Urotherapy in children: Quantitative measurements of daytime urinary incontinence before and after treatment: According to the new definitions of the International Children’s Continence Society

doi:10.1016/j.jpurol.2010.03.010

Journal of Pediatric Urology

Volume 7, Issue 2, April 2011, Pages 213-218

https://doi.org/10.1016/j.jpurol.2010.03.010 Get rights and content

Abstract

Objective

To assess the effectiveness of urotherapy in children with lower urinary tract dysfunction, according to the new definitions of the International Children’s Continence Society.

Material and methods

We performed a retrospective review of 122 children (aged 8.8 ± 2.0 years) treated in an outpatient program for lower urinary tract dysfunction. Exclusion criteria included all neurologic abnormalities. In 98 children (80%) daytime urinary incontinence was a predominant symptom. Therapy consisted of an individually adapted drinking and voiding schedule, pelvic floor relaxation, instructions on toilet behavior, biofeedback uroflowmetry and if necessary recommendations for regulation of defecation. Before and at the end of training, patients were evaluated for number and severity of daytime wet accidents per week, using a scoring system to grade the severity of incontinence. Secondary measurements of accompanying voiding symptoms were performed.

Results

Of the 90 children with daytime urinary incontinence for whom sufficient objective data were collected, 42% became completely dry during the daytime and 36% showed a 50% or greater level of response. Secondary measurements showed a significant reduction in daily voiding frequency (mean 7.0 ± 1.3, P < 0.0001) and mean post-void residual (P < 0.003), and an improvement in flow pattern (P < 0.05).

Conclusions

Urotherapy is successful for the treatment of daytime urinary incontinence in children. Additional benefit was evident in improvement of accompanying voiding symptoms. A combination of the definitions of the International Children’s Continence Society and a scoring system to grade severity improved the evaluation method. Further research into long-term efficacy will be performed.

Introduction

Toilet training is not automatic for every child. Up to 10% of 5–6 year olds experience daytime urinary incontinence. The prevalence decreases with increasing age to 4% in 12–18 year olds [1]. Daytime urinary incontinence can cause major stress in school-age children and can have a negative impact upon a child’s self-esteem [2]. It is desirable to identify and take care of children with daytime urinary incontinence as early as possible.

Since 1996, children in our clinic have been treated with urotherapy according to a special outpatient clinic protocol [3]. This protocol is the result of a multidisciplinary collaboration between the departments of pediatric urology, pediatric physiotherapy and medical psychology. At first, children were treated intuitively and without any protocol. Later on, some fundamental principles of other protocols were enrolled [4]. The resulting therapy is based on the remedy of daytime urinary incontinence, regulation of fluid intake and voiding frequency, increase of maximum voided volume once a normal voiding pattern has been obtained, and treatment of constipation if necessary. Alongside this training setting run by nurse specialists, there is easy access to and cooperation with pediatric physiotherapy and medical psychology. In our practice, urotherapy is reserved for children with functional voiding symptoms; namely, persistent daytime urinary incontinence, urgency and recurrent urinary tract infections (UTIs), despite adequate conservative management, pharmacotherapy and/or surgical interventions.

Different terms are used in the literature, such as bladder training, pelvic floor therapy, urotherapy, behavioral therapy and bladder rehabilitation [4], [5], [6], [7], for non-invasive training programs treating children with lower urinary tract (LUT) dysfunction. The aim of these interventions is to teach children to perform regular, complete emptying of the urinary bladder, and this can be considered as a systematic learning process in which physical reactions are brought under conscious control [8]. No controlled clinical trials have been conducted to study quantitatively the effectiveness of these approaches.

Retrospective studies have indicated improvement in daytime wetting symptoms in 75%–90% of children with complete dryness rates of 51%–82% [5], [6], [9], [10]. Because of the use of differing terminology, definitions, and methods of urotherapy, from outpatient training to an intensive inpatient 10-day course, is it difficult to compare current studies.

