Multi-center randomized controlled trial of cognitive treatment, placebo, oxybutynin, bladder training, and pelvic floor training in children with functional urinary incontinence.

OBJECTIVE: Functional urinary incontinence causes considerable morbidity in 8.4% of school-age children, mainly girls. To compare oxybutynin, placebo, and bladder training in overactive bladder (OAB), and cognitive treatment and pelvic floor training in dysfunctional voiding (DV), a multi-center controlled trial was designed, the European Bladder Dysfunction Study. METHODS: Seventy girls and 27 boys with clinically diagnosed OAB and urge incontinence were randomly allocated to placebo, oxybutynin, or bladder training (branch I), and 89 girls and 16 boys with clinically diagnosed DV to either cognitive treatment or pelvic floor training (branch II). All children received standardized cognitive treatment, to which these interventions were added. The main outcome variable was daytime incontinence with/without urinary tract infections. Urodynamic studies were performed before and after treatment. RESULTS: In branch I, the 15% full response evolved to cure rates of 39% for placebo, 43% for oxybutynin, and 44% for bladder training. In branch II, the 25% full response evolved to cure rates of 52% for controls and 49% for pelvic floor training. Before treatment, detrusor overactivity (OAB) or pelvic floor overactivity (DV) did not correlate with the clinical diagnosis. After treatment these urodynamic patterns occurred de novo in at least 20%. CONCLUSION: The mismatch between urodynamic patterns and clinical symptoms explains why cognitive treatment was the key to success, not the added interventions. Unpredictable changes in urodynamic patterns over time, the response to cognitive treatment, and the gender-specific prevalence suggest social stress might be a cause for the symptoms, mediated by corticotropin-releasing factor signaling pathways.

Urinary incontinence in children.

BACKGROUND: Urinary incontinence (bedwetting, enuresis) is the commonest urinary symptom in children and adolescents and can lead to major distress for the affected children and their parents. Physiological and non-physiological types of urinary incontinence are sometimes hard to tell apart in this age group. METHODS: This article is based on selected literature retrieved by a PubMed search and on an interdisciplinary expert consensus. RESULTS AND CONCLUSION: Nocturnal enuresis has a variety of causes. The main causative factors in monosymptomatic enuresis nocturna (MEN) are an impaired ability to wake up when the bladder is full, due to impaired or absent perception of fullness during sleep, and an imbalance between bladder capacity and nocturnal urine production. On the other hand, non-monosymptomatic enuresis nocturna (non-MEN) is usually traceable to bladder dysfunction, which is also the main cause of diurnal incontinence. A basic battery of non-invasive diagnostic tests usually suffices to determine which type of incontinence is present. Further and more specific testing is indicated if an organic cause is suspected or if the treatment fails. The mainstay of treatment is urotherapy (all non-surgical and non-pharmacological therapeutic modalities). Some patients, however, will need supportive medication in addition. Urinary incontinence has different causes in children and adults and must therefore be diagnosed and treated differently as well. All physicians who treat the affected children (not just pediatricians and family doctors, but also pediatric nephrologists, urologists, pediatric surgeons, and child psychiatrists) must be aware of the specific features of urinary incontinence in childhood.

Clinical evaluation of the short-form pediatric enuresis module to assess quality of life.

AIMS: The aim of this study was to determine the psychometric properties of the German version of the Pediatric Enuresis Module to assess Quality of Life, Short Form (PEMQOL-SF) in a sample of parents of children with urinary incontinence. METHODS: The parents of 88 children (63 male, 25 female, mean age: 9.3 [SD ± 2.5, range 6-18] years) with urinary incontinence were asked to complete the PEMQOL-SF. For evaluation of convergence validity, parents and children completed the respective versions of the DCGM-10 and the PinQ questionnaire. RESULTS: Mean PEMQOL-SF scores were 72.2 [SD ± 14.1] (child impact scale) and 73.7 [SD ± 16.5] (family impact scale). The PEMQOL-SF had a Cronbach's alpha of 0.68 (child impact scale) and 0.80 (family impact scale), respectively. PEMQOL-SF child [family] impact scale scores correlated with the DCGM-10 with scores of r = 0.34 (r = 0.13; self-report version) and r = 0.63 (r = 0.48; proxy version) and with the PinQ with scores of r = -0.31 (r = -0.16; self-report version) and r = -0.63 (r = -0.54; proxy version), respectively. CONCLUSIONS: The psychometric properties of the PEMQOL-SF were good for the family impact scale, but poor for the child impact scale. In its present form, the PEMQOL-SF cannot be recommended for routine clinical use. Nevertheless, a reduction of questionnaire items could lead to better psychometric properties.

