OAB DV urotherapy - Department of Paediatrics and Child Health

Urotherapy for childhood
dysfunctional voiding and
OAB
Tuesday 14th February, 2012, 9.20-10.00am
Urotherapy
•  Urotherapy means non-surgical, non-pharmacological
treatment for LUT dysfunction.
•  Non-standardised term
•  Described as ‘rehabilitation of LUT’
•  Involves
• Education
• Intervention
• Life-style advice
• Documentation
• Support and encouragement
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Aims of Urotherapy
•  Normalise bladder emptying
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-> decreased bladder overactivity
Normalise bladder filling
Facilitate age-appropriate storage
Facilitate optimal bowel function
Normalise defaecation dynamics
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Treatment: Goals
•  No more symptoms
•  urgency, wetness
•  No more signs
• ↑PVR, high pdet, +ve EMG during voiding
•  Normalised flow curve
•  PFM relaxation during void
•  Normalised bladder capacity
•  No further episodes of UTI
•  Reduction in grade of VUR
•  Normal bowel function
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Urotherapy: Patients
•  Significant morbidity without treatment
in 40% children:
•  high detrusor pressure
•  destabilised micturition reflex
•  UTI
•  VUR
•  upper tract damage
•  constipation
•  hypocontractile detrusor
•  renal failure
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Urotherapy: Patients
•  Collateral damage:
• self-esteem
• self-worth
• isolation
• confidence
• socialization
• QoL
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Behavioural co-morbidities
......... “comorbid disorders interfere with treatment for
enuresis/incontinence. Affected children show lower
compliance and treatment results are lower.
Therefore, children with incontinence should be screened for
psychological disorders even in pediatric and urological
settings.
Children with a severe condition should be referred to the
mental health service (child psychiatrists and child
psychologists).An interdisciplinary approach is needed for
optimal care in daytime wetting children.”
• Kuhn et al. Journal of Urology, 182(4 Suppl), 1967-1972.
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• Screening all children • A • L • T • E • R • N • A • T • I • V • E • History, observa6on, explora6on • Short screening ques6onnaires • Problem items/behaviours present? • NO • YES • Standard long ques6onnaires • Problem items/behaviours present? • Treatment of •  enuresis/incon6nence only • NO • YES • Full child psychiatric/ psych assessment • Child psychiatric disorder present? • YES • Treatment of disorder • In addi6on to NE/incon6nence ICCS slide library v1 2011
• NO • Counselling in addi6on to •  treatment of •  enuresis/incon6nence Questionnaires
•  Short
–  Short screening instrument for psychological problems in
enuresis. SSIPPE (Van Hoecke 2007) Validated. 13
items. Yes/no
–  Parental Questionnaire Enuresis/Urinary Incontinence
(von Gontard 2003) Non-validated. 15 items. Yes/no
•  Standard long CBCL (Achenbach 1991) 113 items
•  QoL –generic, disease specific eg PinQ (Bower et al.
2006)
•  Other
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Working with children
•  Education, education, education
•  Understand the pace of assessment and treatment is slower
•  Let the family know at the outset ‘this takes time’
•  The child is your collaborator - in assessment and treatment
•  Treatment is not ‘done’ to the child – he/she participates
•  The child is the focus- not the problem
•  Understand different behaviours eg a withdrawn child, de-motivated child,
•  Offer structured choices, achievable goals. Set the child up for success
not failure
•  Remove blame and guilt for every-one
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Treatment Components
Assessment
Re-assessment
Intervention
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Education
Motivation
Removal of shame
and blame
• Put Documentation
in place
• BECAUSE
• Chronicity
• Motivation
• Relapse
• Ongoing assessment
• Measure outcomes
•  PROGRESS NOTES
•  Child’s name___________________________
•  Date of consultation_____________________
•  Diagnosis______________________________
•  Results
•  Test results______________________________________________________________
•  ________________________________________________________________________
•  Bladder diary
•  Voiding frequency □ <4/day
□ 4-8/day
□ > 8/day
•  Fluid intake _____________________________________________________________
•  MVV_______ Ave.VV________1st am void____________O/N urine vol_____________
•  Wetting
•  ______nights/week _______times/night □ damp □ wet □ flooded
•  ______days/week
-------_______times/day □ damp □ wet □ flooded
•  Medications taken ________________________________________________________
•  ________________________________________________________________________
• 
•  Alarm diary
•  _____ dry nights/week Alarm __________times/night. ____________nights/week.
