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Correlation between uroflowmetry parameters and treatment outcome in children with dysfunctional voiding
Journal of Pediatric Urology (2010) 6, 396e402
Correlation between uroflowmetry parameters and treatment outcome in children with dysfunctional voiding Zivkovic Vesna a,*, Lazovic Milica a, Vlajkovic Marina b, Slavkovic Andjelka c, Dimitrijevic Lidija a a
Clinic of Physical Medicine, Rehabilitation and Prosthetics, Clinical Centre Nis, Bul. Zorana Djindjica 48, 18 000 Nis, Serbia b Department of Nuclear Medicine, Clinical Centre Nis, Bul. Zorana Djindjica 48, 18 000 Nis, Serbia c Clinic of Paediatric Surgery, Clinical Centre Nis, Bul. Zorana Djindjica 48, 18 000 Nis, Serbia Received 1 July 2009; accepted 23 September 2009 Available online 21 October 2009
KEYWORDS Urotherapy; Dysfunctional voiding; Pelvic floor exercises; Uroflowmetry
Abstract Purpose: To investigate the correlation between subjective (clinical) treatment outcome and objective uroflowmetry parameters and curve pattern in children with dysfunctional voiding. Method: Seventy-five children were randomly allocated to two urotherapy programs. Group A was submitted to standard urotherapy and pelvic floor exercises while group B received conservative treatment. Constipation and recurrent urinary tract infections (UTIs) were treated in both groups. Selected children from both groups received pharmacotherapy (anticholinergics or desmopressin). Uroflowmetry with electromyography of the pelvic floor and ultrasound post-void residual (PVR) urine volumes were obtained before and at the end of the 12-month treatment period. Uroflowmetry findings were stratified into two categories based on clinical treatment outcome: ‘cured’ and ‘unchanged’. Uroflowmetry findings were compared between categories at the beginning and the end of the investigation. Results: Voided volume, average and peak flow rates were significantly increased while PVR urine was decreased in children with cured urinary incontinence and nocturnal enuresis compared with ‘unchanged’ category. Significant decrease of PVR urine was noted in children with cured UTIs. The frequency of a bell-shaped curve was significantly higher compared to other curve patterns in children with cured urinary incontinence and UTIs. Conclusion: Post-treatment improvement in clinical symptoms correlated with improvement in uroflowmetry parameters and curve pattern. Correction of voiding phase is necessary for urinary continence achievement and resolution of UTIs. ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ381 63 833 97 87. E-mail address: [email protected] (Z. Vesna). 1477-5131/$36 ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2009.09.013
Correlation between uroflowmetry parameters and treatment outcome in children
Introduction Functional voiding disorders are the most common voiding problem in childhood [1]. The peak prevalence of functional urinary incontinence is at 7 years of age and girls are more affected than boys in all age groups [2,3]. Despite a high spontaneous remission rate, approximately 1% of children continue to wet their underwear in adolescence, which may cause not only psychological morbidity but also significant structural damage to the bladder wall and upper urinary tract [1]. After urge syndrome and voiding postponement, dysfunctional voiding is the third most frequent functional voiding disorder in children. It has been shown that up to 65% of children with UTIs aged between 5 and 9 years have dysfunctional voiding, compared to 23% of those without UTIs [4]. According to the 2006 ICCS standardization of terminology of lower urinary tract function in children, dysfunctional voiding denotes a disorder of the voiding phase of the micturition cycle which is due to involuntary intermittent contractions of the striated muscle of the external urethral sphincter or pelvic floor during voiding in neurologically normal individuals [5]. Urinary incontinence, hesitancy, straining, intermittency and/or weak stream are the typical clinical symptoms. Constipation, encopresis, recurrent UTIs and VUR are strongly associated with dysfunctional voiding [2]. The treatment usually starts with standard urotherapy including simple behavioral modifications, pelvic floor exercises and various forms of biofeedback (visual, tactile, electromyography) in order to teach a child pelvic floor muscle relaxation. In therapy-resistant cases characterized by large PVR urine and recurrent symptomatic UTIs, clean intermittent catheterization is introduced, and even botulinum toxin type A in the most severe cases [6]. Non-invasive urodynamic studies, such as uroflowmetry and electromyography (EMG) of the pelvic floor muscles (PFMs), have proved to be reliable in establishing the diagnosis of dysfunctional voiding and monitoring the treatment results [7]. Despite the high success rates that have been reported from urotherapy programs in children with dysfunctional voiding [8e10], several studies have indicated that post-treatment uroflowmetry findings did not follow patients’ subjective (clinical) improvement [7,11,12]. Therefore, the aim of this study was to analyze the relationship between subjective (clinical) outcome and objective post-treatment uroflowmetry parameters and curve pattern in dysfunctional voiders.
Patients and methods Patients Prospective clinical study included 86 patients with dysfunctional voiding who were referred to the Physical Medicine and Rehabilitation Clinic for urotherapy. All patients had previously been treated by pediatricians in primary care with timed voiding, hydration and constipation management for 3 months without significant success.
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Initial evaluation included a history and physical examination, a 48-h voiding diary, urinalysis and urine culture, ultrasound of kidneys and bladder and uroflowmetry with EMG of the pelvic floor. The diagnosis of dysfunctional voiding was based on clinical symptoms (urinary incontinence, hesitancy, straining, intermittency, weak stream) and three consecutive staccato and/or interrupted uroflowmetry curve shapes with positive EMG activity during micturition. X-ray VCUG was performed in all boys to exclude structural abnormalities of the lower urinary tract, and in all patients with recurrent UTIs to detect the presence of VUR. During the evaluation period all children were UTI free. Children with neurologic disorders, mental retardation and structural abnormalities of the lower urinary tract were excluded from the study.
Treatment groups After the parents had provided written informed consent, children were randomly divided into two groups. Randomization was performed by children drawing a sealed envelope with an enclosed assignment. Group A underwent pelvic floor rehabilitation and conservative treatment, while group B received only conservative treatment.
