Children's Continence Society Research Articles

Management of the refractory nocturnal enuresis patient to desmopressin in a pediatric population: Desmopressin + oxybutynin vs. desmopressin + imipramine

Desmopressin is well accepted as first-line medical therapy for enuresis. If ineffective, combination therapy of desmopressin+oxybutynin or desmopressin+imipramine has been used. This study assessed the efficacy of adjunct therapy with either imipramine or oxybutynin in the management of enuresis patients who failed desmopressin treatment. A retrospective chart review of our database for patients with enuresis was performed. Patients who were prescribed desmopressin, oxybutynin, and imipramine over 14 years for enuresis were included. Two cohorts of patients were examined; group OXY was treated with desmopressin and oxybutynin, and group IMP received desmopressin and imipramine. Pretreatment measurement of Vancouver Symptom Scores (VSS) were used to compare groups using the VSS question "I wet my bed at night" where 4: every night, 3: 4-5 nights per week, 2: 1-2 nights per week, 1: 3-4 nights per month, and 0: never. International Children's Continence Society (ICCS) criteria for continence success was utilized to determine outcomes. 2521 patients prescribed one of the 3 medications were identified. Among them, 81 patients (mean age: 10.5±2.8 years) received combination therapy. Of which, 55 were male and 26 female. Specifically, 58 were prescribed both desmopressin and imipramine (group IMP), 23 desmopressin and oxybutynin (group OXY), and 4 transitioned from OXY to IMP. Mean pretreatment VSS showed no difference between groups. Both groups experienced minimal drops in wet nights with desmopressin alone. A comparison revealed that group IMP reduced wet nights significantly more than group OXY (VSS wet night score 0.7±1.2 vs. 2.3±1.1 respectively, p<0.0001). Non-intent-to-treat complete response rate was 68% vs 5% (OR=42.5, p<0.001) (IMP vs. OXY respectively). Intent-to-treat response rates were 58%. Although first-line desmopressin treatment for enuresis is effective, it does not work for all patients, and many parents and children desire nighttime dryness. Clinicians have combined desmopressin with oxybutynin or imipramine for improved results, but research comparing these modalities is scarce. Our study suggests that the desmopressin and imipramine combination is superior at reducing nights wet compared to desmopressin and oxybutynin, attributed to imipramine's probable central mechanism rather than its secondary anticholinergic properties. Limitations include a modest sample size, retrospective design, and subjective responses to the Vancouver questionnaire. A combination of desmopressin and imipramine was more effective in reducing wet nights and had a complete response rate that was 42.5 times greater than desmopressin and oxybutynin.

Chinese expert consensus on clinical diagnosis and treatment of non-neurogenic lower urinary tract dysfunction in children

Non-neurogenic lower urinary tract dysfunction (NNLUTD) is a common clinical problem in children, which is an important cause of lower urinary tract symptoms, urinary tract infection and vesicoureteral reflux in children, often accompanied by behavioral and psychological problems. At present, there is no consistent evaluation method and treatment for NNLUTD in children. Experts of Pediatric Urodynamics and Pelvic Floor Group of Pediatric Surgery Branch of Chinese Medical Association formulated this consensus according to the NNLUTD related diagnosis and treatment guidelines designated by International Children's Continence Society (ICCS) and International Continence Society (ICS), and combined with the latest relevant literatures at home and abroad, to provide reference for the clinical standard diagnosis and treatment of NNLUTD in children.

Research Progress on the Pathogenesis of Primary Enuresis in Children

Nocturnal enuresis (NE) is a common disease in children, commonly known as bedwetting. The International Children's Continence Society (ICCS) defines intermittent urinary incontinence during nighttime sleep in children aged 5 and above as enuresis. Enuresis can be divided into two types: primary nocturnal enuresis (PNE) and secondary nocturnal enuresis (SNE). PNE refers to nocturnal urinary control ability that has never been achieved for more than 6 months in children aged 5 and above with enuresis; SNE refers to the recurrence of enuresis symptoms after a period of more than 6 months of continuous nocturnal urinary control ability. SNE is relatively rare in clinical practice and is often caused by sudden stress events or other diseases such as snoring. Its pathogenesis and treatment are different from PNE. PNE is a multifactorial disease related to genetics, and its pathogenesis is not fully understood. There are not many research and review articles on its pathogenesis. In recent years, there has been significant progress in the epidemiology and pathogenesis of PNE. The following is a summary.

