CP test article 022613

One of the more common urinary complaints to present in the pediatrician’s office is that of the child who has to void frequently. This most often will be a bladder infection, although a more ominous cause would be diabetes, which fortunately is relatively rare.

Many times, however, an evaluation does not provide a readily apparent explanation, mystifying the physician and the parents. This can result in extensive testing to try to determine what is going on, followed by unnecessary treatments.

However, this condition, called pollakiuria (from the Greek pollakis, meaning often), is both common and benign; experience suggests that a general pediatrician can be expected to see several cases each year, and some authors report that it is as prevalent as bladder infections.^1,2 Other terms that have been used to describe this condition include extraordinary daytime urinary frequency and, in the earliest literature, sham urinary tract infection. The cause is unknown, yet it can be easily diagnosed in the office, parents reassured, and a simple treatment plan provided. Pollakiuria appears to be seen somewhat more often in boys (although this has not been found in all studies) aged usually between 4 and 10 years.^1-6

A typical presentation

Mark is a 5-year-old boy who comes to your office with a chief complaint of having to run to the bathroom frequently-this has been going on for 2 or more weeks. The initial history reveals that when he goes, it is a small amount, but then anywhere from 5 minutes to 1 hour later he is off once again on a bathroom run. His teacher has commented that it is disrupting the flow (as it were) of the classroom, and the parents are also having problems because of this. For example, they can only take short car rides, have to find a bathroom as soon as they arrive at their destination, or many times even make unplanned stops along the way.

Restricting fluid intake and emptying the bladder before embarking on a trip does not avoid the problem. He has been well toilet trained for some time, and this is a new behavior for him. Despite the frequency, he is not having pain when he urinates, is not experiencing enuresis, and is otherwise fine.

1. History

The differential diagnosis includes urinary tract infection, diabetes mellitus, diabetes insipidus, constipation, and bladder detrusor instability, in addition to pollakiuria. The evaluation begins, as always, with the history. Mark is voiding only small amounts frequently; after urinating, he returns to his previous activity. There is no pain when he urinates; he is not having enuresis; and he is not complaining about the behavior, so the family has typically not thought much of it until now that it has been going on for several weeks.

Unlike in diabetes variants, he is not drinking excessively and is not waking up at night to urinate, and in contrast to children with detrusor instability, he will have had normal bladder function before the recent change.⁴ Unless he had bedwetting before this began, he will still be dry at night. In true pollakiuria, there is no constipation or encopresis, and the problem is confined to bladder control.

Early reports in the literature suggested that pollakiuria was associated with emotional events,^1,2,5,6 often a fear of death or the death of a relative, although this is not present in every study.³ However, personal experience indicates that this is very rarely seen in children with this condition. Regarding other causes of stress, they can certainly be present (and many if not most children will have stressors at any given time, even when they are well, if one probes deeply enough), but the child will usually be adjusting well and going about his normal business without other indications of stress (eg, sleep disturbances, school refusal, or anorexia), so it is unclear whether this is of any significance.

02. Physical exam

The next step is, of course, the physical examination. A significant weight loss suggests possible diabetes, whereas excessive weight gain could be seen with nephrotic syndrome and should prompt a careful look for edema. Whenever one is thinking about possible kidney or bladder dysfunction, a blood pressure reading is indicated. The genitalia and surrounding areas will be looked at for signs of local irritation, such as vaginitis in girls. A neurologic examination will rule out a problem with the lower spinal nerves. The abdomen should be palpated to look for enlarged kidneys or, much more common, a back up of stool, suggesting constipation (with or without encopresis). The latter is the most common masquerader when one suspects pollakiuria; constipation can result in pressure on the bladder, leading to frequency. However, in pollakiuria, the physical examination should be benign and unrevealing.

03. Laboratory tests

The laboratory evaluation can be begun and most often completed easily in the office. A simple dipstick urinalysis is usually all that is necessary. A normal specific gravity will rule out diabetes insipidus, and a normal glucose will rule out diabetes mellitus. The absence of pain on urination, enuresis, and so forth should have made a bladder infection unlikely; thus, unless the urinalysis reveals hematuria, positive nitrites, or positive leucocytes, a microscopic examination of the urine is not needed and with a negative history a urine culture is also not required. Renal ultrasounds are not helpful.^2,3,5,6 It has been suggested that there may be an increase in urine calcium in some cases, but in the absence of hematuria, it is not necessary to look for this.⁶

04. Talking to parents

After the history, physical examination, and urinalysis, one then can proceed directly to explaining the condition to the parents and outlining the plan of treatment. Referral to a urologist will not be necessary (and he or she may appreciate not having to see such a patient).

Although there is not a clear understanding of the cause of pollakiuria, as with many bladder problems it is sometimes viewed as being because of an overly “sensitive” (or hyperdynamic) bladder. However, it is easier to view the condition as representing a heightened awareness of the bladder; that is, the problem is more in the perception rather than in the bladder itself.

The following conceptualization covers the basics and has been found in personal experience to be useful for parents. The kidneys are constantly producing new urine and sending it down the ureters to the bladder, which, when stretched, gives the sensation of needing to void. Under normal circumstances, if the amount of urine is small, this sensation is ignored until it builds up to a critical point, at which time the child seeks out the bathroom. Children with pollakiuria do not seem to be able to suppress this sensation and thus feel compelled to urinate, resulting in the sense of urgency and the need to run to the bathroom. This explains why voiding amounts during the day are small despite normal bladder function and also accounts for why pollakiuria can be suppressed if a child is performing an activity of high interest, without accompanying enuresis, as would happen if the bladder itself were dysfunctional. Alternatively, if the child is in a situation where toilet access is not guaranteed, such as during a car ride, the concern over having a voiding accident is increased, and the need to find a bathroom becomes stronger.