Treatment protocol The urotherapy program in both groups began with the education of the parents and children about the normal function of the bladder and external urinary sphincter and the nature of their voiding disorder, as well as their answering the questions regarding motivation for the treatment. If a child was not motivated for the treatment the program was delayed. The importance of regular fluid intake (200 ml 5e6 times per day) and regular voiding was also explained. In the same session, an optimal voiding posture was demonstrated in front of a mirror: a sitting position, with feet supported, hips abducted and abdominal muscles relaxed (both for boys and for girls). Special adaptations of toilet seats were made for smaller children and foot support was provided. After a child experienced the normal sensation of the need to void and a qualified physiotherapist provided simple voiding instructions, each child from both groups was asked to void. Micturition was supervised and corrections were made if necessary, with the aim of achieving a long, strong and loud void. Less than 1 min after voiding, PVR urine volume was measured by ultrasound. In group A children were individually taught to identify PFM. A physiotherapist enhanced the proprioception of PFM activity with each child by palpation. A child was asked to contract the PFM without activating the accessory muscles, and then to relax them. Self-palpation of PFM and m. transversus abdominis was used as a feedback of correct technique. Once a child had learned correct recruitment of the PFM, pelvic floor exercises were introduced. They included 3-s submaximal contractions followed by a prolonged, 30-s relaxation, with the emphasis on relaxation. Children were asked to do 30 repetitions of these exercises daily at home during the whole treatment period. During the treatment period children in both groups were asked to keep: a 48-h voiding diary, voiding chart, nocturnal
398 enuresis chart, and a defecation diary for 14 days, recording defecation frequency, stool consistency, episodes of fecal incontinence and abdominal pain. Additionally, parents of children with nocturnal enuresis were asked to weigh the diapers on wet nights and to record the volume of the first morning void for 1 week (nocturnal urine production). If nocturnal urine production exceeded 130% of expected bladder capacity for age the diagnosis of nocturnal polyuria was made [5]. Bladder capacity was calculated in milliliters using the formula: (age in years 30) þ 30 until the age of 12 years [5]. Reduced bladder capacity was diagnosed when maximal voided volume on 48-h voiding diary was less than 65% of expected bladder capacity for given age [5]. Rome III criteria were used for establishing the diagnosis of functional constipation [13]. Therapeutic sessions were held monthly in both groups. The number of sessions depended on the patient’s clinical (subjective) and objective improvement seen on uroflow. Every session in each group began with analysis of the diaries and charts, and recording of changes from the previous visit regarding urinary incontinence, nocturnal enuresis, defecation frequency and UTIs. Compliance with the treatment was discussed. In group A, every child was asked to perform pelvic floor exercises and corrections were made if necessary. The emphasis was put on regular pelvic floor training at home, and compliance with this was checked. When a child felt the normal need to void, uroflowmetry with EMG and PVR urine measurement was performed in both groups. All children were encouraged to continue with the therapy.
Constipation treatment Constipation was treated in both groups. The treatment consisted of parents’ and children’s education, regular toilet visits after major meals, adequate posture during defecation, and dietary and hydration changes. Laxatives (lactulose, 1 ml per kg body weight per day in one to three doses) were given during the treatment with the aim of achieving one to two stools of milkshake consistency each day.
Recurrent UTI treatment Children from both groups who had symptomatic UTIs and showed positive urine culture on monthly assessment were administrated antibiotic prophylaxis (nitrofurantoin, nightly dose of 1 ml per kg body weight) for 3 months.
Z. Vesna et al. with EMG was performed using a uroflowmeter (UF Master, MMS, The Netherlands). Skin EMG electrodes were placed symmetrically on the peri-anal skin at the 2 and 10o’clock positions. Children voided two times when they felt a need to void. Less than a minute after voiding, PVR urine was recorded by ultrasound (Aloka, SSD-500, Japan). The following parameters were evaluated: voided volume (VV, ml), average flow rate (AFR, ml/s), peak flow rate (PFR, ml/s), flow time (FT, s), shape of the curve, PVR urine volume and total bladder capacity. The shape of the uroflow curve was defined as normal (bell-shaped), staccato, interrupted and plateau according to the 2006 ICCS criteria [5]. A uroflowmetry curve with fluctuations larger than the square root of the maximum flow rate was defined as staccato. Interrupted curve was defined as the curve reaching the baseline during voiding. Plateau-shaped curve had a low amplitude and rather even flow. The 1998 ICCS definition of plateau type as a curve with a value of PFR/ FT < 0.5 was also used [14]. Total bladder capacity (PVR urine volume and voided volume) was expressed as a percentage of age-expected bladder capacity. Subjective treatment results were classified as ‘cured’ in children in whom urinary incontinence and nocturnal enuresis disappeared completely; ‘improved’ where there was a reduction in wetting episodes for more than 50% per week, and ‘unchanged’ where urinary incontinence and nocturnal enuresis persisted. In children with UTIs, less than one UTI per month was classified as ‘cured’, and UTIs that persisted as ‘unchanged’. Children with constipation 3 bowel movements per week, 2 episodes of fecal incontinence per month and no abdominal pain with no laxative treatment for >1 month were classified as ‘recovering’ [15]. Based on subjective (clinical) treatment outcome, uroflowmetry findings were stratified into two categories: ‘cured’ (the group of children in whom urinary incontinence, nocturnal enuresis and UTIs were cured) and ‘unchanged’. Uroflowmetry findings were compared between categories at the beginning and end of the investigation.
Data analysis Statistical analysis was done using the program SPSS 12.0 for Windows. Values were presented as means standard deviation. Descriptive statistics, non-parametric McNemar and parametric paired samples t-test were used. Differences were considered significant if P < 0.05.
Results Pharmacotherapy Patients from both groups who had reduced bladder capacity and did not have PVR urine were prescribed anticholinergics (oxybutynin chloride 0.3 mg/kg body weight per day). Antidiuretic hormone (desmopressin) 0.2 mg oral formulation was prescribed to be taken 1 h before going to bed in all the patients with nocturnal polyuria.
