Risk Factors for Daytime or Combined Incontinence in Children with Cerebral Palsy.

PURPOSE: We identify risk factors for daytime or combined urinary incontinence in children with cerebral palsy. MATERIALS AND METHODS: A cross-sectional case-control study was conducted including children with cerebral palsy with or without daytime or combined urinary incontinence from the CP-Reference Center at Ghent University Hospital and 2 associated special education schools. Factors were subdivided in 3 clusters of demographic and general medical data, cerebral palsy classification, and bladder and bowel dysfunction. Data were obtained using uroflowmetry with electromyography testing, a nonvalidated questionnaire and bladder diaries. Univariate and multivariate analyses were performed for variables and clusters, respectively. A final associative logistic model including all clusters was developed. RESULTS: The study included 34 incontinent children and 45 continent children. Daytime or combined urinary incontinence was associated with intellectual disability (OR 7.69), swallowing problems (OR 15.11), use of external aids (OR 27.50) and use of laxatives (OR 13.31). Daytime or combined urinary incontinence was positively associated with dyskinesia (OR 5.67) or combined spasticity and dystonia (OR 4.78), bilateral involvement (OR 4.25), Gross Motor Function Classification System level IV (OR 10.63) and V (OR 34.00), and severe impairment in manual (OR 24.27) or communication skills (OR 14.38). Lower maximum voided volume (OR 0.97) and oral fluid intake (OR 0.96) influenced daytime or combined urinary incontinence negatively. Pathological uroflow curves were not significantly associated with incontinence. The final model defined functional impairment, intellectual disability and oral fluid intake as predictive factors for daytime or combined urinary incontinence. CONCLUSIONS: Risk analysis revealed functional impairment, intellectual disability and fluid intake as important factors influencing continence in a child with cerebral palsy.

Nigerian parents can harbour harmful views about the causes and treatment of childhood enuresis that result in child abuse.

AIM: The aim of this study was to determine Nigerian parents' views about the causes and treatment of childhood enuresis. METHODS: Parents of children aged 5-17 years were individually interviewed in an urban community in Nigeria using a pretested questionnaire. Their responses about the causes and treatment of enuresis were grouped under common themes. RESULTS: We included 448 respondents in the study: 75.5% were mothers, 44.2% had at least one child with enuresis and only 1.3% had spoken to a doctor about it. Enuresis was thought to be due to playing too much and drinking too much fluid at night by 69.7% and 21.2% of the respondents, respectively. The two most common treatment methods that parents were aware of for enuresis were waking to void (23.7%) and urinating on hot charcoal (20.8%). The most common methods that parents actually employed included waking to void (49.0%), punishing the child (36.9%) and doing nothing (28.8%). CONCLUSION: Most of the respondents believed that playing too much and drinking or eating too much were responsible for childhood enuresis. Parents rarely discussed childhood enuresis with their doctors and some of the self-help measures that were employed may be harmful and could constitute child abuse.

Generalized joint hypermobility and voiding dysfunction in children: is there any relationship?

UNLABELLED: Voiding dysfunction is a common entity in pediatric urology. It is believed to have a multifactorial etiology. The aim of this study was to investigate whether there is an increased prevalence of generalized joint hypermobility (GJH) in children with voiding dysfunction compared to normal children. Moreover, the prevalence of voiding complaints in patients with and without GJH was assessed. A total of 226 children--aged 5 to 14 years--including 113 patients diagnosed with voiding dysfunction and 113 sex/age/body mass index-matched normal children were recruited. GJH was evaluated in both groups using the Beighton score (4 or more= hypermobile). In the patient's group, GJH was significantly more frequent than in controls: 51/113 (45 %) versus 19/113 (17 %) (P=0.001). In addition, in both groups, GJH was more prominent in girls than boys (P<0.05). Urinary tract infection was the most frequent features in children with voiding dysfunction (64 %). In the subgroup of positive GJH, urinary tract infection remained the most common manifestation among the girls (P=0.003), while constipation was the most prevalent manifestation among the boys (P=0.001). CONCLUSION: Our findings suggest that children with voiding dysfunction have significantly higher prevalence of GJH compared to normal children. Further studies are needed to determine the cause and effect of these two common presentations and will help to develop a multidisciplinary approach in understanding and management of voiding dysfunction in children.

Evaluation and treatment of nonmonosymptomatic enuresis.

