Long-term Follow-up of Incontinence and Urge Complaints After Intensive Urotherapy in Childhood (75 Patients Followed Up for 16.2-21.8 Years)

doi:10.1016/j.urology.2011.08.055

Urology

Volume 78, Issue 6, December 2011, Pages 1391-1396

https://doi.org/10.1016/j.urology.2011.08.055 Get rights and content

Objective

To reassess the incontinence and urge complaints in adults who had undergone inpatient urotherapy during childhood and compare the results with the short-term outcomes.

Methods

From 1987 to 1990, 95 children (13 boys and 82 girls; age 6-17 years) underwent hospitalized urotherapy to treat functional lower urinary tract symptoms. This group was traced and a questionnaire was administered by telephone. The long-term data on incontinence and urge complaints were compared with the results at 6 months after training.

Results

Of the 95 patients, 92 were traced, and a cohort of 75 could be analyzed. At long-term follow-up (mean 17.9 years), of the 75 patients, 63 (84%) had a good, 8 (11%) a moderate, and 4 (5%) a poor outcome. At short-term follow-up, 56 of the current 75 patients had had a good outcome, and at long-term follow-up, 47 of these 56 patients still had a good score. However, during the intervening period, 3 of these 56 patients developed incontinence recurrence and scored a poor result, and 6 others scored a moderate result. Originally, after 6 months of follow-up, 7 patients had had a moderate outcome; 5 of these had improved to good, 1 still scored moderate, and 1 had deteriorated over time to poor. Twelve patients had originally had a poor outcome at short-term follow-up. Of these, 11 had spontaneously improved to good and 1 to moderate.

Conclusion

If the original outcomes of pediatric intensive inpatient urotherapy are good, they tend to remain so over time in most patients.

Section snippets

Material and Methods

The original study group of 95 patients was trained during the 1987-1990 period. Of the 95 patients, 13 were boys and 82 were girls. Their age range was 6-17 years (mean 9.9 ± 2.4). They received intensive inpatient training for LUTS after outpatient urotherapy had failed at 1 year of follow-up, during which pharmacologic treatment and training had not had the desired effect. At the end of the inpatient training, the patients were instructed to continue the learned exercises and were followed

Results

Of the original 95 patients, 92 were traced. These patients had an average age of 27.8 years. Six patients (all women) were not included in the long-term follow-up study because training had disclosed an underlying condition or hidden anatomic defect. Of these 6 patients, 1 had a tethered cord, 1 had developed interstitial cystitis, 3 proved to have urethral and bladder neck insufficiency after redundant earlier urethrotomy, and 1 was using intermittent catheterization owing to a severely

Comment

At long-term follow-up, 84% of the clinically treated children with LUTS showed a good result. Of the 56 patients with a good score at short-term follow-up, 47 (84%) retained this score over time. It appears that the effects of training are persistent; the long-term training result is positive. The rate of 84% is a very high and provides a good argument and strong motivation to treat children with LUTS with urotherapy at a young age.

It is still unclear which training elements contribute most to

Conclusions

Clinical urotherapy is successful in the short term for many patients with functional LUTS who initially prove to be therapy-resistant. In the long term, most of these patients will have a positive outcome. However, some patients who at first had a good outcome will develop a relapse, and some patients who at first had a poor training result will recover spontaneously. In our study, the improvement or deterioration appeared after an average of approximately 2 years. It still must be determined

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Cited by (11)