Treatment result evaluation One year after the beginning of the program the patients were re-evaluated by a pediatric urologist, who was unaware of the treatment groups. Control uroflowmetry
A total of 86 patients aged between 3 and 13 years were included in the study. Eleven children dropped out of the study due to non-appearance at the scheduled appointments. Out of 75 children enrolled in the study, 51 (68%) were girls. There were 43 patients in group A (65% girls) and 32 in group B (71% girls). Girls predominated over boys and that difference was statistically significant (P < 0.05). Mean age of children was 7.1 2.5 years. A significant difference in age between the groups and sexes was not found. During the treatment period almost 50% of children were receiving pharmacotherapy: 22 children in group A and 15 children in group B. Anticholinergics were prescribed in 11 children in group A and seven children in group B for
Correlation between uroflowmetry parameters and treatment outcome in children a 6.6-month period (range 3e12). Desmopressin was recommended in 11 children in group A and eight children in group B during a 10-month period (range 3e12). Mean number of therapeutic sessions was 6.5 (range 4e12) in group A and 10 in group B. VUR was detected in four girls in group A and five girls in group B. Antibiotic prophylaxis was prescribed in 15 children in group A and 13 children in group B due to recurrent symptomatic UTIs and VUR. In group A urinary incontinence was present in 24 out of 43 patients (56%) before the treatment. It was cured in 20 patients (P < 0.0001). In group B, out of 18 children (56%) who wetted their underwear during the day at study entry, only two were cured. Urinary incontinence was cured in a significantly larger number of children in group A than in group B (P < 0.001). Improvement in urinary incontinence was noted in three patients in group A (12.5%) and three patients (17%) in group B. Nocturnal enuresis was present in 21 patients (48%) in group A and 15 patients in group B (47%) before the treatment. In group A, nocturnal enuresis was cured in 14 patients (P < 0.0001) and in group B in five patients (33%). The cure rate was significantly higher in group A than in group B (P < 0.05). Improvement in nocturnal enuresis was noted in four boys in group A (21%) and two girls in group B (13.3%). In group A, the mean number of wetting episodes per day (2.5 2.9 vs 0.3 1.1, P < 0.0001) and night (2.6 3.0 vs 0.5 1.6, P < 0.05) per week was significantly reduced at the end of the treatment. In group B, the mean number of daytime wetting episodes (3.5 3.4 vs 2.9 3.3, P < 0.05) and night-time wetting episodes (2.3 2.8 vs 1.2 1.8, P < 0.01) per week was also significantly reduced at the end of the treatment. Nineteen children in group A (44%) and 15 children (63%) in group B had UTIs upon entering the study. UTIs were cured in 13 patients (P < 0.001) in group A and six patients (P < 0.05) in group B. Although more children were cured in group A, the difference was not statistically significant. There was recovery from constipation in all 15 patients in group A (P < 0.001) and in six out of 10 patients in group B (P < 0.05). Tables 1e3 compare pre- and post-treatment uroflowmetry parameters in children with cured/persisting urinary incontinence, nocturnal enuresis and UTIs. There were no significant differences in pre-treatment uroflowmetry findings between ‘cured’ and ‘unchanged’
399
categories. After the therapy, in children with cured urinary incontinence, VV, AFR and PFR were significantly increased (P < 0.05), while PVR urine was decreased (P < 0.05) compared to children who continued to wet during the day. A marked increase in VV, AFR and PFR (P < 0.05) and decrease in PVR urine were observed in children with cured nocturnal enuresis compared to children who continued to wet during the night. In children with cured UTIs only PVR urine demonstrated a marked decrease (P < 0.05) compared to children with persisting UTIs. All children had an abnormal uroflowmetry curve shape with increased pelvic floor activity during voiding on entering the study. In group A, the majority of children had a staccato curve shape, while interrupted curve was noted in six children before treatment. In group B, at presentation, 25 children had staccato while seven children demonstrated an interrupted voiding pattern. The relationship between the uroflowmetry curve shapes at the end of the study and the subjective (clinical) treatment outcome is shown in Table 4. A positive correlation was found between the frequency of the bell-shaped uroflowmetry curve and the treatment outcome in urinary incontinence: out of 22 children with cured urinary incontinence, a bell-shaped uroflow curve was observed in 18 (P < 0.001). In contrast, no relationship was found between the bell-shaped uroflowmetry curve and the treatment outcome in nocturnal enuresis (P Z 0.251), although the majority of children with cured nocturnal enuresis (68% of children) demonstrated a bell-shaped uroflow pattern. The post-treatment uroflowmetry curve type positively correlated with the treatment outcome in children with UTIs. A bell-shaped uroflow curve was observed in 73% of patients with cured UTIs (P < 0.05).
Discussion In this study we presented the clinical and objective results of two urotherapy programs and examined the correlation between objective uroflowmetry parameters and subjective improvement at the end of the 12-month treatment period. The symptomatic treatment results were significantly better in the group of children who had undergone pelvic floor training besides behavioral modifications and pharmacotherapy: urinary incontinence was cured in 83%, nocturnal enuresis in 66%, constipation in 100% and UTIs in 68% of the children. Our results are comparable to prior
Table 1 Comparison of uroflowmetry parameters between children with cured and persisting urinary incontinence before and after treatment. Before therapy
Voided volume (ml) Residual urine (ml) Average flow rate (ml/s) Peak flow rate (ml/s) Flow time (s) Total bladder capacity (%) Ns, not significant.
After therapy
Cured
Unchanged
P
Cured
Unchanged
P
292.6 181.2 34.3 53.8 10.2 4.6 20.9 8.8 30.1 17.6 133.1 70.9
169.2 66.2 42.8 38.5 9.6 5.6 23.1 12.7 26.7 17.1 97.0 38.2
<0.05 Ns Ns Ns Ns Ns
284.4 117.8 12.7 13.8 15.3 6.7 27.4 11.3 24.4 11.1 104.5 36.6
188.0 87.4 35.8 43.6 10.5 6.3 19.3 10.2 24.3 18.7 85.8 29.5
<0.05 <0.05 <0.05 <0.05 Ns Ns
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Z. Vesna et al.
Table 2 Comparison of uroflowmetry parameters between children with cured and persisting nocturnal enuresis before and after treatment. Before therapy
Voided volume (ml) Residual urine (ml) Average flow rate (ml/s) Peak flow rate (ml/s) Flow time (s) Total bladder capacity (%)
After therapy
Cured
Unchanged
P
Cured
Unchanged
P
230.3 109.8 37.1 60.7 7.9 3.4 20.7 10.3 34.5 18.9 96.5 42.6
179.7 88.3 47.3 21.5 6.8 2.9 14.0 5.8 27.2 8.0 117.9 58.8
Ns Ns Ns Ns Ns Ns
256.5 73.9 6.6 6.7 13.6 6.2 25.7 11.7 26.2 22.7 88.8 21.0
140.0 94.0 33.7 32.9 6.4 3.8 12.2 6.7 26.1 9.6 72.4 35.4
<0.001 Ns <0.05 <0.05 Ns Ns
Ns, not significant.
reports in which EMG biofeedback was used during urotherapy [7,10,11]. In the group of children who had conservative treatment and medicaments, urinary incontinence was cured in 11%, nocturnal enuresis in 33%, constipation in 60% and UTIs in 40%. McKenna and McKenna reported that conservative treatment, including education, hydration, regular voiding, and pieces of advice given in order to improve voiding phase, treatment of constipation and genital hygiene, could cure 20% of patients with dysfunctional voiding without further evaluation or medication [16]. Van Gool et al. emphasized that up to 50% of children with non-neurogenic bladderesphincter dysfunction can be cured with just an explanation and ‘remedial teaching’ [2]. The children in our study had the same education program in both groups which was repeated during monthly hospital visits. As pharmacotherapy was prescribed in nearly 50% of children, it certainly had an impact on overall treatment result. The number of patients taking medicaments was almost equal in the two groups, so the impact on treatment result in each group would be the same. Therefore, better clinical results in the group of children who had pelvic floor rehabilitation besides conservative treatment testify to the importance of pelvic floor therapy in the treatment programs of children with dysfunctional voiding. Focusing the child’s attention on the pelvic floor and teaching a child to isolate it and relax it during voiding and defecation are the main goals of the treatment. Bower pointed out in her article that ‘any rehabilitation of micturition must first establish pelvic floor awareness, proprioception and selective increase or decrease of levator activity’ [17].
