Nurse practitioner Lucille Huang, who specializes in pediatric urology, breaks down voiding troubles in kids – a common reason for urological referrals. She explains the relationship between stool and urine elimination, and presents a path to diagnosis – covering anatomical, behavioral and endocrine causes – as well as straightforward treatment steps. Learn when to order imaging and when to refer.
So again, thank you for inviting me again. My name is lucy Oh Hong and I'm one of the nurse practitioners in the urology department at UCSF Benioff. Um So today we're gonna be discussing pediatric bowel bladder dysfunction. So what are the objectives today? Um I would like to define what gallbladder dysfunction is. So I will commonly refer to it today as BBB. Um We're going to hopefully understand the association between bowel bladder dysfunction, urinary tract infections and visible urethral reflux. Um thirdly identify signs and symptoms of gallbladder dysfunction and the management of gallbladder dysfunction. And then also touch base today on the management of recurrent urinary tract infections and also reflux. So firstly I like to go over what is normal avoiding before diving into the abnormal, so normal voiding is um in two phases there is a filling phase and there is a voiding phase. So during filling the bladder muscle is nice and relaxed as it's filling. It's highly compliant, meaning it's elastic and stretchy as it's filling, kind of like a water balloon as it fills up the bladder neck and the sphincter muscles are nice and relaxed and they're closed so we're not leaking the entire time. We're also filling during voiding the bladder muscle contracts and it squeezes in the bladder neck and the sphincter muscles are nice and relaxed to allow for easy passage of europe. Additionally, the bladder capacity increases as the patient grows, thereby allowing for more storage, so more filling as we're older. So what is the definition of bottled water dysfunction? So it is the most common pediatric neurological condition and accounts for about 40 of pediatric urology referrals. Um It is also known as voiding dysfunction and it is the umbrella term to describe abnormalities in filling and emptying of the house and water. There is also about water dysfunction that is related to um neurasthenic causes such as um spina bifida. Um So those are known as androgenic bladders and there is bowel bladder dysfunction that's related to anatomical causes such as bladder outlet conditions, um such as a topic, your orders or obstructions such as um posterior urethral valves. But for the purposes of today's talk, we will be discussing non euro genic, non anatomical causes. And we will also be discussing bowel bladder dysfunction in school age kids and older who are toilet trained. So what is the relationship between 1000 bladder and I really like this picture because um it depicts how the impacted school can cause a mechanical compression of the bladder and of the bladder outlet. So impacted store can cause the true Sir instability which can cause which can cause the Patricia muscle to be overactive. Um So when this Detroit muscle is unstable or um overactive, it can manifest itself as common complaints of water spasms, bladder pain, diarrhea. Um It can manifest itself oftentimes for overactive bladders as urgency frequency. And incontinent um impacted stool can also cause urinary stasis which can lead patients to be at an increased risk for urinary tract infections. Um The mechanical compression of the bladder and the bladder outlet can also decrease sensation of needing to avoid. So that is where a lot of parents and a lot of patients may say that their um their child may not feel that they need to pee or may not feel that they're having an accident. And that is again due to the mechanical compression of the bladder and the bladder outlet. So how is um urinary tract infections and how it is reflux associated with bladder dysfunction? So um al water dysfunction and U. T. I. S. And reflux are highly related um are highly related and they are the highest risk. Kids with gallbladder dysfunction and kids with reflux have the highest risk of recurrent febrile U. T. I. S. So we did discuss earlier that impacted school can cause urinary stasis. So this residual urine is oftentimes associated with your current duties. Um We also discussed that in the filling stage of the avoiding um when there is the true sir instability there is an involuntary water contraction and this involuntary water contraction can cause reflux during the filling stage. Um The other way uh The other thing that we've noticed that um U. T. S. And reflux are associated with B. B. D. Is um from a high pressure avoiding with contracted sphincter. So the image on the right is an image is a Euro dynamic image. Um And I think this image depicts the association of U. T. I. Reflux and BBD very well, specifically highlighting that last point. So this patient had presented with urgency, frequency and continents and frequent urination. And she had this patient um was not responding very well to initial management. So we performed Euro dynamics to further assess the bladder function and um and investigate the bladder further. So on this image, you can see here that at the bottom, at the base of the, at the base of the bladder, uh there is a spinning top urethra appearance and this and this occurs when the sphincter muscle is also contracted during the voiding phase. Um This photo was taken during the voiding phase of Euro dynamics and you can see her, the bladder is nice and full. Um So with the spinning top urethra appearance with the contracting, it is also with the contracting and