INTRODUCTION — Bladder dysfunction, previously referred to as voiding dysfunction, is a general term to describe abnormalities in either the filling and/or emptying of the bladder. It is a common problem in children and constitutes up to 40 percent of pediatric urology clinic visits . In some children, bladder dysfunction is a component of bowel and bladder dysfunction, previously referred to as the dysfunctional elimination syndrome, which involves abnormalities in both bladder and bowel function.
Daytime urinary incontinence, a common feature of bladder dysfunction, can cause major stress in school-age children [2,3], and negatively impact a child's self-esteem . Thus, it is desirable to identify and treat these children as early as possible.
The management of bladder dysfunction in children will be reviewed here. The etiology, clinical features, evaluation, and diagnosis of bladder dysfunction and management of nocturnal enuresis in children are discussed separately. (See "Etiology and clinical features of bladder dysfunction in children" and "Evaluation and diagnosis of bladder dysfunction in children" and "Nocturnal enuresis in children: Management".)
OVERVIEW — The management of a child with bladder dysfunction is primarily directed at improving symptoms and avoiding kidney damage. Therapeutic considerations include the underlying cause of bladder dysfunction including behavioral and neurodevelopment etiologies, the age of the patient, symptom duration and severity, the motivation and attention span of the patient and family, and the presence of potential risk factors for kidney injury such as recurrent urinary tract infections or vesicoureteral reflux. (See "Etiology and clinical features of bladder dysfunction in children", section on 'Dysfunctional voiding'.)
Data on effective treatment of bladder dysfunction in children are limited because of the following flaws in study design:
●Most studies are observational in nature and without a control group. This is an important consideration because many studies use a reduction in the frequency of daytime wetting as the major outcome measure but do not take into account that the spontaneous resolution rate of daytime incontinence is estimated to be 14 percent per year .
●There are often confounding factors that make it difficult to determine which intervention, if any, was effective. As an example, a retrospective study that reported anticholinergic therapy was effective in reducing daytime incontinence failed to account for the effect of biofeedback therapy as a confounding variable . (See 'Oxybutynin' below.)
●The study population has often not been well defined; as a result, it is difficult to compare the results of different studies. In 2006, the International Children's Continence Society (ICCS), a global multidisciplinary organization of clinicians involved in the care of children with lower urinary tract dysfunction, developed standardized definitions of bladder dysfunction to address this issue. In 2015, the ICCS updated and revised these definitions . (See "Etiology and clinical features of bladder dysfunction in children", section on 'Definition of bladder dysfunction disorders'.)
●There is a lack of consensus among experts on the definition of successful treatment for bladder dysfunction. The ICCS has defined treatment outcomes for research purposes . This stratified set of definitions has also been used clinically and is based upon reducing the rate of symptoms as follows:
•Nonresponse: 0 to 49 percent decrease in symptoms
•Partial response: 50 to 89 percent decrease in symptoms
•Response: 90 to 99 percent decrease in symptoms
•Full response: 100 percent decrease or less than one symptom occurrence monthly
Our approach — In our practice, we use a stepped strategy moving from the least to most invasive therapy in the management of children with bladder dysfunction [8,9]. Conservative measures, such as voiding behavior modification and treatment of constipation (if present), are initially used before the use of medications or invasive interventions. Patients with significant behavioral and neurodevelopment issues (eg, attention deficit hyperactivity disorder) are referred to a clinician with expertise in evaluation and treating these underlying conditions.
If conservative therapy fails to significantly improve the symptoms of bladder dysfunction, directed therapy toward the underlying cause of bladder dysfunction is used. These interventions include pharmacologic agents, pelvic floor relaxation techniques, biofeedback, neuromodulation, or intermittent clean catheterization.
CONSERVATIVE MANAGEMENT — Conservative management is generally the initial approach to treating children with bladder dysfunction. It primarily involves voiding behavior modification including timed voiding schedules, and treatment of constipation, if present.
Although no controlled trials have been conducted to study the effectiveness of this approach, retrospective studies have suggested reduction in symptoms in approximately 40 to 70 percent of patients treated conservatively [4,8,10,11].
This was illustrated in a retrospective study from a single center of 63 children with daytime incontinence who were initially treated with voiding behavior modification that included a timed voiding regimen and treatment for constipation . At a mean follow-up of 8.2±3.2 weeks, one-third of patients had a partial response of a 50 percent reduction of incontinent episodes, one-third of patients had a slight response with 10 to 49 percent reduction of incontinent episodes, 20 percent had no change in symptoms, and 4 patients were dry (complete response).
