Dysfunctional Voiding Symptom Score Research Articles

Role of transverse diameter of the rectum in lower urinary tract symptoms and functional constipation in children and adolescents.

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.

Evaluation of lower urinary tract symptoms in children with Down syndrome: A prospective, case-controlled cohort study.

In children with Down syndrome (DS) which causes cognitive impairment and intellectual disability (ID), dysfunctional voiding is proposed to be more common than in the normal population. In this study, we aimed to compare the voiding symptoms of DS children with a control group by validated questionnaires. Thirty-seven DS children without any previous urological complaints and 59 non-DS healthy children as control group was included in the study. Overactive bladder symptoms and dysfunctional voiding were evaluated with validated Overactive Bladder Questionnaire (OAB-V8) and Dysfunctional Voiding Symptom Score (DVSS) questionnaire, respectively. Data were arranged, descriptive and comparative statistical analysis were performed. Demographic data of the two groups were similar except age of completing toilet training being higher in DS group. Total OAB-V8 and DVSS scores were significantly higher in the DS group. The mean scores of questions regarding voiding frequency, urgency and urgency incontinence in OAB-V8 were significantly higher in the DS group. The mean daytime incontinence, urgency, urgency incontinence, and quality of life scores in the DVSS were also significantly higher in the DS group. DS children have more frequent dysfunctional voiding than the normal population. ID of these children may prevent the expression of these symptoms. Awareness and early detection of these symptoms are crucial to prevent devastating complications such as renal failure. Therefore, validated questionnaires are simple, useful, and noninvasive methods.

İşeme Bozukluğu Olan Çocuk Hastalarda Yaşam Kalitesi ve Etkileyen Faktörlerin Değerlendirilmesi

Objective: Health-related quality of life and its influencing factors in pediatric patients with voiding dysfunction and their parents was assessed. Method: The patients who were admitted with urinary incontinence for at least 6 months to the clinics of pediatrics and pediatric nephrology were enrolled in the study. The patients were divided into three group as daytime urinary incontinence (DUI), enuresis and both DUI and enuresis. The Pediatric Quality of Life InventoryTM (PedsQLTM) was administered to patients and mothers. Results: A total of 100 patients with voiding dysfunction aged from 5 years to 18 years (mean age: 8.8±2.6) were included in the study. The mean dysfunctional voiding symptom score was 15.5±6.6 in all groups and significantly higher in the group who experienced both DUI and NE (p<0.001). No significant difference was observed in terms of mean PedsQL scores of the children and their parents between groups with urinary incontinence (65.5±16 and 58.4±13.5, respectively), but strong positive correlation was obtained (p<0.001). The mean PedsQL score for the children aged from 8 years to 12 years was significantly lower than the scores for the children aged from 5 years to 7 years old (p<0.05). The mean PedsQL score for the children aged from 13 years to 18 years was not different from the other age groups. Conclusions: The early diagnosis and treatment of patients aged from 8 years to 12 years who had the lowest PedsQL score is important. Additionally, the success in improvement of the quality of life of children with voiding dysfunction require cooperation with parents.

Bladder and Bowel Dysfunction in Korean Children with Down Syndrome and Parental Quality of Life

PurposeChildren with Down syndrome (DS) are more likely to experience bladder bowel dysfunction (BBD) than typically developing children, which could in turn have a serious effect on children with DS and on their parents and other family members. This study aimed to explore the prevalence of BBD in Korean children with DS and its effect on parental quality of life (QOL). Design and methodsTo assess BBD and parental QOL, we used self-administered questionnaires (Dysfunctional Voiding Symptom Score [DVSS], Rome IV criteria, and World Health Organization Quality of Life scale [WHOQOL-BREF]) for parents of children with DS. We collected data from 86 parents between September and October 2017 through an online community website. ResultsDVSS was elevated in 26.7% of the children with DS. Specifically, 14% had daytime urinary incontinence, and 33.7% had functional constipation. Moreover, 18.6% of children had BBD according to the DVSS and Rome IV criteria. The sensitivity and specificity of DVSS to functional constipation was 55.17% and 87.72%, respectively. The BBD score and total parental QOL score were statistically correlated (r = 0.291, p = 0.007). ConclusionsAlthough children with DS are a high-risk group for BBD, their BBD symptoms are often overlooked because of their intellectual disability. Consequently, this could negatively affect children's and family's health and QOL in the long term. Practice implicationsHealth-care providers should reconsider a routine check-up of BBD in children with DS. If a child has BBD, health-care providers should consult a urologist to determine the appropriate diagnosis and intervention.