with the bladder contracting as well. You can see here the bladder margins and the bladder wall are jagged versus mason smooth, which is typically what the Detroit muscle with the bladder muscle is. So you can see here it's kind of jagged and try speculated and thereby it's it is occurring due to the contraction of the sphincter and the contraction of the bladder muscle, thereby causing this high pressure. So this high pressure than you can act as a pop off valve causing reflux. And it may be difficult to see but there is reflux into this here. Right to stole your order here. So hopefully um I understand being the um By understanding the relationship between the bladder and the ball, we can see how certain symptoms are related to about bladder dysfunction. So one of the common um these are some of the common um concerns and complaints that we get from patients. So first being to syria, which is defined as the burning or discomfort during voiding. So when there is the true story instability or an overactive bladder that can cause bladder spasms and bladder pain. And oftentimes kids may complain that they have um this curious or painful urination due to those bladder spasms. Um From an overactive bladder, we can see urgency frequency. Uh we can see incontinence, urgency frequency being voiding eight or more times during the day, urgency being the sudden or immediate urge and the need to avoid incontinence being the uncontrolled leakage of urine. Um There's also, we often see hesitancy. So the difficulty in initiating a urine stream. We can see straining where patients will need to physically use their abdominal muscles and push in order to pete. Well we see voiding postponement with Children delaying urination. Many Children withholding their urine or avoiding infrequently during the day. So oftentimes patients may say they avoid two or three times a day, or they may also have um daytime and continents. So along the lines, avoiding postponement, there is that um along the lines of avoiding postponement is also constipation, which is the delayed elimination of stool. And also we may see incorporates is the leakage of stool. So these symptoms sound very similar to urinary tract infections. So how do we differentiate between urinary tract infection symptoms and gallbladder dysfunction symptoms? Um So we can first um we can first order a your analysis and urine culture that helps us to rule out a urine infection. So if the urine culture is negative and patients have these symptoms, it is likely associated with bowel bladder dysfunction. If the urine culture is positive, we will treat the acute urinary tract infection. However, if these patients continue to present with these recurrent symptoms um or have recurrent U. T. I. S. It is important to think of any underlying bowel bladder dysfunction that they may have and to treat their underlying bowel bladder dysfunction. So um the good news is that um the treatment the initial treatment or bowel bladder dysfunction symptoms for recurrent U. T. S. Is the same. We all start with bowel bladder management. Um bowel bladder management is also important in preventing further U. T. I. S. So yeah we um so in evaluating um about bladder dysfunction we start with history physical exam. We may do some imaging and we may also do um to your analysis. Uh this also helps to rule out the other types of wild water dysfunction that was mentioned including anatomical or more organic causes. So I like to break down the history by the symptoms applications present. So, um I first off starting with the bows. Um it's important to ask how frequently does the patient have a bowel movement per day? What is the consistency of the school like? Is it hard? Is it soft? Is there any school leaking? Are there any streak marks to the underwear? Um Does the school plug the toilet? So are are these patients having one big one big stool because they're impacted and therefore it's clogging the toilet? Is there any associated pain or straining? Are they having a difficult time getting the bowel movement out? All of this can point to broader dysfunction or some degree of constipation? Yeah. So next urgency frequency, um we often ask how often is it occurring? Does it occur overnight? And if they do answer yes, that it does occur overnight. We do need to be thinking about other causes such as diabetes mellitus or diabetes insipid this and getting a simple your analysis can typically rule that out. Um Usually these kids may also say that they don't pee very much so, asking what the volume of the urine output is. Um Is there a sudden rush in and need to go to the bathroom? Do they feel they need to go and immediately have to run their otherwise they're going to have an accident? Those are common things that families um And patients will say and those are all good um Good things to know because again, it can scare us away from a neurasthenic cause or a diabetic related cause of their urgency frequency. Um In terms of this area, um Sometimes patients may complain that it occurs when they're not avoiding. So that may lead us to think of bladder spasms that are just occurring throughout the day. Um, When is it happening? Is it happening prior to avoiding? During voiding or after avoiding? Um When is it worse? This pain in the urine stream? If it's before avoiding, are their bladder spasms that are happening? Are the patient is the patient with holding urine thereby making the bladder spasms worse? Um, if it's during or post could be related to that the true sir instability that we had discussed where the bladder is contracting and if it's unstable that can that contraction um that pain is worse as the bladder muscle