JPediatr(RioJ).2016;92(2):106---108
www.jped.com.br
EDITORIAL
Daytime
urinary
incontinence:
a
chronic
and
comorbid
condition
of
childhood
夽
,
夽夽
Incontinência
urinária
diurnal:
uma
doenc
¸a
crônica
e
comorbidade
infantil
Anne
J.
Wright
a,b,c,daTheChildren’sBladderClinic,UnitedKingdom
bEvelinaLondonChildren’sHospital,London,UnitedKingdom
cGuy’sandStThomas’NHSFoundationTrust,London,UnitedKingdom dInternationalChildren’sContinenceSociety,Chappaqua,UnitedStates
Inthearticle ‘‘Clinicalcourseofacohortofchildrenwith non-neurogenicdaytimeurinaryincontinencesymptoms fol-lowed at a tertiary center,’’ Lebl et al.1 characterize a cohortof50childrenattendingtheir centerover12 years with the primary symptom of functional daytime urinary incontinence(DUI).Theyconcludethatasubgroupof chil-drenwithclinical characteristicsof an overactivebladder (OAB), without associated comorbidities of urinary tract infection (UTI) and normal urinary tract ultrasound and uroflowmetry,maybetreatedwithoutfurtherinvasive stud-ies.Meanfollowuptimewas4.7yearsandone-thirdofthe groupwereresistanttotreatment.
With regardstothe characteristics of thegroup, their demographics, symptomatology, and co-morbidities are broadlysimilartootherreportedgroupsintertiarysettings fromaroundtheworld.2---7Daytimeurinaryincontinenceis knowntobemorecommon ingirls8---11 in contrastto noc-turnal enuresis and fecal incontinence, which are more common in boys. The age of presentation in this cohort (mean 7.9 years) is two to threeyears after the child is expectedtobedry.12AlargepopulationcohortintheUnited Kingdomfollowedfrombirthtoyoungadulthoodallowsthe
夽 Pleasecitethisarticleas:WrightAJ.Daytimeurinary
inconti-nence:achronic andcomorbid conditionofchildhood.JPediatr (RioJ).2016;92:106---8.
夽夽SeepaperbyLebletal.inpages129---35.
E-mail:Anne.Wright@gstt.nhs.uk
formulation of longitudinal trajectories for children with daytime wetting between the ages of 4.5 and 9.5 years. Eighty-sixpercentareintheso-called‘‘normativegroup’’ andaredry.Ofthe14%whohaveDUI,approximatelyhalf (6.9%) show a resolving trajectory called ‘‘delayed’’ and attainnormalstatus(dry)by9.5yearsofage.Approximately one-fifth (3.2%) had been dry at 4.5 years but relapsed after5yearsofageandremainwetat9.5years,and one-third(3.7%)werepersistent(chronic)wetterswithminimal resolution.13 Thus,DUImaybeprimaryorsecondary, com-mencing at about the time thatchildren enterschool. In addition,thereisincreasingevidencethatbladder dysfunc-tionresultingin lowerurinarytractsymptoms (LUTS)is a common chroniccondition of childhoodthat can carryon intoadulthood.14,15Hence, earlyrecognitionand appropri-ate management are vital in attempting to limit lifelong morbidity.Thereis aneed forgreater awarenessamongst health professionals,parents,and thepublicthat inconti-nenceinchildrenabovetheageof5yearsisnotnormaland thatwe maydochildrenadisservice byplacating parents bysayingtheywill‘‘growoutoftheirdifficulties.’’
