INTESTINAL CLEAN OUT AND MAINTENANCE (ICOM) PROGRAM IN CHILDREN WITH LOWER URINARY TRACT DYSFUNCTION: USING NOVEL INDICES ON ABDOMINAL XRAYS TO GUIDE TREATMENT AND PREDICT OUTCOME
Daniel B. Herz, MD, MS.
Connecticut Children's Hospital, Hartford, CT, USA.
BACKGROUND: Effective treatment strategies are important in children with Bladder and bowel dysfunction (BBD) however risk stratification is not always clear, and treatment varies. We implemented treatment targeting the bowel dysfunction ONLY and report both bladder and bowel outcomes post treatment. We compared abdominal x-rays (AXR) pre and post intestinal cleanout to clinical outcomes. We tested 2 novel indices on AXR (transverse lumbar spine to rectum diameter ratio and a Likert scale of fecal colonic load to predict outcomes.
Methods: Toilet trained children with BBD entered a 3-month prospective intestinal clean out and maintenance (ICOM) program. Children with spinal dysraphism, anorectal malformation, or lower tract obstructive uropathy were excluded. Demographics, presentation, medical history, and lower urinary tract dysfunction (LUTD) scores with Rome criteria and Bristol Stool Scale (RC/BSS) were recorded before and after treatment. LUTD and RC/BSS scores were combined to create a BBD score. Diameters of the lumbar spine and rectum were recorded to calculate a lumborectal ratio (LRR). A 1 to 4 Likert scale based on a 4 quadrant abdomen was used to assess fecal colonic load with added “+” or “-“ for the presence or absence of rectal dilation. These values were correlated to outcomes using an odds ratio. Pre and post ICOM Pediatric Incontinence Quality-of-Life questionnaire (PinQ) were recorded. The ICOM program consisted of a 2-day intestinal clean out with combination osmotic and stimulant laxatives followed by a 3-month maintenance program with progressively de-escalating laxative doses and frequency. Compliance was measured by questionnaire. Follow-up continued for 1 year.
Results: Of the 177 entered, 43 (29%) were male and 106 (71%) female with a mean age= 6.4 years (range= 3.8 to 12.5). Presentation was recurrent UTI (rUTI) in 73 (41%), lower urinary tract symptoms (LUTS) in 102 (58%), and enuresis in 2 (1%). There was associated encopresis in 57 (32%), urinary incontinence in 136 (77%), VUR in 37 (21%), and hematuria in 19 (11%). Initial urine culture was positive in 23 (13%). RC/BSS results were positive in 129 (73%). Mean pre-ICOM BBD score was 22 (range 12-29). After 3 months 149 (84%) children completed the program. Mean post ICOM BBD score < 11 in 103 (81%), with 77 (52%) experiencing complete resolution of LUTS. QoL scores were significantly reduced in 101 (68%) after ICOM program. AXR was positive in 62 (41%) children with negative RC/BSS. Program compliance was excellent in 133 (90%). A LRR = 1.5 or greater and a Likert Scale score = 3+, or = 4 correlated with a good response to ICOM and a high likelihood of LUT symptoms resolving with clean out alone.
Conclusions: Initial management if BBD with intestinal management alone in high risk children will render the majority of children significantly less symptomatic and save over half the need for any bladder related medications or interventions. Initial screening abdominal x-rays can predict this outcome if interpreted with LRR > or = 1.5, or significant fecal colonic load Likert score = 3+ or 4.
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