Alarm therapy for nocturnal enuresis in children: A literature review

AbstractNocturnal enuresis is a common childhood problem impacting the quality of life of children and families. Treatment with an enuresis alarm is recommended for 8–12 weeks by the International Children's Continence Society as first line management of monosymptomatic nocturnal enuresis. However, the effectiveness of alarm therapy varies between 80% and 45.9%. There is minimal evidence within the literature exploring the factors impacting this varying response to alarm therapy. Therefore, this literature review aims to explore factors that impact the effectiveness of the enuresis alarm as a treatment for nocturnal enuresis, in children aged 5–17 years. Literature searches were conducted on MEDLINE (Ovid), SCOPUS and CINAHL Databases. The PRISMA tool was used to report the data in the search strategy. The inclusion criteria of children aged 5 to 17 years was chosen based on International Children's Continence Society Guidelines. English language, academic journals and studies in the past 10 years were selected as additional inclusion criterion to identify the most recent, robust literature for the review. All 13 primary research articles were critiqued using the Caldwell Framework. Data were extracted and presented in table format highlighting study methodology, sample, duration of treatment, relevance to review topic and key findings. The findings highlight factors influencing the effectiveness of alarm therapy related to the impact on the child and family, heighten arousal to the alarm, the duration of therapy, age of child and the impact of overlearning. This review provides health professionals with an insight into strategies that may help children and their family to respond successfully to enuresis alarm treatment.

Internet Health Resources on Nocturnal Enuresis: A Readability, Quality, and Accuracy Analysis.

Nocturnal enuresis is a common yet quality-of-life-limiting pediatric condition. There is an increasing trend for parents to obtain information on the disease's nature and treatment options via the internet. However, the quality of health-related information on the internet varies greatly and is largely uncontrolled and unregulated. With this study, a readability, quality, and accuracy evaluation of the health information regarding nocturnal enuresis is carried out. A questionnaire was administered to parents and patients with nocturnal enuresis to determine their use of the internet to research their condition. The most common search terms were determined, and the first 30 websites returned by the most popular search engines were used to assess the quality of information about nocturnal enuresis. Each site was categorized by type and assessed for readability using the Gunning fog score, Simple Measure of Gobbledygook (SMOG) index, and Dale-Chall score; for quality using the DISCERN score; and for accuracy by comparison to the International Children's Continence Society guidelines by three experienced pediatric urologists and nephrologists. A total of 30 websites were assessed and classified into five categories: professional (n = 13), nonprofit (n = 8), commercial (n = 4), government (n = 3), and other (n = 2). The information was considered difficult for the public to comprehend, with mean Gunning fog, SMOG index, and Dale-Chall scores of 12.1 ± 4.3, 14.1 ± 4.3, and 8.1 ± 1.3, respectively. The mean summed DISCERN score was 41 ± 11.6 out of 75. Only seven (23%) websites were considered of good quality (DISCERN score > 50). The mean accuracy score of the websites was 3.2 ± 0.6 out of 5. Commercial websites were of the poorest quality and accuracy. Websites generally scored well in providing their aims and identifying treatment benefits and options, while they lacked references and information regarding treatment risks and mechanisms. Online information about nocturnal enuresis exists for parents; however, most websites are of suboptimal quality, readability, and accuracy. Pediatric surgeons should be aware of parents' health-information-seeking behavior and be proactive in guiding parents to identify high-quality resources.

