Focused non-invasive assessment of lower urinary tract dysfunction among children with cerebral palsy

Although a correlation has been reported between enlarged rectal diameter and functional constipation (FC), the relevance of measuring the transverse diameter of the rectum for diagnosing FC remains unclear, even in patients with lower urinary tract symptoms (LUTS). This study aimed to measure rectal diameter in children/adolescents diagnosed with LUTS, with and without FC. This cross-sectional study included 4-17 years old children/adolescents attending a multidisciplinary outpatient clinic for urinary disorders between June 2016 and November 2018. All participants had LUTS, with or without FC. Those incorrectly completing the study questionnaires or with neurological and/or anatomical abnormalities of the genitourinary and/or gastrointestinal tract were excluded. Urinary symptoms were evaluated using the dysfunctional voiding symptom score and FC was assessed using the Rome IV criteria. Transabdominal ultrasonography was used to evaluate the bladder and measure rectal diameter. A transverse diameter ≥3 cm defined an enlarged rectum. Bladder capacity (i.e. the bladder volume immediately before voiding), post-void residual urine, bladder wall thickness and first volume voided after ultrasonography were measured. Mean age was 8.9 ± 3.2 years and 55.1% were female. Of 107 patients included, constipation was diagnosed in 72 (67.3%), and lower urinary tract dysfunction in 90 (84.1%). In 72 participants (67.3%), lower urinary tract dysfunction was associated with FC, constituting bladder and bowel dysfunction. Rectal diameter was increased in 51 patients (47.7%). There was no association between rectal diameter ≥ 3 cm and urinary urgency, enuresis, increased daytime urinary frequency, nocturia, daytime incontinence, constipation, severe LUTS or bladder and bowel dysfunction (P > 0.05 in all cases). However, increased rectal diameter was associated with at least one episode of faecal incontinence per week in constipated patients (P = 0.02). There was no correlation between rectal diameter and dysfunctional voiding symptom score (rs = 0.00), bladder capacity (rs = 0.01), post-void residual urine (rs = 0.05), bladder wall thickness (rs = 0.00) or first volume voided after ultrasonography (rs = 0.06); P > 0.05 in all cases. There was no association between the current cut-off point characterising the rectum as distended and the severity of urinary symptoms, even when FC was present. However, the complaint of faecal incontinence associated with increased rectal diameter may suggest functional constipation. The cross-sectional design, however, constitutes a limitation. Further studies may be able to determine the ideal diagnostic cut-off point for bowel and urinary dysfunction. Rectal diameter was not associated with the intensity of LUTS, with or without FC. However, the complaint of faecal incontinence associated with increased rectal diameter may suggest functional constipation.

We aimed to study the presence of lower urinary tract dysfunction (LUTD) and those objective parameters obtained from voiding diary (VD), uroflowmetric (UF) and postvoiding residual urine (PVR) and voiding dysfunction symptom score (VDSS) as possible factors effecting the success rate on STING to correct VUR. Children who underwent STING for the first time due to low-moderate (I-III) grade of VUR were evaluated retrospectively. All children diagnosed with VUR were routinely evaluated for LUTD with VD, UF, PVR and VDSS. Children with LUTD were treated with urotherapy and appropriate medical treatment. Each system with VUR was accepted a renal unit and divided into two groups according to the presence of postoperative VUR: Group 1 no VUR, and Group 2 unresolved VUR. Demographic characteristics, DMSA scintigraphy findings, PVR, VDSS and parameters of VD and UF were compared. 80 children (73 (91.3%) girl, 7 (8.8%) boy) with a total of 112 unit were detected. There were 93 (83%) units in group 1 and 19 (17%) in group 2. No difference was observed in voiding frequency and urinary incontinence in VD, flow pattern, maximum flow rate, MBC/EBC maximum bladder capacity/expected bladder capacity in UF, PVR and VDSS between two groups. 21 (26.25%) children were diagnosed and treated for LUTD and STING was successful in 21 (84%) of 25 units. We believe that effectively treated preoperative LUTD provides comparable STING success rate for correcting low- to moderate-grade vesicoureteral reflux (VUR) in the short term.