The discrepancy between the uroflowmetry parameters, curve patterns, and lower urinary tract symptoms of children with nocturnal enuresis according to the presence or absence of daytime urinary incontinence.

To evaluate the uroflowmetry (UFM), which reflects the urinary symptoms of children with nocturnal enuresis (NE). This study retrospectively investigated 93 children who underwent UFM three times on the same day (≥8 years old; mean age: 9 years and 10 months; 66 boys and 27 girls). Children with the combination of daytime incontinence (DI) and NE (DI+NE group: n = 45) and NE alone (isolated NE group: n = 48) were compared. UFM curve patterns were classified into five types: bell (B), tower (T), staccato (S), plateau (P), and interrupted (I). An unclassified (U) curve pattern was designated when all three curve patterns differed. Patterns other than the B pattern were considered abnormal (A). Each score in the dysfunctional voiding symptom score (DVSS) was also compared between the two groups. The UFM curve pattern was B (n = 21), T (n = 15), S (n = 4), P (n = 1), U (n = 4) in the DI+NE group and B (n = 25), T (n = 10), S (n = 7), P (n = 2), U (n = 4) in the isolated NE group, indicating no significant difference (B vs A; P = .680). The two items of DVSS questionnaire were significantly greater in the DI+NE group than in the isolated NE group (voiding postponement: 0.93 ± 1.18 vs 0.23 ± 0.56, P = .001, urgency: 2.09 ± 1.06 vs 0.56 ± 0.85, P < .001). The abnormal UFM curve patterns did not differ significantly between NE children with and without DI. However, the DVSS questionnaire scores differed significantly. UFM did not reflect the urinary symptoms of children with NE.

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

A presumed association between more severe lower urinary tract symptoms (LUTS) and more severe functional constipation (FC) remains unconfirmed. Because the Rome IV criteria do not quantify FC, an adult constipation scoring system was modified and adapted for use in children. The objective of this study was to assess the correlation between FC severity as determined by the modified constipation scoring system and LUTS severity in children/adolescentsand the correlation between this modified scoring system and the Rome IV criteria. This was a cross-sectional study including 5- to 17-year-old patients with LUTS, with or without FC. Patients with neurological and/or anatomical abnormalities of the genitourinary and/or gastrointestinal tract were excluded. Girls with Dysfunctional Voiding Symptom Score (DVSS) ≥6 and boys with DVSS ≥9 were diagnosed with lower urinary tract dysfunction (LUTD). Patients with at least two positive Rome IV criteria were considered constipated. The severity of FC according to the adapted constipation scoring system was classified as mild for scores of 1-10, moderate for scores 11-20, and severe for scores 21-30. Of 128 patients with LUTS, 71 (55.5%) were female. Lower urinary tract dysfunction was detected in 107 patients (83.6%) and was more common in girls. Functional constipation was present in 80 patients (62.5%). Constipated children had higher constipation scores and DVSS, with both scores increasing with the severity of FC. Correlation was moderate between the constipation score and the DVSS (þ=0.5, p<0.001) and was strong between positivity for a greater number of Rome IV criteria and the constipation score (þ=0.7, p<0.001). Most of the constipated patients had mild or moderate FC, while in 30 non-constipated patients, the constipation score indicated mild FC. Patients from a specialist center are more likely to have more severe medical problems, and this may have influenced the correlation between the scores. The modifications made to the constipation scoring system require a future validation study. Nevertheless, this study provides new data on urinary dysfunction and its association with FCand highlights the need to investigate occult bowel symptoms that could affect the treatment of urinary dysfunction. The intensity of FC as measured by the modified constipation scoring system correlated with the severity of the urinary symptoms in children/adolescents with LUTS/LUTD. In constipated patients, there was a correlation between the modified constipation scoring system and the Rome IV criteria. In non-constipated patients, the constipation scoring system identified symptoms/signs of bowel dysfunction not picked up by the Rome IV criteria. Finally, constipation score modified for use in children and adolescents could be important for research purpose and particularly having a prognostic importance.

