Current Bladder Dysfunction Reports

, Volume 13, Issue 2, pp 56–65 | Cite as

Non-invasive Testing and Its Role in Diagnosis and Management of Children With Voiding Dysfunction

  • Jason P. Van Batavia
  • Andrew J. Combs
Pediatric Voiding Dysfunction (Douglas Clayton and John Thomas, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Pediatric 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.

Recent Findings

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.


Non-invasive testing Voiding dysfunction Pediatrics Uroflowmetry with EMG Urodynamics 


Funding Information

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

  1. 1.
    Sureshkumar P, Jones M, Cumming R, Craig J. A population based study of 2,856 school-age children with urinary incontinence. J Urol. 2009;181(2):808–15; discussion 815-6. Scholar
  2. 2.
    Vaz GT, Vasconcelos MM, Oliveira EA, Ferreira AL, Magalhães PG, Silva FM, et al. Prevalence of lower urinary tract symptoms in school-age children. Pediatr Nephrol. 2012;27(4):597–603. Scholar
  3. 3.
    Palmer LS. Evaluation and targeted therapy of voiding dysfunction in children. Urology. 2016;92:87–94. Scholar
  4. 4.
    Silay MS, et al. Evaluation of functional lower urinary tract dysfunction in children: are the physicians complying with the current guidelines? Sci World J. 2013;2013:341606.CrossRefGoogle Scholar
  5. 5.
    Feldman AS, Bauer SB. Diagnosis and management of dysfunctional voiding. Curr Opin Pediatr. 2006;18(2):139–47. Scholar
  6. 6.
    Farhat W, et al. The dysfunctional voiding scoring system: quantitative standardization of dysfunctional voiding symptoms in children. J Urol. 2000;164(3 Pt 2):1011–5. Scholar
  7. 7.
    Bower WF, Sit FKY, Bluyssen N, Wong EMC, Yeung CK. PinQ: a valid, reliable and reproducible quality-of-life measure in children with bladder dysfunction. J Pediatr Urol. 2006;2(3):185–9. Scholar
  8. 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. Scholar
  9. 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. Scholar
  10. 10.
    Dogan HS, Akpinar B, Gurocak S, Akata D, Bakkaloglu M, Tekgul S. Non-invasive evaluation of voiding function in asymptomatic primary school children. Pediatr Nephrol. 2008;23(7):1115–22. Scholar
  11. 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. Scholar
  12. 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
  13. 13.
    Benninga MA, Nurko S, Faure C, Hyman PE, St. James Roberts I, Schechter NL. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology. 2016;150(6):1443–1455.e2. Scholar
  14. 14.
    Bower WF, Yip SK, Yeung CK. Dysfunctional elimination symptoms in childhood and adulthood. J Urol. 2005;174(4 Pt 2):1623–7; discussion 1627-8. Scholar
  15. 15.
    Combs AJ, van Batavia JP, Chan J, Glassberg KI. Dysfunctional elimination syndromes—how closely linked are constipation and encopresis with specific lower urinary tract conditions? J Urol. 2013;190(3):1015–20. Scholar
  16. 16.
    Koff SA, Wagner TT, Jayanthi VR. The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children. J Urol. 1998;160(3 Pt 2):1019–22. Scholar
  17. 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. Scholar
  18. 18.
    Akbal C, et al. Dysfunctional voiding and incontinence scoring system: quantitative evaluation of incontinence symptoms in pediatric population. J Urol. 2005;173(3):969–73. Scholar
  19. 19.
    Altan M, Çitamak B, Bozaci AC, Mammadov E, Doğan HS, Tekgül S. Is there any difference between questionnaires on pediatric lower urinary tract dysfunction? Urology. 2017;103:204–8. Scholar
  20. 20.
    Schast AP, Zderic SA, Richter M, Berry A, Carr MC. Quantifying demographic, urological and behavioral characteristics of children with lower urinary tract symptoms. J Pediatr Urol. 2008;4(2):127–33. Scholar
  21. 21.
    Van Batavia JP, Fast AM, Combs AJ, Glassberg KI. The bladder of willful infrequent voiders: underactive or underutilized? J Pediatr Urol. 2014;10(3):517–21. Scholar
  22. 22.
    Brubaker L, Nager CW, Richter HE, Visco A, Nygaard I, Barber MD, et al. Urinary bacteria in adult women with urgency urinary incontinence. Int Urogynecol J. 2014;25(9):1179–84. Scholar
