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Dysfunctional voiding
1Pediatric Department, University of Padova, Italy.
Insights
Understanding normal bladder development is key to identifying dysfunctional voiding (DV) in children. DV arises from issues in bladder capacity, sphincter function, or neural control, impacting continence and requiring thorough assessment.
Area of Science:
- Pediatric Medicine
- Urology
- Developmental Pediatrics
Background:
- Normal bladder storage relies on adequate capacity, low pressure, appropriate sensation, a closed outlet, and absence of involuntary contractions.
- Child continence development involves concurrent maturation of bladder capacity, urethral sphincter function, and neural control.
- Dysfunctional voiding (DV) in children is common but poorly understood, with unclear prevalence and etiology.
Purpose of the Study:
- To present milestones in normal childhood continence development.
- To define key factors in bladder storage and voiding control.
- To outline the assessment of children with lower urinary tract dysfunction and dysfunctional voiding.
Main Methods:
- Review of normal bladder development milestones and continence factors.
- Discussion of bladder storage requirements and maturational processes.
- Description of elements for evaluating functional voiding and signs of DV.
Main Results:
- Normal continence depends on the coordinated development of bladder capacity, sphincter function, and neural control.
- Abnormalities in these maturational sequences can lead to clinically significant bladder sphincter control issues.
- Dysfunctional voiding encompasses a range of symptoms including incontinence, frequency, urgency, and associations with UTIs and constipation.
Conclusions:
- Thorough assessment of children with lower urinary tract dysfunction requires detailed history, considering bladder capacity, voiding frequency, residual volumes, and flow rates.
- Standardized definitions by the International Children's Continence Society aid in distinguishing types of urinary incontinence.
- Clinical suggestions are provided for managing dysfunctional voiding in pediatric practice.
Abstract:
Wetting may be considered the Cinderella of paediatric medicine. Before discussing dysfunctional voiding, the milestones of the normal development of continence in the child and the definitions used to describe this topic are presented. Bladder storage requires (1): accommodation of increasing volumes of urine at low intravesical pressure and with appropriate sensation; (2): a bladder outlet that is closed and not modified during increase in intra-abdominal pressure; (3): absence of involuntary bladder contractions. Development of continence in the child involves three independent factors maturing concomitantly: (1) development of normal bladder capacity; (2) maturation of urethral sphincter function; (3) development of neural control over bladder-sphincter function. All these processes are discussed. Abnormalities of any of these maturational sequences, which run parallel and overlapping, may result in clinically evident abnormalities of bladder sphincter control. Although dysfunctional voiding (DV) in children is very common its prevalence has not been well studied and, to date, and its origin is not well known. In a correct evaluation of functional voiding we must take into account different elements: the bladder capacity (that increases during the first 8 years of life roughly 30 ml per year), the micturition frequency, post-void residual volumes, bladder dynamics, urinary flow rates. Thus the correct assessment of children with lower urinary tract dysfunction should include a detailed history. Signs of DV range from urge syndrome to complex incontinence patterns during the day and the night. In addition to incontinence problems, children may have frequency, urgency, straining to void, weak or interrupted urinary stream, urinary tract infections (UTIs) and chronic constipation with or without encopresis. DV are also referred in enuretic children who wet the bed more than one time per night and have a functional bladder capacity lower than attended for age. Recently standardisation and definitions of children's lower urinary tract dysfunction have been approved by International Children's continence Society (ICCS). The ICSS distinguishes between urinary incontinence, stress incontinence, overflow incontinence and urge syndrome. Clinical suggestions are presented for the daily practice.