Several studies of children with dysfunctional voiding have indicated that the objective results did not correlate with patients’ subjective (clinical) improvement [7,11,12]. In the study of Nelson et al., uroflowmetry findings did not correlate with the treatment outcome for urinary incontinence and UTIs [7]. Similarly, McKenna et al. reported improvement in urinary incontinence and enuresis in 89% of patients with dysfunctional voiding while improvement in uroflowmetry parameters was noted in only 42% of patients [11]. They linked this phenomenon to the theory of collateral neuroplasticity, indicating that after subjective improvement objective parameters will also improve after some time due to constant relaxation of pelvic floor muscles during voiding [11]. Additionally, the delay in objective results could be explained by the muscular remodeling. Unbalanced recruitment and relaxation of PFM during voiding in dysfunctional voiders is associated with conversion of specific muscle fiber types and changes in fiber diameter and concentration [17]. Reversal of fundamental changes to muscle physiology requires at least 8 weeks of corrected practice [17]. At the end of the investigation period in our study uroflowmetry parameters such are VV, AFR, PFR and PVR urine demonstrated significant improvements in children with cured urinary incontinence and nocturnal enuresis compared to children who continued to wet during the day and night. These results stress the correlation between subjective and objective improvement, suggesting that improvement of voiding phase verified through improvement of uroflowmetry parameters and especially PVR urine is necessary for gaining continence in dysfunctional voiders. In children with cured UTIs only PVR urine was significantly
Table 3 Comparison of uroflowmetry parameters between children with cured and persisting UTIs before and after treatment. Before therapy
Voided volume (ml) Residual urine (ml) Average flow rate (ml/s) Peak flow rate (ml/s) Flow time (s) Total bladder capacity (%) Ns, not significant.
After therapy
Cured
Unchanged
P
Cured
Unchanged
P
267.5 164.3 39.5 57.3 11.9 9.6 24.0 9.8 28.7 17.7 130.8 55.2
234.5 135.6 40.5 40.4 4.9 4.4 23.8 12.8 29.1 19.6 112.3 42.0
Ns Ns Ns Ns Ns Ns
267.7 128.7 11.1 10.7 15.5 6.0 27.8 7.6 18.2 7.4 106.4 39.2
249.8 105.4 36.3 43.3 14.1 6.6 27.9 13.4 21.4 10.2 103.8 27.0
Ns <0.05 Ns Ns Ns Ns
Correlation between uroflowmetry parameters and treatment outcome in children Table 4 voiding.
401
The relationship between treatment outcome and post-treatment uroflow curve type in children with dysfunctional
Bell-shaped Staccato Interrupted Plateau Total
Urinary incontinence
Nocturnal enuresis
UTI
Cured
Unchanged
Cured
Unchanged
Cured
Unchanged
18** 3 0 1 22
5 4 3 8 20
13 2 0 4 19
7 2 2 6 17
14* 5 0 0 19
4 9 1 1 15
Chi-square test: *P < 0.05, **P < 0.001.
reduced compared to children with persisting UTIs, confirming that PVR urine is the most important risk factor for UTIs in children [18]. In the European Bladder Dysfunction Study (EBDS) there was no correlation between flow pattern at free voiding and treatment outcome in dysfunctional voiding [12]. Analyzing the relationship between uroflow curve shape, the most important factor in interpreting pediatric uroflowmetry [19], and clinical outcome in our patients, it can be observed that the majority of children with a normalized uroflowmetry curve type after therapy showed clinical improvement as well. A bell-shaped curve pattern predominated in children with cured urinary incontinence and UTIs. Children who continued to have staccato and plateau uroflowmetry curves despite urotherapy were more likely to continue with daytime and night-time wetting and UTIs. These disparities with the results of the EBDS could be explained by the difference in the patients’ inclusion criteria. In the EBDS, the diagnosis of dysfunctional voiding was based on clinical manifestations: children who reported a staccato voiding pattern or voiding in multiple fractions with functional urinary incontinence were classified as dysfunctional voiders [12]. Only 67% of these children had a urodynamic pattern of increased PFM activity during voiding, out of which 75% demonstrated a staccato or am interrupted flow pattern on free voiding. The authors did not report whether the PFM activity in these children was also increased during free voiding. In the EBDS children were randomly allocated either to standard treatment or standard treatment plus pelvic floor training but the treatment results were not significantly different between the groups [2], which can be explained by the fact that pelvic floor training was not specifically prescribed only to the children with urodynamically proven dysfunctional voiding. Therefore, we recommend that every urotherapy program should be carefully planned and individually tailored according to clinical manifestations and uroflowmetry parameters and patterns. Further studies with larger numbers of patients are needed to make definite conclusions.
Conclusion Our results strongly suggest that pelvic floor rehabilitation is necessary in the majority of children with dysfunctional voiding for curing urinary incontinence, nocturnal enuresis, constipation and UTIs. Post-treatment uroflow
parameters and curve pattern correlated with improvement in urinary incontinence and UTIs. Larger prospective trials are needed to confirm the relationship between subjective (clinical) and objective improvement in dysfunctional voiders.
Conflict of interest None declared.
