33rd ESPU Congress in Lisbon, Portugal

S21: FUNCTIONAL VOIDING DISORDERS 1

Moderators: Erik Van Laecke (Belgium), Sofia Sjöström (Sweden)

ESPU Meeting on Saturday 22, April 2023, 08:00 - 08:40


08:00 - 08:03
S21-1 (OP)

COULD PELVIC FLOOR DYSFUNCTION BE A CAUSE OF GIGGLE INCONTINENCE?

Aygul KOSEOGLU 1, Tugce ATALAY 1, Ece Zeynep SAATCI 1, Melis UNAL 1 and Halil TUGTEPE 2
1) Uropelvic Solutions Clinic, Pelvic Floor Rehabilitation, Istanbul, TURKEY - 2) Private Tugtepe Pediatric Urology Center, Institude of Graduate Studies, Division of Physiotherapy and Rehabilitation, Istanbul University-Cerrahpasa, Division of Bladder & Bowel Dysfunction, Istanbul, TURKEY

PURPOSE

Giggle Incontinence (GI), is a rare condition characterized by the total emptying of the bladder right after or during laughter. One of the most basic causes of GI is the failure of the pelvic floor muscles (PFM) during laughter, due to the detrusor pressure and abdominal contractions by the PFM atonia. We aimed to investigate the effects of underactive PFM treatment on the GI episodes of children with GI complaints by the evaluation of PFM activations.

MATERIAL AND METHODS

8 (7 female; 1 male) children with GI who applied between the dates of January 2022 and July 2022. NeuroTrac MyoPlusPro4–EMG was used to evaluate the PFM activations. The before and after results were compared by the re-calculation of measurement parameters after the pelvic floor rehabilitation sessions were done once every week.

RESULTS

Patients' age was 10±2.73 years. The severity of incontinence before the treatment of all patients was so severe that they emptied their bladder and wet their clothing. After the treatment, the severity of incontinence decreased to the size of a coin in underwear in 4 patients (50%), and the episodes disappeared completely in 4 (50%) patients. Before treatment, 5 (62.5%) of the patients had underactive, 2 (25%) overactive, and 1 (12.5%) non-functional PFM. After treatment, PFM of all patients was functional. Although the frequency of episodes decreased after treatment, there was no statistically significant difference. PFM strength increased after the treatment, but no statistically significant difference was found. Uroflowmetry and PFM-EMG activation values before and after treatment are given in the table.

CONCLUSIONS

Pelvic floor dysfunctions may be a cause of GI episodes. It is possible to treat children diagnosed with GI with pelvic floor rehabilitation, which includes PFM awareness and functional PFM training.


08:03 - 08:06
S21-2 (OP)

GO WITH THE FLOW? VALIDITY OF OFFICE BASED UROFLOWMETRY STUDIES

Katherine FISCHER, Karl GODLEWSKI, Ethan SAMET, Amanda BERRY, Adriana MESSINA, Joan KO, Stephen ZDERIC and Jason VAN BATAVIA
Children's Hospital of Philadelphia, Pediatric Urology, Philadelphia, USA

PURPOSE

Uroflowmetry is a useful diagnostic tool for pediatric patients with lower urinary tract dysfunction (LUTD) as they are non-invasive and can assist in diagnosis and guide treatment. Universally accepted criteria for an acceptable uroflow study in children are lacking. In addition, office based uroflow may not reflect the true conditions when a child would void. In this study, we investigated the percentage of uroflows considered "valid" or acceptable based on two criteria.

MATERIAL AND METHODS

We retrospectively reviewed our IRB-approved registry of consecutive patients from 5/2014-1/2016 with a primary complaint of LUTD and at least one office uroflow study. Patients with neurogenic bladder were excluded. Criteria for acceptable or "valid" study were: 1) minimal voided volume >100ml for ages 5-13yo, and >200 for ages >14yo (as per Nidhi uroflow device manufacturer); 2) voided volume >50% expected bladder capacity (EBC) for age, with EBC = [age (yrs) + 1] x30ml (as per ICCS standardization document).

RESULTS

759 uroflows from separate clinic appointments of 436 patients (median age 9 yr, IQR=7-12) were assessed. Seven studies (0.9%) had technical/procedural failures and were excluded. For criteria 1 (manufacturer) 392 uroflows (52%) met minimum volume parameters for valid uroflow study. Percentage of uroflow studies considered valid based on age and criteria 2 (ICCS) ranged from 27% (for 5 year olds) to 43% (for 12 year olds). Overall, 36% of studies were considered "valid" while 64% did not meet criteria for an adequate study.

