A pilot randomized controlled trial evaluating the effectiveness of group vs individual urotherapy in decreasing symptoms associated with bladder-bowel dysfunction.

PURPOSE: We determined the feasibility of a definitive trial comparing the effectiveness of group vs individual urotherapy for children with bladder-bowel dysfunction. MATERIALS AND METHODS: Children 6 to 10 years old with bladder-bowel dysfunction were recruited during the course of 1 year. Feasibility data on screening, eligibility, recruitment and protocol compliance rates were collected. Patients with high grade hydronephrosis, vesicoureteral reflux or learning disabilities and those who had previously undergone urotherapy were excluded. Patients were randomized to 1-hour group urotherapy or 15-minute individual urotherapy. Symptoms and quality of life were measured using the Vancouver Nonneurogenic Lower Urinary Tract Dysfunction/Dysfunctional Elimination Syndrome Questionnaire and the Pediatric Incontinence Questionnaire at baseline and at 3 to 6 months of followup. Within/between group comparisons were conducted using t-tests. RESULTS: Of 455 screened children 79 were eligible and 60 were recruited to participate. A total of 24 patients randomized to group urotherapy and 25 randomized to individual urotherapy completed the pilot trial (6 undergoing group and 5 undergoing individual urotherapy withdrew from the study). Symptomology scores between group and individual urotherapy were not different at followup (mean ± SD 14.7 ± 7.9 vs 13.4 ± 6.3, p = 0.54, 95% CI -5.4-2.8). Quality of life scores between patients undergoing group and individual urotherapy at baseline differed (mean ± SD 21.1 ± 10.8 vs 31.0 ± 14.3, p < 0.01, 95% CI 2.7-7.3) but became similar at followup (21.0 ± 14.2 vs 20.1 ± 15.3, p = 0.84, 95% CI -9.4-7.6). Within group analyses demonstrated improvement in symptomology from baseline to followup in patients undergoing group (mean ± SD 3.6 ± 7.6, p = 0.03, 95% CI 0.4-6.8) and individual urotherapy (6.0 ± 5.4, p < 0.01, 95% CI 3.8-8.3). Within group quality of life analyses revealed improvement in Pediatric Incontinence Questionnaire scores from baseline to followup in patients undergoing individual urotherapy (p < 0.01, 95% CI 5.0-16.9) only. CONCLUSIONS: Urotherapy, regardless of modality, effectively improved bladder-bowel dysfunction symptoms. A definitive randomized controlled trial is feasible, considering that a high recruitment rate (76%) for this population has been established.

Two Sessions of Behavioral Urotherapy for Bowel and Bladder Dysfunction: Does It Get Any Better?

This study sets to determine the optimal duration of behavioral urotherapy necessary to achieve maximal improvement in the management of pediatric bowel and bladder dysfunction.

Bladder and bowel dysfunction and the resolution of urinary incontinence with successful management of bowel symptoms in children.

AIM: To investigate the effect of treating defecation problems on urinary incontinence in children suffering from combined urinary bladder and bowel dysfunction (BBD). METHODS: We established a clinical database from medical records of all children referred to the urinary incontinence and gastroenterology outpatient clinics with BBD. The following variables were extracted: symptoms of constipation, faecal incontinence, urinary incontinence, age at onset of symptoms, treatment, including duration and response. All children went through the same treatment protocol. Faecal disorders were treated primarily and once relieved, the daytime incontinence was managed and followed by intervention for nocturnal enuresis. RESULTS: In total, 73 children were included in the study. The treatment regimen resulted in resolution of the defecation disorder in 96% of the patients. Of the children with daytime urinary incontinence, 68% had at least a 50% reduction in number of daytime incontinence episodes by successful relief of bowel dysfunction and 27% became completely continent during daytime. Only 17% of the children suffering from enuresis had a significant reduction in number of wet nights after relief of their faecal problem. CONCLUSION: The empirical treatment approach of managing bowel symptoms before intervening for bladder dysfunction in children with BBD is found to be appropriate.

