Voiding Disorders

Συσχέτιση του πάχους τοιχώματος της Ουροδόχου κύστεως με τα Ουροδυναμικά ευρήματα σε παιδιά με πρωτοπαθή Νυκτερινή Ενούρηση

Βραβειο καλύτερης κλινικοεργαστηριακής εργασίας στο Πανελλήνιο Ουρολογικό Συνέδριο 2010Η Πρωτοπαθής ΝΕ (ΠΝΕ) είναι μια κοινή διαταραχή που επηρρεάζει το 15%-20% των 5 χρονών παιδιών, 10% παιδιών ηλικίας 7 έως 12 χρόνων και έως και 2% των ενήλικων. Ενώ η ακριβής αιτιολογία αυτής της πάθησης έγκειται σε πολλούς παράγοντες προφανώς ακόμα δεν έχει διευκρινιστεί εντελώς. Ο κοινός παθοφυσιολογικός παράγοντας φαίνεται να εμπλέκει την αναντιστοιχία της νυκτερινής παραγωγής ούρων που υπερβαίνει τη λειτουργικής χωρητικότητας της κύστεως, σε συνδυασμό με την αποτυχία αφύπνισης εξαιτίας της αίσθησης της πεπληρωμένης κύστεως. Επίσης , η υπερδραστήρια κύστη έχει παρατηρηθεί σε παιδιά με ΝΕ. Στην παρούσα μελέτη ερευνήσαμε το BWTh που μετρήθηκε με US σε παιδιά με ΠΝΕ με σκοπό να εκτιμηθεί αν το US μπορεί να χρησιμοποιηθεί επιπρόσθετα των UDS μελετών κατά την διάγνωση και την παρακολούθηση παιδιών με ΠΝΕ. Η συσχέτιση μεταξύ του BWTh και των ουροδυναμικών ευρημάτων αναλύθηκαν και παρουσιάζονται στη παρούσα μελέτη.

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OVERACTIVEBLADDER IN CHILDREN

Idiopathic overactive bladder (OAB) is a term that has been adopted by the International Continence Society (ICS) to describe the symptom complex of urinary urgency, which may or may not be associated with urgency urinary incontinence, urinary frequency, and nocturia in the absence of pathologic or metabolic factors that cause or mimic these symptoms.

OAB is often referred to as urge syndrome and is best characterized by frequent episodes of an urgent need to void, countered by contraction of the pelvic floor muscles and holding maneuvers such as squatting and the Vincent curtsy sign. Figure

Depending on fluid intake and urine production, children may experience more episodes of incontinence later in the day as a consequence of fatigue and an impaired ability to concentrate.

In some cases, children with OAB remain dry during the day yet wet at night. However, such children experience daytime urgency and, often, daytime frequency.

International statistics

Studies performed have demonstrated that 2-4% of 7-year-old children have daytime or combined daytime and nighttime incontinence at least once per week and that it is more common in girls than in boys

In a population-based study of children aged 4-6 years in Australia, 19.2% had at least 1 daytime wetting episode in the preceding 6 months, with 16.5% having experienced more than 1 wetting episode and only 0.7% experiencing wetting on a daily basis. Up to 50.7% of children with daytime wetting have been noted to have urgency, with 79% wetting themselves at least once in a 10-day period

Age-related differences in incidence

Urge symptoms seem to peak in children aged 6-9 years and to diminish as they approach puberty, with an assumed spontaneous resolution rate for daytime wetting of 14% per year. The prevalence of urinary incontinence in 7-year-old Swedish children, found that diurnal incontinence was more common in girls (6.7%) than in boys (3.8%)..

The clinical presentation of overactive bladder (OAB) in children is similar to that in adults. The clinical features include urgency, urinary frequency, urinary urge incontinence, and nocturia or nocturnal enuresis.

Voiding Cystourethrography

Voiding cystourethrography (VCUG) is indicated in children with a history of a febrile UTI or recurrent UTIs, depending on age, to rule out vesicoureteral reflux.

Frequency/Volume Chart or Bladder Diary

A frequency/volume chart or bladder diary is helpful in the evaluation of pediatric OAB symptoms. Ideally, these charts should encompass a 3-day period. This will allow assessment of the child’s functional bladder capacity.

Uroflow Study

A uroflow study is also helpful in the assessment of OAB symptoms and is performed by having the child void into a specialized collection device

Postvoid Residual Volume Study

Postvoid residual volume determination is useful in ruling out dysfunctional voiding as a source of symptoms. In children, except in small infants, the bladder completely empties during each micturition.

Approach Considerations

Initial management of overactive bladder (OAB) involves a behavioral and cognitive approach. The child and caregiver must be educated on normal bladder and sphincter function. Pharmacologic treatment is initiated if behavioral therapy fails or symptoms are severe. Medical comorbidities should be treated. Surgical treatment may be considered if behavioral therapy and pharmacologic therapy fail.

As with adults, older children often institute various coping strategies, including defensive voiding, toilet mapping, and restriction of fluid intake. Thus, the management of OAB must consider not only the detrusor overactivity but also the responses to it.The volume and types of fluids should be assessed and modifications made to encourage normal fluid intake as well as avoidance of potential bladder irritants and diuretics such as caffeine.

Tips for Trouble-Free Toilet Training for kids

When you think it’s time, offer these tips for getting kids trained:

• Look for signs of readiness. These include showing interest in the potty or toilet; staying dry during naps or for several hours during the day; being able to follow simple directions; being able to pull down their own pants; and using words, posture or facial expressions that indicate they have to go.
• Make a small potty available in the bathroom. Try doing practice runs when you think your toddler might need to go by having him sit or stand in front of the potty for a few minutes several times a day. Most likely, your toddler won’t actually go. But it can help him recognize the urge to go and associate the potty with it.
• If your child resists, don’t sweat it. Setting up a battle of wills will only make the process unnecessarily difficult for mom and dad. Back off for a few weeks, then try again.
• While potty training, avoid asking: “Do you have to go to the potty?” You’re almost guaranteed your child will tell you “no.”

If a child is 4 or 5 and still not staying dry during the day, or if you suspect a physical cause, discuss it with your Pediatric Urologist.