Lower Urinary Tract Dysfunction In Children Research Articles

Treatment modalities for paediatric functional daytime lower urinary tract disorders: an updated review.

Paediatric functional bladder disorders especially those causing daytime symptoms are a common cause of significant psychosocial and/or physical morbidity and impaired quality of life. Despite the availability of many therapeutic modalities, a significant number of children appear to be refractory to treatment and continue to have symptoms. In this review, we aim to evaluate the current evidence in the use of existing and novel therapeutic options for the management of daytime lower urinary tract disorders in children. We also aim to highlight the controversies around the terminology and diagnosis of paediatric lower urinary tract dysfunction (LUTD) and specific conditions. The article will then provide a reasonable critique of the existing and emerging treatment modalities in functional daytime LUTD in children including their mode of action, efficacy, indications, and recent advances. These include standard urotherapy, specific urotherapy comprised of biofeedback, alarm therapy and electrical neural stimulation and pharmacotherapy involving selective and non-selective anticholinergics, ß3 adrenergic agonists, alpha blockers and botulinum toxin. A better understanding of this common clinical problem may help clinicians achieve better profiling of these children's diagnoses to further enable specific, targeted treatment.

Pay attention to lower urinary tract dysfunction and the clinical application of urodynamic studies in children

Lower urinary tract dysfunction (LUTD) is the dysfunction of bladder and urethra during bladder filling and voiding phase. There are two general categories: neurogenic and non-neurogenic. It can cause upper urinary tract damage if left untreated. Urodynamic study (UDS) can objectively detect the function of detrusor and sphincter of urethra as well as predict the damage of LUTD to upper urinary tract. However, the development of UDS for children in China has not been popularized, which affects the accurate diagnosis and the treatment of LUTD. This article reviewed the importance of paying attention to LUTD and promoting the clinical application of UDS in children, so as to improve the diagnosis and treatment of LUTD in children.

Urologic Presentations and Management Options in Pediatric Mitochondrial Disease

ObjectiveTo review the evaluation and management of urologic pathology related to mitochondiral diseases (MD) in childhood. MethodsA retrospective review was performed of patients with MD from 1/1/2000 – 10/8/2020 who were referred for urologic evaluation at a single pediatric hospital. Clinical and demographic information was reviewed including symptomatology, urodynamic evaluation, and medical/surgical management. Results15 patients were identified for inclusion. Median age of presentation was 5 years and median follow up was 4 years. Patients presented with numerous urologic concerns including urinary retention/incomplete emptying, incontinence, and recurrent urinary tract infection. Urodynamics demonstrated elevated median bladder capacity at 172% of expected as calculated by age. Detrusor sphincter dyssynergia (DSD) was present in 6 (50%). Progression to surgical intervention occurred in 67% at a median time of 3.5 years after initial referral. This included suprapubic tube (SPT) placement and sacral neuromodulation (SNM). ConclusionPatients in this study were found to have a spectrum of lower urinary tract dysfunction (LUTD) with elevated bladder capacity being common. No singular urodynamic feature prevailed although DSD was found in 50%. Progression of symptoms over time was also common. Most patients (67%) did go on to surgical intervention including SPT and SNM. Clinicians should be aware of the possibility of LUTD in children with MD and they should be promptly referred to pediatric urology when LUTD is suspected.

Interferential Electrical Stimulation Efficacy in the Management of Lower Urinary Tract Dysfunction in Children: A Review of the Literature.

Lower urinary tract dysfunction (LUTD) is the most common problem of the referral children to the pediatric urology clinics. If this condition does not treat early in life, it will be a lifelong problem. During recent decades, electrical stimulation therapy has been expanded and extensively used for the treatment of LUTD in both adults and children. The aim of this review is to suggest clinicians an updated understanding of effects of interferential (IF) electrical stimulation therapy in management of LUTD in children. The search was performed in databases of Medline, PubMed, Google Scholar, ,and Scopus for information about IF electrical stimulation and its application using search words such as " IF electrical stimulation", "transcutaneous IF electrical stimulation" , "IF therapy " , " electrical stimulation", "voiding dysfunction" , " LUTD", " urinary incontinence" and " children". As this review focuses on the answer of this question "Does transcutaneous IF electrical stimulation has effect on management of LUTD in children?" we included the reference list of articles identified by this search strategy and selected those we judged relevant according to our keywords. Clinical trial studies that publishing in English were included. Categorical data were reported as frequencies and percentages. Eleven studies were included in this review. The success rate of IF therapy in these studies has been reported from 61% to 90% of children with LUTD and urinary incontinence. IF electrical stimulation is an effective, safe and reproducible option to manage LUTD and urinary incontinence in children.

