Management of bladder dysfunction in children
- Kenneth G Nepple, MD, FACS
Kenneth G Nepple, MD, FACS
- Associate Professor of Urology
- University of Iowa College of Medicine
- Christopher S Cooper, MD, FACS, FAAP
Christopher S Cooper, MD, FACS, FAAP
- Professor of Urology
- University of Iowa College of Medicine
- Section Editors
- Laurence S Baskin, MD, FAAP
Laurence S Baskin, MD, FAAP
- Section Editor — Pediatric Urology
- Frank Hinman, Jr., MD, Distinguished Professorship in Pediatric Urology
- Chief Pediatric Urology
- Professor of Urology and Pediatrics
- UCSF Benioff Children's Hospital
- Tej K Mattoo, MD, DCH, FRCP
Tej K Mattoo, MD, DCH, FRCP
- Section Editor — Pediatric Nephrology
- Professor of Pediatrics
- Wayne State University School of Medicine
Bladder dysfunction, previously referred to as voiding dysfunction, is a general term to describe abnormalities in either the filling and/or emptying of the bladder. It is a common problem in children and constitutes up to 40 percent of pediatric urology clinic visits . In some children, bladder dysfunction is a component of bowel and bladder dysfunction, previously referred to as the dysfunctional elimination syndrome, which involves abnormalities in both bladder and bowel function.
Daytime urinary incontinence, a common feature of bladder dysfunction, can cause major stress in school-age children [2,3], and negatively impact a child's self-esteem . Thus, it is desirable to identify and treat these children as early as possible.
The management of bladder dysfunction in children will be reviewed here. The etiology, clinical features, evaluation, and diagnosis of bladder dysfunction and management of nocturnal enuresis in children are discussed separately. (See "Etiology and clinical features of bladder dysfunction in children" and "Evaluation and diagnosis of bladder dysfunction in children" and "Nocturnal enuresis in children: Management".)
The management of a child with bladder dysfunction is primarily directed at improving symptoms and avoiding renal damage. Therapeutic considerations include the underlying cause of bladder dysfunction including behavioral and neurodevelopment etiologies, the age of the patient, symptom duration and severity, the motivation and attention span of the patient and family, and the presence of potential risk factors for renal injury such as recurrent urinary tract infections or vesicoureteral reflux. (See "Etiology and clinical features of bladder dysfunction in children", section on 'Dysfunctional voiding'.)
Data on effective treatment of bladder dysfunction in children are limited because of the following flaws in study design:
- Farhat W, Bägli DJ, Capolicchio G, et al. The dysfunctional voiding scoring system: quantitative standardization of dysfunctional voiding symptoms in children. J Urol 2000; 164:1011.
- Forsythe WI, Redmond A. Enuresis and spontaneous cure rate. Study of 1129 enuretis. Arch Dis Child 1974; 49:259.
- Nevéus T, von Gontard A, Hoebeke P, et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. J Urol 2006; 176:314.
- Allen HA, Austin JC, Boyt MA, et al. Initial trial of timed voiding is warranted for all children with daytime incontinence. Urology 2007; 69:962.
- Bloom DA. Overactive bladder: paediatric aspects. BJU Int 2000; 85 Suppl 3:43.
- Van Arendonk KJ, Austin JC, Boyt MA, Cooper CS. Frequency of wetting is predictive of response to anticholinergic treatment in children with overactive bladder. Urology 2006; 67:1049.
- Austin PF, Bauer SB, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children's Continence Society. Neurourol Urodyn 2016; 35:471.
- Thom M, Campigotto M, Vemulakonda V, et al. Management of lower urinary tract dysfunction: a stepwise approach. J Pediatr Urol 2012; 8:20.
- Wiener JS, Scales MT, Hampton J, et al. Long-term efficacy of simple behavioral therapy for daytime wetting in children. J Urol 2000; 164:786.
- Desantis DJ, Leonard MP, Preston MA, et al. Effectiveness of biofeedback for dysfunctional elimination syndrome in pediatrics: a systematic review. J Pediatr Urol 2011; 7:342.
- Hagstroem S, Rittig S, Kamperis K, Djurhuus JC. Timer watch assisted urotherapy in children: a randomized controlled trial. J Urol 2010; 184:1482.
- Heilenkötter K, Bachmann C, Janhsen E, et al. Prospective evaluation of inpatient and outpatient bladder training in children with functional urinary incontinence. Urology 2006; 67:176.
- Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics 1997; 100:228.