BLADDER SYMPTOMS IN CHILDREN WITH FUNCTIONAL CONSTIPATION : SYSTEMATIC REVIEW

Background: Functional constipation (FC) affects 3% of children worldwide. FC occurs in 95% of children without an organic reason. Lower urinary tract symptoms (LUTS) and urinary tract infection (UTI) often co-occur. The International Children's Continence Society (ICCS) coined the term bladder and bowel dysfunction (BBD) to stress the frequent combination of bladder and bowel issues.&#x0D; Aim: The purpose of this research is to investigate bladder symptoms in children with functional constipation.&#x0D; Methods: This study confirmed that it met all of the requirements by evaluating the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 criteria. This allowed the researchers to guarantee that the study was as current as possible. Publications that were published between 2015 and 2023 were incorporated into the search strategy, which encompassed a number of different electronic reference databases (including Pubmed and SagePub). We did not consider review papers, duplicate publications, or articles that were only partially written.&#x0D; Result: PubMed database search results yielded 213 articles, while SagePub database search results yielded 112 articles. In 2015, the search results for SagePub returned 13 articles while PubMed returned 19 articles. We compiled a total of eight articles (6 from PubMed and 2 from SagePub) and included three studies that met the inclusion criteria.&#x0D; Conclusion: We can't say for sure how often bladder problems show up in children with FC. This is because the frequency varies a lot, so there aren't many studies. However, children with FC do often have bladder complaints.

Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment

Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment Abstract: Objective: Enuresis and daytime urinary incontinence are common disorders in children and adolescents and are associated with incapacitation and a high rate of comorbid psychological disorders. This interdisciplinary guideline summarizes the current state of knowledge regarding somatic and psychiatric assessment and treatment. We formulate consensus-based, practical recommendations. Methods: The members of this guideline commission consisted of 18 professional associations. The guideline results from current literature searches, several online surveys, and consensus conferences based on standard procedures. Results: According to the International Children's Continence Society (ICCS), there are four different subtypes of nocturnal enuresis and nine subtypes of daytime urinary incontinence. Organic factors first have to be excluded. Clinical and noninvasive assessment is sufficient in most cases. Standard urotherapy is the mainstay of treatment. If indicated, one can add specific urotherapy and pharmacotherapy. Medication can be useful, especially in enuresis and urge incontinence. Psychological and somatic comorbid disorders must also be addressed. Conclusions: The recommendations of this guideline were passed with a high consensus. Interdisciplinary cooperation is especially important, as somatic factors and comorbid psychological disorders and symptoms need to be considered. More research is required especially regarding functional (nonorganic) daytime urinary incontinence.

Is it time to reconsider how we document pediatric uroflow studies?: A study from the SPU Voiding Dysfunction task force

Uroflowmetry is a non-invasive study used in the diagnosis and monitoring of treatment response for lower urinary tract disorders. For optimal clinical utility, uroflow studies rely on careful clinical interpretation by a trained provider, but currently there is a lack of accepted standardized normal values for the measured uroflow parameters in children. The International Children's Continence Society proposed standardizing the terminology for uroflow curve shapes. However, the patterning of curves is largely at the physician's subjective discretion. The aims of this study were to understand inter-rater reliability in interpreting uroflow curves and to define characteristics of uroflow curves that could be used to provide definitive criteria for uroflowmetry parameters. All members of the SPU Voiding dysfunction Task Force were invited to contribute deidentified uroflows to a centralized HIPAA complaint receiving database. All studies were then distributed to all raters for review. Each observer's findings were recorded according to ICCS criteria (ICCS), additional readings were done using a previously reported system which defined curves as smooth or fractionated (SF) and whether the shape resembled a bell, tower, or plateau (BTP). Flow indexes (Qact/Qest) (FI) for Qmax and Qavg were generated using formulas previously reported for children 4-12 and for patients≥12 years. A total of 119 uroflow studies were read by 7 raters and curves were contributed from 5 sites. Kappa scores for the 5 readers from different institutions were 0.34 and 0.28 for the ICCS and BTP methods, respectively (both considered fair agreement). Kappa for smooth and fractionated curves was 0.70 (for each; considered substantial agreement), which were the two highest agreement scores obtained throughout the study. Discriminant analysis (DA) revealed that the FI Qmax was the dominant vector, and that the ICCS uroflow parameters have a total of 42.8% prediction rate in the training sample. Using DA of a smooth/fractionated system, the total prediction rates were 72% and 65.5% for smooth and fractionated, respectively. Given the poor inter-rater agreement for analyzing uroflow curve pattern based on ICCS criteria in this study and others, one may find it reasonable to consider alternative approaches to describing and characterizing uroflow curves. Our study is limited by lack of EMG and post-void residual data. For a more objective uroflow interpretation and comparison of studies among different centers, we recommend using our proposed system (based on FI, and smooth vs. fractionated curve pattern), which is more reliable.

