Introduction
Children with voiding dysfunction have any one or more of these symptoms. The symptoms may be of short duration or long duration. Very often the parents believe this is part of growing up, part of training for urinary incontinence, and hence pay little attention to them. There is also a tendency for some children to postpone passing urine till the last minute like when they are playing or watching a TVserial or cartoon network etc. It is only much later, that the parents realize that these symptoms continue though none of the “reasons” are not there and then rush to their family doctor who may or may not apprise them of the importance of going to a qualified specialist for a check-up and treatment. Dysfunctional voiding may have different presentations in different children of the same age, and thus there can be no generalizations. As you can see, there may be a combination of urinary complaints along with bowel movement abnormalities. When there is a combination of constipation and urinary symptoms, the entity is known in Medical terms as Dysfunctional Elimination Syndrome. This is fairly common, and should not be ignored or overlooked terming it as part and parcel of growing up in that child.
• Recurrent urinary infections
• Straining to pass urine
• Burning or pain while urinating
• Frequent passing of urine during the day
• Urgency to pass urine, cannot hold back for a long time
• Passing urine with an intermittent stream
• Taking a long time to pass urine compared to others of the same age
• Feels like going back to pass urine soon after passing urine
• Constipation
• Wetting of the underclothes during the day
• Bed wetting at night time
• Foul-smelling urine frequently
• Not passing urine for a long period of > 8 – 10 hours
Normal voiding frequency in children after obtaining bladder control, at around 5 years age, is 4 – 7 voids per day. Voiding symptoms reflect alterations in urinary bladder function. The normal voiding cycle consists of bladder filling with urine storage, followed by bladder emptying with voiding. As the child grows from infancy to childhood, the brain takes over the control over micturition(passage of urine).
The micturition cycle involves 2 processes:
Bladder filling and storage of urine
Bladder emptying with voiding
Bladder filling allows the bladder to fill and expand at low pressure. Urine storage depends on bladder muscle(detrusor) inhibition of contractions. Expulsion of urine occurs due to simultaneous contraction of the detrusor muscle and relaxation of the bladder outlet.
Voiding symptoms can occur in a child who has neurological (nerve) abnormality or damage, or, due to a disturbance of the micturition cycle.
Symptoms like urge incontinence with holding maneuvers by children to postpone voiding & prevent leakage have been found in 7% of girls and 3% boys of the age between 5 and 9 years.
Daytime wetting with a frequency of once in 2 weeks has been noted in 10% of children age group 5-6 years, and 5% in age group 6-12 years, and 4% in the age group 12-18 years in the USA. In Sweden, in 7-year-olds, 21 % of girls and 18% of boys had moderate to severe urinary urgency. Daytime urinary incontinence once a week has been found in 3.1% of girls and 2.1% of boys. Some children may have an ongoing urge incontinence urinary dribbling or recurrent urinary infections. These may lead to severe social and emotional problems. Some children may have a transient period of urinary urgency, and occasional wetting accidents till they achieve daytime continence. Some may have persistence for an extended period.
The causes of voiding dysfunction may be many, few of them well defined, and may be present in a single child in various combinations or alone. The causes are :
Overactive bladder
Dysfunction of pelvic floor musculature
Decreased force of detrusor or underactive bladder.
Voiding dysfunction can ultimately lead to many other problems as they grow up without being corrected. A few children with functional voiding disorder may lead to significant renal damage. In other children with voiding disorders, an overactive bladder may contribute to the persistence of vesico ureteral reflux or even recurrence of reflux after surgery for correction of the reflux. In yet other children with voiding disorder, it may lead to incomplete emptying of the bladder, due to which urine stagnates within the bladder for a long time and leads to infection that can be transmitted to the upper tracts.
Even constipation can have an effect on bladder function: either by a direct effect of retained fecal material distending the rectosigmoid colon, or it may be the primary or contributing cause of a voiding disorder. Parents are often ignorant about stooling habits of their own children. Lastly, voiding disorders can result in negative self-esteem, especially in those with daytime incontinence.
Once the parents are made aware that this is an actual problem that needs to be evaluated and treated, they are not sure whom to visit and may land up visiting a doctor who is not trained to treat this problem systematically. This causes the symptoms to get aggravated, with no relief and new symptoms begin.
There could be many reasons for the dysfunctional voiding, most of them usually are functional in nature but must be properly defined, proven, and then specific treatment with or without one or more medications should be given and up over 1 year at least to see that the result is permanent. However, before labeling a child as having a functional cause, organic pathology must be ruled out. This is where a specialist comes into the picture, who will take a detailed history from the child and parents, do a thorough examination of the child from top to toe, get relevant investigations based on history and examination, then conclude if there is an organic problem. In the case of the latter, there may be a surgical solution which will eliminate the symptoms. In some children, more investigations will further make it obvious as to what needs to be done. There may be many children who do not have an organic cause, then based on the history, examination, and investigations, the specialist will start a regime suited for that child. The therapeutic regime may involve behavior modification, exercises, dietary modifications, and one or more oral medications. The regime has to be strictly followed by the child and enforced and supervised by the parents.