Background Lower urinary tract symptoms (LUTS) and dysfunction can be a significant complication of functional constipation (FC), especially in children. The relationship arises due to the close anatomical and functional connections between the bladder, bowel, and pelvic floor muscles. Aim The study aimed to investigate the presence of LUTS and the lower urinary tract dysfunction (LUTD). among children with FC. Patients and methods A cross-sectional descriptive study was carried out on children aged 4–10 years at the pediatric gastroenterology clinic of Alexandria University Children’s Hospital with an established diagnosis of FC according to Rome IV criteria. Age-adapted Agachan score was used to quantify the severity of FC. The Arabic version of the dysfunctional voiding symptom score (DVSS) was used to investigate the presence of LUTD. Results The study was conducted on 105 children (54 boys, 51 girls), 50.5% of the patients had positive DVSS scores; 62.3% were girls and 37.7% were boys with statistically significant positive DVSS in girls. Most patients had moderate to severe scores by using the age-adapted Agachan score. Multivariate logistic regression analysis was used to determine the independent predictors of bladder bowel dysfunction in patients with chronic FC. The independent predictors were dysuria, decreased voiding frequency, urgency, daytime incontinence, and female sex. History of bright red blood in the stools and the presence of anal fissures during the perianal examination were more common with bladder and bowel dysfunction patients than FC alone (P=0.011 and 0.027, respectively). The prognostic performance of age-adapted Agachan score to predict the positivity of DVSS score was found statistically significant. Conclusion Both LUTS and LUTD were correlated positively with FC, a crucial finding that necessitates the awareness of this finding.

Corrigendum

The voiding diary (VD) yields crucial insights into voiding volumes (VV), voiding frequency (VF), and management habits in children with lower urinary tract (LUT) dysfunction. It is recommended to be conducted for a minimum of 2 days. Nevertheless, certain studies have indicated similarities in voided volumes between days in a three-day VD. This study aims to compare VV and VF values across days based on bladder capacity and symptom scores. Children who applied to the pediatric urology clinic due to LUT symptoms between 2022 and 2023 were included in the study. Retrospective evaluation was conducted on the records. Children with neurological deficits and incomplete data were excluded from the study. All children were assessed following the guidelines of ICCS and EUA and underwent a 3-day voiding diary. Mean VV and VF values of the whole group for each day were compared and subgroup analyzes were performed in terms of gender, Voiding Dysfunction Symptom Score (VDSS), bladder capacity (BC), and diagnoses. A total of 109 (53 girls (48.6%), 56 boys (51.4%)) children with a median age of 8 (3-17) were included in the study. 77 (70.6%) children were diagnosed with overactive bladder, 8 (7.4%) with dysfunctional voiding, and 24 (22%) with monosymptomatic enuresis nocturne. The mean VVs between days were similar in the whole group (p = 0.759). Moreover, the mean VV of the first day was similar to the average of both the first two days and the three days (p = 0.021, p = 0.490). Also, the maximum and minimum VVs were similar between days (p = 0.942, p = 0.160, respectively). In subgroup analyses based on gender, bladder capacity, and symptom score, mean VV was also found to be similar. VF values were found to be significantly different between days. There was also a difference between VF values in children with VDSS > 8.5 (p = 0.012) and BC/EBC (%) > 65 (p = 0.030). In subgroup analysis for diagnoses, mean and maximum VV and VF were similar between the groups, except for VF (p = 0.026) in OAB. While the voided volumes of children with non-neurogenic LUT dysfunctions appear to be consistent across the days of the VD, variations in VF might arise, especially among children with a VDSS of > 8.5 and normal bladder capacity. As a result, we believe that using a VD spanning at least two days could enhance diagnostic accuracy and help prevent unnecessary treatment.

The overlooked association between lower urinary tract dysfunction and psychiatric disorders: a short screening test for clinical practice

There is a need to understand the growth and burden of malnutrition in children with cerebral palsy (CP) in order to design appropriate inclusive nutrition strategies. We compared the nutritional status and four-year longitudinal growth of a population-based cohort of children and adolescents (C&A) with CP (n = 97; 2-17 years; 55/42 M/F), and an age and sex matched group without CP (n = 91; 2-17y; 50/41 M/F) in rural Uganda. The cohorts were assessed in 2015 and 2019 for weight, height, social demographic characteristics, and feeding related factors. Nutritional status was determined using the World Health Organization (WHO) Z-scores. Wilcoxon sign rank and Mann-Whitney tests were used to test within and between group differences. Multivariable linear regression was used to determine predictors of the change in growth. Approximately two thirds (62/97 (64%)) of C&A with CP were malnourished (with <-2SD in any of the WHO Z-scores), especially those with feeding difficulties (OR = 2.65; P = 0.032), and those who needed to be fed (OR = 3.8; P = 0.019). Both the CP and non-CP groups deviated negatively from the WHO reference growth curve for height, with a significantly slower growth in the CP group (median change score of height-for-age Z score (HAZ) between assessments = -0.80(-1.56, 0.31), p<0.01), than the non-CP group (median HAZ change score = -0.27(-0.92,0.34, p = 0.034). There was a statistically significant group difference in the median HAZ change score between the CP and non-CP groups (z = -2.21, p = 0.026). Severity of motor impairment measured by the Gross Motor Function Classification System (GMFCS-level) correlated negatively (r = -1.37,95%CI -2.67, -0.08) with the change in HAZ scores among the CP group. Children and adolescents with severe motor impairments exhibit an increased risk of malnutrition and growth retardation compared to their age matched peers without CP, which underscores the need to develop inclusive community-based nutrition strategies for children with cerebral palsy.

