Risk factors for the development of bladder and bowel dysfunction
Thomas Gaither, BS1, Chistopher Cooper, MD2, Zachary Kornberg, BS1, Laurence Baskin, MD1, Hillary Copp, MD, MS1.
1University of California, San Francisco, San Francisco, CA, USA, 2University of Iowa, Iowa City, IA, USA.
Patients with vesicoureteral reflux (VUR) and concomitant bladder and bowel dysfunction (BBD) are at high risk for febrile urinary tract infections (UTIs). Previous studies demonstrate that overweight children are less responsive to treatment for BBD but it is unclear if overweight children are at risk for developing BBD. Similarly, the predictive value of reflux grade and exposure to antibiotic prophylaxis in young children on development of BBD is unknown. We sought to identify risk factors for BBD development that could facilitate more individualized management of children with VUR.
Materials & Methods
We conducted a secondary analysis of the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) and Careful Urinary Tract Infection Evaluation (CUTIE) trials. Patients with baseline BBD (n=97) or unknown BBD status (n=11) were removed. Patients who were not toilet trained at follow-up were excluded (n=298), and those with missing toilet training or BBD status at follow-up were removed (n=78). The outcome of interest was the development of BBD during any time point in the studies. BBD was identified and monitored at each clinical visit through the use of validated questionnaires. Controlling for age at presentation, we used multivariable logistic regression to determine the independent effects of sex, baseline percentile body mass index (BMI), cohort status (RIVUR v. CUTIE), continuous antibiotic prophylaxis (yes/no), and reflux status (dilating versus non dilating) on the development of BBD during the 2-year follow up for each study.
317 patients met inclusion criteria with 83 (26%) from the CUTIE trial and 235 (74%) from the RIVUR trial. The majority of patients (244 patients, 77%) were not toilet trained at baseline visit. The median baseline age (interquartile range, IQR) was 21 months (11-35 months), and 299 (94%) patients were female. The median (IQR) baseline percentile BMI was 64 (39-85), and 108/234 (48%) had dilating reflux at baseline. During the study period, 111 (35%) developed BBD. Patients who developed BBD were more likely to be female compared to those who did not develop BBD (99% v. 91%, p<0.01). Table 1 shows the results of the multivariable analysis. Baseline BMI percentile was not associated with BBD development (aOR=1.0, p= 0.75), whereas female sex was highly associated with BBD development (aOR=10.3, p=0.03). Patients with dilating reflux at baseline were 2.2 times more likely to develop BBD (p=0.01) after controlling for age, sex, treatment group, and BMI. Antibiotic prophylaxis was not associated with BBD development (aOR=0.9, p=0.61).
BBD is common in patients at risk for UTI's. Dilating reflux and female sex were identified as risk factors for development of BBD but neither being overweight or the use of prophylactic antibiotics was associated with the development of BBD.
The risk of developing BBD should be considered when tailoring a comprehensive management plan for children with VUR.
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