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ORIGINAL RESEARCH |
From the 1Division of Urogynecology, Department of Obstetrics and Gynecology, Geisinger Health System, Danville, Pennsylvania; and 2Division of Urogynecology, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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METHODS: Using a case-control study, we surveyed patients presenting with or without urinary incontinence. Cases were patients referred to a tertiary urogynecology clinic, and controls were patients referred to a general gynecology clinic. Patients completed a validated childhood questionnaire about dysfunctional voiding. A total score of 6 or more in girls is indicative of dysfunctional voiding, a condition characterized by urgency, frequency, constipation, urinary or fecal incontinence, and/or urinary tract infections. Using an alpha of 0.05, a power of 80%, and a baseline prevalence of dysfunctional voiding of 8%, we determined that 170 patients were needed to show a 3-fold difference between groups.
RESULTS: Cases (n = 84) and controls (n = 86) had similar baseline characteristics except for body mass index and incidence of previous pelvic surgery. Although the total dysfunctional voiding score was higher in cases than controls (7.3 versus 5.0, respectively; P = .001), the difference in the number (%) of patients with history of childhood dysfunctional voiding between the 2 groups was not significant (47 [56%] versus 36 [42%], respectively; odds ratio 1.76, 95% confidence interval 0.96–3.24; P = .07). When all patients from both groups were combined, there was a higher prevalence of a history of childhood dysfunctional voiding in women with or without current urinary frequency (P = .004), urgency (P = .03), stress incontinence (P = .01), and urge incontinence (P = .009).
CONCLUSION: Women with adult lower urinary tract symptoms may have a higher prevalence of history of childhood dysfunctional voiding.
LEVEL OF EVIDENCE: II-2
There is evidence that the prevalence of nocturnal enuresis and day wetting decreases with age in teenagers.3 However, there seems to be an association between childhood nocturnal enuresis and adult detrusor overactivity; patients with a previous history of nocturnal enuresis have a greater risk of bladder dysfunction developing in adulthood.4,5 Although the influence of childhood enuresis has been examined, the relationship between childhood dysfunctional voiding and urinary incontinence in adulthood is less clear and not well studied.6
Dysfunctional voiding in children is characterized by the presence of a variety of symptoms, including urinary incontinence, urgency, frequency, constipation, fecal incontinence, or urinary tract infections.1,7,8 This condition is usually managed conservatively with bladder training, biofeedback, and medications,8 but if left untreated it can result in significant morbidity, including hydronephrosis, renal insufficiency, the need for multiple surgeries, and, rarely, death.9
The aim of this study was to determine whether adult women presenting with lower urinary tract symptoms have a higher likelihood of having had a history of dysfunctional voiding in childhood. The other objective was to evaluate whether this association is stronger in any particular diagnostic type of incontinence, including stress, urge, or mixed incontinence.
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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The first part of the questionnaire contained questions about the patient’s demographics, history of adult lower urinary tract symptoms (including frequency, urgency, nocturia, stress, and urge incontinence), pelvic surgery, and hormone replacement therapy. All definitions conformed to the International Continence Society standardization of terminology.10 The second part of the questionnaire included a set of 10 questions specifically related to history of childhood dysfunctional voiding. Those questions were derived from a validated questionnaire (The Dysfunctional Voiding Scoring System) used in children to diagnose dysfunctional voiding.8,11,12 Each question has 5 possible answers: almost never = 0, less than half the time = 1, half the time = 2, almost every time = 3, and not available (see Appendix). A total score is calculated by adding the individual responses to the 10 questions, with the range being from 0 to 30. It has been shown that a score of 6 or more is indicative of a history of dysfunctional voiding in girls.8
The primary outcome studied was the difference in the total score obtained on the Dysfunctional Voiding Scoring System between patients presenting with urinary incontinence symptoms (cases) and those presenting for other gynecologic reasons (controls). A secondary outcome was to combine both cases and controls and determine whether a difference existed in the scores between those with and those without current lower urinary tract symptoms. Finally, another outcome measure was a subgroup analysis of the cases to estimate whether the dysfunctional voiding scores differed among those with stress, urge, and mixed urinary incontinence.
The prevalence of childhood dysfunctional voiding in girls varies between 3% and 12%.3,13,14 We considered that the prevalence in our population was 8% and that women presenting with lower urinary tract symptoms were at least 3 times as likely to have had a history of dysfunctional voiding as children when compared with the general population.5 Using an alpha value of 0.05 and a power of 80%, we calculated that a total of 170 patients (85 in each group) were needed to complete the study.
