PEDIATRIC UROLOGY

Dysfunctional voiding and incontinence scoring system: quantitative evaluation of incontinence symptoms in pediatric population
Akbal C, Genc Y, Burgu B, Ozden E, Tekgul S
Department of Urology, Division of Pediatric Urology, Hacettepe University School of Medicine, Ankara, Turkey
J Urol. 2005; 173: 969-73

• Purpose: Functional voiding problems in children are common. Although pathophysiology and presentation of this clinical entity are well described, there is not yet a generally accepted method of quantitative and standard evaluation of clinical symptoms, and there are few studies addressing the issue of symptom scoring in children. We investigated use of a symptom scoring system in children with functional voiding problems and the normal population, and validated it using a scientific tool.
• Materials and Methods: A symptom scoring system was designed empirically. The questionnaire was composed of items regarding daytime symptoms, nighttime symptoms, voiding habits, bowel habits and quality of life. There were 2 groups whose symptoms were evaluated using this scoring system. Group 1 consisted of 86 patients who were admitted to our clinic with various wetting and daytime voiding problems. Group 2 consisted of 265 controls with no urological complaints. Parents of all children were asked to fill out a questionnaire that included the symptom scoring system. Boys with lower urinary tract abnormalities, and patients with spina bifida occulta and neurogenic bladder were excluded from the study. Odds ratios of answers to each item in the questionnaire were used to define strength of the questions to differentiate patients from healthy controls. According to the value of odds ratios, questions were modified and a score for each question was given. Receiver operating characteristic plots were used to define detection cutoff or threshold score, and Youden’s index was used to detect best reflecting optimal sensitivity and specificity.
• Results: The total score was determined to range from 0 to 35, and items were modified to 13 questions and 1 quality of life question at the end of the study. Among the 86 patients in group 1 (female-to-male ratio 1.5:1) mean score was 18.56. Among the 265 controls in group 2 (female-to-male ratio 1.5:1) mean score was 2.88. Statistical analysis revealed that within a confidence interval of 96.2% patients with a score of 8.5 or greater had voiding abnormalities, with 90% sensitivity and 90% specificity. There were no statistically significant differences between the 2 genders and 2 age groups of 4 to 7 and 8 to 10 years.
• Conclusions: This statistically validated functional voiding problems symptom score may provide accurate, objective and scientific bases to grade the symptoms in comparative research, diagnosis, treatment and followup of patients with wetting and functional voiding disorders.
  
  
• Editorial Comment
  Dysfunctional voiding is common, but can be extremely difficult to identify with certainty and even harder to grade. Furthermore, it is very difficult to objectively monitor progress in the treatment of dysfunctional voiding. This is concerning, considering that dysfunctional voiding has considerable importance because of its role in the pathophysiology of urinary tract infections, vesicoureteral reflux and incontinence. In that sense, this paper, describing a new, and indeed the first, validated questionnaire for identifying and grading dysfunctional voiding is of considerable value.
  Although this questionnaire is a major advance, there are some questions that remain to be answered. For example, are all voiding dysfunctions alike? In other words, how well will this scoring system separate children with frequency/urgency from those with infrequent voiding? Also, we know that in many children, bowel and bladder dysfunction co-exist. Moreover, in some children treatment of constipation will help resolve the voiding dysfunction. Unfortunately, this questionnaire only has one question about bowel function and that one only adds 1 point to the scoring system.
  Despite these concerns, this paper is an important contribution. The authors are to be congratulated.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA