What Causes Urinary Hesitancy?

Patient Presentation
A pediatrician asked his colleague for help with considering a differential diagnosis for a college age male who presented with true urinary hesitancy for ~2 weeks. “It’s just not that common a problem in pediatrics,” the pediatrician noted. “The patient has never had any urinary or bowel problems previously, denies dysuria or other pain, or fever. He says he has a normal stream, volume and urinates 6-8 times/day. He denies getting up at night to void. He also denies any bowel problems nor any neurological issues like issues with sensation or problems walking. He also denies any sexual activity for several months,” the pediatrician related to his colleague. “He just says that he wants to void and can’t seem to start his stream in a reasonable amount of time,” the pediatrician said. The second pediatrician agreed that it was not a common problem and asked some more questions about the potential for an occult malignancy or soft neurological signs for a neurological problem which the attending pediatrician said that the patient denied. “I guess I would do a urinalysis and screen him for sexually transmitted infections today and then consult urology. They obviously see this problem more than us and maybe the young man needs to have urodynamics testing or even have a cystoscopy performed,” the colleague stated. “In the meantime you can also have him keep a symptom diary so that you or the urologist can have a better idea of his bowel and bladder patterns,” the colleague also offered.

Discussion
Hesitancy” denotes difficulty in initiating voiding when the child is ready to void,” according to the International Children’s Continence Society. It is not seen that often in pediatrics in isolation, but is commonly associated with other symptoms such as dysuria, frequency, abdominal or anal pain which may indicate common problems such as a urinary tract infection, vaginal/perineal irritation, or constipation. Communication problems can also confound the accuracy of the history as patients and families can have a difficult time describing the urinary problem they are experiencing or may be embarrassed to fully communicate their concerns. Symptom diaries are often helpful to more accurately discern the frequency, and pattern of the problem, along with other concurrent symptoms. Some patients are more comfortable writing about the problem than expressing it verbally and diaries can sometimes assist. Testing for common problems usually begins the evaluation, but consultation with an urologist or another specialist may be necessary.

Learning Point
One of the classic causes of urinary hesitancy is benign prostatic hypertrophy but this is not a common cause in the pediatric and young adult age group. Another cause is medications, but as this age group generally takes fewer medications, drugs are also a less common cause but should be considered in the differential diagnosis.

The differential diagnosis of urinary hesitancy in children and teenagers includes:

  • Obstruction
    • Direct
      • Foreign body
      • Malignancy
      • Prostate
    • Indirect
      • Bowel bladder dysfunction
      • Constipation
      • Pregnancy
      • Abdominal/pelvic malignancy
  • Neurologic/Muscular
    • Bladder neck obstruction
    • Dysfunctional voiding
    • Detrusor urethral sphincter dyssynergy
    • Dysautonomia
    • CNS space occupying lesions – abscess, malignancy
  • Drugs – antidepressants and others which may cause urinary retention
  • Other
    • Sexually transmitted infections
    • Behavioral including abuse
    • Situational – public restrooms

Questions for Further Discussion
1. What are indications for referral to an urologist?
2. What is the difference between dysfunctional voiding and detrusor urethral sphincter dyssynergy?

Related Cases

    Symptom/Presentation: Urine

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Urine and Urination and Bladder Diseases.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Paner GP, Zehnder P, Amin AM, Husain AN, Desai MM. Urothelial neoplasms of the urinary bladder occurring in young adult and pediatric patients: a comprehensive review of literature with implications for patient management. Adv Anat Pathol. 2011 Jan;18(1):79-89.

Glassberg KI, Combs AJ, Horowitz M. Nonneurogenic voiding disorders in children and adolescents: clinical and videourodynamic findings in 4 specific conditions. J Urol. 2010 Nov;184(5):2123-7.

Austin PF, Bauer SB, Bower W, et.al. The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children’s Continence Society. Neurourol Urodyn. 2016 Apr;35(4):471-81.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What are Indications for Continuous Positive Airway Pressure (CPAP)?

Patient Presentation
A 6-year-old male came to clinic with rhinitis and coughing with a fever for 2-3 days. The maximum temperature was 101°F. He was not eating as much and was more fatigued. He denied specific pain. His mother was more concerned because he’s “making lots of loud sounds and snoring at night” also. She stated that he always seemed to be a noisy sleeper and his snoring got worse if he had an upper respiratory tract infection. She denied paused breathing but could not further characterize the sounds or snoring. She denied daytime fatigue when he was otherwise well, but was concerned because her husband had recently started to use a breathing machine at night for “his own snoring and stopping breathing.” The past medical history showed a well child who was obese. The family history also showed obesity and lipid abnormalities. The review of systems was otherwise negative.