Voiding behavior modification — The goal of voiding behavior modification is to rehabilitate the bladder and sphincter function and return the child to normal voiding habits. It encompasses the following components :
●Provide information about normal voiding habits to the family and, if age appropriate, the child. (See "Etiology and clinical features of bladder dysfunction in children", section on 'Definitions of symptoms' and "Etiology and clinical features of bladder dysfunction in children", section on 'Normal voiding'.)
●Review the child's voiding habits, identify habits that deviate from the normal voiding process (table 1), and clearly describe to the family the way in which their child's voiding differs from the normal process.
●Set an individualized voiding regimen to establish regular voiding habits. This most often entails a timed voiding schedule with frequent voids scheduled every two to three hours during the day. Wristwatch alarms can assist the older child in remembering to comply with the timed schedule (timer watch) .
Establishment of a fixed timed schedule is particularly important in a child with attention-deficit disorder. In some cases, working with the school system to create an environment conducive to frequent voiding can be helpful.
In a trial of 60 children initially treated with four weeks of standard routine care, patients who were randomly assigned to a timer-assisted regimen compared with those who remained on standard care were more likely to show improvement in the degree of incontinence (greater than 50 percent decrease in incontinent episodes, 60 versus 18 percent) . Approximately one-third of the children on the timer-assisted regimen obtained complete and sustainable continence.
●Review the posture during voiding and the need to avoid holding maneuvers, such as forcefully crossing the legs, or squatting with a hand or heel pressed into the perineum (Vincent's curtsy) (picture 1). Children should be encouraged to urinate before they have a sense of urgency, to empty their bladders completely, and to avoid abdominal straining.
●Document the voiding process in a diary after implementation of voiding behavior modification. This voiding diary should include the time and volume of each void, the time of each incontinent episode, fluid intake, the time of each bowel movement, and any episode of fecal soiling (form 1). Voiding diaries across the country vary in length (number of days) and are used both as a diagnostic tool and as a therapeutic tool. When the reliability of 24, 48, and 72-hour voiding diaries were evaluated, the 24-hour diary was reliable for recording the number of incontinent episodes, but only marginally reliable for total voiding episodes, the 48-hour diary was reliable for both, and the 72-hour diary was the most reliable for both.
●Establish a reward system to improve the child's compliance and self-esteem . The system should focus on rewarding the child for following the recommended program and not for "being dry," as their incontinence is not something they can control.
Compliance with voiding behavior modification, especially timed voiding, can be labor intensive and requires a high degree of motivation from both the child and parents/caregivers. It is more successful in older children between the ages of 9 and 12 years who are more motivated because of social pressures and respond better to instruction compared with those eight years of age and younger .
Treatment of constipation — Anorectal and lower urinary tract function are interrelated. As a result, constipation is often associated with bladder dysfunction, with a reported frequency of constipation that ranges from 30 to 88 percent of children with bladder dysfunction. This relationship between abnormal bowel and bladder function is referred to as the bowel bladder dysfunction (BBD) or dysfunctional elimination syndrome (DES), and is discussed separately. (See "Etiology and clinical features of bladder dysfunction in children", section on 'Bowel and bladder dysfunction'.)
In patients with BBD, it is proposed that stool evacuation from the rectal vault relieves abnormal pressure of the overactive bladder. The importance of treating constipation is supported by the findings in a large retrospective study of 234 children with chronic constipation, 29 percent of whom had daytime urinary incontinence and 34 percent of whom had nighttime urinary incontinence . Resolution of constipation by disimpaction and maintenance therapy was associated with elimination of wetting in 89 and 63 percent of children with daytime or nighttime urinary incontinence, respectively.
Laxative use appears to be beneficial in children with BBD [15,16]. In one observational study of 46 patients with BBD and daytime urinary incontinence, polyethylene glycol without electrolytes (Miralax) resulted in an overall increase in frequency of bowel movements and improved urinary continence . Daytime urinary dryness was reported in 18 patients, a decrease in daytime urinary incontinence in 26, and there was no change in urinary symptoms in only two children. Laxative therapy was also associated with an increase in voided urine volumes and a decrease in post-void residual volumes.
The treatment of constipation consists of education, disimpaction, and bowel retraining including laxative therapy, and is discussed in detail separately. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)
Other measures — Other conservative measures used to treat children with bladder dysfunction include dietary modification and avoidance of urethritis and, in girls, vaginitis.
