Urinary Tract Damage in Children Who Wet

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Urinary

Tract

Damage

in Children

Who

Wet

Frank Hinman, M.D., F.A.A.P.

Frum the Division of Urology, University of california School of Medicine. San trancisco

ABSTRACT. A complex is described herein, consisting of the

symptoms of urinary and often fecal incontinence, and the

findings of disturbed structure and evacuating function of the

urinary tract, with resultant infection. Emotional imbalance

alters vesicourethral function both physiologically and

path-ologically, and results in poor coordination between

contrac-tion of the detrusor and relaxation of the external sphincter,

similar to the effects of neurogenic disorders. We have

named this condition nonneurogenic neurogenic bladder. If

surgical correction of this structural damage is to succeed it

must follow restoration of coordinated voiding, brought

about by a program of anticholinergic drug administration,

antibacterial therapy, correction of constipation, parental

instruction, and finally strong suggestion often including

hypnosis. Pediatrics, 54: 142, 1974, URINARY/FECAL

INCON-TINENCE, URINARY TRACT DAMA(;, EMOTIONAL IMBALANCE,

UNCOORDINATED VOIDING, THERAPY-CHEMOTHERAPY,

P5Y-CHOTHERAPY (HYPNOSIS).

incontinence and encopresis. Recurrent infections

began when he was 7. After a neurologic

examina-tion revealed no abnormalities, a voiding

cysto-gram was done: the bladder outlet was open but

the bladder was trabeculated. The kidneys

showed chronic pyelonephritis associated with

bi-lateral reflux. After nonsurgical treatment (which

will be discussed below), his wetting stopped and

the condition of his upper urinary tracts improved

appreciably.

This boy’s symptoms, added to the findings of

the diagnostic study, did not demonstrate an

oh-structive or neurogenic basis; could they have a

central or emotional origin and be caused by

in-coordination between the detrusor and the

votun-tary sphincter?

When a boy has both incontinence and urinary

tract damage, a common explanation is difficult to

find for the symptom of wetting and the findings of

the vesical, ureteral and renal changes usually

ob-served in neurologic or obstructive disorders. If a

neurologic defect (from meningomyelocele for

in-stance) or an obstructive lesion (such as urethral

valves) is detected, therapy, usually surgical, will

be directed at the cause. However, if the results of

neurologic examination are negative and a

void-ing cystogram shows no obstruction at the vesical

neck or in the urethra, little good can be expected

from a plastic repair which corrects the structural

abnormalities, because the basic reasons behind

the anomalies still exist. These forces continue to

act and will eventually destroy the repair as they

destroyed the original normal structures.

The problem in diagnosis is exemplified in a boy

who had wet the bed until he was 6 years old, then

continued to have urinary urgency with daytime

PHYSIOLOGICAL CONSIDERATIONS

Coordinated and Incoordinated Micturition

In earlier studies’ using rapid sequence

radiog-raphy, we observed that as the perineum descends

and the external sphincter relaxes, the detrusor

si-multaneously begins its contraction (Fig. 1).

Con-versely, on cessation of urination, the perineum

and external sphincter contract, and the detrusor

then relaxes in a reflex action (Fig. 2). During an

urge to void, on the other hand, the detrusor is

contracting. Voluntary effort is required to hold

up the perineum and maintain contraction of the

(Received January 2; accepted for publication February 20, 1974.)

Read before the anmial meeting of the American Academy

of Pediatrics as the John K. Lattimer Lecture, Chicago,

Oc-tol)er 22, 1973).

ADDRESS FOR REPRINTS: Division of Urology, 1-478,

(2)

A a

A A

FIC. 1. Tracing of bladder contour during initiation of

void-ing. Note that contraction of the detrusor is coordinated

with descent of the bladder base.

external sphincter (Fig. 3). When the external

sphincter cannot be held voluntarily this

“un-physiologic” situation contributes to urgency

in-continence. Repeated forceful detrusor

contrac-tions against a closed sphincter lead to

hypertro-phy of the vesical wall with concomitant changes

in trigone and ureteral orifices, and ultimately to

upper tract damage.