Delayed in toilet training association with pediatric lower urinary tract dysfunction: A systematic review and meta-analysis

Globally, attitudes and practices towards toilet training have changed several decades ago and children are completing toilet training at a later age compared to previous generations. Concurrently, there has been an increase in the incidence of pediatric bladder bowel dysfunction (BBD), including lower urinary tract dysfunction (LUTD). Whether the fact of delayed toilet training may negatively impact the ability of children to obtain bladder and bowel control and cause LUT dysfunction remains controversial. To investigate the association between age at initiation of toilet training or approach to toilet training and the risks of lower urinary tract (LUT) dysfunction. A comprehensive search of the CENTRAL, EMBASE and MEDLINE via Ovid SP, and CINAHL via EBSCO databases was conducted to identify RCTs, cohort or case-control studies investigating the association between age at initiation of toilet training, approach used for toilet training, and pediatric LUT dysfunction. A total of 10 studies with 24,121 participants (aged 5-17) were included for pooled analysis. Overall, the odds ratio (OR) with 95% confidence interval (95%CI) of LUT dysfunction in children who initiated toilet training at a younger age when compared to those who initiated toilet training at an older age, was 0.71 (0.63-0.81), P<0.001), irrespective of the approach used for toilet training (Table). Subgroup analysis for day-time incontinence (persistent daytime wetting) was 0.77 (0.62-0.95), P=0.014; although the outcomes for enuresis fluctuated, favorable results were still observed in the earlier training group (OR:0.63, 95%CI:0.43-0.94, P=0.023). Subgroup analysis for age at initiating toilet training vs LUT dysfunction also showed favorable results in children who were trained earlier, i.e., before 24 months (OR:0.77, 95% CI 0.63-0.94, P=0.009). Sensitivity analysis confirmed that the results were robust. Although the definition about the age of initial toilet training varied greatly in studies, findings from the current study suggested that the optimal time for initiating toilet training may be prior to the age of 24 months; if toilet training was initiated after 24 months or later, it may result in increased prevalence of LUT dysfunction. Since no RCTs studies were included in the current meta-analysis, well-designed longitudinal studies with larger sample size and from different cultural background are needed to confirm these results. This meta-analysis presents preliminary findings that show the incidence of LUTD may be decreased by initiating toilet training in children at a younger age.

Relationship of Urinary Tract Infection to Lower Urinary Tract Dysfunction and Kidney Scar Formation in Children.

Background:Urinary tract infection (UTI) is the most common infection during childhood. Lower urinary tract dysfunction (LUTD) is a broad term that indicates an abnormal voiding pattern in a child without anatomical and neurological impairment. The purpose of this study was to determine the relationship between UTI and LUTD.Methods:This study was conducted at the Children Medical Center Hospital in 2014–2016. The inclusion criteria of this study were at least one UTI confirmed by a positive urine culture and active urine analysis in children who were well toilet-trained previously. Complete physical examination of the genitourinary and skeletal systems was performed to identify patients with anomalies in these systems. The patients with genitourinary system anomalies and obvious and prediagnosed neurological defects of the urinary system such as neurogenic bladder were excluded from the study. To confirm the presence of LUTD, the scoring system of Akbal et al. was applied.Results:A total of 260 patients including 9.2% of males and 90.8% of females were included in this study. The prevalence of LUTD was 63.8% (166 cases) in these patients. In this study, the prevalence of LUTD in patients with a single episode of UTI was 50.5%, while in patients with recurrence of UTI it was 88.9%. In patients with unilateral kidney scar formation, 90.9% had a recurrence of UTI (P = 0.003) which shows a strong correlation of unilateral scar formation with recurrence of UTI.Conclusions:These data suggest that there is a significant relationship between UTI and LUTD in children, so evaluation of voiding dysfunction is necessary in this group. With early diagnosis and appropriate treatment, we can reduce the possible serious and permanent sequels of LUTD in patients with UTIs.

