WHY IS IT IMPORTANT?
Bladder and bowel dysfunction (BBD) is a term used to describe a spectrum of lower urinary tract symptoms (LUTS) and associated bowel complaints (constipation and/or encopresis) (1). It is a common, but under-recognized problem encountered by general paediatricians. Most cases are due to functional voiding disorders and constipation, rather than secondary or organic causes (1). BBD symptoms can negatively impact a child’s quality of life; thus, timely diagnosis and management are essential.
PRACTICAL TIP #1: CLINICAL ASSESSMENT OF BBD
Begin by obtaining a detailed clinical history of voiding routines, LUTS (i.e., frequency, dysuria, and enuresis), and prior urinary tract infections (UTI). Recognize overactive bladder symptoms including incontinence, urinary urgency, and holding manoeuvres (i.e., crossing of legs) (1). Requesting and reviewing voiding and bowel diaries (48 to 72 hours duration), a Bristol Stool Scale, and fluid/dietary intake can help to objectively identify patterns of BBD symptoms (1). Be aware of red flags that may suggest an underlying organic cause (Table 1). As there is a known association between BBD and neuropsychiatric disorders (i.e., anxiety, hyperactivity) (2), it is important to inquire about behaviour difficulties. Social history of recent life stressors and screening for sexual abuse should be considered.
Table 1.
Sign/Symptoms that may suggest possible organic causes of bladder and bowel dysfunction (BBD)
| Signs/Symptoms (red flags) | Possible organic etiology of BBD |
|---|---|
| Constant dampness, continuous incontinence/dribbling | Duplex kidney with ectopic insertion of ureter (girls), neurogenic bladder |
| Excessive thirst or drinks an excessive amount of water | Diabetes mellitus, diabetes insipidus, kidney disease |
| Female with pain in straddle position, dribbling postvoid, abnormal fused labia | Labial adhesion |
| Male with ballooning during micturition, urine pooling under foreskin, tight foreskin | Phimosis or paraphimosis |
| Cutaneous signs of spinal dysraphism (sacral dimple, deviated gluteal cleft, hair tuft) | Neurogenic BBD (cord tethering, spina bifida/meningomyelocele, spinal tumors) |
| Neurological deficits (i.e., saddle numbness and tingling, or weakness in arms or legs) | Neurogenic BBD (spinal anomalies, transverse myelitis, central nervous system disease) |
| Recurrent febrile urinary tract infections | Vesicoureteral reflux |
| Weak urinary stream | Neurogenic causes of BBD Posterior urethral valve |
Sign/Symptoms (red flags) on clinical history that may suggest possible organic causes of bladder bowel dysfunction (BBD).
Complete physical examination is important for identifying potential anatomical causes of BBD (1). Specifically, it should include external genitalia assessment for anomalies (i.e., physiologic and pathologic phimosis in males and labial adhesions in females). Focused abdominal exam and exam of the perianal area may be helpful to rule out organic causes of constipation (i.e., anorectal malformations), but digital rectal exam is usually not indicated. A neurological exam must be completed with careful attention to the lumbosacral area for spinal dysraphisms and any neurological deficits particularly in the lower extremities.
A comprehensive history/physical form has been developed to help guide clinicians in assessing BBD (Supplementary File, ref. (3)).
PRACTICAL TIP #2: DIAGNOSTIC INVESTIGATIONS
Investigations are not routinely indicated if the clinical history and physical exam are suggestive of a functional cause of BBD (4). Patients with LUTS should have urinalysis completed. If there are active UTI symptoms at the time of the visit, urine culture should be sent. Renal and bladder ultrasounds are indicated in patients with febrile UTI under 2 years old, recurrent culture-positive UTIs in older patients, and suspected urinary tract anomalies (i.e., ectopic ureter) (4). If neurological concerns are present, MRI spine should be considered. Plain film x-rays are not typically indicated for assessing constipation. Additional investigations such as uroflowmetry studies and renal scans should only be done with specialist consultation.
PRACTICAL TIP #3: MANAGEMENT OF BBD
The general paediatrician’s office is an ideal setting for the initiation of BBD treatment and begins with bladder and bowel retraining and behavioural modification strategies including the following components (4):
1) Timed voiding—Encourage scheduled void every 2 to 2.5 hours while awake; emphasize proper technique (i.e., toilet posture, sitting, and double void); a vibrating watch may be a helpful reminder and promote independence.
2) Routine hydration—Adequate fluid intake of minimum 6 to 8 cups of water a day; instruct ‘drink a cup of water after every void’.
3) Constipation management (5)—Balanced diet (whole grain, fruits, and vegetables; concomitant and consistent use of stool softeners (PEG 3350) and bowel clean out when necessary.
4) Education resources—BBD symptoms can lead to significant psychosocial distress for families. Begin by educating children and families about normal urination and stooling using educational materials (6). Ongoing familial support is essential for treatment adherence.
Patients with comorbid neuropsychiatric conditions may present with more severe and challenging BBD symptoms. These children should have active involvement of psychology or psychiatry to optimize their response to therapies.
Patients with active UTIs should receive antibiotics, and routine prophylaxis may be considered if there is significant vesicoureteral reflux, or reserved after specialist consultation. Anticholinergics should be avoided in the initial phase.
While most children with BBD will respond to these behavioural strategies, referral to a specialist with expertise (e.g., urology, nephrology) is indicated in refractory cases with no response after 6 months or those with severe symptoms or red flags.
SUMMARY OF PRACTICAL TIPS
In the assessment and management of paediatric BBD, clinicians should:
Be aware of red flags (Table 1) that suggest an organic or anatomical cause.
Screen for neuropsychiatric symptoms and psychosocial stressors; consider involving involve psychology and psychiatry.
Perform an external genital exam and neurological exam.
Check urinalysis when LUTS are present; no additional investigations are generally indicated.
Initiate management early with bladder and bowel behavioural modification strategies.
ACKNOWLEDGEMENTS
The authors would like to acknowledge Megan Saunders, Yara El-Bardisi, and BBD network physicians.
Funding: There are no funders to report for this submission.
Potential Conflicts of Interest: The authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
References
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