Chronic Urinary Problems

Ann P. Guillot MD

Ida J. McNamara BSN, RN

INTRODUCTION

Problems with the genitourinary tract often present in the course of childhood. These range from the acute to the chronic, from the merely annoying to the life threatening, and from the readily treatable to those for which there is no effective treatment. This chapter discusses normal voiding and then presents the diagnosis and primary care management of several common chronic urinary problems.

Normal Voiding

ANATOMY, PHYSIOLOGY, AND PATHOLOGY

Normal physiologic and developmental progression from infancy to later childhood includes the attainment of urinary continence, with the attendant ability to empty the bladder completely and voluntarily. The age of learning to use the toilet reliably is debatable and may depend a great deal on parenting styles. Self-toileting for urination usually occurs some time before the fourth birthday and may occur by the second birthday for some children.

The tasks involved in bladder control are complex. The normal infant voids reflexively, emptying the bladder completely as soon as it begins to fill. The bladder muscle is called the detrusor. In infancy, the detrusor has not yet developed the ability to relax with filling; thus, small volumes of urine produce a rise in pressure, which then triggers voiding. For the first few months of life, infants void about 20 times a day.

During the second year of life, the detrusor begins to relax as it fills with urine, and the interval between voids lengthens out. Voiding is still involuntary. It is not until the next phase of development that the child develops central recognition of the sensation of bladder fullness. This sensation allows activation of the external sphincter, keeping the sphincter closed until voluntary voiding can take place.

Even after the child has developed the ability to recognize the sensation of fullness and maintain continence, the job of voiding is complex. The youngster must get to the toilet, manage clothing removal, and then allow sphincter relaxation at the same time that the detrusor contracts to empty smoothly and completely. The whole process is not developmentally easy, requiring the cooperation of autonomic, sensory, and motor nervous systems and skeletal and smooth muscles.

Primary Nocturnal Enuresis

Primary nocturnal enuresis (PNE) is defined as nighttime bedwetting after daytime continence has been achieved. There may be a genetic component in PNE.

EPIDEMIOLOGY

Normal progress toward full diurnal and nocturnal continence can go awry in many ways. The most common is PNE. Although the exact causes are unknown, many children are affected. About 20% of 5-year-olds wet consistently during sleep. Every year of life, some 15% of affected children outgrow the disorder. There is a very high incidence of positive family history in children who have PNE. Often, children find it helpful to know that other family members have had to deal with nighttime bedwetting and have been able to stay dry as they have grown older.

HISTORY AND PHYSICAL EXAMINATION

Often families will seek help for their child to overcome PNE. The initial history and physical examination can be helpful to the child and family, and it gives the primary care provider important information.

The history should clarify the following issues:

Is the problem primary (has always been present, with no consistent period of dry nights, lasting more than 6 months) or secondary (has recurred after consistent dryness for more than 6 months)?
Does wetting occur only during sleep (nocturnal enuresis) or also during waking hours (diurnal enuresis)?
Is there a family history of voiding problems (other affected family members may never have discussed the problem)?
Is there any history of UTIs or UTI symptoms?

The provider should also note the following:

The voiding pattern, especially frequency, urgency, or dribbling urinary stream;
Any history of constipation, because bowel and bladder emptying problems are often associated;
Whether the child exhibits excessive drinking, especially the need the drink during the night (enuresis is rarely due to polyuria secondary to diabetes mellitus or to a urinary concentrating defect);
Other neurodevelopmental problems, whether motor or cognitive (most children with PNE do not differ developmentally from their peer group in this respect);
The family’s thoughts and attitudes about the enuresis, because PNE can be a major stressor that may affect many other areas of childrearing.

The physical examination should evaluate the child for the following:

Growth, using a growth chart and previous and current growth values;
Blood pressure, using norms for age and height;
A palpable bladder, which suggests inefficient or incomplete emptying;
Abnormalities of the external genitalia;
Anal tone, which may be decreased if sacral innervation is abnormal;
Lower extremity strength and reflexes, which may be abnormal if lumbosacral innervation is abnormal;
Abnormalities of the lower back, including pigmentation, hairy patches, dimples, or sinus tracts over the lumbosacral spine (all clues to spinal cord problems).

