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Original Article • IBJUInt. braz j urol 49 (6) • Nov-Dec 2023 • https://doi.org/10.1590/S1677-5538.IBJU.2023.0201 copy

Association between rectal diameter and response to treatment with parasacral transcutaneous electrical nerve stimulation and behavioral changes in children and adolescents with bladder and bowel dysfunction

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose:

Parasacral Transcutaneous Electrical Stimulation (TENS) is one of the treatments for children with Bladder and Bowel Dysfunction (BBD). Some studies showed that children with increased Rectal Diameter (RD) have more Functional Constipation (FC). However, RD prediction in maintenance of BBD after treatment was never evaluated. Our aim is to evaluate the association between RD and response to treatment in children and adolescents with BBD.

Materials and Methods:

This study evaluated patients from 5-17 years old with BBD. Dysfunctional Voiding Scoring System (DVSS), Rome IV criteria, and the Constipation Score were used. RD was measured using abdominal ultrasound before treatment according to the technique established by Klijn et al. and was considered enlarged when >3cm. No laxatives were used during treatment. Descriptive analysis and binary regression were performed and the area under the ROC curve was calculated.

Results:

Forty children were included (mean age 8.4±2.8 years, 52.5% male). Before treatment, RD was enlarged in 15 children (37.5%) (mean diameter 3.84±0.6cm), with FC persisting post-treatment in 11/15(73.3%). Those patients also required more laxatives following treatment and had more severe FC. Binary regression showed pretreatment RD to be an independent predictor of the persistence of FC post-treatment (OR=9.56; 95%CI:2.05-44.60). In ROC curve analysis, the sensitivity was 100% (95%CI: 0.49-1.0) and specificity 77.14% (95%CI:0.60-0.90) for rectal diameter >3 cm. The likelihood ratio was 4.38 (95%CI:2.40-8.0) for the persistence of BBD following treatment.

Conclusion:

RD appears to be relevant in the evaluation of children with BBD, not only as a diagnostic tool but also as a predictor of treatment outcome.

Keywords:
Lower Urinary Tract Symptoms; Pediatrics; Ultrasonography

Parameters	Rectal diameter before treatment		p-value
Parameters	< 3 cm (n=25)	≥ 3 cm (n=15)	p-value
DVSS, median (IQR)	13 (10-16)	14 (11-17)	0.54^† † Mann Whitney test.
Urinary urgency, n (%)	25 (100)	14 (93.3)	0.19^* * = Fisher's exact test;
Daytime incontinence, n (%)	23 (92)	12 (80)	0.27^* * = Fisher's exact test;
Holding maneuvers, n (%)	20 (80)	13 (86.7)	0.59^* * = Fisher's exact test;
Daytime urinary frequency, n (%)	14 (56)	9 (60)	0.80^* * = Fisher's exact test;
Nocturia, n (%)	8 (32)	3 (20)	0.33^* * = Fisher's exact test;
Enuresis, n (%)	18 (72)	14 (93.3)	0.10^* * = Fisher's exact test;
Lower urinary tract dysfunction, n (%)	23 (92)	14 (93.3)	0.87^* * = Fisher's exact test;
Constipation score, median (IQR)	9 (6-11)	11 (10-16)	0.01 ^† † Mann Whitney test.
Feeling of incomplete evacuation, n (%)	13 (52)	7 (46.7)	0.74^* * = Fisher's exact test;
Time in lavatory per attempt >5 minutes, n (%)	14 (56)	12 (80)	0.12^* * = Fisher's exact test;
Assistance to evacuate, n (%)	3 (12)	2 (13.3)	0.90^* * = Fisher's exact test;
Unsuccessful attempt to defecate, n (%)	18 (72)	14 (93.3)	0.10^* * = Fisher's exact test;
Abdominal pain, n (%)	14 (56)	11 (73.3)	0.27^* * = Fisher's exact test;
Bristol Stool Scale: Types 1 and 2, n (%)	12 (48)	5 (33.3)	0.36

Parameters	Rectal diameter before treatment		p-value
Parameters	<3 cm (n=25)	≥ 3 cm (n=15)	p-value
^∆ ∆ = delta; IQR = interquartile range; DVSS, median (IQR)	- 9.4	- 6.2	0.09^† † Student's t-test;
Urinary urgency, n (%)	6 (24%)	8 (53.3)	0.06^* * Fisher's exact test;
Daytime incontinence, n (%)	8 (32)	7 (46.5)	0.35^* * Fisher's exact test;
Holding maneuvers, n (%)	5 (20)	7 (46.7)	0.08^* * Fisher's exact test;
Daytime urinary frequency, n (%)	2 (08)	4 (26.7)	0.11^* * Fisher's exact test;
Nocturia, n (%)	4 (16)	2 (13.3)	0.82^* * Fisher's exact test;
Enuresis, n (%)	12 (48)	12 (80)	0.05^* * Fisher's exact test;
Lower urinary tract dysfunction, n (%)	7 (28)	7 (46.7)	0.23^* * Fisher's exact test;
Constipation, n (%)	7 (28)	11 (73.3)	0.005 ^* * Fisher's exact test;
Constipation score, median (IQR)	4 (1.5-6)	9 (4-11)	0.003 ^†† †† Mann Whitney test.
Feeling of incomplete evacuation, n (%)	6 (24)	8 (53.3)	0.06^* * Fisher's exact test;
Time in lavatory per attempt >5 minutes, n (%)	4 (16)	6 (40)	0.09^* * Fisher's exact test;
Assistance to evacuate, n (%)	0	2 (13.3)	0.06^* * Fisher's exact test;
Unsuccessful attempt to defecate, n (%)	6 (24)	14 (93.3)	< 0.001 ^* * Fisher's exact test;
Abdominal pain, n (%)	7 (28)	7 (46.7)	0.23
Bristol Stool Scale: Types 1 and 2, n (%)	8 (32)	7 (46.7)	0.35
Use of laxatives after treatment, n (%)	6(24)	11 (73.3)	0.02

Over the last month	Almost never	Less than half the time	About half the time	Almost every time	Not available
1. I have had wet clothes ot wet underwear during the day.	0	1	2	3	NA
2. When I wet myself, my underwear is soaked.	0	1	2	3	NA
3. I miss having a bowel movement every day.	0	1	2	3	NA
4. I have to push for my bowel movements to come out.	0	1	2	3	NA
5. I only go to the bathroom one or two times each day.	0	1	2	3	NA
6. I can hold onto my pee by crossing my legs, squatting or doing the "pee dance".	0	1	2	3	NA
7. When I have to pee, I cannot wait.
8. I have to push to pee.	0	1	2	3	NA
9. When I pee it hurts.	0	1	2	3	NA
10. Parents to answer. Has your child experienced something stressful like the example below?	NO (0)			YES (3)
TOTAL

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