UCSF pediatric providers offer guidance based on their experience with urinary incontinence, testicle abnormalities and phimosis. Their game plan for getting kids from wet to dry breaks down incontinence types, explains the constipation connection, and dispels misconceptions about bed-wetting alarms.
mm mm. The title of our Sammy is common curbside consults and pediatric urology that focus on incontinence. Obviously there's a lot more to pediatric urology than just these slides, but we decided to kind of dig deeper into this topic so that um, hopefully you'll have a very full understanding at the end of this. But in addition we just redid our education materials and made it electronic. So by the end of this presentation sometime, um, they'll be sending out a pdf of our new booklet, which will cover a lot of the information coverage here. Right, Material conditions of life. There we go. So are learning objectives are to go over various types of urinary incontinence and their management options. The difference between retract tile and undescended testicles and the management of moses. Fine, a little bit of historical context. This is nothing new. As you can see back in 1550, there's been documents recommending Juniper Berries, cypress leaves and beer to cure bedwetting, different recommendations to the first century in the 1700s. However, my favorite is as recent as 1970 Frogs were captured and tied to a child's Penis so that when the child began to urinate at night, the frog would croak here the child and stop the urination kind of acting as a bedwetting alarm. Fine. Um, I am going to start this case with the review of a typical urology patients given the presentation uh, in other places, pre pandemic. And so when I was looking at it this week, I thought of updating my, my patient history in case to match a more 2020 style patient. But I decided not to do that in the hopes of, you know, a little bit of reminiscing of what life used to be like. So, uh, go with me on this. But you're rushing into clinic, there was more traffic than you anticipated. You sit down at your desk and of course your double booked and the patients are roomed and waiting. It's a busy day and if everything goes smoothly you should be able to get out on time. You walk into the first room. It seems simple enough. The chief complaint is urinary accidents in a seven year old, probably a UTI. You're sleepy. Brain thinks as the coffee is guilting, you awake, you go into the exam room. Mom word lee tells you that she started having daytime accidents a few months ago. And um but they were only once a week now she's having them daily. Her teacher is frustrated, convinced she's acting out. She is embarrassed. Mom states I'm doing laundry all the time. It has been really hard on us. She reports that there is no pain with urination, no blood in her P. And the thing, but she says she's most worried about is that she doesn't even feel when the accidents are happening. You order your analysis in urine culture. It comes back normal not what this is a typical patient we see in urology and our reference back to this case. So let's give her a name Elizabeth. But what we're talking about today is not a neurasthenic or organic form of incontinence but rather functional incontinence. Um Listen are some of the differentials for urinary incontinence based on what I'm talking about today. If you have a difficult time managing it, please refer to us for further work out. A healthy child that has never been successfully potty trained or started um wetting their pants or bed again we're always happy to see slide. Um The normal sequence of developmental control. First a child gains control over pooping both the nighttime and daytime bowel movement. Then he or she gains control over daytime urination and finally control over nighttime urination. This is how babies develop. And this is the same sequence of treatment that we follow, right? So what happens when the sequence doesn't happen? It's called incontinence. Um and clients is defined as the uncontrollable leakage of urine. It's a very high stress burden on families. Parents often tell me that this is the big family secret and that they're afraid to let their child sleep over at grandma's or a camp because of accidents incontinence accounts for over 400,000 outpatient business a year and it most commonly affects Children ages 3 to 10 fine. Good poopers make good piers. This is our urology motto and we will come back to it over and over again. Fine. I'm going to talk a lot about the relationship between stool retention and incontinent. But remember this image and I'll refer back to it as it makes a convincing point that internally the rectum sits right next to the bladder. And so it makes sense that pooping and peeing are related. Bye! What is constipation? The simple answer. More food is going in than is coming out. It is really, really hard to define in Children because oftentimes Children are pooping every day. However, they're not fully evacuating the rectum. Um, and so history versus symptoms sometimes make this a very confusing thing to figure out ideally, a child should be having 1 to 2 bristol, four or five every single day. I'm on this slide or some examples of history taking questions as you look through that. Let's go back to Elizabeth based on these questions. What we know about bowel involvement. Um, this is the history we get Mom is surprised to find out that she doesn't have a bowel movement daily. Actually it can be every 2-3 days and sometimes she needs to strain to evacuate. We find out that accidents got worse after week at camp, eating camp food. She avoids through her underwear to her pants. Um Daily, although her underwear is always just a little dance since potty training Elizabeth has always been a busy kid trying to avoid quickly or holding her urine to the point of doing a potty dance. She usually drinks two cups of water when she is home. Moms not sure what she drinks at school. Mom reports that she has what the bed since potty training and it's not really concerned about that now. But thought I thought I should know. That's why her physical exam is normal with a normal your analysis, but you