Obesity and lower urinary tract dysfunction in children and adolescents: Further research into new relationships

Lower urinary tract dysfunction (LUTD) involves faults in the filling and emptying phases of bladder function in toilet-trained children with no previous infection or any other obvious pathology. Lower urinary tract dysfunction is associated with conditions such as vesicoureteral reflux, recurrent urinary infection, behavioral alterations and decreased quality of life. The literature suggests an association between LUTD and obesity; however, the association between each individual symptom and obesity has yet to be evaluated. To evaluate the association between excess weight and LUTD in children and adolescents in a community-based sample. This cross-sectional study included 423 children and adolescents aged 5-17 years, and randomly selected in public places and schools between May and July 2015. The participants and their mothers completed the Dysfunctional Voiding Scoring System (DVSS) questionnaire, except for the questions on constipation and with the addition of a question on enuresis. They also completed the Rome III questionnaire, in which two positive responses defined the presence of constipation. Participants were classified as being of normal weight, overweight or obese, which was based on the BMI-for-age indicator. Mean age was 9.7 years (SD 2.9), with girls comprising 50.6% of the sample and adolescents 52.5%. The prevalence of LUTD was 7.1%, with 13.5% of participants being overweight and 12.1% obese (Figure). Constipation was present in 5.9% of participants and enuresis in 10.8%. In the multivariate analysis, three factors were independently and significantly associated with a positive DVSS: age <10 years (β=0.76; 95% CI: 0.34-1.18), constipation (β=1.79; 95% CI: 0.88-2.70) and obesity (β=0.89; 95% CI: 0.25-1.52). Only bladder filling symptoms were associated with obesity. This may be explained by the fact that both obese individuals and those with emptying symptoms were shown to have activation alterations in the same brain regions. One limitation of this study was the use of questionnaires alone to diagnose LUTD and constipation. Only the bladder-emptying symptoms of LUTD appear to be associated with obesity. This hypothesis may serve as a basis for future studies.

Role of Uroflowmetry in Children with Ano-Rectal Malformation in Anticipating Upper Urinary Tract Damage

Background: The lower urinary tract dysfunction (LUTD) has high incidence in children with anorectal malformation (ARM) which if left untreated leads to upper tract damage. Aim: To determine role of uroflowmetry in early diagnosis of LUTD in children with ARM. Methods: This prospective study included twenty consecutive patients of ARM and every patient underwent uroflowmetry at-least 6 weeks after definitive procedure. Results: The mean age of patients was 3.015±0.86 years. Of the twenty patients, there were 12 (60%) males and 8 (40%) females; 11 (55%) were high ARM, 4 (20%) were intermediate and 5(25%) were low ARM. Lower urinary tract symptoms (LUTS) was present in 8/20 (40%) patients but uroflowmetric abnormalities were present in 11/20 (55%) patients. Forty five percent (5/11) patients with abnormal uroflowmetry were asymptomatic and 25% (2/8) symptomatic patients had normal uroflowmetry. The incidence of uroflowmetric abnormalities was significantly higher in patients with spinal anomalies (p=0.03; χ2=4.1) and those with high ARM (p=0.004; χ2=8.1). Conclusion: Uroflowmetry is a noninvasive method that may help in early detection of neurovesical dysfunction in asymptomatic children and subsequent cystometric analysis in patients with uroflowmetric abnormalities can be done for early definitive diagnosis and prevention of upper urinary tract damage.

Are lower urinary tract symptoms in children associated with urinary symptoms in their mothers?

The association between parents who suffered daytime incontinence as children and children who are incontinence has been reported. However, the association of lower urinary tract (LUT) dysfunction in children and urinary symptoms in mothers has not been studied. To test the hypothesis that the children of mothers with lower urinary tract symptoms (LUTS) are more likely to have urinary symptoms. A cross-sectional multicenter study was conducted in two cities in Brazil. Children/adolescents of 5-17 years of age and their mothers were interviewed. Children with neurological problems, previously detected urinary tract abnormalities or who refused to sign the informed consent or assent form were excluded. The DVSS questionnaire was used to evaluate the presence of LUTS in the children and the ICIQ-OAB questionnaire was used to evaluate their mothers. Constipation in the children was investigated using the ROME III criteria. A total of 827 mother-child pairs were included, with 414 of the children (50.06%) being male. Mean age was 9.1±2.9 years for the children and 35.9±6.5 years for the mothers. Urinary symptoms (occurring at least once or twice a week) were present in 315 children (38.1%), incontinence in 114 (13.8%) and urinary urgency in 141 (17%). Of the mothers, 378 (45.7%) had at least one LUTS, with 103 (12.5%) having incontinence and 153 (18.5%) urgency. According to the DVSS, the overall prevalence of LUT dysfunction was 9.1%. The children's DVSS scores were significantly associated with the mothers' ICIQ-OAB scores (p<0.0010). Mothers with urinary symptoms were 2.5 times more likely to have a child with LUT dysfunction (95%CI: 1.52-4.17; p<0.001), while mothers with overactive bladder were 2.8 times more likely to have a child with an overactive bladder (95%CI: 1.63-4.86; p<0.001). In the multivariate analysis, these same characteristics were confirmed as independent predictive factors of the presence of LUT dysfunction in the child. Children of mothers with incontinence and urinary urgency were also more likely to have incontinence and urgency. Mothers with typical symptoms of overactive bladder are more likely to have a child with LUT dysfunction. This correlation is also positive for the isolated symptoms of urinary urgency and incontinence. Independent predictive factors of the presence of LUT dysfunction in children were: being female, enuresis, constipation, and having a mother with LUTS.

Concised Form for Lower Urinary Tract Dysfunction Symptom Scale in Children.

Symptom Scales (SS) are questionnaires for evaluating and following up of special illnesses. SS used for the diagnosis and follow-up of Lower Urinary Tract Dysfunction (LUTD) in children is called LUTD Symptom Scale (LUTDSS). Aim of the present study was to identify the questions which are more important for the diagnosis of LUTD in children and create a simpler SS. From January 2005 to March 2015, 631 children between the age 5 and 15 were enrolled in this study. Eleven children with active urinary tract infections were excluded from the study. Two hundred sixty three children from the nursery and secondary school saying that they have no urinary complaints and having LUTDSS <9 were designed as control group. Three hundred fifty seven children with LUTDSS score ≥9 were thought as having LUTD and diagnoses were verified with 3-day bladder diaries and 2-time Uroflow-EMG-PVR tests. The answered questions of LUTDSS in patient and control group were compared. Children with daytime incontinence (first question of questionnaire) were 47.7 (4.8-510) times (p=0.01), children with enuresis (third question) were 59.53 (6.2-961) times (p=0.001), children with pause while urinating (eighth question) were 28.7 (4.4-2090) times (p=0.001), children with urgency (tenth question) were 54.7 (29.3-604) times (p=0.039) more likely to have LUTD than the children not having these complaints. The area under ROC curve created by using 1,3,8, and 10 questions was calculated 86.4%. The diagnosis and control of LUTD can be made by using only 1., 3., 8. and 10. questions, and these 4 questions could form simpler SS for LUTD in children.

Pathophysiological and Therapeutic Considerations for Non-Neurogenic Lower Urinary Tract Dysfunction in Children.

Non-neurogenic lower urinary tract dysfunction (LUTD) in children is very common in clinical practice and is important as an underlying cause of lower urinary tract symptoms, urinary tract infection and vesicoureteral reflux in affected children. LUTD in children is caused by multiple factors and might be related with a delay in functional maturation of the lower urinary tract. Behavioral and psychological problems often co-exist in children with LUTD and bowel dysfunction. Recent findings in functional brain imaging suggest that bladder bowel dysfunction and behavioral and psychiatric disorders in children might share common pathophysiological factors in the brain. Children with suspected LUTD should be evaluated properly by detailed history taking, validated questionnaire on voiding and defecation, voiding and bowel diary, urinalysis, screening ultrasound, uroflowmetry and post-void residual measurement. Invasive urodynamic study such as videourodynamics should be reserved for children in whom standard treatment fails. Initial treatment of non-neurogenic LUTD is standard urotherapy comprising education of the child and family, regular optimal voiding regimens and bowel programs. Pelvic floor muscle awareness, biofeedback and neuromodulation can be used as a supplementary purpose. Antimuscarinics and α-blockers are safely used for overactive bladder and dysfunctional voiding, respectively. For refractory cases, botulinum toxin A injection is a viable treatment option. Prudent use of urotherapy and pharmacotherapy for non-neurogenic LUTD should have a better chance to cure various problems and improve self-esteem and quality of life in affected children.