Because the bladder itself functions well, children with pollakiuria do not have nocturia or new-onset bedwetting. When they are asleep, they are not aware of small amounts of urine entering the bladder, and because the bladder is unimpaired, it can retain the urine without incontinence until the child awakens at his usual time and empties a normal amount of urine from his bladder.

Parents should be able to relate to this concept. Something similar can happen to adults if they awaken at night and start to be aware of their bladder; if they do not fall back asleep promptly, they will often feel an urge to void and must do so in order to feel comfortable again, even if it was an amount that they could have held in during the day without difficulty.

05. Treatment plans

Treatment has traditionally been that of benign neglect with just an explanation of the condition, perhaps with some directed counseling regarding the putative stressor trigger.^1,2,5,6 This involves reassuring the parents and child and waiting for the condition to self-resolve. Reducing dietary intake of oxalate-rich beverages such as tea and acidic juices such as apple in children who consume large amounts of them, along with liberal intake of water, have been proposed as ancillary approaches while riding the condition out.^5,6 A wait-and-see method does work, but it can take quite some time, requiring 1 to 5 months on average for the condition to go away, during which time the pollakiuria can continue to be disruptive to normal routines.^1-6

Medication is often tried; this would typically be an anticholinergic drug such as oxybutynin on the assumption that there is a form of bladder dyssenergy taking place. This has usually been reported to be ineffective, which is not surprising given that the problem in pollakiuria is felt to be sensory rather than motoric, and of course it is not without adverse effects such as drowsiness or dry mouth.^5,6 Indomethacin has also been proposed as a treatment, but there are no controlled studies looking at its value, and it is again with potential adverse effects.⁶ Given this, and the fact that pollakiuria is a benign self-limited condition, there is no role for the use of medication as treatment. Similarly, biofeedback has been advanced as a therapeutic option in an uncontrolled study, with a long response time for effectivenss.³ Although safe, this is again unproven and can be expensive.

06. Changing behaviors

A simple behavioral regimen has demonstrated its effectiveness in practice in the outpatient setting. Timed voiding is a technique that is often used for children with bladder dysfunction/dyssynergy and involves having a child void regularly to train the bladder. The method proposed here is that of timed not-voiding.

After explaining the cause (namely that of oversensitivity to a normal bladder) to the family, they are told that the child needs to learn to ignore the urges and postpone voiding. Thus, after he has gone to the bathroom, a timer (on a microwave or cell phone) is set, and the child is informed that if he does not void during that time, he will earn a previously agreed on small reward (eg, stickers, candy, extra video time); keeping a reward chart to measure progress is also useful for reinforcing the behavior.

Although this can be done after each void, this can quickly become burdensome, and the family will often not have access to the child throughout the day (eg, if he is at school, where such a program may prove onerous for a teacher). Fortunately, variable timing schedules are also effective in behavior modification, and the most practical course will often be to set up a few reward periods scattered over the course of the day.

For the first day, a time that the child can easily achieve is chosen (if he is voiding every 30 minutes, one may start with 15 minutes on the timer) so that he can see how the rewards work. The time is then lengthened by 5 to 20 minutes per day, with reward chances a few times each day, always trying to pick a length in which the likelihood of earning a reward is essentially 100%. Once the child can go 90 to 120 minutes between voids, the program can be dropped (or the family may use the reward system to target a different behavior). If a child voids before the timer goes off, there is no punishment; he just has to wait until the next opportunity to win a reward. Personal experience in the office indicates that well over 90% of children will respond without the need for further work-up or referral to urology.

So, the next time a child is brought to your office with excessive voiding, keep pollakiuria in mind. This can be easily diagnosed in the office with a focused history and physical examination, along with a urinalysis. Treatment, consisting of an explanation to the parents and child to demystify the problem, coupled with a simple behavioral approach, should enable the pediatrician to handle most cases in a timely fashion without the need for extensive testing, medication, or referral to a specialist.

References

Bass LW. Pollakiuria, extraordinary daytime urinary frequency: experience in a pediatric practice. Pediatrics. 1991;87(5):735-737.

Cohen HA, Nussinovitch M, Kauschansky A, et al. Extraordinary daytime urinary frequency in children. J Fam Prac. 1993;37(1):28-29.

Glazier DB, Ankem MK, Ferlise V, Gazi M, Barone, JG. Utility of biofeedback for the daytime syndrome of urinary frequency and urgency of childhood. Urology. 2001;57(4):791-794.

Hellerstein S, Linebarger JS. Voiding dysfunction in pediatric patients. Clin Peds. 2003;42(1):43-49.

Corigliano T, Renella R, Robbiani A, Riavis M, Bianchetti MG. Isolated extraordinary daytime urinary frequency of childhood: a case series of 26 children in Switzerland. Acta Paediatri. 2007;96(9):1347-1349.

Bergmann M, Corigliano T, Ataia I, et al. Childhood extraordinary daytime urinary frequency-a case series and a systematic literature review. Pediatr Nephrol. 2009;24(4):789-795.