30th ESPU Congress - Lyon, France - 2019

S19: FUNCTIONAL VOIDING DISORDERS

Moderators: Piet Hoebeke (Belgium), Gundela Holmdahl (Sweden)

ESPU Meeting on Saturday 27, April 2019, 08:00 - 09:00


08:00 - 08:03
S19-1 (PP)

★ IMPACT OF PEVIC FLOOR INTERFERENTIAL ELECTRICAL STIMULATION ON BLADDER BOWEL DYSFUNCTION IN CHILDREN

Seyedeh-Sanam LADI-SEYEDIAN 1, Lida SHARIFI RAD 2, Seyed Mohammad GHOHESTANI 1, Alireza ALAM 1 and Abdol-Mohammad KAJBAFZADEH 3
1) Tehran University of Medical Sciences, Pediatric Urology and Regenerative Medicine Research Center, Tehran, ISLAMIC REPUBLIC OF IRAN - 2) Tehran University of Medical Sciences, Department of Physical Therapy, Tehran, ISLAMIC REPUBLIC OF IRAN - 3) Children's Hospital, Urology, Tehran, ISLAMIC REPUBLIC OF IRAN

PURPOSE

Bladder bowel dysfunction (BBD) is a spectrum of lower urinary tract symptoms accompanied with bowel complaints. Given the close interaction between the bladder and bowel due to their common innervation as well as associated pelvic floor muscles, patients often present with bowel complaints as well. Efficacy of combined pelvic floor interferential (IF) electrical stimulation and muscle exercises was assessed on BBD in children in this study.

MATERIAL AND METHODS

A total of 35 children with BBD (17 boys, 18 girls; mean age 7.4±2.2) were included in the study. Children were evaluated with kidney and bladder ultrasounds, uroflowmetry/EMG, and a complete voiding and bowel habit diary before treatment. Exclusion criteria were neuropathic disease, anatomical defects and mental retardation. Participants were randomly allocated into two groups including group A (n=17) who underwent standard urotherapy and PFM exercises and group B (n=18) who received standard urotherapy, PFM exercises in addition to IF electrical stimulation. All children were re-evaluated by kidney and bladder ultrasounds, uroflowmetry/EMG and a voiding and bowel habit diary after end of treatment sessions and 6 months later.

RESULTS

Constipation was improved in 8/17 and 14/18 of children in groups A and B respectively (P<0.05) after treatment. Daytime incontinence improved in 5/6 children in group B and 3/8 of children in group A after treatment. Significant difference in uroflowmetry measures was not observed between two groups after the treatment.

CONCLUSIONS

Combination of PFM exercises and IF electrical stimulation is an effective, safe and reproducible modality for treatment of BBD in children. 


08:03 - 08:06
S19-2 (PP)

MANAGEMENT OF FUNCTIONAL URINARY INCONTINENCE IN CHILDREN WITH PELVIC FLOOR MUSCLES TRAINING

Seyedeh-Sanam LADI-SEYEDIAN 1, Lida SHARIFI RAD 2 and Abdol-Mohammad KAJBAFZADEH 3
1) Tehran University of Medical Sciences, Pediatric Urology and Regenerative Medicine Research Center, Tehran, ISLAMIC REPUBLIC OF IRAN - 2) Tehran University of Medical Sciences, Department of Physical Therapy, Tehran, ISLAMIC REPUBLIC OF IRAN - 3) Children's Hospital, Urology, Tehran, ISLAMIC REPUBLIC OF IRAN

PURPOSE

The pelvic floor muscles (PFMs) have long been recognized as important structural and functional components of the pelvis. Recently, PFMs training with or without biofeedback is widely used as an alternative option for many of refractory lower urinary tract malfunctions in adults and also in  children. In this study we compared the efficacy of PFMs training with and without biofeedback on functional urinary incontinence in children with voiding dysfunction.