discover her underwear is damp in the office. On physical exam we looked at, we look at abdominal exam. G you examine the sacral region of the sign. Is there something abnormal on exam, especially in the sacral region. Please make the appropriate referrals for further work up flights. There are several different types of daytime incontinence and while they all have different ideologies, the initial treatment is the same fine. Um on the slide, you'll find several of the different types of daytime incontinent and you'll see again the initial treatment for all functional and continent is the same side, but um causes of daytime incontinence. This is where we're going to refer back to the photo that I showed you in the beginning with the distended rectum, manually compressing the bladder. Um Also it's important to recognize that Children are often very busy and ignore the urge to avoid or rush um and don't finish bleeding completely right management. Like I said before, the child is constipated until proven otherwise. Um, the way I described this to parents is often that even though it seems like their child is scooping every day, even if they're posting multiple times a day, the fact that they're having urinary symptoms is a sign of stool retention. Now they're not constipated in the sense that poop isn't coming out, which is how we tend to think of constipation there can't located in the sense that they aren't emptying fully daily and over time that has defended the rectum. So for Children, less than 45 lb, we recommend a seven capsule mirror locks clean out. Um, for two days. Who? That is a seven capsules on day one, seven capitals on day two for £45 and higher. We um, recommend half a bottle of me relax, which is 14 capsules on day one and 14 capsules on day two. The goal of this is diarrhea. The goal is to get everything out and the reason the doses seems so high is because we don't want to have to do this all the time. We want it to work the first time we want to empty it out. But we do recommend at times repeating clean out um after the clean out. We recommend a daily capital of Maryland because the only way to get the rectum to shrink back down is by being smarter than the rectum. The rectums job is to hold on to poop and it's very good at its job. The body is very good at doing the functions it's supposed to. So in order to get it to um Shrine back down to a smaller size, it has to be empty. And so we recommend daily maintenance near last with 1-2 capsules. Fine. Right. Um Some families don't want to use me relax and that's fine on the slide, you'll see some alternatives. Uh Anecdotally speaking, me relax works the best because it works on the direct pathway. That is the problem as school system direct. Um It gets um dried out, right? The bodies re absorbing a fluid because it relaxes an osmotic laxative. It acts by pulling fluid back into the poop, which is the direct pathway. That is the problem. Fine. Um Good poopers make good piers. So in addition to the bowels we also need to work on the bladder. And in this essentially we go back to potty training. Um In our case of Elizabeth, the case study, she said that she didn't have sensation of needing to pee and that is a really common thing. It's often very worrisome to parents. But what we say in the beginning is that I have zero expectation of the child having the sensation to pee because they don't need it. We need to put them on a schedule every two hours, sometimes every three hours, but usually every two hours, we recommend that they go to the bathroom. This is the hardest intervention I think I asked parents to do because it's a fully lifestyle change. And um, I've made a lot of New Year's resolutions and I've broken a lot of New Year's resolutions. So when you ask Children to do this, it is a big deal. It's, it's a lot to do. And um, following through for a long period of time is difficult, but essentially you can't have an accident if you're always empty. I'm, but my child doesn't feel the accidents happening. Like I said before, um we're the latter is a muscle, were training it to kind of feel at different sensations. If the child's been holding their pee for a long period of time, then they've trained that bladder muscle to not really need to feel the sensation. But in addition, if there's a big old distended rectum that's pushing up on the spine or squishing the bladder, the sensations might be getting lost. Um, So by working on the pooping and then the habits we are addressing the child's inability to feel accidents, fine accidents right after avoiding. So, um, this is usually the patient that comes in with just a little bit of urine in their underwear. For uncircumcised boys retracting the foreskin so that urine isn't pulling under the foreskin is uh, is key to ending this. But for girls, um, they could be doing what's called vaginal voiding, essentially, Peeing with their knees really close together will cause urine to travel along the skin and reflux into the vagina. And so they peed in the toilet, they stand up, they pull up their underwear and that urine falls right out into the underwear. So they did everything right, but their underwear still wet because the urine isn't fully falling into the toilet. So for this, it's just a positioning change. We have kids sit with their knees really wide apart and bend forward. Uh, well, ask parents to put stickers on the floor to remind the kids, you know how wide their knee should be and occasionally even turn the child around on the toilet so that urine will fall straight into the toilet. Fine. Now, let's say you did all this bowel programs, time boarding, increased water intake so that the child can pee every two hours and they're still having accidents. What? But let's see are they doing it? Um Oftentimes we have to do to clean out once or twice before we really get good results. But we'll also ask parents to write a boiling diary. If the patient is truly avoiding every five minutes, 10 minutes all day long. Um then maybe they have a little bit of overactive bladder, which can be transient. It can come and go. Um And our voiding diary instructions are to use two nonconsecutive days after a bowel clean