Studies in our laboratory2 have shown that, if

the closure forces which reside in the urethral

high pressure zone remain elevated instead of

fall-ing before detrusor contraction, micturition is

in-complete. The reflex neurogemc bladder has a

similar functional response-but in this case from

nerve damage resulting in loss of central

coordina-tion of detrusor and perineum. This similarity is

demonstrated when pyelograms of a child with

neurogenic bladder secondary to

meningomyelo-cele (Fig. 4, left) are compared with those of the

boy without neurologic abnormalities cited above

(Fig. 4, right). No qualitative difference in the

changes of the urinary tract is seen.

Incoordina-tion has brought about similar end results in both

cases.

Role of Maturation

Maturation of central control mechanisms

un-doubtedly plays a rote in the achievement of

con-tinence in infants. Campbell’s ingenious studies3

showed that young rats void ten times more

fre-quently than mature animals (Table I). However,

F,u. 2. Same tracing during voluntary interruption of

void-ing. Note elevation of bladder base with relaxation of

de-trusor.

FIG. . Same tracing, with urge to void. The bladder base

is elevated, the bladder neck open and the detrusor

con-tracted.

TABLE I

FREQUENCY OF VOIDING vs. AGE OF RATS#{176}

Age Voidings per day

Childhood (to 12 weeks) 100

Adulthood (5 months) 10

(3)

FIG. 4. Left, Voiding cystogram of 10-year-old boy with daytime wetting and encopresis, showing trabeculation, bilateral reflux,

and chronic pyelonephritis in the absence of outlet obstruction or demonstrable neurologic abnormality. Right, Voiding

cysto-gram of 6-year-old boy with meningomyelocele and reflex neurogenic bladder with incontinence. Note bilateral reflux and

chronic pyeloiiephritis similar to that shown at left.

to maintain that pathological delay in maturation

of the reflex control centers accounts for abnormal

function at 8 or 10 years of age overlooks the fact

of much earlier maturation of the remainder of the

nerve pathways.

Effects of Emotional Stress on Urination

Common experience shows that hyperactivity

of the detrusor resulting in frequent urination of

relatively small volumes (although an emotionally

conditioned diuresis may supplement it)4 occurs at

such times as school examinations5 (Fig. 5).

Measurable increases in intravesical pressure

were recorded in women by Straub when he

brought up emotionally charged topics (Fig. 6).

The truth that the external sphincter is also

influ-enced by eniotions is demonstrated in the

diffi-culty some normal men have in voiding while

ob-served. The release of such tension by general

an-esthesia was graphically shown by Tanagho et al.7

as a fall in intraurethral pressure (Fig. 7).

Thus, for normal micturition, central control of

both detnisor and external sphincter must be

coor-dinated.

CLINICAL EVIDENCE

In a previous report8 (with Dr. Franz

Bau-mann), 14 cases were analyzed (Table II). These

cases ranged from those of boys having symptoms

(4)

6-1431

400- QUIZr

TABLE II

CHARACTERISTICS’

0 6AM

Age About 9 Years

Enuresis and daytime wetting

Encopresis

Trabeculation

Reflux or UVJ obstruction No neurologic abnormality No outlet obstruction “Failure” personalities

FI;. 5. A hypothetical graph relating voiding frequency and

voided volume of urine to anticipation and completion of

school quiz.

REASSUI’O

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CwDOOO “OP JOl

-

- - R:AX(O .

:..-#{149}wO,(S#{149} cop#{149};t,

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‘,Pt . W,N,(S

FI;. 6. Intravesical pressure recorded during interview. Note

rise when emotionally charged material was discussed.

(Courtesy of Straub, L. R., et al., JAMA, 141:1139, 1949.)

Aes1esQ Cu’a’e

A B C

FI;. 7. Intraurethral pressure recordings before and during

general anesthesia. Note fall to almost base (nonstriated

niuscle) levels as shown by subsequent curarization.

(Courte-sy of Tanagho, E. A., and Miller, E. R.:

mt.