If the history confirms PNE without any history of UTIs, abnormalities of daytime voiding pattern, excessive thirst, or developmental abnormalities, and if the physical examination is normal, a urinalysis and urine culture should be done to rule out any evidence of UTI, glycosuria, significant proteinuria, or hematuria. If these tests also are normal, the diagnosis of uncomplicated PNE is made.

MANAGEMENT

There are several approaches to caring for this problem. First, the family should understand that it is a common problem and one that many children outgrow spontaneously. If the family and patient desire a more active approach to hurrying the resolution, the most successful treatment is behavioral. This may consist of a reward system (eg, a sticker chart rewarding dry nights) and counseling the child to assume more responsibility for the problem (eg, taking responsibility for changing sheets when they are wet). In addition, some families have had success with a frequent waking program, in which the parent wakes the child several times during the early night to void, until the child can stay dry without prompting.

Moisture monitors, such as the battery-driven bell and pad, have been useful for some children. These work by awakening the child as he or she starts to void, thus conditioning the youngster to wake at the sensation of bladder fullness.

The success rate of focused behavioral programs (with or without monitors) is about 75%. The relapse rate after treatment is stopped (20%) is the lowest of all the therapies (Schmitt, 1997; Monda & Hussman, 1995; Tietjen & Hussman, 1996). These treatments aim to teach the child to awaken at the sensation of bladder fullness and to avoid reflex voiding. They are therefore the most physiologically normalizing of the therapies, but they require the most effort and motivation on the part of the child and the family to carry out.

Medications, including tricyclics and DDVAP (desmopressin), can be used, but their effectiveness and side effects make them controversial. Imipramine has been used since the 1960s for this purpose and is fairly effective. However, if an overdose is taken, the side effects are lethal. Even at the prescribed dose, the drug may increase blood pressure. Once the drug is stopped, the relapse rate of nocturnal enuresis is high. DDAVP can be used intranasally and/or orally in a dose of 10 to 40 μg at bedtime and is also quite effective. However, there have been case reports of seizures secondary to hyponatremia during use of this drug, and the relapse rate once it is discontinued is very high. It is perhaps best to use DDAVP in the lowest effective dose and only for short-term, intermittent episodes (eg, to maintain continence while at overnight camp) (Robson, 1998).

It is important that the provider attend to the family dynamics surrounding the continence issue, because it is often a heavily charged one. The clinician must be willing to spend time with both the child and the family to explore the anxiety and discouragement that accompany PNE, no matter what treatment is chosen. The more the child can feel responsible for making progress and the more encouraging the family can be, the better. Chapter 63 offers an in-depth discussion of primary care management of PNE using behavioral therapies.

Secondary Enuresis and Other Forms of Voiding Dysfunction

When the initial history reveals that the child has had a period of dryness for 6 months or more and then starts to have enuresis, or when the child has daytime wetting, the likelihood is much higher that there will be associated physiologic abnormalities and that treatment will be more complicated. Likewise, further diagnostic evaluation is indicated when there are abnormalities in the physical examination, as previously described. There is a greater than 60% chance that children in this category will have associated UTIs, which are often recurrent. This figure has not altered in intervening decades (Dodge, West, Bridgforth, & Travis, 1970; Jones et al., 1972). Children who meet these criteria should have a urinalysis and urine culture. They should generally also have a renal ultrasound and fluoroscopic voiding cystourethrogram (VCUG). If abnormalities are apparent on the imaging studies, the patient should be referred to a pediatric urologist or nephrologist for consultation. If the child is constipated, efforts at treatment should begin. Antibiotic treatment for UTIs can be initiated, and efforts to empty the bladder regularly and completely can also be started.

Voiding dysfunction may be due to abnormalities in the bladder’s ability to relax and fill properly. This will lead to urgency incontinence and frequency, which may be treated with an anticholinergic drug, such as oxybutynin. UTIs will complicate and exacerbate bladder irritability. If UTIs are recurrent, antibiotic prophylaxis may be necessary over a several-month period as well.