The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children's Continence Society.

The impact of the original International Children's Continence Society (ICCS) terminology document on lower urinary tract (LUT) function resulted in the global establishment of uniformity and clarity in the characterization of LUT function and dysfunction in children across multiple healthcare disciplines. The present document serves as a stand-alone terminology update reflecting refinement and current advancement of knowledge on pediatric LUT function. A variety of worldwide experts from multiple disciplines within the ICCS leadership who care for children with LUT dysfunction were assembled as part of the standardization committee. A critical review of the previous ICCS terminology document and the current literature was performed. Additionally, contributions and feedback from the multidisciplinary ICCS membership were solicited. Following a review of the literature over the last 7 years, the ICCS experts assembled a new terminology document reflecting current understanding of bladder function and LUT dysfunction in children using the resources from the literature review, expert opinion and ICCS member feedback. The present ICCS terminology document provides a current and consensus update to the evolving terminology and understanding of LUT function in children. Neurourol. Urodynam. 35:471-481, 2016. © 2015 Wiley Periodicals, Inc.

Radiological bladder characteristics in VCU for young children with high-grade VUR

It has been suggested that infants with dilating vesicoureteral reflux (VUR) often have lower urinary tract (LUT) dysfunction. Signs such as high voiding pressure levels, low bladder capacity and dyscoordination at voiding have previously been thought to be indicative of dysfunction. However, these findings have also been recognised in healthy infants and are, thus, not specific to dysfunction in this age group. The urodynamic findings of interest for LUT dysfunction in children with high-grade VUR have been shown to be high bladder capacity with incomplete emptying, and often with overactivity during filling. Because the bladders in children with VUR are often only investigated with voiding cystourethrography (VCUG) and not urodynamics, the question has arisen as to whether some of the urodynamic findings indicating dysfunction can be recognised as radiological signs. The aim of the present study was to evaluate whether cystometric signs of LUT dysfunction in infants with high-grade VUR could be recognised in VCUG. One hundred and fifteen infants (80 boys) with Grades III-V VUR were included and investigated repeatedly with videocystometry (VCM) at a median age 6, 21 and 39 months. The sign looked for in the VCUG was bladder size (large, normal or small), according to the chosen levels in the bony pelvis. To validate the chosen levels for the different bladder sizes, bladder capacity data from a longitudinal study in healthy children were used. In addition, abnormalities in bladder wall/form and filling of the posterior urethra without voiding, as signs of bladder overactivity and detrusor-sphincter dyscoordination, were evaluated. Bladder size was estimated on VCUG as large, normal or small, according to pelvic landmarks. Large bladder size was mainly seen at the second and third evaluations (64% and 46%), whereas small capacity was mainly seen during the first year (33%). Corresponding cystometric capacities (ml) showed a significant difference between the groups of small, normal and large bladder size. The cystometric capacities of large and small bladder size were also compared with bladder capacity in healthy controls, where large had significantly higher bladder capacity versus age (P = 0.0001) and small had significantly lower (P = 0.011) bladder capacity versus age than in the healthy controls. Bladder shape/wall pathology was mainly seen during the first year (42%), combined with small capacity, and correlated to overactive contractions during filling. Moreover, filling of the posterior urethra without voiding, indicating detrusor/sphincter dyscoordination at voiding, was quite common during the first year (33%), and then successively decreased. The clinical implication from this study of small children with high-grade VUR was that a large bladder on VCUG was synonymous with a high-capacity bladder. According to earlier studies, this is a sign of LUT dysfunction in this age group and should therefore be an indicator for additional studies of bladder function. Overactive contractions could also be recognised in VCUG, but only at the infant evaluation, which should also be regarded as an indicator of LUT dysfunction. All other bladder VCUG signs mainly seen during early infancy were signs of immature bladder function and not a result of VUR dysfunction.