CONCLUSIONS

Over half of the office-based uroflow studies obtained in children with LUTD did not meet voided volume criteria for acceptability according to ICCS criteria. Given these findings, in addition to standardization of methods for interpreting uroflowmetry studies in children, future innovations should allow patients to access uroflowmetry on a flexible schedule, possibly at home, to capture "natural" voids.


08:06 - 08:09
S21-3 (OP)

BOWEL BLADDER DYSFUNCTION IN CONTROL CHILDREN IN A PEDIATRIC UROLOGY OFFICE

Priscilla RODRIGUEZ 1, Alexandra REHFUSS 2, Adam HOWE 2, Karla GIRAMONTI 2, Paul FEUSTEL 3 and Barry KOGAN 2
1) Albany Medical College, Albany, USA - 2) Albany Medical College, Urology, Albany, USA - 3) Albany Medical College, Neuroscience, Albany, USA

PURPOSE

Bowel bladder dysfunction (BBD) is common in children. Risk factors for BBD include age, gender, obesity, and behavioral issues such as ADHD. We sought to determine if children without bowel/bladder symptoms have similar risk factors. 

MATERIAL AND METHODS

All patients/parents in our Pediatric Urology practice >3 yrs old who were reportedly toilet trained were provided the validated Swedish Bowel Bladder Questionnaire (BBQ). Total score as well as sub-scores for storage, emptying and constipation were prospectively collected. Controls were: a) those with genital urinary abnormalities who did not complain of BBD. Univariable/multivariable regression analyses were performed.

RESULTS

Median BBQ score for the 252 control patients was 3 with IQR of 1 to 5.5 (in contrast, the median BBQ for those with likely voiding dysfunction, n=214, was 15 with IQR: 5 to 15). Total BBQ score exceeded 6 in 15% (38/252) of control patients. Multivariable analysis revealed that age-adjusted (-0.23 ± 0.05 per year) total BBQ scores increased with ADHD (+1.98 ± 0.78; p=0.012) but were unaffected by gender or BMI. The storage subscale had similar results. However, the emptying subscale of the BBQ showed only gender (boys 0.5 ± 0.2 < girls, p <0.018) being statistically different. The bowel subscales showed no significant effect of any variable.

CONCLUSIONS

15% of children with genital or urinary abnormalities and no voiding complaints have noticeable BBD uncovered by the BBQ. We conclude that the Swedish BBQ is a sensitive indicator of BBD even in children not complaining of those problems. 


08:09 - 08:12
S21-4 (OP)

AGREEMENT BETWEEN ROME IV AND INSTRUMENTS TO ASSESS FUNCTIONAL CONSTIPATION - CONSTIPATION SCORE, RECTAL DIAMETER, BRISTOL SCALE, AND DYSFUNCTIONAL VOIDING SCORING SYMPTOM - IN CHILDREN AND ADOLESCENTS.

Clara Nunes PAMPONET, Glicia Estevam DE ABREU, Maria Karolina Velame SANTOS, Noel Charlles NUNES, Maria Thais De Andrade CALASANS and Ubirajara De Oliveira  BARROSO
Bahiana School of Medicine and Public Health, Center of Urinary Disorders in Children, Salvador, BRAZIL

PURPOSE

To assess the agreement between the Rome IV criteria (RC IV) and instruments used to diagnose functional constipation (FC) in children and adolescents.

MATERIAL AND METHODS

In children and adolescents aged between 5 and 17 years, the RC IV and instruments that also measure FC were applied - Cleveland Clinic Constipation Score adapted for children (CCS), Rectal diameter (RD), Bristol Scale (BS), and questions 3 and 4 of the Dysfunctional Voiding Scoring Symptom (3 DVSS and 4 DVSS). The RC IV was the gold standard instrument (FC = ≥ 2 positive items). The agreement was evaluated by the kappa test and Roc curve.

