Editorial: urinary incontinence in children: controversies concerning the bladder outlet

Editorial on the Research Topic
Urinary Incontinence in Children: Controversies Concerning the Bladder Outlet

“ Becoming potty trained”: it seems so easy but for many children it is not, even when anatomy and neurologic pathways seem normal ( 1 ). An adequate assessment of the lower urinary tract is needed to make a proper diagnosis and to initiate therapy, according to the existing guidelines. Bladder dysfunction is well-defined and the treatment protocols are widely accepted, pelvic floor dysfunction can be effectively trained by the urotherapist, but still little is known about the bladder neck (BN).

The International Children’s Continence Society (ICCS) has recently referred to primary BN dysfunction as a delay in it’s opening but has not clearly defined it.

This research topic is focused on evaluation of the BN, looking at its anatomical substrate and finding the best diagnostic tools to interpret its function. The BN is not a static muscle but a continually sensing and reacting unit. Finally, current treatment options are discussed, both conservative and surgical.

Morphology and function of the BN can be evaluated with video urodynamic studies (VUDS), i. c. radiation. Another way to “ look” at the BN is described by Schroeder et al. In their lucid article they use ultrasound (US) transperineally to evaluate the BN. They show that, in the proper atmosphere, a “ normal” situation can be simulated for assessment without additional stress for the child. They give tips and tricks on how to perform this investigation and show the benefits of perineal US for the position (static-anatomical) and for the function and reaction (dynamic-functional) of the BN to coughing and holding maneuvers ( 2 ). It even provides the opportunity to train relaxation and holding maneuvers with the child while watching the US pictures and in that way is an educational and therapeutic tool.

The advantage of dynamic ultrasound is that it is a ready to use instrument in the office without radiation exposure ( 3 , 4 ). However, the perineal ultrasound technique is not easy to learn, is observer dependent and in children, is only used in a few centers. Reproducibility of this method needs further evaluation.

2. de Jong TP, Klijn AJ, Vijverberg MA, de Kort LM. Ultrasound imaging of sacral reflexes. Urology (2006) 68: 652–4. doi: 10. 1016/j. urology. 2006. 03. 077

3. Dalpiaz O, Curti P. Role of perineal ultrasound in the evaluation of urinary stress incontinence and pelvic organ prolapse: a systematic review. Neurourol Urodyn.(2006) 25: 301–6; discussion 307. doi: 10. 1002/nau. 20261

4. Tunn R, Petri E. Introital and transvaginal ultrasound as the main tool in the assessment of urogenital and pelvic floor dysfunction: an imaging panel and practical approach. Ultrasound Obstet Gynecol.(2003) 22: 205–13. doi: 10. 1002/uog. 189

5. de Jong TP, Klijn AJ. Urodynamic studies in pediatric urology. Nat Rev Urol.(2009) 6: 585–94. doi: 10. 1038/nrurol. 2009. 200

6. Combs AJ, Grafstein N, Horowitz M, Glassberg KI. Primary bladder neck dysfunction in children and adolescents I: pelvic floor electromyography lag time – a new noninvasive method to screen for and monitor therapeutic response. J Urol.(2005) 173: 207–10. doi: 10. 1097/01. ju. 0000147269. 93699. 5a

7. Combs AJ, Van Batavia JP, Horowitz M, Glassberg KI. Short pelvic floor electromyographic lag time: a novel noninvasive approach to document detrusor overactivity in children with lower urinary tract symptoms. J Urol.(2013) 189: 2282–6. doi: 10. 1016/j. juro. 2013. 01. 011

8. Franco I. Overactive bladder in children. Part 1: pathophysiology. J Urol.(2007) 178: 761–8. doi: 10. 1016/j. juro. 2007. 05. 014

9. Franco I. Overactive bladder in children. Part 2: Management. J Urol.(2007) 178: 769–74. doi: 10. 1016/j. juro. 2007. 05. 076