- Pashankar DS, Bishop WP. Efficacy and optimal dose of daily polyethylene glycol 3350 for treatment of constipation and encopresis in children. J Pediatr 2001; 139:428.
- Erickson BA, Austin JC, Cooper CS, Boyt MA. Polyethylene glycol 3350 for constipation in children with dysfunctional elimination. J Urol 2003; 170:1518.
- Herndon CD, Joseph DB. Urinary incontinence. Pediatr Clin North Am 2006; 53:363.
- Finney SM, Andersson KE, Gillespie JI, Stewart LH. Antimuscarinic drugs in detrusor overactivity and the overactive bladder syndrome: motor or sensory actions? BJU Int 2006; 98:503.
- Nijman RJ. Role of antimuscarinics in the treatment of nonneurogenic daytime urinary incontinence in children. Urology 2004; 63:45.
- Bolduc S, Upadhyay J, Payton J, et al. The use of tolterodine in children after oxybutynin failure. BJU Int 2003; 91:398.
- Yamanishi T, Chapple CR, Chess-Williams R. Which muscarinic receptor is important in the bladder? World J Urol 2001; 19:299.
- Chapple CR, Yamanishi T, Chess-Williams R. Muscarinic receptor subtypes and management of the overactive bladder. Urology 2002; 60:82.
- Curran MJ, Kaefer M, Peters C, et al. The overactive bladder in childhood: long-term results with conservative management. J Urol 2000; 163:574.
- van Gool JD, de Jong TPVM, Winkler-Seinstra P, et al. A comparison of standard therapy, bladder rehabilitation with biofeedback, and pharmacotherapy in children with non-neuropathic bladder sphincter dysfunction. Presented at 2nd annual meeting of International Children's Continence Society, Denver, Colorado, August 23-26, 1999.
- Sureshkumar P, Bower W, Craig JC, Knight JF. Treatment of daytime urinary incontinence in children: a systematic review of randomized controlled trials. J Urol 2003; 170:196.
- Hellerstein S, Zguta AA. Outcome of overactive bladder in children. Clin Pediatr (Phila) 2003; 42:553.
- Van Arendonk KJ, Knudson MJ, Austin JC, Cooper CS. Improved efficacy of extended release oxybutynin in children with persistent daytime urinary incontinence converted from regular oxybutynin. Urology 2006; 68:862.
- Jonville AP, Dutertre JP, Barbellion M, Autret E. [Adverse effects of oxybutynin chloride (Ditropan) in pediatrics]. Arch Fr Pediatr 1993; 50:27.
- Gish P, Mosholder AD, Truffa M, Johann-Liang R. Spectrum of central anticholinergic adverse effects associated with oxybutynin: comparison of pediatric and adult cases. J Pediatr 2009; 155:432.
- Nijman RJ. Classification and treatment of functional incontinence in children. BJU Int 2000; 85 Suppl 3:37.
- Kay G, Crook T, Rekeda L, et al. Differential effects of the antimuscarinic agents darifenacin and oxybutynin ER on memory in older subjects. Eur Urol 2006; 50:317.
- Pathak AS, Aboseif SR. Overactive bladder: drug therapy versus nerve stimulation. Nat Clin Pract Urol 2005; 2:310.
- Sommer BR, O'Hara R, Askari N, et al. The effect of oxybutynin treatment on cognition in children with diurnal incontinence. J Urol 2005; 173:2125.
- Youdim K, Kogan BA. Preliminary study of the safety and efficacy of extended-release oxybutynin in children. Urology 2002; 59:428.
- Goessl C, Sauter T, Michael T, et al. Efficacy and tolerability of tolterodine in children with detrusor hyperreflexia. Urology 2000; 55:414.
- Nijman RJ, Borgstein NG, Ellsworth P, Djurhuus JC. Tolterodine treatment for children with symptoms of urinary urge incontinence suggestive of detrusor overactivity: results from 2 randomized, placebo controlled trials. J Urol 2005; 173:1334.
- Raes A, Hoebeke P, Segaert I, et al. Retrospective analysis of efficacy and tolerability of tolterodine in children with overactive bladder. Eur Urol 2004; 45:240.
- Yucel S, Akkaya E, Guntekin E, et al. Should we switch over to tolterodine in every child with non-neurogenic daytime urinary incontinence in whom oxybutynin failed? Urology 2005; 65:369.
- Reinberg Y, Crocker J, Wolpert J, Vandersteen D. Therapeutic efficacy of extended release oxybutynin chloride, and immediate release and long acting tolterodine tartrate in children with diurnal urinary incontinence. J Urol 2003; 169:317.
