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Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma Department of Urology Section of Pediatric Urology

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Page 1: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Dysfunctional Elimination Syndrome

Vincenzo Galati, D.O.Stephen Confer, MD

Ben O. Donovan, MDBrad Kropp, MD

Dominic Frimberger, MD

University of Oklahoma Department of Urology

Section of Pediatric Urology

Page 2: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Objectives

• Normal Elimination

• Dysfunctional Elimination Syndrome

• Non-Neurogenic Neurogenic Bladder

• Biofeedback

• Review of the literature

Page 3: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Development of Urinary Control

• Infancy: Reflex voiding– Detrusor contracts when bladder full

– External urinary sphincter contracts during filling

• Voiding pattern in infants (feeding)• Development of continence

– ↑ capacity and control of striated sphincter

– Control over spinal micturition reflex

Page 4: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Stooling

• Normally– Newborn meconium passes w/in 24 hrs– First few weeks: BMs 6 X q day– By 5 months: BMs 3 X q day– Age 2: BMs bid– Age 4: BM q day

J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

Page 5: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Dysfunctional Elimination

• Unknown etiology

• Abnormal elimination pattern

• Bowel or bladder incontinence

• Withholding maneuvers

Page 6: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Holding Maneuvers

Page 7: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Dysfunctional Elimination

• Prevalence approximately 15% (Hellstrom et al. 1991)

• Overlooked factor in pediatric UTIs

• 40% of toilet trained with 1st UTI

• 80% with recurrent UTI

• Risk factor for VUR and renal scarring

Page 8: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Bad Bladder Habits

• Infrequent visits to bathroom

• Inadequate time in bathroom

• Bad posture

• Poor hygiene

Page 9: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

What Happens?

• Infrequent voiding

– Over distended bladder

• Failure to relax pelvic floor

– Voiding against closed sphincter

• ↑ PVR

Page 10: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

What Happens?

• Bad posture– Can’t relax

• Bad hygiene or aggressive soaps– Dysuria and incomplete voiding

Page 11: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

•Children rated wetting themselves at school as the third most catastrophic event behind losing a parent and going blind.

Ollendick et al, Behav Res Therapy, 1989.Ollendick et al, Behav Res Therapy, 1989.

Page 12: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Functional Bowel Disturbances

• Constipation– Hard BM occurring < 3 X per week

• Most likely to occur in 3 situations• Can induce bladder dysfunction • 50% of dysfunctional voiding have

constipation

J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

Page 13: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma
Page 14: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Functional Constipation

• Symptoms– Infrequent passage of stool

– Hard stool

– Palpable stool in abdomen or in rectal vault

– Fecal soiling

J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

Page 15: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Functional Constipation

• Management:– Parental education (hydration and fiber)– Many require stool softeners– Visit toilet 30-40 minutes after a meal

• Forward leaning, T&L extension, hip abduction, foot support that allows 90° of hip/knee flexion

J.W. Chase, Y. Homsy, C. Siggaard, F. Sit, and W.F. Bower. Functional Constipation in Children. J of Urology. 2004;171, 2641-2643.

Page 16: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Treatment of Day Time Wetting

• 1st line is Behavior Modification– Diary– Bathroom every 2 hrs– Good posture – Ample time– Good hygiene

Page 17: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Treatment of Day Time Wetting

• Treat Constipation

• Biofeedback– Learn to relax pelvic muscles

• Medications – Ditropan ↓ pressure but CONSTIPATES!– ? Role of α-blocker and Botox

Page 18: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Non-neurogenic neurogenic bladder (NNGNGB)

• Nocturnal and diurnal incontinence

• Dribbling, overflow, urge incontinence

• Bowel dysfunction

• Recurrent UTI’s

• Bladder instability

• Voluntary DSD during voiding

Page 19: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

NNGNGB

– VCUG large PVR

– Reflux noted in about 50%

Page 20: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

NNGNGB - Treatment

– Sterilize Urine– Bladder retraining– Normalize bowel function– Anticholinergics eliminate unstable bladder

contractions– Sympatholytics and diazepam to reduce

outflow resistance– May need CIC

Page 21: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Biofeedback

• Treatment option for children with DSD• Goal: develop control over pelvic floor

muscles during voiding• Visual electromyography feedback• Maintain relaxed pelvic floor with voiding • Success up to child/parent/physician • Problem: can be invasive

Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470-1475.

Page 22: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Modified Biofeedback Program

• Noninvasive UDS• Psychological

techniques– Externalizing voiding

problem

– Empowerment and praise

Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470-1475.

77 Children Completing Biofeedback Study

No. (%)

Recurrent UTI 59 (76)

Day incontinence 48 (63)

Night incontinence 36 (47)

Anticholinergic tx 38 (49)

VUR 19 (24)

Bowel symptoms 44 (58)

Page 23: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Modified Biofeedback Program

Improvement No. (%)

Subjective:

Pronounced 47 (61)

Moderate 24 (31)

None 6 (8)

Objective:

Pronounced 47 (61)

Moderate 28 (36)

None 2 (3)

• Concluded:– Effective for 92% of

children with DSD

Chin-Peukert, et al. A Modified Biofeedback Program For Children With Detrussor-Sphincter Dyssynergia: 5-Year Experience. J of Urology, 2001; 166, 1470-1475.

Page 24: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Alpha-blocker therapy be as an alternative to biofeedback for dysfunctional voiding?

• Efficacy of alpha-blocker vs biofeedback

• Prospective study 28 pts (12/16)

• On timed voiding, constipation treatment and anticholinergics for at least 6 mo

• Pts reevaluated at 3 and 6 months– Incontinence episodes, UTIs, mean urinary

flow rates, PVR, and parental satisfaction

Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology, 2005; 174, 1612-1615.

Page 25: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Alpha-blocker therapy be as an alternative to biofeedback for dysfunctional voiding?

• Improved post treatment PVR– NO DIFFERENCE

• Complete improvement in urge incontinence– NO DIFFERENCE

• Combination effective in refractory cases (5/6)

• No side effects reported• Concluded alpha blockers were

a viable alternative

0

10

20

30

40

50

60

70

PVR Bio(ml)

PVR AB(ml)

Flow Bio(ml/s)

Flow AB(ml/s)

0 months

3 months

6 months

Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology, 2005; 174, 1612-1615.

Page 26: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Botulinum A Toxin Urethral Sphincter injection in Children with NNGNGB

• Prospective (10 children)

• 50-100 units injected • Immediately following

all but 1 voided without catheterization

• PVR ↓ by 89% 0

50

100

150

200

250

300

350

400

PVR (ml)

DLPP (cm H2O)

Q max (ml/sec)

Selcuk, et al. Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A Prospective Study. J of Urology, 2005; 174, 1612-1615.

Page 27: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Closing Statements

• Best treatment is prevention

• DES diagnosis of exclusion

• Constipation treatment and timed voiding

• Biofeedback

• Adjunctive treatment in refractory cases– Alpha blockers– BOTOX

Page 28: Dysfunctional Elimination Syndrome Vincenzo Galati, D.O. Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma

Vincenzo Galati

Thank YouThank You


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