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.
the title of our Sammy is common curbside consoles 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 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 Elektronik. So by the end of this presentation, sometime they'll be sending out a pdf of our new booklet, which will cover a lot of the information coverage here. Fight, move, feel kinda changes, lives. There we go. So are learning. Objectives are to go over various types of urinary incontinence and their management options. The difference between retract Thailand undescended testicles and the management of by Moses. Fine. A little bit of historical context. Um, this is nothing new. As you can see, back in 15 50 there's been documents recommending Juniper berry, Cyprus leaves and beer to cure bedwetting. Different recommendations to the first century. In the 17 hundreds, 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 gonna start this case with the review of a typical urology patients given this 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 Thio match, um, or 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 patient, their rooms 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 u T I. You're sleepy, brain. Thanks. Says the coffee is jolting. You awake, you go into the exam room. Mom word. Li 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 was 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's 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 and your own 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 name Elizabeth. But what we're talking about today is not a neural agenda or organic form of incontinence, but rather functional and continents. 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 at 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. I. So what happens when this sequence doesn't happen? It's called incontinent. Um, in comments 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 sleepover at Grandma's or ah camp. Because of accidents. Incontinence accounts for over 400,000 out patient visits a year, and it most commonly affect 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. Applied. I'm going to talk a lot about the relationship between stool retention and incontinence, But remember this image and I'll refer back to it as it makes the convincing point that internally, the rectums, it's right next to the bladder and so it makes sense that pooping and peeing are related. I'm What is constipation? The simple answer. More food is going in than is coming out. It is really, really hard. Thio 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 45 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 to 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. Flat slide for 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. Do you examine the sacred region of the spine? If there's something abnormal on exam, especially in the sacred region, please make the appropriate referrals for further work out flight. There are several different types of daytime incontinent, 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 incontinence, and you'll see again the initial treatment for all functional incontinent is the same slide, but, um, causes of daytime incontinent. 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. Sutton management. Like I've 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 pooping 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 stated in the sense that they aren't emptying fully daily and over time, that has distended the rectum. So for Children less than £45 we recommend a seven cap full. Mira lacks clean out, um, for two days. So what? That is a seven Capitals on day one, seven Capitals on day two for £45 and higher. We, um, recommend half a bottle of me relax, which is 14 capitals 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 wanna have to do this all the time. We want it toe 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 cap full of Mira lacks because the only way to get the rectum to shrink back down is by being smarter than the rectum. The rectums job is toe hold on the poop, and it's very good at its job. The body is very good at doing the functions. It's supposed thio. So in order to get it toe, um, shrink back down to a smaller size, it has to be empty. And so we recommend daily maintenance near last with 1 to 2 capsules. Fun, 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, Mira lacks works the best because it works on the direct pathway. That is the problem. As school system, the rectum make it, um, dried out right? The bodies re absorbing the fluid because my relaxes an osmotic laxatives. It acts by pulling fluid back into the poop, which is the direct pathway that is the problem. Fine. Um, good poopers make good peers. So in addition to the bowels, we also need toe work on the bladder. And in this, essentially we go back to potty training. Um, in our case of Elizabeth, the case studies, she said that she didn't have sensation of needing to pee, and that is a really common thing is often very worrisome, Thio 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. Eyes 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, work the slaughter is a muscle. Were training it to kind of feel at different sensations. If the child's been holding their P 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 A child's inability to feel accidents. Five accidents right after avoiding. So, um, this is usually the patient that comes in with just a little bit of urine and their underwear for uncircumcised boys. Retracting the foreskin so that urine isn't pooling 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 you're in 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 is just a positioning change. We have kids sit with their knees really wide apart and bend forward. We'll ask parents to put stickers on the floor to remind the kids you know how wide their needs 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 ball programs, time boarding, increased water intake so that the child can see every two hours and they're still having accidents. What next life? 