Innovation for Pelvic Health

Incontinence in a child can be a diffi cult problem for child, parent, and physician. A comprehensive history and physical examination will often narrow down the cause of the problem and lead to the development of a treatment plan; however, sometimes more extensive testing is needed because incontinence  may be multi-factorial. Often the treatment strategy needs to be similarly multi-modal.

 In some children, detrusor-sphincter discoordination is completely or partly responsible for incontinence. In these cases, biofeedback or pelvic-fl oor retraining can be useful to correct the improper behavior. Since biofeedback is time-consuming and labor-intensive, the best results are obtained with properly selected children, a friendly environment, nurses with excellent teaching skills and sensitivity, and an appropriate reward system to acknowledge the child’s efforts and successes.
We have had excellent success with traditional biofeedback therapy using auditory and visual cues; however, software has been developed allowing for animation biofeedback, and our experience with this has been even more promising.

Urinary continence development
Normal coordinated voiding develops over the fi rst few years of life. Neonates have variable voiding patterns, with discoordinated voiding being more common than previously believed. Unstable bladder contractions are seen among 5% to 18% of healthy infants during urodynamic studies. 1,2  Voiding is stimulated by feeding and occurs typically during naps and sleep after meals. Complete bladder emptying can occur after 2 to 3 small voidings, leaving large post-voiding residual volumes. 3,4 Boys will often void at bladder pressures exceeding 100 cm H2O. 1,2

For the development of normal voiding, children need to develop adequate bladder capacity, external sphincter control, and voluntary detrusor muscle control.5  The small bladder size (30–60 cc) of newborns helps to account for their frequency of voiding. As the bladder capacity increases (30 cc/year 6) the frequency of voiding decreases.7  External striated sphincter control typically occurs by 3 years, and detrusor muscle control occurs by 4 years.

 Children should have urinary control after achieving these age milestones. Urine should be stored in an adequately sized and stable bladder, with tonic contraction of the sphincter. As the bladder reaches capacity, the contraction of the external sphincter is at its peak. The sphincter then relaxes, and then the bladder contracts without outlet resistance; complete emptying should result.

Causes of incontinence
 Incontinence is the involuntary loss of urine from the bladder. If complete urinary control has never been achieved for greater than 6 months, the incontinence is considered primary. Secondary incontinence implies a loss of control that has been maintained for over 6 months. Diurnal wetting means loss of control during daytime, while nocturnal wetting describes nighttime loss only. Simplistically, one can divide the etiology of incontinence into bladder causes, sphincter causes, or both.

 Bladder causes are primarily detrusor overactivity, reduced bladder capacity, or reduced bladder compliance.  These processes can result in urinary frequency and urgency, and the inability to reach the bathroom in time leads to incontinence. Some children with normal bladders delay urination until the urge to void is no longer controllable.  Others drink excessively, overextending a normal bladder without suffi cient time to get to a bathroom. In order to delay voiding, children within any of these populations tighten the external sphincter. When this behavior leads to incomplete relaxation of the sphincter during the voiding phase, increased tone during voiding, or intermittent relaxation of the sphincter, dysfunctional voiding ensues.

 Sphincter causes of incontinence may be related to the functional pathophysiology just described, or there may be other sphincteric problems. If there is a deficiency in sphincter tone, the bladder will not be able to store urine to its capacity, and incontinence will occur. This sometimes is associated with giggling or periods of physical stress. A discussion ofneurogenic or other structural causes of incontinence is beyond the scope of this monograph.

Evaluating the incontinent child
History The history should detail urologic, medical, and surgical issues. Attention should be paid to confounding conditions such as attention defi cit disorder, diabetes, neurologic conditions, and medications. An extensive voiding history should include the timing of voidings and accidents, activities during incontinent episodes, associated frequency, urgency, and dysuria. One should question the female patient as to positioning on the toilet and wiping technique. Sufficient questioning may associate the incontinence with certain foods or fl uid intake, and this should be confi rmed with a food and voiding diary maintained over nonconsecutive days. Bowel dysfunction commonly co-exists with and needs to be understood in relation toincontinence. In addition, it is essential to identify any social or familial stressors such as school performance, changes to family dynamics, or peer relationships.