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

Lower urinary tract dysfunction (LUTD) often presents with other associated comorbidities such as urinary tract infections, constipation, fecal incontinence, and vesicoureteral reflux. However, the psychiatric conditions that can be associated with LUTD tend to go unnoticed. The evaluation, diagnosis, and treatment of LUTD and psychiatric disorders in children are difficult and time-consuming. Moreover, there is currently no accepted consensus on this subject. In this study, the authors aimed to investigate the relationship between the subgroups of both LUTD and psychiatric disorders. LUTD were divided into 4 groups by using voiding dysfunction symptom score (VDSS), bladder diary, and uroflowmetry/electromyography (UF/EMG) test. A short screening test for psychological problems was used to detect psychiatric disorders accompanying each LUTD group. In terms of psychiatric disorders, the patients were divided into two groups: externalizing and internalizing disorders. A total of 156 children were diagnosed with LUTD. Seventy-six patients had overactive bladder (OAB), 53 had dysfunctional voiding (DV), 14 had primary bladder neck dysfunction (PBND), and 13 had underactive bladder (UAB). Psychiatric disorder was detected in 46 children (29.4%). Of these, 32 had an externalizing and 14 had an internalizing disorder. In terms of age, externalizing disorders were more common in children aged between 6 and 11 years (87.5%), whereas internalizing disorders were seen equally in both age groups. Among these, attention deficit hyperactivity disorder (ADHD) was the most common psychiatric disorder (16.1%). The LUTD groups with the most frequent psychiatric disorders were UAB (53.8%), PBND (35.7%), and OAB (28.9%). Most of the studies investigating the relationship between the lower urinary tract and psychiatric disorders so far have been concerned with the lower urinary tract symptom (LUTS) (such as nighttime or daytime incontinence) and ADHD. However, the present study was performed according to the LUTD classification, which is primarily based on VDSS, bladder diary, and UF/EMG tests. Furthermore, psychiatric disorders were classified into their subgroups. The results have shown that around a quarter of children with LUTD also had comorbid psychiatric disorders. The relationship between LUTD and psychiatric disorders constitutes a critical point. Identifying this association can contribute to the comprehensive diagnosis and treatment for these patients. LUTD and psychiatric disorders can be seen together, and this can be detected by the short screening test for psychological problems. Therefore, the authors think that patients who applied with LUTS should undergo this short test along with the routine urinary system examination and tests.

Can we predict vesicoureteral reflux resolution in patients with non-neurogenic lower urinary tract dysfunction?

To analyze factors influencing reflux resolution in patients with the coexistence of non-neurogenic lower urinary tract dysfunction and vesicoureteral reflux. The data of 153 children who were diagnosed with vesicoureteral reflux and accompanying non-neurogenic lower urinary tract dysfunction between 2010 and 2015 were retrospectively evaluated. Patients with neurogenic and anatomical malformations, monosymptomatic nocturnal enuresis, previous history of vesicoureteral reflux surgery, irregular and/or incomplete follow-up data were excluded. After exclusion of 55 patients, 98 patients were enrolled in this study. Patients were divided into two groups according to the presence of spontaneous vesicoureteral reflux resolution during the follow-up period. Group1 consisted of 54 children with spontaneous vesicoureteral reflux resolution, whereas group2 included 44 children without resolution. Medical history, physical examination, urinalysis, uroflowmetry combined with electromyography, ultrasonography, as well as the Dysfunctional Voiding and Incontinence Symptom Score questionnaire were also evaluated. The mean age at presentation was 7.57±0.23years (range 5-13years), and the mean follow-up period was 28.3months. Significant differences were noted between the two groups in terms of dysfunctional voiding and incontinence symptom score, bladder wall thickness, and the post-void residual urine volumes. In addition, lower urinary tract symptoms, namely frequency, urgency and daytime incontinence, were found to be higher in group2. In multivariate analysis, post-void residual urine volume and Dysfunctional Voiding and Incontinence Symptom Score were found to affect reflux resolution rates (P=0.002, P=0.002, respectively). The absence of significant post-void residual urine volume, and a low Dysfunctional Voiding and Incontinence Symptom Score increase the likelihood of spontaneous resolution rates of vesicoureteral reflux in children with non-neurogenic lower urinary tract dysfunction.

Differentiating Tower from Bell Curves in Smooth Continuous Uroflowmetry Curves of Healthy Adolescents

Introduction: The definition of each uroflow pattern is vague, and therefore, interpreting uroflowmetry curves is associated with low inter-rater agreement. The aim of the study is to evaluate whether subjective or objective parameters could better differentiate tower from bell curves. Materials and Methods: Uroflow curves of community healthy adolescents with smooth continuous curves and minimal fluctuations within optimal bladder volume were independent reviewed by two experienced pediatric urodynamists and classified as bell or tower. The objective parameters generated from uroflow curves including Franco-Yang (F-Y) index (≧80) and angle at peak flow rate (A_Qmax ≧80°) were also used to differentiate tower from bell. The participants were asked to complete dysfunctional voiding symptom score (10 items, score 0–3). Results: A total of 287 adolescents with a mean age of 15.3 ± 1.7 years were enrolled and 150 curves were eligible for analysis. The inter-rater agreement was low (kappa = 0.27). Adolescents with uroflow curves classified as tower though F-Y index and A_Qmax were associated with higher urgency score than those with bell curves. However, adolescents with the tower curves defined by interpreters did not have higher urgency scores. Conclusions: Objective classification of tower curves with may be more reliable than subjective classification by the urodynamists. However, a significant proportion of participants with tower curves did not have urgency symptoms.

Validation of Serbian Version of Dysfunctional Voiding Symptom Score (DVSS) Questionnaire.

Objective: The aims of our study were to translate the dysfunctional voiding symptom score (DVSS) from English to Serbian; culturally adopt the items; assess the internal consistency and the test–retest reliability of DVSSSR in patients with dysfunctional voiding (DV); evaluate and test the construct and divergent validity of DVSSSR against demographic parameters (gender and education); and examine the level of explained variability for each item of DVSSSR against demographic parameters (gender and education). Methods: The cross-sectional observational study included 50 patients with dysfunctional voiding aged 5 years and above. The DVSS questionnaire was translated from English into Serbian by the forward–backward method. Internal consistency was assessed with Cronbach α and test–retest reliability with intraclass correlation coefficient (ICC). For validity testing we performed construct and divergent validity analyses. Results: There was excellent internal consistency for every item except for Item 6 (0.787) and Item 3 (0.864), where internal consistency was good. The observed test/retest ICC for average measures was more than 0.75 (excellent) for all DVSSSR items. Gender and educational level does not correlate significantly with each item of DVSSSR (p > 0.05). For divergent validity, there were no significant differences in mean values of each item of DVSSSR between genders and different levels of education (p > 0.05). Variability that can be explained for gender and educational level was below 10%. Conclusion: Translated DVSSSR is of adequate validity and reliability for assessing DV in children.

Biofeedback as single first-line treatment for non-neuropathic dysfunctional voiding children with diurnal enuresis.

Non-neurogenic dysfunctional voiding (NDV) accounts for a significant portion of pediatric urology outpatient clinic visits. Biofeedback (BF) is a promising, non-invasive modality for treating children with DV and daytime wetting. Our objective was to investigate BF's efficacy as a single first-line treatment for children with NDV and diurnal enuresis. A retrospective cohort study was conducted with a total of 61 consecutive patient records from January 2009 to March 2016. All children with NDV who had BF as first-line treatment were included. Full urological histories, physical examinations, dysfunctional voiding symptom score (DVSS), urine analysis, ultrasound (US), and uroflowmetry (UFM), and electromyogram (EMG) were performed and recorded for all patients before and after finishing the last BF cycle. The patient's satisfaction scale was also obtained. The mean age was 10±2.6 years. Most patients (80.3%) were females. The presenting symptoms were diurnal enuresis, urinary tract infections, and voiding discomfort in 52 (85.2%), 16 (26.2%), and 38 (62.3%) patients, respectively. Six months after the last BF cycle, there was a statistically significant objective improvement in US and UFM+EMG findings with the disappearance of EMG signals in 40 of 61 (65.5%) patients. There was also a significant subjective symptomatic improvement, as the mean DVSS had decreased from 14 to 7.9 (p=0.003). Forty-seven patients (77%) were satisfied, while only eight (13.1%) were not. BF is considered a potentially effective, single first-line treatment modality for children with DV and diurnal enuresis. Long-term outcome assessments are needed to assess the children's compliance and symptom recurrence.

Determine the Relationship Between Abdominal Muscle Strength, Trunk Control and Urinary Incontinence in Children with Diplegic Cerebral Palsy.