ThehallmarksymptomofOAB(asdefinedbythe Interna-tionalContinenceSociety)isurgency,16whichwasreported by 56% of this cohort. The urodynamic correlate of OAB is detrusor overactivity (DO), which occurred in 92% of performed urodynamicsstudies(UDS) (n=38).Thislack of concordance may reflect the child’s inability to describe theirsymptomsadequatelyorlackofawarenessofwhat nor-malvoidingshouldentail.Itmayalsobethattheirparents
http://dx.doi.org/10.1016/j.jped.2016.01.003
Daytimeurinaryincontinence 107
incorrectly interpret urgency as voiding postponement;12 holdingontoolong,(namederroneouslybytheauthorsas
urinaryretention)or‘‘leavingthingstillthelastmoment.’’ Other childhood and adult studies have also found that urgencyisapoorindicatorofunderlyingpathophysiology.6,17 Goodconcordance (85%, p<0.05)for DO in UDS fromthis studyrequiredthesymptomsofurgency/urgeincontinence togetherwithincreasedurinaryfrequency,nohistoryof uri-narytractinfection,andnormalnon-invasiveinvestigations ofultrasoundanduroflowmetry.Applying thesecriteriato this cohort of children would mean that 62% would still requireinvasivetesting,astheUTIratewashigh.Thismay be warranted giventhe high rateof vesicoureteric reflux (27.8%)andabnormalrenalscintigraphyresults(43.3%), fur-therhighlightingtheroleofbladderdysfunctioninrecurrent urinarytractinfection.18
The symptom of DUI seldom occursin isolation2---7 and thecomorbiditiesinthiscohortaresignificantand overlap-ping;70% hadnocturnalenuresis (nocturiaisnotreported andcanbealateroutcomeofearlierenuresis),62% recur-renturinarytractinfections,62%constipation,and16%fecal incontinence.Comorbidity symptomsmaybeperceivedby theparent and/orchild asmoredistressing than theDUI, which may present with smaller, more concealable vol-umes than enuresis andbe moresocially acceptable than fecalincontinence.Thiscanresultinamismatchbetween parentalexpectationsoftreatmentandthetreatment start-ingpointprescribedbythepediatrician.Inaddition,while emotionalandbehavioralcomorbiditieswerenotreported inthiscohort,itiswellestablishedthatchildhood inconti-nenceisassociatedwiththesedisordersandmayaffectthe severityandtreatmentoutcomes.Forthisreason,the Inter-national Children’s Continence Society (ICCS) recommend thatallincontinentchildrenbenefitfromactivescreening foremotional/behavioraldisorders.19Thus,inordertoallow pediatricianstomoreaccuratelycapturetheheterogeneity andcomplexityof childhoodincontinence, itmaybetime for the ICCS torecommend a multi-axial diagnostic algo-rithm similartothe concept of the multi-axial diagnostic frameworkusedbyDiagnosticandStatisticalManualof Men-talDisorders(DSM)orInternationalClassificationofDiseases (ICD 10).20,21 It could incorporate features of symptoma-tology;physical,developmental,andemotional/behavioral comorbidity; quality of life and severity indicators; and underlying pathophysiology such as DO, external urethral sphincteractivity,detrusorunderactivity,etc.
Withregardstotreatment,thisstudyreportedsignificant improvementinallLUTSatthetimeoffollow-up,whichwas generally longer (4.7 years±3.2 years) than that quoted inotherstudies.Thismaybeduepartlytothefactthata stepwiseapproachisrequired fortreatment,startingwith boweldysfunctionandmovingontodaytimeandthen night-timesymptoms.Theauthorsdonotdetailtheirtreatment protocolwithstepwiseoutcomes,butinacohortofDanish childrenwithDUI,Hagstroem etal.reportthattreatment of boweldysfunctionaloneresulted in aDUIcureof 17%. Urotherapy(with orwithout a timerwatch)then resulted in a further 73% resolution (this was more effective in olderchildrenwithrelativelylargerbladdercapacity)and, finally, 26% of the entire cohort required treatment with anticholinergics, of whom 81% responded.7 Lebl’s1 cohort hadahighertreatment-resistantrateof32%,comparedto
6%intheDanishstudy(followuptimeoftwoyears)andthis islikelytobeduetotheexclusionofanychildrenwithUTI inthelatter.Othergroupshavealsodemonstratedthevalue ofurotherapy,akeycomponentofwhichiseducationofthe childandparentastothecausesofincontinence,thereby relievingtheburdenofguiltandshamefrombothparties,2,3 aswellasexplainingtherationaleoftreatmentapproaches. Insummary,thiscohorthighlightsanumberoffeatures for the group of children presenting with daytime uri-naryincontinence,illustratingimportantconcepts,practice points,andprinciples.Timelyandappropriatediagnosisand interventionwillhopefullyameliorateshort-andlong-term effectsforthechildrenandtheirfamilies.
Conflicts
of
interest
Theauthordeclaresnoconflictsofinterest.
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