Urol. Nephrol.,

4:165, 1972.)

PLATION OF VOIDING FREQUENCY AND VOLUME

TO SCHOOL QUIZ

. 300-‘4’ 200-0 100-250

f

200 . ‘50 ‘00 50

00 10 20 30 40 50

Awake

changes (Fig. 8, left and right) (although changes

in bladder and urethral function were present as

shown by the almost universal occurrence of

in-fection)9 to those of boys with severe upper tract

damage associated with trabeculation, reflux, and

renal atrophy (Fig. 9).

Repeatedly, the histories contained terms

de-scriptive of emotional problems: sensitive, evasive

child; domineering, exacting father; does not wet

- when secure in his pajamas; timid child; temper

- tantrums; compulsive; discriminated against at

-;-. home. Fecal soiling often accompanied the

un-nary incontinence, and fecal impaction would be

found on examination.

Two boys had had surgical interventions for

correction of their structural abnormalities. In

one, a Y-V-plasty gave benefit for one week, and in

the other a succession of ureteral reimplantations

failed and a ureterocolostomy was the

unsatisfac-tory end result.

Experience with the first child recognized to

have this combination of wetting and urinary tract

damage in the absence of demonstrable cause is

given in detail here because it led the way to

treat-ment of the rest.

After a lifetime of enuresis and daytime wetting

associated with the passage of infrequent and

large stools and with soiling, this boy became

in-fected at age 5 and remained intermittently so

until seen in consultation at 8 years of age. He was

found to have not only infected urine but bilateral

obstruction of the ureterovesical junctions in a

“Christmas tree” bladder typical of neurogenic

bladder (Fig. 10). Radiographic examination of

the vesical neck and urethra and complete

neu-rologic studies gave negative results. The boy was

then seen in consultation by Dr. Franz Baumann,

who initiated application of his experience in

hyp-notherapy of ordinary enuretic children to these

more severe problems, and whose collaboration is

detailed in two previous publications.8’10

Dr. Baumann reported: “It is my impression

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FIc. 8. Left, Intravenous urogram showing mild ureterectasis and subureteral diverticulum.

Right, Voiding cystogram. No reflux is present.

school and by himself and is living up to a fable of

failure. He is expecting to fail. Each failure then

reinforces this expectation. In the

hypnotherapeu-tic interview tonight, the possibility and the

likeli-hood of change was introduced as a new concept.

The fact that he could make changes in his

behav-ion appeared to surprise him. Other concepts

in-troduced were: it could be a pleasure to put his

urine where he really wanted it, mainly in the

toi-let, and that he could enjoy every success in

put-ting it there, without being bothered by failures

which would in time become less and less

com-mon. When he asked me whether I thought he

would do this, I explained to him that perhaps this

was nothing more than a habit he got into as a

baby; that habits are learned and therefore can

also be unlearned and that this might be just the

right time for him to unlearn this habit which he

really did not like. He accepted these thoughts

and new ideas most happily. It will have to be

re-inforced and time will tell whether this approach

is of value to this particular boy.” (He was dry the

next morning.)

“If he is completely free from organic illness,

one should spend time trying to reorient this

fami-ly in which he plays the role of the wet baby. In

fact, the patient as well as the family will require

considerable support.”

TREATMENT

Suggestive (or hypnotic) therapy is a major part

of treatment but is not sufficient The

pro-gram (Table III) must include administration of

anticholinergic drugs to enable the child to cope

more easily with his detrusor contractions;

anti-bacterial therapy to eliminate infection; stool

soft-eners; involvement of the parents in the

therapeu-tic process, with the purpose of reducing tension

and of giving reassurance to the child; and, finally,

strong suggestion and reinforcement, often most

readily accomplished under light hypnosis.

RESULTS (Table IV)

When the patients were treated in the manner

described, the symptoms uniformly disappeared.

Incontinence returned after a period of time in

some cases but further suggestion relieved it.

En-copresis cleared away as well. Structural changes

in the upper tract and bladder responded less

completely since, as reflections of alterations in

the muscular coats of the conducting systems, they

(6)

in which reflux or obstruction at the

ureterovesi-cal junction persists was necessary in a few cases.