Pediatric incontinence questionnaire (PINQ): translation and transcultural adaptation to Brazilian Portuguese

ObjectiveLower urinary tract symptoms (LUTS) affect approximately 10% of children worldwide and are related to psychosocial manifestations and compromised quality of life, both for children and their families. The assessment of emotional conditions of LUTS in children is recommended by International Children's Continence Society; however, there is no specific instrument in the Brazilian Portuguese language. Therefore, the aim of this study was to translate, culturally adapt and assess the internal consistency of the Brazilian Portuguese version of the Pediatric Incontinence Questionnaire (PINQ). Material and methodsThis cross-sectional study was performed at two referral centers for childhood voiding dysfunction. The 20-item PINQ was translated into Brazilian Portuguese and culturally adapted according to Beaton, 2000. His-standard methodology consists of 6 phases: translation, synthesis, back-translation, expert committee, and pre-test. The internal consistency was assessed using Cronbach's alpha. ResultsThe PINQ-br version was developed, validated by a committee of experts, and pre-tested on 44 children diagnosed with lower urinary tract symptoms, 23 boys and 21 girls (mean age: 9.7 and 9.6 years old respectively), as well as on their parents. The internal consistency was considered satisfactory, reaching Cronbach's alpha coefficient of 0.74 when applied to children and 0.82 when applied to parents. ConclusionsThe PINQ was translated and culturally adapted to Brazilian Portuguese to assess the impact of LUTS on the health-related quality of life in Brazilian children and adolescents.

Role of Transabdominal Ultrasonography in the Evaluation of Pediatric Patients With Daytime Wetting: A Single-Center Pilot Study.

Urinary incontinence (UI) is a frequent cause of admission to pediatric nephrology outpatient clinics. The aim of this study was to determine whether anatomical changes in lower urinary tract structures (retrovesical angulation [RVA] and bladder neck position [BNP]) are associated with UI in pediatric patients with daytime-wetting in comparison to healthy children. In this prospective study, patients with daytime UI diagnosed using the Dysfunctional Voiding Symptom Score of the International Children's Continence Society and 3-day-voiding/bowel diary were compared with an age- and sex-matched control group without incontinence. In addition to routine clinical evaluation, RVA and BNP were measured at rest using transabdominal ultrasound (TA-US). Intra-rater agreement was estimated. A total of 88 children were included in the study, with 44 children (22 boys, 22 girls) each in patient and control groups. RVA was significantly greater and BNP was significantly lower in the patient group versus control group (RVA: 134.30 ± 10.05 vs 127.94 ± 13.15, P=.013; BNP: 11.88 ± 4.53 vs 17.20 ± 5.55, P < .001, respectively). Irrespective of the presence of incontinence, girls had a significantly greater RVA than boys (P < .001). However, there was no difference between sexes in BNP values (P=.630). Intra-rater agreement was very strong for RVA (P < .001, r=.897), and strong for BNP (P < .001, r=.774). TA-US imaging is a non-invasive and practical procedure routinely performed in pediatric patients presenting with UI complaints. Our study demonstrated anatomical changes in lower urinary tract structures in pediatric patients with UI. These changes should be considered in the diagnosis, follow-up, and treatment of patients with UI.

Relationship between primary monosymptomatic enuresis and process toilet training: a case-control.

