Fourth International Consultation On Incontinence (ICI) - Children Committee Highlights

Main Category: Urology / Nephrology
Also Included In: Pediatrics / Children's Health
Article Date: 24 Jul 2008 - 3:00 PDT

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Serdar Tegkul, MD, Committee Chair

PARIS, FRANCE (UroToday.com) - Dr. Tegkul began by noting the difficulties in producing Level 1 data for the pediatric population, as it is very difficult to recruit for randomized controlled trials. He reviewed the International Children's Continence Society's definition of pediatric incontinence, which is the "involuntary loss of urine at inappropriate and socially unacceptable time and place in children greater than 5 years old". There are three broad categories including nocturnal eneuresis (NE), daytime and nighttime incontinence, and daytime only. The last two categories are generally grouped together in terms of etiology and treatment.

NE, as discussed previously, can be divided into monosymptomatic NE (MNE), which is NE without daytime LUTS, and non-monosymptomatic NE (nonMNE), which is NE with concomitant daytime LUTS. He also commented that secondary NE is usually associated with a psychiatric or behavioral comorbidity. With respect to epidemiology, MNE is prevalent in 15% of 5 year olds and is always more common in boys by a 3:2 ratio. There are three causes of MNE, namely sleep disturbances, nocturnal polyuria and reduced nocturnal bladder capacity. Sleep disturbance is usually seen in children who fail to wake up to auditory stimuli, for example, and is generally regarded as a form of maturational delay. Nocturnal polyuria can be caused by excessive fluid intake, excessive renal solute excretion, or alterations in ADH. Dr. Tegkul noted that reduced nocturnal bladder capacity is generally not the sole cause of MNE and is best understood as nocturnal detrusor overactivity. He stressed that history is the most important part of the evaluation of MNE. Attention must be paid to LUTS, bowel symptoms, behavioral problems, and specific patterns of wetting episodes. Urinalysis is the only study recommended. Treatment should start after age 5 whenever the condition becomes a problem for the child and/or family. He stressed the educational component of treatment, although it is rarely successful as sole therapy. Conservative therapies, including voiding prior to sleep, fluid reduction, caffeine avoidance, and toileting the child at night, are logical and should be used. The two mainstays of active treatment for MNE are alarms and desmopressin. Alarm therapy has Level 1a evidence with 76 RCT's evaluated. The overall cure rate was quoted at 70% within 3 months. The biggest downside is that it requires a motivated family, as the parents usually must assist the child to the bathroom when the alarm is triggered. Dr. Tegkul next discussed desmopressin, which he stated was safe for long-term use in the pediatric population and had a very low incidence of hyponatremia. There is also Level 1a evidence for its use, with average 4.5 times increase dry rate on drug therapy. Relapse rates are somewhat high, however. Imipramine is also effective and has Level 1 evidence, although concerns over side effects made it a distant third choice for primary therapy, and the committee gave it a Grade C recommendation.

Dr. Tegkul moved on to discuss children with day and night incontinence. This includes those with functional causes (OAB, dysfunctional voiding, voiding postponement), anatomic incontinence (exstrophy, ectopic ureter, etc.), and neurogenic patients (myelomeningocele). He noted that unlike in MNE, children with functional day and night incontinence could develop serious morbidity including bladder outlet obstruction, urinary tract infections, reflux and renal damage. These children are sometimes wet and also have OAB symptoms, bowel difficulties (incontinence or constipation) and UTI's. Dr. Tegkul reviewed the neurological development of children with respect to the urinary tract and stated that these functional problems may represent a maturational delay in both the somatic (sphincters/pelvic floor) and autonomic systems (bladder, bowels). He also briefly discussed underactive bladder, "giggle" incontinence and Hinman Syndrome, which is now thought to represent merely a severe form of dysfunctional voiding syndrome. In children with day and night incontinence from a functional disorder, the initial evaluation should include a history with attention to voiding habits, LUTS, bowel symptoms, behavioral issues and family/social dynamics. An objective LUTS questionnaire and voiding diary were suggested. In addition to a standard physical exam, urinalysis was recommended, as was a uroflow and post-void residual measurement. Upper tract imaging is optional, and invasive urodynamics is rarely needed, except in patients refractory to conventional treatment, those with unexplained symptoms, or in children with recurrent UTI's. Recommended initial treatment involves education, behavioral therapy, fluid/caffeine restriction, bowel management and instruction in proper voiding techniques (Level 2 evidence). There is mixed evidence on the use of anticholinergics. Tolterodine is perhaps the most commonly used medication, but generally has poor efficacy (Level 1 Grade C). Oxybutynin has significant side effects and Level 2 evidence (Grade C). Propiverine has one RCT and was given a Grade A/B recommendation on Level 1 evidence. Dr. Tegkul reminded the audience that none of the anticholinergics are approved for use in children. There is little evidence for its use, but suppressive antibiotics were recommended for children with recurrent UTI in this setting. Botulinum Toxin is also not approved for use in this situation, but has shown good efficacy in two trials for OAB in children refractory to anticholinergics (Level 3 Grade C). In children with pelvic floor overactivity (dysfunctional voiding, elimination syndrome), biofeedback may be useful (Level 2 Grade B).

The last portion of this presentation focused on neurogenic incontinence. Dr. Tegkul reviewed the myelodysplastic conditions and noted that only 10-15% of these children have "normal" lower urinary tract function and up to 60% will develop upper tract damage if untreated. He discussed the goals in these patients of achieving continence and protecting renal function. He noted that the most significant advancement in the treatment of these conditions was the popularization of clean intermittent catheterization by Lapides in the early 1970's.

The most important initial studies are videourodynamics and upper tract imaging. Urodynamics should make note of compliance and capacity, leak point pressures, overactivity and reflux. Initial therapy in these children is medical, usually with anticholinergics (Level 2 Grade B) and CIC (Level 1 Grade A). Dr. Tegkul then briefly reviewed the wide range of surgical options employed in the treatment of these patients including augmentation techniques and choice of tissue (ureter is ideal but often not available, ileum is best bowel segment), continence promoting procedures, and sphincter ablative procedures. For catheterizable stomas, the appendix was recommended as a first choice, and a Monti tube may be used if it is not available.

The last several slides addressed the topic of psychological disorders in children with incontinence. Children with NE (mostly secondary and nonMNE) and those with daytime incontinence have approximately a 30% prevalence of psychological disorders. Those with fecal incontinence have even higher rates. The most commonly identified disorder is attention deficit hyperactivity disorder. Dr. Tegkul stressed the importance of identifying and treating this component.

Moderated by Joachim W. Thüroff, MD, and Masaru Murai, MD, at the Fourth International Consultation on Incontinence (ICI) - July 5 - 8, 2008. Palais des Congres, Paris, France.

Written by William Jaffe, MD, a Contributing Editor with UroToday.com

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