IS SPINA BIFIDA OCCULTA ASSOCIATED WITH LOWER URINARY TRACT DYSFUNCTION IN CHILDREN?

This study investigated the sprint cycling performance and neuromuscular characteristics of Paralympic athletes with cerebral palsy (CP) during a fatiguing maximal cycling trial compared with those of able-bodied (AB) athletes. Five elite athletes with CP and 16 AB age- and performance-matched controls performed a 30-sec Wingate cycle test. Power output (W/kg) and fatigue index (%) were calculated. Electromyography was measured in five bilateral muscles and expressed in mean amplitude (mV) and median frequency (Hz). Power output was significantly higher in the AB group (10.4 [0.5] W/kg) than in the CP group (9.8 [0.5] W/kg) (P < 0.05). Fatigue index was statistically similar between the AB (27% [0.1%]) and CP (25% [0.1%]) groups. Electromyographic mean amplitude and frequency changed similarly in all muscle groups tested, in both affected and nonaffected sides, in the CP and AB groups (P < 0.05). Neuromuscular irregularities were identified in the CP group. The similarity in fatigue between the CP and AB groups indicates that elite athletes with CP may have a different exercise response to others with CP. The authors propose that this may result from high-level training over many years. This has rehabilitative implications, as it indicates near-maximal adaptation of the CP body toward normal levels.

This study is a preliminary quantification and characterization of the development of marginal and canonical syllable patterns in 10 infants at risk for cerebral palsy (CP). We calculated marginal and canonical babbling ratios from parent-infant laboratory recordings of 10 infants at two time points, approximately 13 and 16 months of age. The frequency and diversity of labial, coronal, and velar types of marginal and canonical syllables were also examined. Differences across three outcome groups were compared: infants later diagnosed with CP (n = 3, CP group), risk of CP due to ongoing gross motor delays (n = 4, risk group), and current typically developing status with resolved gross motor delays (n = 3, TDx group). Performance on the Mullen Scales was included for perspective on cognitive development. Higher marginal syllable ratios were observed in the CP and risk groups than the TDx group. An increasing canonical syllable ratio across the two ages was consistently observed in the TDx group. The TDx group produced a greater frequency and diversity of canonical syllable types than the risk and CP groups, and of marginal syllable types than the CP group. This study offers preliminary support for the possibility that speech motor impairment in infants with CP have the potential to be observed and quantified early in vocal development prior to the expected onset of first words. Prolonged rates of marginal syllable forms may be suggestive of speech motor impairment; however, additional longitudinal outcome data over a longer time course and a larger sample of infants are needed to provide further support for this possibility.

Lower urinary tract dysfunction (LUTD) is prevalent among children and can cause chronic kidney disease. Multiple factors linked to LUTD, including genetic, physical, and behavioral characteristics, have been identified. However, research on the links among time spent on screens (television, computer, smart phones and tablets), physical activity, sleep duration and LUTD is limited. The aim of this study was to investigate the relationships among screen use, physical activity, sleep duration and LUTD among Thai children. In this cross-sectional study the parents or guardians of children aged 3–6 years in Thailand anonymously answered the online questionnaires (Dysfunctional Voiding Symptom Score and the surveillance of digital media habits in early childhood questionnaire®). Multivariable analysis was used to identify associated factors. Participants were 1,891 adult parents or guardians. The median age of the children was 4.9 years, and 53.8% were boys. Bladder and bowel dysfunction (BBD) was highly prevalent among girls and young children. Female sex and high average screen use were associated with BBD, with odds ratios of 3.74 (95% CI: 2.96–4.74; P < 0.001) and 1.10 (95% CI: 1.03–1.16; P = 0.002), respectively. In subgroup analysis based on gender and age, the analysis revealed that prolonged screen use was significantly associated with BBD only in girls (Adjusted OR = 1.12; 95% CI: 1.04–1.21; P = 0.002) and only in children aged 3 to < 5 years (Adjusted OR = 1.13; 95% CI: 1.05–1.22; P = 0.001), with no significant association found in their counterparts. However, increased amount of moderate-to-vigorous physical activity and short sleep duration were not associated to BBD. Higher screen use was associated with early lower urinary tract symptoms and bowel symptoms in preschool-kindergarten aged 3–<5 years and in girls. Parents and clinicians should be aware of the links between BBD and children’s prolonged screen use.