The aim of this study is to determine the relationship between abdominal muscle strength, trunk control and urinary incontinence in children with diplegic cerebral palsy. The current study had a cross-sectional design using analytical study as well as an observational research model. Fifty children between the ages of 5 and 18 years who were diagnosed with diplegic clinical type of cerebral palsy were included in this study using improbable-random sampling method. After patients' demographic information were obtained, Dysfunctional Voiding and Incontinence Symptoms Score Questionnaire (DVISS), Dysfunctional Voiding Symptom Score (DVSS), the manual muscle test of the muscles, Trunk ControlTest (TCT) and Trunk Control Measurement Scale (TCMS) were completed in order to evaluate trunk control. Also, Gross Motor Function Classification System (GMFCS) was performed in order to define the functional level. In this study, a highly correlated negative relationship was found between DVISS and DVSS scores with muscle abdominal strength, TCMS and TCT. In addition, a highly correlated positive relationship was found between both GMFCS and DVISS and GMFCS and DVSS. This is the first study that describes the effect of trunk control and muscle strength on urinary incontinence in children with diplegic cerebral palsy. This study showed that there is a correlation between trunk control, muscle strength and urinary incontinence.

Non-invasive evaluation of botulinum-A toxin treatment efficacy in children with refractory overactive bladder.

We aimed to evaluate the efficacy and safety of intravesical onabotulinum toxin A (onaBoNTA) injections for the treatment of children diagnosed with refractory overactive bladder (OAB) by using non-invasive methods. A total of 31 pediatric patients with a mean age of 10.2years received intravesical onaBoNTA injection at the dose of 10 U/kg (max: 200 U). Twenty-one patients who failed to respond to the first injection, received second injection 6months after the first one. The patients were retrospectively evaluated after the 1st and the 2nd injections by means of standardized questionnaire forms and voiding diary records. In the 6-month follow-up, 10 patients (32.2%) were determined to have full response after the first injection. The number of patients with partial response and no response were found to be 15 (48.4%) and 6 (19.4%), respectively. The mean value of Dysfunctional Voiding and Incontinence Symptom Score (DVISS) of the patients with full response was 8.5 before the injection, which decreased to 1at 6-month follow-up and to 0.5at 12-month follow-up (p < 0.001). Twenty-one patients without full response after the first injection received a second injection 6months after the first one. Full response was achieved in 9 (42.9%) of the 21 patients who had a second injection, but only partial response was achieved in 9 (42.9%). Three (14.3%) of the remaining patients did not respond to the second injection either. 1-year follow-up evaluations revealed that the rates of the full response, partial response, and no response were 61.3, 29, and 9.7%, respectively. Based on our results, onaBoNTA therapy is an effective and reliable second-line off-label therapy in the management of patients with non-neurogenic OAB that is refractory to medical therapy. Asking the patients/guardians to fill out a standardized questionnaire form before and after the therapy enables easy and non-invasive assessment of the response to the therapy.

Prolonged toilet training in children with Down syndrome: a case‐control study

ObjectivesChildren with Down syndrome have delayed psychomotor development, which is a factor that influences the level of difficulty in toilet training. The current study aims to estimate the age toilet training starts and completes in children with DS compared to children with normal psychomotor development and to evaluate the method and type of toilet training most frequently used, as well as its association with lower urinary tract symptoms and functional constipation. MethodsA case‐control study was carried out from 2010 to 2015. All parents completed a questionnaire designed to assess the toilet training process. Lower urinary tract symptoms were assessed through the application of the Dysfunctional Voiding Symptom Score. The presence of functional constipation was assessed according to the Rome III criteria. ResultsThe study included 93 children with Down syndrome and 204 children with normal psychomotor development (control group [CG]). The mean age of toilet training onset was 22.8 months in those with DS and 17.5 months in the CG (p=0.001). In children with DS, the mean age when completing toilet training was 56.2 months and 27.1 months in the CG (p=0.001). Among children with DS, females completed toilet training earlier (p=0.02). The toilet training method used most often was child‐oriented approach in both groups. No association was observed with the presence of lower urinary tract symptoms or functional constipation and the age of beginning and completing toilet training in both groups. ConclusionChildren with Down syndrome experienced prolonged toilet training time. Prospective longitudinal studies are essential to gain insight into the toilet training of these children.