●Dietary modification includes the elimination of dietary products that increase bladder activity, such as caffeine, orange juice, tomato products, and spicy foods . In addition, other dietary products may reduce the risk of urinary tract infections, which are associated with bladder dysfunction. These include cranberry juice and active yogurt cultures, which have a probiotic effect.
●Patients should be counseled to avoid bubble baths or cleaning the perineal areas with soap, which can result in (or worsen already existing) urethritis or in girls, vaginitis. Poor perineal hygiene increases the possibility of perineal and genital irritation . Discomfort from these disorders during urination may contribute to voiding postponement with low voiding frequency and long-time intervals between voids, resulting in overdistension of the bladder. With continued bladder overdistension, the detrusor muscle becomes overstretched and hypoactive, leading to a weak or absent contraction referred to as an underactive bladder. (See "Etiology and clinical features of bladder dysfunction in children", section on 'Voiding postponement and underactive bladder'.)
●Vaginal voiding (reflux of urine into the vaginal vault during urination) can also lead to vaginitis. Girls suspected of having vaginal voiding should be instructed to sit for an additional one or two minutes after emptying their bladders to allow the drainage of urine that has refluxed into the vaginal vault to occur. (See "Etiology and clinical features of bladder dysfunction in children", section on 'Vaginal voiding'.)
DIRECTED THERAPY — If conservative management fails to relieve the symptoms of bladder dysfunction, the underlying cause of bladder dysfunction should be identified, followed by appropriate therapy.
Evaluation that includes kidney and urinary tract imaging, urinary flow measurements, and/or urodynamic studies differentiates among neurologic, anatomic, and functional causes of bladder dysfunction in children. The management of neurologic and anatomic lesions are discussed separately. (See "Myelomeningocele (spina bifida): Urinary tract complications" and "Chronic complications of spinal cord injury and disease" and "Overview of congenital anomalies of the kidney and urinary tract (CAKUT)".)
The interventions used in treating functional causes of bladder dysfunction include the following, which are discussed in the sections below:
●Pelvic floor relaxation measures
●Other interventions such as electrical stimulation therapy, botulinum toxin injection, surgery, or clean intermittent catheterization
Functional causes of bladder dysfunction and their diagnosis are discussed separately. (See "Etiology and clinical features of bladder dysfunction in children" and "Evaluation and diagnosis of bladder dysfunction in children".)
In our practice, these interventions are used for the most common functional causes of bladder dysfunction as follows:
●Overactive bladder – In children who fail an initial trial of conservative measures (ie, timed voiding schedule and/or treatment for constipation), the next intervention is the addition of an anticholinergic agent, which can often be beneficial.
●Underactive bladder – Timed voiding is the primary treatment for underactive bladder, as well as double-voiding for those who have increased post-void residual. Anticholinergics should be avoided as they can increase incomplete bladder emptying. In some children, clean intermittent catheterization can be beneficial.
●Non-neurogenic dysfunctional voiding – Due to the concern over upper tract deterioration from increased pelvic pressure, a child with non-neurogenic dysfunctional voiding (defined as abnormal contraction of the sphincter and/or pelvic floor musculature during voiding) is best managed by a urologist. Specialized testing with urodynamics is often required to evaluate the nature of bladder dysfunction and determine the most appropriate treatment regimen, which may consist of pelvic floor relaxation measures, biofeedback, or the administration of an alpha antagonist. (See "Etiology and clinical features of bladder dysfunction in children", section on 'Dysfunctional voiding'.)
PHARMACOLOGIC THERAPY — Anticholinergic agents and alpha-adrenergic receptor antagonists have been used in the treatment of bladder dysfunction in children, primarily in those who have failed conservative therapy:
●Anticholinergic agents — Anticholinergic agents decrease the frequency of uninhibited detrusor (bladder muscle) contractions during the filling phase of the bladder  and increase bladder capacity. They are used to treat children with overactive bladders (OABs) and/or small bladder capacity [19,20]. The proposed mechanism of action involves blocking the M3 muscarinic receptor subtype, which primarily mediates detrusor contraction [21,22].
Although anticholinergic agents have been used as initial therapy in children with OABs [4,23], pharmacologic therapy is typically reserved for the patient who has not responded to a trial of conservative therapy.
●Alpha adrenergic receptor antagonists – Alpha adrenergic receptor antagonists, which act as smooth muscle relaxants at the bladder neck and proximal urethra, have been used in patients with non-neurogenic dysfunctional voiding and/or urinary retention.
