Improvement in bladder function in children with functional constipation after a bowel management program.

PURPOSE: We sought to determine if children with functional constipation (FC) would have an improvement in bladder function with treatment of constipation with a bowel management program (BMP). METHODS: A single-institution review was performed in children aged 3-18 with FC who underwent a BMP from 2014 to 2020. Clinical characteristics, bowel management details, and the Vancouver Symptom Score for Dysfunctional Elimination Syndrome (VSS), Baylor Continence Scale (BCS), and Cleveland Clinic Constipation Score (CCCS) were collected. Data were analyzed using linear mixed effect modeling with random intercept. RESULTS: 241 patients were included with a median age of 9 years. Most were White 81 and 47% were female. Univariate tests showed improvement in VSS (- 3.6, P < 0.0001), BCS (- 11.96, P < 0.0001), and CCCS (- 1.9, P < 0.0001) among patients having undergone one BMP. Improvement was noted in VSS and CCCS among those with more than one BMP (VSS: - 1.66, P = 0.023; CCCS: - 2.69, P < 0.0001). Multivariate tests indicated undergoing a BMP does result in significant improvement in VSS, BCS, and CCCS (P < 0.0001). CONCLUSIONS: There is significant improvement in bladder function in children with FC who undergo a BMP. For patients with bowel and bladder dysfunction and FC, a BMP is a reasonable treatment strategy for lower urinary tract symptoms.

Bowel and Bladder Dysfunction Is Associated with Psychiatric Comorbidities and Functional Impairment in Pediatric Obsessive-Compulsive Disorder.

Objective: Neuropsychiatric disorders are common in children with bowel and bladder dysfunction (BBD), a syndrome associated with urinary frequency, urgency, holding, incontinence, and constipation. We evaluated BBD symptom severity in children and youth attending a tertiary care obsessive-compulsive disorder (OCD) clinic. Methods: Consecutive patients attending initial OCD assessments between 2016 and 2020 were invited to participate in a registry study. Diagnosis of OCD and comorbidities was established by structured clinical interview. OCD severity and impact were assessed with the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) and the Child Obsessive Compulsive Impact Scale (COIS-R; self-report), respectively. BBD symptoms were quantified with the Vancouver Symptom Score (VSS), a validated self-report measure. Results: One hundred twelve participants completed the VSS (mean age 13.5 ± 3.3, range 7-20). Based on a cutoff score of 11 corresponding to pediatric urologist-diagnosed BBD, 30.4% of participants screened positive, including more females than males (39.3% vs. 21.4%; p = 0.04). Daytime urinary incontinence was present in a greater proportion of participants with OCD forbidden thoughts (34.8% vs. 8.2%, p = 0.002), major depressive disorder (MDD; 38.5% vs. 6.8%, p = 0.001), and somatization disorder (60% vs. 9%, p = 0.001) compared with those without. A regression model including CY-BOCS, COIS-R, psychiatric comorbidities, medications, age, and gender explained 52.2% of the variance in VSS; COIS-R, tic disorder, and MDD were significant predictors. Conclusion: BBD symptoms are common and associated with high OCD-related impairment and psychiatric comorbidities. Standardized assessment may facilitate identification of BBD symptoms in this population and is critical to mitigating long-term physical and mental health impacts. Further studies are required to assess the relationship between BBD and OCD treatment outcomes.

Bladder and bowel symptoms experienced by children with osteogenesis imperfecta / Sintomas urinários e intestinais apresentados por crianças com osteogênese imperfeita

Abstract Objective: To estimate the prevalence and presentation of bladder, bowel, and combined bladder and bowel symptoms experienced by children with osteogenesis imperfecta and to describe the socio-demographic and clinical profile of these children. Method: A descriptive study was conducted with a convenience sample of parent-child pairs of toilet-trained children aged from 3 to 18 years. Pairs were interviewed using three tools: (1) Socio-Demographic and Clinical Questionnaire; (2) Dysfunctional Voiding Scoring System; (3) Rome III Criteria along with the Bristol Stool Scale. Data were stratified by socio-demographic and clinical variables and analyzed using descriptive statistics. Results: Thirty-one parent-child pairs participated in the study; 38.7% (n = 12) children reported bowel symptoms, 19.4% (n = 6) reported a combination of bladder issues (such as holding maneuvers and urgency) and bowel symptoms (such as hard or painful bowel movements and large diameter stools). There were no reports of isolated bladder issues. Among the child participants, 16 (51.7%) identified as female and 20 (64.5%) were 5-14 years old. The most prevalent type of osteogenesis imperfecta was type III (n = 12; 38.7%) and eight (25.8%) children reported using a wheelchair. Conclusion: This is the first study to examine the prevalence and presentation of bladder, bowel, and combined bladder and bowel symptoms in children with osteogenesis imperfecta, offering a preliminary socio-demographic and clinical profile of these children. This research is an important step toward effective screening, detection, and access to care and treatment, especially for clinicians working with this group of very fragile patients.

