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排尿障礙治療中心 版權所有
Dysfunctional Voiding in Children
Hann-Chorng Kuo
Department of Urology
Buddhist Tzu Chi General Hospital
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Development of
Urethral Sphincter
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Specific striated sphincter muscle closely
applied to the smooth muscle at membranous
urethra and mid-urethra
A ring shape sphincter in early adolescence,
which account for initial high voiding pressure
in infancy and early vesicoureteral reflux
An omega shape shincter in adolescence after
development of urogenital septum
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Congenital Abnormalities
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Myelodysplasia
Lipomeningocele
Sacral agenesis
Tethered cord
Cerebral palsy
Bladder extrophy
Posterior urethral valve
Anorectal malformations
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Myelomeningocele
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The most common form of NVD in children
Early detection and folic acid treatment
markedly decrease spinal defects
Upper and lower motor bladder dysfunction
and pelvic floor dysfunction may occur in
thoracic or sacral lesions
Early prophylactic treatment of DESD by CIC,
anticholinergics are beneficial
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Myelomeningocele, detrusor areflexia
and incontinence
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Meningomyelocele & Bilateral VUR &
Recurrent UTI
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Lipomeningocele
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Difficult to identify by physical examination,
MRI is the best diagnostic method
Intradural lipoma results in disease and
presentation
The most common urodynamic findings are
consistent with an upper motor neuron lesion
DESD is less common
Detrusor hyperreflexia and areflexia can be
found in this group of lesion
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Sacral agenesis
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Often discovered at older children with
incontinence
Loss of the lower vetebral bodies by Xray or MRI
Patients have stable neurological lesion
Patients may have no signs of
denervation, hyperreflexia, areflexia,
intact sphincter, sphincter dyssynergia
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Tethered cord syndrome
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Most commonly seen in patients after
surgery for myelomeningocele
Isolated tethered cord is less common
Severe bladder dysfunction and
refractory incontinence may occur
Surgical division of the filum may
improve symptoms
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Cerebral Palsy
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Develops most commonly in premature infant
Infection and anoxia result in a nonprogressive brain lesion and muscular
disability
Continence is often delayed to develop but
intact
Uninhibited detrusor contractions without
DESD is the most commonly urodynamic
finding
Pseudodyssynergia may occur
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Cerebral palsy with frequency
dysuria due to DI
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Bladder extrophy
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Characterized by extrophic bladder,
abdominal wall defect, epispadias, pelvic
diastasis, VU reflux, inguinal hernia
Staged reconstruction by abdominal wall
closure, epispadias repair, bladder neck
reconstruction and correction of VUR
Improved pelvic floor reconstruction after
osteotomy has better continence rate
Bladder augmentation may be indicated
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Posterior Urethral Valve
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The most common cause of BOO in newborn
Present with incontinence and recurrent UTI
Severe PUV may be detected antenatally, mild
form is found in older children
Bilateral hydroureter and hydronephrosis may
develop in severe form of valve disease
Transurethral ablation of valve resumes
normal bladder but bladder function depends
Anticholinergics, CIC and augmentation by
ureter may be indicated
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Anorectal Malformations
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Rare congenital lesions of cloaca
Associated with congenital GU abnormalities
in 20% with low and 60% high lesions,VUR,
NVD, renal agenesis, renal dysplasia,
cryptorchidism
Urethrorectal fistula may develop at at high,
intermediate or low level
Neurogenic voiding dysfunction in 50%
Tethered cord is the main vertebral
abnormality, which account for NVD
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Dysfunctional Voiding
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A group of neurologically intact children
presents with incontinence, dysuria, large
residual urine, recurrent UTI, unilateral or
bilateral hydronephrosis
Urodynamically classified into small capacity
hypertonic bladder, detrusor hyperreflexia,
lazy bladder syndrome,non-neurogenic
neurogenic bladder
Treatment bases on interaction of bladder
and external sphincter
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Patient evaluation – history
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Antenatal GU abnormalities – hydronephrosis,
enlarged bladder, open spinal cord defect
Past surgical history – detethering procedure,
VP shunt, urinary diversion
Occurrence of UTI and antibiotics
Bowel habit, fecal incontinence, and stool
softeners
Catheterization schedule, urine amount
Medication and adverse effects
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Physical examination
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Neurological examination – gait,
discrimination of extremities, motor
strength, DTR (S1,2), BCR (S2-4)
Sacral dimple, hair patch, lipoma
Enlarged bladder
Vincent curtsey
Anal tone, volitional contraction of
pelvic floor muscles
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Urodynamic study
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Estimated bladder capacity: (age+2)x30 ml
Infusion rate: 10% of capacity
Catheter: <6Fr intraurethral dual channel
catheter, suprapubic catheter is preferable for
pressure flow study
Abdominal pressure by rectal catheter
Pelvic floor EMG – surface or needle
Measuring bladder compliance, detrusor
pressure, and EMG activities coordination
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Detrusor external sphincter