out. So we know that there's no vowel involvement. No the rectum not tapping the bladder internally. Um and then write down the times quantity and how much they leak, like it's underwear saturated. Is it just a little bit wet? Um Most Children should be able to stay dry avoiding every two hours. So um this will give us more information on if they're rushing if they're if they're not actually following the to our guideline, which is really difficult to do. Um Or if they're truly, you know, avoiding every two hours and still having accidents. We would consider renal and bladder ultrasound and a referral to urology. Fine nighttime functional incontinence nocturne on your slides. Um Nocturnal and your recess is uh interesting because there is some type of genetic component. So if one parent what the bed As a child, the child has a 40% chance of wetting the bed. If both parents went to bed, then the child has a 70% chance of winning. But interestingly, most Children will end at the same age. Their parents stopped wetting the bed. So there is something in development. And genetics that will have Children stop wetting the bed at age is similar to the when their parents did primary nocturnal A racist is when the child has never been dry for a period of six months or more. In secondary is they've been drive for six months and then all of a sudden they started wedding again. Right? Yeah. There are three main factors to nocturnal and you're racist. Nocturnal polly Yuria. The vasopressin is not concentrating the urine impaired sleep arousal. The child's not waking up and bladder dysfunction. The nerves are not sending the appropriate signaling about needing to avoid in the same manner as daytime and you're racist. The child is constipated and help proven otherwise. But um, well, uh, fine. Yeah. Uh, so we would do the same clean out as we do for daytime incontinence. The only difference is avoiding multiple times before bed and marking wet and dry nights on a calendar. I also recommend front loading the water intake for the day to encourage Children to drink most of their water before three or four o'clock. I never tell parents to restrict fluids after four o'clock. If someone is thirsty, they need to be able to drink. However, if you're very hydrated and you know, drinking all your water, we're hoping that you'll be less thirsty and you won't guzzle several water bottles right before bed. Um, rather than restricting fluids. I have parents ask their Children to avoid. More often, I find by avoiding, more often you get better responses and every parent, you know, that gets referred to as has tried restricting fluids and very rarely, I mean if they referred to us, we will they will still have the problem, but it doesn't work essentially. But Now when a child has both daytime and nighttime and continents, nighttime incontinence doesn't improve before daytime and continents. So I set those expectations early for the family that first we need to get them dry during the day and then we can get them dry at night. five bed wetting alarm after we have good control over the bowels, the daytime habits, the water intake. Um we will recommend a bedwetting alarm. This alarm wakes the child up during voiding. This is more successful than random. Wake up, which a lot of families would like to do. Um The reason is because the body can learn to respond to the sensation of a full bladder and then with the alarm going off waking up, we're training the connection between the brain and the bladder that seo when I feel this overnight, I need to wake up. Um What goes wrong or what isn't done correctly is that oftentimes Children sleepwalk through this or um parents say their child doesn't wake up to the alarm even though it's so loud, I have no expectation of this alarm waking the child up. The reason is because accidents usually happen in the deepest days of sleep and so I expect this alarm to wake a parent up who then wakes the child up in order to ensure the child is fully awake. We asked them to remember something, whether it's a pack word or a math problem or um solve a riddle something to generate a new memory so that they're fully aroused, fully awake, finish peeing, um clean up the bed and then go back to sleep and doing that successfully. Night after night works really well to resolve. Um not tremble in your recent right, I went over this a little bit already but things that don't really work is fluid restriction or just random wake up. Um It seems the logical thing to do. But the problem with random wake ups is you can wake the child up five minutes after they just peed in their beds. Um Or they could be paying multiple times at night and you can maybe get one or two and so it just doesn't work in an interrupt sleep food restriction. Children should be allowed to drink if they're thirsty fine. Uh We don't have a specific brand of alarm that we recommend. We just recommend finding one on amazon that vibrates and makes noise but bye Desmond present. So D. D. A. V. P. Is a vasopressin analogue that enhances water reabsorption in the collecting death of the kidney. Um It is what we call a holiday pill. It can give kids um a week or two of dry nights. You know we use it sometimes for camp occasionally. You've used it when you start the bedwetting alarm to give them that mental emotional win. Um However, it's not a cure and it's kind of just a band Aid effect that won't last very long on the real problems, which has to do with the habits and the sleep. Bye. Of note. If a child is waking up multiple times a night and having lots of your impala Yuria, your analysis should be done and you have to think about diabetes, insipid, diabetes mellitus, um, conclusions things to take away. Most importantly, good Supers make good piers. The treatment all starts the same and nighttime issues do not improve until daytime issues. And if you are concerned about anything, please don't hesitate to call the feeling myself. Um We're always happy to talk with you or to see these stations. So we're going to talk a little bit now about geologic conditions and not everyone can hear me. Um It's not. Please let me know. Um So one of the most common levels we get to