MATERIAL AND METHODS

This study included 30 children (6 boys, 24 girls; mean age 8.3±2.1) with functional urinary incontinence that underwent pelvic floor rehabilitation. Children were randomly divided into two treatment groups.  Group I (n=15) underwent only PFM exercises and group II (n=15) received pelvic floor muscle biofeedback therapy. Prior to starting the study, a 3-day voiding diary, renal and bladder ultrasounds and uroflowmetry/EMG were performed for all participants. Children who had neuropathic disease, anatomical defects and mental retardation were excluded from the study. Renal and bladder ultrasounds, a 3-day voiding diary and uroflowmetry/EMG were performed for evaluating of both groups at 6 months and one year after completion of the treatment.

RESULTS

Urinary incontinence improved in the both groups after the treatment. Daytime incontinence improved in 9/15 and 8/15 of children in groups I and II respectively. There was no significant difference in uroflowmetry measures between two groups after the treatment.

CONCLUSIONS

Pelvic floor training with or without biofeedback raises children’s awareness regarding abdominal and PFMs function and relaxation. This rehabilitative program is an effective approach for management of non-neuropathic urinary incontinence in children.


08:06 - 08:09
S19-3 (PP)

THE PEDIATRIC BLADDER AND BOWEL DYSFUNCTION NETWORK: AN INNOVATIVE INITIATIVE TO IMPROVE THE MANAGEMENT OF BLADDER AND BOWEL DYSFUNCTION IN CHILDREN

Roberto IGLESIAS LOPES 1, Martha POKAROWSKI 2, Rebecca ROCKMAN 3, Niraj MISTRY 3, Ronik KANANIM 4, Ivor MARGOLIS 3, Roushdi AMANI 3, Leo LEVIN 3, Manbir SINGH 3, Walid FARHAT 2, Martin KOYLE 2 and Joana DOS SANTOS 2
1) Hospital das Clínicas, University of São Paulo Medical School, Urology, São Paulo, BRAZIL - 2) The Hospital for Sick Children, University of Toronto, Urology, Toronto, CANADA - 3) The Hospital for Sick Children, University of Toronto, Pediatrics, Toronto, CANADA - 4) North York General Hospital, Pediatrics, North York, CANADA

PURPOSE

Most cases of Bladder and Bowel Dysfunction (BBD) improve with bladder retraining and constipation treatment. Increasing numbers of children with BBD in Urology practice results in delays in care. Objectives: 1) Identify barriers preventing BBD care by pediatricians; 2) assess the impact on care from a Pediatric BBD network (BBDN) in which children with BBD who are referred to Urology in a single quaternary center are re-referred to a network of community pediatricians (closer to home). 

MATERIAL AND METHODS

An online survey was answered by 100 community pediatricians. The Dysfunctional Voiding Score System, Bristol stool chart, and anonymous satisfaction survey are completed by families at 0, 3 and 6 months. Results from multiple community pediatric offices and a Urology clinic in a single quaternary center was compared. 

RESULTS

Polyethylene glycol 3350 is recommended by at least 98.9%, however voiding diaries, increased fluid intake, and bladder retraining were recommended by only 47.9%, 56% and 78.6%, respectively. A total of 123 patients were treated by BBDN since April 2016. Initial DVSS (p=0.73), Bristol stool (p=0.83) and overall experience (p=0.50) were similar in the community compared with Urology clinic. 3 months repeat DVSS at Urology clinic was significantly lower than initial DVSS (6±3 vs. 11±4.3, respectively, p=0.01). Wait times decreased by 40% in 3 months. 

CONCLUSIONS

Constipation is adequately managed by community pediatricians, however improvement in bladder retraining strategies are needed. Educational initiatives are recommended for improvement of the management of BBD in children.


08:09 - 08:18
Discussion
 

08:18 - 08:21
S19-4 (PP)

★ TOLERANCE PROFILE OF THE INVASIVE URODYNAMIC STUDY (IUDS) IN THE PEDIATRIC PATIENT.

March JA 1, Conca MA 1, Polo A 1, Serrano-Durbá A 1 and Domínguez C 2
1) La Fe Universitarian Hospital, Pediatric Urology, Valencia, SPAIN - 2) La Fe Universitarian Hospital, Pediatric Urology, Valencia, SPAIN

PURPOSE

Measure the tolerance of IUDS in children. Create a patient profile according to study tolerance. Assess whether the influence of age in the tolerance.