On the basis of some research evidence and consensus, up to one-third of patients with enuresis will have daytime urinary symptoms indicative of lower urinary tract (LUT) dysfunction. (8)(9) On the basis of international consensus, children with enuresis and LUT dysfunction are correctly identified as having nonmonosymptomatic enuresis (NMSE) (formerly termed diurnal enuresis). (1)(2) On the basis of some research evidence and consensus, an adequate voiding and elimination history is the primary tool in differentiating between MSE and NMSE. (2)(7)(8). On the basis of some research evidence and consensus, therapy for NMSE is based on addressing underlying LUT dysfunction, constipation, and comorbid behavioral conditions before addressing enuresis. (2)(8)(9)(12) On the basis of some research evidence and consensus, treatment of underlying BBD and comorbid conditions will often result in improvement or resolution of enuresis. (2)(8)(9)(12). On the basis of international consensus, if enuresis is still present and a concern after treatment of underlying LUT, specific medical or behavioral therapy for enuresis should be offered to the family.(2)(8).

Applying children's enuresis treatment with amitriptyline for canine post-spaying urinary incontinence: A pilot estriol-controlled randomized clinical trial.

Urinary incontinence due to urethral sphincter mechanism incompetence (USMI) affects up to 20% of bitches that undergo spaying surgery. Amitriptyline is a tricyclic antidepressant whose urinary retention is a reported side effect. This study aimed to assess the efficacy and safety of amitriptyline when compared to estriol orally. Fifteen bitches with a clinical diagnosis of post-spaying UI were evaluated during 60 days in a non-blinded randomized clinical trial. All patients were enrolled after clinical evaluation consisting of anamnesis, physical examination, and complementary exams (complete blood count, biochemical parameters, urinalysis, and abdominal ultrasound). The amitriptyline (AMT) group consisted of 8 bitches, which received the initial dose of 1 mg/kg every 12 h, whereas the estriol (EST) group consisted of 7 bitches which were initially treated with 1 mg/animal every 24 h. Patients underwent clinical evaluation at 7 days, and then at 21 and 60 days of treatment to assess safety and efficacy, as well as adjustments of dose when necessary. A urinary incontinence scale was used to assess the level of incontinence and therapeutic response to treatment. During the period of the study, estriol was fully effective in 71% of cases and amitriptyline in 62%. Both drugs proved safe in the medical treatment of USMI, with adverse effects such as somnolence (AMT, n = 5/8) and male attraction (EST, n = 1/7). The results support the amitriptyline recommendation as a substitute for estriol in USMI treatment.

Enuresis and more.

We describe Pervasive Refusal Syndrome, an important but rare, debilitating condition that may present to paediatric services. Although previous reports have described improvement seen with care delivered in the mental health setting, we have demonstrated treatment predominately delivered in a paediatric ward environment associated with successful recovery.

Efficacy of sacral transcutaneous electrical nerve stimulation in patients with overactive bladder refractory to anticholinergic treatment: a prospective multi-center study. / Eficacia de la electroestimulación transcutánea sacra en pacientes con vejiga hiperactiva refractarios a fármacos anticolinérgicos. Estudio prospectivo y multicéntrico.

OBJECTIVE: To determine whether sacral transcutaneous electrical nerve stimulation (S-TENS) is an effective treatment in patients refractory to anticholinergic drugs (Achs). MATERIALS AND METHODS: A prospective multi-center study of patients with overactive bladder (OB) refractory to Achs treated with S-TENS from 2018 to 2021 was carried out. S-TENS was applied over 3 months. Symptom progression was assessed using the voiding calendar and the Pediatric Lower Urinary Tract Symptoms Score (PLUTSS), excluding questions 3 and 4 -referring to enuresis- so that progression of daytime symptoms only (LUTS variable) was analyzed. RESULTS: 66 patients -50% of whom were female- were included, with a mean age of 9.5 years (range: 5-15). S-TENS significantly lowered PLUTSS (19.1 baseline vs. 9.5 final, p< 0.001) and LUTS (13.1 baseline vs. 4.8 final, p< 0.001). It also reduced the number of mictions (8.5 baseline vs. 6.4 final, p< 0.001), while increasing urine volume in the voiding records (214 ml baseline vs. 258 ml final, p< 0.001). Enuresis was the only variable refractory to S-TENS. Complication rate was 3% (2 patients with dermatitis in the S-TENS application area). CONCLUSIONS: S-TENS is effective and safe in the short-term in patients with OB refractory to Achs. Further studies assessing long-term efficacy and potential relapses are required.