dyssynergia (DESD)
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Type 1: Onset of EMG activity with initiation of
voiding
Type 2: intermittent inappropriate external
sphincter contraction during voiding,which
causes a reflex inhibition of detrusor
contraction
Type 3: Persistent increased EMG activity
during filling and voiding phases, which causes
large residual urine and incontinence
Pseudodyssynergia: presence of urodynamic
DESD in neurologically intact patient
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Leak-point pressures
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Detrusor leak-point pressure (DLPP): The
detrusor pressure causing urinary leakage per
urethrum in the absence of detrusor
contractions
A DLPP of more than 40 cm water has a risk
of upper tract deterioration
Valsalvar LPP (VLPP): Assessing urethral
resistance by abdominal straining, a VLPP
<60 cm water indicates intrinsic sphincter
deficiency
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Indications for urodynamic
study in children
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Spinal dysraphisms
Spinal cord injury
Cerebral palsy with voiding dysfunction
Sacral agenesis
Imperforated anus
Diurnal enuresis
Suspicious voiding dysfunction and UTI
Dysfunctional voiding
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Urodynamic studies in children
with dysfunctional voiding
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Uroflowmetry with surface EMG
Cystometry with abdominal pressure
and EMG
Pressure flow study recording
Pves,Pabd, Pdet, EMG activity, and
uroflowmetry
Videourodynamic study by suprapubic
catheter or intra-urethral catheter
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Uroflowmetry – flat flow
pattern with non-relaxing ES
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Uroflowmetry – Staccato
pattern and poor relaxing ES
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Videourodynamics via
cystostomy pressure flow study
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Dysfunctional Voiding
Associated with the followings
 Diurnal enuresis
 Urinary urgency
 Urinary frequency
 Constipation
 Urinary tract infection
 Vesicoureteral reflux
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Pathogenesis of
dysfunctional voiding
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Increased voiding pressure during voiding
with contraction of the urethral sphincter
Dysfunctional bowel evacuation and
constipation
Treatment directed at urodynamic
abnormalities reduce the incidence of
breakthrough UTI and increase resolution of
vesicoureteral reflux
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Typical spinning top
voiding cystourethrography
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Development of
dysfunctional voiding
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Long-standing pelvic floor dysfunction
results in paradoxical sphincter
contraction
Pelvic laxity
Inappropriate stimulation of guarding
reflex results in inhibition of detrusor
contraction
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Detrusor instability without
dyssynergic external sphincter
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Dysfunctional voiding and
Urinary tract infection
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Elevated postvoid residual urine
Host resistance – ability of bladder to
wash out pathogens
Well hydration, void with strong stream,
and complete voiding are important in
prevention of UTI
Treatment aims at relaxation of the
pelvic floor rather than the bladder
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Recurrent UTI in siblings with
Dysfunctional voiding
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Non-neurogenic neurogenic
bladder– Hinman syndrome
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The severest form of dysfunctional
voiding
Symptom complex including nocturnal
enuresis, diurnal enuresis, constipation,
encopresis, UTI, and upper tract
dilatation
Uninhibited detrusor contractions and
dyssynergic external sphincter
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Treatment of non-neurogenic
neurogenic bladder
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Voiding retraining
Biofeedback
Anticholinergic therapy
Hypnosis
Psychotherapy
Management of constipation
Antibiotics
Clean intermittent catheterization
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Dysfunctional voiding and
Vesicoureteral reflux
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Play a major role in etiology of
congenital VUR
Important in development of VUR in
older child without congenital VUR
Responsible for reflux exacerbation and
renal scarring
Therapy to VUR should aim at
correction of dysfunctional voiding
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Bilateral VUR in a girl with
Dysfunctional voiding
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Right VUR and DI without
dysfunctional voiding
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Resolution of VUR after
Anticholinergic therapy
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Urodynamic studies in infants
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High voiding pressures (160cm water)
with low bladder capacity in infant with
gross dilating reflux
Voiding pressure in infant without reflux
is 80 cm water
By age 2 years, voiding pressure
diminished (70 cm water) and capacity
increased, but unstable detrusor remain
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High voiding pressures in
infancy
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Transient functional bladder outlet obstruction
Boys with high grade reflux have dilated
posterior urethra
Higher voiding pressure is seen in children
with grades IV and V reflux
Normalization of voiding pressures explains
high rate of reflux resolution in childhood
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Urodynamic studies in
older children
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Up to 60% of children with reflux have
urodynamic abnormality
Detrusor overactivity and sphincter
dyscoordination
Primary sphincter overactivity is more
associated with high grade reflux and
renal scarring
Bladder instability improves over time
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Pitfalls in urodynamic study in
infants and children
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Poor cooperation of patient
Appropriate size of intra-urethral
catheter – 3 Fr, 5 Fr, 7 Fr?
