Non-invasive Testing and Its Role in Diagnosis and Management of Children With Voiding Dysfunction
Purpose of Review
The symptoms of non-neurogenic lower urinary tract dysfunction (LUTD) including urinary incontinence, frequency, and urgency are among the most common reasons for which children are referred to pediatric urologists. The workup for LUTD is often time consuming and a source of frustration for patients, parents, and clinicians alike. In this review, we describe the non-invasive tests that are available and discuss their utility in the evaluation and management of children with LUTD.
The available non-invasive tests that can aid in the diagnosis and management of children with LUTD include urine studies, uroflowmetry ± simultaneous electromyography, assessment of post-void residual, renal/bladder ultrasound, and pelvic ultrasound. These tests can often help obviate the need for more invasive tests such as urodynamic studies and can be particularly helpful in complex or difficult cases that do not respond to standard urotherapy.
Non-invasive tests can help us in our goal of improving diagnostic ability to better classify the child’s LUTD into an actual condition which allows targeted treatment in the hope of better outcomes and more satisfied patients and families.
KeywordsNon-invasive testing Voiding dysfunction Pediatrics Uroflowmetry with EMG Urodynamics
This work was supported in part by the 2016–2017 Urology Care Foundation Research Scholar Award Program (JPV) and by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001879 (JPV). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Compliance With Ethical Standards
Conflict of Interest
Mr. Combs has nothing to disclose.
Dr. Van Batavia has received grant funds from the Urology Care Foundation and from the National Center for Advancing Translational Sciences of the National Institutes of Health.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 5.Feldman AS, Bauer SB. Diagnosis and management of dysfunctional voiding. Curr Opin Pediatr. 2006;18(2):139–47. https://doi.org/10.1097/01.mop.0000193289.64151.49.CrossRefPubMedGoogle Scholar
- 8.•• Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, et al. 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;191(6):1863–1865.e13. https://doi.org/10.1016/j.juro.2014.01.110.CrossRefPubMedGoogle Scholar
- 9.Neveus T, et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children’s Continence Society. J Urol. 2006;176(1):314–24. https://doi.org/10.1016/S0022-5347(06)00305-3.CrossRefPubMedGoogle Scholar
- 11.Van Batavia JP, Combs AJ, Hyun G, Bayer A, Medina-Kreppein D, Schlussel RN, et al. Simplifying the diagnosis of 4 common voiding conditions using uroflow/electromyography, electromyography lag time and voiding history. J Urol. 2011;186(4 Suppl):1721–6. https://doi.org/10.1016/j.juro.2011.04.020.CrossRefPubMedGoogle Scholar
- 12.•• Van Batavia JP, et al. Use of non-invasive uroflowmetry with simultaneous electromyography to monitor patient response to treatment for lower urinary tract conditions. J Pediatr Urol. 2014;10(3):532–7. The authors describe their use of uroflowmetry with simultaneous electromyography and specifically EMG lag time to monitor 159 children with four common lower urinary tract conditions. While on targeted therapy, improvements in EMG lag time from baseline were statistically significant for children with detrusor overactivity and primary bladder neck dysfunction.CrossRefPubMedGoogle Scholar
- 17.Maternik M, Chudzik I, Krzeminska K, Żurowska A. Evaluation of bladder capacity in children with lower urinary tract symptoms: comparison of 48-hour frequency/volume charts and uroflowmetry measurements. J Pediatr Urol. 2016;12(4):214.e1–5. https://doi.org/10.1016/j.jpurol.2016.04.004.CrossRefGoogle Scholar
- 26.• Franco I, et al. A quantitative approach to the interpretation of uroflowmetry in children. Neurourol Urodyn. 2016;35(7):836–46. The authors describe the development of a reproducible and reilable method to interprete uroflowmetry patterns called the flow index (FI). The authors tested the FI on uroflow data from 1,268 healthy children and showed that the index was statistically robust in predicting uroflow patterns—bell, plateau, and tower.CrossRefPubMedGoogle Scholar
- 28.Clothier JC, Wright AJ. Dysfunctional voiding: the importance of non-invasive urodynamics in diagnosis and treatment. Pediatr Nephrol. 2017; https://doi.org/10.1007/s00467-017-3679-3.
- 29.Combs AJ, et al. Primary bladder neck dysfunction in children and adolescents I: pelvic floor electromyography lag time—a new noninvasive method to screen for and monitor therapeutic response. J Urol. 2005;173(1):207–10; discussion 210-1. https://doi.org/10.1097/01.ju.0000147269.93699.5a.CrossRefPubMedGoogle Scholar
- 30.Combs AJ, van Batavia JP, Horowitz M, Glassberg KI. Short pelvic floor electromyographic lag time: a novel noninvasive approach to document detrusor overactivity in children with lower urinary tract symptoms. J Urol. 2013;189(6):2282–6. https://doi.org/10.1016/j.juro.2013.01.011.CrossRefPubMedGoogle Scholar
- 34.Chang, SJ, Chiang, IN, Hsieh, CH, et al. Age and gender-specific nomograms for single and dual post-void residual urine in healthy children. Neurourol Urodyn. 2013;32:1014–18.Google Scholar
- 35.Mostafavi SH, Hooman N, Hallaji F, Emami M, Aghelnezhad R, Moradi-Lakeh M, et al. The correlation between bladder volume wall index and the pattern of uroflowmetry/external sphincter electromyography in children with lower urinary tract malfunction. J Pediatr Urol. 2012;8(4):367–74. https://doi.org/10.1016/j.jpurol.2011.07.009.CrossRefPubMedGoogle Scholar
- 36.• Tangal S, et al. Evaluation of a new ultrasound measurement tool for the diagnosis of dysfunctional voiding in pediatric population: full/empty bladder wall thickness ratio. Urology. 2014;83(6):1369–72. The authors describe a new ultrasound measurement, the ratio of full to empty bladder wall thickness (F/E BWT) and compare it in 198 healthy children and 126 children with dysfucntional voiding. F/E BWT ratios were higher in children with dysfunctional voiding compared with healthy children and thus the authors conclude that this ratio may serve as a non-invasive tool for evaluating lower urinary tract symptoms in children.CrossRefPubMedGoogle Scholar
- 42.Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr, 2006;43(3):e1–13.Google Scholar
- 45.National Collaborating Centre for, W.s. and H. Children’s, National Institute for Health and Clinical Excellence: Guidance, in Constipation in Children and Young People: Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care. London: RCOG Press National Collaborating Centre for Women's and Children's Health; 2010.Google Scholar
- 46.Capitanucci ML, Camanni D, Demelas F, Mosiello G, Zaccara A, de Gennaro M. Long-term efficacy of percutaneous tibial nerve stimulation for different types of lower urinary tract dysfunction in children. J Urol. 2009;182(4 Suppl):2056–61. https://doi.org/10.1016/j.juro.2009.03.007.CrossRefPubMedGoogle Scholar
- 48.•• Quintiliano F, et al. Transcutaneous parasacral electrical stimulation vs oxybutynin for the treatment of overactive bladder in children: a randomized clinical trial. J Urol. 2015;193(5 Suppl):1749–53. The authors randomized 28 children with overactive bladder to received transcutaneous parasacral electrical stimulation versus oxybutynin. They found that parasacral transcutaneous electrical stimulation (TENS) was as effective as oxybutynin in treating overactive bladder and more effective than oxybutynin in treating constipation with less side effects.CrossRefPubMedGoogle Scholar