POLLAKIURIA
615
m e disorders in the absence of concurrent infec- tious disease: a 2-year-old male with onset of akinetic seizures 11 months following CNS "pro- phylaxis"; a 3-year-old female with generalized convulsions 11 months after "prophylaxis"; and a 7-year-old female with statrls epilepticus and fine motor incoordination 22 months after preventive CNS treatment. Cerebrospinal fluid glucose and protein were normal, and neither pleocytosis nor leukemic cells were found. Three additional pa- tients have complained of a self-limited syndrome lasting about one week of headache, somnolence, anorexia, and photophobia five to eight weeks fol- lowing completion of the course of irradiation and intrathecal methotrexate.
SUE
MCINTOSH, M.D.GREGG
T.
ASPNES, 1M.D. Department of Pediatrics Yale University School ofMedicine
333
Cedar Street
New Haven, Connecticut 06510
REFERENCES
1. Aur, R. J. A., Simone, J., and Hustu, H., et al.: Central nervous system therapy and combin- ation chemotherapy of childhood lymphocy- tic leukemia. Blood, 37:272, 1971.
2. Holland, J. F., and Glidewell, 0.: Chemother- apy of acute lyrnphocytic leukemia of child- hood. Cancer, 30: 1480, 1972.
3. Kay, H. E., Knapton, P. J., O'Sullivan, J. P., d al.: Encephalopathy in acute leukemia asso- ciated with methotrexate therapy. Arch. Dis. Child., 47344, 1972.
4. Pinkel, D., and Hernandez, K.: Drug dosage and remission duration in childhood lympho- cytic leukemia. Cancer, 27:247, 1971. 5. Simone, J. V., Holland, E., and Johnson, W.:
Fatalities during remission of childhood leu- kemia. Blood 39:759, 1972.
POLLAKIURIA
In contrast to symptoms of respiratory or gastrointestinal tract disease, it is relatively un- common for children to b e brought to physi- cians' offices or pediatric clinics with primary complaints referable to the urinary tract.' When children do present with such com- plaints, the most common symptoms are enure- sis, dysuria, oliguria (in association with acute febrile episodes), hematuria, polyuria, and pol- lakiuria.
Pollakiuria is a descriptive term which refers
to an increase in the frequency of urination during a specified time period. This symptom is distinct from polyuria, which is defined as the passage of an increased volume of urine during a specified time period. Although poly- uria and pollakiuria usually occur concomit- tantly, they may occur separately. T h e follow- ing case reports briefly summarize the history, physical findings and results of laboratory and radiologic investigation of four children who recently presented with a primary complaint of pollakiuria.
CASE
REPORTS Case 1An 8-year-old Caucasian male presented with a chief complaint of urinary frequency of one week duration. He was voiding small quantities of urine 30 to 40 times a day. There was no dysuria, noc- turia, polyuria, hematuria, or enuresis. There was no previous history of urinary tract disease. Toilet training was completed at 26 months of age with- out difficulty.
Physical examination was entirely normal. Dur- ing the examination the patient voided approxi- mately 10 ml of urine on three occasions. Each voiding was accompanied by some straining and a weak urinary stream. He was noted to be constant- ly fidgeting and appeared anxious. A urinalysis, urine culture, complete blood cell count (CBC), blood urea nitrogen ( BUN), serum electrolytes and blood sugar were normal. An intravenous pyelogram and voiding cystourethrogram failed to demonstrate any abnormality.
Upon completion of the evaluation for an or- ganic etiology of the patient's symptoms, a number of informal counseling sessions were held. A variety of interviewing techniques were employed. Although no specific areas of anxiety could be identified, the patient's symptoms abated during a six-week period of time. A follow-up visit six months later revealed the patient remained symp- tom free.
Case 2
A 6-year-old black female presented with a two- month history of pollakiuria, voiding small quan- tities of urine 25 to 30 times per day. There was occasional dribbling and dysuria. There was no history of fever, enuresis, nocturia, hematuria, straining with urination, or polyuria. There was no previous history of urinary tract symptoms. Toilet training had been completed by 22 months of age without incident.
