bladder capacity (>125 % EBC for age) otherwise normal voiding with a quiet EMG; and (4) primary bladder neck dysfunction, a condition diagnosed by prolonged EMG lag time in association with hesitancy, an abnormal, depressed uroflow, and a quiet EMG. Assessment of therapeutic response in these four conditions should be based not only on amelioration of symptoms but on correction of their objective abnormal pretreatment uroflow/EMG parameters. Lastly, we have found that LUTS and uroflow patterns alone often do not represent the condition they are thought to, and unless uroflowmetry is done with simultaneous pelvic floor electromyography to better identify the condition, incorrect diagnoses and suboptimal therapy are increasingly likely. We encourage adult urologists to read this article as much that is discussed as regards children can be applied to adults as well.

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Abbreviations

DO:

Detrusor overactivity

DUD:

Detrusor underutilization disorder

DV:

Dysfunctional voiding

EBC:

Estimated bladder capacity

EMG:

Electromyography

ICCS:

International Children’s Continence Society

ICS:

International Continence Society

IDOD:

Idiopathic DO disorder

LUT:

Lower urinary tract

LUTS:

LUT symptoms

OAB:

Overactive bladder

PBND:

Primary bladder neck dysfunction

PVR:

Post-void residual urine

Qave:

Average urinary flow rate

Qmax:

Maximum urinary flow rate

UDS:

Urodynamics

Uroflow:

Uroflowmetry

Uroflow/EMG:

Uroflow with simultaneous EMG

VUDS:

Videourodynamics

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Austin PF, Bauer S, Bower W, et al. The standardization of terminology of bladder function in children and adolescents: update report from the Standardization Committee of the International Children’s Continence Society. J Urol. 2014;6:1863–5. This is the latest ICCS terminology document and is a must read, perhaps simultaneously with this paper as regards our comments on LUT dysfunction, its revised definition of DV, the confusing entity of ”voiding postponement”, and its focus on symptoms rather than the cause of the symptoms.

  2. Abrams P, Cardoza L, Fall M, et al. The standardization of terminology of lower urinary tract function: report from the Standardization Sub-committee of the International Continence Society. Neurol Urodyn. 2002;21:167–8. This is the ICS’ terminology document. Note their definition of the terms “condition”, DV, and “OAB”, and the discussion of uroflow patterns as regards to our interpretation of the patterns.

  3. Glassberg KI, Combs AJ, Horowitz M. Nonneurogenic voiding disorders in children and adolescents: clinical and videourodynamic findings in 4 specific conditions. J Urol. 2010;184:2123–7. This is where we introduced our classification of LUT dysfunction based on UDS findings.

  4. Van Batavia JP, Combs AJ, et al. Simplifying the diagnosis of 4 common voiding conditions using uroflow/electromyography, electromyography lag time and voiding history. J Urol. 2011;186:1721–7. The paper described how the 4 LUT conditions could be identified noninvasively with uroflow/EMG instead of invasively with UDS.

  5. Neveus T, von Gontard A, Hoebeke P, et al. The standardization of terminology of lower urinary tract dysfunction in children and adolescents: report from the Standardization Committee of the International Children’s Continence Society. J Urol. 2006;176:314–28. The second ICCS terminology document and worth reading.

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  11. Van Batavia JP, Combs AJ, Glassberg KI. Short pelvic floor EMG lag time II: use in management and follow-up of children treated for detrusor overactivity. Pediatr Urol. 2013;10:255–61. This article looks at short EMG lag time from a reverse perspective, ie, the association of detrusor overactivity with various short lag time cut-offs.

  12. Wenske S, Combs AJ, Van Batavia JP, et al. Can staccato and interrupted /fractionated uroflow patterns alone correctly identify the underlying lower urinary tract conditions? J Urol. 2012;187:2188–94. Staccato and interrupted flow usually do not represent what the ICCS 2006 terminology paper suggests they represent. For example a staccato flow was thought to be indicative of DV but by a series of patients in whom a staccato uroflow pattern was matched against a simultaneously obtained EMG only onethird of staccato flows turned out to be DV.