The pertinent physical exam showed a tired male with normal temperature, respiratory rate of 22/minute, heart rate of 88 beats/minute and a body mass index of 28. HEENT showed clear rhinorrhea, +3 tonsils with a smaller midface/oropharynx without erythema or exudate, and tympanic membranes were normal. His lungs had transmitted upper airway noises but no adventitial breath sounds. The rest of his examination was normal.

The diagnosis of an upper respiratory tract infection was made. After discussing the acute infection, the pediatrician discussed the possibility of obstructive sleep apnea and referred the child to an otolaryngologist. A sleep study was performed showing obstructive sleep apnea and the child underwent tonsillectomy and adenoidectomy with marked improvement in his snoring even during acute illnesses. Life style interventions for obesity were also being worked on by the family.

Discussion
Obstructive sleep apnea syndrome (OSAS) is defined as a “disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns.” It is different than primary snoring which is snoring without apnea, sleep arousals, or problems with gas exchange.
OSAS symptoms include snoring (often with snorts, gasps or pauses), disturbed sleep (often frequent arousals) and daytime neurobehavioral problems. Sleepiness during the day can occur but is less common in children. Risk factors include black race, obesity, adenotonsillar hypertrophy, craniofacial abnormalities, neuromuscular disorders, or family history of disordered breathing.

OSAS occurs in all ages and is most likely under diagnosed with a 2% prevalence rate. Primary snoring has a prevalence of 3-12%. Problems of untreated OSAS include failure to thrive, cor pulmonale including pulmonary and systemic hypertension, and cognitive and behavioral problems. The gold standard for diagnosis is overnight sleep study (polysomnography).

In addition to lifestyle issues such as avoiding tobacco smoke, air pollutants and allergens and treatment of rhinitis and weight loss strategies in some patients, treatment of OSAS for children usually begins with tonsillectomy and/or adenoidectomy. While this can treat many patients, others still will have OSAS. Noninvasive ventilation such as continuous positive airway pressure (CPAP) may be the next step for some children. CPAP devices use a small turbine to create increased pressure that is delivered to the upper airway by a fitted mask. Additional options include other oral-facial surgeries, orthodontic treatments or dental appliances. Drug treatment with nasal steroids and/or montelukast have also been used.

Learning Point
Indications for non-invasive ventilation including CPAP consist of:

  • For neonates, infants and pediatric patients
    • Asthma
    • Bronchiolitis
    • Obstructive sleep apnea syndrome
    • Pneumonia
    • Muscle fatigue, impending of respiratory muscles
    • Myopathies
    • Ventilator management
      • Good respiratory drive but still needing minimal respiratory support
      • Weaning
    • Lung collapse prevention
  • For adults
    • Obstructive sleep apnea syndrome
    • Chronic obstructive pulmonary disease with exacerbation
    • Acute congestive heart failure with pulmonary edema
    • Acute lung injury
    • Neuromuscular disorders
    • Pneumonia
    • Ventilator weaning

Absolute and relative contraindications include unstable cardiopulmonary status or need for continuous or near continuous ventilator treatment, inability to protect the airway including reduced consciousness or excessive secretions, air trapping or air leak diseases, problems with facial structures including trauma, burns, recent surgery or esophageal or gastric surgery, patients who are very anxious or uncooperative.

Questions for Further Discussion
1. What is the difference between CPAP and BiPAP?
2. What are your local resources for sleep studies?
3. What history and physical examination findings are there for OSAS?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sleep Apnea and Snoring.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Praud JP, Dorion D. Obstructive sleep disordered breathing in children: beyond adenotonsillectomy. Pediatr Pulmonol. 2008 Sep;43(9):837-43.

Marcus CL, Brooks LJ, Draper KA, et.al.; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012 Sep;130(3):576-84.

Sweet DG, Carnielli V, Greisen G, et.al.; European Association of Perinatal Medicine. European consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants–2013 update. Neonatology. 2013;103(4):353-68.

Gonzalez Mangado N, Troncoso Acevedo MF2, Gomez Garcia T. Home ventilation therapy in obstructive sleep apnea-hypopnea syndrome. Arch Bronconeumol. 2014 Dec;50(12):528-34.