OBJETIVOS: Determinar si la electroterapia nerviosa transcutánea a nivel sacro (TENS-S) es un tratamiento efectivo en pacientes refractarios a fármacos anticolinérgicos (Ach). MATERIAL Y METODOS: Estudio prospectivo y multicéntrico: pacientes con VH refractaria a Ach tratados con TENS-S entre 2018-2021. El TENS-S se aplicó durante 3 meses. La evolución sintomática fue evaluada utilizando el calendario miccional y el cuestionario PLUTSS (Pediatric Lower Urinary Tract Symptoms Score), pero excluyendo sus preguntas 3 y 4 (referidas a la enuresis) para analizar solamente la evolución de la sintomatología diurna (variable LUTS). RESULTADOS: Fueron incluidos 66 pacientes (50% niñas), con una edad media de 9,5 años (rango: 5-15). El TENS-S disminuyó significativamente el PLUTSS (19,1 inicial vs 9,5 final, p< 0,001) y el LUTS (13,1 inicial vs 4,8 final, p< 0,001). Además, redujo el número de micciones (8,5 inicial vs 6,4 final, p< 0,001) y aumentó el volumen de orina en los registros miccionales (214 ml inicial vs 258 ml final, p< 0,001). La enuresis fue la única variable refractaria al TENS-S. La tasa de complicaciones fue del 3% (2 pacientes, dermatitis en el área de aplicación del TENS-S). CONCLUSIONES: El TENS-S es efectivo y seguro a corto plazo en pacientes con VH refractarios a los Ach. Deben realizarse estudios para evaluar la eficacia a largo plazo y posibles recaídas.

Enuresis associated with sleep disordered breathing in children with sickle cell anemia.

PURPOSE: Enuresis and sleep disordered breathing are common among children with sickle cell anemia. We evaluated whether enuresis is associated with sleep disordered breathing in children with sickle cell anemia. MATERIALS AND METHODS: Baseline data were used from a multicenter prospective cohort study of 221 unselected children with sickle cell anemia. A questionnaire was used to evaluate, by parental report during the previous month, the presence of enuresis and its severity. Overnight polysomnography was used to determine the presence of sleep disordered breathing by the number of obstructive apneas and/or hypopneas per hour of sleep. Logistic and ordinal regression models were used to evaluate the association of sleep disordered breathing and enuresis. RESULTS: The mean age of participants was 10.1 years (median 10.0, range 4 to 19). Enuresis occurred in 38.9% of participants and was significantly associated with an obstructive apnea-hypopnea index of 2 or more per hour after adjusting for age and gender (OR 2.19; 95% CI 1.09, 4.40; p = 0.03). Enuresis severity was associated with obstructive apneas and hypopneas with 3% or more desaturation 2 or more times per hour with and without habitual snoring (OR 3.23; 95% CI 1.53, 6.81; p = 0.001 and OR 2.07; 95% CI 1.09, 3.92; p = 0.03, respectively). CONCLUSIONS: In this unselected group of children with sickle cell anemia, sleep disordered breathing was associated with enuresis. Results of this study support that children with sickle cell anemia who present with enuresis should be evaluated by a pulmonologist for sleep disordered breathing.

Prevalence of enuresis and daytime urinary incontinence in children and adolescents with sickle cell disease.

PURPOSE: There is a known association between sickle cell disease and enuresis. However, the cause of this association is unclear. We tested the hypothesis that children with sickle cell disease would have more symptoms of overactive bladder than a control group. MATERIALS AND METHODS: Questionnaires were distributed to 155 legal guardians of children and adolescents 5 to 17 years old with sickle cell disease and to 100 legal guardians of a control group of children. RESULTS: Individuals with and without sickle cell disease were distributed uniformly regarding gender and age. A total of 50 patients (32.3%) in the sickle cell disease group had enuresis vs 5 (5%) in the control group (p = 0.000). Daytime urinary incontinence was observed in 36 individuals with (23.2%) and 11 (11.0%) without sickle cell disease (p = 0.014). A total of 52 patients with sickle cell disease (33.5%) complained of urgency, compared to 10 controls (10%, p = 0.000). A total of 49 patients with sickle cell disease (31.6%) had frequency, compared to 6 controls (6%, p = 0.000). Of all patients who reported enuresis or daytime incontinence only 1 with enuresis had received specific treatment. CONCLUSIONS: There is a significant association between sickle cell disease and enuresis and overactive bladder symptoms such as daytime incontinence, urgency and frequency. Thus, all children and adolescents with sickle cell disease should be questioned regarding the presence of these symptoms to facilitate treatment for these conditions.

Mental health considerations in pediatric enuresis.

Enuresis is a common condition during the childhood years. Although distressing to both children and parents, enuresis often goes unreported. Because of its common occurrence, psychiatric nurses should become knowledgeable about enuresis and understand how to assess and treat it when appropriate.

Seventeen-Year-Old Female With History of Depression Presented With Mania and Enuresis.