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Correlation between uroflowmetry parameters and treatment outcome in children with dysfunctional voiding Zivkovic Vesna a,*, Lazovic Milica a, Vlajkovic Marina b, Slavkovic Andjelka c, Dimitrijevic Lidija a a
Clinic of Physical Medicine, Rehabilitation and Prosthetics, Clinical Centre Nis, Bul. Zorana Djindjica 48, 18 000 Nis, Serbia b Department of Nuclear Medicine, Clinical Centre Nis, Bul. Zorana Djindjica 48, 18 000 Nis, Serbia c Clinic of Paediatric Surgery, Clinical Centre Nis, Bul. Zorana Djindjica 48, 18 000 Nis, Serbia Received 1 July 2009; accepted 23 September 2009 Available online 21 October 2009
KEYWORDS Urotherapy; Dysfunctional voiding; Pelvic floor exercises; Uroflowmetry
Abstract Purpose: To investigate the correlation between subjective (clinical) treatment outcome and objective uroflowmetry parameters and curve pattern in children with dysfunctional voiding. Method: Seventy-five children were randomly allocated to two urotherapy programs. Group A was submitted to standard urotherapy and pelvic floor exercises while group B received conservative treatment. Constipation and recurrent urinary tract infections (UTIs) were treated in both groups. Selected children from both groups received pharmacotherapy (anticholinergics or desmopressin). Uroflowmetry with electromyography of the pelvic floor and ultrasound post-void residual (PVR) urine volumes were obtained before and at the end of the 12-month treatment period. Uroflowmetry findings were stratified into two categories based on clinical treatment outcome: ‘cured’ and ‘unchanged’. Uroflowmetry findings were compared between categories at the beginning and the end of the investigation. Results: Voided volume, average and peak flow rates were significantly increased while PVR urine was decreased in children with cured urinary incontinence and nocturnal enuresis compared with ‘unchanged’ category. Significant decrease of PVR urine was noted in children with cured UTIs. The frequency of a bell-shaped curve was significantly higher compared to other curve patterns in children with cured urinary incontinence and UTIs. Conclusion: Post-treatment improvement in clinical symptoms correlated with improvement in uroflowmetry parameters and curve pattern. Correction of voiding phase is necessary for urinary continence achievement and resolution of UTIs. ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ381 63 833 97 87. E-mail address: [email protected] (Z. Vesna). 1477-5131/$36 ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2009.09.013
Correlation between uroflowmetry parameters and treatment outcome in children
Introduction Functional voiding disorders are the most common voiding problem in childhood [1]. The peak prevalence of functional urinary incontinence is at 7 years of age and girls are more affected than boys in all age groups [2,3]. Despite a high spontaneous remission rate, approximately 1% of children continue to wet their underwear in adolescence, which may cause not only psychological morbidity but also significant structural damage to the bladder wall and upper urinary tract [1]. After urge syndrome and voiding postponement, dysfunctional voiding is the third most frequent functional voiding disorder in children. It has been shown that up to 65% of children with UTIs aged between 5 and 9 years have dysfunctional voiding, compared to 23% of those without UTIs [4]. According to the 2006 ICCS standardization of terminology of lower urinary tract function in children, dysfunctional voiding denotes a disorder of the voiding phase of the micturition cycle which is due to involuntary intermittent contractions of the striated muscle of the external urethral sphincter or pelvic floor during voiding in neurologically normal individuals [5]. Urinary incontinence, hesitancy, straining, intermittency and/or weak stream are the typical clinical symptoms. Constipation, encopresis, recurrent UTIs and VUR are strongly associated with dysfunctional voiding [2]. The treatment usually starts with standard urotherapy including simple behavioral modifications, pelvic floor exercises and various forms of biofeedback (visual, tactile, electromyography) in order to teach a child pelvic floor muscle relaxation. In therapy-resistant cases characterized by large PVR urine and recurrent symptomatic UTIs, clean intermittent catheterization is introduced, and even botulinum toxin type A in the most severe cases [6]. Non-invasive urodynamic studies, such as uroflowmetry and electromyography (EMG) of the pelvic floor muscles (PFMs), have proved to be reliable in establishing the diagnosis of dysfunctional voiding and monitoring the treatment results [7]. Despite the high success rates that have been reported from urotherapy programs in children with dysfunctional voiding [8e10], several studies have indicated that post-treatment uroflowmetry findings did not follow patients’ subjective (clinical) improvement [7,11,12]. Therefore, the aim of this study was to analyze the relationship between subjective (clinical) outcome and objective post-treatment uroflowmetry parameters and curve pattern in dysfunctional voiders.
Patients and methods Patients Prospective clinical study included 86 patients with dysfunctional voiding who were referred to the Physical Medicine and Rehabilitation Clinic for urotherapy. All patients had previously been treated by pediatricians in primary care with timed voiding, hydration and constipation management for 3 months without significant success.
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Initial evaluation included a history and physical examination, a 48-h voiding diary, urinalysis and urine culture, ultrasound of kidneys and bladder and uroflowmetry with EMG of the pelvic floor. The diagnosis of dysfunctional voiding was based on clinical symptoms (urinary incontinence, hesitancy, straining, intermittency, weak stream) and three consecutive staccato and/or interrupted uroflowmetry curve shapes with positive EMG activity during micturition. X-ray VCUG was performed in all boys to exclude structural abnormalities of the lower urinary tract, and in all patients with recurrent UTIs to detect the presence of VUR. During the evaluation period all children were UTI free. Children with neurologic disorders, mental retardation and structural abnormalities of the lower urinary tract were excluded from the study.
Treatment groups After the parents had provided written informed consent, children were randomly divided into two groups. Randomization was performed by children drawing a sealed envelope with an enclosed assignment. Group A underwent pelvic floor rehabilitation and conservative treatment, while group B received only conservative treatment.