Resumo Objetivo: Estimar a prevalência e a apresentação de sintomas urinários, intestinais e urinários e intestinais combinados sofridos por crianças com osteogênese imperfeita e descrever o perfil sociodemográfico e clínico dessas crianças. Método: Foi realizado um estudo descritivo com uma amostra de conveniência de pares de pais-filhos de crianças treinadas para usar o banheiro com idades entre três e 18 anos. Os pares foram entrevistados utilizando três instrumentos: 1) o Questionário Sociodemográfico e Clínico; 2) o questionário Dysfunctional Voiding Scoring System; 3) os Critérios de Roma III juntamente com a Escala de Bristol para Consistência de Fezes. Os dados foram estratificados por variáveis sociodemográficas e clínicas e analisados com estatísticas descritivas. Resultados: Participaram do estudo 31 pares de pais-filhos, 38,7% (n = 12) crianças relataram sintomas intestinais, 19,4% (n = 6) relataram uma combinação de problemas urinários (como segurar e urgência miccional) e sintomas intestinais (como fezes duras ou evacuações dolorosas e fezes de grande dimensão). Não houve relatos de problemas urinários isolados. Entre as crianças, 16 (51,7%) eram meninas e 20 (64,5%) tinham entre 5 e 14 anos. O tipo mais prevalente de osteogênese imperfeita foi o III (n = 12; 38,7%) e 8 (25,8%) crianças relataram usar cadeira de rodas. Conclusão: Este é o primeiro estudo a examinar a prevalência e a apresentação de sintomas urinários, intestinais e urinários e intestinais combinados em crianças com osteogênese imperfeita e que mostra um perfil sociodemográfico e clínico preliminar dessas crianças. Nossa pesquisa é um passo importante com relação ao efetivo rastreamento, detecção e acesso ao cuidado e tratamento, principalmente para os profissionais de saúde que trabalham com esse grupo de pacientes tão frágeis.

Bladder and bowel symptoms experienced by children with osteogenesis imperfecta.

OBJECTIVE: To estimate the prevalence and presentation of bladder, bowel, and combined bladder and bowel symptoms experienced by children with osteogenesis imperfecta and to describe the socio-demographic and clinical profile of these children. METHOD: A descriptive study was conducted with a convenience sample of parent-child pairs of toilet-trained children aged from 3 to 18 years. Pairs were interviewed using three tools: (1) Socio-Demographic and Clinical Questionnaire; (2) Dysfunctional Voiding Scoring System; (3) Rome III Criteria along with the Bristol Stool Scale. Data were stratified by socio-demographic and clinical variables and analyzed using descriptive statistics. RESULTS: Thirty-one parent-child pairs participated in the study; 38.7% (n=12) children reported bowel symptoms, 19.4% (n=6) reported a combination of bladder issues (such as holding maneuvers and urgency) and bowel symptoms (such as hard or painful bowel movements and large diameter stools). There were no reports of isolated bladder issues. Among the child participants, 16 (51.7%) identified as female and 20 (64.5%) were 5-14 years old. The most prevalent type of osteogenesis imperfecta was type III (n=12; 38.7%) and eight (25.8%) children reported using a wheelchair. CONCLUSION: This is the first study to examine the prevalence and presentation of bladder, bowel, and combined bladder and bowel symptoms in children with osteogenesis imperfecta, offering a preliminary socio-demographic and clinical profile of these children. This research is an important step toward effective screening, detection, and access to care and treatment, especially for clinicians working with this group of very fragile patients.

Pupillometric assessment of dysautonomia in pediatric bowel and bladder dysfunction: a pilot study.