Poobani, SK. Noninvasive Ventilation Procedures. eMedicine. Available from the Internet at:
http://emedicine.medscape.com/article/1417959-overview#a3 (rev. 12/21/2015, cited 4/5/17)

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

How Do I Keep My Prescription Stimulant Safe At College?

Patient Presentation
A 17-year-old female with attention deficit disorder with hyperactivity was being seen for her health maintenance examination. She was going to college in the fall and wanted to know what was the best way to keep her methylphenidate prescriptions safe in her dorm room. The past medical history showed she had been diagnosed after having school difficulties when she was in the 5th grade. She had been taking a long-acting medication with good response and some minor weight loss occasionally for the past 7 years.

The pertinent physical exam showed a healthy female with normal vital signs and her weight was at the 10% as it had been for the past 2 years. Her examination showed a Tanner V female without abnormalities. The diagnosis of a healthy female was made. The pediatrician discussed several issues about transitioning to college. “Discretion is important. Don’t go around telling everyone you have the medicine and just take it discretely in your room. Roommates may end up being your lifetime friends or may be someone you cannot trust. Remember they have to earn your trust before you tell them. Keep the medicine locked up. Either you buy a small safe and keep it hidden or there may be one in your room that you can use. Always keep your door locked. That is the first rule,” the pediatrician advised.

Discussion
Going away to college presents new and exciting opportunities for young adults. It also is an important time for transitioning many adult responsibilities to the young adult too. Keeping safe is important and safety tips for college can be reviewed here.

Any medication can be abused. Prescription stimulants are no different. Normally prescription stimulants are used for treatment of attention deficit disorder, narcolepsy and treatment resistant depression. They can help increase alertness, attention, and energy, cognition, learning and memory. However for these reasons and because they are easy to obtain and relatively inexpensive, prescription stimulants are commonly abused on college campuses. Side effects of prescription stimulant abuse includes addiction, cardiovascular side effects, withdrawal symptoms (fatigue, sleep problems or depression) and even hostility, paranoia or psychosis.

Learning Point
While some of the recommendations for safe use of prescription medications in college are specific for controlled substances like stimulants, they are generally true for any medication. Students and their families should consider the following questions:

  • Who will prescribe the medication? Regular hometown physician, student health center, local physician in the college location, or a combination.
  • How often will the student need to followup with the prescriber?
    • The regular physician is often very willing to continue to prescribe medications with followup arranged during scheduled college breaks such as Thanksgiving, Spring Break, etc.
    • However it is important to at least have a local physician who can assist the student if a problem arises. Dosing adjustments are not uncommon nor are side effects because of the changes in student’s lifestyle.
      Also other mental health problems may arise such as increased anxiety or depression that also needs to be addressed.

    • Similarly, it is often helpful to have a relationship with a local pharmacy before a potential problem arises.
  • What pharmacy will be used? Regular pharmacy, local pharmacy, combination
    • Pre-dated paper prescriptions for controlled substances could be taken to college by the student and then taken to the local pharmacy to be filled.
      This is often the safest and most direct way to obtain the medication.

    • Paper prescriptions could also be sent by the regular physician through the postal service to the student at college or the local pharmacy.
    • The problem is that the paper prescription could be lost or even potentially stolen.
      Another option would be to use the regular pharmacy to fill the prescription which might work well if the student is routinely going back to their home from college.

    • A third option is for the regular pharmacy to fill the prescription and mail the medication to the student. This can be done but requires the student to sign for the medication and there are some other restrictions for using this option.
      Parents cannot fill the prescription and then send the medication to their student through the postal service.
  • Where and how should the student store their medication?
    • Dorm rooms (and even apartments) are easy to gain access to. People often leave the door open “just for a minute” while they talk with someone or go down the hallway. This invites problems including theft of medications.
      Roommates can go through the student’s belongings or invite other people into the room who may also do this.

    • Medications like all valuables should be kept locked up in a safe place. Dorms may provide a room or drawer safe, but students often need to buy a small safe that they can discretely place in their room or even attach to some of the heavy furniture in the room.
      There are many different styles of safes.