Use of baclofen in children with dysfunctional voiding: a preliminary report

IntroductionThe aims of the present study were to examine the effectiveness and safety of baclofen in children with dysfunctional voiding (DV).Material and methodsThirty children with primary DV were enrolled. Patients underwent history taking, complete physical examination, urine analysis and culture, ultrasonography of the urinary system, a uroflowmetry study and post urine residue analysis. The Dysfunctional Voiding Symptom Score (DVSS) questionnaire was completed and other related symptoms were recorded. Oral baclofen was started for the study group at a dose of 1 mg/kg in 3 divided doses. Ultrasonography, a uroflowmetry study and questionnaire were repeated 3 months later.ResultsWe observed a mean decrease of 14.67 ml in post void residual urine (PVRU) after 3 months. After usage of baclofen, increase in Qmax (5.74), increase in mean flow rate (8.2 vs. 11.3), and an average decrease of 12.3 in the DVSS questionnaire (p <0.001) were also observed. The number of voluntary voiding and wetting episodes were significantly decreased after treatment with baclofen (p = 0.001). Three main complaints of the patients were urgency (p = 0.001), dysuria (p = 0.004) and straining (p = 0.004) and all were significantly decreased after medical therapy with baclofen.ConclusionsBaclofen may be useful in treatment of pediatric dysfunctional voiding. It was well tolerated among our patients with a remarkable reduction in their symptoms.

Do uroflowmetry and post - void residual urine tests necessary in children with primary nocturnal enuresis?

ABSTRACTObjectives:To examine the benefits of repetitive uroflowmetry and post void residual urine (PVR) tests in children with primary nocturnal enuresis (PNE).Material and methods:Children aged ≥6 years with PNE who visited our clinics for management of enuresis were included for study. Patients were requested to complete a questionnaire including baseline characteristics and Dysfunctional Voiding Symptom Score (DVSS), 2-day bladder diary, and Rome III criteria for constipation. Two uroflowmetry and PVR tests were requested. Children with congenital or neurogenic genitourinary tract disorders were excluded. All children underwent urotherapy and desmopressin combined with anticholinergics or laxatives if indicated. The definition of abnormal flow patterns (≥1 abnormal), elevated PVR (≥1 abnormal), small maximal voided volume (MVV), nocturnal polyuria (NP) and response to treatment complied with the ICCS standardization document. Kaplan-Meier survival analysis and Cox proportional-hazards regression tests were used to evaluate the predictors of response.Results:In total, 100 children aged 8.5±2.3 years were enrolled for study (M: F=66:34) with 7.3±7.4 months of follow-up. Poor correlation was observed between DVSS/small MVV and PVR (p>0.05). Univariate analysis revealed that elevated PVR is associated with significantly less hazard of complete response to medical treatment (HR: 0.52, p=0.03), while not significantly associated with abnormal flow patterns, NP, constipation or small MVV. Multivariate analysis revealed that only elevated PVR (HR 0.30, 95% CI 0.12-0.80) and NP (HR 2.8, 95% CI 1.10-7.28) were significant predictors for complete response.Conclusions:In managing pediatric enuresis, elevated PVR is a significant predictor for lower chance of complete response to treatment whether they had high DVSS or not.

Prolonged toilet training in children with Down syndrome: a case–control study

ObjectivesChildren with Down syndrome have delayed psychomotor development, which is a factor that influences the level of difficulty in toilet training. The current study aims to estimate the age toilet training starts and completes in children with DS compared to children with normal psychomotor development and to evaluate the method and type of toilet training most frequently used, as well as its association with lower urinary tract symptoms and functional constipation. MethodsA case–control study was carried out from 2010 to 2015. All parents completed a questionnaire designed to assess the toilet training process. Lower urinary tract symptoms were assessed through the application of the Dysfunctional Voiding Symptom Score. The presence of functional constipation was assessed according to the Rome III criteria. ResultsThe study included 93 children with Down syndrome and 204 children with normal psychomotor development (control group [CG]). The mean age of toilet training onset was 22.8 months in those with DS and 17.5 months in the CG (p=0.001). In children with DS, the mean age when completing toilet training was 56.2 months and 27.1 months in the CG (p=0.001). Among children with DS, females completed toilet training earlier (p=0.02). The toilet training method used most often was child-oriented approach in both groups. No association was observed with the presence of lower urinary tract symptoms or functional constipation and the age of beginning and completing toilet training in both groups. ConclusionChildren with Down syndrome experienced prolonged toilet training time. Prospective longitudinal studies are essential to gain insight into the toilet training of these children.