It must be again emphasized that operative

treat-ment should not be attempted until bladder

func-tion has returned to normal, as evidenced by

persistent control of urination.

DISCUSSION

Relation of Bowel Dysfunction to Incontinence and Infection

In a large group of enuretic children studied by

Baumann1#{176} encopresis was found in 59 of the 73

boys who had diurnal incontinence and, usually,

Fic. 9. Voiding cystogram demonstrating refiuix with

ureter-ectasis and chronic pyelonephritis.

enuresis. Suggestion and hypnotherapy generally

caused the fecal soiling and the incontinence to

cease. These facts indicate that the two symptoms

have a common origin.

Acute urinary retention can be brought on by

severe constipation (Table V) but probably

be-cause of the production of excessive reflex stimuli

from anus to external sphincter. It is also

conceiv-able that a large bolus of feces could fill the true

pelvis and directly compress the ureters or

blad-den outlet, although there is no direct evidence for

it. The fact that the bolus is present demonstrates

that the act of defecation is poorly coordinated

and wilt require the same treatment as the

associ-ated incontinence. In fact, among 39 children

with fecal impaction only two were found to have

urinary tract infection.”

A recent study by Silverberg’2 (Table VI) infers

that constipation causes infection because it is

FI;. 10. Cystogram showing typical ‘Christmas tree”

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TABLE III

TREATMENT OF NONOBSTRUCTIVE BLADDER DI50RDER’#{176}

1. Anticholinergic drugs

2. Antibacterial therapy

3. Stool softeners 4. Parental instruction

5. Suggestion and hypnosis

TABLE IV

RESULTS

Improvement from wetting

Correction of encopresis

Reversal of vesical and

upper tract changes Relief from infection

TABLE V

RESULTS OF SUGGESTION AND HYPNOTHERAPY ON

URINARY AND FECAL CONTROL (BoYs, AGE 7 TO 13 YEARS)#{176}

Number improved

Urinary incontinence

Diurnal incontinence 1 1 10

Nocturnal and diurnal 62 54

incontinence

Total 73 64

Fecal incontinence (encopresis) or retention

Encopresis 59 59

Intermittent 14 5

constipation

Total 73 64

#{176}Datafrom F. W. Baumann, Children’s Hospital of San

Francisco, 1972.

TABLE VI

FACTORS IN URINARY TRACT INFECTION0

Total Toilet-Trained

Sample Constipation Age 4

Bacteriuria

Absent 100 2 80%

Present 300 90 58%

#{176}Datafrom 0. S.Silverberg et at., University of Alberta

Hospital, 1973.

present in almost a third of children with

bacteni-unia. However, an appreciably higher number of

children whose toilet training was delayed until

after age 4 had both constipation and bactenuria

compared to those with early urinary continence.

A study of 76 children with unexplained urinary

tract infection at the Montreal Children’s

Hospi-taP3 showed that 45 were constipated-an

mci-dence of 60%. Only nine of the 45 had recurrences

of infection after retraining for their abnormal

bowel habits, and those were the ones who failed

in following the program. The training of

neces-sity involved strong suggestion and would be

ex-pected to result in improved emptying of the

blad-den as well as of the bowel. The conclusion may be

reached that fecal problems have origins similar

to those of urinary dysfunction, although

undoubt-edly interactions occur which exacerbate both.

Other Syndromes and Symptom-Complexes

(Table VII)

Several students have sought subtle nerve

defi-cits to explain functional abnormalities in

chil-dren without readily recognizable neurologic

dis-14. i5 The most recent report, that by

Wil-liams,mn is representative. Among 15 children of

both sexes who had lifelong incontinence with

constipation and fecal soiling, he submitted 1 1 to

the urecholine test for rv’7 In seven the

results were positive, in one equivocal, and in

three negative. The test was not reliable under

anesthesia-which of course raises some doubt that

it was measuring only denervation. The often

asked question of whether the wetting has caused

the emotional disturbances or the reverse was

in-vestigated in psychiatric evaluation of five

chit-dren: in only one was the disturbance causative of

an emotional problem; in the other four the

emo-tional disturbances were believed to be the result

of the incontinence. Without doubt wetting does

compound the emotional problem-which of

course cannot be equated with causing it.