•  Time/s of alarm_________________ Waking to alarm YES NO With help YES NO
•  Size of wet patch
□ small
□ medium □ large
•  Problems________________________________________________________________
•  Bowel diary
•  Bowel actions ________/day ________/week
BSS ____________________________
•  □ Self-initiated
□ Sits
•  Soiling YES / NO
□ Stain □ Scrape _________/day _________/week
•  Parent’s compliance □ good
□ fair
□ poor
□ N/A
•  Child’s compliance □ good
□ fair
□ poor
□ N/A
•  Progress overall __________________________________________________________
•  ________________________________________________________________________
•  Today’s Flow/scan pattern_______________ MFR_________ml/sec PVR_______ mls
Urinalysis_________________________
•  Further management/problems_________________________________________________
__________________________________________________________________________
•  Further referrals_____________________________________________________________
•  Name
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Signature
Treatment: Education
•  ? child’s understanding of bladder
structure and function
•  Don’t assume child / parents
understand LUT
•  Age-appropriate explanation of
•  anatomy
• aetiology of specific dysfunction
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Treatment: Education
•  What is not associated with disorder
• laziness, naughtiness, dirtiness, low IQ
•  Attribute dysfunction to external factors
•  Establish prevalence in realistic context
•  Explore motivation
•  Establish child as co-investigator and collaborator
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First-active bowel management
• For 6 months minimum
• Hygiene, correct wiping, containment
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Treatment: “Standard Therapy”
•  Routine hydration
•  Regular, optimal voiding
•  Pelvic floor muscle awareness
•  +/- pharmacotherapy
•  +/- biofeedback training
•  +/- neuromodulation
•  +/- alternative / holistic intervention
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“Standard Therapy”
•  Routine hydration
• Often voluntary dehydration
• Re-set high set-point for thirst
• Drinks of 200mls +/- age -dependent
•  5-6 / day
• Dilutes concentrated (? irritating) urine
• Avoid sugar and caffeine
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“Standard Therapy”
•  Regular voiding:
• Every 2-3 hours
• May need vibrating alarm watch
• Prevent over-distension (including overnight)
• Re-establish sensory awareness
• Minimised OAB activity -> leakage
• Must be unopposed emptying
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PFM Relaxation
Let’s first identify
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Correct PFM action
“lift”
Co-contraction of lower Trans versus Abs, NOT Rectus Abs
Lower chest breathing
• From
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Raizada
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2011 V & Mittal RK. Pelvic floor anatomy and applied physiology. Gastroenterol Clin N Am. 2008,37: 493-509
Treatment: PF relaxation
•  Learn to contract and relax the PF muscles
•  Without valsalva / accessory muscles
•  Practice of correct recruitment +/- any form of
biofeedback
— Therapist Palpation/observation
— Lower transversus abdominis
— Perineal body/lift
— Med’l border ischium
— Muscle balance between PFM and upper abdominals-observe
breathing/abd’l action
•  Child palpation/observation
•  Self-palpation of PF or transverse abdominus
•  Watching abdomen in mirror and identifying rectus activity
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PFM Relaxation
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Pelvic floor muscle: awareness and relaxation
• Sufficient awareness to practise correctly
• Apply during initiation of void
• Apply throughout void
• Apply during defaecation
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PFM Relaxation
•  Optimal voiding mechanics
•  Supported seating / squatting
•  Neutral lumbar spine
• ? Foot position
•  Feet on stool; knees apart
•  Prevent urine entrapment
•  No pushing
•  Focused abdominal relaxation
•  Aim for a “waterfall” void
•  ? Double void
• Poor lumbo-thoracic posture
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PFM Relaxation
•  +/- biofeedback during
voiding
• Real time uroflow
• Auditory feedback
• EMG
• Abdominal ultrasound
• Post void ultrasound for
residual volume
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Use of TAUS
PFM relaxation
• PFM contraction
•  5year-old girl
• Bladder neck ‘lift”
• SAGGITAL VIEW
• Rectus abdominis
• Transversus abdominis
• Bladder neck
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Use of TAUS
Measure rectal diameter
• Measurement of rectal diameter illustrated by Singh et al (2005)
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Treatment OAB
Pharmacotherapy
•  When to supplement standard therapy with
anticholinergics:
• Idiopathic OAB with no evidence of dysfunctional
emptying
• OAB with concurrent VUR or RUTI
• Very small FBC
• Properties: anti-muscarinic, local anaesthetic, SM
relaxant
• S/E: personality changes, headache, blurred vision,
constipation, dry mouth, flushing
Monitor bladder emptying and constipation
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Treatment
Pharmacotherapy
•  Other medications
•  alpha-blockers: for dysfunctional bladder neck; may
be used when PFM retraining doesn’t improve PVR
• Botulinum toxin A
•  Antibiotics
Treatment of UTI (of course)
Long-term prophylaxis in some children with recurrent UTIs due to
residual urine
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Recent review articles:
•  Barroso, U., Jr., Tourinho, R., Lordelo, P., Hoebeke, P., & Chase, J.
