Urotherapy in the treatment of children and adolescents with bladder and bowel dysfunction: a systematic review

Assis, Gisela Maria; Silva, Camilla Pinheiro Cristaldi da; Martins, Gisele

doi:10.1016/j.jped.2019.02.007

Acessibilidade / Reportar erro

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Review articles • J. Pediatr. (Rio J.) 95 (6) • Nov-Dec 2019 • https://doi.org/10.1016/j.jped.2019.02.007 copy

Urotherapy in the treatment of children and adolescents with bladder and bowel dysfunction: a systematic review^☆ ☆ Please cite this article as: Assis GM, Silva CP, Martins G. Urotherapy in the treatment of children and adolescents with bladder and bowel dysfunction: a systematic review. J Pediatr (Rio J). 2019;95:628-41.

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To identify and describe the protocols and clinical outcomes of urotherapy interventions in children and adolescents with bladder bowel dysfunction.

Method:

Systematic review carried out in June 2018 on Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL),Excerpta Medica dataBASE (EMBASE), Scientific Electronic Library Online (SciELO), Cochrane Library, and PsycInfo databases. Clinical trials and quasi-experimental studies carried out in the last ten years in children and/or adolescents with bladder and bowel symptoms and application of at least one component of urotherapy were included.

Results:

Thirteen clinical trials and one quasi-experimental study were included, with moderate methodological quality. The heterogeneity of the samples and of the methodological design of the articles prevented the performance of a meta-analysis. The descriptive analysis through simple percentages showed symptom reduction and improvement of uroflowmetry parameters. The identified urotherapy components were: educational guidance, water intake, caffeine reduction, adequate voiding position, pelvic floor training, programmed urination, and constipation control/management.

Conclusion:

This review indicates positive results in terms of symptom reduction and uroflowmetry parameter improvement with standard urotherapy as the first line of treatment for children and adolescents with bladder bowel dysfunction. It is recommended that future studies bring contributions regarding the frequency, number, and time of urotherapy consultations.

Keywords
Bladder bowel dysfunction; Urotherapy; Behavior therapy; Dysfunctional elimination syndrome; Dysfunctional voiding; Child

Descriptors of bladder and bowel Dysfunction	Urotherapy descriptors	Pediatrics descriptors
Bladder bowel dysfunction (non-controlled) Lower urinary tract symptoms Overactive urinary bladder Urinary incontinence Urinary retention Enuresis Urination disorders Encopresis Constipation Dysfunctional elimination syndrome Dysfunctional voiding	Urotherapy (non-controlled) Behavioral therapy Patient education as Topic Bladder training	Child Adolescent

	Title	Year of publication	Number of participants	Experimental group
1	The evaluation of combined standard urotherapy, abdominal and pelvic floor retraining in children with dysfunctional voiding	2011	n = 86 43 control 43 experimental	Diaphragmatic breathing and pelvic floor muscle training.
2	Correlation between uroflowmetry parameters and treatment outcome in children with dysfunctional voiding	2010	n = 86 43 control 43 experimental	Diaphragmatic breathing and pelvic floor muscle training.
3	Transcutaneous interferential electrical stimulation for the management of non-neuropathic underactive bladder in children: A randomized clinical trial	2016	n = 36 18 control 18 experimental	Transcutaneous interferential electrical stimulation.
4	Management of non-neuropathic underactive bladder in children with voiding dysfunction by animated biofeedback: a randomized clinical trial	2015	n = 50 25 control 25 experimental	Animated biofeedback.
5	Bladder training video versus standard urotherapy for bladder and bowel dysfunction: a non-inferiority randomized, controlled trial	2017	n = 150 75 control 75 experimental	Video animation.
6	The impact of a bladder training video versus standard urotherapy on quality of life of children with bladder and bowel dysfunction: A randomized controlled trial	2017	n = 150 75 control 75 experimental	Video animation.
7	Parasacral transcutaneous electrical neural stimulation (PTENS) once a week for the treatment of overactive bladder in children: A randomized controlled trial	2017	n = 16 8 control 8 experimental	Parasacral transcutaneous electrical stimulation.
8	Are interferential electrical stimulation and diaphragmatic breathing exercises beneficial in children with bladder and bowel dysfunction?	2017	n = 79 24 control 25 control + breathing 30 experimental	Interferential electrical stimulation diaphragmatic breathing.
9	Efficacy of combined anticholinergic treatment and behavioral modification as a first line treatment for non-neurogenic and non-anatomical voiding dysfunction in children: a randomized controlled trial	2007	n = 72 20 control 20 control + placebo 32 experimental	Tolterodine (anticholinergic).
10	A pilot randomized controlled trial evaluating the effectiveness of group vs. individual urotherapy in decreasing symptoms associated with bladder-bowel dysfunction	2015	n = 60 30 control 30 experimental	Group urotherapy guidelines.
11	Animated biofeedback: An ideal treatment for children with dysfunctional elimination syndrome	2011	n = 80 40 control 40 experimental	Animated biofeedback.
12	Two sessions of behavioral urotherapy for bowel and bladder dysfunction: does it get any better?	2014	n = 368 No control group - effectiveness evaluation by number of consultations	Does not apply.
13	Combined functional pelvic floor muscle exercises with Swiss ball and urotherapy for management of dysfunctional voiding in children: a randomized clinical trial	2014	n = 60 30 control 30 experimental	Pelvic floor exercises. Swiss ball.
14	Long-term prospective evaluation of an inpatient voiding reeducation program for lower urinary tract conditions in children	2013	n = 64 32 control 32 experimental	Urotherapy started three months after diagnosis