Lower urinary tract dysfunction is frequently seen in urinary tract infections in children and is often associated with reduced quality of life.

Previous studies suggest that 6-46% of children suffer from lower urinary tract dysfunction (LUTD). This study evaluated the prevalence of LUTD in children with a urinary tract infection (UTI) and assessed the impact of standard urotherapy on patients with LUTD. We enrolled 228 patients who were 4years of age or older with at least one episode of UTI, together with a control group of 100 children. All the children were evaluated using the Pediatric Lower Urinary Tract Symptom Score (PLUTSS), and the intervention group were re-assessed after therapy to gauge their response. Lower urinary tract dysfunction was detected in 134 (59%) patients. Their mean PLUTSS was 15.9±5.3, and 78% of these patients had a reduced quality of life (QOL). After 5±2.7months of behavioural therapy, 105 (78%) patients with LUTD were evaluated for the second time. This showed that LUTD was ameliorated in 69% of the patients and improved in 26%, with a mean post-treatment PLUTSS of 6.6±5.6. Two control group children had LUTD. Lower urinary tract dysfunction was frequently seen in patients with UTIs, but standard urotherapy was usually successful. Most of the patients in our study with LUTD also had an impaired QOL.

Impact of an interdisciplinary approach in children and adolescents with lower urinary tract dysfunction (LUTD).

The lower urinary tract dysfunction (LUTD) corresponds to changes in the filling or emptying of urine caused by neurogenic, anatomical and functional alterations. To evaluate the impact of treatment in children and adolescents with LUTD. Historical cohort of 15 year follow-up with the participation of 192 patients (123F, 69M), aged 0.1 to 16.8 years, analyzed at admission (T0) and at final follow-up (T1). Most patients belong to a neurologic bladder dysfunction group (60.4%). The treatment was uroterapy with behavioral and cognitive intervention, timed voiding, oral hydration, laxative diet, biofeedback, sacral nerve stimulation, clean intermittent catheterization (CIC), anticholinergic therapy, rectal enema, treatment of urinary tract infection (UTI) and, in refractory cases, surgical procedures such as continent and incontinent urinary diversion (vesicostomy), bladder augmentation and conduit for performing antegrade colonic enema. The main symptoms were daytime urinary incontinence (82.3%), the non-monosymptomatic nocturnal enuresis (78.6%), fecal incontinence (54.2%) and constipation (47.9%). There was a significant reduction of urinary tract infection (p = 0.0027), daytime urinary incontinence (p < 0.001), nocturnal enuresis (p < 0.001), fecal incontinence (p = 0.010) and of vesicoureteral reflux (p = 0.01). There was significant increase in the use of CIC (p = 0.021), of anticholinergic therapy (p < 0.001) and decrease of chemoprophylaxis (p < 0.001). This study showed that treatment of LUTD in children must be individualized, and requires constant monitoring of clinical, laboratory and imaging to minimize the risk of kidney damage.

Evaluation of Functional Lower Urinary Tract Dysfunction in Children: Are the Physicians Complying with the Current Guidelines?

Objective. To elucidate whether the diagnostic and treatment approaches of the physicians for functional lower urinary tract dysfunction (LUTD) in children is complying with the current guidelines. Material and Methods. We have conducted an internet-based national survey for the physicians from different departments randomly sampled from the database of Turkish Paediatric Urology Society. Participants were asked to answer two-page questionnaire consisting of 4 main sections: “demography,” “working conditions,” “daily practice,” and “scientific knowledge.” Kruskal Wallis and multiple logistic regression were used for statistical analyses. Results. Of the 117 departments a total of 93 have completed the survey (n: 58 urology; n: 35 paediatric nephrology). Routine use of a questionnaire with validated symptom scoring system was found to be 13.9%. Of the participants, only 38.7% were asking all of the patients to fill the bladder diary. During treatment, only 24.7% were applying standard urotherapy for every patient. Almost half of the clinicians (45.1%) believed that they were personally insufficient during the evaluation of those children. Finally, 86% reported that children with LUTD were not adequately approached. Conclusions. Evaluation of LUTD in children is not complying with the current guidelines. General approach for those children needs to be revisited by the clinicians.