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 asked, parents should write a boiling diary. If the patient is truly avoiding every five minutes, 10 minutes, all day long on, then maybe they have a little bit of overactive bladder, which can be transient. It can come and go, um, and are avoiding diary instructions are to use two nonconsecutive days after about clean out. So we know that there's no vowel involvement. No, the rectums not tapping the bladder internally. Um, and then right down the time quantity and how much they leak like his 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 two hour guideline, which is really difficult to dio, um, or if there 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, incontinent, not turn on your resistance slide. Um, nocturnal in 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 was a bed, then the child there's 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 in genetics that will have Children stop wetting. The bed at age is similar to the when their parents and primary nocturnal lyricist 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. Good. Yeah, there's three main factors. Thio, Nocturnal and you're racist. Nocturnal. Polly Yuria. The Visa president is not concentrating the urine impaired sleep arousal. The child's not waking up and bladder dysfunction the nerves. They're not sending the appropriate signaling about needing to avoid in the same manner as daytime and your ISA. The child is constipated until proven otherwise. But, um well, uh, fine eso 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. You know, several water bottles right before bed. Um, rather than restricting fluids, I have parents ask their Children to avoid mawr. Often I find by avoiding mawr often you get better responses. And every parent you know that gets referred to us has tried restricting fluids and very rarely, I mean, if they're referred to us, we will. They will still have the problem. But so it doesn't work essentially like now when a child has both daytime and nighttime and continents, nighttime incontinent 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 vowels, 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 dio. 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, Oh, 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 phase of sleep. And so I expect this alarm toe 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 password or a math problem or, um, solve a riddle, something to generate a new memory so that they're fully aroused fully awake, finished being, um, clean up the bed and then go back to sleep. And doing that successfully night after night works really well to resolve, um, nocturnal any recess. Bye. I went over this a little bit already, but things that don't really work with fluid restriction or just randomly cups um it seems the logical thing to do. But the problem with random wake up is you could 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 it. Interrupts sleep, food restriction. Children should be allowed to drink if they're thirsty. Like 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 what does Mark Preston so D. D a. V p is a visa president analog that enhances water re absorption in the collecting deaths 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 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 have to do with the habits and the sleep. But of note, if a child is waking up multiple times tonight on having lots of urine Polly area, your knowledge should be done. And you have to think about diabetes insipid if their diabetes the lightest but, um, conclusions things to take away. Most importantly, good Cooper's make good peers. 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. We're always happy to talk with you or to see these stations. So we're gonna talk a little bit now about neurologic conditions, and then everyone can hear me. It's not. Please let me know S 01 of the most common fields. We get understanding testicles in the tractor testicles. So I understand the testicles are defined as a testicle that does not occupied with dependents moral position. Normally, testings develops within the abdomen. Of this under investigation, the normal testicular path is to migrate from the scrolling. Uh, right. They entered the starting before birth. So members of the testing the moment migration stops in the abdomen with planning area, however, symptoms after both. The test is maybe in this program that we're not being described. But then they continue. Thio, as Bethany was saying, A best way thio 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 in or keep XY, which is to bring the testicle down into the scrotum, and we stick it in place and again. It's usually done around one year of age earlier. If it's a bilateral undescended testes surgery 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 eyes, 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. Okay, so another common complaint that we see is for Moses now, normally in pre pube, it'll boys thief foreskin should be retracted to see at least the mediates. So if we're able to see more, that's great. But we do want to at least be able to see the Metis in boys who are in puberty. The foreskin should be able to be fully retracted to expose the media's the glands, the corona and the penile shaft. And sometimes what happens is the foreskin does not retract. And so we call that for Moses. And there are two types. There's physiologic and pathologic, physiologic pharmacists is normal and uncircumcised voice 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 impurity as the testosterone levels allow the foreskin adhesions to separate. Pathologic, for Moses is typically with scarring and fibrosis tissue. And on exam, you see the sort of thickened whitefish, 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 pharmacists includes recurrent urinary tract infections, recurrent ballon itis, ballooning of the foreskin with urination. Where you're in can pull underneath the foreskin, Um, difficulty peeing or any sort of urinary retention. Dis Yuria, painful erections para pharmacists 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. So treatment for physiologic pharmacists and pathologic for Moses is the same We do. Start with Conservative Management, which includes a steroid cream and stretching thes steroid cream we use is trying and sin alone 0.1% that we ask. The families should 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, Onda patients who remain symptomatic or have persistent pathologic for Moses, 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 stretchy that the adhesions don't come back or the pharmacist does not recur. And it's usually just gently retracting the foreskin, especially an older kids teaching them to gently retract the foreskin, um, before peeing and to gently retract the foreskin, um, clean in 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 pair for Moses. And certainly if there's any pair, pharmacist, active pair pharmacists, those patients should be referred to the emergency room right away. So ah, quick note on circumcisions. So outside the newborn period, circumcisions become a bit more involved requiring general anesthesia, and there's risk with general anesthesia, there could be a risk of bleeding and infections. Um, because these procedures typically are done in the O. R. So we dio we do like it when caregivers are asked about circumcisions at birth. If they do want to Circumcision at birth and toe have it done in the newborn period. We don't recommend elective circumcisions, so it's magma, something we often see associated with pharmacists. It's the collection of that skin cells on from the glands Penis and the inter foreskin that's caused by the foreskin. Occasions separating, Um, it can appear as this mobile annual or lump that you guys that's underneath the foreskin. ITT's you, um, usually if we see a lump like that under the foreskin, it's usually smeg muds. Nothing concerning, um, Magma's 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 thes 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. Thio, UCSF, we have this here for you.