Brain Bladder Flow: Do patients with LUTS and neuropsychiatric co-morbidities have differences in uroflow patterns?
Katherine M. Fischer, MD1, Leah Beland, MD2, Ethan Samet, MD1, Amanda Berry, PhD, MSN, BSN, CPNP1, Adriana Messina, MSN, CRNP, FNP-BC1, Stephen Zderic, MD1, Jason P. Van Batavia, MD, MSTR1.
1Children's Hospital of Philadelphia, Philadelphia, PA, USA, 2Northwell, Manhasset, NY, USA.
BACKGROUND: Lower Urinary Tract Symptoms (LUTS), including urge incontinence, dysfunctional voiding, frequency, and primary nocturnal enuresis (PNE) are very common complaints seen by the pediatric urologist. Several studies have shown an increased prevalence of neuropsychiatric disorders in patients with LUTS as compared to the general population. However, little is known about whether these patients have differences in their presenting symptoms or objective parameters such as uroflow curves. In this study, we investigated whether pediatric patients with LUTS and neuropsychiatric co-morbidities have differences in their uroflow patterns as compared to those without a neuropsychiatric co-morbidity. We hypothesized that there would be significantly more patients with neuropsychiatric diagnoses and LUTS who had abnormal uroflow curves as compared to those without a neuropsychiatric co-morbidity.
Methods: We retrospectively reviewed our IRB-approved registry to identify patients seen for LUTS between 5/2014 and 1/2016 who had completed a uroflow as part of their evaluation. Patients with neurogenic bladder or known urologic abnormalities were excluded. Demographic data, the presence of any neuropsychiatric diagnosis, presenting LUTS symptoms, and DVISS score at initial and final visit were abstracted on chart review. Uroflow curves were reviewed by a pediatric urologist and classified into pattern types based on ICCS criteria. Presenting symptoms, DVISS scores at initial and final visits and uroflow patterns were compared between patients with and without neuropsychiatric co-morbidities using Fisher’s exact test for categorical variables and Wilcoxon rank sum test for continuous variables.
Results: A total of 381 patients met inclusion criteria. Table 1 includes demographic data of the cohort. Median age was 9 years and there were significantly more females without neuropsychiatric co-morbidities (54.8% vs. 43%, p=0.048). ADHD (52%), general anxiety (32%) and development delay (30%) were the most frequent neuropsychiatric co-morbidities noting some patients in this group had multiple diagnoses. Both the initial and final DVISS scores were significant higher in the patients with neuropsychiatric co-morbidities (p<0.001). Encopresis was the only symptom that was significantly more common in patients with a neuropsychiatric co-morbidity (2.8% vs. 11%, p=0.003). Patients with a neuropsychiatric co-morbidity were significantly more likely to have an abnormal (non-bell shaped) uroflow curve (41.3% vs. 64.1%, p<0.001) and were also significantly more likely to have a non-smooth uroflow curve, either interrupted or plateau type, (18.5% vs. 44%, p<0.001) with a staccato flow being the most common pattern (n=39, 39%).
Conclusions:Providers who take care of children with LUTS must consider patients’ psychiatric health when diagnosing and treating LUTS. Our data suggests that LUT symptomatology is more severe when neuropsychiatric diagnoses are present and that these patients are also more likely to have abnormal uroflow results. Further work is needed to determine whether standard treatments for LUT dysfunction such as urotherapy and biofeedback work as effectively in children with neuropsychiatric co-morbidities as those without.
Table 1. Characteristics of patients without vs. with neuropsychiatric comorbidities
| No Neuropsych Diagnosis (n=281) | Any Neuropsych Diagnosis (n=100) | p-value | ||
| Age at Presentation (years), median (IQR) | 9 (7, 12) | 9 (7, 12) | 0.69 | |
| Female | 154 (54.8%) | 43 (43.0%) | 0.048 | |
| Race | 0.78 | |||
| Asian | 6 (2.1%) | 2 (2.0%) | ||
| Black or African American | 45 (16.0%) | 19 (19.0%) | ||
| Native Hawiian or Pacific Islander | 1 (0.4%) | 0 (0.0%) | ||
| Other | 67 (23.8%) | 18 (18.0%) | ||
| Declined | 2 (0.7%) | 0 (0.0%) | ||
| White | 160 (56.9%) | 61 (61.0%) | ||
| ADHD | 0 (0.0%) | 52 (52.0%) | ||
| Autism Spectrum Disorder | 0 (0.0%) | 18 (18%) | ||
| Depression | 0 (0.0%) | 11 (11%) | ||
| Developmental Delay | 0 (0.0%) | 30 (30.0%) | ||
| General Anxiety | 0 (0.0%) | 32 (32.0%) | ||
| Suicide Attempt | 0 (0.0%) | 1 (1.0%) | ||
| Suicidal Ideation | 0 (0.0%) | 3 (3%) | ||
| Self-Harm | 0 (0.0%) | 5 (5%) | ||
| Trauma or Abuse History | 0 (0.0%) | 4 (4%) | ||
| Oppositional Defiant Disorder | 0 (0.0%) | 11 (11%) | ||
| Sleep Disturbances | 0 (0.0%) | 9 (9%) | ||
| Initial DVISS Score, median (IQR) | 10 (6, 14) | 14 (9, 20) | <0.001 | |
| Final DVISS Score, median (IQR) | 7 (2, 12) | 11 (7, 16) | <0.001 | |
| Encopresis | 8 (2.8%) | 11 (11.0%) | 0.003 | |
| Monosymptomatic Primary Nocturnal Enuresis | 38 (13.5%) | 16 (16.0%) | 0.62 | |
| Multisymptomatic Nocturnal Enuresis | 71 (25.3%) | 31 (31.0%) | 0.29 | |
| Daytime Incontinence | 90 (32.0%) | 33 (33.0%) | 0.90 | |
| Giggle Incontinence | 6 (2.1%) | 1 (1.0%) | 0.68 | |
| Constipation | 100 (35.6%) | 41 (41.0%) | 0.34 | |
| Hesitancy | 16 (5.7%) | 7 (7.0%) | 0.63 | |
| Frequency | 103 (36.7%) | 28 (28.0%) | 0.14 | |
| Urgency | 71 (25.3%) | 23 (23.0%) | 0.69 | |
| Non-Bell Shaped Uroflow Curve | 109 (38.8%) | 63 (63.0%) | <0.001 | |
| Smooth vs. Non-Smooth Uroflow Curve | <0.001 | |||
| Smooth (Bell shaped, Plateau, Tower) | 229 (81.5%) | 56 (56.0%) | ||
| Non-Smooth (Interrupted, Staccato) | 52 (18.5%) | 44 (44.0%) | ||
| Flow Type (by ICCS criteria) | <0.001 | |||
| Bell Shaped | 172 (61.2%) | 37 (37.0%) | ||
| Interrupted | 16 (5.7%) | 5 (5.0%) | ||
| Plateau | 8 (2.8%) | 5 (5.0%) | ||
| Staccato | 36 (12.8%) | 39 (39.0%) | ||
| Tower | 49 (17.4%) | 14 (14.0%) |
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