(2011). Electrical stimulation for lower urinary tract dysfunction in
children: A systematic review of the literature. Neurourology and
Urodynamics.
•  De Gennaro, M., Capitanucci, M., Mosiello, G., & Zaccara, A. (2011).
Current State of Nerve Stimulation Technique for Lower Urinary Tract
Dysfunction in Children Journal of Urology, 185, 1571-1577.
•  Barroso, U., Jr., Hoebeke, P., Van Laeke, E., De Gennaro, M., Fox, J., &
Chase, J. (2011). Electrical Stimulation for Lower Urinary Tract
Dysfunction. Dialogues in Pediatric Urology, 32(4).
30
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Urotherapy
Neuromodulation
•  Neuromodulation for OAB
• Increases release of neurotransmitters à
• ↓cholinergic activity
• ↑ beta adrenergic activity (-> relax bladder vault)
• VIP, serotonin
•  Inhibition of OAB: 5-10Hz
• TENS –pudendal afferents, S2,3 foraminae,
S3 dermatome
• SANS/PTNS (20Hz)
• Electro-acupuncture
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Urotherapy
Neuromodulation
—  Contraction of detrusor:
—  Intravesical stimulation
—  Bladder pain
—  Suprapubic or spinal
—  Pelvic floor/sphincter strenthening
—  Anorectal malformation
—  Pelvic floor relaxation
—  Not routinely used for sensory awareness
—  ? Perineal / anal electrode
—  Adjunctive- not stand-alone therapy
—  Training in electrotherapeutics prerequisite for clinical use
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Urotherapy
Neuromodulation Efficacy
• No known predictors of efficacy
• Most studies pre/post intervention series
• Sans- 50-80% improvement in clinical refractory OAB
symptoms (De Gennaro M et al. 2004.,Hoebeke P et al 2002)
• For OAB Tens -clinical changes:
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Significant decrease number wet episodes
Significant decrease urge intensity
Significant improvement in FVC parameters
Significant improvement in U/D parameters
• Electrical Stimulation for Lower Urinary Tract Dysfunction in Children. A Systematic Review of the Literature.
Ubirajara Barroso J, Rafael Tourinho, Patrícia Lordêlo, Janet Chase, Piet Hoebeke
Neurourol Urodyn 2011 (in press)
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Urotherapy
Neuromodulation Efficacy
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Hagstrom et al. report on RCT
Tens refractory daytime urinary urge incontinence
N=27
The active group had a significantly greater decrease in daily
incontinence episodes compared to the sham treated group (p
<0.01)
•  No change in MVV or AVV ? Changes related to sensory
mechanisms
•  First line treatment (Lordelo et al)
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Hagstroem et al., 2009. J Urol, 182(4 Suppl): p. 2072-8.
Lordelo et al. 2009 J Urology, 182(6), 2900-2904.
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Urotherapy
Neuromodulation Efficacy
— IVS - neurogenic and idiopathic detrusor
underactivity -voiding was normalised in 85% effect long lasting in 72%; idiopathic > neurogenic
(Gladh G et al 2003)
— Efficacy requires:
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patient co-operation
preserved reflex arc
compliant bladder
active detrusor fibres
total or partial integrity of PFM innervation (Fall & Lindstrom 1991)
• Gladh, G., Mattsson, S., & Lindstrom, S. (2003). Neurourology and Urodynamics, 22(3), 233-242
• Fall, M., & Lindstrom, S. (1991).Urologic Clinics of North America, 18(2), 393-407.
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Urotherapy
Neuromodulation neurogenic bladder
•  Different outcome measures – difficult to collate studies
•  Some improved bladder storage
•  Some improved emptying
•  Minimal improvement in continence
•  1 RCT using IFT - with significant improvement in all UDS
parameters except for maximum bladder capacity and
significant improvement in continence in treatment group
( Kajbafzadeh et al 2009)
• Kajbafzadeh et al. (2009).Urology, 74(2), 324-329.