Bowel and bladder dysfunction (BBD) refers to a heterogeneous group of voiding disorders, accounting for an estimated 40% of pediatric urology visits. Symptoms of BBD include enuresis, urgency, and urinary retention, often accompanied by constipation. The aim of this pilot study was to explore whether a pupillary response can be characterized for BBD, by examining the pupillary light reflex (PLR) before and after voiding among patients with BBD. A total of 28 patients aged from 7 to 21 years were recruited from the Wetting, Infections, and Stooling Help clinic at Children's National Medical Center. An infrared pupilometer was used to assess the PLR. Both baseline static and dynamic pupillometry assessments were obtained before and after voiding. Measurements were also taken after 5 min in the supine position, followed by 5 min standing to induce an orthostatic stressor. Visual inspection of the graphed data revealed a characteristic shape in 11 of 28 patients with voiding symptoms. In these 11 patients, the redilation arm of the PLR shows a 'notch,' or a brief reconstriction of the pupil before resting pupil size is reestablished (figure). This feature of the PLR has not been seen in previous and parallel studies using pupillometry to evaluate other populations. The results of this study suggest that a subset of patients with BBD may have a significant perturbation of autonomic regulation, identifiable through analysis of the PLR. To our knowledge, this 'notch' during redilation has not been previously described or seen in other patient populations and may represent a distinctive and readily identifiable physiologic marker of disease. These results are broadly aligned with results of other studies that have examined ANS activity in patients with BBD, although further study is needed to confirm the results of this pilot study and to assess relative contributions of sympathetic and parasympathetic function in producing pupillary abnormalities. This study has several limitations, including the small sample size, the absence of data on severity and duration of symptoms, and the absence of a control group of patients without any voiding symptoms. A simple tool for diagnosing BBD and for monitoring response to treatment could significantly improve the quality of treatment for one of the most common pediatric urologic complaints. Given the heterogeneity of symptoms under the BBD umbrella, pupillometric data could guide selection of treatment options, as well as assess adequacy of response to pharmacologic therapy.

Assessment of pediatric bowel and bladder dysfunction: a critical appraisal of the literature.

OBJECTIVE: Bowel and bladder dysfunction (BBD) is a clinical syndrome defined by the coexistence of constipation and lower urinary tract symptoms. Although BBD is a common condition in pediatric urology and can cause significant stress to patients/parents, clinical diagnosis of BBD has not been standardized. Bowel and bladder dysfunction instruments have gained popularity over the past decade to aid in diagnosis. In this review, the currently published BBD symptom questionnaires were summarized and an analysis on their psychometric validation process was provided. SUBJECTS/PATIENTS: PubMed was searched for articles on BBD symptom questionnaires/instruments/surveys since 2000. Two investigators (R.Y.J. & M.S.K.) conducted the search in duplicate. The search was limited to English language. The included search terms were 'dysfunctional elimination syndrome', 'bowel and bladder dysfunction', 'dysfunctional voiding', 'voiding dysfunction symptom score', and 'dysfunctional voiding symptom scale'. Reference lists of included studies were screened for missed studies. Unpublished abstracts presented at the following scientific meetings were also manually searched for: the American Urological Association, the Society for Pediatric Urology, and the American Academy of Pediatrics Section on Urology. Exclusion criteria included articles in languages other than English, articles not related to BBD questionnaires, and articles not pertaining to pediatric patients. RESULTS: After initial search, a total of 54 articles were obtained. Of the seven questionnaires reviewed, only one did not measure sensitivity or specificity. Almost all questionnaires showed excellent discriminative property with an Area under the curve (AUC) >0.85. Criterion validity was not reported in any of the questionnaires. Known-group validation was used as a common method to evaluate construct validity. Internal consistency was reported in 2 studies, and only 1 study measured questionnaire responsiveness during initial validation. CONCLUSIONS: Although BBD is a common pediatric urology condition; a large amount of heterogeneity exists in the questionnaires' psychometric testing and validation process. To further improve the diagnosis and management of BBD in pediatric patients, there is a need for consensus on the gold standard questionnaire measure.

Contemporary Management of Vesicoureteral Reflux.

The past 30 years have seen broad changes in the diagnosis and management of vesicoureteral reflux (VUR). Recently, a clinical debate has generated an open discussion in academic circles. New evidence has shifted treatment patterns away from widespread surgical management and recently brought into question some pharmacologic treatments. VUR is usually not hazardous by itself but is a significant risk factor for urinary tract infection (UTI) and less commonly, renal scarring and insufficiency. Given the costs and morbidity of UTI as well as the potential for significant renal injury, our approach remains conservative. Careful follow-up, parental education about pathophysiology and management of VUR and UTI, and management of bowel and bladder dysfunction (BBD) when present, are the foundation of treatment. Additionally, though we recognize the limitation of continuous antibiotic prophylaxis (CAP), we believe the benefits outweigh the risks and costs for many patients. Careful observation can be considered in patients with a single medical home, parental understanding of what UTI signs and symptoms are, low grade VUR, no history of complicated UTIs and close follow-up. Surgical management remains a relevant option for select patients who fail conservative measures with breakthrough UTIs or failure to resolve. Minimally invasive surgical options are available with acceptable outcomes though open ureteroneocystostomy still carries the highest success rate.

Simultaneous urodynamic and anorectal manometry studies in children: insights into the relationship between the lower gastrointestinal and lower urinary tracts.