Challenges Facing Renal Transplantation in Pediatric Patients With Lower Urinary Tract Dysfunction

In pediatric patients with end-stage renal disease, renal transplantation is the established therapy of choice. The commonest cause is a congenital abnormality of the kidneys and urinary tract, often associated with lower urinary tract dysfunction (LUTD). Historically, such patients were denied transplantation, but it is now widely accepted that transplant outcomes comparable with the non-LUTD population are achievable. Nonetheless, the optimal management of pediatric end-stage renal disease patients with LUTD is unclear, with no guidelines to distinguish between the need for conservative management or surgical reconstruction of the lower urinary tract. Furthermore, the most appropriate surgical procedure and optimal timing of surgical intervention is far from clear. In this review, we outline common conditions that produce LUTD in children; discuss difficulties encountered in assessing the need for surgical treatment; provide an overview of the surgical procedures available; and consider the evidence for and against surgical intervention before, during, and after renal transplantation.

Nonpharmacological treatment of lower urinary tract dysfunction using biofeedback and transcutaneous electrical stimulation: a pilot study

To report a series of children with lower urinary tract dysfunction (LUTD) whose urge syndrome was treated by electrical stimulation, and their voiding dysfunction by biofeedback; none of the children were using anticholinergic drugs during treatment. In all, 36 children who presented with symptoms of urinary urgency and/or daily incontinence completed the treatment and were prospectively evaluated. The mean (range) follow-up was 13.8 (4-24) months, and their mean age 7 (3-14) years, 17 children were aged <5 years. The children were divided into two groups: group 1, with urge syndrome treated with superficial parasacral electrical stimulation, and group 2, with voiding dysfunction, treated with biofeedback. In group 1, the mean (range) number of electrical stimulation sessions was 13.1 (4-20). Of the 19 children treated, 12 had a complete clinical improvement, six a significant improvement, and one a mild improvement. In group 2, the mean (range) number of biofeedback sessions was 6 (4-14). Of the 17 children treated, there was complete improvement of symptoms in 10, significant improvement in two and mild improvement in five. Six children who had no resolution of symptoms after biofeedback had salvage therapy with electrical stimulation, after which four had complete improvement of symptoms, and two a 90% and 40% improvement, respectively. Taking the two groups together, after treatment, four children developed isolated episodes of urinary tract infection. Of 21 children with nocturnal enuresis, bed-wetting continued in 13 (62%) after treatment. In this short-term follow-up, the nonpharmacological treatment of voiding dysfunction using biofeedback, and of urge syndrome by electrical stimulation, was effective for treating LUTD in children.

Comparative analysis of the frequency of lower urinary tract dysfunction among institutionalised and non‐institutionalised children

To evaluate the level of symptoms of lower urinary tract dysfunction (LUTD) in orphans in institutions, and compare these data with schoolchildren of the same age group who were not institutionalised, as LUTD in children is related to factors such as social isolation and low self-esteem, with other psychological changes also being cited, although it is unknown whether these problems are primary or secondary to the symptoms of LUTD. Children institutionalised in orphanages with no parental presence and who are isolated from a family environment are probably more sensitive to psychological disturbances. Psychological changes have been associated with symptoms of urgency and urinary incontinence. Thus 89 orphans were compared with 143 schoolchildren not in institutions. A questionnaire was devised and completed by the care-taking staff in the orphanage, while for the schoolchildren the parents completed the questionnaire. The mean age in the institutionalised children was 7.9 years and that of the control group 7.8 years (P = 0.32). Thirty-nine (44%) of the orphans were boys, vs 74 (54%) of the control group (P = 0.17). The incidence of urgency, diurnal urinary incontinence, nocturnal enuresis and constipation in the orphans and in the control group were: 45 (51%) and 57 (40) (P = 0.17), 36 (40%) and 19 (13%) (P < 0.001), 39 (47%) and 38 (27%) (P = 0.002), and 27 (30%) and 43 (30%) (P = 0.76), respectively. Children living in orphanages have a significantly higher level of diurnal urinary incontinence and nocturnal enuresis than those not in an institution.