MATERIAL AND METHODS

Prospective observational study of 139 patients who underwent an EUDS (2013-2018).

Inclusion criteria: patient who could understand and express their experience with IUDS.

The visual pain analog scale (VAS) (0-10) was used. Variables: age, gender, etiology (neurogenic/urotopic/functional) and the technique (type of IUDS, difficulty in urethral catheterization, need for urethrostomy/vesicostomy probing, collaboration in the drilling, collaboration during the test, time spent). A VAS score in children>4 (onset of pain) (dependent variable) was considered a painful test. Statistical analysis: descriptive (Chi square and t-Student), multivariate using binary logistic regression. Significance p <0.05.

RESULTS

IUDS was performed in its entirety in 95% (n = 133) of the patients. Mean age 7.7 ± 2.4 years (3-12.5 years). 52% (n = 69) were male. Etiology: neurogenic 42% (n = 56), uropathic 41.4% (n = 55), functional 16.5% (n = 22). Type of EUD: 84% cystomanometry (n = 112), pressure / flow 15.8% (n = 21). Time invested in the test (average): 25 ± 3.9 minutes.

Median VAS: 2 (2-6). VAS>4 in 41.3% (n = 55). Absence of lumbosacral sensory-motor impairment (OR 5 (1.5-16.5)) (p = 0.008), difficulty in urethral catheterization (OR 31 (3.8-51)) (p = 0.001) and time invested in the test (OR 1.2 (1.1-1.3)) (p = 0.020) have been the variables that have influenced obtaining an VAS score of pain onset (>4).

CONCLUSIONS

The invasive urodynamic study is a well tolerated test by patients of pediatric age.In pediatric patients without lumbosacral sensory-motor alterations, in which the EUD could be performed regardless of their age, it would be important to apply measures both to improve the urethral catheterization and to reduce the total time invested in the test.


08:21 - 08:24
S19-5 (PP)

★ PEDIATRIC BLADDER AND BOWEL DYSFUNCTION WITHIN AN OUTPATIENT PSYCHIATRIC CLINIC

Rebecca ELLENS 1, Rebecca KLISZ-HULBERT 2 and Yegappan LAKSHMANAN 3
1) Hurley Medical Center, Pediatrics, Flint, USA - 2) Wayne State University, Department of Psychiatry and Behavioral Neurosciences, Detroit, USA - 3) Children's Hospital of Michigan, Urology, Detroit, USA

PURPOSE

Co-existing psychiatric conditions may pose problems with the management of bladder bowel dysfunction (voiding dysfunction and hard stool consistency or BBD). We examined BBD symptoms in children presenting to a community-based pediatric psychiatry clinic.

MATERIAL AND METHODS

Parents of children seen at an outpatient psychiatry clinic were recruited before or after their appointment. Dysfunctional Voiding Scoring System (DVSS) and Bristol Stool Form Scale (BSFS) were completed by the child, with parental collaboration for children under 11 years. Parents also completed a bladder-bowel health history survey and the child’s primary and secondary psychiatric diagnoses were collected from the clinic.

RESULTS

Of 56 pediatric psychiatry patients, 28.6% of children exceeded clinical cutoffs on the DVSS and 32% endorsed constipation (Bristol 1-2). DVSS scores were significantly higher than previously reported healthy controls, and BSFS scores were significantly lower than previously reported in either clinical or healthy controls.  Among children endorsing clinically significant voiding symptoms (n=28), a minority of parents reported awareness of a bladder or bowel concern (10.7%) or engagement in related medical care (3.5%) on the health history survey. Finally, the odds of clinically significant BBD symptoms did not differ between children with and without an ADHD diagnosis.