Primary monosymptomatic nocturnal enuresis (PMNE) is a prevalent condition in childhood, and the pathophysiology is multifactorial. This study investigated the relationship between the toilet training process (TT) and PMNE in children and adolescents. A case-control study was carried out from 2015 to 2020. The presence of PMNE was identified according to International Children's Continence Society criteria. A semi-structured questionnaire was applied to assess TT. The study included 103 children and adolescents with PMNE and 269 participants with normal psychomotor development without PMNE (control group [CG]). Readiness signals were more remembered and less frequent in participants with PMNE (p=0.001) when compared to control group. No differences were found between the groups regarding the onset age of the daytime TT (p= 0.10), the nocturnal TT (p=0.08), the acquisition of daytime continence (p=0.06), and the type of equipment used for the TT (p=0.99). The use of Child-Oriented approach in group of children with enuresis was lower than in controls [87.4% (90/103) versus 94% (250/266)], respectively (OR= 0.44, 95% CI 0.21-0.94, p = 0.039). The age of onset of TT, acquisition of daytime continence, and the type of equipment were not associated with higher occurrence of PMNE. On the other hand, the Child-Oriented approach was a protective factor for the occurrence of PMNE.

An evaluation of parental attitudes and attachment in children with primary monosymptomatic nocturnal enuresis: A case-control study

Enuresis is a common childhood disorder associated with the lack of bladder control that would be expected based on the child's age or developmental stage. Enuresis affects the lives of both children and their parents due to the burden it entails in daily life. In this study, we aimed to evaluate the dimensions of attachment between children with enuresis and their mothers, as well as the relationship with parental attitudes. This study included 70 children were diagnosed with primary monosymptomatic nocturnal enuresis (PMNE) based on the guidelines of the International Children's Continence Society (ICCS) along with 70 children with not enuresis and any psychiatric disorders. We asked the mothers of all participants to complete the Parental Attitude Research Instrument, and the children to complete The Experiences in Close Relationships Scale Revised - Middle Childhood. Both groups in our study were well balanced in terms of gender, age, and sociodemographic data. Children with enuresis were found to score higher on the anxiety and avoidance dimensions of the attachment scale with statistical significance (p<0.01). Also, on the scale completed by the mothers of children with enuresis, the subtests indicating overprotective parenting and strict discipline presented significant differences (p<0.01). Data obtained in our study demonstrate that enuresis can have a negative effect on the mother-child attachment and parental attitudes. The use of harsh language or punishment by the mother in response to the failure of the child to achieve nocturnal dryness may affect the attachment between the mother and the child, and cause the child to experience negative emotions such as shame, anxiety, embarrassment, frustration, and loneliness. We think that it would be useful to evaluate the mother-child attachment and the crisis experienced by the family after each wetting incidence in combination with parental attitudes and behaviors in the treatment of enuresis cases.

The Safety and Efficacy of Fluoxetine for the Treatment of Refractory Primary Monosymptomatic Nocturnal Enuresis in Children: A Randomized Placebo-Controlled Trial.

We investigated the efficacy and safety of fluoxetine, a selective serotonin reuptake inhibitor, for treating refractory primary monosymptomatic nocturnal enuresis in children. Children 8-18 years old with severe primary monosymptomatic nocturnal enuresis unresponsive to alarm therapy, desmopressin, and anticholinergics were screened for eligibility. After excluding children with daytime urinary symptoms, constipation, underlying urological, neuropsychiatric, endocrinological, or cardiac conditions, patients were randomly and equally assigned to 10 mg fluoxetine once daily or placebo for 12 weeks. The primary outcome was treatment response according to the International Children's Continence Society terminology. Treatment-related adverse effects and nighttime arousal were secondary outcomes. A total of 150 children were enrolled, of whom 110 (56 in fluoxetine group and 54 in placebo group) with a mean age of 11.8 (SD 2.46) years were finally analyzed. After 4 weeks, 7.1% and 66.1% of the fluoxetine group achieved complete response and partial response (defined as 50%-99% reduction of the number of wet nights), respectively, versus 0% and 16.7% of the placebo group (P < .001). At 12 weeks, complete and partial responses were achieved in 10.7% and 21.4% of the fluoxetine group, respectively (vs 0% and 14.8% of the placebo group, P = .023). Fluoxetine-treated patients had fewer wet nights (4.7 [SD 4.2] fortnightly vs 9.7 [SD 3.5] at 4 weeks, P < .001; 5.7 [SD 4.4] vs 9.9 [SD 3.4] at 8 weeks, P < .001; 7.5 [SD 4.6] vs 9.9 [SD 3.4] at 12 weeks, P = .003). Fluoxetine was associated with improved nighttime arousal (P = .017), and minor and rapidly reversible adverse effects in 5 (8.9%) patients. Fluoxetine is safe treatment for refractory primary monosymptomatic nocturnal enuresis in children with good initial response that declines at 12 weeks.

