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Pediatric Bladder Dysfunction: What to Do When Nothing Is Working

Pediatric Bladder Dysfunction: What to Do When Nothing Is Working 1024 575 Pam Georgiana

Experts review the options, helping providers and families choose the right third-line treatment for their child.

Pediatric non-neurogenic bladder dysfunction, or disordered voiding, can harm patients’ self-esteem and cause stress on the family dynamic and routine. The standard pediatric treatment involves behavioral modifications such as diet, bladder training, timed voiding and pelvic floor exercises.

When symptoms persist, medications such as anticholinergics or alpha-blockers are the second line of treatment. The recent Federal Drug Administration approval of beta-3-agonists for pediatric bladder dysfunction patients provides an additional choice. However, these medications can be expensive, and more research is needed on side effects with long-term use.

A Review of Third-Line Therapy

For the small group of children who need additional medical intervention, third-line procedural therapies are available. Recently, Current Urology Reports asked Seth A. Alpert, MD, pediatric urologist at Nationwide Children’s and professor of urology at The Ohio State University College of Medicine, to review and summarize the current research. In his new publication, Dr. Alpert offers insights into the efficacy, advantages and disadvantages of each procedure to help other providers better understand and counsel families on their best choice. Dr. Alpert’s paper was published online in August 2024.

“Nationwide Children’s provides comprehensive care for young patients with bladder dysfunction, including all third-line treatments covered in the paper, so I was honored to be asked to use our first-hand experience to write this review,” Dr. Alpert says.

The third-line treatments discussed in the paper are botulinum toxin A injection (BoTNA), posterior tibial nerve stimulation (PTNS), parasacral transcutaneous electrical nerve stimulation (PTENS) and sacral neuromodulation (SNM). These procedures vary in invasiveness, efficacy and the need for patient or family intervention.

Botulinum Toxin A (BoTNA)

When injected directly into the bladder through a scope under anesthesia, BoTNA paralyzes the muscle and reduces involuntary bladder contractions and urinary incontinence. However, the effects only last between 6 and 12 months, requiring repeat injections. The research shows response rates between 44% and 95%. After just one treatment, pediatric patients can see improvements in bladder volume and overactivity. While this procedure is minimally invasive, it does require an outpatient procedure with anesthesia.

“Botox is usually a safe and effective treatment for an overactive bladder in children,” Dr. Alpert says. “However, the temporary results require repeated treatments, which can be challenging for patients and families.”

Posterior Tibial Nerve Stimulation (PTNS)

This minimally invasive procedure stimulates the tibial nerve in the ankle via a needle or adhesive electrodes. When electrical impulses are delivered to this nerve, symptoms like urinary frequency, urgency and incontinence are reduced. The procedure requires a series of 30-minute sessions at the physician’s office and regular follow-up treatments. An in-home treatment option has recently become available for adult patients but has yet to be investigated in children. Some patients experience discomfort from the needle insertion into their skin.

“Efficacy rates vary depending on the patient and the delivery, but overall, PTNS improves bladder control and quality of life for patients and families,” Dr. Alpert says. “However, the time-intensive regimen and inconsistent insurance coverage may be prohibitive.”

Parasacral Transcutaneous Electrical Nerve Stimulation (PTENS)

PTENS also involves the external electrical stimulation of nerves, this time in the lower spine. Electrodes placed on the skin deliver mild electrical impulses to the sacral nerves, which are responsible for controlling the bladder, pelvic floor muscles and lower bowel functions. PTENS can be administered in a medical setting or at home. Treatment is typically performed once or twice daily for 20 minutes. The intensity and duration of therapy is dependent on the patient. Adverse side effects are similar to PTNS. In one randomized test, about 62% of patients reported complete resolution of symptoms.

“PTENS is typically well-tolerated and can be an attractive option for families who can’t always travel to a doctor’s office,” Dr. Alpert says.

Sacral Neuromodulation (SNM)

The most invasive of the third-line procedures, SNM, is not FDA-approved SNM for use in children under 16. The procedure requires the surgical implantation of a small device that delivers electrical impulses to the sacral nerves. By continuously modulating the nerves, SNM reduces urinary urgency, frequency and incontinence. In several large cohort studies, 94% of patients experienced improvement. Nevertheless, the potential need for multiple surgeries for battery replacement over a patient’s lifetime and the resulting exposure to fluoroscopy is a concern for both providers and families. In addition, there are barriers to insurance coverage for pediatric patients.

“There’s a growing body of evidence that this procedure can be highly effective for patients who don’t respond to other treatments,” Dr. Alpert says. “We’ve seen very positive results here at Nationwide.”

One Size Doesn’t Fit All

Dr. Alpert stresses that these third-line procedures present both advantages and disadvantages for patients and families. The best choice will depend on several factors, including age, the severity of symptoms, response to other treatments, cost, insurance coverage and family dynamics.

“The best thing a pediatrician or urologist can do is to educate themselves on the options so that they can successfully counsel families to make the best choice for their child,” Dr. Alpert says.

 

Reference:

Lombardo AM, Alpert SA. Third-Line Therapeutic Interventions for Non-neurogenic Bladder Dysfunction in Children. Curr Urol Rep. Published online August 2, 2024. doi:10.1007/s11934-024-01227-3

Image credit: Adobe Stock

About the author

Pam Georgiana is a brand marketing professional and writer located in Bexley, Ohio. She believes that words bind us together as humans and that the best stories remind us of our humanity. She specialized in telling engaging stories for healthcare, B2B services, and nonprofits using classic storytelling techniques. Pam has earned an MBA in Marketing from Capital University in Columbus, Ohio.

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