is contracting and then after avoiding while the bladder is recovering. If there's still any um instability or over activity of that bladder that can be felt after avoiding. So knowing where in the stream sometimes is also helpful and the location where is this pain? Um Oftentimes boys will complain of penile pain and it is this referred pain at the base of the bladder usually um That is associated with that the truce or instability with that over activity. And those bladder spasms. So incontinence um Typically we like to know how, what um is it just a couple of spots to their underwear? Is their entire underwear wet? Is it all the way out to their pants? Um How what um Is there is there any um is there any dry period or is the underwear always wet? Are they wet a time? Night time or they wet the entire time? All of this is important because if their wedding all the time and their underwear is always damp, it can help us decide whether or not there's an anatomical costs such as an ectopic ureter, which can contribute to always damp clothing that occurs day and night. Um Knowing how often they avoid, if there are withholding maneuvers, are they, are they waiting until the last minute to p are they not paying frequently? Um, That can all contribute to incontinence as the bladder fills and if we're not empty that can overflow and cause and continents. Yeah, so urinary tract infections. So it is important to know if they've had federal ups or non purple ups and that gives us a good idea as to whether there is any kidney involvement and presumably any sort of reflux. So we typically like to ask what are their usual presenting symptoms for you? T do they have syria, urgency, frequency? He, materia and continents. Those uh, those symptoms typically are more of a lower tract infections, so more localized to the bladder, whereas more systemic symptoms including fever, nausea, vomiting, chills and flank pain tend to lead us to think more of an upper tract, some more kidney involvement. Um So distinguishing between the two is important to know whether there's kidney involvement and presumably if there's any reflux. Um And then some other common symptoms that we usually get from families are smelling p foul smelling P. Um strong smelling p dark colored p cloudy P. Um In the absence of any urinary other urinary symptoms or systemic symptoms, these are usually not indicative of the urine infection. Um smelly P can come from vaginal voiding. So as the urine reflux is up into the vagina, it bacteria can colonize the vagina and cause an odor, thereby giving that foul smelling urine to the odor. Dark colored urine and cloudy urine. Again, in the absence of any other symptoms typically resolves with increased fluids and increased urination. And then sometimes patients are asymptomatic but have a positive urine culture, which represents a asymptomatic back to your area. And so represents some sort of colonization. And again for these symptoms, we typically hold off on testing and hold off on antibiotics and try about bladder Dysfunction Treatment 1st. That way we are being judicious with antibiotic use in preventing any further antibiotic resistance. So physical exam, um physical exam is an important part of the evaluation as well. So we do an abdominal exam palpitating for any school palpitating for potentially a distended bladder. If the butter is distended, potentially the patient is withholding or not urinating very frequently. We also do a back exam looking for asymmetric rodeo folds, any concerning, say, growth pimples or hair Tufts. Again, that may lead us to think potentially there is a neurasthenic cause and what we would consider doing an MRI of the spine looking for any more a genic conditions and referral and potentially a referral to see another specialist. Um On the genital exam we're looking for any for the anatomical positioning, Is everything in the correct place? Uh We're looking at the underwear to see if there's any moisture. Is there any um stool leakage? Is there any ST marks that make uh make us think of some angkor praecis that is there? Um We're looking to see if there's any pulling of urine in the vagina and the penis. If there is pulling in the vagina that leads us to think maybe there's some vaginal avoiding that may be contributing to incontinence. Is there any associated a fema? Is there any vaginal coitus? Again that may be contributing to some complaints of this serious. So the the exam certainly helps in um differentiating between gallbladder, the different types of gallbladder dysfunction and may give us a better idea as to where their complaints are coming are coming from. And the other thing, are there any labial adhesions? Um is it obstructing the urethra and that may be causing some urine polling and potentially some recurrent U. T. I. S. So steps to management. Um So we typically manage gallbladder dysfunction in a stepwise way. And the reason we do that is because Bells can cause a time urinary symptoms which can then cause nighttime urinary symptoms. So we go in this stuff wise ways because if the balls are optimized for the daytime urinary symptoms are optimized them, everything downstream may get better on its own. So we always start with um we always start in a stepwise manner, starting with bowel management first. So um what is our management? So we always start with a clean out and after the cleanup will do a maintenance dose of some sort of oxidative. Um So for the clean out, typically we consider uh we choose to clean out Based on the patient's weight based on school burden based on also tolerance of medication. So for patients less than £45 or who are younger, we may start with