2.1 Lower urinary tract anatomy/physiology & / Lecture online
Introduction
Bladder and bowel problems in children are complex condition;s several causes play a role in their development. To properly treat the child with urinary and bowel problems, it is crucial to have knowledge about the anatomy of the urinary tract. How does the system work and what is the interplay and involvement of the central nervous system. Knowledge of the dysfunction and associated definitions are essential to make a correct diagnosis
Learning objectives
The participant
- Can name and explain the (neuro) anatomy and physiology of the lower urinary tract
- Can explain and name the function of the pelvic floor muscles.
- Can explain what happens during bladder filling and emptying
- Has an understanding of the pathophysiology of incontinence in children, the most common causes.
Literature
Book: Pediatric incontinence Evaluation and clinical management: 3, Section 1 chapter 1 Neurophysiology of voiding
Book Pediatric incontinence evaluation and clinical management: chapter 3 Functional brain imaging in bowel and bladder control chapter 3
2.2; Terminology LUTD & Assessment /Lecture online
Introduction
Proper treatment starts with proper diagnosis. To reach a correct diagnosis, knowledge about terminology, the different sub-diagnoses, about diagnostic instruments and examinations is essential.
The medical history, psychosocial history, micturation and defecation diary, flowmetry and ultrasound are indispensable diagnostic tools. Because there may be overlap between the various sub-diagnoses, but also because age, maturity of the child and any behavioral problems and/or environmental factors influence a successful outcome, as a urotherapist you are co-responsible for correctly interpreting anamnesis and additional investigations.
Learning objectives
The participant
- Can apply terminology for children with urinary tract infections and/or urinary incontinence (Lower urinary tract dysfunction LUTD)
- Knows the main features of the classification of LUTD
- Can explain the place and function of voiding-defecation history , observation and questionnaires as diagnostic methods
- Can apply and interpret information of history.
- Can explain the role and function of flowmetry and ultrasound
Literature
Book: Pediatric incontinence Evaluation and clinical management: Section 3, evaluation of bowel and bladder dysfunction.
a. Chapter 9; Uroflowmetry and postvoid residual urine test in incontinent children.
b. Chapter 10; Evaluation of the child with voiding dysfunction
c. Chapter 11; evaluation constipation and fecal incontinence.
Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, Rittig S, Vande Walle J, von Gontard A, Wright A, Yang SS, Nevéus T. The standardization of terminology of lower urinary tract function in children and adolescents: update report from the Standardization Committee of the International Children's Continence Society. J Urol. 2014 Jun;191(6):1863-1865.e13. doi: 10.1016/j.juro.2014.01.110. Epub 2014 Feb 4. PMID: 24508614..
Chang SJ, Van Laecke E, Bauer SB, von Gontard A, Bagli D, Bower WF, Renson C, Kawauchi A, Yang SS. Treatment of daytime urinary incontinence: A standardization document from the International Children's Continence Society. Neurourol Urodyn. 2017 Jan;36(1):43-50. doi: 10.1002/nau.22911. Epub 2015 Oct 16. PMID: 26473630.
Tekgul S, Stein R, Bogaert G, Undre S, Nijman RJM, Quaedackers J, 't Hoen L, Kocvara R, Silay MS, Radmayr C, Dogan HS. EAU-ESPU guidelines recommendations for daytime lower urinary tract conditions in children. Eur J Pediatr. 2020 Jul;179(7):1069-1077. doi: 10.1007/s00431-020-03681-w. PMID: 32472266
Chase J, Bower W, Gibb S, Schaeffer A, von Gontard A. Diagnostic scores, questionnaires, quality of life, and outcome measures in pediatric continence: A review of available tools from the International Children's Continence Society. J Pediatr Urol. 2018 Apr;14(2):98-107. doi: 10.1016/j.jpurol.2017.12.003. Epub 2018 Feb 2. PMID: 29429829.