Our approach — In our practice, an anticholinergic agent is frequently added when children fail an initial four-to-eight-week trial of conservative measures (ie, timed voiding schedule and/or treatment for constipation). Our agent of choice is the extended-release form of oxybutynin started at an oral dose of 5 mg per day. If significant improvement is not noted after four weeks and there are no serious side effects, the dose is increased to 10 mg per day. Any side effect that is present should be tolerable to the patient before increasing the drug dose. In children who cannot yet take pills, oxybutynin elixir is used at a dose of 0.1 to 0.2 mg/kg per dose given two or three times a day.
Treatment effect should be seen within one week of medication initiation. In children who do respond to oxybutynin, a trial of medication is attempted once a child is free of overactive bladder symptoms for four months. If symptoms of urgency or incontinence reoccur, then the medication is re-started.
Oxybutynin — The most commonly used anticholinergic agent for overactive bladder (OAB) is oxybutynin, particularly the extended-release formulation (Ditropan XL). Despite limited evidence as discussed below, we use oxybutynin for children with overactive bladders who fail to adequately improve with conservative management. We typically use the extended-release form of oxybutynin at 5 mg per day, which is approved for use in children five years and older, as bladder dysfunction is generally defined only in children five years or older, since daytime urinary continence normally occurs by four years of age. If prescribed for younger children, the short-acting form of oxybutynin is given at a dose of 0.2 mg/kg per dose three times a day (or 1 mg per year of age per dose).
Although this medication is approved by the United States Food and Drug Administration (FDA) for the treatment of OAB in children, there has only been one small clinical trial published in abstract form that has evaluated oxybutynin's efficacy compared with placebo in reducing childhood daytime urinary incontinence . There was no improvement in the frequency of daytime wetting between oxybutynin and placebo (RR 0.74, 95% CI 0.26-2.16) . In adult patients, however, there are data that demonstrate oxybutynin compared with placebo reduces urinary incontinence. (See "Urgency urinary incontinence/overactive bladder (OAB) in females: Treatment", section on 'Medication prescribing details'.)
●In one study of 81 children with daytime incontinence who were treated with oxybutynin for three months or longer, 31 patients were completely dry, 25 were significantly improved (more than 50 percent fewer daytime incontinent episodes), 19 were slightly improved (10 to 50 percent fewer daytime accidents), and 6 were unchanged in their symptoms at a mean follow-up of 1.2 years . A confounding unaccounted factor in this study was the use of biofeedback therapy in 27 patients.
●In another study of 144 children with OAB, two-thirds of the patients failed to improve with conservative management and were treated with anticholinergic medication . At a mean follow-up of 3.2 years, 68 of the 144 children (47 percent) had no OAB symptoms, and 61 (42 percent) had significant improvement.
●A third study of 30 children with OAB who failed to respond to timed voiding and limited fluid intake, demonstrated routine use of anticholinergic medication resulted in complete resolution of symptoms in 21 patients and significant improvement in 5, at a mean follow-up of 2.7 years . Almost 40 percent of patients who achieved complete resolution or significant improvement were dependent upon medication to retain continence at the time of last follow-up.
The extended-release formulation of oxybutynin (Ditropan XL) is administered once a day, while oxybutynin requires dosing three times per day. Of 27 children with persistent incontinence while receiving oxybutynin, 13 patients became dry or had significant decrease in daytime incontinence at the first clinic visit after changing to the extended-release formulation . Increases in voided bladder volume and total bladder capacity were also noted after the medication change. The improved outcome may be explained with improved compliance due to once-a-day dosing. As a result, the preferred oxybutynin preparation to treat children with OAB is the extended-release formulation.
Side effects — Oxybutynin blocks not only the muscarinic M3 receptor subtypes, but also the M1 receptor subtypes. This action accounts for the common adverse effects associated with oxybutynin, which appear to be more frequent in children than adults .
In the previously discussed retrospective study of 81 children, 47 patients (58 percent) experienced no side effects from oxybutynin . In the remaining children, the most common side effects and their frequency were as follows:
●New-onset constipation (19 percent)
●Dry mouth (17 percent)
●Flushing (14 percent)
●Heat intolerance (4 percent)
In one study based upon voluntarily reported data up until January 2007 from the Food and Drug Administration Adverse Event Reporting System, central nervous system (CNS) side effects associated with oxybutynin were proportionally more common in children than adults (37 pediatric versus 143 cases in adults) . The most common CNS complaint included hallucination, followed by agitation, sedation, confusion, amnesia, and nightmares. In most cases, symptoms occurred within one month of treatment with oxybutynin.
