0022-534 7/92/1485-1706$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL AssoCIATION, INC.
Vol. 148, 1706-1707, November 1992
Printed in U.S.A.
COMMENTARY: VOIDING DYSFUNCTION AND REFLUX TERRY D. ALLEN From the Children's Medical Center of Dallas, Dallas, Texas
Urination in the neurologically intact individual is a beauti- voiding dysfunction carries a high risk of failure (about 30% in fully coordinated event involving 2 separate and distinct organ our experience) and it is not uncommonly followed by increassystems: 1) the visceral system, represented by the bladder, ing hydronephrosis even when the reflux is successfully corwhich is not under direct voluntary control, and 2) the somatic rected. Fortunately, evidence of voiding dysfunction is usually system, represented by the external urethral sphincter, which not difficult to find if one actually seeks it. The key to diagnosis can be contracted at will. Because of the diverse origins, the lies in the voiding history of the child. Children who make activity of these 2 systems must be !;oordinated at the brain frequent or infrequent trips to the bathroom, exhibit urgency stem rather than at the cord level. Yet, despite its complexity, to the point of incontinence or posturing in an effort to avoid the act of urination appears to be deceptively simple and so it, have lower abdominal cramps, wetness or recurrent infecnatural that only during the last 15 to 20 years has discoordi- tions, or have hydronephrosis or worsening reflux without a nation in voiding been recognized as a clinical entity. 1 • 2 Chil- clear cause are suspect for voiding dysfunction. This informadren with this disorder use the external urethral sphincter to tion can often be obtained only by specific inquiry into the delay or interrupt normal urination because of social or emo- voiding habits of the child and, therefore, it should be discussed tional stresses. The result of such inappropriate activity is the during the interview. A urinary diary, especially when combined development of a form of subvesical obstruction, albeit func- with measurements of voided volume, provides good documentional in nature, which is manifested by a spectrum of findings, tation of the voiding pattern. A diary will not only help to including chronically elevated intraluminal pressures, an un- reveal children with bizarre voiding habits but also families stable bladder, residual urine, recurrent urinary tract infections, that are in such disarray that they cannot even maintain such hydronephrosis, vesicoureteral reflux and renal failure. a record, which is not an inconsequential part of the overall The relationship between dysfunctional voiding and reflux is problem in many of these children. not a casual one. As many as half of the children with voiding Examination of these patients should include palpation of dysfunction have vesicoureteral reflux, and its acquired nature the lower abdomen for a distended bladder, inspection of the is evident in patients of whom earlier films show no reflux at lower back for evidence of a spinal malformation and analysis onset of symptoms. 3 The impact of voiding dysfunction upon of the urinary stream. Boys can be observed voiding into a vesicoureteral reflux is 2-fold. 1) It may be a significant factor container, while girls can be assessed by listening through a in the initiation and perpetuation of reflux. In fact, it may be partially opened bathroom door. In either event, some insight impossible to deal effectively with reflux until proper attention can be obtained into the ability of the child to generate a has been given to the underlying bladder problem. 2) The forceful and continuous stream. This information, when comincreased intraluminal pressure associated with the voiding bined with data relative to residual urine, gives an overall view dysfunction magnifies the potential damage that may result of voiding efficiency. Some fortunate physicians have access to from reflux by providing the force needed to drive the bacteria a flow meter and a sonographic device for estimating residual into the parenchyma, thus converting a relatively harmless urine so that a remarkably clear representation of the condition pyelitis into a devastating pyelonephritis. In any event, no can be obtained noninvasively. When required, additional imeffort to understand the pathophysiology of reflux or to pre- aging of the urinary tract and even formal urodynamic studies scribe treatment is complete without considering the question can be obtained but it is remarkable how much can be learned of voiding dysfunction. with simple tools. It is not easy to determine with certainty how widespread a The treatment of voiding dysfunction is straightforward in phenomenon voiding dysfunction really is, since there is no theory, although it is sometimes difficult in practice. Basically, sharp line of distinction between children with voiding dys- the retentive pattern of holding back the urine and failing to function and normal children learning bladder control. Never- suppress the external urethral sphincter during voiding has to theless, the peak incidence for the clinical presentation of reflux be replaced with that of frequent, relaxed urination with comin children historically occurs at age 3 to 5 years, 4 rather than plete emptying. The child should be sent to the bathroom in infancy as would be expected with a purely congenital approximately every 2 hours during the day and voiding peranomaly. This finding suggests that voiding dysfunction may formance should be monitored by recording in the diary the have a more prominent role in the etiology of reflux than has time of voiding and the volume of urine passed. Most children been appreciated in the past. Although the International Reflux will produce urine at an average rate of about 1 to 2 cc/kg. per Study in Children Planning Committee attempted to exclude hour and a carefully recorded voiding diary may reveal signifivoiding dysfunction to study pure reflux, van Gool et al con- cant variation from that pattern in some cases of dysfunctional ducted a more detailed examination of the children ultimately voiding. When required, anticholinergics can be added to the entered into the study and found evidence of voiding dysfunc- treatment program to counteract involuntary contractions but tion in 18%. 