# Vesicoureteral Reflux in the Child with Lazy Bladder Syndrome: The Infrequent Voider

Authors: Marco Grasso; Fabrizio Torelli; Salvatore Blanco; Flavio Fortuna; Marco Baruffi
Journal: Advances in Urology
 (2008)

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## Abstract

The Infrequent Voider Syndrome or Lazy Bladder Syndrome in children is characterized by a large capacity bladder, frequently associated with a significant volume of residual urine.
Usually these patients arrive at medical examination with a history of recurrent urinary infections but without anomalies in the upper urinary tract. We report about a young girl affected by one-sided2° degree vesico-ureteral reflux due to Lazy Bladder Syndrome that had never been diagnosed before. This patient has been submitted to a prompt bladder training and seems presently to have at last gained a physiological micturition after 9 months of follow-up, without actual evidence of vesicoureteral reflux.
Therefore we must stress that it is prominently important considering  about infrequent micturition in a paediatric case history or a large capacity bladder, possible presence of bladder dysfunction and vesicoureteral reflux too.


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## Body

## 1. Introduction

It has  been known for nearly 30
years  that there are children (mainly girls) who acquire abnormal micturition
patterns in their first years of life, even without neurological or urological
injuries. Such anomalies may lead to a sheer bladder disorder. Every child that
is affected by altered bladder dynamics is at risk of developing pathologies
such as urinary infection, vesicoureteral reflux (VUR) and so on.We report about “a classic” case of Infrequent
Voider Syndrome that we observed after the patient wandered for a long time
across several other urologic and paediatric services. This is an evidence
about how such a clinical picture has not an easy diagnosis and is often
ignored.


## 2. Case Report

About 2 years ago a 5-year-old girl
with recurrent urinary infection was admitted in another hospital and checked.
A 2° grade active right vesicoureteral reflux was found by voiding
cystourethrography. She was treated by assuming orally a long-term
antibacterial therapy: a prophylactic evening dose of trimethoprim-sulfa
combination. After one year vesicoureteral reflux remained unchanged by X-ray
check and she had a urinary infection relapse for a temporary break in
antibacterial therapy. The parents took her to another urological department and
were advised to submit their daughter to ureteral reimplantation surgery.They were not persuaded and took
their little girl to our outpatients’ department.She was a little girl presenting
normal somatic characteristic for her age, quite shy and affectively deeply
attached and dependent from her mother who accompanied her. Her physical
objectivity did not signal anything which could lead to urological pathologies.
Looking at the cystourethrography (Figure1) we observed a large vesical
capacity, abnormal for the patient’s age; an ultrasound exam of the urinary
tract confirmed this observation: her bladder contained a volume of 500 cc.Figure 1
Large vesical capacity
and vesicoureteral reflux at cystourethrography.The girl seemed calm with no need of
urinating. Finally, persuaded by her mother she had an uroflowmetry test; the
girl completely emptied her bladder, urinated 500 mL, with a normal flow.Searching in the remote pathological
anamnesis we found that the girl had always urinated rarely, twice or three
times a day, remaining sometimes for more than 12 hours without urinating.She had often refused to urinate in
the evening before going to sleep, saying she did not need to.Her mother did not attribute any
importance to this habit and she did not insist. In both of them it was clear a
fear of urinating in bathrooms out of their home because of the scarce hygiene
conditions and the past urinary infections of the girl.The patient refused every  kind of
invasive diagnostic approach such as urodynamic examination, cystoscopy. We could proceed in the diagnosis only by asking a micturition diary
which has confirmed our clinical suspect of Lazy Bladder Syndrome.From a therapeutic point of view,
the girl has been directed to a bladder training therapy.We only used behavioral therapy
notifying to the girl a strict daily micturition scheme to modify the child’s
voiding habit and achieve a different behavior which included more frequent
micturition and a new conception of the use of public toilettes. Consulting did
not prescribe any other approach considering the good level of cooperation of
the girl.The absence of evident
postmicturition residuals enabled us to avoid anticolinergic-alpha-adrenergic
blockade therapies
or invasive procedures such as intermittent catheterization or endovesical
electrical stimulation.After 9-month follow-up the patient
seems to have changed her micturition habits; she is still following a
prophylactic antibacterical therapy.The last ultrasonographic evaluation
does not show any negative evidence of the upper urinary tract.The cystography check done 9 months later than the
previous one and after 6 months of behavioral therapy pointed out the
disappearance of the vesicouretheral reflux.


## 3. Discussion

The Lazy Bladder Syndrome mostly
concerns young girls. The history usually starts at 5–10 years of age
with urinary infections, daytime incontinence, or as an accidental report
during a consulting for other purposes.Typically the
bladder is expanse, easily palpable as it can have a urine content of more than
1 litre, often with a conspicuous postmicturition residual and surprisingly a
normal upper urinary system.The cause is unknown, but it
probably has a behavioral origin. It regards children who learned to retain the
urine for long periods. It is not uncommon that their parents inculcated them,
even if not intentionally, the fear of contaminate themselves or even the idea
that it is “evil” getting wet of urine.It is often found in children
excessively tidy or clean which makes them avoid any toilette that is not their
own one.They often urinate only in the
morning and in the evening to avoid the school bathrooms.There are some other children who
had in their first years painful
micturition because of urinary infections, and they still have a deep fear of
it, getting used to urinate as less as possible [1].Next to these clear clinical cases,
we can find less evident ones in which we can find the absence of
postmicturition residual but always high capacity bladders, as in our case
report.The uroflowmetry test can appear morphologically normal,
making it harder to recognize a latent bladder disfunction, which can lead, if
not treated, to irreparable damages of the upper urinary tract (Hoebeke  et
al. found in these children 17% VUR and Njman  20%) [2, 3]. Therefore,
the risk run by our little 4-year-old patient was very high.An urodynamic evaluation may prove,
in advanced cases, detrusor hypocontractility
from the permanent bladder iperextension and the need of a quite strong
abdominal effort, depending on the coexistence of vesical sphincter dyssynergy, therefore a high
pressure bladder emptying.It is possible that in some cases,
this determines and prevents the spontaneous resolution of a ureteral reflux,
as in our case report, considering the correlation between reflux, capacity,
and bladder pressure.In these cases, the rieducative
treatment of bladder training becomes necessary to lead the child to urinate
psychologically without effort, without bladder iperextension trying to recover
the vesicoureteral junction
competence and a normal bladder volume. In fact, it is very difficult to gain
some advantages when voiding disorders have already caused important alteration
of urinary apparate. It is arduous to differentiate between lazy bladder and
neurological bladder syndrome.This is why an early diagnosis can
be more advantageous than ever and we believe that the finding of a high
bladder capacity in the child with infrequent micturition has to be always
considered with worry and accurately evaluated, as a possible clinical
expression of Lazy Bladder Syndrome.To sum up, always  for the purpose of
an early diagnosis, we propose  a diagnostic algorithm (Algorithm1).The management of vesicoureteral reflux (VUR) should be performed after a careful diagnostic approach. It is important to remember that high-bladder pressures may induce VUR. Voiding frequency, bladder capacity, and residual urine volume are key points facing children with recurrent urinary tract infections (UTIs).Algorithm 1
Diagnostic algorithm for Lazy Bladder Syndrome (*Bladder Capacity = age (years) + 2 × 30 mL).



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