    • Students should use discretion and not talk about or advertise that they are taking the medications.
    • When medications are hidden and locked up, it can also be a challenge for the student to remember to take their medication.
      • Students will have to balance remembering to take their medication. Some students may opt to use a weekly pill sorter that is placed somewhere they will see it daily, but keep the rest of the medication locked up.
        Some students who use this option also put a multivitamin with the medication so if asked, they can honestly say they are taking a vitamin and not arouse suspicion. A pill sorter may also be more easily remembered if traveling on weekend trips.
        If college is close to home, only having a small amount of medication in the dorm room (1-2 weeks for example) may be another option.
  • How can students remember to take their medication?
    • Taking medication the same time every day as it builds the habit is one of the most common methods.
    • Using an alarm on a phone or watch is another idea.
    • Visual reminders on a calendar or note on a desk/mirror may also be helpful. Visual reminders should be discrete though.
  • What happens if the student runs out of medication or it is lost or stolen?
    • This is one reason to have a local physician involved as problems do arise. A local physician may be willing to prescribe a small amount until the student can obtain a full prescription.
    • Theft of medication should be reported to Campus Security. Security could potentially find the medication but more likely it will help them to monitor criminal activity on campus for prevention or apprehension.
      Also a student who honestly would lose their medication later is more likely to be believed by a health care provider who is now being asked to prescribe additional medication, i.e. the student is less likely to be selling the medication if they reported to security.

Questions for Further Discussion
1. What other advice do you offer your college students and families about prescription medication in a dorm room?
2. What college safety tips do you offer your college students?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Prescription Drug Abuse and Drugs and Young People.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

National Institute on Drug Abuse. Commonly Abused Drugs Charts.
Available from the Internet at https://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts#prescription-stimulants (rev. 1/2016, cited 3/28/2017).

National Institute on Drug Abuse. Misuse of Prescription Drugs.
Available from the Internet at https://www.drugabuse.gov/publications/research-reports/misuse-prescription-drugs/which-classes-prescription-drugs-are-commonly-misused
(rev. 8/2016, cited 3/28/17).

Federal Drug Administration. Is it legal for me to personally import drugs?
Available from the Internet at https://www.fda.gov/AboutFDA/Transparency/Basics/ucm194904.htm (rev. 3/20/17, cited 3/28/17).

United States Postal Service. 453 Controlled Substances and Drugs, Publication 52. Hazardous, Restricted and Perishable Mail.
Available from the Internet at http://pe.usps.com/text/pub52/pub52c4_019.htm
(cited 3/28/17).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Adult Problems Can Start with Fetal Undernutrition?

Patient Presentation
After watching a movie set during World War II, a pediatrician’s teenage son said, “That movie wasn’t very realistic. They didn’t have the right arms for a lot of the troops. Plus somebody forgot when they filmed it that the Battle of the Bulge occurred in the winter. There was no snow on the ground in the movie. Plus, if you look, all the people, including the civilians, look pretty healthy. Their faces are fat and they all have shoes and decent looking clothes. The people should be looking sicker at the end of the war.” “I noticed the people too. They all looked pretty well fed and clothed as you said. In 1944-45 there was a total famine Netherlands, and I bet in Belgium too so people wouldn’t be looking that good,” she remarked. During the ensuing conversation, the teen noted that war and famine continue today. The pediatrician said, “Yes and the health problems because of poor nutrition and other problems continue even after the children grow up.” “Like what kinds of problems?” he asked. “I know that there is an increased risk of heart disease and diabetes. There’s probably more but I haven’t read about it in quite a while,” she said. “Do people know what makes the problems even when people are old?” he asked. “Probably, but again I haven’t read about this in a long time. Maybe I’ll see if I can find you an answer,” she replied.

Discussion
Developmental origins of health and disease (DOHaD) is a scientific hypothesis that proposes that fetal nutrition has permanent effects on growth, metabolism, and structure. These changes, or biological programming, are felt to occur at critical periods in fetal development “…when developmental changes in the organism towards increasing complexity, greater plasticity, and more efficient functioning occurs rapidly and may be most easily modified either in favorable or unfavorable directions.” Fetal undernutrition has been studied more than overnutrition, and various nutritional components (protein, micronutrients) have been studied but to a lesser degree. Exposure to fetal undernutrition during these critical periods may create a “thrifty phenotype” where adaptions to the fetal nutrient-limited environment allows the fetus to survive, but induces permanent changes that later on are unhealthy. Epidemiological studies linking birthweight to adult chronic diseases have shown a variety of outcomes (see Learning Point below). Many times the relationship shows a “U” shaped pattern of extremes of birth weight (lowest and highest) having the greatest risks of adult chronic diseases.

