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Indian Pediatr 2009;46: 1093-1095 |
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Association of Voiding Dysfunction with
Functional Constipation |
Niloofar Hadjizadeh*, Farzaneh Motamed…,
Sina Abdollahzade and Sima Rafiei#
From the *Divisions of Nephrology and
…Gastroenterology,Department
of Pediatrics; Imam Khomeini Hospital, #Children Medical Center Hospital,
#Students’ Scientific Research Center; Tehran University of Medical
Sciences, Tehran, Iran.
Correpondence to: Dr Sina Abdollahzade, Department of
Pediatrics, Children Medical Center Hospital, Tehran University of Medical
Sciences, Tehran, Iran.
Email:
[email protected]
Received: April 11, 2008;
Initial review: May 19, 2008;
Accepted: December 8, 2008.
Published online 2009 April 1.
PII:S097475590800198-2
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Abstract
To identify the frequency of voiding dysfunction in
patients with functional constipation, dysfunctional voiding soring
system (DVSS) was surveyed in 85 patients with functional constipation.
Urinalysis, culture and renal ultrasound were performed in all cases. If
the child had urinary tract infection, voiding cystourethrography and
DMSA scan were performed. Fifty four patients (63.5%) out of 85 had
voiding dysfunction (DVSS score above 6 in females and above 9 in males)
compared to 28 out of 280 normal children (10%) in control group (P<0.001).
Voiding dysfunction symptoms should be examined carefully in patients
with functional constipation.
Key words: Child, Constipation, Iran, Voiding dysfunction.
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T he urinary and lower
gastrointestinal tract are anatomically and physiologically interdependent
systems sharing common features including embryologic origin, passing
through pelvic floor musculature and sacral innervations(1-3).
Inappropriate contractions and imbalanced relaxation of pelvic floor
muscle along with behavioral discrepancies in the absence of anatomic or
neurological disease make a common pathway in which the final endpoint
would be dysfunctional emptying in both systems, a condition known as
dysfunctional elimination syndrome (DES)(2). Functional, non-organic
constipation is frequently diagnosed in patients with DES and its role in
dysfunctional voiding is highlighted(4).
Most studies have focused on urinary abnormalities in
patients with DES(5-7), despite the fact that voiding dysfunction
comprises a subset of the clinical picture of this syndrome(8). Resolution
of bladder symptoms after successful treatment of constipation is also
documented(9). Very few studies describe the presence of voiding
dysfunction in children with functional constipation(4). This prospective
study was performed to identify the frequency of voiding dysfunction in
patients with functional non-organic constipation.
Methods
The study group included 85 children with functional
constipation referred to pediatric gastroenterology clinic of the Children
Medical Center Hospital between April 2004 to March 2005. Functional
constipation was defined as 2 or more weeks of a chain of symptoms
including infrequent passage of stools, difficulty passing stools, feces
that are large and hard or in small pieces, abdominal pain, palpable stool
in the abdomen, and stool in the rectal vault, with exclusion of organic
causes. The work-up included a thorough history and physical examination
with attention to neurologic examination and anatomic anomalies to exclude
organic causes of constipation. Relevant X-ray (plain films of
sacral spine and MRI in selected cases) and a history of medications were
obtained for each patient. Voiding cystourethrography (VCUG) was done in
patients with UTI. In patients with history of pyelonephritis and/or
vesicoureteral reflux, DMSA scan was done.
All patients were subjected to the dysfunctional
voiding scoring survey (DVSS)(10). We used a modified version of DVSS, in
which urinary records consisting of questions that enquired about
incontinence, nocturnal enuresis, dysuria and other urinary symptoms were
taken into account and symptoms related to constipation were excluded.
Each question was scored on a 0 to 3 scale (0-never, 1-sometimes, 2-about
half the time and 3-most of the time). A control group, consisting of 280
age and sex-matched normal children were surveyed using the same
questionnaire.
The DVSS Scores were validated separately for boys and
girls and those with a total score of 9 were diagnosed as having
dysfunctional voiding with a sensitivity of 81% for boys and score of 6 or
more with a sensitivity of 93% for girls(10). For all children, urinalysis
and culture, and abdominal ultrasonography were performed.
The study was approved by the Ethics Committee of the
University; informed written consent was obtained from the parents of the
participants. Comparisons between control and patients groups were
performed by appropriate tests; risk analysis was undertaken using odds
ratio with 95% confidence intervals of differences. P<0.05 was
considered significant.
Results
Of eighty-five patients with constipation, 60 (70.6%)
were girls. The mean age of the patients was 5.7±2.7 yr. Fifty four
(63.5%) patients had symptoms of voiding dysfunction (DVSS score above 6
in females and above 9 in males) compared to 28 out of 280 normal children
(10%) in control group (P<0.001; odds ratio 15.74, 95% confidence
interval 8.7-28.4)
Forty five (52.9%) patients had urinary tract infection
and 36 (42.4%) had nocturnal enuresis. Ultrasonography revealed urinary
residue ³10
cc after voiding in 13 patients. On VCUG, 11 of 33 (33%) showed
vesicoureteral reflux (2 bilateral and 9 unilateral). Of these 11
patients, 8 (72.7%) had voiding dysfunction. Nine patients had focal areas
of reduced radiotracer uptake on DMSA renal scan.
Discussion
DES is a combination of urinary symptoms and
gastrointestinal complaints. The anatomic proximity, the common neural
pathways and the mutual passage through pelvic floor explains the dual
involve-ment(2).
We found a high prevalence of voiding dysfunction in
children who were primarily consulted for functional constipation. We
found 54 patients (63.5%) to have symptoms of voiding dysfunction
according to the DVSS scores. Compared to normal controls, this denotes a
15-fold increase of voiding dysfunction in patients with functional
constipation. This high prevalence is consistent with other reports(11).
Seventy five percent girls and 36% boys had symptoms of voiding
dysfunction (P<0.01) and the male/female ratio for affected
patients was 0.20. In contrast, in a study by Curran, et al.(12),
this ratio was 0.6. The higher incidence of voiding dysfunction in our
female patients could be attributed to cultural beliefs and improper
training of voiding in girls that encourage them to avoid voiding in
unfamiliar places.
Renal and bladder ultrasonography, showed urinary
residue in 13 patients after double voiding, which was significantly
higher in voiding dysfunction group (P<0.05). This finding is also
reported elsewhere(13). Considering the high frequency of urinary tract
infections and vesicoureteric reflux in our patients and other
reports(14), combined treatment of constipation and voiding dysfunction
should be administered to this group of patients to eliminate bladder and
bowel symptoms(4,14,15).
Our findings suggest that voiding dysfunction is common
in children with constipation. All patients with a primary diagnosis of
functional constipation should be systematically questioned for urinary
symptoms.
Contributors: NH and FM collected patients'
records, performed data analysis and drafted the manuscript. SA and SR
contributed to data acquisition and performed the review of the
literature.
Funding: This research has been supported by Tehran
University of Medical Sciences and Health Services.
Competing interests: None stated.
What This Study Adds?
• Voiding dysfunction is common in children with
constipation and all patients with functional constipation should be
evaluated for urinary symptoms.
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