The term voiding dysfunction refers to disorders of bladder emptying or filling. It can encompass enuresis, recurrent urinary tract infections and loss of bladder function.¹ Between 5 million and 7 million U.S. children experience enuresis. The psychosocial impact of this problem can be significant.^2,3

For patients with voiding dysfunction, many barriers to treatment exist. Families may be too embarrassed to discuss symptoms, and providers may not ask specifically about voiding difficulties.⁴ Primary care practices have limited time and resources to complete a comprehensive evaluation of voiding dysfunction and deliver the extensive patient and family education needed for successful treatment.

Mechanics of Dysfunction

Enuresis is the involuntary expulsion of urine. It can occur during the day (diurnal) or at night (nocturnal).¹ Diurnal enuresis may occur with or without nocturnal enuresis. Nocturnal enuresis is classified as primary or secondary. In primary nocturnal enuresis, the child has never been dry at night. In secondary nocturnal enuresis, wetting recurs after a dry period of more than 6 months. Neurogenic etiologies of voiding dysfunction are outside the scope of this article and are not discussed here.

Filling Phase

Diurnal symptoms related to an overactive detrusor can result in uninhibited bladder contractions that cause urinary frequency with urgency or incontinence (e.g., urge syndrome and urge incontinence).¹ Girls may exhibit a classic posturing position known as Vincent's curtsy, squatting down on the heel of one foot to try to suppress the urge to void. Some children may wet without the sensation of bladder emptying.

Voiding Phase

Dysfunctional voiding is a pattern of bladder-sphincter dysfunction in which the child incompletely relaxes or actively uses the pelvic floor muscles during voiding. This creates functional outflow obstruction that increases resistance downstream from increasing pressures.¹ Children may not be aware they are tightening the pelvic floor. This habit may evolve from repeated voiding dysfunction and progress to an interrupted urinary stream in the form of staccato or fractionated voiding. This results in incomplete emptying of the bladder. Over time, this can lead to increasing postvoid residuals, recurrent urinary tract infection, bladder wall thickening, trabeculation and secondary vesicoureteral reflux. Chronic functional bladder outflow obstruction may lead to so-called lazy bladder syndrome and infrequent voiding. Detrusor contractility decreases, emptying is inefficient and a large, floppy bladder develops. Urge sensation may disappear, and overflow incontinence may occur.

Hinman syndrome (neurogenic bladder) is a form of bladder-sphincteric dysfunction characterized by external sphincter contraction during voiding. It creates bladder outlet obstruction.¹ Over time, this results in a trabeculated, large capacity bladder that does not empty efficiently. The patient experiences urinary incontinence and may develop recurrent urinary tract infections and increasing bladder pressures transmitted to the upper urinary tracts, resulting in hydroureteronephrosis, vesicoureteral reflux and ultimately renal demise.

Many of these children also have significant bowel dysfunction. The relationship between bowel symptoms and dysfunctional voiding, including recurrent urinary tract infections, has long been known, but the term to describe this relationship is a more recent development.¹ Dysfunctional elimination syndrome describes the combination of urinary and bowel symptoms. Constant irritation of the bladder as a result of contact with a distended rectum secondary to constipation may affect the bladder's ability to function properly. Mechanical compression of the bladder and bladder neck from the distended rectum may lead to urinary obstruction and incite detrusor instability, resulting in symptoms including urge syndrome, urge incontinence, dysfunctional voiding and nocturnal enuresis.

Literature Review

The relationship between nocturnal enuresis and decreased self-esteem and self-concept is well documented. The presence of diurnal enuresis compounds the problem. The understanding that nocturnal enuresis is a cause of psychological distress rather than a symptom of psychological disturbance is a more recent phenomenon.^5,6 A common hypothesis presumes a negative self-concept or negative self-esteem with the presence of nocturnal enuresis.^7,8 Studies have documented a link between enuresis and problems such as child abuse, increased suicide risk, poor parental attachment and school or behavioral problems.^7,9-11 Studies have also documented statistically significant improvement in self-esteem and self-concept in children who are successfully treated for enuresis.^12-14

Voiding dysfunction clinics specialize in treating the underlying causes of voiding dysfunction. Many of these clinics are directed by nurse practitioners.

