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,
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
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
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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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 5000 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
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
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”
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
ENURESIS
I
ENCOPRESISTABLE 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
UninhibitedNBSupervoiders
I
Dysfunctional lazy
bladder
I
Occult NBI
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
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,
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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,
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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 amis-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
