VESICOURETERAL REFLUX WITH BOWEL & BLADDER DYSFUNCTION. Dr. Vijayan Manogran Hospital Umum Sarawak, Kuching

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1 VESICOURETERAL REFLUX WITH BOWEL & BLADDER DYSFUNCTION Dr. Vijayan Manogran Hospital Umum Sarawak, Kuching

2 BOWEL & BLADDER DYSFUNCTION (BBD) Children with abnormal LUTS of storage, voiding or both and inclusive of OAB, UI, voiding postponement, underactive bladder and dysfunctional voiding Can include constipation and encoperesis Associated with VUR high risk of UTI & reduced rate of spontaneous resolution of VUR higher risk of renal injury

3 BOWEL & BLADDER DYSFUNCTION (BBD) Age of onset varies; commonly immediate post toilet training (may be seen prior and well after) Causes variable; commonly failure of ext sphincter +/- pelvic floor muscle relaxation high void pressures with incomplete bladder emptying (also similar for constipation) UTI & increased VUR

4 How About in Children < 2 years old (Infants) Almost 50% of infants with Grade III V VUR will have some form of bladder dysfunction i.e. high bladder capacity (dilated bladder dysfunction), overactive bladder or incomplete bladder emptying. (Bowel was not assessed) Sillen et al BJU 1999 Sillen et al J Urol 1999 Breakthrough UTIs are thus common in this group!

5 VUR & BBD in Children Does BBD change the natural history of VUR cf children without BBD? Does the child with BBD have a higher risk of renal injury or reduced success of medical / surgical treatment cf with child without BBD? No grading system for BBD! No standard description either

6 2010 AUA Reflux Guidelines Committee 15 articles from including 2039 children (75% females, 32% had concurrent BBD) VUR Resolution UTI With BBD Without BBD With CAP 31% 61% Endoscopic Sx 50% 89% Open Sx 89% 89% With CAP 44% 13% Open / Endo Sx 23% 5% Renal Cortical Abn % 13-15% May have included children with both storage disorders & DSD Now to improve surgical outcomes, pre-treat the BBD (Includes those with bladder training, anticholinergics, stool softeners in BBD group but the efficacy of each was not assessed)

7 AUA 2010 Recommendations Recommendation 1: Sx indicative of BBD should be sought in the initial evaluation. Recommendation 2: If clinical evidence of BBD is present, treatment of BBD is indicated, preferably before any surgical intervention for VUR is undertaken. There are insufficient data to recommend a specific treatment regimen for BBD, but possible options include behavioral therapy, biofeedback (appropriate for children > age five), anticholinergics, alpha blockers, and treatment of constipation. Monitoring the response to BBD tx to determine whether tx should be maintained or modified. Recommendation 3: CAP is recommended for the child with BBD and VUR due to the increased risk of UTI while BBD is present and being treated. HOW LONG?

8 Translate to Clinical Practice 4 year old girl with VUR with UTI? Hx looking for sx of BBD UTI recurrent? Any tx before? On CAP? If BBD +ve assess void and bowel habits Bristol Stool chart Paediatric Symptom Checklist (35 questions) UFEME and C&S Bladder diary (only > 5 yrs old & has bladder control; done for 14 days)

9 Type 1 Separate hard lumps, like nuts (hard to pass) Type 2 Sausage-shaped but lumpy Type 3 Like a sausage but cracks on its surface Type 4 Like a sausage or snake, smooth and soft Type 5 Soft blobs with clear-cut edges (passed easily) Type 6 Fluffy pieces with ragged edges, a mushy stool Type 7 Watery, no solid pieces, entirely liquid Figure 3 The Bristol Stool Form Score chart, which can be used to evaluate bowel dysfunction in children with vesicoureteral reflux. Permission obtained from Informa Healthcare Lewis, S. J. & Heaton, K. W. Scand. J. Gastroenterol. 32, (1997). Evaluating BBD in patients with VU When evaluating BBD in children with VU assessment include history and examinati (with culture if indicated), bladder diary (r and volumes voided, whether wet or dry), p ual urine volume (generally obtained by b Dysfunctional Voiding Symptom Score,3 Form Score (Figure 3),31 and uroflow (wi electromyography using patch electrodes) Bristol Stool Chart History and examination The AUA reflux guidelines recommend that symptoms indicative of BBD should b during the child s initial evaluation for VU urinary frequency, urinary urgency, prolo intervals, daytime wetting, perineal and holding manoeuvres (posturing to prev and constipation or encopresis.4,32 Add EAU guidelines state that detection of urinary tract dysfunction] is essential in tre with VUR (Table 3).6 Important points history that should be investigated includ of i ncontinence the frequency, volume during incontinent episodes, whether the in associated with urgency or giggle, whether

10 OVERALL MANAGEMENT Medical Behavioural modification (Bladder retraining, biofeedback) +/- Antibiotic prophylaxis Surgery Subureteral injection of bulking agents (endoscopic) Ureteral reimplantation

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12 THANK YOU