  13. Wenske S, Van Batavia JP, Combs AJ, et al. Uroflow patterns in children with dysfunctional voiding. J Ped Urol. 2014;10:250–4. Even though only one-third of children with a staccato glow pattern have DV, he majority of children with DV have a staccato flow and most of the remainder have either an interrupted flow pattern or a combined staccato/interrupted flow.

  14. Combs AJ, Glassberg AD, Gerdes D, Horowitz M. Biofeedback therapy for children with dysfunctional voiding. Urol. 1998;52:312–5. Describes the technique of biofeedback that employs uroflow/EMG and its audio component.

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  17. Glassberg KI, Van Batavia JP, Combs AJ, Wenske S. Are idiopathic detrusor overactivity/OAB and dysfunctional voiding one entity? Presented at Fall Congress of Society of Pediatric Urology, Las Vegas, 2013.

  18. Van Batavia JP, Combs AJ, Fast AM, et al. Use of non-invasive uroflowmetry with simultaneous electromyography to monitor patient response to treatment for lower urinary tract conditions. J Pediatr Urol. 2014;10:532–7.

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  22. Smey F, King LR, Firlit CF. Dysfunctional voiding in children secondary to internal sphincter dyssynergia: treatment with phenoxybenzamine. Urol Clin North Am. 1980;7:337–47. The first article to describe PBND in children. They called the condition internal sphincter dyssynergia.

  23. Donohoe JM, Combs AJ, Glassberg KI. Primary bladder neck dysfunction in children and adolescents II: results of treatment with alpha adrenergic antagonists. J Urol. 2005;173:212–6. The second of our articles on PBND and reinforces the use of EMG lag time for the diagnosis and follow-up of PBND while on alpha blocker therapy.

  24. Van Batavia JP, Combs AJ, Horowitz M, et al. Primary bladder neck dysfunction in children and adolescents III: results of long term alpha blocker therapy. J Urol. 2010;183:724–30. Brings out that PBND appears to be a chronic entity. When alpha blockers are discontinued a pretreatment prolonged EMG lag time and symptoms usually return.

  25. Hoebeke P, van Laecke E, Van Camp C, et al. One thousand video-urodynamic studies in children with nonneurogenic bladder sphincter dysfunction. BJU Int. 2001;87:575–80. A wonderful review of Hoebeke’s findings in 1000 urodynamic studies on children with LUTS. It is a good companion article to read with reference 3.

  26. Koff SA, Wagner TT, Jayanthi VR. The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflus and urinary tract infections in children. J Urol. 1998;160:1019–23. Good read from a historical perspective. Note that the title says “syndromes” not a singular “dysfunctional elimination syndrome” that the ICCS suggested that Koff had reported upon. It in fact was meant to represent multiple conditions just as implied by “bladder and bowel dysfunction”.

  27. Peters CA, Skoog SJ, Arant Jr BS, et al. Summary of the AUA guideline of management of primary vesicoureteral reflux in children. J Urol. 2010;184:1134–7. A wonderful review regarding current thinking of vesicoureteral reflux.

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Conflict of Interest

Kenneth I Glassberg and Andrew J. Combs declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Authors and Affiliations

  1. Department of Urology Columbia University Medical Center, New York, NY, USA

    Kenneth I. Glassberg

  2. Department of Urology, Division of Pediatric Urology Weill Cornell Medical Center, New York-Presbyterian Hospital, New York, NY, USA

    Andrew J. Combs

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  1. Kenneth I. Glassberg
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  2. Andrew J. Combs
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Correspondence to Kenneth I. Glassberg.

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Glassberg, K.I., Combs, A.J. Lower Urinary Tract Dysfunction in Childhood: What’s Really Wrong with These Children?. Curr Bladder Dysfunct Rep 9, 389–400 (2014). https://doi.org/10.1007/s11884-014-0270-7

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  • DOI: https://doi.org/10.1007/s11884-014-0270-7

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