Comparison of Pediatric Psychiatry patients with Healthy Controls

Psychiatry Sample

Historically Healthy Controls

(Reference)

One Way

p-value

Mean+/- SD DVSS Total Score 5.68 +/- 3.92 4.41 +/- 3.76 (Farhat et al, 2000) p = 0.043
Mean +/- SD Bristol Stool Score 2.88 +/- 0.77 4.20 +/- 0.50 (Russo et al, 2013) p < 0.0001

CONCLUSIONS

A significant number of children undergoing psychiatric treatment present with BBD symptoms, which are often unidentified and unaddressed. While children within this psychiatric population demonstrate more severe BBD symptoms overall, ADHD may not pose unique risk.


08:24 - 08:27
S19-6 (PP)

VIDEO-URODYNAMICS: ADOLESCENT'S PERSPECTIVE

Kay WILLMOTT, Anne WRIGHT, Massimo GARRIBOLI and Joanna CLOTHIER
Evelina London Children's Hospital, Paediatric nephro-urology, London, UNITED KINGDOM

PURPOSE

To understand from the adolescent’s  perspective the discomfort and emotions felt during video-urodynamic investigation (VUD). To identify whether there is a difference in placement of catheter discomfort between those regularly catheterising and those not catheterising and between genders

MATERIAL AND METHODS

Single-centre, prospective, anonymised questionnaire study performed on consecutive VUD in paediatric patients aged 12-19 years, over 5 month period.

Questionnaire completed immediately following investigation.

Specific questions regarding discomfort related to all aspects of the study recorded and emotions felt during the study, using Likert scale, 1-5 (5 high). Patient asked to rate experience  vs expectation 1-5 (5 much worse than expected).Values expressed as median.

Mann-Whitney test used to assess for any differences in discomfort between those regularly catheterising and not, and between genders.

RESULTS

35 questionnaires completed (14 years, 50% male, 3% neuropathic).

Pain score: bladder catheter placement 1.5/5, rectal line 2/5, holding a void 3/5, voiding 1/5, EMG stickers 1/5, removal of bladder catheter 2/5, removal of rectal line 2/5. Overall score 2.0.

Emotions: Anxious 3/5, frightened 2/5, embarrassed 2/5. Overall experience 2/5 (better than expected).

Only 3 patients performing catheterisation in the group so insufficient numbers to compare. No significant difference between males and females for discomfort during bladder (p= 0.11) and rectal line placement (p=0.39).

CONCLUSIONS

Adolescents express low levels of discomfort during VUD. The experience is slightly better than the expectation. Anxiety, fear and embarrassment are regularly experienced at low level and need to be considered. Males and females expressed same level of discomfort with catheter placement.


08:27 - 08:30
S19-7 (PP)

FREQUENCY VOIDING CHART APPLICATION FOR CHILDREN WITH NON NEUROGENIC LOWER URINARY TRACT DYSFUNCTION, DOES IT INCREASE COMPLIANCE OR NOT?

Liesbeth Lilian DE WALL, Barbara B.M KORTMANN, Evi VAN KEMPEN, Lisanne A.M KRAGT, Maartje VAN DEN BOSCH, Bob BLANKENSTIJN and Wout F FEITZ
RADBOUDUMC, AMALIA'S CHILDREN HOSPITAL, DEPARTMENT OF PEDIATRIC UROLOGY, Nijmegen, NETHERLANDS

PURPOSE

The frequency voiding chart (FVC) is a valuable tool in the diagnosis and treatment of children with non-neurogenic lower urinary tract dysfunction. In general, compliance rate regarding to complete and correctly filled in FVC’s is moderate. A digital application might improve this compliance. The aim of the study was to develop a digital FVC application in collaboration with patients and healthcare providers and to test its compliance, applicability and feasibility compared to conventional paper FVC’s.

MATERIAL AND METHODS

A prospective, observational study of thirty patients between 5-12 years old and  their parents was conducted. All subjects received a paper FVC and subsequently a digital FVC between January and April 2018.

RESULTS

The completion rate of the digital FVC was significant lower than the paper version, respectively 47% versus 76% (p = 0.003).  The digital FVC was found to be more user friendly (100%vs33%), more appealing (100%vs10%) and more educative (62%vs20%) than the paper version. Child participation was scored in 64% for the digital FVC versus 40% for the paper version. Technical problems during downloading and installation of the digital FVC occurred in 68%.