Abnormalities in memory have been reported in older adult patients treated with oxybutynin . However, similar effects on memory or other cognitive functions appear to be less frequent in children [22,32]. In one study, neuropsychological testing found no associated cognitive impairment in children after four weeks of oxybutynin therapy . Despite the prevalent use of anticholinergics in children, studies on the long-term impact on cognitive development are absent .
Although one observational study reported fewer side effects with the use of the extended-release formulation of oxybutynin (Ditropan XL) compared with oxybutynin , another study reported similar frequency of side effects between the two different preparations .
Contraindications — Because oxybutynin decreases detrusor contractions, its use is contraindicated in patients with underactive bladder (also known as "lazy bladder syndrome"), interrupted (fractionated) voiding pattern, history of urinary retention, or high post-void residual volumes.
Solifenacin — Solifenacin is a selective anticholinergic agent at the M3 muscarinic receptor site. In 2020, solifenacin was approved by the FDA for the treatment of neurogenic detrusor overactivity in children aged two years and older based on limited data [36-38]. While there is not a specific approved indication for pediatric non-neurogenic OAB, solifenacin may potentially be considered as an option as the medication has been approved for adult treatment of OAB. However, the FDA approval for solifenacin for neurogenic OAB has not changed our practice to date in the management of non-neurogenic OAB. Solifenacin may be considered for patients who have intolerable adverse effects from oxybutynin, our initially preferred agent. As a selective M3 anticholinergic that is more bladder specific there is potential for solifenacin to limit common anticholinergic side effects.
The most commonly reported side effects of solifenacin are constipation, dry mouth, abdominal pain, and somnolence. Stated contraindications were gastric retention, decreased gastric motility, or significant bladder outlet obstruction.
Other anticholinergic agents — The following agents have not been approved by the FDA for use in children. They are approved for use in adults with dysfunctional voiding, as discussed separately. (See "Urgency urinary incontinence/overactive bladder (OAB) in females: Treatment", section on 'Antimuscarinics (anticholinergics)' and "Lower urinary tract symptoms in males".)
●Tolterodine is a selective competitive muscarinic receptor antagonist that has not been FDA approved for use in children. It has been shown to improve detrusor compliance and bladder capacity in patients with OAB .
In a placebo-controlled trial of 711 children ranging from 5 to 10 years of age, patients were randomly selected to receive tolterodine (2 mg per day) for 12 weeks . There was no overall difference in the number of incontinent episodes. However, a subset analysis demonstrated a decrease in the frequency of incontinence in children with a weight at or below 35 kg, suggesting a possible under-dosage effect in heavier children.
A retrospective study of 200 children with OAB reported that tolterodine therapy resulted in complete continence or significantly reduced frequency of incontinent episodes (greater than a 50 percent reduction) in approximately one-half of the patients . Other smaller observational studies suggest that tolterodine was effective in patients who failed oxybutynin therapy [20,42].
Although there are few studies that compare different anticholinergic agents, one retrospective study of 132 children with daytime incontinence and symptoms of OAB reported that oxybutynin compared with either short- or long-acting tolterodine was more effective in controlling daytime urinary incontinence and frequency .
Beta3-adrenoceptor agonists — Beta3-adrenoreceptor agonists activate beta3 adrenergic receptors in the bladder resulting in relaxation of the detrusor smooth muscle during the urine storage phase, thus increasing bladder capacity. In the United States, mirabegron is the only beta3-adrenoreceptor agonist approved for treatment of neurogenic detrusor overactivity (NDO) in children aged three years and older. The efficacy of mirabegron is supported by an open-label trial of 68 children and adolescents, all of whom received mirabegron. At the end of six months, average maximum cystometric capacity increased to 87 mL (95% CI, 66 – 108 mL) and detrusor pressure at the end of bladder filling decreased to 16 cmH20 compared to baseline measurements . The same trial reported treatment-emergent adverse events possibly or probably related to treatment in 15 and 1 percent of patients, respectively. No reported serious treatment-emergent adverse effects were considered to be related to treatment. In addition, observational studies of children with overactive bladder refractory to anticholinergic therapy reported that mirabegron either as monotherapy or in combination with other agents appeared to be beneficial with improvement of symptoms [45-47].