Association between a constipation scoring system adapted for use in children and the dysfunctional voiding symptom score in children and adolescents with lower urinary tract symptoms

Introduction: This study aimed to investigate trunk control, balance, and upper extremity skill quality in ambulatory children with diplegic cerebral palsy (CP) classified as Gross Motor Function Classification System (GMFCS)-I and -II, as well as to compare the GMFCS groups among themselves and with healthy children. Methods: Twenty-five children with spastic diplegic CP (11.80 ± 2.66 years) and 30 healthy children (13.57 ± 3.48 years) were included. Functional levels were classified with the GMFCS, with 13 children classified as GMFCS-I and 12 as GMFCS-II, while trunk control was assessed with the Trunk Control Measurement Scale (TCMS), balance with the Single-Leg Stance and Four-Square Step Tests, and upper extremity functionality with the Quality of Upper Extremity Skills Test (QUEST). Results: There was no significant difference in age, body mass index, or gender distribution between the CP and control groups (p > 0.05). The healthy group outperformed both CP groups in all clinical evaluations. No significant differences were found between GMFCS-I and GMFCS-II groups in the Single-Leg Stance Test, Four-Square Step Test, and QUEST parameters (p > 0.05). However, TCMS subdomains static sitting (p = 0.009), dynamic reaching (p = 0.018), selective movement control (p = 0.012), and total scores (p = 0.006) were significantly higher in the GMFCS-I group. A moderate positive correlation and a 54% regression rate were observed between the QUEST and TCMS scores. Conclusion: Trunk control is a key determinant of upper extremity skill quality in children with CP. Core stabilization should be prioritized to improve upper extremity functionality and manage disability levels effectively.

To evaluate the feasibility of quantitative analysis of muscle stiffness in the medial gastrocnemius muscle (GCM) by acoustic radiation force impulse (ARFI) ultrasound elastography in children with spastic cerebral palsy (CP). Seventeen children with spastic CP and 25 healthy children participated in the study between the years 2016-2017. The medial GCM in the CP group was assessed using the Modified Ashworth Scale (MAS) by a physiatrist. ARFI was used to measure the shear-wave velocities (SWVs) of the medial GCM. The mean SWV value for each MAS score was calculated and used for statistics. The mean SWV values of the medial GCM in the CP and healthy groups were 3.17±0.81m/s (mean±SD) and 1.45±0.25m/s (mean±SD), respectively. The SWV of the medial GCM significantly increased in the CP patients when compared with controls (p<0.001). In addition, the SWV values were correlated with the MAS scores (p<0.001). The interobserver agreement expressed as the interclass correlation coefficient was 0.65 (95% CI 0.33-0.84, p<0.001). ARFI imaging demonstrated a difference in muscle stiffness in the medial GCM between the CP and healthy groups. This method is a feasible imaging modality for the noninvasive assessment of contracting muscles in children with CP.

The aim was to simultaneously investigate inflammatory biomarkers, neopterin, the kynurenine/tryptophan (Kyn/Trp) pathway, vitamin D (VitD), vitamin D binding protein (VDBP), and erythrocyte folate, in cerebral palsy (CP). A case-control study was conducted at Mersin University Hospital. Three- to ten-year-old patients with spastic CP (n = 50) and age- and gender-matched healthy controls (n = 55) were included. Serum levels of neopterin, Trp, Kyn and 25OHD, plasma VDBP, and erythrocyte folate concentrations were measured. Indoleamine-2,3-dioxygenase 1 (IDO-1) enzyme activity was evaluated according to the Kyn/Trp ratio. Comparison and correlation analyses were performed. The levels of neopterin, Trp, and Kyn were lower in children with CP than in healthy controls (p = 0.037, p < 0.001, and p = 0.003, respectively). IDO1 was not significantly different between the CP and control groups (p = 0.214). The levels of VitD and VDBP were higher in children with CP (p < 0.001 and p = 0.001, respectively). The level of erythrocyte folate was also higher in children with CP (p < 0.001). No significant correlation was found between age and inflammatory biomarkers in the CP group. Neopterin was correlated with the level of Gross Motor Function Classification System (GMFCS) level (r = 0.292, p = 0.044), while there was no significant correlation between the other biomarkers and the level of GMFCS in the CP group. Inflammatory biomarkers of neopterin and Kyn are lower, inflammatory biomarkers of VDBP and erythrocyte folate are higher, and anti-inflammatory VitD is higher in children with spastic CP compared to healthy children. More knowledge is needed to demonstrate inflammatory and anti-inflammatory status in children with CP.