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Urotherapy
Neuromodulation Bowel
Sacral Tens –clinically bowel sensation improves but not studied
•  RCT -Transcutaneous electrical stimulation using IFC increased bowel
motility, decreased bowel transit time, pain and soiling and improved
physical QoL in children with STC.
•  Daily home-based IFT further improved defaecation frequency
•  Pilot study IFT lumbo-sacral placement of electrodes–sig >se def’n no,
improvement in abd’l pain
•  SN implantation – children with bladder and bowel dysfunction,
constipation
•  improved in 12 of 15 patients (80%)
•  7 (41%) had resolution
• Clarke et al. 2009J Pediatr Surg, 44: 408
• Ismail et al. 2009 J Pediatr Surg, 44: 2388
• Humphreys et al. 2006 J Urology, 176(5), 2227-2231
• Roth et al. 2008 J Urology, 180(1), 306-311 (discussion 311).
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Neuromodulation: Summary
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Positive role for neuromodulation in children with LUTD
Adjunctive to other intervention
No known predictors of efficacy
Understanding of electrotherapeutics is a prerequisite for
clinical use
•  Neuromodulation of the bowel shows promise
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Urotherapy
Clean intermittent catherisation
•  The friend of the upper tracts
•  Assist in bladder emptying
•  Assist in reducing high detrusor pressures
•  Can be introduced through stoma
•  Very young children can learn to use
•  Essential with neurogenic bladder, earlier commencement ->
better protection
•  Bladder underactivity, ↑PVR, recurrent UTI, wetting
•  Prevent overdistension day and night
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Urotherapy
Urethro-vaginal reflux
•  Post-void dampness
•  24 hours of reverse toileting ie facing wall/cistern -may be
diagnostic
•  Teach the child to void with anterior pelvic tilt
•  Knees well apart
•  So urinary stream directed down, not back
•  Increasing IAP ie. cough at end of voiding will help vagina
empty
• Mattsson, S. and G. Gladh Pediatrics, 2003. 111(1): p. 136-9.
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Urotherapy
Troubleshooting
•  Specifics of problems
•  Strategies to change situation in future
• Action by child
• Action by teacher / parent / other
• Who needs to facilitate change
•  Contact with teacher
•  Containment advice in key situations
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Urotherapy
: Review
•  “.. frequent follow-up with emotional support and
encouragement .. important components of
intervention” (Longstaffe et al 2000)
•  Irrespective of treatment success
•  How frequent: depends on
• Type of intervention
• Feedback / measures needed
• Child’s motivation
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Urotherapy
Outcome Measures
•  Realistic and achievable
• improved hydration: e.g. finish drink bottle
• regular voiding
• completion of FVC / bowel diary
• use of watch alarm
•  Unambiguous:
• Quantified
•  Precise: e.g. wet patch or dried wet patch
•  Validated and reliable
• LOOK AT ICCS WEBSITE
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Urotherapy
Efficacy
•  Evaluate by resolution of symptoms
• Incontinence episodes / pads used
• Urge episodes
• UTI
• Faecal soiling
• Psychological effects and QoL
•  Resolution of signs
• Bladder emptying efficiency (incl. PVR)
• Bladder wall changes
• Dyssynergic voiding pattern
• Grade of VUR
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Urotherapy approaches are significantly better than historical
results utilising anticholinergic medication alone
Urotherapy effective in decreasing urinary tract infections,
improving constipation, and decreasing the need for
intervention in patients with vesicoureteral reflux
• Bauer et al.1980. Urologic Clinics of North America, 7(2), 321–361.
• De Paepe et al. 1998) British Journal of Urology, 81(Suppl 3), 109–113.
• Herndon, C. D., Decambre, M., & McKenna, P. H. 2001Journal of Urology, 166(5), 1893–1898.
• McKenna, L. S., & McKenna, P. H. 2004 Journal of Wound, Ostomy and Continence Nursing, 31(6), 351–356.
• McKenna, P. H., & Herndon, C. D. 2000 Curr Opin Urol 10(6): 599-606. Current Opinion in Urology, 10(6), 599–606.
• van Gool, J. D., & Vijverberg, M. A.1992 Scandinavian Journal of Urology and Nephrology, 141(Suppl), 93–103.
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For how long?
•  Till symptoms or signs have resolved
•  Till the child is happy
•  Till the family is happy
•  Till the bladder is “normal” as you can make it
•  Till the upper tracts are at least risk
•  Bowel function is normal or actively managed
•  AND if there is likely to be change/deterioration you will
know about it because of recall appointments
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