Physical examination was normal with the ex- ception of slight irritation of the vulva region. Re-
A series of patient interviews was conducted employing the technique of projective doll play. Through these interviews it was learned that the child felt everyone paid attention to her when she was sick, that it felt "good to urinate, and that she would sometimes urinate when she was angry at her mother. The interviewer observed the pa- tient masturbating on several occasions. The pa- tient was counseled in alternative methods of ex-
pressing anger and gaining attention. The symp- toms resolved after two months of counseling and she was found to be asymptomatic eight months later.
Case 3
A 3%-year-old black female presented with a two-month history of pollakiuria, voiding small quantities of urine 20 to 30 times per day. In ad- dition, she experienced several episodes of encop- resis shortly after the onset of the pollakiuria. There was no history of difficulty with toilet train- ing, enuresis, dysuria, or previous history of urin- ary tract symptoms or disease. An interview with the patient's mother revealed that there was con- siderable marital discord. The mother felt that her husband rejected this child and gave all his at- tention to the patient's 5-year-old male sibling.:
The physical examination was entirely normal. Repeated urinalysis and urine cultures were nor- mal. A CBC, hemoglobin electrophoresis, and in- travenous pyelogram were normal.
The patient's symptoms disappeared 12 weeks after she was first seen at this facility. The disap- pearance of symptoms coincided with the parents' marital separation.
Case 4
A 12-year-old Haitian male presented with a three-year history of intermittent pollakiuria. When symptomatic he would strain to void small quantities of urine approximately 40 times per day. Physical examination was normal. Repeated urin- alysis, urine cultures, an intravenous pyelogram, voiding cystourethrogram, and cystoscopy were normal.
After a number of interviews with the patient it was learned that he had long-standing conflicts related to school. He volunteered that his fre- quency of urination was related to his level of anxiety. He did not accept medication or a referral to the psychiatry clinic. The patient was seen nine months later and still had pollakiuria. In addition, he had begun to experience headaches and ab- dominal pain when he was "nervous." He again refused treatment.
DISCUSSION
Conditions most frequently associated with polyuria (increased volume of urine) are di- abetes mellitus, diabetes insipidus, chronic renal diqease, sickle-cell disease, hypercalce-
mia, and primary or psychogenic polydipsia. T o recognize pollakkiuria (increased frequency of urination) t h e physician should b e aware of the normal voiding patterns. T h e following values can serve as a guide in assessing normal patterns of micturition: children 3 to
5
years of age void 8 t o 1 4 times per d a y(24
hours) with a n approximate volume of 6 0 0 t o700
ml; children
5
to8
years of age void6
to 12 times per d a y with a n approximate volume of 650 to 1,000 ml; a n d children8
to14
years of a g e void 6 to 8 times per d a y with a n ap- proximate volume of 8 0 0 to 1400 ml. These ialues are dependent upon the age of t h e pa- tient, fluid intake, and insensible water loss.Pollakiuria may b e a manifestation of t h e following conditions:
Genitourinary tract infections: Pollakiuria may result from urinary tract infections, b u t it is not a common presenting complaint. I t is en- countered more commonly in viral and chemi- cal cvstitis and urethritis than in bacterial in- fections. This symptom may also b e associated with vulvovaginitis.
Appendicitis:
An
inflamed retrocoecal ap- pendix may cause irritation of t h e right ureter and lead to pollakiuria, proteinuria, pyuria, and microscopic hematuria.Nephrolithiasis: Pollakiuria may occur dur- ing an attack of renal colic.
Concentrated acidic urine: A highly concen- trated acidic urine may irritate t h e urethra a n d result in p o l l a k i ~ r i a . ~
Pregnancy: During pregnancy t h e uterus may exert pressure o n t h e bladder a n d give rise to pollakiuria. This is most likely to occur during early pregnancy and near term.