Long-term functional and psychosocial outcome in adolescents and young adults treated for lower urinary tract dysfunction in childhood
2021, Journal of Pediatric Urology
Lower urinary tract dysfunction (LUTD) in childhood might affect lower urinary tract function and psychological wellbeing later in life. This study presents long-term functional outcome, psychological outcome and quality of life (QOL) of adolescents and young adults treated for childhood LUTD compared to healthy age-matched controls. In addition, association with past treatment outcomes is evaluated.
A single-centre cross-sectional study of former patients treated in childhood (currently 16–26 years old) was conducted. Participants completed a survey composed from validated questionnaires: the Overactive Bladder Questionnaire, the Hospital Anxiety and Depression Scale, the Pediatric Quality of Life Inventory and the Short Form 36 Health Survey.
Fifty-two former patients (out of 133) agreed to participate and returned the survey (mean age 21 ± 4.1 years). Sixty-nine control subjects were included (mean age 21 ± 2.9 years). Urinary tract symptoms were more common in former patients than controls. Storage symptoms more frequently reported were (urge) urinary incontinence, stress urinary incontinence (SUI) and nocturia. Voiding symptoms more frequently reported were intermittency and feeling of incomplete emptying, Fig. 1. There were no differences in urinary tract symptoms or urinary incontinence subdivided by childhood treatment outcome (complete response, partial response or no response), respectively p = 0.17 and p = 0.58. Results of the overactive bladder questionnaire revealed higher urinary symptom bother scores (score 14 versus 5 p < 0.01) and lower disease-specific QOL (score 95 versus 98 p = 0.02) in former patients compared to controls. General QOL and psychosocial wellbeing were not significantly different between the two groups. A childhood treatment duration extending 2,5 years was an independent prognostic factor for subsequent urinary tract symptoms later in life (OR = 1.5, 95% CI 1.1–2.0). Psychological comorbidity was more often present in former patients (35%) versus controls (10%), p < 0.01.
Adolescents and young adults treated for childhood LUTD are more prone to report urinary tract symptoms later in life, especially if treatment duration was extensive. However general QOL and psychosocial wellbeing later in life are not or only mildly affected.
The long-term added value of voiding school for children with refractory non-neurogenic overactive bladder: an inpatient bladder rehabilitation program
2020, Journal of Pediatric Urology
Citation Excerpt :
Bladder rehabilitation programs, both outpatient and inpatient, have proven to be a useful treatment modality in children with non-neurogenic overactive bladder since 1982 [7–10,12,14,16–26]. However, to the authors knowledge, this is one of the largest studies describing an inpatient bladder rehabilitation program [7–9,12,14,21,23,25,27]. Another strength of this study is the long-term follow-up until one year after the training program.
Despite adequate management, 20% of children with overactive bladder (OAB) syndrome fail to improve their bladder function. To approach the need for alternative strategies, an inpatient bladder rehabilitation ‘voiding school’ program was established.
The objective of this study was to evaluate the short- and long-term (1-year follow-up) outcome of this voiding school program in children with refractory OAB. In addition, the authors aimed to identify which children achieved the best outcomes with this voiding school program.
The charts of all children (n = 357, mean age: 9.7 ± 2.0 years, 63.6% boys) with refractory OAB who attended voiding school between 2000 and 2010 were reviewed. A linear mixed model with random intercept was used to evaluate the incontinence (expressed by enuresis and daytime incontinence voiding scores) and maximal voiding volume (MVV).
This study demonstrated an overall beneficial long-term effect of the inpatient program on day- and night-time incontinence, in which 36.6% of children achieved dryness during day- and night-time. In addition, the mean overall decline in the number of wet nights and days declined with 4 extra dry days and/or nights per week, in comparison with the level of continence before attending the voiding school program.
In contrast, only a temporary increase in MVV was seen, however, without relapse incontinence. At last, the authors identified the negative impact of decreasing age, male sex, dysfunctional voiding and nocturnal polyuria on the overall outcome of the inpatient program.
An inpatient rehabilitation ‘voiding school’ program is a successful and safe treatment modality for children with refractory OAB that results in long-term significant increase of continence, as well as amelioration in degree of severity. The worst outcomes of this voiding school program were detected in children with young age, who were boys, or had associated nocturnal polyuria, dysfunctional voiding, and/or faecal incontinence.
SENS-U: clinical evaluation of a full-bladder notification – a pilot study
2019, Journal of Pediatric Urology
Urinary incontinence is one of the most commonly treated disorders in children at school age. Recently, a new, wearable bladder sensor became available, the SENS-U Bladder Sensor. The SENS-U is a small, wireless ultrasonic sensor, which continuously monitors the bladder filling and provides a personalized notification when it is time to go to the toilet. In this study, the aim was to examine the performance of the SENS-U as a full-bladder–based notification system in children during daily life activities.