understand the festivals and retractable testicles. So on this, normal testicles are defined as a testicle that does not occupy the dependence moral position. Normally, testing is developed within the avenue of the shoulders. I'm going to station the normal testicular profits to migrate from the scrolling uh migrate into the screening before birth. So members of the testing, the normal migration starts in the abdomen of the playing area. However, sometimes after this, the test is moving this problem but will not be indiscriminate. But then they continue to make, as Bethany was saying, the best way to differentiate between an undescended testes and a retractable testes is by exam. That is the best diagnostic tool. Your ultrasounds do not help. So once you found in, once we know that there is an undescended testes, the treatment is surgery and we usually do an orchid opec's E. Which is to bring the testicle down into the scrotum and we stitch it in place and again it's usually done around one year of age earlier. If it's a bilateral undescended testes surgery at the same day and we do do general anesthesia. Um patients do experience some pain a couple of days after surgery. And Tylenol and Motrin usually is is good to keep the pain at bay and manage the pain. They don't typically need anything stronger than Tylenol and Motrin. And we do ask that they do not do any strenuous activity for about three weeks after surgery. Yeah, Whoops. So another common complaint that we see is pharmacists. Now, normally in pre puberty boys, the foreskin should be retracted to see at least the mediators. So if we're able to see more, that's great. But we do want to at least be able to see the metis and boys who are in puberty. The foreskin should be able to be fully retracted to expose the neatest the glands, the corona and the penile shaft. And sometimes what happens is the foreskin does not retract. And so we call that pharmacists and there are two types. There's physiologic and pathologic physiologic pharmacists is normal and uncircumcised boys and may self resolve. Separation of the adhesions may naturally occur over time and usually about eight years of age. If not then it does usually resolve in puberty as the testosterone levels allow the foreskin adhesions to separate pathologic from Asus is typically with scarring and fibrosis tissue. And on exam you see this sort of thickened whitish um blanched sort of tissue around the orifice that's hard to touch. Um It can occur through forceful retraction of the foreskin that can cause bleeding of the foreskin and that over time can scar the foreskin. So indications to treat both physiologic and pathologic diagnosis includes recurrent urinary tract infections, recurrent ballon itis ballooning of the foreskin with urination where urine can pull underneath the foreskin, um difficulty peeing or any sort of urinary retention. Dis Yuria, painful erections. Para from Asus or if the families or the patient physically need to manually put pressure on the penis or the abdomen in order to eliminate the urine. It's So treatment for physiologic pharmacists and pathologic pharmacist is the same. We do start with conservative management which includes a steroid cream and stretching. The steroid cream we use is training Sinaloan 0.1% that we ask the families to use twice daily and after each application of the cream. We do ask the families to gently stretch the foreskin for about a minute. Um gentle stretching is actually the thing that will treat the pharmacist because it will physically loosen up and stretch the foreskin. The steroid cream itself just loosens the foreskin and softens the foreskin whereas the actual stretching will help to separate the adhesions. So we do ask that the parents really focus on the stretching when they're doing when they're doing the treatment. If conservative management fails and the patients remain symptomatic or have persistent pathologic pharmacists we do then at that point recommend a circumcision. So once the pharmacist is treated it is important to teach the families and the patients to take care of the uncircumcised penis to ensure that the foreskin stays nice and loose and strategy that the adhesions don't come back or the pharmacist does not recur and it's usually just gently retracting the foreskin, especially in older kids teaching them to gently retract the foreskin um before peeing and to gently retract the foreskin um and cleaning the shower and by doing that several times a day again allows that skin to stay nice and loose and stretchy. And we also teach kids that it's always important that once they pull the foreskin back that they always pull it forward and kind of tuck the penis away in a sense to prevent any para pharmacists and certainly if there is any para pharmacist active para from Asus those patients should be referred to the emergency room right away. So a quick note on circumcisions. So outside the newborn period circumcisions become a bit more involved requiring general anesthesia. And there's risks with general anesthesia. There could be a risk of bleeding and infections because these procedures typically are done in the uh the O. R. So um we do uh we do like it when caregivers are asked about circumcisions at birth if they do want to circumcision at birth and to have it done in the newborn period we don't recommend elective circumcisions. So this magma is something we often see associated with pharmacists. It's the collection of dead skin cells from the glands, penis and the inner foreskin that's caused by the foreskin occasions separating. Um It can appear as this mobile annual er lump that you guys that's underneath the foreskin. It's you um usually if we see a lump like that under the foreskin it's usually smeg MMA it's nothing concerning um stigmas benign and it can stay there for a long time and it's okay and typically it goes away. And what we teach families to do is just gently retract the foreskin and clean it. And that usually will take care of these magma. Okay, so thank you guys for joining us on our presentation today. Um we have a slide here. If you guys have any questions about referring patients to UCSF, we have this here for you.