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Long-term prospective evaluation of an inpatient voiding reeducation program for lower urinary tract conditions in children

  • Urology - Original Paper
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Abstract

Purpose

Our aim was to evaluate the efficacy of our treatment program for children with lower urinary tract conditions, developed at the Department of Pediatric Nephrology of the University Children’s Hospital in Ljubljana.

Methods

Sixty-four patients with lower urinary tract conditions were randomly allocated to two groups. Group A received treatment immediately, whereas patients of group B received no treatment for a period of 3 months—the amount of time it takes to complete our program. No child in group B experienced spontaneous regression of their symptoms in the 3-month delay period, while the patients of group A were already being treated and were achieving results. Thus, all the patients of group B then entered the program in exactly the same way as patients of group A.

Results

The final success rate in both groups did not differ significantly (p = 0.706–1.000) and ranged from 86.2 % for group A and 86.7 to 90 % for group B. Long-term follow-up showed statistically identical success rates (p = 1.000).

Conclusion

This prospective controlled study with long-term follow-up (48 months) shows that our treatment program, applied as an inpatient voiding school program, is an effective method, with durable results.

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Acknowledgments

We would like to express our gratitude to all the participants in our study and all the staff of the Department of Pediatric Nephrology of the University Children’s Hospital in Ljubljana who helped this treatment program become a reality. Special thanks go to Urša Reja, M. Sc. for all the help with the statistical analysis.

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Authors and Affiliations

  1. Department of Pediatric Nephrology, University Children’s Hospital, University Medical Center Ljubljana, Bohoričeva ul. 20, 1000, Ljubljana, Slovenia

    Tanja Golli, Anamarija Meglič & Rajko B. Kenda

Authors
  1. Tanja Golli
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  2. Anamarija Meglič
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  3. Rajko B. Kenda
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Corresponding author

Correspondence to Tanja Golli.

Appendices

Appendix 1: Protocol for the treatment program of lower urinary tract conditions

Inpatient part of the program

Day-to-day plan

  1. (a)

    Day 1

    1. 1.

      Check the child has undergone all necessary diagnostic procedures and meets all the criteria for the treatment of daytime voiding dysfunction

    2. 2.

      Regular daily routine

  2. (b)

    Day 2

    1. 1.

      Regular daily routine

  3. (c)

    Day 3

    1. 1.

      Regular daily routine

    2. 2.

      Quiz on regular daily routine components

  4. (d)

    Day 4

    1. 1.

      Regular daily routine

    2. 2.

      One-on-one consultation with in-house psychologist

  5. (e)

    Day 5

    1. 1.

      Regular daily routine

    2. 2.

      Graduation ceremony where children receive certificates for completing the inpatient part of the program

    3. 3.

      Consultation (of pediatrician and nurse) with the parents on the practical aspects of applying the daily routine in the home environment

    4. 4.

      Receiving 1-month bladder diary for the child

    5. 5.

      Receiving written instructions on daily routine for parents

Regular daily routine

  1. (a)

    Teaching and monitoring appropriate fluid intake

    Age (years)

    Amount of fluid in time intervals (ml)

    By 10 a.m.

    By 12 a.m.

    By 2 p.m.

    By 4 p.m.

    By 6 p.m.

    By 8 p.m.

    Total in 24 h

    5–9

    300

    200

    200

    150

    100

    50

    1,000

    10–14

    400

    300

    300

    200

    100

    100

    1,400

    15–18

    500

    500

    400

    300

    200

    100

    2,000

  2. (b)

    Regular and appropriate voiding habits

    • Voiding every 2–3 h during the day. When the child repeatedly feels the need to void more frequently than this, the nurse will encourage him to lengthen the intervals between voiding.

    • The child should take enough time to void, so that he/she empties the bladder completely (pictures on the bathroom walls encourage this).

    • Attention to the correct posture during voiding in girls (feet flat on the floor or on an appropriate stool, back straight).

    • Attention to the relaxation of the pelvic floor muscles (see pelvic floor muscle exercises) during urination and the continuous flow of urine during voiding (“boys watch, girls listen” technique).