A 17-year-old girl with a history of depression was referred by her psychologist to the emergency department (ED) because of concerning behavioral changes for the past 2 weeks. She was engaging in erratic behaviors, including excessive baking, handling broken glass, mixing chemicals, and swimming alone while clothed. She denied any intention to harm herself or others. She was feeling energized in the morning despite only sleeping a few hours at night. She also urinated on herself the day before her ED visit. Her examination and preliminary testing findings in the ED were largely normal. Her initial presentation was concerning for a psychiatric etiology, such as new-onset bipolar disorder given previous history of depression and recent impulsive symptoms suggestive of mania. As her clinical course evolved and urinary incontinence continued, her definitive diagnosis was made by an interdisciplinary team that included child psychiatry and pediatric neurology.

New ideas in the cause of bladder dysfunction in children.

PURPOSE OF REVIEW: The management of children with urinary incontinence and dysfunctional voiding problems can be very difficult at times. The present array of bladder-oriented treatments are marginally successful and for a long time patients were told that they would outgrow their symptoms. In this review, we look at the most recent findings in the urologic and psychiatric literature and try to piece together these two disparate fields and figure out how children who wet are best managed. RECENT FINDINGS: It became clear that children with attention deficit disorder were always more difficult to manage than those without neuropsychiatric problems. As the years have progressed and imaging technology has improved, we have begun to look into the active brain. This research has been conducted primarily in the fields of psychiatry and neuroscience, but there have been some seminal studies that point to a link between defects in the brain and functional urinary problems in children. In this review, we will attempt to outline the reasons why the traditional bowel program works and why there are such a large number of patients with neuropsychiatric problems who have functional urinary problems as children. SUMMARY: Utilizing an approach that focuses on a treatment paradigm that is neurocentric instead of vesicocentric allows us to treat children who do not respond to the usual treatments and target the brain with centrally active medications such as tricyclics and serotonin reuptake inhibitors. Understanding that it is a problem in the central nervous system, and that in some cases it is necessary to treat the underlying neuropsychiatric problems to be able to get these children to remain dry is a very important step in the management of children with refractory wetting problems.

Clinical and urodynamic effect of methylphenidate for the treatment of giggle incontinence (enuresis risoria).

AIMS: We retrospectively investigated the efficacy of methylphenidate (MPH) in giggle incontinence (GI), and the relationship between GI and urodynamic parameters. METHODS: Nine (n = 9) female GI patients underwent 1 year of treatment with 5 mg MPH. Three questionnaires, voiding diaries, and UDS were conducted before and after treatment. The severity of GI was classified into mild, moderate, and severe. Clinical success was characterized as: full response, response, partial response, and non-response. RESULTS: The mean age of all patients was 16.2 ± 2.3 years. Five patients had mild, one had moderate, and three had severe grade incontinent. All patients reported complete cessation of wetting after MPH treatment. The mean duration of asymptomatic period was 7 ± 3.2 months. There were no statistically significant score changes in all three questionnaires: Urgency Perception Scale (UPS), Overactive Bladder Symptom Score (OABSS) and Primary Overactive Symptom Questionnaire (POSQ), and voiding diaries (P > 0.05). In UDS, there were no statistically significant altered parameters, except maximum urethral closure pressure (MUCP) and maximum urethral pressure (MUP). After treatment, the mean MUCP was increased from 52.2 ± 6.8 to 73.0 ± 5.4 cmH(2) O (P < 0.05), and the mean MUP was increased from 48.6 ± 7.3 to 70.2 ± 5.0 cmH(2) O (P < 0.05). CONCLUSIONS: MPH can be a viable option for the primary treatment of GI, and it may be related to increasing urethral closure pressure. It was not possible to establish if a relationship between GI and detrusor overactivity exists.

Isolated coronal urethral duplication in an adolescent presenting with enuresis.

SUMMARY: This report describes an isolated urethral duplication in the coronal plane in a child referred with primary 'enuresis'. This presentation is unique because duplications usually occur in the sagittal plane. In patients with suspected urethral duplication, magnetic resonance imaging in conjunction with catheterisation of the distal duplicate opening accurately delineates the abnormality, so that individualised treatment strategies can be considered.

Clinical and urodynamic spectrum of bladder function in cerebral palsy.