Bladder or sphincter dysfunction exists when the bladder fills well, but the sensation of fullness is poor and the sphincter does not relax well enough to allow an uninterrupted urinary stream. The bladder may have a very large capacity, but it will be incompletely emptied with each void. The residual urine in the bladder increases the risk of UTI and may add to the risk of bladder irritability or even to the risk of vesicoureteral reflux. The child with bladder or sphincter dysfunction requires behavior modification. Through practice, the child learns to empty the bladder regularly, every 2 hours while awake, taking care to allow time to empty completely. The child may need to use a timer as a reminder to stay on the toilet for 2 to 5 minutes; distraction techniques may be needed for the younger child. To achieve success with this plan, the child’s understanding and intent to participate are essential.

• Clinical Pearls

The conversation about timed voiding and staying on the toilet long enough to empty must take place between the provider and the child.
The topic can be tremendously frustrating to both child and parents, requiring consistency in approach over a long period of time. The provider should help the parents in enlisting the understanding and support of the school, including teachers and the school nurse, as well as any day care providers.
If UTIs are present, prophylactic antibiotic treatment may be required. If urgency is part of the picture, an anticholinergic drug may be useful.

Both UTIs and urgency can be associated with enough increase in bladder pressure to cause actual damage to the renal parenchyma. A small percentage of patients with severe bladder dysfunction will progress to end-stage renal failure. Most, however, will be amenable to bladder management and can attain dryness with consistent efforts to control UTIs or urgency, while promoting good bladder emptying. Chapter 63 may provide the reader with other insights into the diagnosis and management of secondary enuresis.

Children who have reflux must be managed appropriately for that disorder, as described in the following section. Those rare patients whose enuresis is caused by true polyuria will share the characteristic of drinking large volumes of liquids, even waking at night to drink. They need to be assessed more fully and, in fact, require referral to a pediatric endocrinologist or a pediatric nephrologist for evaluation.

Vesicoureteral Reflux

ANATOMY, PATHOLOGY, AND PHYSIOLOGY

Ordinarily, the ureters pump urine into the bladder, and the junction of the ureter with the bladder tunnels inside the bladder wall long enough to create extrinsic pressure on the ureter. The result is that urine is trapped in the bladder and not allowed to move back up the ureter, even when the pressure inside the bladder is great. When the peristaltic activity of the ureter is poor or when the ureteric tunnel in the bladder wall is too short, the pressure inside the bladder may cause urine to move back up the ureter toward the kidney. This situation is called vesicoureteral reflux (VUR). VUR exerts pressure on the renal parenchyma while also bringing bacteria from the bladder, which may cause renal scarring even when VUR is asymptomatic, especially in the young child.

Although common, VUR decreases in incidence as children grow. Therefore, if VUR is mild or moderate, scarring of the kidneys can be prevented if the patient can be kept free of infection until spontaneous resolution occurs. Some children with the following conditions will require surgical correction of reflux:

Very severe reflux
Breakthrough infections in spite of medical management
Failure of VUR to resolve and continued UTIs after several years of medical management

DIAGNOSTIC STUDIES

Vesicoureteral reflux can be diagnosed only by VCUG. This requires that a urethral catheter be placed and the bladder filled with fluid that can be imaged either by fluoroscopic or radionuclide technique. Renal ultrasound may suggest the presence of reflux if there is waxing and waning distention of the renal pelvis with voiding. However, neither renal ultrasound nor intravenous pyelogram (IVP) can rule out the presence of VUR.

Occasionally, a diagnosis of UTI may be unclear. There may be fever or flank pain without a clearly positive urine culture. In this situation, a renal scan using dimercaptosuccinic acid (DMSA) is the most sensitive test available to find areas of poor renal function characteristic of pyelonephritis. The DMSA scan is also useful in defining areas of renal scarring and has replaced the IVP in most cases for this purpose.

MANAGEMENT

When a child is managed medically for VUR, a urine culture should be done whenever symptoms suggesting UTI are present, including fever. The patient should also have occasional surveillance cultures when not symptomatic (ie, every 1–2 months). Surveillance cultures are especially important if the child is very young or if there is bladder dysfunction. Surveillance cultures may be collected by clean-catch or bag, and are useful if negative. If results are positive or unclear,
the culture will need to be repeated promptly by catheterization or suprapubic aspiration. Follow-up imaging should be done annually to monitor for resolution of the reflux and for normal growth of the kidneys (Elder et al., 1997).

Clinical Warning

If breakthrough infections occur, if there is bladder dysfunction in a child with reflux, or if spontaneous resolution does not occur, the patient should be referred to a pediatric urologist or nephrologist for consultation.

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