Dr. YK Amdekar writes on voiding dysfunction in children and how it can encompass multiple disorders for several reasons. In this article, he pens down the symptoms, causes, investigations, and management to overcome this urological issue.

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Introduction

Voluntary control on passing urine develops over the first few years with the child remaining dry initially during the day and thereafter also by night. Depending on toilet training, most children achieve control during the day by 3-4 years and night by 5-6 years. Though few children continue to wet the bed at night for a longer duration.

The ideal time for toilet training in children should start only after the child demonstrates the urge to pass urine by gestures or manoeuvres and should proceed slowly as per the child’s response. Urination appears to be a natural and simple process but a complex mechanism is involved for the bladder to do what the brain orders. However, the problems may arise at any age.

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Back to basics

Once the bladder starts filling to its normal capacity, it sends a message to the brain requesting an order to release. If the facility does not exist, the brain orders to wait for some more time and orders release as soon as possible. But there is a limit to which the bladder can distend and hold on. If the order to release does not come in time, the bladder decides to release urine by itself without the brain order, even without proper facility and incontinence results.

In normal health, such a neurological network works well and maintains a dry state. This network includes the sympathetic and parasympathetic nerves, their connections in the spinal cord, centre of micturition in the pons that relays information to the brain cortex to get the final order and pass it on to the spinal centres. Several muscles are involved such as bladder detrusor, external sphincter muscle and pelvic floor muscles. When the detrusor contracts, the sphincter must open and pelvic floor muscles must relax to allow urine exit. Any abnormality in this circuit results in voiding disturbances.

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Symptoms

Voiding problems manifest in various ways such as:

• Frequency (passing urine number of times more than usual), urgency (strong urge to pass urine)
• Hesitancy (difficulty in initiating an act of urination)
• Straining
• Slow, weak or interrupted stream of urine
• Retention (not emptying completely)
• Overflow incontinence, dribbling and bedwetting (enuresis beyond the expected age of control)

Such symptoms may be transient as in the case of UTI or may also be intermittent or persistent. If left untreated, may cause renal damage.

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Causes

Broadly, causes can be divided into neurogenic and non-neurogenic.

1. Neurogenic problems arise from the cerebral cortex, pons, spinal cord or nerves due to various causes that result in detrusor-sphincter dyssynergia (incoordination between detrusor and sphincter – when detrusor contracts, sphincter also contracts to result in functional obstruction to the passage of urine).
2. Non-neurogenic problems present as overactive, underactive or dysfunctional bladder and may arise from weak pelvic muscles, use of alcohol, caffeine or drugs like antihistamines or atropine, urinary tract infection, overweight and lifestyle issues.

Anatomical obstructive malformation in the lower urinary tract and constipation are other important causes of voiding problems and recurrent UTI.

Chronic constipation results in distention of the rectosigmoid that presses on the urethra and also may be due to the common sharing of neural pathways.

Young children tend to hold urine for long by ignoring the urge to pass urine being busy with playing or at times avoiding unclean washrooms in schools. It may lead to daytime wetting. Giggle incontinence results while laughing in children who are susceptible to detrusor instability and generally it disappears as the child grows. Urethral irritation due to local fungal infection may cause frequent urination and at times urgency or incontinence.

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Clinical approach

A detailed history of voiding helps to define the type of problem. Urgency is the hallmark of an overactive bladder, where the child often has daytime urinary incontinence and tries to hold urine by standing on tiptoes, crossing of legs or squatting with heels pressed into the perineum. Infrequent urination is the hallmark of underactive bladder and such children strain while voiding. History of constipation is often overlooked as a contributory factor to voiding problems.

Neurological examination may pick up lower motor neurone lesion in lower limbs with distended bladder with overflow incontinence or continuous dribbling without bladder distention. Examination of the lower spine may reveal subtle signs such as a tuft of hair indicating lower spinal cord defect. Upper motor neurone diseases may also result in voiding problems but the major presentation is other than just voiding issues such as a change in sensorium or seizures. It is important to observe the flow of urine and the patient’s manoeuvres while passing urine that gives clues to the type of voiding problems.

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Investigations

1. Routine urinalysis may reveal evidence of UTI that should further be confirmed with a urine culture.
2. Imaging studies include USG to assess post-void residual urine volume and rarely CT scan or micturating cystourethrogram.
3. EMG of pelvic muscles may help to define the status of these muscles.
4. Urodynamic studies are required in selected cases of suspected detrusor-sphincter dyssynergia.
5. In the case of neurological disorders, relevant investigations are necessary.

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Management

• Non-neurological voiding problems are treated with behaviour modification, bladder retraining, biofeedback and Kegel exercises to strengthen pelvic floor muscles
• Drugs are rarely necessary but may be required in selected cases such as prophylactic antibiotics for patients with high infection risk or anticholinergics for temporary use
• Neurological causes need relevant surgical correction or medical palliative management such as repeated bladder catheterisation to avoid residual urine retention

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Conclusion

In summary, voiding problems are often not reported in time by patients, especially in the case of non-neurological issues. These problems need timely intervention to prevent permanent renal damage besides disrupting normal life. Toilet training is important in early childhood and delayed or too early enthusiastic attempts may both lead to problems.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.