Urological Association guideline for the treatment of bladder dysfunction in children

Bladder and bowel dysfunction (BBD) is one of the most common reasons for referral to pediatric urology clinics, responsible for up to 40% of clinic consults.1 BBD describes a constellation of symptoms related to voiding and defecation without a neurogenic or anatomic cause. The association of bowel and bladder symptoms is well-described.2 The lower urinary tract symptoms (LUTS) include storage type, such as urgency, frequency, and urge incontinence, or voiding type, such as hesitancy, slow urinary flow, and intermittency. Gastrointestinal symptoms include constipation and encopresis. The term BBD is applied to a heterogeneous group of clinical presentations. Some children present primarily with frequency, urgency with or without incontinence; others postpone their urination and do not empty their bladder. In an effort to standardize the terminology related to BBD, its subtypes and symptoms, the International Children’s Continence Society (ICCS) has published a classification, which is gaining more acceptance in pediatric urology literature.3 We have strived to align this guideline with this classification. BBD is a known risk factor for urinary tract infection (UTI) and vesicoureteral reflux (VUR).4 Many studies have shown the importance of BBD management in prevention of UTIs and treatment of VUR.5 BBD is associated with reduced quality of life and significant psychosocial burden for children and families.6 It is not uncommon for children with BBD to be stigmatized and bullied. Mood disorders and anxiety are also seen in these children.7 BBD is a clinical construct. Many different validated questionnaires, such as the Dysfunctional Voiding Symptom Score (DVSS) and Vancouver Symptom Score, have been designed in an attempt to standardize the diagnosis, classify the type, and evaluate the severity of this complex clinical diagnosis. These instruments have also been used to follow clinical response to treatment.8-10 The treatment of bowel dysfunction is an essential part of the overall management and should not be overlooked. The scope of the current guidelines is limited to the management of the lower urinary tract. The purpose of these guidelines is to identify the best available evidence regarding the management of BBD in children, assess the level and quality of the evidence, and generate recommendations for clinicians.