In 2006, the International Children’s Continence Society (ICCS) published a report with new definitions and a standardized terminology. Its main use will be in a research setting, where adherence to the same terminology will make it easier to compare studies and decrease confusion among researchers. There is also a lack of consensus among experts on the definition of successful treatment for LUT dysfunction; therefore, the ICCS made some recommendations regarding urotherapy [11].

In accordance with the new definitions of the ICCS, we decided to assess retrospectively the effectiveness of urotherapy in children with LUT dysfunction treated in our hospital using an outpatient clinic protocol, and to add a scoring system to grade the severity.

Section snippets

Patients and methods

Definitions used within this study conform to the standards recommended by the ICCS [11] except where specifically noted.

A retrospective study was accomplished of a group of 122 children who participated in the training program between April 1999 and June 2008. The group consisted of 49 boys and 73 girls varying in age between 5 and 14 years (8.8 ± 2.0). All children were referred to the pediatric urologist with a longer period of existing complaints of the LUT. Table 1 shows the inclusion

Results

Of the 122 children included in our study, daytime urinary incontinence was in 98 (80%) a predominant symptom. Of these 98 children, 72 (75%) also had nocturnal enuresis. Of the remaining 24 children, 14 had nocturnal enuresis only and 10 children were continent. Fifty-five children (45%) had a prior history of recurrent UTIs. In 32% signs of constipation were evident. Urodynamic studies showed that detrusor overactivity during filling was the most common filling-phase dysfunction (35%). A

Discussion

Urotherapy is an important tool in the treatment of idiopathic LUT dysfunction in children. Our study indicates improvement in daytime urinary incontinence in 78% of the children at the end of the training, with a complete dryness rate of 42%. Many previous studies suggest that urotherapy is useful in the treatment of LUT dysfunction [5], [6], [10], [12], [13], [14] and the present study supports this.

In our study we used the terminology of the ICCS [11] to make it easier to compare future

Conclusion

Urotherapy was shown to be successful for the treatment of daytime urinary incontinence in up to 78% of children. The majority of patients experienced an improvement of symptoms. Additional benefit was evident in the improvement of other voiding symptoms such as voiding frequency, flow pattern and PVR urine volume. Combined use of the definitions of the ICCS and a scoring system to grade the severity of incontinence may improve evaluation methods and enable comparison between future studies.

Conflict of interest/funding

None.

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Cited by (41)