Wit-hams16 concluded that even though a child may be

wet and dirty on a psychologic basis and have

re-sidual urine with consequent infection, his urinary

tract would not deteriorate so rapidly, thus occult

neuropathy of the autonomic system must be

im-plicated. Treatment consisted of a discipline of

bladder and bowel emptying and of drug

adminis-tration, which is reminiscent of the therapy of the

patients reviewed here.

During a study of urinary flow rate and force,

Gleason’8 calculated the residual energy of the

stream. A high level of residual energy indicates

strong detrusor function and low urethral

resist-ance. Five boys, all with enuresis and frequency of

urination, had unexpectedly high levels of this

re-sidual energy-sometimes above twice the normal

(Table VIII)-and produced a stream force half

again greater than that achieved by normal

(8)

ENURESIS

I

ENCOPRESIS

TABLE VIII

0

NEUROGENIC

BLADDER

MENIN-GOMYELOCELE

CONGENITAL MEGACOLON (Hirschsprung)

#{176}Datafrom Gleason, 1972.

TABLE X

EMG RESPONSES IN ENURETIC CHILDREN#{176}

#{176}Datafrom Walvoord, King and Flynn, 1973.

TABLE VII TABLE IX

OTHER SYNDROMES INTERRELATION OF SYNDROMES OF VESICAL DYSFUNCTION

Subclinical neurogenic bladder

-D. I. Williams -J. P. Smith -D. C. Martin

Dysfunctional lazy bladder

-W. A. Campbell

Uninhibited neurogenic bladder

-J. Lapides

Hyperactive child syndrome

Supervoiders

-D. M. Gleason

Symptoms: enuresis and frequency

Findings: vesical trabeculation

Age Force Flow Residual

Etiergy

J.G. 14 8 23.4 60

S.P. 5 7.2 17.6 78

G.G. 7 7.0 20.2 60

T.R. 9 7.8 22.5 53.8

R.R. 11 6.6 21.1 49.2

Mean 7.3 21.0 66.2

Normal

Children 5.0 21.6 30.2

these boys had become hypertrophied as a result

of the incoordinated wetting and were thus

capa-ble of producing a powerful stream when the

ex-ternal sphincter opened widely on command.

Relation of Incontinence to Enuresis

A continuum from enuresis to frank neurogenic

bladder probably exists (Table IX). It starts with

enuresis (principally a psychogenic

manifesta-lion), then shades into the so-called uninhibited

neurogenic bladder (which term implies a slightly

more developmental retardation). It then passes

through neurogenic disturbances so occult that

they cannot yet be identified, to detectably

abnor-mat neurologic states. A dividing line between

en-I

UninhibitedNB

Supervoiders

I

Dysfunctional lazy

bladder

I

Occult NB

I

Functional neurogenic bladder

M F EMG Strain Defecate

13 3 Normal I

6 1 Abnormal I

3 3 Abnormal I

copresis and congenital megacolon may be easier

to define, because of the availability of biopsy.

That enuresis overlaps more severe forms of

in-continence is shown by the study of Walvoord

and King’9 that uncovered radiographically

de-monstrable urinary tract abnormalities in nine of

42 boys with enuresis. Moreover, in nine of 22

boys in whom they measured perineal activity by

electromyogram, these authors detected

paradoxi-cal activity during straining and attempts to

defe-cate (Table X)-a clear evidence of incoordination.

Whether the so-called uninhibited neurogenic

bladder is just another form of the

symptom-com-plex described here cannot be determined

(9)

REFERENCES

1. Hinman, F., Miller, G. M., Nickel, E., and Miller, E. R.:

Vesical physiology demonstrated by

cineradiogra-phy and serial roentgenography: Preliminary

re-port. Radiology, 62:713, 1954.