Health related quality of life of a tertiary referral center population with urinary incontinence using the DCGM-10 questionnaire.

PURPOSE: We evaluated health related quality of life of pediatric patients with nonneurogenic urinary incontinence and determined potential influencing factors. Also, health related quality of life results in our sample were compared to those of other chronic childhood health conditions. MATERIALS AND METHODS: This cross-sectional study was done at 3 tertiary referral centers for childhood urinary incontinence. From July 2007 to April 2008 we consecutively evaluated 65 boys and 38 girls with a mean +/- SD age of 9.3 +/- 2.2 years (range 6 to 18) and their parents. Of the patients 12 had monosymptomatic enuresis, 79 had nonmonosymptomatic enuresis and 12 had isolated daytime incontinence. To evaluate participants we used the self-reported and proxy versions of the 10-item DISABKIDS chronic generic measure, short version, a health related quality of life questionnaire with cross-cultural validity. RESULTS: Mean questionnaire total scores were 43.2 and 42.8 for the self-reported and proxy versions, respectively, which showed significant correlation (r = 0.628). Age, sex, urinary incontinence type and severity, fecal incontinence and constipation had no significant association with questionnaire total scores (each p >0.05). Compared to questionnaire results in a reference sample of children with chronic health conditions average scores in our sample did not differ significantly from those in pediatric patients with asthma, arthritis, atopic dermatitis, cystic fibrosis, diabetes or epilepsy on the self-reported version, and asthma, atopic dermatitis, cystic fibrosis or epilepsy in the proxy version. CONCLUSIONS: Health related quality of life of children and adolescents with urinary incontinence appears to be comparable to that in pediatric patients with other chronic conditions, eg asthma or epilepsy.

German version of the Pediatric Incontinence Questionnaire for urinary incontinence health related quality of life.

PURPOSE: We translated and cross-culturally adapted the English version of the Pediatric Incontinence Questionnaire, and tested the reliability and validity of the German version. MATERIALS AND METHODS: This cross-sectional study was done at 3 tertiary referral centers for childhood urinary incontinence. The self-reported and proxy English version was translated and cross-culturally adapted. From July 2007 to April 2008 we evaluated the German version in 91 boys and 54 girls with a mean +/- SD age of 9.3 +/- 2.2 years (range 6 to 18) with nonneurogenic urinary incontinence and in their parents. For concurrent criterion related validity, the German questionnaire scales were compared with those of the DCGM-10/-12. RESULTS: On reliability testing of the self-reported and proxy German versions Cronbach's alpha was 0.84 and 0.86, respectively. Interrater convergence between the self-reported and proxy versions showed an ICC of 0.81. Reproducibility was satisfactory for the self-reported and proxy versions (ICC 0.77, 95% CI 0.77-0.90 and 0.85, 95% CI 0.67-0.84, respectively). German version scores correlated with DCGM-10/-12 scores (self-report and proxy r = -0.71 and -0.69, respectively). Mean German version total scores were 23.0 in boys and 23.9 in girls. Except for a slight significant association between age and German version total score in the proxy version (p = 0.01), age, sex and incontinence type or severity (number of wet days/nights per 14 days) were not significantly associated with German version total scores. CONCLUSIONS: The German version of the Pediatric Incontinence Questionnaire is a valid and reliable outcome measure to assess health related quality of life in children and adolescents with urinary incontinence.

Long-term effects of a urotherapy training program in children with functional urinary incontinence: a 2-year follow-up.

OBJECTIVE: To evaluate the long-term effectiveness of a urotherapy training program implemented at our institution. Day- and/or night-time wetting as a consequence of functional urinary incontinence is a common problem in childhood. A number of treatment methods are available, among them urotherapy. MATERIAL AND METHODS: Forty-eight patients (age range 10-14 years) with urge incontinence or dysfunctional voiding were evaluated with a questionnaire 2 years after completion of a urotherapy training program. RESULTS: Two years after completion of training, 86.7% of the inpatient and 93.8% of the outpatient groups with day-time wetting and 79.2% of the inpatient and 41.6% of the outpatient groups with night-time wetting were cured or had improved. CONCLUSIONS: Compared with the published data on the natural course of incontinence, the urotherapy program evaluated in this study resulted in higher success rates. Compared with 6-month follow-up, improvement rates proved to be stable, and cure rates (with the exception of patients with night-time wetting in the outpatient training group) even increased significantly during the 2-year follow-up.