Incontinence training in children with cerebral palsy: A prospective controlled trial
2022, Journal of Pediatric Urology
Urinary incontinence is the most frequently observed lower urinary tract symptom in children with cerebral palsy (CP). Being continent can positively influence quality of life of the child and the social environment.
To investigate the effectiveness of incontinence training with urotherapy in children with CP.
A population-based case-control study was conducted including 21 children with CP and 24 typically developing children between 5 and 12 years old, both with daytime incontinence or combined daytime incontinence and enuresis.
Children received treatment for one year with three-monthly examination by means of uroflowmetry, a structured questionnaire and bladder diaries. Children started with three months of standard urotherapy. After three, six and nine months of training, specific urotherapy interventions (pelvic floor muscle training with biofeedback, alarm treatment or neuromodulation) and/or pharmacotherapy could be added to the initial treatment. Therapy was individualized to probable underlying conditions.
Effectiveness was controlled for spontaneous improvement due to maturation and analysed by means of longitudinal linear models, generalized estimating equations and multilevel cumulative odds models. Comparison with typically developing children was assessed by means of Kaplan–Meier survival analysis.
Results suggest effectivity rate of incontinence training is lower and changes occur more slowly in time in children with CP compared to typically developing children (Figure).
Within the group of children with CP, significant changes during one year of training were found for daytime incontinence (p < 0.001), frequency of daytime incontinence (p = 0.002), frequency of enuresis (p = 0.048), storage symptoms (p = 0.011), correct toilet posture (p = 0.034) and fecal incontinence (p = 0.026).
Maximum voided volume and fluid intake at the start of training were significantly lower in children with CP and could explain a delayed effectiveness of urotherapy. Treatment of constipation demonstrated a positive effect on maximum voided volume and should be initiated together with standard urotherapy when constipation is still present after implementation of a correct fluid intake schedule. Future research with a larger sample size is recommended.
Incontinence training with urotherapy can be an effective treatment for urinary incontinence in children with cerebral palsy. In the current cohort, effectivity rate of incontinence training was lower and changes occurred more slowly in children with cerebral palsy compared to typically developing children.
Long-term functional and psychosocial outcome in adolescents and young adults treated for lower urinary tract dysfunction in childhood
2021, Journal of Pediatric Urology
Citation Excerpt :
Urodynamic studies were done if indicated. Since 1996, two trained nurse specialists have provided treatment in our clinic according to an outpatient clinical protocol in line with current standardized documents [13,14]. Since ICCS's definitions were first published in 2006, retrospective chart analyses was performed to determine the type of LUTD of all former patients, including those treated before 2006.
Lower urinary tract dysfunction (LUTD) in childhood might affect lower urinary tract function and psychological wellbeing later in life. This study presents long-term functional outcome, psychological outcome and quality of life (QOL) of adolescents and young adults treated for childhood LUTD compared to healthy age-matched controls. In addition, association with past treatment outcomes is evaluated.
A single-centre cross-sectional study of former patients treated in childhood (currently 16–26 years old) was conducted. Participants completed a survey composed from validated questionnaires: the Overactive Bladder Questionnaire, the Hospital Anxiety and Depression Scale, the Pediatric Quality of Life Inventory and the Short Form 36 Health Survey.
Fifty-two former patients (out of 133) agreed to participate and returned the survey (mean age 21 ± 4.1 years). Sixty-nine control subjects were included (mean age 21 ± 2.9 years). Urinary tract symptoms were more common in former patients than controls. Storage symptoms more frequently reported were (urge) urinary incontinence, stress urinary incontinence (SUI) and nocturia. Voiding symptoms more frequently reported were intermittency and feeling of incomplete emptying, Fig. 1. There were no differences in urinary tract symptoms or urinary incontinence subdivided by childhood treatment outcome (complete response, partial response or no response), respectively p = 0.17 and p = 0.58. Results of the overactive bladder questionnaire revealed higher urinary symptom bother scores (score 14 versus 5 p < 0.01) and lower disease-specific QOL (score 95 versus 98 p = 0.02) in former patients compared to controls. General QOL and psychosocial wellbeing were not significantly different between the two groups. A childhood treatment duration extending 2,5 years was an independent prognostic factor for subsequent urinary tract symptoms later in life (OR = 1.5, 95% CI 1.1–2.0). Psychological comorbidity was more often present in former patients (35%) versus controls (10%), p < 0.01.
Adolescents and young adults treated for childhood LUTD are more prone to report urinary tract symptoms later in life, especially if treatment duration was extensive. However general QOL and psychosocial wellbeing later in life are not or only mildly affected.