In this pilot study, children (6–16 years) who were admitted for an inpatient bladder training were included. Parallel to one training day, the child would wear the SENS-U to estimate the bladder filling and it informed the child when the bladder was almost full. When the child received a full-bladder notification, the child was taught to inform the urotherapist/researcher, in order to determine the level of response.
Fifteen patients (boys/girls: 7/8; mean age: 11.5 ± 1.7 years) were included. Based on a personalized volume-based threshold, the SENS-U notified these children of a full bladder with a median notification rate of 92.9%. In the remaining cases, children voided before the threshold was reached (e.g. defecation). Children responded positively to the notification of the SENS-U, resulting in a median level of response equal to 100%.
The SENS-U was able to monitor the natural bladder filling accurately during activities of daily living and provided a personalized notification to the children when it was almost time to go to the toilet. Future research will focus on investigating the efficacy of the SENS-U compared to daily clinical practices.
Does a serious game increase intrinsic motivation in children receiving urotherapy?
2019, Journal of Pediatric Urology
Urotherapy is considered the treatment of choice for children suffering daytime urinary incontinence (DUI). Urotherapy intends to improve bladder dysfunction for children with DUI. For children with refractory DUI, an intensive inpatient bladder training program exists, which focuses on relearning, concentration on, and awareness of the bladder. Children's motivation and adherence are key determinants of a successful training outcome. It is hypothesized that motivation endurance throughout the treatment process may be enhanced by a serious game training tool, which could make the training more appealing and rewarding.
The study explores intrinsic motivation in children receiving bladder training for DUI and whether using a serious game improves their intrinsic motivation.
In this pragmatic study, 50 children were allowed to choose among receiving bladder training with (intervention group) or without the application of a serious game (control group). At 4, 8, and 12 weeks of training, children and parents were asked to complete the Intrinsic Motivation Inventory (IMI). Children also completed the Pediatric Urinary Incontinence Quality of Life Tool (PinQ) before the start of the training and 6 months thereafter. At 6-month follow-up, patients were ask to participate in two focus groups, wherein the children discussed how they used the serious game and which improvements they would prefer.
Children who received standard bladder training with the addition of a serious game did not differ in terms of intrinsic motivation from children who underwent standard bladder training only. Training results were equal in both the groups, with 80% good or improved. Incontinence-related quality of life (QoL) improved accordingly.
In contrast to the study expectations, this game did not increase intrinsic motivation. Findings on training and QoL results are consistent with those of previous studies in both interventions. Although a randomized design could have yielded more valid results than this preference-based approach, the latter is more congruent with clinical practice. In contrast to existing bladder diary apps, this game offers a combination of child-friendly instructions, explanation of bladder (dys)function, and keeping a bladder diary. Mobile devices are playing an increasingly important role in health care; therefore, an urotherapy app can be a complementary therapeutic tool.
Most children find it attractive to combine bladder training with a serious game. However, no added value was found regarding intrinsic motivation and training results. All children with persistent DUI in this cohort were highly motivated to complete an intensive bladder training program.
Central inhibition of refractory overactive bladder complaints, results of an inpatient training program
2015, Journal of Pediatric Urology
Citation Excerpt :
In this study, 26 (27.1%) patients could not be reached for follow-up and the reasons are unknown. Regardless, an intensive and expensive clinical treatment conveys favorable long-term results on symptoms, quality of life and psychological well-being of the child [9,11]. Taking these factors into account together with the reduction of hospital visits, surgery and the use of medication, one may wonder whether this inpatient training should be seen as expensive or rather as an investment.
Overactive bladder (OAB) in children has an overall reported incidence of 16.6–17.8%, with its prevalence of 0.2–9% varying largely between age and gender. OAB is the most important burden in pediatric urology because of the limited effect of treatment. OAB with imperative urge and/or urge incontinence can often be successfully treated with urotherapy and pharmacological treatment. Nevertheless, approximately 20% of patients are considered to be therapy resistant for common treatment options. For the latter group, an inpatient cognitive and biofeedback training program for children has been developed.
Our objective is to evaluate the effect of an inpatient cognitive and biofeedback training program for children with urge complaints and urge incontinence based on overactive bladder (OAB) after failed earlier treatment by anticholinergic medication and by outpatient urotherapy. A search for predictors for success of treatment outcome is included in the study.