The use of Beta3-adrenoreceptor agonists in adults are discussed elsewhere. (See "Urgency urinary incontinence/overactive bladder (OAB) in females: Treatment", section on 'Our approach to treatment' and "Lower urinary tract symptoms in males".)
Alpha adrenergic receptor antagonists — Alpha adrenergic receptor antagonists relax the smooth muscle at the bladder neck and proximal urethra. They are used in adult patients, especially in men with urinary retention due to benign prostatic hyperplasia. (See "Lower urinary tract symptoms in males", section on 'Alpha adrenergic-receptor antagonists'.)
There are limited data on the use of these agents in children. Small studies have demonstrated improvement in children with daytime urinary incontinence and urinary retention. However, evidence is limited and of poor quality, and the routine use alpha adrenergic receptor antagonists cannot be recommended based upon the available literature.
●In a trial of 38 children with bladder dysfunction, patients were randomly selected to receive doxazosin or placebo . Although the findings were not statistically significant, there was a trend towards a decrease in urinary incontinence frequency in patients who received doxazosin compared with placebo-treated controls (4 versus 14 incontinent episodes per week from a median baseline of 18 weekly episodes). In addition, patients treated with doxazosin compared with controls had a greater reduction in their bladder dysfunctional symptoms, which was assessed by a dysfunctional voiding symptom parental survey.
●In a retrospective study of 55 children (mean age 7.9 years) with bladder dysfunction and urinary retention, doxazosin, an alpha adrenergic receptor antagonist, reduced the average post-void residual volume from 65 mL to 8 mL . There was also a decrease in daytime incontinence in 42 children with the use of this medication.
●In a retrospective study of 26 children with primary bladder neck dysfunction, treatment with an alpha adrenergic receptor antagonist resulted in improved mean average (5.5 to 12.6 mL per sec) and maximal (10.3 to 19.7 mL per sec) urinary flow rates . In addition, mean post-void residual volumes decreased from 99 to 9 mL with alpha blocker therapy.
●In an observational study of 23 children with bladder neck dysfunction, the number of incontinent episodes decreased from 5.6 to 0.8 per day with tamsulosin therapy (selective alpha adrenergic receptor antagonist) . In addition, increases in the average and maximum urinary flow rate and a reduction in post-void residual urine and abnormal uroflow patterns were observed during tamsulosin therapy. There was no significant effect on blood pressure (BP), with mean BP before and during tamsulosin therapy of 98/55 and 110/61 mmHg, respectively.
These data suggest that there may be a role for alpha adrenergic receptor antagonists in children with bladder dysfunction. Because of their mode of action of blocking the alpha receptor resulting in smooth muscle relaxation of the bladder neck and proximal urethra, it would be expected that these agents would be particularly beneficial in children with non-neurogenic dysfunctional voiding and in those with primary bladder neck dysfunction. Further trials are needed to determine whether this class of medication is beneficial and safe in children with specific disorders of voiding dysfunction.
Biofeedback and pelvic floor muscle training — Biofeedback therapy teaches children how to identify and control the muscle groups (pelvic floor muscle) involved in voiding [52,53]. It can utilize noninvasive urodynamic monitoring, such as uroflow measurement and adhesive pads on the perineum to measure and record sphincter activity, and provide immediate feedback to the patient about his/her bladder function. The child observes real-time visual displays of urinary flow and electromyography (EMG) activity [54,55]. The visual or auditory feedback allows the child to become aware of and gain control over their bladder function by teaching the child to learn how to voluntarily relax or contract their sphincter and pelvic musculature, thus modifying the observed measurements. Pelvic muscle (Kegel) exercises strengthen the pelvic floor musculature to provide a backboard for the urethra to compress on and to reflexively inhibit detrusor contractions (see "Female urinary incontinence: Treatment", section on 'Pelvic floor muscle (Kegel) exercises'). This is in contrast to pelvic floor relaxation, in which the child learns to relax the pelvic muscle groups involved with voiding without urodynamic monitoring feedback.
Biofeedback programs can also be tailored to children by utilizing interactive computer games that are controlled by pelvic floor contraction and relaxation, or urinary flow rate [56,57]. The child can observe real-time visual displays of urinary flow and electromyography (EMG) activity and modify these measurements by changes in the contraction or relaxation of the sphincter or pelvic floor muscles.