The long-term added value of voiding school for children with refractory non-neurogenic overactive bladder: an inpatient bladder rehabilitation program
2020, Journal of Pediatric Urology
Despite adequate management, 20% of children with overactive bladder (OAB) syndrome fail to improve their bladder function. To approach the need for alternative strategies, an inpatient bladder rehabilitation ‘voiding school’ program was established.
The objective of this study was to evaluate the short- and long-term (1-year follow-up) outcome of this voiding school program in children with refractory OAB. In addition, the authors aimed to identify which children achieved the best outcomes with this voiding school program.
The charts of all children (n = 357, mean age: 9.7 ± 2.0 years, 63.6% boys) with refractory OAB who attended voiding school between 2000 and 2010 were reviewed. A linear mixed model with random intercept was used to evaluate the incontinence (expressed by enuresis and daytime incontinence voiding scores) and maximal voiding volume (MVV).
This study demonstrated an overall beneficial long-term effect of the inpatient program on day- and night-time incontinence, in which 36.6% of children achieved dryness during day- and night-time. In addition, the mean overall decline in the number of wet nights and days declined with 4 extra dry days and/or nights per week, in comparison with the level of continence before attending the voiding school program.
In contrast, only a temporary increase in MVV was seen, however, without relapse incontinence. At last, the authors identified the negative impact of decreasing age, male sex, dysfunctional voiding and nocturnal polyuria on the overall outcome of the inpatient program.
An inpatient rehabilitation ‘voiding school’ program is a successful and safe treatment modality for children with refractory OAB that results in long-term significant increase of continence, as well as amelioration in degree of severity. The worst outcomes of this voiding school program were detected in children with young age, who were boys, or had associated nocturnal polyuria, dysfunctional voiding, and/or faecal incontinence.
Voiding school as a treatment for daytime incontinence or enuresis: Assessing the effectiveness of intervention by measuring changes in wetting episodes
2018, Journal of Pediatric Urology
Most urotherapy interventions are planned for children with daytime incontinence or symptoms, and are based on individual education. This study conducted a voiding school (VS) program with groups of 4–6 children with daytime incontinence or enuresis with or without daytime symptoms.
The aim of this quasi-experimental study with a one-group pretest–posttest design was to assess the effectiveness of the VS intervention for treating children's daytime incontinence or enuresis.
Sixty-nine 6–12-year-old children with incontinence classified as treatment resistant participated in the VS at an outpatient clinic. Based on a power analysis, a sample of 52 participants was required. The VS involved two whole-day group visits 2 months apart. The educational content of the intervention was based on the International Children's Continence Society's standards for urotherapy, and was delivered with child-oriented teaching methods, including group discussions with peers. The primary outcome measure was the number of dry days and nights. The amount of wetting was also estimated, and the frequency of voiding measured. Data were collected with 1-week voiding diaries before and after each visit. Changes in dependent variables between four measurement points was measured by using repeated measures variance analysis. The long-term effectiveness was evaluated from patient records concerning 3-month follow-up phone calls or other contacts 8–18 months after the VS.
Fifty-eight children, 34 girls and 24 boys, completed the study. Twelve children had daytime incontinence, 18 had enuresis, and 28 had both. The number of dry days increased from a mean of 3.5–5.3 (P < 0.001), and the number of dry nights increased from a mean of 2.4–3.9 (P < 0.001) (Summary table). Thirteen (22%) children became completely dry. Three of them had daytime incontinence, five enuresis, and five both. Twenty-four out of 40 (60%) children with daytime incontinence, and 23 out of 46 (50%) children with enuresis showed ≥50% decrease in wetting episodes. The amount of wetting reduced, but the voiding frequency remained unchanged based on the voiding diaries. Twenty-two (45%) of the children were completely dry (six had daytime incontinence, nine enuresis, and seven both), and 16 (39%) showed further improvement, but eight (16%) children remained unchanged 8–18 months after the VS.
Voiding school (VS) was an effective intervention for treating both daytime incontinence and nocturnal enuresis in children who had not benefited from standard treatment and were classified as treatment resistant.
Bladder Training Video versus Standard Urotherapy for Bladder and Bowel Dysfunction: A Noninferiority Randomized, Controlled Trial
2017, Journal of Urology
Citation Excerpt :
Although evidence has shown that SU delivered through direct, 1-on-1 contact between the clinician and the child/family represents an effective way of managing BBD symptoms regardless of the delivery mode,10 the optimal followup to determine success after urotherapy is still debatable, ranging from 3 to 12 months.8,18 We have found that although mean symptomology scores in our patients significantly improved at the last followup visit, they remained greater than 11, indicating ongoing BBD as reported by others.8,18–20 Our relatively short followup of 3 months may not have been long enough to allow for definitive implementation of behavioral strategies, long-lasting management of constipation or a full benefit from pharmacological therapy when required.