Seventy children with therapy refractory incontinence based on OAB went through a 10-day in-hospital training program between 2007 and 2010. The children were aged between 7 and 13 years (mean 9.29 years) and 48 (68.6%) were male. An essential part of this program is teaching the children central inhibition of their bladder to suppress bladder overactivity. Before attending this training program patients had on average 41.1 months of fruitless treatment by urotherapy and medication, and if needed preceding surgery for meatus correction or deobstruction. The training result was evaluated 6 months after completion of the inpatient training program. A questionnaire was subsequently conducted 2 years after the training to evaluate the long-term efficacy of this program.
Six months after training, evaluation showed that 30 of the 70 patients (42.9%) were free of complaints, 22 (31.4%) had a significant reduction in complaints and 18 (25.7%) had no improvement. Logistic regression analysis was used to look at several variables predicting training outcome. A higher age during clinical training was found to be a predictor for a good training outcome. After 2 years, 44 (62.9%) patients were reached for long-term follow-up. Of these patients, 28 (63.6%) reported a good effect of the training and 11 (25%) experienced no improvement in symptoms compared with before clinical training. Objectively, 26 (59.1%) were dry and 18 (40.9%) were incontinent to some extent. A total of 30 (68.2%) patients had not relapsed into urge complaints (McNemar’s test P-value <0.05).
Age was found to be a predictor of a good training result, which is in line with the findings of other publications where children above the age of 8 demonstrate better and faster training results. The absolute number of participants to perform statistical analysis on was low, even though it was the number maximally achievable in this cohort, possibly explaining how other variables could not be found to predict training outcome.
No differences in outpatient therapy results were observed between patients having received earlier outpatient urotherapy in our hospital when compared with being trained elsewhere. This is coherent with previous research indicating that for outpatient training, the attention offered to the child is of paramount importance.
Regarding long-term follow-up, keeping in mind long-term follow-up patient numbers were incomplete, a good effect of the training was seen with a clear reduction in incontinence complaints. Far fewer children are suffering from urge complaints, although some patients had relapsed into urge complaints.
The inpatient cognitive and biofeedback training program for refractory OAB complaints has been demonstrated to cure or improve 74.3% of patients, and conveyed favorable long-term results in approximately 75.0% of patients. A higher age during clinical training was found to be a predictor for good training outcome.
A 20-year study of persistence of lower urinary tract symptoms and urinary incontinence in young women treated in childhood
2014, Journal of Pediatric Urology
Citation Excerpt :
To our knowledge, data on the prevalence of LUTS in adulthood of girls treated for UI and LUTS in childhood have not been reported. Recently, the long-term outcome of UI and urge complaints in adult patients (average age: 27.8 years) who underwent intensive urotherapy in childhood has been re-assessed by Vijverberg et al. [20]. However, they did not investigate prevalence of LUTS in this population; they analyzed the outcome of intensive urotherapy, considering the persistence of one or more of the following variables: number of wet incidents during day, micturition frequency, urge complaints, and flow pattern.
To determine whether urinary incontinence (UI) and lower urinary tract symptoms (LUTS) persist over years, patients treated for UI and LUTS in childhood were re-evaluated in adulthood.
Forty-seven women (cases) treated in childhood for daytime UI/LUTS (group A) and nocturnal enuresis (group B) self-completed (average age: 24.89 ± 3.5 years) the International Consultation on Incontinence Questionnaire for Female with LUTS (ICIQ-FLUTS). ICIQ-FLUTS was self-administered to 111 healthy women (average age: 23 ± 5.1 years) from a nursing school as a control group. Data obtained from ICIQ-FLUTS and quality of life (QoL) score (0–10) were compared (Fisher's exact test) between patients and controls, and between group A (n = 28) and group B (n = 19).
Prevalence of LUTS was higher in patients than in controls. The difference between patients and controls was statistically significant (p = 0.0001) for UI (34% vs. 7%) and feeling of incomplete bladder emptying (49% vs. 28%). QoL score was >5 in 59% of patients and 1% of controls (p = 0.0001). No significant differences were found between groups A and B.
UI and LUTS are confirmed in young women who suffered for the same condition in childhood. Longitudinal studies are needed to assess if these symptoms persist or are newly onset.

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Pediatric UrologyLong-term Follow-up of Incontinence and Urge Complaints After Intensive Urotherapy in Childhood (75 Patients Followed Up for 16.2-21.8 Years)

Objective

Methods

Results

Conclusion

Section snippets

Material and Methods

Results

Comment

Conclusions

J Urol

J Urol

Urology

Urology

Urology

J Urol

J Pediatr Urol

J Urol

J Urol

Pediatric Urology
Long-term Follow-up of Incontinence and Urge Complaints After Intensive Urotherapy in Childhood (75 Patients Followed Up for 16.2-21.8 Years)