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Voiding Dysfunction

Voiding Dysfunction:  Voiding dysfunction occurs when a child does not empty his/her bladder normally.  As the bladder fills with urine, the bladder sends a message to the brain saying it is time to go to the bathroom.  Children learn as they potty train that they can squeeze their pelvic floor muscles to prevent accidents and prolong the time between bathroom visits.  Over time, this can cause an imbalance in the contraction and relaxation of the bladder muscle and pelvic floor muscles.

Signs and symptoms: Voiding dysfunction can present in many different forms including urinary frequency, urinary urgency, daytime incontinence, nighttime incontinence, incomplete bladder emptying, and frequent urinary tract infections.  Voiding dysfunction impacts everyone differently. 

Evaluation:  A thorough history and physical is completed.  A bladder scan is done to check if the child was able to completely empty their bladder after voiding.  If the child is not completely emptying their bladder, they are likely not relaxing their muscles during urination.  The child may also have an EMG/ uroflowmetry to assess their muscle activity during urination, urine flow rate, and urine flow time. 

Treatment: Initial treatment is a conservative plan of increased water intake, timed voiding, constipation management, and good hygiene.  Further treatment may include biofeedback therapy or medication.  Treatment for voiding dysfunction can be a lengthy process, but it is also very successful!



What is enuresis? Most children achieve some degree of daytime and nighttime bladder control by age four. Any kind of incontinence that occurs during sleep in a child who is five years old or older is called enuresis. About 20 percent of five-year-old children have at least occasional enuresis, but approximately 15 percent per year of these children will spontaneously grow out of their condition.

Enuresis is slightly more common in boys than girls. Up to 25 percent of all wetter’s are described as having secondary enuresis. This means that the child has had a period of time (typically six to 12 months) being dry during sleep. In contrast, children who have never been dry when they sleep are said to have primary enuresis. While some cases of secondary enuresis can be linked to a recent trauma or stress, their evaluation, treatment and response are generally no different than those with primary enuresis. In the past, when there were few treatment options, it was common to ignore or downplay the situation and hope for improvement with time. Today, with increasing opportunities for children to spend nights away from home (e.g., camps, sleepovers and overnight field trips), it has become a concern at an earlier age. It should be emphasized that the cause of all forms of incontinence, enuresis included, is almost never due to laziness or deliberate willfulness by the child. So, a parent should keep a supportive and understanding attitude. However, in a small number of situations, behavioral issues may play a significant role.



Bladder Exstrophy

Exstrophy: This is the most significant congenital urinary tract anomaly that is compatible with life. There is a spectrum of exstrophy complex that extends from epispadias (mildest) to cloacal exstrophy (most severe). Exstrophy complex has urinary, genital and orthopedic manifestations.

In epispadias the urethra is open and on the dorsal aspect of the penis (see pic). In classic bladder exstrophy the bladder is also opened and on the abdominal wall (see pic).

With cloacal exstrophy the bladder is completely divided and there is also associated abnormalities of the bowel and spine (see pic). In all of the various forms of exstrophy, the orthopedic manifestation is separation of the pubic tubercles and changes in the pelvic bones. The urinary issues include long term incontinence and sexual function. 

Evaluation: Prenatal evaluation may suggest the presence of exstrophy. Diagnosis is evident on evaluation at birth. If exstrophy has been identified on antenatal ultrasound, delivery should be performed at a center that has experience with surgical management of exstrophy, so that early management can be performed.

Management: Surgical management can be performed at birth (preferred) or soon thereafter with closure of the bladder in children with bladder exstrophy. In boys and girls with epispadias, reconstruction may be delayed until 6 – 12 months. The goals of exstrophy reconstruction are to insure that kidney function is protected, prevent recurrent urinary tract infections and provide functional and cosmetic outcomes for the abdominal wall and the penis/vagina.