Treatment protocol The urotherapy program in both groups began with the education of the parents and children about the normal function of the bladder and external urinary sphincter and the nature of their voiding disorder, as well as their answering the questions regarding motivation for the treatment. If a child was not motivated for the treatment the program was delayed. The importance of regular fluid intake (200 ml 5e6 times per day) and regular voiding was also explained. In the same session, an optimal voiding posture was demonstrated in front of a mirror: a sitting position, with feet supported, hips abducted and abdominal muscles relaxed (both for boys and for girls). Special adaptations of toilet seats were made for smaller children and foot support was provided. After a child experienced the normal sensation of the need to void and a qualified physiotherapist provided simple voiding instructions, each child from both groups was asked to void. Micturition was supervised and corrections were made if necessary, with the aim of achieving a long, strong and loud void. Less than 1 min after voiding, PVR urine volume was measured by ultrasound. In group A children were individually taught to identify PFM. A physiotherapist enhanced the proprioception of PFM activity with each child by palpation. A child was asked to contract the PFM without activating the accessory muscles, and then to relax them. Self-palpation of PFM and m. transversus abdominis was used as a feedback of correct technique. Once a child had learned correct recruitment of the PFM, pelvic floor exercises were introduced. They included 3-s submaximal contractions followed by a prolonged, 30-s relaxation, with the emphasis on relaxation. Children were asked to do 30 repetitions of these exercises daily at home during the whole treatment period. During the treatment period children in both groups were asked to keep: a 48-h voiding diary, voiding chart, nocturnal
398 enuresis chart, and a defecation diary for 14 days, recording defecation frequency, stool consistency, episodes of fecal incontinence and abdominal pain. Additionally, parents of children with nocturnal enuresis were asked to weigh the diapers on wet nights and to record the volume of the first morning void for 1 week (nocturnal urine production). If nocturnal urine production exceeded 130% of expected bladder capacity for age the diagnosis of nocturnal polyuria was made [5]. Bladder capacity was calculated in milliliters using the formula: (age in years 30) þ 30 until the age of 12 years [5]. Reduced bladder capacity was diagnosed when maximal voided volume on 48-h voiding diary was less than 65% of expected bladder capacity for given age [5]. Rome III criteria were used for establishing the diagnosis of functional constipation [13]. Therapeutic sessions were held monthly in both groups. The number of sessions depended on the patient’s clinical (subjective) and objective improvement seen on uroflow. Every session in each group began with analysis of the diaries and charts, and recording of changes from the previous visit regarding urinary incontinence, nocturnal enuresis, defecation frequency and UTIs. Compliance with the treatment was discussed. In group A, every child was asked to perform pelvic floor exercises and corrections were made if necessary. The emphasis was put on regular pelvic floor training at home, and compliance with this was checked. When a child felt the normal need to void, uroflowmetry with EMG and PVR urine measurement was performed in both groups. All children were encouraged to continue with the therapy.
Constipation treatment Constipation was treated in both groups. The treatment consisted of parents’ and children’s education, regular toilet visits after major meals, adequate posture during defecation, and dietary and hydration changes. Laxatives (lactulose, 1 ml per kg body weight per day in one to three doses) were given during the treatment with the aim of achieving one to two stools of milkshake consistency each day.
Recurrent UTI treatment Children from both groups who had symptomatic UTIs and showed positive urine culture on monthly assessment were administrated antibiotic prophylaxis (nitrofurantoin, nightly dose of 1 ml per kg body weight) for 3 months.
Z. Vesna et al. with EMG was performed using a uroflowmeter (UF Master, MMS, The Netherlands). Skin EMG electrodes were placed symmetrically on the peri-anal skin at the 2 and 10o’clock positions. Children voided two times when they felt a need to void. Less than a minute after voiding, PVR urine was recorded by ultrasound (Aloka, SSD-500, Japan). The following parameters were evaluated: voided volume (VV, ml), average flow rate (AFR, ml/s), peak flow rate (PFR, ml/s), flow time (FT, s), shape of the curve, PVR urine volume and total bladder capacity. The shape of the uroflow curve was defined as normal (bell-shaped), staccato, interrupted and plateau according to the 2006 ICCS criteria [5]. A uroflowmetry curve with fluctuations larger than the square root of the maximum flow rate was defined as staccato. Interrupted curve was defined as the curve reaching the baseline during voiding. Plateau-shaped curve had a low amplitude and rather even flow. The 1998 ICCS definition of plateau type as a curve with a value of PFR/ FT < 0.5 was also used [14]. Total bladder capacity (PVR urine volume and voided volume) was expressed as a percentage of age-expected bladder capacity. Subjective treatment results were classified as ‘cured’ in children in whom urinary incontinence and nocturnal enuresis disappeared completely; ‘improved’ where there was a reduction in wetting episodes for more than 50% per week, and ‘unchanged’ where urinary incontinence and nocturnal enuresis persisted. In children with UTIs, less than one UTI per month was classified as ‘cured’, and UTIs that persisted as ‘unchanged’. Children with constipation 3 bowel movements per week, 2 episodes of fecal incontinence per month and no abdominal pain with no laxative treatment for >1 month were classified as ‘recovering’ [15]. Based on subjective (clinical) treatment outcome, uroflowmetry findings were stratified into two categories: ‘cured’ (the group of children in whom urinary incontinence, nocturnal enuresis and UTIs were cured) and ‘unchanged’. Uroflowmetry findings were compared between categories at the beginning and end of the investigation.
Data analysis Statistical analysis was done using the program SPSS 12.0 for Windows. Values were presented as means standard deviation. Descriptive statistics, non-parametric McNemar and parametric paired samples t-test were used. Differences were considered significant if P < 0.05.
Results Pharmacotherapy Patients from both groups who had reduced bladder capacity and did not have PVR urine were prescribed anticholinergics (oxybutynin chloride 0.3 mg/kg body weight per day). Antidiuretic hormone (desmopressin) 0.2 mg oral formulation was prescribed to be taken 1 h before going to bed in all the patients with nocturnal polyuria.