Frequent increased abdominal pressure
Different infusion rate and compliance
in different age
Differential diagnosis of volitional
voiding and detrusor overactivity
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Urodynamics and Clinical
course of VUR
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Treatment of detrusor overactivity with
anticholinergics improves resolution or
improvement in VUR than stable bladders
A higher surgery rate in stable bladder with
VUR
Controversy remains in correlation of
urodynamic abnormalities with grades of VUR
and anticholinergic treatment with resolution
rate of VUR
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Resolution of VUR and improved DI after
anticholinergic and CIC in myelomeningocele
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Dysfunctional elimination
syndromes (DES)
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Children are both infrequent voiders and
constipated
Associated with an increased risk of urinary
tract infection
With or without reflux
Incontinent day and night with fecal soiling
Observed to engage in holding maneuver to
avoid urination and defecation
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DES – A learned habit
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A learned habit acquired during toilet
training
Most often occur in girls
Recurrent cystitis due to short urethra
and bladder colonization
Congenital VUR or secondary VUR due
to these aberrant toilet training habits
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Breakthrough UTI and
Dysfunctional voiding
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Girls with history of voiding dysfunction
have higher rates of breakthrough UTI
(4 times more common in DES)
Unsuccessful surgical outcome was
seen in children with DES
Adequate hydration, timed voiding,
stool softeners, laxatives, as well as
anticholinergics may be helpful
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Voiding dysfunction without
UTI
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Children with mono-symptomatic enuresis
have a very low urodynamic abnormality
VUR has been found in child with frequency
urgency and urinary incontinence without
history of UTI
15% of children had positive urodynamic
findings and 16% had renal scarring
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Diurnal incontinence due to
pelvic floor hypertonicity & DI
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Urge incontinence in a girl with
dysfunctional voiding & DI
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Treatment of Dysfunctional
voiding in Children
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Adequate hydration and timed voiding
Stool softeners and laxatives
Anticholinergics – Ditropan, tolterodine
Biofeedback – pelvic floor relaxation,
computerized game
Intermittent catheterization
Antibiotics for recurrent UTI
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Improved bladder compliance and DI after
ditropan therapy in myelomeningocele
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Adequate hydration
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Provide adequate urine production and
wash out effect of bladder
Prevent constipation and reduce
colonization of pathogen in perineum
Reduce detrusor instability through
dilution of urine and decrease urine
permeability into urothelium
Time voiding is required
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Medication for
dysfunctional voiding
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Oxybutynin – effective in reducing detrusor
overactivity, side effects of mucosal dryness &
constipation
Ditropan XL – elimination of peak drug effect
and reduce adverse effects
Tolterodine – M3 anticholinergic
Alpha-adrenergic blocker to reduce urethral
resistance
Phenylpropanolamine, pseudoephedrine – in
ISD with incontinence ready for CIC
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Pelvic floor rehabilitation
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Identification of pelvic floor muscles
Regular pelvic floor muscle exercises
provide adequate relaxation of pelvic
floor including urethral sphincter
A synergistic voiding pattern can be
achieved after rehabilitation
Combined with fluid and anticholinergic
therapy
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Biofeedback for
pelvic floor muscle relaxation
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Correcting paradoxical contractions of pelvic
floor and urinary sphincter muscles with
voiding
Success relies on motivation of children
Uroflow- surface EMG integrated biofeedback
Cystometry biofeedback to inhibit detrusor
overactivity in patients with DI
Visual or audio biofeedback may be more
successful than verbal biofeedback
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Biofeedback
Pelvic floor muscle retraining
排尿障礙治療中心 版權所有
Electrical stimulation to inhibit
detrusor overactivity
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CMG biofeedback to inhibit
Detrusor overactivty
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Urethral injection of Botulinum
A toxin in dysfunctional voiding
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New technique in reducing urethral
resistance by paralyzing striated
urethral sphincter
Intra-detrusor injection to reduce
detrusor overactivity and increase
bladder capacity
Restoration of normal voiding pattern
Repeat injection may be necessary
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Botulinum A toxin (Botox)
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Reduction of MUCP after
Botulinum A toxin injection
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Reduction of voiding pressure
after Botulinum A toxin