pediatric bladder discomfort

[des1164]

Hi, Below is a description of my friend in Norway's daughter.  Noted are her symptoms, any suggestions
What I was wondering was if you could look into the following symtoms and tell me how doctors/nurses would go about diagnosing/treating.

-  feeling of discomfort to feeling of terrible pain in the bladder area.  Unable to urinate although she has to.  Started approx. 14 months ago.
    feeling of "knives" sticking up into her bladder.   Doctors in Bergen consider spasms.

-  Uroflow rate and ultrasound check was carried out 3 times in a 3 - 4 hour time period last wednesday.
    I don't know the results of the flow rate, but we were told that on all 3 ultrasounds taken that there is residual urine in the bladder.
    Wall thickness of the bladder normal.

We haven't received the letter Bergen is going to send to Haugesund yet with more details. Treatment  is needed.  We don't know what.
We're thinking maybe

                         pelvic floor spasms  or some type of bladder spasms (maybe physical therapy could be helpful)

                         Some type of voiding dysfunction (how are the different types of dysfuctions treated?)

Sphincter relaxation and bladder contraction must occur in a coordinated fashion for proper emptying.  Causes of problems can be neurologic or nonneurologic.??????

We are concerned that the proper tests will be taken and addressed seriously.  It is important to make sure that there isn't back up into the ureters which could cause kidney damage in years to come.  ect.........

How would one go about treating a patient with these sysmtoms in your neck of the woods?

Hope you can enlighten us regarding this matter Deb.  We have to be on top of the situation before meeting with a new round of doctors.
We've read ALOT on net., but we're not in the medical profession and struggle to understand it all.

[David A Burks, MD]

Hi,  You didn't tell me how old the child is.  She is apparently old enough to describe her symptoms so I assume she is at least 6 yrs old.  I also assume that someone checked her urine multiple times and this is not simple urinary tract infection since it's been going on for 14 months.  I also assume she doesn't have a known neurological problem like spina bifida or a spinal cord injury. I assume she had no previous voiding problems and the current symptoms occured for the first time 14 months ago.  The question is--is this a neurogenic problem, a structural problem, a functional problem, or an inflammatory problem?

Neurological problem: She clearly needs a careful neurological examination by her pediatrician including evaluation of her lower extremity reflexes, pelvic sensation rectal tone and rectal function.  She probably needs a MRI or CT scan of her spine to rule out spina bifida occulta or a tethered spinal cord.  Either could cause bladder,  bowel, and or pelvic floor dysfunction.  

Structural problem:  She needs at least a renal, bladder and pelvic ultrasound to rule out a mass or some congenital malformation.

Functional problem:  There is a problem called the Hynman syndrome or the non-neurogenic neurogenic bladder.  Patients develope a nonrelaxation of the pelvic floor muscles during attempted voiding due to psychological stress/anxiety causing pelvic floor pain, spasms, retention and  elevated residual volumes.  If a neurogenic problem has been ruled out, the treatment is pelvic floor physical therapy with biofeedback to teach relaxation during voiding, retraining the pelvic floor muscles.

Inflammatory problem:  Interstitial Cystitis is an inflammatory disorder of the bladder that can cause bladder pain, frequency and urgency.  Also it can cause pelvix floor spasms and nonrelaxation of the pelvic floor during voiding due to the pain.  Pelvic floor physical therapy may also help this condition.  It needs evaluation by a Urologist who specializes in voiding dosorders.  It's usually rare in children but I have diagnosed an 8 yr old with it. Treatment is difficult and should be considered only when all the above have been ruled out. I look into the bladder with a scope will be needed to rule it in and rule out other conditions.

This young lady needs to see a Pediatric Urologist who specializes in voiding disorders and can do a urodynamic evaluation of the bladder and pelvic floor to sort out what the problem is, and who has access to a pelvic floor specialist who can do pelvic floor biofeedback to correct the problem.  She also may need to see a pediatric neurologist to r/o the neurogenic problems.  This will probably be a challenging problem to treat and will require a multidiciplinary team approach.  Good Luck