Treatment result evaluation One year after the beginning of the program the patients were re-evaluated by a pediatric urologist, who was unaware of the treatment groups. Control uroflowmetry
A total of 86 patients aged between 3 and 13 years were included in the study. Eleven children dropped out of the study due to non-appearance at the scheduled appointments. Out of 75 children enrolled in the study, 51 (68%) were girls. There were 43 patients in group A (65% girls) and 32 in group B (71% girls). Girls predominated over boys and that difference was statistically significant (P < 0.05). Mean age of children was 7.1 2.5 years. A significant difference in age between the groups and sexes was not found. During the treatment period almost 50% of children were receiving pharmacotherapy: 22 children in group A and 15 children in group B. Anticholinergics were prescribed in 11 children in group A and seven children in group B for
Correlation between uroflowmetry parameters and treatment outcome in children a 6.6-month period (range 3e12). Desmopressin was recommended in 11 children in group A and eight children in group B during a 10-month period (range 3e12). Mean number of therapeutic sessions was 6.5 (range 4e12) in group A and 10 in group B. VUR was detected in four girls in group A and five girls in group B. Antibiotic prophylaxis was prescribed in 15 children in group A and 13 children in group B due to recurrent symptomatic UTIs and VUR. In group A urinary incontinence was present in 24 out of 43 patients (56%) before the treatment. It was cured in 20 patients (P < 0.0001). In group B, out of 18 children (56%) who wetted their underwear during the day at study entry, only two were cured. Urinary incontinence was cured in a significantly larger number of children in group A than in group B (P < 0.001). Improvement in urinary incontinence was noted in three patients in group A (12.5%) and three patients (17%) in group B. Nocturnal enuresis was present in 21 patients (48%) in group A and 15 patients in group B (47%) before the treatment. In group A, nocturnal enuresis was cured in 14 patients (P < 0.0001) and in group B in five patients (33%). The cure rate was significantly higher in group A than in group B (P < 0.05). Improvement in nocturnal enuresis was noted in four boys in group A (21%) and two girls in group B (13.3%). In group A, the mean number of wetting episodes per day (2.5 2.9 vs 0.3 1.1, P < 0.0001) and night (2.6 3.0 vs 0.5 1.6, P < 0.05) per week was significantly reduced at the end of the treatment. In group B, the mean number of daytime wetting episodes (3.5 3.4 vs 2.9 3.3, P < 0.05) and night-time wetting episodes (2.3 2.8 vs 1.2 1.8, P < 0.01) per week was also significantly reduced at the end of the treatment. Nineteen children in group A (44%) and 15 children (63%) in group B had UTIs upon entering the study. UTIs were cured in 13 patients (P < 0.001) in group A and six patients (P < 0.05) in group B. Although more children were cured in group A, the difference was not statistically significant. There was recovery from constipation in all 15 patients in group A (P < 0.001) and in six out of 10 patients in group B (P < 0.05). Tables 1e3 compare pre- and post-treatment uroflowmetry parameters in children with cured/persisting urinary incontinence, nocturnal enuresis and UTIs. There were no significant differences in pre-treatment uroflowmetry findings between ‘cured’ and ‘unchanged’
399
categories. After the therapy, in children with cured urinary incontinence, VV, AFR and PFR were significantly increased (P < 0.05), while PVR urine was decreased (P < 0.05) compared to children who continued to wet during the day. A marked increase in VV, AFR and PFR (P < 0.05) and decrease in PVR urine were observed in children with cured nocturnal enuresis compared to children who continued to wet during the night. In children with cured UTIs only PVR urine demonstrated a marked decrease (P < 0.05) compared to children with persisting UTIs. All children had an abnormal uroflowmetry curve shape with increased pelvic floor activity during voiding on entering the study. In group A, the majority of children had a staccato curve shape, while interrupted curve was noted in six children before treatment. In group B, at presentation, 25 children had staccato while seven children demonstrated an interrupted voiding pattern. The relationship between the uroflowmetry curve shapes at the end of the study and the subjective (clinical) treatment outcome is shown in Table 4. A positive correlation was found between the frequency of the bell-shaped uroflowmetry curve and the treatment outcome in urinary incontinence: out of 22 children with cured urinary incontinence, a bell-shaped uroflow curve was observed in 18 (P < 0.001). In contrast, no relationship was found between the bell-shaped uroflowmetry curve and the treatment outcome in nocturnal enuresis (P Z 0.251), although the majority of children with cured nocturnal enuresis (68% of children) demonstrated a bell-shaped uroflow pattern. The post-treatment uroflowmetry curve type positively correlated with the treatment outcome in children with UTIs. A bell-shaped uroflow curve was observed in 73% of patients with cured UTIs (P < 0.05).
Discussion In this study we presented the clinical and objective results of two urotherapy programs and examined the correlation between objective uroflowmetry parameters and subjective improvement at the end of the 12-month treatment period. The symptomatic treatment results were significantly better in the group of children who had undergone pelvic floor training besides behavioral modifications and pharmacotherapy: urinary incontinence was cured in 83%, nocturnal enuresis in 66%, constipation in 100% and UTIs in 68% of the children. Our results are comparable to prior
Table 1 Comparison of uroflowmetry parameters between children with cured and persisting urinary incontinence before and after treatment. Before therapy
Voided volume (ml) Residual urine (ml) Average flow rate (ml/s) Peak flow rate (ml/s) Flow time (s) Total bladder capacity (%) Ns, not significant.
After therapy
Cured
Unchanged
P
Cured
Unchanged
P
292.6 181.2 34.3 53.8 10.2 4.6 20.9 8.8 30.1 17.6 133.1 70.9
169.2 66.2 42.8 38.5 9.6 5.6 23.1 12.7 26.7 17.1 97.0 38.2
<0.05 Ns Ns Ns Ns Ns
284.4 117.8 12.7 13.8 15.3 6.7 27.4 11.3 24.4 11.1 104.5 36.6
188.0 87.4 35.8 43.6 10.5 6.3 19.3 10.2 24.3 18.7 85.8 29.5
<0.05 <0.05 <0.05 <0.05 Ns Ns
400
Z. Vesna et al.
Table 2 Comparison of uroflowmetry parameters between children with cured and persisting nocturnal enuresis before and after treatment. Before therapy
Voided volume (ml) Residual urine (ml) Average flow rate (ml/s) Peak flow rate (ml/s) Flow time (s) Total bladder capacity (%)
After therapy
Cured
Unchanged
P
Cured
Unchanged
P
230.3 109.8 37.1 60.7 7.9 3.4 20.7 10.3 34.5 18.9 96.5 42.6
179.7 88.3 47.3 21.5 6.8 2.9 14.0 5.8 27.2 8.0 117.9 58.8
Ns Ns Ns Ns Ns Ns
256.5 73.9 6.6 6.7 13.6 6.2 25.7 11.7 26.2 22.7 88.8 21.0
140.0 94.0 33.7 32.9 6.4 3.8 12.2 6.7 26.1 9.6 72.4 35.4
<0.001 Ns <0.05 <0.05 Ns Ns
Ns, not significant.
reports in which EMG biofeedback was used during urotherapy [7,10,11]. In the group of children who had conservative treatment and medicaments, urinary incontinence was cured in 11%, nocturnal enuresis in 33%, constipation in 60% and UTIs in 40%. McKenna and McKenna reported that conservative treatment, including education, hydration, regular voiding, and pieces of advice given in order to improve voiding phase, treatment of constipation and genital hygiene, could cure 20% of patients with dysfunctional voiding without further evaluation or medication [16]. Van Gool et al. emphasized that up to 50% of children with non-neurogenic bladderesphincter dysfunction can be cured with just an explanation and ‘remedial teaching’ [2]. The children in our study had the same education program in both groups which was repeated during monthly hospital visits. As pharmacotherapy was prescribed in nearly 50% of children, it certainly had an impact on overall treatment result. The number of patients taking medicaments was almost equal in the two groups, so the impact on treatment result in each group would be the same. Therefore, better clinical results in the group of children who had pelvic floor rehabilitation besides conservative treatment testify to the importance of pelvic floor therapy in the treatment programs of children with dysfunctional voiding. Focusing the child’s attention on the pelvic floor and teaching a child to isolate it and relax it during voiding and defecation are the main goals of the treatment. Bower pointed out in her article that ‘any rehabilitation of micturition must first establish pelvic floor awareness, proprioception and selective increase or decrease of levator activity’ [17].