5 Moreover, this subgroup of patients was less likely no medications can replace bladder retraining in the treatment to have reflux resolve spontaneously and more prone to recur- of this condition. Generally, a child who voids every 2 hours rent urinary tract infections. with a continuous, uninterrupted stream and empties the bladGiven the fact that voiding dysfunction exists and that it der completely will maintain the pressure within the urinary may be a significant factor in vesicoureteral reflux, it follows tract at low levels and will exhibit resolution of the abnormal that children with reflux need to be assessed for the presence symptomatology. In addition, in 75% of our children with of this phenomenon. Failure to do so may lead to a management vesicoureteral reflux associated with voiding dysfunction reflux plan that is not only ineffectual but could even be harmful. For resolved as bladder function stabilized. Treatment of voiding example, reimplantation of the ureter in a child with major dysfunction is time-consuming and can be exhausting but if it 1706
are V/Drth the effort
&.s a factor in with another of treatment that can be to that of expectant management antibacterials. f6,rns·c,on,u, has shown that the active treatment of these functional disorders can be a c:::;;;;'.-;.;;·::c:·.Cc·::-:." factor in the outcome of reflux. REFERENCES l. Hinman, F. and Baumann, F. W.: Vesical and ureteral damage from voiding dysfunction in boys without neurologic or obstructive disease. J. Urol., 109: 727, 1973.
A.Hen,
D · The t1on-neurcgenic neurogenic bladder, J, Urol.
1
3. Allen, T. · Vesicoureteral reflux as a manifestation of tional voiding. In: Reflux Edited and P. Kincaid-Smith. New 171-180, 1979. 4. and King, L. R.: Vesicoureteral reflux: history, etiology and conservative management. In: Clinical Pediatric Uro!Og'J. Philadelphia: W. B. Saunders Co., chapt. 11, pp. 342365, 1976. 5. van Gool, J. D., Hjalmas, Tamminen-Miibius, T. and Olbing, complex of dysfunctional voiding, H.: Historical clues to tract infection and vesicoureteral reflux, J. Urol., part 2, 1992.
Vol. 148, 1706-1707, November 1992
Printed in U.S.A.
COMMENTARY: VOIDING DYSFUNCTION AND REFLUX TERRY D. ALLEN From the Children's Medical Center of Dallas, Dallas, Texas
Urination in the neurologically intact individual is a beauti- voiding dysfunction carries a high risk of failure (about 30% in fully coordinated event involving 2 separate and distinct organ our experience) and it is not uncommonly followed by increassystems: 1) the visceral system, represented by the bladder, ing hydronephrosis even when the reflux is successfully corwhich is not under direct voluntary control, and 2) the somatic rected. Fortunately, evidence of voiding dysfunction is usually system, represented by the external urethral sphincter, which not difficult to find if one actually seeks it. The key to diagnosis can be contracted at will. Because of the diverse origins, the lies in the voiding history of the child. Children who make activity of these 2 systems must be !;oordinated at the brain frequent or infrequent trips to the bathroom, exhibit urgency stem rather than at the cord level. Yet, despite its complexity, to the point of incontinence or posturing in an effort to avoid the act of urination appears to be deceptively simple and so it, have lower abdominal cramps, wetness or recurrent infecnatural that only during the last 15 to 20 years has discoordi- tions, or have hydronephrosis or worsening reflux without a nation in voiding been recognized as a clinical entity. 1 • 2 Chil- clear cause are suspect for voiding dysfunction. This informadren with this disorder use the external urethral sphincter to tion can often be obtained only by specific inquiry into the delay or interrupt normal urination because of social or emo- voiding habits of the child and, therefore, it should be discussed tional stresses. The result of such inappropriate activity is the during the interview. A urinary diary, especially when combined development of a form of subvesical obstruction, albeit func- with measurements of voided volume, provides good documentional in nature, which is manifested by a spectrum of findings, tation of the voiding pattern. A diary will not only help to including chronically elevated intraluminal pressures, an un- reveal children with bizarre voiding habits but also families stable bladder, residual urine, recurrent urinary tract infections, that are in such disarray that they cannot even maintain such hydronephrosis, vesicoureteral reflux and renal failure. a record, which is not an inconsequential part of the overall The relationship between dysfunctional voiding and reflux is problem in many of these children. not a casual one. As many as half of the children with voiding Examination of these patients should include palpation of dysfunction have vesicoureteral reflux, and its acquired nature the lower abdomen for a distended bladder, inspection of the is evident in patients of whom earlier films show no reflux at lower back for evidence of a spinal malformation and analysis onset of symptoms. 