RESULTS

118 children and adolescents with a median age of 8 (IQR 6 -11) were evaluated, including 60 (50.8%) boys. Eighty-three (70.3%) were constipated. The agreement analysis showed BS kappa = 0.067, p=0.33; RD kappa = 0.007, p = 0.927; 3 DVSS kappa = 0.187, p=0.039; 4 DVSS Kappa = 0.416, p < 0.001; 3 DVSS plus 4 DVSS kappa = 0.231, p=0.005; CCS sensitivity = 78.31%, specificity = 88.57% (associated criterion >6, area under the Roc curve=0.908, p=0.001) and RD sensitivity = 42.86%, specificity = 91.30% (associated criterion ≤ 1.9, area under the Roc curve = 0.540, P=0.803).

CONCLUSIONS

The CCS is an instrument with good accuracy for the diagnosis of CF, and can be used as a diagnostic instrument for CF. In turn, the DVSS has a low agreement and the BS and RD instruments do not show agreement. Therefore, they cannot replace the RC IV.


08:12 - 08:23
Discussion
 

08:23 - 08:26
S21-5 (OP)

A SIMPLE PREDICTION MODEL FOR WHEN TO OBTAIN RENAL/BLADDER ULTRASOUND IN CHILDREN WITH NON-NEUROGENIC LOWER URINARY TRACT DYSFUNCTION

Katherine FISCHER, Amanda BERRY, Adriana MESSINA, Ethan SAMET, Stephen ZDERIC and Jason VAN BATAVIA
Children's Hospital of Philadelphia, Pediatric Urology, Philadelphia, USA

PURPOSE

Despite the high prevalence of lower urinary tract dysfunction (LUTD) in children, there is no consensus on when to obtain renal/bladder ultrasound (RBUS). Predicting which patients benefit from RBUS is challenging as the majority will be normal. We hypothesized that higher DVISS scores and a positive urinary tract infection (UTI) history would be associated with a higher likelihood of RBUS abnormality.

MATERIAL AND METHODS

We retrospectively reviewed office visits from 5/2014-1/2016 to identify those seen for non-neurogenic LUTD who received RBUS as part of their work-up. RBUS results were divided into: clinically important abnormalities and normal/insignificant findings. Demographic data, DVISS score, and UTI history were abstracted. Association between positive UTI history, DVISS score, gender, and race and RBUS abnormality were evaluated.

RESULTS

333 patients (median age 9years, 58% female) received RBUS as part of non-neurogenic LUTD work-up and 15 (4.5%) had a clinically important abnormality. Abnormal RBUS was significantly associated with positive UTI history (p=0.019) and higher median DVISS (p=0.002). Positive UTI history and DVISS score were significantly associated with RBUS abnormality on univariate and multivariate analysis (OR=4.74, p=0.006; OR=1.13, p=0.001). ROC curve for this model had AUC=0.8. DVISS score cutoff of 12 was determined to be ideal for predicting abnormal RBUS. Using a cutoff of DVISS>12 and positive UTI history, patients with both risk factors were significantly more likely to have an abnormal RBUS (4 of 31 patients,12.9%) than those with zero (0 of 138 patients,0%) (p=0.041). 6-7% of patients with one risk factor had abnormal RBUS finding.

CONCLUSIONS

We identified factors associated with increased likelihood of significant RBUS abnormality in pediatric non-neurogenic LUTD patients and create an evidence-based approach to determining who should undergo imaging. We found that DVISS score>12 and UTI history are useful in guiding this decision.


08:26 - 08:29
S21-6 (OP)

ACCURACY OF AUTOMATED BLADDER SCANNER: RESULTS FROM A PROSPECTIVE MULTICENTRE STUDY

Alejandro ROSSI 1, Emma Molyneux MOLYNEUX 2, Amit MANIYAR 2, Akinlabi AJAO 1, Julie SMITH 3, Kate ROLLASON 4, Kathryn SIDDLE 5, Ellen BULLMAN 6, Nicola SMITH 7, Massimo GARRIBOLI 7, Anupam LALL 8, Harriet CORBETT 9 and Anju GOYAL 1
1) Royal Manchester Children's Hospital, Paediatric Urology, Manchester, UNITED KINGDOM - 2) Royal Manchester Children's Hospital, Paediatric Radiology, Manchester, UNITED KINGDOM - 3) Alder Hey Children's Hospital, Department of Paediatric Radiology, Liverpool, UNITED KINGDOM - 4) Alder Hey Children's Hospital, Paediatric Radiology, Liverpool, UNITED KINGDOM - 5) Great North Children's Hospital, Royal Victoria Infirmary, Paediatric Radiology Department,, Newcastle Upon Tyne, UNITED KINGDOM - 6) Evelina Children's Hospital, Paediatric Radiology, London, UNITED KINGDOM - 7) Evelina Children's Hospital, Paediatric Urology, London, UNITED KINGDOM - 8) Great North Children's Hospital, Royal Victoria Infirmary, Paediatric Urology Department, Newcastle Upon Tyne, UNITED KINGDOM - 9) Alder Hey Children's Hospital, Paediatric Surgery, Liverpool, UNITED KINGDOM

