Lower Urinary Tract Dysfunction in Childhood: What’s Really Wrong with These Children?

Lower urinary tract dysfunction, in otherwise neurologically and anatomically normal children, encompasses a variety of LUT conditions that are often diagnostically challenging. Currently, the most common diagnostic approach has been the one advocated by the ICCS in which the primary focus is on symptomatology, clinical history, and various uroflow patterns, and results are judged on the basis of symptomatic improvement. For example, the “daytime conditions” of OAB and voiding postponement are a compilation of symptoms and presumptions and do not represent true, urodynamically defined conditions. Our approach differs in that while symptoms and clinical history are taken into account, we routinely incorporate uroflow with simultaneous pelvic floor EMG in their assessment and define the various LUT conditions on the basis of specific uroflow/EMG criteria. We focus on the driving forces responsible for those symptoms and have found that most children with LUT dysfunction have one of four conditions: (1) dysfunctional voiding (active pelvic floor EMG during voiding, +/−DO); (2) idiopathic detrusor overactivity disorder, similar to OAB but with DO documented by a short EMG lag time and a quiet EMG during voiding; (3) detrusor underutilization disorder, willful postponement of urination resulting in an expansive bladder capacity (>125 % EBC for age) otherwise normal voiding with a quiet EMG; and (4) primary bladder neck dysfunction, a condition diagnosed by prolonged EMG lag time in association with hesitancy, an abnormal, depressed uroflow, and a quiet EMG. Assessment of therapeutic response in these four conditions should be based not only on amelioration of symptoms but on correction of their objective abnormal pretreatment uroflow/EMG parameters. Lastly, we have found that LUTS and uroflow patterns alone often do not represent the condition they are thought to, and unless uroflowmetry is done with simultaneous pelvic floor electromyography to better identify the condition, incorrect diagnoses and suboptimal therapy are increasingly likely. We encourage adult urologists to read this article as much that is discussed as regards children can be applied to adults as well.