a seven capital me relax clean out into 30, mixed into 32 oz of electrolytes. For older patients or patients who weigh £45 or more, we may do a 14 capital may relax clean out in 64 ounces of electrolyte. Uh for younger patients or patients who can't tolerate such a high volume, we may do one cap full of me, relax three times a day for three days. And alternatively, for patients who don't tolerate me, relax very well. We made you magnesium citrate 100 and 50 millimeters or 300 million liters once a day For 1-2 days. So once they're cleaned out, we want to maintain that state for them. So we typically will put them on a maintenance dose of some sort of laxative in our first choice is usually me relax and we do one cap full of me relax and eight ounces of fluids and we'll have the parents titrate. The mirror lacks does seem in order to produce daily soft bowel movements. Alternatively, we may use actuals or set up depending on the tolerance of their locks. So the goal of our management is to have types four and five bowel movements once to twice a day every day. Uh huh. So bladder management. So we know that bladder dysfunction can come in the form of overactive bladders. The truth or instability and continents withholding. So we encourage patients to pee every two hours. The reason we say every two hours is because the bladder typically fills up in two hours and it gets full in two hours. So when it's full, we ask that the patients go and either bladder, we also encourage double void, so avoiding twice each time. This way it ensures that we are emptying our bladder that we're getting rid of any bladder residual. Um We also ask girls especially to do lower, like abduction voids if there's um any vaginal avoiding as well. And so that involves sitting on the toilet with their legs apart or sometimes even sitting backwards on the toilet. That way it prevents the back flow of urine into the vagina, which can cause that vaginal avoiding, which may contribute to some incontinence. Um We also know that bladder dysfunction can come in the form of over over activity of the bladder and also contraction of the sphincter muscle. So we encourage patients to practice relaxation techniques in order to relax the pelvic floor. And that may include taking a book in or taking a tablet in to distract their mind. So they're not tensing up their sphincter muscle and causing that contraction of this finger as they're trying to pee. Um We also ask patients to take their time to avoid to ensure that they're empty and to also push fluids and increase fluids so that again, um it helps them to avoid and helps that broader to cycle every two hours. So um we may also sometimes order labs. Uh this is especially important for patients with complaints of urgency frequency, especially that a per day and night. Um It's important to rule out any diabetes myelitis or diabetes insipid tous. And again, given that the symptoms of urinary tract infections and bowel bladder dysfunction are so mostly related and similar. Um It's also good to get it to rule out urine infection as well. So imaging some of the imaging that we do um may consist of a K. U. B. And this is to evaluate um the school burden. It can help determine whether the initial school burden and what type of file cleanup they may need. It may also be helpful, let's say for patients who are not responding to bowel bladder dysfunction treatment. Um Getting an X ray to evaluate the stool burden can let us know whether or not their bowels are actually optimized and whether or not maybe another clean out would be um would be helpful. We also consider ordering renal blood or ultrasounds. And this is especially recommended for any patient who has had a urine infection in the past to evaluate their kidneys and see if there's been any renal scarring or renal damage. Any rational length discrepancy that again may um may lead us to, which may um help in our management and to see if there's been any damage to the kidney from any during infections. Um it also helps to rule out any anatomical ideologies, such as an ectopic yarder. Um We use it to assess any hydro necrosis, which again may help us in our determination of any reflux or potentially even chronic bowel bladder dysfunction. Um if we can assess for post void residuals. So again, how well is that patient avoiding? Are they able to empty if they're unable to empty? Is that contributing to their urinary symptoms? And then also to take a look at the bladder appearance. How does the bladder wall look, does the blotter look normal? All of those things are important in helping us manage and um diagnosed gallbladder dysfunction. So this is from a patient who has been having a chronic constipation and also in Capri since. And uh this patient has been on a daily battle regiment with persistence of his of their symptoms. So on the left is a is the X ray imaging of the school burden prior to a clean out. And so the radiologist reading of this was that there was a large store burden with colonic distention, so this kid is quite impacted. Um So we had recommended a bowel clean out for two days. So on the right is the picture of the house um soon after about clean out and the radiology rating of this particular image is that there's decreased school burden. Um So I I like this photo because it highlights how about clean out is helpful and the difference that it makes, it also helps um because um we want to start with about clean out in our initial management. Um Because if we just start with a maintenance dose with an impacted with an impacted um rectum and an impacted colon, like in the left picture, a maintenance dose isn't really going to be very helpful in