Data analysis was performed with the SPSS 11.0 statistical package (SPSS Inc, Chicago, IL). Student t test was performed to compare the 2 groups for continuous data; 
2, Fisher exact test, and the Mann-Whitney U and Kruskal-Wallis tests were used for categorical data. To account for possible confounding variables, baseline demographic characteristics that were statistically different between the 2 groups were controlled by including them in a multiple logistic regression model as covariates. Individual fields in the 10-question scoring system were compared in the 2 groups by dichotomizing the answers into group A ("about half the time" and "almost every time") and group B ("not available," "almost never," and "less than half the time").
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RESULTS |
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Table 3 presents the mean total dysfunctional voiding scores and the number (%) of patients scoring 6 or more (cutoff value for dysfunctional voiding in girls8) in cases and controls. Even after controlling for body mass index, previous hysterectomy, and previous bladder repair, the difference in the total dysfunctional voiding score was significantly higher in the cases than in the controls, with P = .02 (data not shown). Of note is that some controls also had one or more lower urinary tract symptoms. Table 3 also includes the mean total dysfunctional voiding scores and the number (%) of patients scoring 6 or more of all patients from both groups, with or without any lower urinary tract symptom. There was a higher prevalence of a history of childhood dysfunctional voiding in women with or without current urinary frequency (60% versus 38%, odds ratio [OR] 2.48, 95% confidence interval [CI] 1.34–4.61; P = .004), urgency (58% versus 41%, OR 2.02, 95% CI 1.09–3.75; P = .03), stress incontinence (59% versus 40%, OR 2.21, 95% CI 1.18–4.15; P = .01), and urge incontinence (61% versus 40%, OR 2.31, 95% CI 1.23–4.37; P = .009).
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Figure 1 presents the difference in the dysfunctional voiding scores in the cases who had different types of incontinence. There was no statistically significant difference in the total scores between patients with the diagnosis of stress, urgency, mixed, or other incontinence (P = .9).
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DISCUSSION |
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Although we did not demonstrate that cases had a significantly higher prevalence of childhood dysfunctional voiding (score 
6) compared with the controls, many of the control patients did in fact have lower urinary tract symptoms. This, in part, explains why the prevalence of childhood dysfunctional voiding of 42% in our control group was much higher than anticipated. Another approach would have been to recruit controls from a less-biased female population like the internal medicine or family practice clinics with a possibly lower prevalence of current lower urinary tract symptoms.
The fact that there was no significant difference in history of childhood dysfunctional voiding between those who had at least one adult lower urinary tract symptom compared with those who had no symptoms is likely due to the small numbers in the latter group. When patients with individual symptoms of frequency, urgency, stress and urge incontinence, and overactive bladder were compared with those who did not have such symptoms, we found that there was a higher prevalence of dysfunctional voiding in childhood in each category of lower urinary tract symptom.
Our study showed that there is a significant association between patients presenting with lower urinary tract symptoms and a history of infrequent urination, postponement of urination, and urinary urgency in childhood (Table 2). Among other factors, history of childhood stress was also significantly more common in the cases compared with the controls. Bladder dysfunction has been shown to be more common in sexual abuse survivors.19 Lower urinary tract symptoms have also been associated with high levels of anxiety and psychopathology.20 Analysis of the different groups with urinary incontinence (stress, urge, and mixed) in our population did not reveal any difference with respect to a history of childhood dysfunctional voiding. However, the group sizes were too small to achieve any statistical significance.
The weakness in our study is the nature of the study design itself (case-control). One bias involved in a case-control study includes "recall bias," where patients with present urinary incontinence may be more sensitized to remember having had urinary problems in childhood. Also, the dysfunctional voiding scoring system has been validated in children but not in adults attempting to recall their childhood history of lower urinary tract symptoms. This was used as a proxy measure because of the lack of any other more objective tool to measure history of childhood dysfunctional voiding in adult women. Another bias is the "referral filter bias," in which patients with lower urinary tract symptoms selected from the urogynecology clinic (cases) are different from the general population (controls), as evidenced by the differences in body mass index, previous hysterectomy, and bladder repair. Finally, this was a questionnaire study completed by patients without the presence of a research coordinator to ensure accuracy. Consequently, some of the data points remained blank or unanswered because of absent or improper responses.
In conclusion, this study did not demonstrate that women presenting to the urogynecologist with lower urinary tract symptoms are more likely to have had a history of childhood dysfunctional voiding. However, there may be an association between adult symptoms of frequency, urgency, stress or urge incontinence, and childhood dysfunctional voiding. Future directions include prospectively following into adulthood a cohort of children, including those with and those without dysfunctional voiding (scores 6), to determine whether there is indeed a higher likelihood of developing urinary incontinence in the former group and whether this likelihood is more prevalent in a particular subtype of incontinence.
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APPENDIX |
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Footnotes |
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doi:10.1097/01.AOG.0000190222.12436.38
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REFERENCES |
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