A girl who runs to the toilet frequently and wets- dysfunctional voiding

H.K., a 5years old girl was brought with complaints of frequency of urination and wetting on and off during the daytime. She was dry at night time.

On further questioning she was well till about 3 years of age when she developed frequency of urination and constipation. She had 2 attacks of urinary infections which were treated by her pediatrician. She used to run to the toilet and still sometimes leak in the undergarments. Detailed history also revealed her habit of squeezing the legs or sometimes sitting in the corner with heel pressed into the perineum (Vincent’s Curtsy). The problems had worsened over the last one year. That is why she was referred to a Pediatric urologist clinic.

On examination H.K. was a cheerful and shy 5 year old girl. Her spine examination was normal and lower limbs were also normal. Rest of examination was also normal. Ultrasound and urine examinations were also normal. Spine x-ray was normal but it showed a loaded colon suggestive of constipation. A urodynamic study was showed hyperactive bladder with uninhibited contractions and high pressures. The bladder capacity was also less for age.

She was started on anticholinergic medicines and also medicines for constipation. Her diet was also modified to have more roughage to prevent constipation. The dose was adjusted over a period of next two weeks till she was dry for three hours. She has done well and now at three months she is being gradually tapered off the Anticholinergics.

Rodynamic Study showing Small unstable capacity bladder with High pressures and uninihibited contractions

Urodynamic Study after therapy showing good capacity bladder with stable dynamics

Facts about Dysfunctional Voiding (DV)

• Dysfunctional voiding means a voiding disorder without any organic cause. A thorough clinical examination must be done to rule out any neurological disorder causing urinary symptoms.
• A broader term "DYSFUNCTIONAL ELIMINATION SYNDROME"(DES) is more appropriate for this child as the child had severe constipation also.
• DES was coined by Dr Stephen Koff to describe children with difficulties in urinary and bowel emptying. During Dr Singal's tenure at Ohio State University, USA in 2005, he had closely worked with Dr Koff on this subject.
• DES/ DV are very common disorders and the usual age is toddlers and school going kids.
• DES/DV predisposes children to urinary infections and some of these may be having VUR also.
• Regular voiding habits, proper diet including fruits and salads (to combat constipation) and parental training play a major part in preventing this disorder.
• Therapy is targeted at tackling constipation, regularizing voiding schedule by incentives/ voiding diary and medicines to calm the bladder for short term.
• Urinary infections are treated by antibiotics and if there are recurrent infections then a MCU may be done to look for VUR. If VUR is there then prophylactic antibiotics are started to prevent renal damage.
• Adequate treatment of DES/DV may cause the VUR to disappear as well prevent infections.

Dr A.K.Singal is an expert & top Pediatric urologist and is best known for treating children with wetting, incontinence and urinary infections. He is available in his clinics in Navi Mumbai, India.

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