Although not entirely elucidated, it is felt that fetal programming through epigenetics is at least part of the mechanism. “Epigenetics encompasses change to marks on the genome that are copied from one cell generation to the next, which may alter gene expression, but which do not involved changes in the primary DNA sequence.”

  • DNA methylation is one of the most epigenetic mechanisms studied. One of the most common examples is after translation, a cytosine residue sitting next to a guanine residue is methylated to form a cytosine-phosphate-guanine dinucleotide (CpG).
    These CpGs are important gene regulators. For example, folic acid carries a methyl group and is being studied for possible DNA methylation.

  • Histones are proteins which package and order the chromatin. They can be chemically modified in many different ways including methylation, acetylation, phosphorylation, etc. Acetylation is one of the most studied mechanisms.
    Butyrate (from dietary fiber), diallyl disulfide (from garlic) or retinoic acid (from spinach, carrots, eggs) can control gene expression through histones.

  • microRNAs are small RNA molecules encoded in the genome that control gene expression. They appear to be able to directly affect gene expression but also through other mechanisms such as DNA methylation or histone modifications.
    Retinoic acids, curcumin (from tumeric) and genistein (from soy) are different nutritional factors that can control gene expression through microRNAs.

Epigenetics affect can the total number of cells produced and tissue remodeling. For example, in pregnant animals who experience protein deprivation, the total number of nephrons are permanently decreased and the offspring later has an increased risk of hypertension. There is also evidence of fetal tissue remodeling in response to fetal undernutrition particularly in the pancreas, liver and hypothalamus. Even umbilical cord tissue has been related to later outcomes such as childhood adiposity. Areas that seem to be prioritized for adequate fetal nutrition are the brain, heart and adrenal gland at the expense of other organs such as the liver, kidney, pancreas, lung and skeletal muscle. It is theorized that the functions of these latter organs are ones that the pregnant mother performs for the fetus, therefore they are more affected.

Epigenetic patterns are inherited and it is felt that this is at least one reason for transmission of some of the risk factors to subsequent generations (ie the child or grandchild of the fetus).

While epigenetics are felt to place the fetus at risk, environmental factors potentially can add to it or help to mitigate it. The social theories are framed around the idea that multiple environmental stressors (often chronic such as chronic poverty) accumulate during the person’s lifetime and increase disease vulnerability. This duality may be part of the reason for racial and socioeconomic differences in health and disease outcomes. For example, low birth weight is lowest in teen US African American women, but low birth weight increases with advancing maternal age. This is possibly because the older mother has been exposed to more lifetime stressors. On the positive side, there is also data which supports other “critical” times when the offspring may experience environments which help to mitigate these developmental effects. For example, at risk children who experience early positive social experiences have shown some mitigating effects to abnormal stress responses.

Learning Point
Fetal undernutrition has been associated adult problems and diseases such as:

  • Poorer “human capital”
    • Shorter stature
    • Increased obesity/lower lean body mass – small infants become big children/adults
    • Lower cognition
    • Lower academic achievement, work capacity, income
    • Increased stress responses
    • Decreased immune function
  • Increased disease risk
    • Coronary artery disease and mortality
    • Hypertension
    • Diabetes or insulin resistance or glucose intolerance
    • Chronic kidney disease – decreased glomerular filtration
    • Chronic lung disease – decreased lung function
  • Fetal overnutrition
    • Fetal macrosomia
    • Metabolic disease

Questions for Further Discussion
1. What are problems associated with acute malnutrition?
2. How common is food insecurity in your area?
3. What resources are available to provide appropriate nutrition to reproductive age women, children and teens in your area?
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Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Fetal Health and Development

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Barker DJ, Osmond C, Kajantie E, Eriksson JG.
Growth and chronic disease: findings in the Helsinki Birth Cohort.
Ann Hum Biol. 2009 Sep-Oct;36(5):445-58.

Canani RB, Costanzo MD, Leone L, et al.
Epigenetic mechanisms elicited by nutrition in early life.
Nutr Res Rev. 2011 Dec;24(2):198-205.

Fall CH. Fetal malnutrition and long-term outcomes.
Nestle Nutr Inst Workshop Ser. 2013;74:11-25.

Rubin LP. Maternal and pediatric health and disease: integrating biopsychosocial models and epigenetics.
Pediatr Res. 2016 Jan;79(1-2):127-35.

Reichetzeder C, Dwi Putra SE, Li J, Hocher B. Developmental Origins of Disease – Crisis Precipitates Change. Cell Physiol Biochem. 2016;39(3):919-38.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital