# Interactions of Constipation, Dysfunctional Elimination Syndrome, and Vesicoureteral Reflux

Authors: Sarel Halachmi; Walid A. Farhat
Journal: Advances in Urology
 (2008)

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## Abstract

Vesicoureteral reflux (VUR) is simply described as incompetence of the unidirectional valve at the ureterovesical junction (UVJ), leading to backflow of urine to the kidney. Today, it is clear that VUR is not only related to the UVJ function but also to a combination of processes including immunity, bladder and pelvic floor function, dysfunctional voiding, and constipation. Although our surgical aims directed towards improving the valve coaptation at the UVJ, we understand today the importance of the diagnosis and treatment of constipation and dysfunctional voiding adjunctively.


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## Body

## 1. Introduction

The frequency of stools in most children
decreases from a mean of four per day in the first week of life to 1.7 per day
by the age of 2. Over this interval, stool volume increases more than tenfold,
while maintaining a consistent water content of approximately 75%, and the
intestinal transit time from mouth to rectum increases from 8 hours in the
first month of life to 16 hours by the age of 2 to 26 hours by the age of 10 [1, 2].Constipation generally is defined by the hard
nature of the stool, the pain associated with its passage or the failure to
pass three stools per week [1]. In most children,
functional fecal retention is the most common chronic disorder of defecation
caused by the voluntary withholding of feces due to fear of painful defecation.
Many events may lead to unpleasant defecation such as aggressive toilet
training; for instance, as children approach toilet-training age, the child's gratifying
impulse to defecate is in conflict with parental constraints to establish bowel
control and a premature or excessive parental emphasis on continence may lead
the child to the decision to withhold the stools [3]. Other causes for fecal
holding are changes in routine or diet, an intercurrent illness, or postponing
the defecation because the child is too busy or toilets are unavailable [3, 4]. Once the child has
experienced the painful passage of hard stool, he or she attempts to avoid the
expected discomfort by exerting voluntary withholding. The rectum accommodates
to the contents and the urge to defecate gradually vanishes. As the cycle is
repeated, greater amounts of hard stool are built up in the rectum and pass
with even greater pain, frightening the child [5, 6].It has been reported that 34% of toddlers in
the UK and 37% of Brazilian children younger than 12 years were considered by
their parents to be constipated [7]. In the absence of painful
symptoms, parents are generally unaware of the bowel habits of children older
than 4 or 5 years. It is our experience that parents paid little attention to
the frequency of their child's bowel movements, but paid much attention to the
number of urinary and fecal incontinence episodes.Encopresis or fecal soiling is usually the
result of looser stool leaking or overflowing from a rectum that has been
distended by retained stool; soiling occurs whenever the child tries to expel
gas or the muscles which are used to withhold become fatigued. While encopresis is
three to six times more common among males than females [1], we observed that voiding
position may contribute to this higher prevalence of soiling in boys, as they
stand to void, thus soiling in
their underwear unknowingly. We speculate that the difference in females
is that they remove their underwear and will sit on the toilet to void. Thus,
the natural voiding position has a direct impact on the statistics of
encopresis in boys compared to girls.


## 2. Impact of Constipation on the Urinary System

There are many reports correlating constipation with
functional bladder-outlet dis-coordination being responsible for urinary
incontinence, urinary tract infections, vesicoureteral reflux, and even false
uroradiologic pathology [8–11]. The impacted stool in the
rectum compresses the bladder, reduces its functional capacity, and provokes
earlier sensation to  void. In addition, chronic pelvic floor spasm prevents
complete relaxation during voiding, and will attribute to postvoid residuals. Klijn et al. [12] showed that the diameter of
the  rectum in patients with dysfunctional voiding is higher compared to asymptomatic
healthy children. The average rectal diameter in the dysfunctional voiding and
constipated patients was 4.9 cm versus 2.1
in the control group (P<.001)Kasirga et al. [13] compared 38 children concerning chronic
functional constipation to 31 healthy children and found significant higher
frequency of urinary tract infection and urgency. Neumann et al. [14] found that 34% of chil-dren
with urinary tract infections had abnormal bowelpatterns, and most parents
were not forthcoming with this information. O'Regan et al. [11, 15] noted that constipation was
associated with recurrent urinary tract infections and bladder instability in
girls. They found that 50% of the mothers denied constipation to be present in
their children, but
questioning of the individual children revealed that most had only 2 to 3 bowel
movements per week. O'Regan et al. [11, 15] also showed that children
with enuresis had constipation. In 22 children with enuresis, rectal
examination and rectal manometric studies proved constipation. Treatment of
constipation resulted in resolution of enuresis. Uninhibited bladder
contractions, observed in enuretic constipated children, were also noted in
children with constipation alone, suggesting that constipation is a commonly
unrecognized etiologic factor in enuresis [16].Loening-Baucke [7] evaluated the
frequency of urinary incontinence and urinary tract infection in 234
chronically constipated and encopretic children before, and after the start of
treatment for constipation. Followup, at least 12 months after commencement of
treatment, revealed that the constipation was relieved successfully in 52% of
thepatients. Relief of constipation resulted in disappearance of daytime
urinary incontinence in 89% of the patients, nighttime urinary incontinence in
63% of the patients, and disappearance of recurrent urinary tract infections in
all patients who had no anatomic urinary abnormalities.


## 3. Constipation Dysfunctional Elimination Syndrome and Reflux

Numerous studies connected between
vesicoureteral reflux and dysfunctional elimination syndrome (DES). O'regan  et al. [17] correlated the directly established
association of reflux, uninhibited bladder conduction, and constipation. The
author examined
urodynamic and rectal manometry on 17 children with VUR. All 17 had rectal dilatationand uninhibited bladder contraction confirming the vicious connection of these 3
conditions.Koff et al. [10] assessed the influence of
functionalbladder and bowel disorder on the natural history of children with
primary reflux. The authors assessed 143 children who  had either spontaneous
resolution of VUR or (82%) had breakthrough infection that led to definitive
surgical management. Among patients without DES, only 18% had breakthrough
infections and surgical correction. The rate of DES was higher in children with
breakthrough infections, 77% versus 23%. The spontaneous resolution of reflux
was longer in an average of 1.6 years in children with DES.  Moreover,
unsuccessful surgery or development of de novo contralateral reflux and post-successful
surgery urinary tract infections appeared only in patients with DES. Care
should be taken in the interpretations of the results of this paper as patients
were selected to this study based on the presence of reflux. Naseer and steinhardt [18] demonstrated deleterious
effect of dysfunctional voiding on VUR treatment end point—the development of scars. Among 538 with DES, 192 (13.5%) already had
scars at initial assessment, 31 (2.1%) developed new scars despite meticulous
care by the urology clinic. Eleven of those were referred to surgical treatment,
however 6 developed new scars despite successful surgery.Silva et al. [19] tried to identify
independent factorspredicting the resolution of VUR. DES was one of the 4
independent predictors for VUR resolution. The author concluded that treatment
of DES is a cornerstone in the management of VUR. Upadhyay et al. [20] too demonstrated the
relationship between DES, DES management, and the resolution of VUR. Using a
DES standardized symptom score which included questions regarding bladder andbowel habits, the authors showed direct correlation betweenimprovement in the
symptoms score and resolution of VUR. In 7 pa-tients with spontaneous resolution
of VUR, there was also  statistically significant symptom score improvement, in
addition 4 patients showing the same symptom scoreimprovement had also
reduction of at least 2 grades in VURgrading. Improvement monitored by symptom
score showed compliance to behavioral therapy and could predict VUR improvement
and resolution.In contrast to the above-mentioned studies, Sheikh
et al.  [21] assessed the relationship
between early UTI, DES, and VUR. The authors examined 248 children, 123 of them had culture-proven UTI
diagnosed by the age of 2. Control group consisted of 125 patients to whom urinalysis was performed due to
fever ruled out UTI. Questionnaire
given to all children showed no significant presence of DES (22% versus 21%). In
patients with UTI who were later diagnosed with VUR, DES was present in 18%
compared to 25% of those without VUR. The authors concluded that neither UTI
nor VUR diagnosed before the age of 2 was associated with DES in school-aged
children. The rate of DES is low-er in patients with UTI and VUR compared to
those with-out VUR, however there is still a significant percentage of patients
with UTI and VUR who
had DES. Chen et al.  [22] studied 2759 patients who
had renal sonography and voiding cystogram for various clinical entities. The
authors used multivariate logistic regression approach to quantify the
associations between DES and other pediatric urology factors. They showed that
DES is present in 36%-36.1% of girls with unilateral and bilateral VUR, and in 20.5–21.2% of boys, respectively. The higher rate of DES ingirls was independent of UTI
and VUR status.
In patients that diagnosed with VUR due to other entities beside UTI (sibling
VUR, prenatal hydronephrosis, etc.), the association to DES was negative.
Although this evidence may oppose the hypothesis that relationship between DES
and VUR exists, however we think that these results clearly reflects the
variety of patients categorized under VUR. Indeed, sibling VUR and VUR detected
for other reasons rather than UTI is usually considered less significant, and
the lower rate of related DES and UTI may give the explanation why. In this study, patients with VUR and UTI had almost doubled risk of DES supporting our belief that DES plays a major role in the pathophysiology of VUR.


## 4. Conclusions

Constipation plays a major role in the function and dysfunction of the
urinary tract. Patients with constipation have concomitant urinary tract
problems including infection, incontinence, enuresis, and VUR. There are strict evidences that constipation
is related to the presence of reflux, urinary tract infections, breakthrough
infections, presence of scars, and the appearance of new scars. Patients with
constipation and DES have lower and longer rates of spontaneous resolution of reflux and vice versa, adherent to behavioral treatment, and improvement of the
constipation is related to spontaneous VUR resolution.Evaluation and treatment of constipation and DES should be
an integral part of the initial assessment and management of a child with VUR,
it would be also advocated to postpone definite surgical correction in patients
with severe DES in
order to improve surgical outcome.



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*Source: 828275-2008-06-04.xml*