CONCLUSIONS

Currently the paper FVC is still the best option with a higher compliance rate despite the fact that a digital FVC is considered more user-friendly, more educative and is associated with an increase in the child’s participation.


08:30 - 08:42
Discussion
 

08:42 - 08:45
S19-8 (PP)

ONABOTULINUM TOXIN A VS EXTENDED RELEASE TOLTERODINE FOR THE MANAGEMENT OF IDIOPATHIC OVERACTIVE BLADDER IN CHILDREN (OVERT): FEASIBILITY RESULTS FROM A PILOT RCT

Charlotte MELLING 1, Victoria OZKAN 2, Michaela BROWN 3, Paula WILLIAMSON 3, Malcolm LEWIS 4, Nicholas WEBB 4 and Anju GOYAL 1
1) Department of Paediatric Urology, Royal Manchester Children's Hospital, UK, Manchester, UNITED KINGDOM - 2) The National Institute for Health Research,, Wellcome Trust Clinical Research Facility, Manchester University Hospital NHS Foundation Trust, UK, Manchester, UNITED KINGDOM - 3) Clinical Trials Research Centre, University of Liverpool, UK, Liverpool, UNITED KINGDOM - 4) Department of Paediatric Nephrology, Royal Manchester Children's Hospital, UK, Manchester, UNITED KINGDOM

PURPOSE

Idiopathic overactive bladder (IOAB) in children places a significant socio-economic cost on health-care systems and communities, and is a substantial proportion of paediatric urological practice. There is limited evidence available from well-conducted studies to inform on the methodology of larger RCTs.  This pilot RCT aims to inform on the feasibility of larger multi-centre RCTs for refractory IOAB in children.

METHODS

This prospective single centre pilot RCT invited 98 children aged 7-16years with refractory IOAB to recruit to the study.  Randomisation to tolterodine or Botox® followed confirmation of IOAB on urodynamics.  Follow-up was undertaken at 1.5, 3 and 6 months. Aims were to determine the eligibility, recruitment, follow-up rates and acceptability of assessment tools.  Outcome measures included number of wetting episodes/day and urodynamic parameters.

RESULTS

The trial ran over 28 months and cost £273,000.  85/98(86.7%) were recruited, 13/85(15.2%) children failed eligibility criteria and 23/85(27%) did not consent to participate. Of 62 screened with urodynamics, only 46(74.1%) had IOAB and were eligible for randomisation. 2 patients withdrew.  Only 35/46(76%) agreed to post-intervention urodynamics  at 1.5months.  Baseline and 1.5month bladder diaries were returned in 42/46(91.3%) and 41/46(89%) and were partially completed in another 6.5% and 8.7% participants.  Feedback on bladder diaries highlighted practical difficulties in data collection. There was 1 serious adverse event, a UTI requiring hospital stay. No urinary retention was seen in either group.

CONCLUSIONS

47%(46/98) of children with IOAB proceeded to randomisation. 26% of presumed refractory IOAB do not have IOAB on urodynamics. We recommend early urodynamic assessment if poor response to oral therapy. A uroflow maybe a more acceptable tool for follow-up.  Despite research team oversight, clinical data collection was suboptimal in 35%, highlighting need for modified tools with built-in patient benefit scales.  An RCT to compare oral with intravesical therapies in IOAB in children is safe and feasible, with modifications to improve patient-reported data collection.


08:45 - 08:48
S19-9 (PP)

CURRENT PHARMACOLOGICAL MANAGEMENT OF IDIOPATHIC OVERACTIVE BLADDER IN CHILDREN: A NATIONAL STUDY

Charlotte MELLING and Anju GOYAL
Royal Manchester Children's Hospital, Paediatric Urology, Liverpool, UNITED KINGDOM

PURPOSE

Advances in standardising terminology and the publication of guidelines by the ICCS attempt to streamline management of idiopathic overactive bladder (IOAB). Nevertheless, variability in practice is commonplace, with increasing use of newer oral medications and intravesical Botulinum toxin (BtA).  Knowledge of current practice amongst paediatric urologists facilitates discussion and directs future research.  This study presents the current pharmacological management of IOAB in children in a large western European nation. 