kids with constipation and or ankle praecis. It may soften some of the stool but not all of the stool. And so that stool that softened that's liquefied may travel around the stool that's impacted there and further cause any worsening of their ankle presses or common commonly also may have some lost uh loose stool or very serious soft stool or diarrhea. Those are some common complaints and that made it ear uh um that may cause parents or families to not want to continue with about management. So we typically like to start off with about clean out to clean everything out and kind of start you and start fresh and then put them on a maintenance dose to maintain that cleaned out state for them. So this is a rain of bladder ultrasound that was done for a patient who had urgency frequency and hesitancy. So on this particular ultrasound, the kidneys were normal um and I didn't show that here, but on the left is the bladder prior to avoiding. So there was about 140 CCs in the bladder. And then the patient voided. And on the right is the picture after the patient voided. So there was still about 86 CCS left. And so this um this residual likely contributed to the patient's urgency frequency because the bladder is not completely empty. And if the if the patient is staying hydrated, that bladder is going to fill up a lot faster sooner than every two hours, thereby contributing to that urgency frequency. There's also some mild mild bladder wall thickening and that can be related to the over activity of the bladder muscle, um over activity of the bladder muscle, um That is causing some hypertrophy of the bladder or muscle and thereby giving it that mildly thickened bladder wall appearance and that can be associated with sort of prolonged about bladder dysfunction. But um we may also need to be thinking about other causes. But again, given that this patient has about water dysfunction, we want to manage the bladder and get it relaxed with that. Hopefully that mildly thickened bladder wall appearance is no longer there on repeat ultrasound. So um management of infections and reflux typically starts with BBB management and we want to optimize BBB first because that may help to resolve reflux, Especially low grade reflux. Um So grades one and two. The bowl of management is to prevent any sort of renal scarring and any sort of renal damage. So it's important to prevent infections. Um It's also important to optimize the bladder um for for surgical repair so that surgery is successful. So some of the surgeries that are performed is D. Flux or a readable re implantation. And it's important to first optimize the bladder to ensure that it's not high pressure because if it's high pressure that can cause a pop off belt and that can cause the surgery to be unsuccessful were not as successful. Um Other considerations include using um antibiotic prophylaxis. Um We know that antibiotic prophylaxis do decrease and help prevent recurrent febrile U. T. I. S. So it is um an important consideration to take, especially for kids who have high grade reflux. So grades 34 and five kids who are working on optimizing their bowel bladder dysfunction and any patient who may not be able to verbalize their symptoms. This is a good option for them. Um Are drug of choice is usually nitro for in tone 1 to 2 mics per kick Or Bactrim based on trying to print 1- two. Mixed Arcade as well. Okay so the other thing that we can consider doing is also a BCG to evaluate for reflux. We may get an initial VCU. G. If a patient presents with abnormal findings on the ultrasound and our current U. T. I. S. Or breakthrough U. T. I. S. And then repeating the V. C. U. G. To see if the bell blogger dysfunction management is working. Um So that's also something to consider when managing U. T. I. S. And reflux. So let's say we've um started initial bob water management. Um What are some additional tools that we can use if let's say the patient is not responding very well. So one of the things that we can consider is a voiding diary and this is a good diagnostic pool to determine if there's any over activity of the bladder. And if there is we may consider starting something like an antique or allergic. The trumpian dosed at 0.1 to 0.2 mics per kick per dose twice to three times a day. It is important to also review side effects of the medication including most commonly constipation, dry mouth or any facial flushing. Um Something else that we can also do is Euro flow, So we do have a Euro flow machine in our bowel bladder dysfunction clinic and that helps us to see how the patient is avoiding and gives us a curve to further diagnose how they're avoiding pattern is and what sort of treatment would be helpful. The other thing is biofeedback which helps with any kids who are not responding very well to initial bowel bladder dysfunction treatment who may have contraction of the bladder and contraction of the pelvic floor muscles. And biofeedback helps kids to learn to coordinate those muscles while while the bladder is filling and while they're avoiding. So those are additional management tools that we can use. So when to refer, please refer any time. We are happy to see um Any patients uh please refer if you uh if you want an initial consultation for potentially about bladder dysfunction management and treatment. Um if the patient persists to have managed our gallbladder dysfunction symptoms um if there's any add more abnormalities on the reign of bladder ultrasound, all of those things should be referred. And we do have telehealth available as well, to which a lot of our kids um with gallbladder dysfunction, we do see on telehealth, and they do really like so telehealth is available.