Lopes I, Veiga ML, Braga AA, Brasil CA, Hoffmann A, Barroso U Jr. A two-day bladder diary for children: Is it enough? J Pediatr Urol. 2015 Dec;11(6):348.e1-4. doi: 10.1016/j.jpurol.2015.04.032. Epub 2015 Jun 26. PMID: 26386888.
2.3 Standard and Specific Urotherapy- Lecture online
Urotherapy is described as a cognitive, behavioral and physical training to improve bladder and lower urinary tract problems. Understanding, explanation, education and behavior change regarding toilet visits, toilet posture and urges are important aspects of urotherapy.
Explaining bladder function and dysfunction to a child is crucial. When children understand their bladder issues, they become more motivated to participate in training. It is essential that the information is conveyed in an effective manner, ensuring that both the child and their parents fully comprehend the nature of the condition. This understanding encourages adherence to the instructions provided by the urotherapist.
After diagnosis and explanation, treatment is typically initiated in accordance with the principles of urotherapy. In addition to understanding standard and specific urotherapy, it is essential to know how to select the form that is appropriate for the child's diagnosis and history.
Learning objectives
The participant:
- Can explain what urotherapy is.
- Knows the differences between standard urotherapy and specific urotherapy
- Knows the 5 learning elements of urotherapy
- Can explain which learning element receives emphasis depending on subdiagnoses
- Can explain and apply how a child receives instructions and explanations
- Can explain the importance of voiding diary during urotherapy
Literature
Article:
Nieuwhof-Leppink AJ, Hussong J, Chase J, Larsson J, Renson C, Hoebeke P, Yang S, von Gontard A. Definitions, indications and practice of urotherapy in children and adolescents: - A standardization document of the International Children's Continence Society (ICCS). J Pediatr Urol. 2021 Apr;17(2):172-181. doi: 10.1016/j.jpurol.2020.11.006. Epub 2020 Nov 5. PMID: 33478902.
Book: pediatric incontinence evaluation and clinical management: evaluation of bowel and bladder dysfunction. Section 4
a. Chapter 12 Implementation of urotherapy, Wendy F. Bower
b. Chapter 14 Biofeedback for the treatment of functional voiding problems, Ann Raes
c. Chapter 21 Psychological management of BBD, 201 Monika Equit and Alexander von Gontard
2.4 Q&A Discussion / Live online meeting
During this online session you will have the opportunity to ask questions based on the lectures you have attended. We will discuss the case study below and how your own clinic is organised, guided by the following tasks and questions.
Preparation:
Case Study
Louise, 10 years old, comes to the clinic with urinary incontinence. She wets herself every day at different times. During the history she states that she has daily stools, Bristol Stool Scale 2. Her voiding diary shows that she drinks 5-6 times a day with a total volume of 1200 ml and urinates 6 times with a volume of 200-350 ml. On the flow meter she has a staccato flow pattern, duration 25 seconds, Q max 31 ml/s , the voided volume is 165 ml and the ultrasound shows a residual volume of 60 ml.
Constipation seems to play a role. However, this is not conclusive because this girl has stool every day. However, the Bristol Stool Scale 2 indicates constipation. By ultrasound and rectal measurement, the rectal diameter is 4 cm, you can show the child and parents that stool may be a cause incontinence.
What questions are essential in this history?
- What additional examination do you need to make a proper diagnosis.
- Which diagnosis is plausible?
Assignment work out the questions below and take it to class.
You will discuss this with your fellow participants.
- What is the practice in your own institution regarding diagnostics and treatment?
- Is the practice based on guidelines, protocols and standards? If so. On which ones?
- What questionnaires are relevant for a first visit to the practice
- If available from your own practice ; Collect 2 micturition and defecation diaries from your own practice and describe which characteristics fit one of the sub diagnoses.
- If available from your own practice; Collect 3 flow results from your own practice and describe the patterns.
- Describe the normal values of a flow pattern of an 8-year-old child.
- Describe the incontinence diagnoses and the corresponding flow.
- If available from your own practice, collect 2 ultrasound images before and after voiding.