- Andersson KE, Martin N, Nitti V. Selective β₃-adrenoceptor agonists for the treatment of overactive bladder. J Urol 2013; 190:1173.
- Kramer SA, Rathbun SR, Elkins D, et al. Double-blind placebo controlled study of alpha-adrenergic receptor antagonists (doxazosin) for treatment of voiding dysfunction in the pediatric population. J Urol 2005; 173:2121.
- Cain MP, Wu SD, Austin PF, et al. Alpha blocker therapy for children with dysfunctional voiding and urinary retention. J Urol 2003; 170:1514.
- 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.
- Vanderbrink BA, Gitlin J, Toro S, Palmer LS. Effect of tamsulosin on systemic blood pressure and nonneurogenic dysfunctional voiding in children. J Urol 2009; 181:817.
- Schulman SL. Voiding dysfunction in children. Urol Clin North Am 2004; 31:481.
- KEGEL AH. Stress incontinence and genital relaxation; a nonsurgical method of increasing the tone of sphincters and their supporting structures. Ciba Clin Symp 1952; 4:35.
- Nelson JD, Cooper CS, Boyt MA, et al. Improved uroflow parameters and post-void residual following biofeedback therapy in pediatric patients with dysfunctional voiding does not correspond to outcome. J Urol 2004; 172:1653.
- Schulman SL, Von Zuben FC, Plachter N, Kodman-Jones C. Biofeedback methodology: does it matter how we teach children how to relax the pelvic floor during voiding? J Urol 2001; 166:2423.
- Herndon CD, Decambre M, McKenna PH. Interactive computer games for treatment of pelvic floor dysfunction. J Urol 2001; 166:1893.
- McKenna PH, Herndon CD, Connery S, Ferrer FA. Pelvic floor muscle retraining for pediatric voiding dysfunction using interactive computer games. J Urol 1999; 162:1056.
- Vasconcelos M, Lima E, Caiafa L, et al. Voiding dysfunction in children. Pelvic-floor exercises or biofeedback therapy: a randomized study. Pediatr Nephrol 2006; 21:1858.
- Combs AJ, Glassberg AD, Gerdes D, Horowitz M. Biofeedback therapy for children with dysfunctional voiding. Urology 1998; 52:312.
- Yamanishi T, Yasuda K, Murayama N, et al. Biofeedback training for detrusor overactivity in children. J Urol 2000; 164:1686.
- Chin-Peuckert L, Salle JL. A modified biofeedback program for children with detrusor-sphincter dyssynergia: 5-year experience. J Urol 2001; 166:1470.
- Drzewiecki BA, Kelly PR, Marinaccio B, et al. Biofeedback training for lower urinary tract symptoms: factors affecting efficacy. J Urol 2009; 182:2050.
- Tugtepe H, Thomas DT, Ergun R, et al. Comparison of biofeedback therapy in children with treatment-refractory dysfunctional voiding and overactive bladder. Urology 2015; 85:900.
- Fazeli MS, Lin Y, Nikoo N, et al. Biofeedback for nonneuropathic daytime voiding disorders in children: a systematic review and meta-analysis of randomized controlled trials. J Urol 2015; 193:274.
- Palmer LS, Franco I, Rotario P, et al. Biofeedback therapy expedites the resolution of reflux in older children. J Urol 2002; 168:1699.
- Groen J, Bosch JL. Neuromodulation techniques in the treatment of the overactive bladder. BJU Int 2001; 87:723.
- Trsinar B, Kraij B. Maximal electrical stimulation in children with unstable bladder and nocturnal enuresis and/or daytime incontinence: a controlled study. Neurourol Urodyn 1996; 15:133.
- Gladh G, Mattsson S, Lindström S. Anogenital electrical stimulation as treatment of urge incontinence in children. BJU Int 2001; 87:366.
- Hoebeke P, Van Laecke E, Everaert K, et al. Transcutaneous neuromodulation for the urge syndrome in children: a pilot study. J Urol 2001; 166:2416.
- Bower WF, Moore KH, Adams RD. A pilot study of the home application of transcutaneous neuromodulation in children with urgency or urge incontinence. J Urol 2001; 166:2420.
- Barroso U Jr, Lordêlo P, Lopes AA, et al. Nonpharmacological treatment of lower urinary tract dysfunction using biofeedback and transcutaneous electrical stimulation: a pilot study. BJU Int 2006; 98:166.