BACKGROUND: Children with urinary incontinence (UI) have associated functional constipation (FC) and fecal incontinence (FI). The physiology between lower urinary tract (LUT) and anorectum in children has not been elucidated. AIMS: Observe the effect of rectal distention (RD) on LUT function, and bladder filling and voiding on anorectal function. METHODS: Children with voiding dysfunction referred to Boston Children's Hospital were prospectively enrolled in combined urodynamic (UDS) and anorectal manometry (ARM). Anorectal and urodynamic parameters were simultaneously measured. Patients underwent two micturition cycles, first with rectal balloon deflated and second with it inflated (RD). Lower urinary tract and anorectal parameters were compared between cycles. KEY RESULTS: Ten children (seven UI, four recurrent UTIs, nine FC ± FI) were enrolled. Postvoid residual (PVR) increased (p = 0.02) with RD. No differences were observed in percent of bladder filling to expected bladder capacity, sensation, and bladder compliance with and without RD. Bladder and abdominal pressures increased at voiding with RD (p < 0.05). Intra-anal pressures decreased at voiding (p < 0.05), at 25% (p = 0.03) and 50% (p = 0.06) of total volume of bladder filling. CONCLUSIONS & INFERENCES: The PVR volume increased with RD. Stool in the rectum does not alter filling cystometric capacity but decreases the bladder's ability to empty predisposing patients with fecal retention to UI and UTIs. Bladder and abdominal pressures increased during voiding, demonstrating a physiological correlate of voiding dysfunction. Intra-anal pressures decreased during bladder filling and voiding. This is the first time intra-anal relaxation during bladder filling and voiding has been described.

Outcomes of targeted treatment for vesicoureteral reflux in children with nonneurogenic lower urinary tract dysfunction.

PURPOSE: There is a known association between nonneurogenic lower urinary tract conditions and vesicoureteral reflux. Whether reflux is secondary to the lower urinary tract condition or coincidental is controversial. We determined the rate of reflux resolution in patients with lower urinary tract dysfunction using targeted treatment for the underlying condition. MATERIALS AND METHODS: Patients diagnosed and treated for a lower urinary tract condition who had concomitant vesicoureteral reflux at or near the time of diagnosis were included. Patients underwent targeted treatment and antibiotic prophylaxis, and reflux was monitored with voiding cystourethrography or videourodynamics. RESULTS: Vesicoureteral reflux was identified in 58 ureters in 36 females and 5 males with a mean age of 6.2 years. After a mean of 3.1 years of treatment reflux resolved with targeted treatment in 26 of 58 ureters (45%). All of these patients had a history of urinary tract infections before starting targeted treatment. Resolution rates of vesicoureteral reflux were similar for all reflux grades. Resolution or significant improvement of reflux was greater in the ureters of patients with dysfunctional voiding (70%) compared to those with idiopathic detrusor overactivity disorder (38%) or detrusor underutilization (40%). CONCLUSIONS: Vesicoureteral reflux associated with lower urinary tract conditions resolved with targeted treatment and antibiotic prophylaxis in 45% of ureters. Unlike the resolution rates reported in patients with reflux without a coexisting lower urinary tract condition, we found that there were no differences in resolution rates among grades I to V reflux in patients with lower urinary tract conditions. Patients with dysfunctional voiding had the most improvement and greatest resolution of reflux. Additionally grade V reflux resolved in some patients.

Randomized, double-blind, placebo-controlled trial of polyethylene glycol (MiraLAX®) for urinary urge symptoms.

OBJECTIVE: Polyethylene glycol (PEG) is common first-line therapy for urinary symptoms despite minimal evidence-based support. We performed a randomized, double-blind, placebo-controlled study of PEG for initial treatment of overactive bladder (OAB) symptoms in children. PATIENTS AND METHODS: Patients aged >3 years underwent baseline urinary symptom questionnaire (USQ, scored 0-16), bowel symptom questionnaire (scored 0-20) and abdominal X-ray (KUB). Patients were randomized to placebo/PEG regardless of parent's perception of constipation. After 1 month, patients completed follow-up questionnaires and KUB. Improvement was defined as decrease in USQ (ΔUSQ) ≥ 3 points. Secondary analyses compared urinary and bowel symptoms to KUB. RESULTS: Of 138 enrolled patients, 71 (51.4%) completed 1 month of therapy. Analyses of those randomized to placebo vs. PEG and non-completers demonstrated similar demographics, baseline symptoms, and KUB. Patients treated with placebo and PEG both had significant improvement in USQ scores (p < 0.0001). Patients treated with placebo and PEG responded similarly to placebo (ΔUSQ 3.7 vs. 3.4, p = 0.773), with improvement in nearly half (48.5% PEG vs. 44.7% placebo). There was no correlation between KUB and urinary or bowel symptoms. CONCLUSIONS: Nearly 50% of patients with urinary urge symptoms treated with either placebo or PEG for 1 month had improvement in urinary symptoms. KUB did not correlate with baseline or follow-up urinary or bowel symptoms.