Functional urinary and fecal incontinence in neurologically normal children: symptoms of one 'functional elimination disorder'?

OBJECTIVE: To clarify the relationship between disordered defecation and non-neuropathic bladder-sphincter dysfunction (NNBSD) by comparing the prevalence of symptoms of disordered defecation in children with NNBSD before and after treatment for urinary incontinence (UI), and assessing the effect of such symptoms on the cure rate for UI. PATIENTS AND METHODS: In the European Bladder Dysfunction Study, a prospective multicentre study comparing treatment plans for children with NNBSD, 202 children completed questionnaires on voiding and on defecation, at entry and after treatment for UI. Four symptoms of disordered defecation were evaluated; low defecation frequency, painful defecation, fecal soiling, and encopresis. RESULTS: At entry, 17 of the 179 children with complete data sets had low defecation frequency and/or painful defecation (9%), classified as functional constipation (FC). Of the 179 children, 57 had either isolated fecal soiling or soiling with encopresis (32%), classified as functional fecal incontinence (FFI). After treatment for UI, FFI decreased to 38/179 (21%) (statistically significant, P = 0.035); for FC there were too few children for analysis. After treatment for UI, 19 of the 179 children (11%) reported de novo FFI. Symptoms of disordered defecation did not influence the cure rate of treatment for UI. CONCLUSIONS: FFI improved significantly after treatment for UI only, but not in relation to the outcome of such treatment. FFI did not influence the cure rate for UI. There was little to support a causal relation between disordered defecation and NNBDS ('functional elimination syndrome').

Cognitive-behavioral stress management training for boys with functional urinary incontinence.

OBJECTIVE: To evaluate an inpatient education program involving cognitive-behavioral stress management training of boys (aged 8-12 years) with functional urinary incontinence. METHODS: The short- and long-term intervention effects of the new program on incontinence frequency, quality of life, and coping with daily and illness-related stressors were investigated in 15 boys, compared to 10 boys on a more knowledge-oriented education program without stress management. The efficacy was evaluated by non-parametric methods. RESULTS: In both groups daytime wetting decreased while adaptive coping with daily stressors increased. Only the boys in the experimental group improved their wetting frequency during the night, maladaptive coping with illness-related stressors, and self-esteem. CONCLUSIONS: Stress management training should be incorporated in patient education programs to enhance coping of children with illness-related stressors and low self-esteem.

Prospective evaluation of inpatient and outpatient bladder training in children with functional urinary incontinence.

OBJECTIVES: To evaluate, in a prospective study, the effectiveness of a bladder training program. Daytime and/or nighttime wetting as a consequence of functional urinary incontinence is a common problem in childhood. Various treatment options are available, including with cognitive-behavioral "bladder training." METHODS: Sixty patients (age 8 to 12 years) with urge incontinence or dysfunctional voiding were evaluated. After a no-treatment control period (average 6 months), patients underwent a 6-day bladder training course, which was offered either as inpatient or outpatient training, leaving the choice to the patients' parents. Clinical assessments were recorded at the beginning of the control period, at training entry and training completion, and after 1 (inpatient training group only), 3, and 6 months. RESULTS: Six months after training completion, 64.1% and 64.7% of the inpatient and outpatient groups with daytime wetting and 51.5% and 17.7% of the inpatient and outpatient groups with nighttime wetting were cured or had improved, respectively. The spontaneous cure rate during the 6-month control period was 0% to 20.5%. Of the inpatient group with urge incontinence, the functional bladder capacity increased by 15%. The children aged 9 to 12 years in the inpatient group had significantly greater cure rates than the 8-year-old children. CONCLUSIONS: Compared with the control period, the bladder training program evaluated in this study resulted in significantly greater success rates. The results lead to the assumption that children with nighttime wetting treated in the inpatient training will succeed better than those in outpatient training. The cure and improvement rates of daytime wetting were greater than those for nighttime wetting.