Methods

I conducted a retrospective review of charts for patients who received treatment from me, a pediatric nurse practitioner who specializes in urology. I direct a university-based pediatric voiding dysfunction clinic in Augusta, Ga. I reviewed charts from January 2003 (clinic opening) through December 2007. Patients ranged in age from 4 to 18 years. I reviewed only charts documenting a minimum of two visits. I excluded patients who had known neurologic or genitourinary anatomic abnormalities. One hundred forty of 355 charts met these criteria.

Statistical Analysis

I analyzed the data using a paired T-test to determine the difference between pretreatment and postreatment measurements. I used chi-square analysis to compare binary variables. The significance was taken as p < 0.05 for all tests.

Results

Results showed a statistically significant improvement in voiding dysfunction symptoms after treatment at the pediatric voiding dysfunction clinic. Improvement occurred by the first follow-up visit. Interventions were aimed at treating the underlying causes of voiding dysfunction and included a comprehensive dietary and behavior modification program promoting lifelong healthy habits.

Tables 1, 2 and 3 contain details about the chart reviews. Statistically significant variables included urinary frequency, urgency, posturing, urge incontinence, full wetting accidents, deferred voiding, nocturnal enuresis and encopresis. Although constipation improvement was not statistically significant, improvement in encopresis (leakage of newly formed stool around retained stool in the rectal vault) was significant. Therefore, improvement occurred in the most severe cases of constipation with resolution of encopresis.

Discussion and Implications

The box accompanying this article outlines components of care for children with voiding dysfunction. These techniques are common in my practice and were employed with patients covered in the chart review. All participants received a comprehensive intervention with dietary and behavior modification. These measures resulted in quantifiable improvement in symptoms and quality of life. All participants received gender-specific voiding instructions, including a timed voiding schedule, double voiding and spread-leg voiding.

Timed voiding schedules require a child to make a trip to the bathroom at least every 2 hours, regardless of urge to void. Double voiding refers to remaining in the bathroom for 2 to 3 minutes after the initial urinary stream finishes and trying to void again. This helps ensure full emptying of the bladder each time. I encourage younger children to mark the time by slowly singing the ABC song two or three times. I encourage older children to keep track of time by wearing a wrist watch. Spread-leg voiding allows girls to eliminate irritation caused by voiding against closed legs. It requires clothing to be pulled all the way down to the ankles and for the legs to be placed on either side of the toilet bowl. Closed leg voiding can result in a trapping of urine in the vaginal vault, known as vaginal reflux. To reduce the potential for pelvic floor tightening, I teach girls to relax during voiding. A common technique is to blow slowly on a pinwheel or bubble wand.

I recommend dietary modifications for all children. These include elimination or reduction of known dietary irritants and increased water and fiber intake. Dietary irritants include caffeine, carbonation, artificial colors, citrus and calcium. I recommend eliminating all soda, tea and artificially colored drinks; citrus drinks and dairy products should be reduced to a handful per week. Many children do not drink enough liquids, which results in concentrated urine that also irritates the bladder. Children should drink just enough fluid so that urine appears more like water, with a yellow tinge.

Another common problem is constipation. This responds well to increased water and fiber intake. A stool softener is a useful adjunct to the dietary recommendations. The child with constipation should sit on the toilet after each meal, to take advantage of the gastrocolic reflex and promote regular emptying.

To ensure that these behavioral strategies are used in the school setting, I give each patient's family a letter for teachers or administration. It requests adequate bathroom breaks and allowance for use of a water bottle throughout the day.