We evaluated whether an animated bladder training video was as effective as standard individual urotherapy in improving bladder/bowel symptoms.
Patients 5 to 10 years old who scored greater than 11 on the bladder/bowel Vancouver questionnaire were included in a noninferiority randomized, controlled trial. Children with vesicoureteral reflux, neuropathic bladder, learning disabilities, recent urotherapy or primary nocturnal enuresis were excluded from analysis. Patients were randomly assigned to receive standard urotherapy or watch a bladder training video in clinic using centralized blocked randomization schemes. Bladder/bowel symptoms were evaluated at baseline and 3-month followup by intent to treat analysis. A sample size of 150 patients ensured a 3.5 difference in mean symptomology scores between the groups, which was accepted as the noninferiority margin.
Of 539 screened patients 173 (37%) were eligible for study and 150 enrolled. A total of 143 patients (95%) completed the trial, 5 (4%) were lost to followup and 2 (1%) withdrew. Baseline characteristics were similar between the groups. Baseline mean ± SD symptomology scores were 19.9 ± 5.5 for the bladder training video and 19.7 ± 6.0 for standard urotherapy. At 3 months the mean symptomology scores for the bladder training video and standard urotherapy were reduced to 14.4 ± 6.5 and 13.8 ± 6.0, respectively (p = 0.54). The mean difference was 0.6 (95% CI –1.4–2.6). The upper 95% CI limit of 2.6 did not exceed the preset 3.5 noninferiority margin.
The bladder training video was not inferior to standard urotherapy in reducing bladder/bowel symptoms in children 5 to 10 years old. The video allows families to have free access to independently review bladder training concepts as often as necessary.
Postvoidal residual urine is the most significant non-invasive diagnostic test to predict the treatment outcome in children with non-neurogenic lower urinary tract dysfunction
2016, Journal of Pediatric Urology
Citation Excerpt :
In their retrospective series of 122 patients, Mulders et al. grouped their patients as 5–8 years and 9–16 years of age. Their results showed similar response rates; however, the full response rate was significantly higher in the older patient group [13]. This could be attributed to better compliance to treatment in older children.
Uroflowmetry (UF) alone is often inadequate or unreliable to diagnose lower urinary tract dysfunction (LUTD). Therefore, other non-invasive tests, such as ultrasound (US), post-voiding residual volume (PVR) assessment and symptom scales, are used as well for objective definition of the problem.
The aim of this study was to investigate the possible predictive function of the non-invasive diagnostic tests for the response to treatment.
The prospective registry data of 240 patients with LUTD, from November 2006 to September 2013, were retrospectively analyzed. All patients were aged 5–14 years old. Patients with a previous diagnosis of vesicoureteral reflux (VUR), neurogenic bladder, monosymptomatic nocturnal enuresis (NE) were excluded from the study. Uroflowmetry, US, PVR and the Dysfunctional Voiding and Incontinence Symptom Scale (DVISS) were performed on every patient at their first visit and follow-ups. A DVISS <9 was considered as the DVISS response; parental opinion was based on International Continence Society criteria of clinical response. Time passed until clinical response was the last outcome parameter.
Mean age was 8.2 years. Median follow-up was 60.5 months. A total of 62% of patients had complete response, 28.1% had partial response, and 9.7% had no response. Demographic variables were not associated with clinical outcome. Co-existing enuresis nocturna, multiple pharmacotherapy, and increased DVISS were associated with longer time until clinical response. Post-voiding residual volume assessment was the only test to have a prognostic value.
Resolution rates of LUTD ranged from 40 to 90%. High resolution rate could be attributed to the long follow-up period, and the chance of spontaneous resolution. Treatment modalities and co-existing NE were associated with longer time until clinical response. Only PVR was associated with prognosis. This was the first study in literature to report such findings. It was seen that the normalization of pathologic patterns was a good sign for treatment success. The DVISS results showed significantly higher rates of incontinence compared to initial symptoms defined by the patients and/or their parents. This showed the importance of using scoring systems to better define the severity of symptoms. It was hard to establish a standardized cut-off value for bladder wall thickness on US. However, US was a good test for diagnosing additional pathologies.
Increased PVR was the single tool that was associated with prognosis and, therefore, should always be performed after UF. In addition, DVISS can help parents be counseled about their treatment expectations.

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Urotherapy in children: Quantitative measurements of daytime urinary incontinence before and after treatment: According to the new definitions of the International Children’s Continence Society

Abstract

Objective

Material and methods

Results

Conclusions

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusion

Conflict of interest/funding

Urology

J Urol

J Urol

Urology

J Urol

J Urol

J. Urol.