Voiding difficulties are frequent in preschool age children due todelay in maturation of bladder and micturition pathways. Normal micturition and continence rely on structural UT integrity,neurologic maturation, and coordination between somatic andautonomic nervous system units, including the central nervoussystem, spinal cord pathways, nerves innervating the bladder/urinary sphincter, and the autonomic system. Daytime continence is usually achieved before nighttime continence. Mostchildren are dry, day and night, by 4 to 5 years of age. Nocturnalenuresis is the involuntary loss of urine during sleep. Childrenwith primary enuresis have never had a prolonged (usually >3months) span of nighttime continence. Up to 10% of 5-year-oldchildren have primary enuresis with 15% spontaneous resolution per year. Boys are affected more than girls with increasedincidence in families (40% at 6 years of age if one affected parent, 70% if two affected parents). Secondary enuresis involvesloss of nighttime control after an extended period of drynessand generally requires evaluation to uncover the cause.
Decision-Making Algorithm Available @ StudentConsult.com Clinical Manifestations
Dysfunctional voiding (DV) may manifest as incontinence, fre- quency, urgency, hesitancy, dysuria, lower abdominal pain, or recurrent UTI. Symptoms may vary over time and be associatedwith obvious neurologic problems (spinal cord injury, encephalitis), constipation, and/or behavioral problems. DV symptomsmay vary, depending on recent UTI or changes in family orschool life/stressors. The majority of children with DV are anatomically, neurologically, and psychologically normal.
Evaluation for DV may be performed at any age, but isolatedurinary incontinence in an otherwise normal child is notusually evaluated until 5 years of age. A urinalysis and urineculture should be done to exclude occult infection and renal disease. Children with daytime incontinence should undergorenal/bladder ultrasound to exclude structural abnormalities. Urodynamic evaluation is typically reserved for childrenwith a suspicion of neurogenic bladder or known neurologicetiology.
For children with recurrent UTI, prophylactic antibiotics may be useful. Timed voiding and anticholinergic medications are used to treat bladder hyperactivity and sensory defects. More complicated treatment regimens include biofeedback, α-blockers, and intermittent catheterization. For children with simple primary enuresis, the bed wetting alarm provides safe and effective resolution of the problem for greater than 70% of affected children; medical therapy with anticholinergics, imipramine, or DDAVP may also be used in selected children.
Hypospadias occurs in approximately 1 in 500 newborn infants. In this condition the urethral folds fail to fuse completely over the urethral groove leaving the urethral meatus located ventrally and proximally to its normal position. The ventral foreskin is also lacking, and the dorsal portion gives the appearance of a hood. Severe hypospadias with undescended testes is a form of ambiguous genitalia. Etiologies include congenital adrenal hyperplasia with masculinization of females or androgen insensitivity. UT anomalies are uncommon in association with hypospadias. Hypospadias may occur alone, but in severe cases can be associated with a chordee (a fixed ventral curvature of the penile shaft). Rarely when the urethra opens onto the perineum, the chordee is extreme, and the scrotum is bifid and sometimes extends to the dorsal base of the penis.