Impact of New vs. Old International Children's Continence Society Standardization on the Classification of Treatment Naïve Enuresis Children at Screening: The Value of Voiding Diaries and Questionnaires.

Expert consensus papers recommend differentiating enuresis using questionnaires and voiding diaries into non- (NMNE) and monosymptomatic enuresis (MNE) is crucial at intake to decide the most appropriate workout and treatment. This national, Belgian, prospective study investigates the correlation, consistency, and added value of the two methods, the new against the old International Children’s Continence Society (ICCS) definitions, and documents the prevalence of the two enuresis subtypes in our population. Ninety treatment-naïve enuretic children were evaluated with the questionnaire, and the voiding diary and the two clinical management tools were compared. Almost 30% of the children had a different diagnosis with each method, and we observed inconsistencies between them in registering Lower Tract Symptoms (κ = –0.057–0.432 depending on the symptom). Both methods had a high correlation in identifying MNE (rs = 0.612, p = 0.001) but not for NMNE (rs = 0.127, p = 0.248). According to the latest ICCS definitions, the incidence of MNE was significantly lower (7 vs. 48%) with the old standardization.ConclusionThe voiding diary and the questionnaire, as recommended by the ICCS at the screening of treatment-naïve enuretic patients, are considerably inconsistent and have significantly different sensitivities in identifying LUTS and thus differentiating MNE from NMNE. However, the high incidence of LUTS and very low prevalence of MNE suggest that differentiating MNE from NMNE to the maximum might not always correlate with different therapy responses.

Clinical Correlation Between Overactive Bladder and Allergy in Children.

Background:The International Children's Continence Society defines overactive bladder (OAB) as a clinical syndrome characterized by urgency of urination usually accompanied by frequent urination and nocturia symptoms. This study aims to explore the correlation between overactive bladder (OAB) and allergy in children.Method:The clinical characteristics of 918 patients diagnosed with OAB from January 2020 to March 2021 were retrospectively analyzed. Risk factors for OAB were analyzed using logistic regression analysis, and the effect of desloratadine in the treatment of OAB was evaluated.Results:The incidence of allergic cough or allergic rhinitis in the mild OAB group was higher than the moderate–severe group. Urodynamics demonstrated that the proportion of patients with a sensitive bladder in the overactive detrusor group was significantly higher than the non-overactive detrusor group. The effective rate of treatment of OAB in patients complicated with allergies and taking desloratadine was 90.14%, which was significantly higher than in patients who were not taking desloratadine, and blood IgE level was a risk factor of ineffective treatment with desloratadine.Conclusion:OAB is correlated with allergies in children, and desloratadine can effectively improve OAB symptoms.

Noninvasive Evaluation of Bladder Bowel Dysfunction and its Extrapolation as Biofeedback Therapy to Train Pelvic Floor Muscles.

Aims:This study aimed to evaluate the noninvasive methods to diagnose bladder bowel dysfunction (BBD) and its extrapolation on biofeedback therapy and pelvic floor exercises (PFE) to treat these children.Settings and Design:A retrospective cohort study at a tertiary care center was conducted between January 2010 and December 2020, on 204 children, aged 4–18 years, arbitrarily divided into two groups-4–12 and 13–18 years.Subjects and Methods:Details of lower urinary tract dysfunction were recorded as International Children's Continence Society nomenclature. Bowel habits were recorded and functional constipation was graded using ROME IV. The data recorded were urine analysis, a voiding diary, a dysfunctional voiding symptom score, and uroflowmetry with or without electromyography. Ultrasonography, voiding cystourethrogram, and magnetic resonance imaging were done in appropriate cases. Dysfunctional Voiding Severity Score was used to assist the evaluation and outcome. The treatment protocol included urotherapy, uroflow biofeedback, PFEs, prophylactic antibiotics, pharmacotherapy, and treatment of constipation.Statistical Analysis Used:Statistical analysis was done using SPSS version 26 and paired t-test was used for comparison and calculating P value.Results:There was a significant improvement in DVSS and uroflow parameters. However, the magnitude of change produced varied among the age groups. Patients who failed to show any clinical benefit were subjected to alternative therapies such as intrasphincteric Botulinum A toxin with or without neuromodulation.Conclusions:Integrated uroflow biofeedback (IUB) and PFE expedites the recovery by supplementing the effect of urotherapy; hence, this should be offered to all children with BBD.