	1	2	3	4	5	6	7	8	9	10	11	12^a a It was not possible to apply the tools because it was not a clinical trial.	13	14
Modified JADAD scale ¹⁶16 Araujo V. Assessment of quality of scientific evidence on musical interventions in caring for cancer patients. Interface (Botucatu). 2014;18:479-92.
Was the study described as randomized?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	NA	Yes	Yes
Was the study described as double-blind?	No	No	No	Yes	No	No	No	No	No	No	No	NA	No	No
Was there a description of exclusions and losses?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA	Yes	Yes
Was the method for random sequence generation described and appropriate?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	No	Yes	Yes	NA	Yes	No
Was the double-blind method described and appropriate?	No	No	No	No	No	No	No	No	No	No	No	NA	No	No
Final score	3	3	3	4	3	3	3	1	2	3	3	NA	3	2
The Cochrane collaboration tool ¹⁷17 de Carvalho AP, Silva V, Grande AJ. Avaliação do risco de viés de ensaios clínicos randomizados pela ferramenta da colaboração Cochrane. Diagn Tratamento. 2013;18:38-44.
Random sequence generation (selection bias)	Low	Low	Low	Low	Low	Low	Low	High	Uncertain	Low	Low	NA	Low	Uncertain
Allocation concealment (selection bias)	Low	Low	Low	Low	Low	Low	Low	High	Uncertain	Low	Uncertain	NA	Low	Uncertain
Blinding of participants and personnel (performance bias)	High	High	High	High	High	High	Low	High	High	High	High	NA	High	Low
Blinding of outcome assessment (detection bias)	High	High	High	High	High	Low	High	High	High	Low	High	NA	High	Low
Incomplete outcome data (attrition bias)	High	High	Low	Low	Low	Low	Low	High	Low	Low	Low	NA	Low	Low
Selective outcome reporting (reporting bias)	High	Low	Low	Low	High	High	Low	Low	High	Low	Low	NA	High	Low

Symptom/Article		1	3	4	8	11	13
Urinary incontinence	n	32	18	25	20	40	30
	Pre	18	3	4	4	11	11
	Post	16	1	2	4	3	7
	Resolution	11%	67%	50%	0%	73%	36%
Nocturnal enuresis	n	32	18	25	20	40	30
	Pre	15	7	5	4	9	8
	Post	10	5	3	4	5	6
	Resolution	33%	29%	40%	0%	44%	25%
Urinary tract infection	n	32	18	25	20		30
	Pre	15	11	13	7		13
	Post	9	5	7	7		5
	Resolution	40%	54%	46%	0%		62%
Constipation	n	32	18	25	20	40	30
	Pre	10	3	5	20	20	6
	Post	4	2	2	17	12	3
	Resolution	60%	33%	60%	15%	40%	50%
Fecal incontinence/encopresis	n				20	40
	Pre				9	20
	Post				7	16
	Resolution				22%	20%
Post-voiding residue	n				20
	Pre				12
	Post				07
	Resolution				42%
Voiding symptoms	n				20
	Pre				3
	Post				0
	Resolution				100%
Delayed urination	n				20
	Pre				2
	Post				2
	Resolution				0%
Voiding urgency	n					40	30
	Pre					16	11
	Post					9	8
	Resolution					44%	27%

Parameters/Article		1	3	4	8	11	13
Volume of urine (mL)	Pre (mean)	238.4	407	407	270.55	230	180
	SD	123.9	129	121	131.86	7.5	67-402
	Post (mean)	204.9	361	345	243.61	240	203
	SD	114.6	105	115	122.95	10.8	75-393
Post-voiding residue (mL)	Pre (mean)	37.9	80	83	-	13	0
	SD	36.2	48	51	-	2.5	0-100
	Post (mean)	30.1	49	41	-	11.3	0
	SD	33.2	23.3	34	-	1.8	0-50
	Reduction	20.6%	38.7%	50.6%	-	13.1%	-
Mean flow	Pre (mean)	9.7	5.2	6.3	11.85	7.5	7.3
	SD	4.5	2.2	2.2	5.73	2.6	3.5-18.7
	Post (mean)	9.5	8.8	7.8	12.25	10.2	8
	SD	6.8	3.2	5.3	6.96	6.7	3-19.5
Maximum flow	Pre (mean)	21.3	9.5	10.3	23.88	18	16.6
	SD	11.4	2.4	2.4	8.16	6.6	8.1-29
	Post (mean)	18.1	11.8	12.5	24.15	23.3	16
	SD	11.4	5.7	5.7	9.55	12.9	5-37
Flow time (s)	Pre (mean)	29.1	65	44	25.97	27.4	20
	SD	12.5	20	27	9.51	10.4	7-72
	Post (mean)	29.5	56	39	23.51	18.5	21
	SD	20.1	21	25	8.79	12.3	10-71
Bladder capacity	Pre (mean)	-	463	475	-	237	-
	SD	-	121	168	-	94	-
	Post (mean)	-	366	387	-	240	-
	SD	-	67	123	-	80	-