Physical examination

The examination must be thorough. Subtle findings on the back such as caféau-lait spots or unusual hair pattern or dimples may implicate a spinal cord disorder that should be confirmed by MRI (magnetic resonance imaging). A pelvic or abdominal mass may be palpated. In a boy, meatal stenosis may lead to incomplete voiding, high voiding pressures, and bladder instability with incontinence. In girls, the introitus should be inspected for labial adhesions or evidence of vaginal pooling that may lead to dripping of urine without notice.

Urine studies

Urinalysis should be performed and followed by urine culture when indicated.

Uroflowmetry and electromyography (EMG)

These are valuable, noninvasive tools for understanding bladder dynamics in the incontinent child. The child voids into a uroflowmeter attached to electromyographic patches on both the perineal and abdominal musculature. Complete absence of both perineal and abdominal muscle activity during the flow of urine in a bell-shaped curve is considered normal. The bladder should be empty after voiding as confi rmed by either catheterization (prior to formal urodynamics) or by ultrasound. In children with discoordinated voiding, the perineal muscles continue to contract, increase their contraction, or intermittently contract during voiding. This can result in a flattened or interrupted flow curve, increased bladder voiding pressures, incomplete voiding, urinary tract infections, or incontinence. It is important to ascertain that the flow-EMG patterns correlate with the clinical complaints and the subjective flow described by the child and/or parent.

 Urodynamics with bladder and rectal catheterization should be performed when the information already obtained fails to indicate a diagnosis or there is an inadequate response to treatment.

Imaging

 Renal and bladder ultrasound can detect anatomical abnormalities requiring additional studies. Measurement of post-voiding urine volumes can provide insight into the effi ciency of bladder emptying. A voiding cystourethrogram (VCUG) should be performed when an abnormality is detected by ultrasound or if the EMG-urofl owmetry implicates possible outflow obstruction.

Treating incontinence

The goal of the evaluation described above is to identify the etiology of incontinence so as to initiate appropriate therapy. Sometimes a combination of therapies is needed because the cause is multifactorial.

Pharmacotherapy

Several medication classes have been used to treat the incontinent child. Children with bladder instability or small functional bladder capacity may find anticholinergic agents (e.g., oxybutynin chloride, tolterodine L-tartrate) useful in either tablet or liquid formulation. 8 Because of their limited side effects and reduced daily dosing, longer-acting agents (e.g., extended-release versions of tolterodine L- tartrate and oxybutynin chloride) may improve compliance. Giggle incontinence has been treated successfully with methylphenidate.9 In children with heightened smooth-muscle sphincter tone, alpha blockers (e.g., tamsulosin hydrochloride, doxazosin mesylate) have been used successfully.10

Diet

Food logs help to identify dietary habits that cause or aggravate incontinence. Some children simply need to reduce the volume of fluid intake. Others need to eliminate or reduce their intake of caffeine, carbonated drinks, citrus juices, dairy products, or heavily sugared foods. To have the child accept these changes, it is important to introduce them as a way for the child to help in his/her own treatment rather than as a punishment.

Toileting

Modifications in toileting habits and techniques can be important. Employing a timed-voiding schedule that might include double voiding can reduce or eliminate post-voiding residual urine. It is important that girls void in a position that prevents vaginal urine pooling. Dabbing the external genitalia without absorbing more-interiorly splashed urine can lead to damp panties. Vaginitis can irritate the urethra, leading to symptoms similar to those associated with urinary tract infection, including incontinence.

Bowel management

Stool in the rectosigmoid can press on the bladder, leading to bladder instability, urgency, frequency, and incontinence. Hence, improving the effi ciency of stool passage can lead to bladder stability and more efficient bladder emptying. Some children simply need to be encouraged to sit daily or for longer periods to better empty the rectum. Other children need dietary supplementation (e.g., prunes, fiber, and fluids), over-the-counter agents (e.g., mineral oil, senna) or prescription medications (e.g., polyethylene glycol 3350).

Biofeedback principles

Biofeedback involves obtaining information about specifi c biological patterns, such as incontinence, and then developing voluntary control techniques to change those patterns. For incontinence, biofeedback requires teaching children to identify and then to gain control over the external striated urinary sphincter. This is a labor-intensive process that requires a positive working relationship between a specially trained professional and a motivated child of appropriate developmental age (typically older than five years).

 Once the suitable candidate is identifi ed (discoordinated detrusor-sphincter activity on EMG-fl owmetry), biofeedback can be initiated. The child works on identifying the correct muscle groups responsible for continence. With EMG patches on the perineum, the child is asked to squeeze the puborectalis group as though to prevent a bowel movement. Once this is accomplished, identification of the pubourethralis muscle group is next. Once the muscle groups are identified, the next phase is muscle strengthening. Repetitive brief strong contractions (intended to strengthen fast-twitch muscles) and prolonged maximal contractions (to strengthen slow-twitch muscles) are performed.