The impact of DSM-5 and guidelines for assessment and treatment of elimination disorders.

Elimination disorders are very common in children: 10 % of 7-year-olds wet at night (nocturnal enuresis), 2-3 % during daytime (diurnal urinary incontinence) and 1-3 % soil (faecal incontinence). In the past decades, many subtypes of elimination disorders have been identified with different symptoms, aetiologies, comorbid disorders and specific treatment options. The aim of the paper is to present a short overview of the proposed DSM-5, the ICCS and the Rome-III classification systems, of assessment and of treatment. The DSM-5 criteria no longer reflect current research data and a revision is needed. Classification systems of the International Children's Incontinence Society (ICCS) for enuresis and urinary incontinence and the ROME-III criteria for functional gastrointestinal disorders offer new and relevant suggestions for both clinical and research purposes. Assessment of most elimination disorders can be performed in paediatric and child psychiatric primary care settings. The standard assessment consists of a thorough history, frequency/volume charts, specific questionnaires, a full physical examination, sonography and urinalysis. If possible, a child psychiatric assessment is performed. In all other settings, screening with a validated behavioural questionnaire and referral if indicated is recommended. All other investigations are indicated only in complicated cases and if an organic cause is to be ruled out. Treatment is symptom oriented and based on the exact diagnosis of the type of elimination disorder. Counselling is recommended in every case. Most elimination disorders can be treated by specific treatment programmes integrating cognitive-behavioural elements. Nocturnal enuresis is best treated with alarms. Medication can be indicated in nocturnal enuresis (desmopressin), urge incontinence (anticholinergics such as oxybutynin, propiverine, etc.) and faecal incontinence with constipation (polyethylene glycol). Comorbid behavioural and emotional disorders require additional treatment.

Fragile x syndrome and elimination disorders in a 6-year-old girl.

A case of a 6-year-old girl with multiple elimination disorders (nocturnal enuresis, functional urinary incontinence and fecal incontinence) and a fragile X-syndrome is described. The late diagnosis of the fragile X-syndrome had implications for treatment as well as for family interaction. With the knowledge of the diagnosis the parents reacted in a more understanding manner regarding the behavioral problems of the child, whereby the elimination problems were reduced. The need for further research on elimination disorders in children with genetic disorders is discussed.

Can individualized health care plans help increase continence in children with dysfunctional elimination syndrome?

School-age children with dysfunctional elimination syndrome (DES) do not always have school support for their treatment plans, including an every 2-hr voiding schedule. The objective of this study was to increase school support of treatment plans by allowing access to bathrooms, thereby improving continence. An eight-question survey about bathroom access at schools was given to parents at baseline. The author contacted school nurses requesting that treatment plans be incorporated into individual health plans (IHPs) with teacher support of the IHP. Six weeks later, school nurses were contacted and parents completed a postintervention survey to determine whether IHPs were supported by teachers. Voiding diaries were used to document continence. Seventeen parents completed the survey at baseline, and 13 children were enrolled in the intervention. After the intervention, 100% of the children had IHPs and teacher support of treatment plans. Ninety-two percent had increased continence. IHPs improved teacher support of children's treatment plans and improved their continence.

Diagnostic agreement predicts treatment process and outcomes in youth mental health clinics.

Several studies have documented low rates of agreement between clinician- and researcher-generated diagnoses. However, little is known about whether this lack of agreement has implications for the processes and outcomes of subsequent treatment. To study this possibility, the authors used diagnostic agreement to predict therapy engagement and outcomes for 197 youths treated in 5 community mental health clinics. Diagnostic agreement predicted better therapy engagement, with the agree group having fewer therapy no-shows and cancellations and a decreased likelihood of therapy dropout. Additionally, support for a link between agreement and treatment outcomes was found, as the agree group obtained larger reductions in parent-reported internalizing problems during treatment. These findings suggest that diagnostic accuracy may be an important precursor to successful treatment and highlight the importance of future research to find ways to incorporate standardized diagnostic procedures into clinical care settings.