Although biofeedback has been reported to help normalize the uroflow and EMG pattern, decrease post-void residual, and increase urinary flow rates, it remains unclear whether biofeedback is effective in early resolution of incontinence .
Several observational studies in children report that biofeedback therapy appears to reduce symptoms associated with bladder dysfunction and decrease post-void residual volumes [13,54,56,58-63]. In contrast, a meta-analysis of four trials that assessed the effects of biofeedback in children with symptoms of nonneuropathic voiding disorders reported no difference in the likelihood of resolution of incontinence at six months between patients who received biofeedback and controls . In addition, there was no difference in the risk of recurrent UTI. Both the authors and an accompanying editorial comment that data are sparse and further investigation is warranted to see if there is a specific group of patients with nonneuropathic voiding disorders who would benefit from biofeedback therapy. As noted above, previous reports have shown that biofeedback improved voiding bladder function, and incontinence is considered a failure of the bladder's storage function, which may explain the lack of early benefit in continence demonstrated by the meta-analysis review, despite improvement in voiding parameters after biofeedback .
Biofeedback therapy has been reported to improve resolution of vesicoureteral reflux (VUR) and/or decrease the risk of recurrent UTIs in children with bladder dysfunction. In one study of 25 children with detrusor-sphincter dyssynergy and VUR, the resolution rate for VUR was 55 percent over one year with biofeedback therapy . However, resolution of VUR was only in patients with low-grade reflux. Two studies have reported that with biofeedback recurrent UTIs resolved in 70 to 80 percent of patients [54,55].
Indications — In our practice, biofeedback is reserved for children with bladder and sphincter dyssynergia that is contributing to persistent daytime incontinence despite an adequate trial of conservative therapy and/or pharmacotherapy. It is also used for children with significant post-void residuals who have recurrent urinary tract infections and constipation.
Electrical stimulation therapy (neuromodulation) — Electrical stimulation therapy, also referred to as neuromodulation, involves implantation of noninvasive devices that can stimulate pelvic muscle contractions and/or modulate detrusor activity. These electrical stimulation therapies include noninvasive pelvic muscle stimulation via electrodes in the anus or vagina [66,67], sacral nerve stimulation (SNS) via implanted or transcutaneous electrodes [68-75], or transcutaneous stimulation of the peripheral tibial nerve [76,77].
Although use in children with bladder dysfunction is limited, it is thought that electrical stimulation therapy would benefit patients with overactive bladder by stimulating spinal inhibitory pathways that reduce detrusor (bladder muscle) contractions (figure 1) . Several small observational studies and trials have suggested that electrical stimulation therapy decreases incontinence and urgency in children with bladder dysfunction who have failed to respond to both conservative management and pharmacologic therapy [66-72,76,77,79-83]. In particular, transcutaneous nerve electrical stimulation (TENS) of the sacral root S3, which requires placement of electrodes on the skin over the sacral area, appears to be a promising therapy in children with incontinence and overactive bladder (OAB).
●In a systematic review of the literature, a meta-analysis of five small trials with 245 patients reported that office-based neurostimulation resulted in partial improvement of symptoms associated with overactive bladder but not a definitive complete response .
●In a small clinical trial of 40 children (ages 5 to 17 years) diagnosed with bowel bladder dysfunction, parasacral TENS was associated with improvement in enuresis and functional constipation 
However, information from large trials using similar protocols regarding the long-term benefit of electric stimulation is needed to determine whether this therapy should be used routinely (and when) in the management of bladder dysfunction.
Indications — In our practice, neuromodulation is used in a select group of children who have overactive bladder refractory to behavioral and anticholinergic therapy. We use TENS sacral stimulation for 20 minutes twice daily as this is a regimen that appears to be safe and well tolerated in children.
Botulinum toxin — Botulinum toxin A is injected directly using cystoscopic guidance into the detrusor muscle or external urinary sphincter. It is thought to block neurotransmitter release from the peripheral afferent nerve terminals and inhibit efferent muscular contraction . Botulinum toxin A has been primarily studied in children with neurogenic detrusor-sphincter dyssynergy or overactivity [81,85]. (See "Botulinum toxin for treatment of lower urinary tract conditions: Indications and clinical evaluation".).
Limited data on its effects in children with non-neurogenic dysfunctional voiding suggest improvement in symptom scores and a reduction of post-void residual volume . In children with overactive bladder, botulinum toxin injection appears to improve symptoms and increase bladder capacity [87,88]. However, further studies are required to determine whether botulinum toxin injection has a role in the treatment of patients (both adults and children) with bladder dysfunction and whether it is safe and effective long-term.