  23. 23.
    Drake MJ, Morris N, Apostolidis A, Rahnama'i MS, Marchesi JR. The urinary microbiome and its contribution to lower urinary tract symptoms; ICI-RS 2015. Neurourol Urodyn. 2017;36(4):850–3. Scholar
  24. 24.
    Chang SJ, Yang SS. Inter-observer and intra-observer agreement on interpretation of uroflowmetry curves of kindergarten children. J Pediatr Urol. 2008;4(6):422–7. Scholar
  25. 25.
    Wenske S, van Batavia JP, Combs AJ, Glassberg KI. Analysis of uroflow patterns in children with dysfunctional voiding. J Pediatr Urol. 2014;10(2):250–4. Scholar
  26. 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
  27. 27.
    Franco I, Franco J, Lee YS, Choi EK, Han SW. Can a quantitative means be used to predict flow patterns: agreement between visual inspection vs. flow index derived flow patterns. J Pediatr Urol. 2016;12(4):218.e1–8. Scholar
  28. 28.
    Clothier JC, Wright AJ. Dysfunctional voiding: the importance of non-invasive urodynamics in diagnosis and treatment. Pediatr Nephrol. 2017;
  29. 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. Scholar
  30. 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. Scholar
  31. 31.
    Glassberg KI, Van Batavia JP, Combs AJ. Can children with either overactive bladder or dysfunctional voiding transition from one into the other: are both part of a single entity? J Pediatr Urol. 2016;12(4):217.e1–8. Scholar
  32. 32.
    Van Batavia JP, Combs AJ, Glassberg KI. Short pelvic floor EMG lag time II: use in management and follow-up of children treated for detrusor overactivity. J Pediatr Urol. 2014;10(2):255–61. Scholar
  33. 33.
    Van Batavia JP, Combs AJ, Horowitz M, Glassberg KI. Primary bladder neck dysfunction in children and adolescents III: results of long-term alpha-blocker therapy. J Urol. 2010;183(2):724–30. Scholar
  34. 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. 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. Scholar
  36. 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
  37. 37.
    Godbole P, et al. Dynamic pelvic floor ultrasound for lower urinary tract symptoms in children--initial report on normative values. J Pediatr Urol. 2013;9(6 Pt A):950–4.CrossRefPubMedGoogle Scholar
  38. 38.
    de Jong TP, et al. Effect of biofeedback training on paradoxical pelvic floor movement in children with dysfunctional voiding. Urology. 2007;70(4):790–3. Scholar
  39. 39.
    Burgers R, de Jong TP, Benninga MA. Rectal examination in children: digital versus transabdominal ultrasound. J Urol. 2013;190(2):667–72. Scholar
  40. 40.
    Joensson IM, Siggaard C, Rittig S, Hagstroem S, Djurhuus JC. Transabdominal ultrasound of rectum as a diagnostic tool in childhood constipation. J Urol. 2008;179(5):1997–2002. Scholar
  41. 41.
    Klijn AJ, et al. The diameter of the rectum on ultrasonography as a diagnostic tool for constipation in children with dysfunctional voiding. J Urol. 2004;172(5 Pt 1):1986–8. Scholar
  42. 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
  43. 43.
    Leech SC, McHugh K, Sullivan PB. Evaluation of a method of assessing faecal loading on plain abdominal radiographs in children. Pediatr Radiol. 1999;29(4):255–8. Scholar
  44. 44.
    Ferguson CC, Gray MP, Diaz M, Boyd KP. Reducing unnecessary imaging for patients with constipation in the pediatric emergency department. Pediatrics. 2017;140(1):e20162290. Scholar
  45. 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. 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. Scholar
  47. 47.
    Lordelo P, et al. Transcutaneous electrical nerve stimulation in children with overactive bladder: a randomized clinical trial. J Urol. 2010;184(2):683–9. Scholar
  48. 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
  49. 49.
    Barroso U Jr, et al. Posterior tibial nerve stimulation vs parasacral transcutaneous neuromodulation for overactive bladder in children. J Urol. 2013;190(2):673–7. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of UrologyChildren’s Hospital of PhiladelphiaPhiladelphiaUSA
  2. 2.Department of UrologyNew York Presbyterian-Weill Cornell Medical CenterNew YorkUSA

Personalised recommendations