Drugs: Antihistamines may cause pollakiuria and dysuria as side effects.3
Stephens et a1.4 described a transient
but
of- ten protracted phase of abnormal micturitional behavior which they termed t h e Sham syn- drome. T h e features of this clinical syndrome, which mimics urinary tract infections in symp- toms, are combinations of pollakiuria, urgency, precipitancy a n d hesitancy of urination, dy- suria, enuresis, and daytime wetting. These symptoms may b e on a psychogenic basis a n d may b e manifestations of anxiety, anger, or fear.POLLAKIURIA
617
examination, CBC, urinalysis, and urine cul- ture. If the results of this initial phase of eval- uation are normal, the physician must decide whether or not to proceed with further diag- nostic studies, such as an intravenous pyelo- gram, voiding cystourethrogram, urologic con- sultation, cystoscopy, and cystometrics. Before embarking on this- second phase of evaluation it is suggested that serious consideration be given to the possibility that the symptom is a manifestation of a primary psychologic dis- order. The detailed history should include the following questions: Is there a family history of urinary tract problems? Could this be a learned symptom? What are the parents' and the child's response to the symptom (is there acceptance, anger or concern)?-Was there an episode of psychic stress between 3 and
4
years of age, the time when bladder control is usually achieved? At what age was toilet train- ing initiated and was it achieved without dif- ficulty?The approach suggested by Green and Hag- gerty6 in the evaluation of psychogenic factors in children with recurrent abdominal pain is applicable to the child with pollakiuria. This approach includes considering the following factors: ( 1 ) Why did the family seek help at this time and whose idea was it?
( 2 )
How did the problem begin and when does it occur? ( 3 ) What does the parent feel is wrong?(4)
Are there any conscious gains?(5) Why was
this symptom selected? (6) What do the par- ents expect?Some other factors to be looked for are the presence of physical illness, hypochondriasis, or chronic illness in parents or siblings; mari- tal discord; psychologic illness in the parents; an unsatisfactory parent-child relationship; difficulty in handling aggressive, hostile, or sexual feelings; inappropriate sleeping arrange- ments; and school problems. Pollakiuria may b e a manifestation of acute or chronic emotion- al stress as illustrated in the patients reported. Therapy should b e aimed a t either relieving the stress or assisting the child in coping with stressful situations that are not easily resolved. The pediatrician is capable of providing ther- apy in many such cases, so long as his goals are reasonable. Senn and Solnit' have stated that the goal of most psychotherapy is not to restructure the patient's personality nor the im- possible goal of forever irradicating symptoms. By using his imagination, feeling, intuition,
and common sense blended with technical skill and experience in dealing with children, the physician can assess the nature and extent of the problem and something of its dynamics. By his personal relationship with the parent and the patient, the pediatrician should b e able to provide appropriate support.
SUMMARY
The distinction between polyuria and polla- kiuria is discussed and the causes of both symptoms are enumerated. Four cases of pol- lakiuria are presented, demonstrating that the etiology of pollakiuria may be on a psycho- social basis. In addition, a therapeutic ap- proach is recommended for physicians who may encounter such children and fail to dis- cover an organic basis for the symptoms.
RUSSELL S. ASNES, M.D.
RICHARD
L. MONES,
M.D.Pediatric Ambulatory Care Division Department of Pediatrics
Columbia University College of Physicians and Surgeons
and Babies Hospital
The Childrens' Medical and Surgical Center of New York.
New York,
New
York 10032
The authors wish to acknowldge the helpful suggestions of Dr. Jules Bemporad and Dr. Richard
E. Behrman.
ADDRESS FOR REPRINTS: (R.S.A.)
3975 Broadway, New York, New York 10032.
REFERENCES
1. Brease, B.B., Disney, F.A., and Talpey, W.: The nature of a small pediatric group prac- tice.
Pediatrics,
38: 264, 1966.2. Rubin, M.I.: The urinary system. In Nelson,
W.E., Vaughn, V.C., and McKay, R.J., eds.: Textbook of Pediatrics. Philadelphia: W.B. Saunders Co., 1969, p. 1107.
3. Goodman, L.S., and Gilman, A., eds,: The Pharmacological Basis of Therapeutics. New York: The Macmillan Co., 1971, p. 635. 4. Stephens, F.D., Whitaker, J., and Hewstone,
A.S.: True, false, and sham urinary tract in- fections in children. Med. J. Aust., 2:840, 1966.
5. Green, M., and Haggerty, R.J., eds.: Ambula- tory Pediatrics. Philadelphia: W.B. Saunders Co., 1968, pp. 225-228.