Comparison and characteristics of children successfully treated for daytime urinary incontinence

Daytime urinary incontinence (DUI) is defined as an involuntary leakage of urine during daytime in children 5 years or older. It is a common disorder in the pediatric population most often caused by an overactive bladder (OAB). A stepwise approach is recommended in the treatment of DUI, with standard urotherapy (SU) being first line treatment followed by pharmacological treatment when SU is unsuccessful. To our knowledge few studies have compared patients achieving continence solely on urotherapy with patients achieving continence on a combination of urotherapy and pharmacological treatment in the pediatric population. The aim of the study was to characterize and compare children suffering from OAB and DUI who became continent solely on urotherapy with patients achieving continence on a combination of urotherapy and pharmacological treatment. All children successfully treated for DUI from 2015 to 2020 were retrospectively analyzed and compared using data from patient's records, 48-h flow-volume charts, and uroflowmetry analysis. 180 children were successfully treated for DUI. Of these 23 (13%) had bowel dysfunction, 94 (52%) were successfully treated with standard urotherapy (SU) and 64 (35%) needed pharmacological treatment. Children who achieved continence on a combination of SU and pharmacological treatment had a significantly higher baseline voiding frequency (7.6 and 6.5 respectively, p=0.007) and more baseline incontinence episodes during daytime when compared to children who became dry solely on urotherapy (2.2 and 1.1 respectively, p<0.001). Both groups had a similar baseline age (p=0.96) and received a similar duration of standard urotherapy prior to the eventual pharmacological treatment (p=0.73). Most children achieved daytime continence solely on standard urotherapy. We found that children requiring additional pharmacological treatment to achieve continence suffer from a more severe overactive bladder. As such it could be speculated that children with high voiding frequencies and multiple daily incontinence episodes may benefit from adding anticholinergics to SU earlier during the course of treatment, than what is recommended by the International Children's Continence Society (ICCS) today. However prospective interventional studies are needed for safe conclusions. Our comparison showed that children requiring a combination of SU and pharmacological treatment to achieve continence, had a significantly higher baseline voiding frequency and more baseline incontinence episodes when compared to children requiring only SU to achieve continence.

Evaluating nocturnal polyuria in Japanese children with nocturnal enuresis.

The purpose of this study was to assess whether enuretic Japanese patients with nocturnal polyuria (NP) who met Hoashi's criteria (6-9 years: ≥200 mL; 10 years and older: ≥250 mL) met the International Children's Continence Society (ICCS; expected bladder capacity × 130%) and Rittig's criteria for nocturnal polyuria (>[age+9] × 20 mL). We also compared the effectiveness of 1-desamino-8-d-arginine vasopressin (DDAVP) with the three criteria. Fifty-four patients who had NP with normal bladder capacity were enrolled: 36 boys (67%); median age, 8 (interquartile range: 7-9). We compared the diagnostic differences between the Hoashi's criteria and international standards (ICCS and Rittig's) for NP and the short-term effects of DDAVP. The patients received DDAVP for 8 weeks; we evaluated the association between each evaluation method and the effects of therapy. Only 17% of the patients met both Hoashi's and ICCS criteria, whereas 26% met both Hoashi's and Rittig's criteria. The therapeutic effect of DDAVP did not differ significantly between these two groups: there was an effective rate of 73% (Hoashi's criteria) versus 50% (ICCS criteria), P = 0.19, and an effective rate of 71% (Hoashi's criteria) versus 62% (Rittig's criteria), P = 0.84. Hoashi's criteria are widely used but, according to both the ICCS and Rittig's criteria, approximately 80% of the patients did not fulfill the definition of NP. However, 8 weeks after the DDAVP treatment began, no significant difference was observed in the therapeutic effect of DDAVP according to each set of criteria. The definition of NP should account for the physical disparities between Japanese people and Westerners.