    • We do not wake children to void during the night.

  3. (c)

    Pelvic floor muscle exercises

    • Boys and girls under 8 years: the “balloon” exercise, usually performed while watching one-self in a mirror. First, the child relaxes the abdominal muscles to create a large balloon, thus also relaxing the pelvic floor muscles; then, the child “deflates” the balloon, tightening the abdominal and consequentially the pelvic floor muscles—20 repetitions 3 times per day.

    • Girls over 8 years: classic Kegel exercises, where the child contracts the muscles of the pelvic floor as if wanting to stop the flow of urine (but never performing the exercises during urination, except to check the effective use of pelvic floor muscles during the learning phase)—30 repetitions 3 times per day.

  4. (d)

    Preventing and treating constipation

    • The child should have at least one bowel movement per day, while receiving a diet high in fiber, fresh fruits, and vegetables.

    • Ideally, regular bowel movements in the morning should be achieved during the program, but if the child does not defecate by 4–6 p.m. each day an additional laxative will be prescribed.

  5. (e)

    Daily psychological evaluation and support

    • Addressing child’s well-being in hospital setting.

    • Following compliance with program.

    • Assessing interactions with nursing staff.

    • Assessing interactions during free play-time.

    • Giving individual advice during one-on-one sessions.

Outpatient part of the program

  1. I.

    First follow-up (1 month after the completion of the inpatient program)

    1. (a)

      Reviewing the bladder diary

    2. (b)

      Addressing any questions, problems arising at home

    3. (c)

      Reinforcing the daily routine instructions learned during the inpatient part of the program

    4. (d)

      Auto-evaluation score

    5. (e)

      New 1-month bladder diary

    6. (f)

      New appointment in 1 month

  2. II.

    Second follow-up (2 months after the completion of the inpatient program)

    1. (a)

      Reviewing the bladder diary

    2. (b)

      Addressing any questions, problems arising at home

    3. (c)

      Reinforcing the daily routine instructions learned during the inpatient part of the program

    4. (d)

      Auto-evaluation score

    5. (e)

      New 1-month bladder diary

    6. (f)

      New appointment in 1 month

  3. III.

    Third follow-up (3 months after the completion of the inpatient program)

    1. (a)

      Reviewing the bladder diary

    2. (b)

      Addressing any questions, problems arising at home

    3. (c)

      Reinforcing the daily routine instructions learned during the inpatient part of the program

    4. (d)

      Auto-evaluation score

    5. (e)

      DVSS questionnaire score

    6. (f)

      New appointment in 3 months

Long-term follow-up after the completion of our treatment program

  1. I.

    Forth follow-up (6 months after the completion of the inpatient program)

    1. (g)

      Auto-evaluation score

    2. (h)

      New appointment in 6 months

  2. II.

    Fifth follow-up (12 months after the completion of the inpatient program)

    1. (i)

      Auto-evaluation score

    2. (j)

      New appointment in 24 months

  3. III.

    Sixth follow-up (36 months after the completion of the inpatient program)

    1. (k)

      Auto-evaluation score

    2. (l)

      New appointment in 12 months

  4. IV.

    Seventh follow-up (48 months after the completion of the inpatient program)

    1. (m)

      Auto-evaluation score

    2. (n)

      New appointment in 12 months

Appendix 2: Subjective auto-evaluation scale

The patient alone (or with the help of the parents in case of very young children) was asked to choose which of the following three options best described their current status, when compared to the symptoms present at the recruitment to our program. We emphasized that there were no wrong or right answers and that we wanted their honest opinion on their status.

  • More than 90 % decrease in symptoms (incontinence, urge incontinence, voiding postponement…)

  • 50–90 % decrease in symptoms (incontinence, urge incontinence, voiding postponement…)

  • Less than 50 % decrease in symptoms (incontinence, urge incontinence, voiding postponement…).

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Golli, T., Meglič, A. & Kenda, R.B. Long-term prospective evaluation of an inpatient voiding reeducation program for lower urinary tract conditions in children. Int Urol Nephrol 45, 299–306 (2013). https://doi.org/10.1007/s11255-012-0348-0

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