3 The impact of voiding dysfunction upon of the urinary stream. Boys can be observed voiding into a vesicoureteral reflux is 2-fold. 1) It may be a significant factor container, while girls can be assessed by listening through a in the initiation and perpetuation of reflux. In fact, it may be partially opened bathroom door. In either event, some insight impossible to deal effectively with reflux until proper attention can be obtained into the ability of the child to generate a has been given to the underlying bladder problem. 2) The forceful and continuous stream. This information, when comincreased intraluminal pressure associated with the voiding bined with data relative to residual urine, gives an overall view dysfunction magnifies the potential damage that may result of voiding efficiency. Some fortunate physicians have access to from reflux by providing the force needed to drive the bacteria a flow meter and a sonographic device for estimating residual into the parenchyma, thus converting a relatively harmless urine so that a remarkably clear representation of the condition pyelitis into a devastating pyelonephritis. In any event, no can be obtained noninvasively. When required, additional imeffort to understand the pathophysiology of reflux or to pre- aging of the urinary tract and even formal urodynamic studies scribe treatment is complete without considering the question can be obtained but it is remarkable how much can be learned of voiding dysfunction. with simple tools. It is not easy to determine with certainty how widespread a The treatment of voiding dysfunction is straightforward in phenomenon voiding dysfunction really is, since there is no theory, although it is sometimes difficult in practice. Basically, sharp line of distinction between children with voiding dys- the retentive pattern of holding back the urine and failing to function and normal children learning bladder control. Never- suppress the external urethral sphincter during voiding has to theless, the peak incidence for the clinical presentation of reflux be replaced with that of frequent, relaxed urination with comin children historically occurs at age 3 to 5 years, 4 rather than plete emptying. The child should be sent to the bathroom in infancy as would be expected with a purely congenital approximately every 2 hours during the day and voiding peranomaly. This finding suggests that voiding dysfunction may formance should be monitored by recording in the diary the have a more prominent role in the etiology of reflux than has time of voiding and the volume of urine passed. Most children been appreciated in the past. Although the International Reflux will produce urine at an average rate of about 1 to 2 cc/kg. per Study in Children Planning Committee attempted to exclude hour and a carefully recorded voiding diary may reveal signifivoiding dysfunction to study pure reflux, van Gool et al con- cant variation from that pattern in some cases of dysfunctional ducted a more detailed examination of the children ultimately voiding. When required, anticholinergics can be added to the entered into the study and found evidence of voiding dysfunc- treatment program to counteract involuntary contractions but tion in 18%. 5 Moreover, this subgroup of patients was less likely no medications can replace bladder retraining in the treatment to have reflux resolve spontaneously and more prone to recur- of this condition. Generally, a child who voids every 2 hours rent urinary tract infections. with a continuous, uninterrupted stream and empties the bladGiven the fact that voiding dysfunction exists and that it der completely will maintain the pressure within the urinary may be a significant factor in vesicoureteral reflux, it follows tract at low levels and will exhibit resolution of the abnormal that children with reflux need to be assessed for the presence symptomatology. In addition, in 75% of our children with of this phenomenon. Failure to do so may lead to a management vesicoureteral reflux associated with voiding dysfunction reflux plan that is not only ineffectual but could even be harmful. For resolved as bladder function stabilized. Treatment of voiding example, reimplantation of the ureter in a child with major dysfunction is time-consuming and can be exhausting but if it 1706
are V/Drth the effort
&.s a factor in with another of treatment that can be to that of expectant management antibacterials. f6,rns·c,on,u, has shown that the active treatment of these functional disorders can be a c:::;;;;'.-;.;;·::c:·.Cc·::-:." factor in the outcome of reflux. REFERENCES l. Hinman, F. and Baumann, F. W.: Vesical and ureteral damage from voiding dysfunction in boys without neurologic or obstructive disease. J. Urol., 109: 727, 1973.
A.Hen,
D · The t1on-neurcgenic neurogenic bladder, J, Urol.
1
3. Allen, T. · Vesicoureteral reflux as a manifestation of tional voiding. In: Reflux Edited and P. Kincaid-Smith. New 171-180, 1979. 4. and King, L. R.: Vesicoureteral reflux: history, etiology and conservative management. In: Clinical Pediatric Uro!Og'J. Philadelphia: W. B. Saunders Co., chapt. 11, pp. 342365, 1976. 5. van Gool, J. D., Hjalmas, Tamminen-Miibius, T. and Olbing, complex of dysfunctional voiding, H.: Historical clues to tract infection and vesicoureteral reflux, J. Urol., part 2, 1992.