Neurodevelopmental disorders and incontinence in children and adolescents: Attention-deficit/hyperactivity disorder, autism spectrum disorder, and intellectual disability-A consensus document of the International Children's Continence Society.

Neurodevelopmental disorders (NDs) are incapacitating disorders, which begin early in life, are mainly caused by genetic and neurobiological factors, and show a tendency to persist. They are associated with higher rates of incontinence in children and adolescents, including nocturnal enuresis, daytime urinary incontinence, fecal incontinence, and constipation. Without diagnosis and treatment, they will interfere with incontinence treatment leading to less favorable outcomes. The aim of thisInternational Children's Continence Society (ICCS) document is to provide an overview of the three most important NDs, that is, attention-deficit/hyperactivity disorder, autism spectrum disorder (ASD), and intellectual disability (ID). This consensus paper was commissioned by the ICCS. A selective, nonsystematic review was performed. Guidelines, reviews, and selected studies were included. The recommendations are consensus-based. ADHD is the most common ND with special relevance in clinical practice. ASD and ID are less common, but more severe disorders than ADHD. Basic principles of the assessment and treatment of NDs are provided. Incontinence is common among patients with NDs. Specific modifications and practical approaches in the treatment of incontinence in children with NDs are outlined. Incontinence in children and adolescents with NDs is common. Effective treatment of incontinence should be adapted and modified to the specific needs of patients with NDs. A multiprofessional approach is recommended.

TeleBBD: Telehealth management of bladder bowel dysfunction – A provider survey of benefits and limitations

Bladder bowel dysfunction (BBD), defined by the International Children's Continence Society (ICCS) as a spectrum of lower urinary tract and bowel symptoms, represents to up to 40% of pediatric urology consults. Management of BBD involves strict behavioral management with frequent follow ups by urology advanced practice providers (APPs). If left untreated, patients may develop secondary comorbidities that impact their renal and/or bladder function, bowel function, and psychosocial well-being. Previous studies have reported feasibility for virtual post-operative visits and prenatal consultations, however, telehealth management of BBD, or TeleBBD, has not yet been studied. The goal of this study is to survey APPs in pediatric urology to understand how TeleBBD compares to in-person visits, and identify benefits and limitations of TeleBBD. An online survey via Qualtrics was designed based on current practice guidelines for BBD management and telehealth considerations. Survey was distributed in September 2020 via the Pediatric Urology Nurses & Specialists listserv. Group qualitative coding was completed by the authors to generate themes that emerged from the results. A total of 53 APPs from across 21 states in the US completed the online survey, with 49 (92%) APPs reporting currently providing TeleBBD. Those who did not provide TeleBBD typically do not manage BBD patients. Summary Table shows the comparison of TeleBBD with in-person visits, with many elements of TeleBBD better or the same as in-person visits. APPs reported that TeleBBD has been most beneficial in increasing access and overall improvement in follow up which is significant for management of this chronic condition. Barriers include access to technology/internet and inability to perform full physical exams via televisit. Limitations of the study include lack of validated survey and small sample size. Overall increased access and improved patient adherence and resolution from BBD is significant for this patient population for prevention of secondary comorbidities. This is the first study to survey APPs across the US specifically exploring indication of TeleBBD as well as comparison of TeleBBD with in-person visits. The perception of improved access to care and less no-show rates is significant especially during the pandemic in providing continuity of care and prevent secondary comorbidities. Additionally, TeleBBD was felt to be just as effective as in-person visits for patient adherence to treatment, and other components of care, with the exception of ability to provide physical exams. Providers leveraged the benefits of TeleBBD and shared strategies for best practices.