	Educational guidance	Water intake	Potential bladder irritants	Position for voiding	Pelvic floor training	Programmed urination	Constipation control
1	Vesico-urethral or ureteral function?	200 mL, 5-6 times/day	Not described	Abducted hips, relaxed abdomen, foot support, use of toilet seat reducer	Not described	Not described	Adequate position, diet and hydration, lactulose 1 mL/kg, one to three times a day until evacuation 1-2× a day with milkshake consistency
2^a a Articles 2 and 6 do not have a detailed description, as they are articles published by the same authors and with the same method as the previously shown studies (1 and 5).	The same	The same	The same	The same	The same	The same	The same
3	Urinary and gastrointestinal function	Fluid intake according to bladder emptying (every 2-3 h)	Not described	Foot support for small children, leg opening and relaxation of the pelvic and abdominal muscles	Pelvic floor muscle contraction for 10 s and relaxation for 30 s at each treatment session	Not described	High fiber diet. Sit in the toilet in a comfortable position, after the three main meals, for 5 min
4	Urinary and gastrointestinal function	Fluid intake according to bladder emptying (every 2-3 h)	Not described	Posture correction for better pelvic and abdominal relaxation	Not described	Not described	Lactulose was administered to children with diet-refractory constipation
5	Bladder emptying and filling. Bladder and bowel control (educational material with written guidelines).	Not described	Not described	Not described	Not described	Not described	Medications to improve fecal consistency, according to the clinical evaluation
6^a a Articles 2 and 6 do not have a detailed description, as they are articles published by the same authors and with the same method as the previously shown studies (1 and 5).	The same	The same	The same	The same	The same	The same	The same
7	Not described	Increase fluid intake, avoid intake 2 h before bed.	Avoid caffeinated beverages.	Comfortable position to urinate and evacuate	Not described	Urination after waking up and before going to sleep; program urination with an interval of 3-4 h. Avoid delaying urination when you feel like it.	Intake of high fiber foods
8	Urinary and gastrointestinal function and explanation on the coexistence of urinary and intestinal problems.	200 mL 5-6× a day	Not described	Sit comfortably in the toilet. Abducted hips, feet supported and relaxed abdomen	Not described	Not described	High fiber diet. Position oneself on the toilet 3× a day, after main meals, for 5-10 min to try to evacuate
9	Not described	Not described	Not described	Relaxation of the pelvic floor during urination	Not described	Programmed urination	Special diet and laxatives
10	Anatomy and Physiology of the Urinary System	Not described	Not described	Progressive relaxation	Not described	Bladder training	Not described
11	Bladder and bowel function	Increased hydration	Not described	Not described	Not described	Programmed urination	Fiber intake. Laxatives when necessary
12	Not described	Not described	Not described	Appropriate position on the toilet	Not described	Urination interval	Diet and water intake adjustment according to the appearance of stool
13	Urinary and gastrointestinal function	Water intake at each urination (2-3 h)	Not described	Ideal posture for voiding with foot support and toilet seat reducer. Contraction and relaxation of the abdominal muscles and pelvic floor musculature prior to voiding.	Sphincter training mechanism	Programmed urination	Fibers and mild laxatives.
14	Not described	Water intake monitoring	Not described	Enough time to empty the bladder. Pictures in the bathroom can help. Attention to girls' posture (feet supported, and erect spine). Attention to pelvic relaxation and continuity of the urinary stream (girls see, and boys hear).	Pelvic floor exercises. Children (boys and girls) under the age of eight learn balloon exercise (facing the mirror, they fill the abdomen to form a balloon, then deflate the balloon to relax the pelvic floor). Repeat 20 times, 3 times a day. Girls over 8 years of age, Kegel exercises (contraction and relaxation of the pelvic floor), 30 repetitions 3× a day, test the effectiveness by interrupting the urine stream.	Urination every 2-3 h. If urination is more frequent, encourage longer intervals. Avoid urination at night.	Diet rich in fibers, fresh fruits and vegetables. Laxative in case of lack of evacuation up to 4-6 p.m.

Sociedade Brasileira de Pediatria Av. Carlos Gomes, 328 cj. 304, 90480-000 Porto Alegre RS Brazil, Tel.: +55 51 3328-9520 - Porto Alegre - RS - Brazil
E-mail: jped@jped.com.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] * Corresponding author. E-mail:giassis21@hotmail.com (G.M. Assis).