- De Gennaro M, Capitanucci ML, Mastracci P, et al. Percutaneous tibial nerve neuromodulation is well tolerated in children and effective for treating refractory vesical dysfunction. J Urol 2004; 171:1911.
- Humphreys MR, Vandersteen DR, Slezak JM, et al. Preliminary results of sacral neuromodulation in 23 children. J Urol 2006; 176:2227.
- Malm-Buatsi E, Nepple KG, Boyt MA, et al. Efficacy of transcutaneous electrical nerve stimulation in children with overactive bladder refractory to pharmacotherapy. Urology 2007; 70:980.
- Roth TJ, Vandersteen DR, Hollatz P, et al. Sacral neuromodulation for the dysfunctional elimination syndrome: a single center experience with 20 children. J Urol 2008; 180:306.
- Capitanucci ML, Camanni D, Demelas F, et al. Long-term efficacy of percutaneous tibial nerve stimulation for different types of lower urinary tract dysfunction in children. J Urol 2009; 182:2056.
- Schurch B, Corcos J. Botulinum toxin injections for paediatric incontinence. Curr Opin Urol 2005; 15:264.
- Dwyer ME, Vandersteen DR, Hollatz P, Reinberg YE. Sacral neuromodulation for the dysfunctional elimination syndrome: a 10-year single-center experience with 105 consecutive children. Urology 2014; 84:911.
- Hagstroem S, Mahler B, Madsen B, et al. Transcutaneous electrical nerve stimulation for refractory daytime urinary urge incontinence. J Urol 2009; 182:2072.
- Lordêlo P, Teles A, Veiga ML, et al. Transcutaneous electrical nerve stimulation in children with overactive bladder: a randomized clinical trial. J Urol 2010; 184:683.
- Schober MS, Sulkowski JP, Lu PL, et al. Sacral Nerve Stimulation for Pediatric Lower Urinary Tract Dysfunction: Development of a Standardized Pathway with Objective Urodynamic Outcomes. J Urol 2015; 194:1721.
- Schurch B, Hauri D, Rodic B, et al. Botulinum-A toxin as a treatment of detrusor-sphincter dyssynergia: a prospective study in 24 spinal cord injury patients. J Urol 1996; 155:1023.
- Petronijevic V, Lazovic M, Vlajkovic M, et al. Botulinum toxin type A in combination with standard urotherapy for children with dysfunctional voiding. J Urol 2007; 178:2599.
- Hoebeke P, De Caestecker K, Vande Walle J, et al. The effect of botulinum-A toxin in incontinent children with therapy resistant overactive detrusor. J Urol 2006; 176:328.
- Léon P, Jolly C, Binet A, et al. Botulinum toxin injections in the management of non-neurogenic overactive bladders in children. J Pediatr Surg 2014; 49:1424.
- Metwalli AR, Cheng EY, Kropp BP, Pope JC 4th. The practice of urethral dilation for voiding dysfunction among fellows of the Section on Urology of the American Academy of Pediatrics. J Urol 2002; 168:1764.
- Pohl HG, Bauer SB, Borer JG, et al. The outcome of voiding dysfunction managed with clean intermittent catheterization in neurologically and anatomically normal children. BJU Int 2002; 89:923.
- Saedi NA, Schulman SL. Natural history of voiding dysfunction. Pediatr Nephrol 2003; 18:894.
- Beksac AT, Koni A, Bozacı AC, et al. Postvoidal residual urine is the most significant non-invasive diagnostic test to predict the treatment outcome in children with non-neurogenic lower urinary tract dysfunction. J Pediatr Urol 2016; 12:215.e1.
- Kuh D, Cardozo L, Hardy R. Urinary incontinence in middle aged women: childhood enuresis and other lifetime risk factors in a British prospective cohort. J Epidemiol Community Health 1999; 53:453.
- Our approach
- CONSERVATIVE MANAGEMENT
- Voiding behavior modification
- Treatment of constipation
- Other measures
- DIRECTED THERAPY
- PHARMACOLOGIC THERAPY
- Anticholinergic agents
- - Oxybutynin
- Side effects
- - Other anticholinergic agents
- - Our approach
- Beta3-adrenoceptor agonists
- Alpha adrenergic receptor antagonists
- OTHER TREATMENTS
- Biofeedback and pelvic floor muscle training
- - Indications
- Electrical stimulation therapy (neuromodulation)
- - Indications
- Botulinum toxin
- LONG-TERM PROGNOSIS
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS