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Bladder and bowel dysfunction in children: An update on the diagnosis and treatment of a common, but underdiagnosed
Joana Dos Santos1, Roberto I Lopes1, Martin A Koyle1
1Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada.
Insights
Bladder and bowel dysfunction (BBD) in children involves urinary and fecal issues, often linked to other conditions. Early treatment of BBD is crucial for better outcomes and preventing long-term health problems.
Area of Science:
- Pediatric Urology
- Pediatric Gastroenterology
- Child Psychology
Background:
- Bladder and bowel dysfunction (BBD) encompasses lower urinary symptoms and fecal elimination issues like constipation and encopresis in children.
- BBD is increasingly prevalent, causing significant physical and psychosocial distress for children and families.
- It frequently co-occurs with conditions such as vesicoureteral reflux (VUR), recurrent urinary tract infections (UTIs), attention-deficit/hyperactivity disorder (ADHD), and autism spectrum disorder (ASD), complicating treatment and outcomes.
Purpose of the Study:
- To review the clinical presentation, diagnostic approaches, and treatment strategies for BBD in children.
- To highlight the importance of early diagnosis and intervention to prevent secondary comorbidities.
- To provide guidance on behavioral, pharmacological, and surgical interventions based on current literature and expert opinion.
Main Methods:
- Comprehensive literature review of BBD in children.
- Analysis of diagnostic criteria and clinical presentation.
- Evaluation of evidence for various treatment modalities, including urotherapy, pharmacotherapy, and minimally invasive procedures.
Main Results:
- The majority of BBD cases improve with urotherapy, adequate fluid intake, and constipation management.
- Pharmacological interventions, primarily anticholinergics and alpha-blockers, are considered when conservative measures fail.
- Minimally invasive treatments like onabotulinumtoxinA injections and neurostimulation offer alternatives for refractory cases.
Conclusions:
- Early diagnosis and management of BBD are essential for improving children's health and well-being.
- A stepwise approach, starting with behavioral interventions and progressing to pharmacotherapy or minimally invasive treatments, is recommended.
- Addressing BBD is critical to prevent long-term renal and bladder complications, as well as psychosocial challenges.
Abstract:
Bladder and bowel dysfunction (BBD) describes a spectrum of lower urinary symptoms (LUTS) accompanied by fecal elimination issues that manifest primarily by constipation and/or encopresis. This increasingly common entity is a potential cause of significant physical and psychosocial burden for children and families. BBD is commonly associated with vesicoureteral reflux (VUR) and recurrent urinary tract infections (UTIs), which at its extreme may lead to renal scarring and kidney failure. Additionally, BBD is frequently seen in children diagnosed with behavioural and neuropsychiatric disorders such as attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Patients with concomitant BBD and neuropsychiatric disorders have less favourable treatment outcomes. Early diagnosis and treatment of BBD are critical to avoid secondary comorbidities that can adversely impact children's kidney and bladder function, and psychosocial well-being. The majority of patients will improve with urotherapy, adequate fluid intake, and constipation treatment. Pharmacological treatment must only be considered if no improvement occurs after intensive adherence to at least six months of urotherapy ± biofeedback and constipation treatment. Anticholinergics remain the mainstay of medical treatment. Selective alpha-blockers appear to be effective for improving bladder emptying in children with non-neurogenic detrusor overactivity (DO), incontinence, recurrent UTIs, and increased post-void residual (PVR) urine volumes. Alpha-1 blockers can also be used in combination with anticholinergics when overactive bladder (OAB) coexists with functional bladder outlet obstruction. Minimally invasive treatment with onabotulinumtoxinA bladder injections, and recently neurostimulation, are promising alternatives for the management of BBD refractory to behavioural and pharmacological treatment. In this review, we discuss clinical presentation, diagnostic approach, and indications for behavioural, pharmacological, and surgical treatment of BBD in children based on a thorough literature review. Expert opinion will be used when scientific evidence is unavailable.
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