Several studies of children with dysfunctional voiding have indicated that the objective results did not correlate with patients’ subjective (clinical) improvement [7,11,12]. In the study of Nelson et al., uroflowmetry findings did not correlate with the treatment outcome for urinary incontinence and UTIs [7]. Similarly, McKenna et al. reported improvement in urinary incontinence and enuresis in 89% of patients with dysfunctional voiding while improvement in uroflowmetry parameters was noted in only 42% of patients [11]. They linked this phenomenon to the theory of collateral neuroplasticity, indicating that after subjective improvement objective parameters will also improve after some time due to constant relaxation of pelvic floor muscles during voiding [11]. Additionally, the delay in objective results could be explained by the muscular remodeling. Unbalanced recruitment and relaxation of PFM during voiding in dysfunctional voiders is associated with conversion of specific muscle fiber types and changes in fiber diameter and concentration [17]. Reversal of fundamental changes to muscle physiology requires at least 8 weeks of corrected practice [17]. At the end of the investigation period in our study uroflowmetry parameters such are VV, AFR, PFR and PVR urine demonstrated significant improvements in children with cured urinary incontinence and nocturnal enuresis compared to children who continued to wet during the day and night. These results stress the correlation between subjective and objective improvement, suggesting that improvement of voiding phase verified through improvement of uroflowmetry parameters and especially PVR urine is necessary for gaining continence in dysfunctional voiders. In children with cured UTIs only PVR urine was significantly
Table 3 Comparison of uroflowmetry parameters between children with cured and persisting UTIs before and after treatment. Before therapy
Voided volume (ml) Residual urine (ml) Average flow rate (ml/s) Peak flow rate (ml/s) Flow time (s) Total bladder capacity (%) Ns, not significant.
After therapy
Cured
Unchanged
P
Cured
Unchanged
P
267.5 164.3 39.5 57.3 11.9 9.6 24.0 9.8 28.7 17.7 130.8 55.2
234.5 135.6 40.5 40.4 4.9 4.4 23.8 12.8 29.1 19.6 112.3 42.0
Ns Ns Ns Ns Ns Ns
267.7 128.7 11.1 10.7 15.5 6.0 27.8 7.6 18.2 7.4 106.4 39.2
249.8 105.4 36.3 43.3 14.1 6.6 27.9 13.4 21.4 10.2 103.8 27.0
Ns <0.05 Ns Ns Ns Ns
Correlation between uroflowmetry parameters and treatment outcome in children Table 4 voiding.
401
The relationship between treatment outcome and post-treatment uroflow curve type in children with dysfunctional
Bell-shaped Staccato Interrupted Plateau Total
Urinary incontinence
Nocturnal enuresis
UTI
Cured
Unchanged
Cured
Unchanged
Cured
Unchanged
18** 3 0 1 22
5 4 3 8 20
13 2 0 4 19
7 2 2 6 17
14* 5 0 0 19
4 9 1 1 15
Chi-square test: *P < 0.05, **P < 0.001.
reduced compared to children with persisting UTIs, confirming that PVR urine is the most important risk factor for UTIs in children [18]. In the European Bladder Dysfunction Study (EBDS) there was no correlation between flow pattern at free voiding and treatment outcome in dysfunctional voiding [12]. Analyzing the relationship between uroflow curve shape, the most important factor in interpreting pediatric uroflowmetry [19], and clinical outcome in our patients, it can be observed that the majority of children with a normalized uroflowmetry curve type after therapy showed clinical improvement as well. A bell-shaped curve pattern predominated in children with cured urinary incontinence and UTIs. Children who continued to have staccato and plateau uroflowmetry curves despite urotherapy were more likely to continue with daytime and night-time wetting and UTIs. These disparities with the results of the EBDS could be explained by the difference in the patients’ inclusion criteria. In the EBDS, the diagnosis of dysfunctional voiding was based on clinical manifestations: children who reported a staccato voiding pattern or voiding in multiple fractions with functional urinary incontinence were classified as dysfunctional voiders [12]. Only 67% of these children had a urodynamic pattern of increased PFM activity during voiding, out of which 75% demonstrated a staccato or am interrupted flow pattern on free voiding. The authors did not report whether the PFM activity in these children was also increased during free voiding. In the EBDS children were randomly allocated either to standard treatment or standard treatment plus pelvic floor training but the treatment results were not significantly different between the groups [2], which can be explained by the fact that pelvic floor training was not specifically prescribed only to the children with urodynamically proven dysfunctional voiding. Therefore, we recommend that every urotherapy program should be carefully planned and individually tailored according to clinical manifestations and uroflowmetry parameters and patterns. Further studies with larger numbers of patients are needed to make definite conclusions.
Conclusion Our results strongly suggest that pelvic floor rehabilitation is necessary in the majority of children with dysfunctional voiding for curing urinary incontinence, nocturnal enuresis, constipation and UTIs. Post-treatment uroflow
parameters and curve pattern correlated with improvement in urinary incontinence and UTIs. Larger prospective trials are needed to confirm the relationship between subjective (clinical) and objective improvement in dysfunctional voiders.
Conflict of interest None declared.
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402 [10] Herndon A, Decambre M, McKenna P. Interactive computer games for treatment of pelvic floor dysfunction. J Urol 2001; 166:1893e8. [11] McKenna PH, Herndon CD, Connery S, Ferrer FA. Pelvic-floor muscle retraining for paediatric voiding dysfunction using interactive computer games. J Urol 1999;162:1056e63. [12] Bael A, Hildegard L, de Jong T, Hoebeke P, Nijman R, Sixt R, et al. The relevance of urodynamic studies in urge syndrome and dysfunctional voiding: a multi-center controlled trial in children. J Urol 2008;180:1486e96. [13] Rasquin A, Di Lorenzo C, Forbes D, Guiraldes E, Hyams J, Staiano A, et al. Childhood functional gastrointestinal disorder: child/adolescent. Gastroenterology 2006;130: 1527e37. [14] Norgaard JP, Van Gool JD, Hjalmas K, Djurhuus JC, Hellstrom AL. Standardization and definitions in lower urinary tract dysfunction in children. International Children’s Continence Society. Br J Urol 1998;81(Suppl. 3):1e16.
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