Risk Factors for the Development of Bladder and Bowel Dysfunction - Beyond the Abstract

Bladder and bowel dysfunction (BBD) is increasingly recognized as an entity that has a negative impact on urinary tract health. Since BBD is a known risk factor for recurrent urinary tract infections (UTIs) and potential renal scarring, it is important to understand and recognize factors that place children at risk for BBD. The American Urological Association Vesicoureteral Reflux (VUR) guidelines recommends treatment of BBD before any surgical intervention for VUR is undertaken. Previously risk factors for the development for BBD were not well defined. Female sex was highly associated with BBD in a large multivariable analysis of >2500 patients at risk for UTI, but this study found no association between BBD and reflux. Similarly, overweight children were shown to be less responsive to treatment of BBD, but it was unclear if overweight children were at risk for developing BBD. We sought to identify the risk factors for the development of BBD with a secondary data analysis of two studies (RIVUR and CUTIE) that prospectively measured BBD status with a validated questionnaire, the DVQ score. 

Our most noteworthy and novel finding in the study was that patients with dilating reflux were twice as likely to develop BBD within a 2-year time frame. We also confirmed that girls are more likely to develop BBD than boys.  Baseline BMI and management with antibiotic prophylaxis were not associated with BBD development. The results of our study included 318 patients that met inclusion criteria (74% of patients were from the RIVUR trial and 26% of patients from the CUTIE trial). The median age at study entry was 21 months and the majority of included children were female (94%) who were not toilet trained at the baseline visit. The median percentile BMI was 64, with 48% having dilating reflux at baseline. A weakness in our study is that it is a secondary analysis of studies not designed specifically to evaluate for risk factors in the development of BBD. Nonetheless, we have identified dilating reflux and female sex as being risk factors for the development of BBD, which can be helpful in assessing risk and developing a comprehensive management plan for children with VUR. 

BBD encompasses a spectrum of lower urinary tract symptoms (LUTS) that often is accompanied by fecal elimination issues such as constipation and/or encopresis. Because of such a broad definition and variation in provider practices of detection and management, BBD is often an underdiagnosed and undertreated pediatric problem. Moreover, assessing BBD via validated questionnaire in toilet trained children as our primary screening method captures a snapshot in time and may be insufficient as a screening tool for this population due to daily fluctuations in bladder and bowel habits. Some have suggested using a voiding diary mobile application as a possible alternative because it could provide a more complete picture of BBD as opposed to a single interval visit. 

BBD and/or precursors to BBD are likely present prior to toilet training, and yet we currently have little conception of who these patients are and the symptoms that manifest prior to toilet training. Further investigation to increase our understanding of the timeline for BBD development and manifestation of detectable clinical symptoms prior to toilet training are critical. 

In our study we conclude that screening for BBD in children with dilating VUR is a useful endeavor with little to lose and much to be gained by early detection and management of BBD to prevent possible complications such as recurrent UTIs and renal scarring. 

Written by: Jeremy Goodman, Thomas W. Gaither, Department of Urology, University of California, San Francisco, San Francisco, California, and Hillary L. Copp, MD MS, Associate Professor, University of California, San Francisco, Department of Urology, Pediatric Urology

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1. Skoog SJ, Peters CA, Arant BS Jr, et al. Pediatric Vesicoureteral Reflux Guidelines Panel summary report: clinical practice guidelines for screening siblings of children with vesicoureteral reflux and neonates/ infants with prenatal hydronephrosis. J Urol. 2010;184(3):1145–1151
2. Santos JD, Lopes RI, Koyle MA. Bladder and bowel dysfunction in children: An update on the diagnosis and treatment of a common, but underdiagnosed pediatric problem. Canadian Urological Association Journal. 2017;11(1-2Suppl1):S64-S72. doi:10.5489/cuaj.4411.

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