Surgery — In children with a neurogenic bladder, surgery is commonly used to alter the urinary tract for safe storage of urine and/or to achieve continence. In contrast, patients with non-neurogenic bladder dysfunction rarely require surgical intervention. In rare cases of non-neurologic bladder dysfunction, when markedly elevated bladder pressure develops, a child may require enlargement of his/her bladder to reduce bladder pressure, and thus prevent kidney damage. Bladder augmentation is usually achieved by adding an isolated segment of bowel to the bladder.
Cystoscopy with urethral dilation is no longer routinely used to treat children with bladder dysfunction as there are little data to support the utility of this intervention .
Catheterization — In children who postpone micturition, the bladder becomes overdistended and the detrusor muscle becomes overstretched and hypoactive leading to a weak or absent contraction referred to as an underactive bladder, which was formerly called "lazy bladder syndrome" or myogenic failure. In these cases, bladder emptying is often incomplete, resulting in large post-void residual volumes and an increased risk of urinary tract infection (UTI). Clean intermittent catheterization (CIC) is an effective and safe intervention for bladder emptying . It allows patients to attain continence and reduces the rate of recurrent UTIs. CIC should be done in association with an established timed voiding schedule. (See 'Voiding behavior modification' above.)
LONG-TERM PROGNOSIS — The long-term outcome of children with bladder dysfunction is typically excellent with resolution of their symptoms [91,92].
This was best illustrated in a review of 199 patients treated at one tertiary center in the United States, in which 98 parents and 51 patients were contacted by phone at least 6.5 years after initial presentation . At the time of follow-up, 91 percent of the patients no longer were incontinent and 82 percent no longer had urinary tract infections. This resolution of symptoms is most likely due to the natural history of bladder dysfunction rather than to medical interventions.
One study suggested that girls with childhood incontinence compared with those without bladder dysfunction are more likely to have urge symptoms and incontinence in adulthood .
RESOURCES — The International Children's Continence Society provides guidelines for the evaluation and treatment of bladder dysfunction, as well as information for the general public.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Urinary incontinence in children".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Daytime wetting in children (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Conservative management – Management of a child with bladder dysfunction, defined as any abnormality in either the filling and/or emptying of the bladder, is directed at improving the child's symptoms and avoiding kidney damage. In our practice, a stepped approach is used starting with the least invasive therapy (ie, voiding behavior modification), and if the patient remains unresponsive, moving to more invasive and/or costly interventions (ie, medications or biofeedback). The initial therapeutic measures include voiding behavior modification with timed voiding schedules, and treatment of constipation, if present. (See 'Overview' above and 'Conservative management' above.)
●Patients who fail conservative management – In patients who fail conservative treatment, directed therapy is focused on improving the symptoms of a specific cause of bladder dysfunction. Interventions include pharmacologic therapy, biofeedback, electrical stimulation therapy, surgery, and clean intermittent catheterization. The choice of interventions is based upon the underlying condition and severity of symptoms, as follows.
•Children with overactive bladder who fail to respond to conservative therapy – For these children, we suggest a trial of an anticholinergic agent to reduce symptoms (Grade 2B). Our preferred agent is an extended-release form of oxybutynin because its once-a-day dosing improves compliance. An alternative to pharmacologic therapy is neuromodulation; however, this is an expensive and not universally available treatment modality with limited data on its effectiveness in children. (See 'Pharmacologic therapy' above and 'Biofeedback and pelvic floor muscle training' above and "Urgency urinary incontinence/overactive bladder (OAB) in females: Treatment", section on 'Medication prescribing details'.)
•Children with underactive bladder and elevated post-void residuals – For these children, we suggest timed voiding and double-voiding. In some children who fail to respond to voiding modification, we suggest adding a trial of clean intermittent catheterization (CIC) to timed voiding schedule for effective bladder emptying (Grade 2C). (See 'Catheterization' above.)
•Children with non-neurogenic dysfunctional voiding (abnormal contraction of the sphincter and/or pelvic floor musculature during voiding) or primary neck bladder dysfunction – For these children, we suggest biofeedback therapy to reduce symptoms (Grade 2C). Although alpha adrenergic receptor antagonists have been used in treating these conditions in children, data are limited and their routine use cannot be recommended based upon the available literature. (See 'Biofeedback and pelvic floor muscle training' above and 'Alpha adrenergic receptor antagonists' above.)
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