METHODS

54 paediatric urologists attending a 2018 national Paediatric Urology congress responded to a 20-question survey presented at the congress.  Respondents could only submit one answer per question, and one survey per respondent using secure software to disable any manipulation. Data were reviewed prospectively by a single reviewer.  

RESULTS

98% of respondents to this national survey regularly manage children with IOAB.  48% use 48hr frequency/volume charts, the remainder use 3 or 7-day bladder diaries.  Anticholinergics remain the most commonly used drugs for initial therapy: Oxybutynin is first line therapy for 85%, Second line is tolterodine (53%) and third line is solifenacin(37%).  Newer medication such as Mirabegron is used either alone or in combination with solifenacin as 4th line management in 55%.  80% use intravesical BtA, and 84% perform an invasive urodynamic assessment prior to BtA.  Post-BtA, assessment was clinical in 18%, 24% use urodynamics and non-invasive uroflow is preferred by 58%. 76% believe the most clinically significant outcome of treatment is patient-reported improvement.  Treatment success is defined variably: 49% define as completely dry whereas 35% accept 90% improvement as success.

CONCLUSIONS

IOAB forms a significant proportion of paediatric urological clinical practice. Newer medication,such as mirabegron, is now being used either alone or in combination, by over half of paediatric urologists. In oral therapy resistant IOAB, BtA is being used in 80%, usually after urodynamic assessment, but post-BtA assessment is variable. 


08:48 - 08:51
S19-10 (PP)

INCIDENCE OF FEBRILE URINARY TRACT INFECTION IN CHILDREN WITH HIRSCHSPRUNG DISEASE IS INCREASED IN THE FIRST MONTHS OF LIFE

Faten LETAIEF 1, Anne DARIEL 2, Benoit TESSIER 3, Claude BORRIONE 2, Sarah GARNIER 3, Christophe LOPEZ 3, Dominique FORGUES 3, Hossein ALLAL 3, Marie-Pierre GUIBAL 1, Olivier MAILLET 3, Jean-Michel GUYS 4, Thierry MERROT 4 and Nicolas KALFA 1
1) CHU Lapeyronie, Montpellier, FRANCE - 2) CHU La Timone, Chirurgie pediatrique viscéral et urologique, Marseille, FRANCE - 3) CHU Lapeyronie, Chirurgie pédiatrique viscéral et urologique, Montpellier, FRANCE - 4) CHU La Timone, Chirurgie pédiatrique viscéral et urologique, Marseille, FRANCE

PURPOSE

Dysfunctional voiding is a risk factor for febrile urinary tract infection (FUTI) in children. Patients treated for Hirschprung disease (HD) may present persistent constipation and postoperative bladder dysfunction. Little data is available regarding the HD as a risk factor of FUTI. This study aimed to find out whether the children with HD are more prone to develop FUTI than controls.

MATERIAL AND METHODS

A comparative case-control retrospective study included patients with HD from 2005 to 2016. Three controls were included per case and were matched for both sex and age at follow-up.

RESULTS

555 children were included (129 patients and 426 controls). The overall incidence of FUTI in children with HD was not significantly higher than in controls (3.10% vs 4,22%,p=0,86). Recurrence of FUTI was not more frequent in the HD group (0% vs 0.23%). Neither the length of bowel segment with HD nor the surgical technique were a significant risk factor for FUTI. Patients with soiling did not have an increased risk of FUTI compared to those with normal bowel movement (4.54% vs 1,06%, p=0.61) and to controls (4.54% vs 4.22%,p=0,75). FUTI occurred more frequently during the first 3 months of life in the HD group than in controls (n=4/4 vs n=2/18,p=0.002) and the risk of neonatal FUTI is higher (3.1% vs 0.4%,p=0.028).

CONCLUSIONS

HD does not increase the overall incidence of FUTI but the risk of neonatal FUTI is higher in HD patients than in controls. An early optimal bowel management and parental education in the first months of life may be relevant.


08:51 - 09:00
Discussion