2. Tanagho, E. A., Miller, E. R., Lyon, R. P., and Fisher, R.:

Spastic striated external sphincter and urinary

tract infection in girls. Brit. J Urol., 43:69, 1967.

3. Campbell, W. E., III: Personal communication.

4. Schottstaedt, W. W., Grace, W. J., and Wolff, H. G.: Life

situation, behavior patterns, and renal excretion of

fluid and electrolytes. JAMA, 157: 1485, 1955.

5. Smith, D. R.: Psychogenic aspects of urinary function. J.

Omaha Mid-West. Clin. Soc., 25:35, 1964.

6. Straub, L. R., Ripley, H. S., and Wolf, S.: Disturbances of

bladder function associated with emotional states.

JAMA, 141:1139, 1949.

7. Tanagho, E. A., and Miller, E. R.: Abnormal voiding and

urinary tract infection.

mt.

Urol. Nephrol., 4:165,

1972.

8. Hinman, F., and Baumann, F. W. : Vesical and ureteral

damage from voiding dysfunction in boys without

neurologic or obstructive disease. J. Urol., 109:727,

1973.

9. Hinman, F.: Bacterial elimination. J. Urol., 99:811, 1968.

10. Baumann, F. W., and Hinman, F. : Treatment of

inconti-nent boys without obstn,ctive uropathy. J. Urol., to

be published.

11. Shopfner, C. E.: Modern concepts of lower urinary tract

obstruction in pediatric patients. Pediatrics,

45:194, 1970.

12. Report of constipation-bacteriuria association in

chil-dren. World Medical Reports, Pediatric News 7/4:3, 1973.

13. Neumann, P. Z., Dedomini, 1. J., and Nogrady, M. B.:

Constipation and urinary tract infection.

Pediat-rics, 52:241, 1973.

14. Dorfman, L. E., Bailey, J., and Smith, J. P.: Subclinical

neurogenic bladder in children. J. Urol., 101:48,

1969.

15. Datta, N. S., Martin D. C., and Schweitz, B.: The occult

neurological bladder: Detection by

electromyogra-phy of the anal sphincter. Surg. Forum, XXI:544,

1970.

16. Williams, D. I.: Occult neurogenic bladder. Read before the meeting of the Society of Pediatric Urologic

Surgeons, Liverpool, 1973.

17. Lapides, J., Friend, C. H., Ajamian, E. P., and Reus,

W. F. : Denervation supersensitivity as a test for

neurogenic bladder. Surg. Cynec. Obstet., 114:241,

1962.

18. Gleason, D. M., Bottacini, M. R., Reilly, R. J., et at.: The

residual stream energy is a diagnostic index of male

urinary outflow obstruction. Invest. Urol., 10:72, 1972.

19. Walvoord, D. J., and King, L. R.: Anal sphincter

elec-tromyelography in diagnosis of diurnal

inconti-nence and subclinical neurogenic bladder, to be

published.

IS CAT LEUKEMIA TRANSMISSIBLE TO MAN?

A recent editorial in the New England Journal of Medicine cited eight

char-actenistics of cat leukemia viruses which suggest that they may be

leukemogen-ic in man (Levy, S. B., New Eng.

J.

Med., 290:513, 1974). Cat leukemia is a

mis-nomer, since about 90% of cases so classified are actually lymphoma. Thus, it is

human lymphoma more than leukemia that should be examined for a

relation-ship to feline exposure not only during intrauterine life or infancy, as suggested

by Dr. Levy, but also among older persons with immune suppression, either

in-born or acquired, who are known to be at increased risk of lymphoreticular

neo-plasia. When these tumors are found in immunodeficient persons, the physician

should inquire about exposure to cats, and when found, should seek appropriate

virologic studies of both the patient and pet.

Bethesda, Maryland

ROBERT W. MILLER, M.D.

Epidemiology Branch

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1974;54;142

Pediatrics

Frank Hinman

Urinary Tract Damage in Children Who Wet

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1974;54;142

Pediatrics

Frank Hinman

Urinary Tract Damage in Children Who Wet

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