Voiding disorders in children
Voiding disorders are commonly encountered in our daily practice.They most often result from functional disturbances caused by malfunctioning of the lower urinary tract or delayed maturation of the central nervous system.
Maturation of the nervous and urinary system occurs gradually as the child develops. Voiding occurs involuntarily in infants as the brain is not yet involved.Conscious control over voiding is gained as child grows. At the age of 3 years, a child should be able to control the voiding reflex and urinate at a convenient time and place.
Normal Bladder cycle -:
- In a normal cycle, your child’s bladder stretches easily when it fills with urine and then contracts fully during voiding.
- There should be no premature contractions of the bladder or increases in pressure as it fills.
- During the normal voiding phase, there should be complete relaxation of the external urethral sphincter muscle so the urine released from the bladder flows smoothly and completely, without interruption, as the bladder empties itself.
- An interrupted or intermittent flow of urine or incomplete emptying are signs of voiding dysfunction.
Voiding dysfunction means that your child is unable to completely empty her bladder.
Whatever the reason, some children get into a pattern of not relaxing their external urethral sphincters. Their bladders can tolerate this for months and in some cases years, depending on how hard the child works to avoid urinating.Eventually the bladder muscle, which has to continually work against this voluntary blockage, will become so strong that it will overcome the blockage and periodically empty on its own, whether the child is sitting in a classroom or out on the soccer field
What causes voiding dysfunction?
Sometimes, the disruption of the voiding cycle may be the result of a neurological problem. This could be the result of an abnormality of the spinal cord or brain that affects how nerves help control the function of the bladder and urinary sphincter.
However, it’s more often a learned problem. For example, your child may continually hold his urine in all day because he doesn’t want to stop playing to go to the bathroom.
Children get into this routine for different reasons:
- Some may be routinely too busy to break for the bathroom.
- Others may have experienced a urinary tract infection that caused pain and as a result are afraid of urinating.
- Sometimes the problem is related to abnormal potty training.
- A child may have taken on abnormal urinating habits from the beginning.
What are the symptoms of voiding dysfunction?
Incontinence during the day and night may be the first sign that there is a problem.
Other symptoms include:
- Urinary tract infection
- frequent urination
- urgent urination
- pain or straining with urination
- hesitancy
- dribbling
- intermittent urine flow
- pain in the back, flank, or abdomen
- blood in the urine
How is voiding dysfunction diagnosed?
If your child is experiencing the symptoms described above, it’s likely that he’ll be referred to a Paediatric urologist for evaluation. The Paediatric urologist will most likely take a history of your child’s voiding patterns and may ask you to create a voiding diary. This is the most important component of correctly diagnosing a dysfunctional voiding pattern. The voiding diary is a 48-hour record of urinary output and fluid intake. Voiding diary allows to analysethe number of voids and daily urine output.
This is usually followed by a thorough physical examination, urinalysis, and urine culture
- Renal bladder Ultrasound: The test is used to determine the size and shape of the your child’s kidney, and to detect a mass, obstruction or other abnormalities.
- Blood tests: To see how well your child’s kidneys are working
- Voiding Cystourethrogram (VCUG): Aspecial X-raythat is done by inserting a catheter in the bladder and injecting a dye through it and visualizing your child’s urinary tract in X-ray. The images will show if there is any abnormality in the bladder or urethra (like obstruction) or is there any reverse flow of urine into the ureters and kidneys also known as Vesicoureteric reflux or VUR.
- Uroflowmetry: It is a non-invasive test which evaluates voiding in near-natural conditions. The flow curve is a product of detrusor contraction strength and bladder outlet resistance. A normal non-obstructed flow curve is bell-shaped. Abnormal curves are plateau-shaped, tower-shaped, interrupted-shaped, staccato-shaped and indicate different types of abnormalities.
- Urodynamic studies or UDS: It is a detailed study of bladder function may be used to both confirm the diagnosis of a dysfunctional voiding pattern and to document the effect of the medications.
How is voiding dysfunction treated?
- The most important instruction to the parent and child is to have your child completely relax while urinating – Taking more time in the bathroom.
- A timed voiding schedule – where you’ll ask your child to go to the bathroom right when he wakes up, every two to three hours thereafter, and upon going to bed at night.
- Avoiding constipation
- Eating a high fiber diet
- Increasing water consumption
- Perineal hygiene
- Changing their posture or position during voiding
- Emptying the bladder twice to make sure it voids completely
These simple changes are often enough to help your child work through the problem.
- In some children, however, medication may be necessary to decrease bladder hyperactivity enough to facilitate attempted changes in voiding habits.
- Rarely, extensive reconstructive surgery such as bladder augmentation(adding a piece of the intestine or stomach to the bladder to increase bladder capacity) may be necessary
- It’s essential to prevent urinary tract infections and make sure that any other associated problems, such as vesicoureteral reflux, bladder dysfunction, or kidney problems, are being appropriately controlled.
The key with voiding dysfunction is to identify it early on, treat it, and limit the possible negative effects it can have on your child’s urinary system.