Limitations

Data collection for this chart review was limited by exclusions based on lack of a follow-up visit for comparison and lack of long-term data for analysis secondary to a percentage of the population that is mobile or lost to follow-up.

Future Research

The development of a primary care screening and assessment tool based on assessment variables incorporated in this study may be helpful in the diagnosis of voiding dysfunction. Prompt identification of voiding dysfunction symptoms may decrease delays in treatment and potentially decrease the incidence and severity of comorbidities. Because voiding dysfunction includes a constellation of many symptoms, thorough evaluation is time intensive and is often difficult in many primary care settings. Coupled with cultural, economic and geographic barriers to care, this often results in lack of access. Dissemination of the results of this study may lead to an increase in the body of knowledge for evidence-based practice and ultimately to increased use of nurse practitioner-directed voiding dysfunction clinics.

Putting It Into Practice

This chart review documented efficacious treatment for voiding dysfunction focused on treatment of underlying causes. The key components are dietary and behavior modifications. This approach to treatment leads to empowerment of the child and family and to decreased use of medications and invasive diagnostic studies.

References

1. Yeung CK, et al. Voiding dysfunction in children: non-neurogenic and neurogenic. In: Wein AJ et al, eds. Campbell's Urology. 9^thed. Philadelphia: W.B. Saunders Company; 2007.

2. Collier J, et al. An investigation of the impact of nocturnal enuresis on children's self-concept. Scand J Urol Nephrol. 2002;36(3):204-208.

3. Theunis M, et al. Self-image and performance in children with nocturnal enuresis. Eur Urol. 2002;41(6):660-667.

4. Cendron M. Removing the stigma: helping reduce the psychosocial impact of bedwetting. Urol Nurs. 2002;22(4):286-287.

5. Butler RJ. Impact of nocturnal enuresis on children and young people. Scand J Urol Nephrol. 2001;35(3):169-176.

6. Goin RP. Nocturnal enuresis in children. Child Care, Health Devel. 1998;24(4):277-288.

7. Hagglof B, et al. Self-esteem in children with nocturnal enuresis and urinary incontinence: improvement of self-esteem after treatment. Eur Urol. 1998;33(Suppl 3):16-19.

8. Redsell SA, Collier J. Bedwetting, behaviour and self-esteem: a review of the literature. Child Care Health Devel. 2001;27(2):149-162.

9. Can G, et al. Child abuse as a result of enuresis. Pediatr Int. 2004;46(1):64-66.

10. Liu X, Sun Z. Age of attaining nocturnal bladder control and adolescent suicidal behavior. J Affect Disord. 2005;87(2-3):281-289.

11. Schober JM, et al. The impact of monosymptomatic nocturnal enuresis on attachment parameters. Scand J Urol Nephrol. 2004;38(1):47-52.

12. Hagglof B, et al. Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence. Scand J Urol Nephrol. 1997;183:79-82.

13. Longstaffe S, et al. Behavioral and self-concept changes after six months of enuresis treatment: a randomized, controlled trial. Pediatrics. 2000;105(4 Pt 2):935-940.

14. Morison MJ, et al. 'You feel helpless, that's exactly it': parents' and young people's control beliefs about bed-wetting and the implications for practice. J Adv Nurs. 2000;31(5):1216-1227.

Penny Noto is a pediatric nurse practitioner who specializes in urology. She has a doctorate in nursing practice and is the director of the pediatric dysfunctional voiding clinic at the Medical College of Georgia in Augusta.

Interventions for Children With Voiding Dysfunction

Dietary modification: eliminate irritants, increase fluid and fiber intake

Behavior modification: gender-specific voiding regimen, relaxation techniques, bowel routine

Gender-specific voiding regimen includes timed voiding, double voiding and spread-leg voiding techniques

Relaxation techniques include pinwheel voiding

Treatment of constipation, including stool softener as appropriate

Bathroom privilege letter for school