PURPOSE: The nature of voiding function and dysfunction associated with cerebral palsy is described in the literature without concurrence of opinion. We correlated urodynamic findings with voiding patterns to better understand and manage voiding dysfunction in children with cerebral palsy. MATERIALS AND METHODS: Voiding patterns and urodynamic studies in our last 31 patients with cerebral palsy were reviewed. Patients and families were surveyed on the child ability to void spontaneously, clean intermittent catheterization requirement, daytime incontinence and enuresis. Urodynamics consisted of slow fill water cystometry and patch electromyography. Measured parameters were bladder capacity based on age, capacity pressure, compliance, uninhibited contractions, bladder sensation and external sphincter activity. Patients were stratified by voiding status and statistical analysis was performed with p <0.05 considered significant. RESULTS: The 15 boys and 16 girls were 4.5 to 16.6 years old. Three children required clean intermittent catheterization for bladder drainage and 28 (90.3%) voided spontaneously. Diapers were worn by 24 patients (77.4%). There were daytime incontinence and enuresis in 12 patients (38.7%), daytime incontinence only in 11 (35.5%) and enuresis in 1 (3.2%). Seven patients (22.6%) were continent day and night. When correlated with urodynamic parameters, continent children tended to have a larger bladder, lower bladder capacity pressure, higher compliance, fewer uninhibited contractions and similar sphincter activity. The only statistically significant difference was in bladder sensation. CONCLUSIONS: There is a spectrum of clinical and urodynamic bladder function in children with cerebral palsy. Of these children 77.4% void spontaneously but are incontinent. Incontinence is more likely present during the day and rarely limited to enuresis. Urodynamically continent children have a similar storage profile and differ from children with daytime or nocturnal incontinence in the ability to sense bladder fullness.

Level of soluble CD30 after kidney transplantation correlates with acute rejection episodes.

Measurement of soluble CD30 (sCD30) levels may predict acute rejection episodes (ARE). To explore the value of sCD30 after transplantation, we tested serum sCD30 levels in 58 kidney transplant cases at 1 day before and 7 and 28 days after transplantation by enzyme-linked immunosorbent assay (ELISA). The incidences of ARE after kidney transplantation were recorded simultaneously. Meanwhile, 31 healthy individuals were selected as a control group. The results showed a relationship between sCD30 level in serum before kidney transplantation and the incidence of ARE. However, the relationship was more significant between serum sCD30 levels at day 7 after kidney transplantation and the incidence of ARE. There was no obvious relationship between serum sCD30 levels at day 28 after kidney transplantation and the incidence of ARE. These results suggested that the level of sCD30 at day 7 posttransplantation provides valuable data to predict ARE.

Recurrent urinary tract infection and functional voiding disorders.

This study was carried out to determine the association of recurrent urinary tract infections with functional voiding disorders. Sixty eight children with suspected functional voiding disorders were prospectively evaluated clinically and by non-invasive urodynamics. Invasive urodynamics were carried out when indicated. Group I comprised 34 children with symptoms suggestive of functional voiding disorders and recurrent urinary tract infections (mean age 6.3+/-2 yr) and Group II comprised 34 children with symptoms suggestive of functional voiding disorders without recurrent urinary tract infections (mean age 6.7+/-2 yr). The underlying bladder abnormalities in Groups I and II were detrusor instability in 22 (64.7%) and 30 (88.2%), respectively (P>0.05) and dysynergic voiding in 10 (29.4%), and 1 (2.9%), respectively (P<0.05). Children with recurrent urinary tract infections are more likely to have a dysynergic voiding pattern than children presenting with other symptoms of functional voiding disorders.

Management of "open" syringocele based on urodynamic findings.

INTRODUCTION: Depending on the type and size of the syringocele and the age of the patient, syringocele is treated medically or surgically, with endoscopy or open surgery. We report our experience in 10 "open" consecutive cases of syringocele, propose a clinical classification and discuss the management. MATERIAL AND METHODS: In all patients (pts), diagnosis was achieved through voiding cystourethrography. All pts performed multichannel urodynamic studies. Pts with impaired compliance and/or detrusor instability (4 pts out of 10) underwent endoscopic unroofing. They were followed up until to 24 months after the endoscopic procedure. Pts with normal urodynamic findings were treated medically and followed with clinical examination. All pts performed an urinalysis every 2 weeks for the first three months and monthly for an year. RESULTS: In endoscopic treated pts, voiding cystourethrography showed a normal profile of the urethra at 3 months follow-up. Pts with UTI, but with normal urodynamic parameter were treated with antibiotic therapy. At serial follow-up, all pts were completely symptom-free. Urinalysises were normal, negative for infection or haematuria. DISCUSSION: In the literature to date, there isn't accordance if and when treated "open" syringoceles. In our opinion, it is useful to classify "open" syringocele based on urodynamic findings. Syringocele needs endoscopic surgical treatment if it is obstructed or a cause of dysfunctional alteration of the bladder, in order to avoid unnecessary surgery in syringocele without urodynamic abnormality.