It is important that appropriate positive reinforcement and rewards be part of the management approach. Positive reinforcement charts allow children to mark clinical progress made during biofeedback sessions. Simple rewards are useful goals to help further progress with staying dry. Children are instructed to perform their exercises at home and to keep records of the assignments; these records and their clinical progress are reviewed at each session. The assignments are typically performed at home without any devices, although home biofeedback units are available. These principles of positive reinforcement can be helpful in motivating children to adhere to other behavior modifi cations such as dietary adjustments, bowel-habit changes, and timed voiding.

Biofeedback efficacy

There are several studies documenting the success of biofeedback for managing childhood incontinence in large groups of children of different ages. Hoebeke et al 11 reported a 92% cure rate among 50 children between 6 and 13 years old with dysfunctional voiding who underwent biofeedback; success persisted for at least 6 months in 82% of the children. Many of the same researchers reported resolution of incontinence in the majority of a group of 20 children under 5 years old.12
 Weiner 13 found that nearly 60% of 48 patients questioned 5 years after behavior modification treatment that included Kegel exercises continued to have daytime urinary control. Schulman 14 found similar success rates among 102 patients when biofeedback was performed in front of a uroflow machine or EMG tracings or both.

Animated biofeedback

All physicians involved with treating incontinent children will agree that the two most important factors for successful biofeedback are the motivated child and the skilled nurse. Clearly, any method that can attract and then motivate a child to engage in biofeedback or can accelerate the success of a motivated child is welcomed. The biofeedback units used in the studies reported above require the child to use auditory and visual signals in helping to identify the correct muscles. This can be challenging and frustrating for even the motivated child.

Animation and computer graphics have a primary role in the entertainment of children and adolescents in contemporary American society. Applying this technology to educational processes could improve the effi cacy of biofeedback. McKenna 15,16 reported his experience using an interactive computer game to assist with biofeedback in 168 children. The success rates were similar to those of studies not using computer games.

We recently started using the Urostym (Laborie Medical) biofeedback program that has animation programs appealing to several age groups. At the Second Joint Meeting of the European Society for Paediatric Urology (ESPU) and American Academy of Pediatrics Section on Urology (AAP) in Uppsala, Sweden in June 2005 we presented our initial experience comparing biofeedback with and without animation. 17

We compared outcomes of the last 30 cases of biofeedback using EMG alone (group A) with our fi rst 30 cases using the animated Urostym program (group B). Both groups were comprised of girls of similar age (7.3 years versus 6.9 years). All 60 children presented with urinary complaints and demonstrated detrusor-sphincter discoordination (DSD) on EMG-uroflow tests. Post-voiding residual measurements were made by ultrasound. There was no significant difference between the two groups regarding relief of daytime incontinence (A=94%, B=92%), frequency (A=94%, B=93%), or urgency (A=92%, B=90%). DSD resolution was achieved in 95% of children in both groups while post-void residual was reduced to similar degrees (from 31% to 9% in group A and 28% to 8% in group B). However, the children using the animated biofeedback achieved success in significantly fewer sessions (3 sessions) than children undergoing biofeedback without animation (6 sessions) (P<.05, t-test). Despite our proven experience without animated biofeedback systems and our inexperience with an animated system, the animated biofeedback program provided a shorter time to success. We attributed this expedited result to the animation engaging the children, which facilitated muscle isolation and compliance.

Summary

Incontinence in children can be a diffi cult problem. However, through good history taking, physical examination, and non-invasive testing, the causes of the problem can often be ascertained. Often, a multimodal treatment plan is needed to address the multifactorial cause of the incontinence. Biofeedback is an effective
treatment modality for the incontinent child with discoordination between the detrusor and external striated sphincter. While conventional biofeedback programs provide excellent results, animated programs can provide similar results in less time.

References
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17. Palmer LS. Animated biofeedback yields similar but more rapid results than non-animated biofeedback [abstract 117]. J Ped Urol. 2005;1(3):192-3. Presented at the 2nd Joint Meeting of the European Society for Paediatric Urology (ESPU) and American Academy of Pediatrics Section on Urology (AAP); June 17, 2005; Uppsala, Sweden.