Utility of Voiding Dysfunction Symptom Score in Diagnosis and Treatment of Enuresis Nocturna

Utility of Voiding Dysfunction Symptom Score in Diagnosis and Treatment of Enuresis Nocturna

Is There Any Difference Between Questionnaires on Pediatric Lower Urinary Tract Dysfunction?

To investigate the diagnostic properties of 3 different scoring systems (Dysfunctional Voiding Symptom Score [DVSS], Dysfunctional Voiding and Incontinence Symptoms Score [DVISS], Incontinence Symptom Index-Pediatric [ISI-P, for children older than 11 years]) that are used to evaluate lower urinary tract symptoms in pediatric population. Eighty-four participants were evaluated by detailed history, physical examination, 3 different scoring systems (DVSS, DVISS, ISI-P), ultrasonography, and uroflowmetry. Depending on the tests, cases were stratified as healthy or lower urinary tract symptoms (LUTS) by 2 urologists who were blinded to the questionnaires. Patients were reevaluated by the same tests and questionnaires 3 months after treatment. Diagnostic properties of questionnaires were calculated. Additionally, parents were asked to scale the improvement of symptoms subjectively from 0% to 100% to correlate to each of the three scoring systems. The mean ages of the normal and the LUTS groups were 9.1 ± 2.6 years and 10.1 ± 2.8 years, respectively (P = .301). Gender (male:female) distribution was 21:21 in the LUTS group and 25:17 in the control group (P = .381). In terms of diagnosis, DVISS has the highest accuracy (sensitivity: 81%, specificity: 97.6%, accuracy: 89%) followed by ISI-P (sensitivity: 55.6%, specificity: 100%, accuracy: 82%) and DVSS (sensitivity: 54.8%, specificity: 97.6%, accuracy: 76%). The similar order was valid for the 23 patients older than 11 years (accuracy for DVISS: 87%, for ISI-P: 82%, and for DVSS: 78%). In terms of response to treatment, all 3 tests showed good correlation with parents' ratings (DVSS: P < .001, DVISS: P = .005, ISI-P: P = .042). Although DVISS had the highest accuracy in distinguishing the patients from healthy controls, all 3 questionnaires seem to be equivalent for the evaluation of response to treatment.

Constipation and Lower Urinary Tract Dysfunction in Children and Adolescents: A Population-Based Study.

To evaluate the correlation between constipation and lower urinary tract dysfunction (LUTD) and nocturnal enuresis in a population-based study. This is a cross-sectional study. The criteria for inclusion were children and adolescents of between 5 and 17 years and who agreed to sign the informed consent form. The study excluded students with neurological problems or who had documented abnormalities of the urinary tract. To identify the presence and severity of LUTD, we used the Voiding Dysfunction Symptom Score (DVSS). To evaluate the presence of constipation, Rome III questionnaire was used. We interviewed 829 children and adolescents, of which 416 (50.18%) were male. The mean (SD) age was 9.1 (±2.9) years. The overall prevalence of LUTD was 9.1%, predominantly in girls (15 versus 3.1%, p < 0.001). Constipation was found in 9.4% of boys and 12.4% of girls (p = 0.169). Constipated children were 6.8 times more likely to have LUTD than those not constipated (p < 0.001, coefficient and correlation of 0.411). Constipation was found in 8.2% of children without LUTD and in 35.2% of children with LUTD. We performed multivariate analysis to identify urinary symptoms that are independent predictors of the presence of constipation. The presence of infrequent urination (p = 0.004) and holding maneuvers (p < 0.001) were independent predictors. It was noted also noted that constipated children, according to the Rome III criteria, possess a worse DVSS (p < 0.001). Regarding the presence of nocturnal enuresis, 12.6% of children and adolescents had constipation in association with this symptom. However, this relationship was not statistically significant (p = 0.483). Constipated children were 6.8 times more likely to have LUTD than those not constipated. Among the urinary symptoms, infrequent voiding and holding maneuvers are independent factors of urinary expressions in constipated children. Children with more severe constipation have more prominent urinary symptoms. The presence of enuresis was not associated with constipation.