PURPOSE

Bladder volumes(BV) estimation with automated bladder scanner(BS) is integral to assessment of Lower Urinary Tract dysfunction in nurse-led clinics. We observed high Post Void Residual recordings (PVR) with Bladdder Scanner in children where standard ultrasound scan (US) had shown satisfactory emptying. Automated BS are designed to look for fluid and when there is minimal PVR, it tends to pick up other fluid-filled structures such as bowel loops or artefacts caused by bowel gas. Thus, we designed a multicentre prospective observational study comparing BS volumes with US volumes.

MATERIAL AND METHODS

Four centres participated. Pre and post-void BV were measured in patients attending for abdominal ultrasonography in radiology departments using both BS and US. Patients with known abnormal shaped bladders were excluded.

RESULTS

Ninety-nine patients (52% female, mean age of 9.2 years(range: 2-17 years)) were included.

Pre-void BS volumes ranged from 1-734mls(median: 126mls) and US from 5-653mls(median: 121mls). The intraclass correlation coefficient (ICC) was high(0.88 (p<0.001)), indicating that measurements were concordant suggesting high degree of reliability.

Post-void BS volumes ranged from 0-153mls(median: 18mls) and US from 0-74mls(median: 7mls). The ICC was lower(0.46 (p<0.001)), indicating that the measurements were discordant and reliability was poor.

CONCLUSIONS

BS and US have high concordance when the bladder is full but poor discordance on PVR assessment,with the BS giving a false high volume due to wrong interpretation of artefacts as fluid signal. This will lead to false assessment of emptying ability and should be kept in mind when making management decisions based on PVR assessments by BS.


08:29 - 08:32
S21-7 (OP)

USE OF A SHORT SCREENING INSTRUMENT FOR PSYCHOLOGICAL PROBLEMS IN CHILDREN WITH LUTS: A PROSPECTIVE STUDY

Jose MURILLO-NETTO 1 and Israel FRANCO 2
1) Universidad de Juiz de fora, Pediatric Urology, Granbery, BRAZIL - 2) Yale School of Medicine, Pediatric urology, New Haven, USA

PURPOSE

Our aim was to evaluate uroflow data in patients who presented with LUTS over 3-year period and ascertain if certain uroflow tendencies were present depending on the Ghent  psychological  problems scale  (GSSPP) and VDVS scoring.

MATERIAL AND METHODS

Vancouver scale (VDVS) and GSSPP data was collected on all patients seen in our continence clinic prospectively along with uroflowmetry results. All voiding diagnosis were combined into 4 groups; DSD, Urinary incontinence (UI) Urgency or frequency (UF) and Voiding dysfunction (VD) which was commonly used as a catch all diagnosis. First and last uroflow results as well as VDVS were identified. Flow indexes were calculated for all flows. Only flow studies with over 50 cc of voided urine were utilized for analysis. Statistical analysis was performed with SPSS ver 28.0.

RESULTS

1949 unique patients of which 791 had at least 2 uroflows performed with a voided volume (VV) in excess of 50 cc. Median age of males was 9 (IQR 7-11) yo and females 8 yo (IQR 6.25-11). No differences were seen amongst four dx groups in VDVS scores before and after treatment. No differences were noted in flow characteristics in patients with or with out positive scores for emotional or hyperactivity scores on GSSPP. In contrast the inattention score ≥ 2 in males had  significant QvgFI (1.00±0.4 vs 0.63±0.32) in uf group. When the inattention and hyperactivity scores were combined and the sum was ≥ 3 uf was  different in both males and females for QavgFI (males=1.00±0.4 vs 0.63±0.32)(females=0.99±0.29 vs 1.35±0.26 p=0.01) in uf group with positive scores associated with lower flow scores and indexes. 

CONCLUSIONS

Patients with inattention had Qavg FI which were lower in males and females who have UF.  VDVS scores do not correlate with GSSPP scores and VDVS does not correlate with any flow parameters.


08:32 - 08:40
Discussion