PEDIATRIC UROLOGY

Dysfunctional elimination syndrome as an etiology of idiopathic urethritis in childhood
Herz D, Weiser A, Collette T, Reda E, Levitt S, Franco I.
Division of Pediatric Urology, Department of Urology, New York Medical College, New York, NY, USA
J Urol. 2005; 173(6): 2132-7

• Purpose: Idiopathic urethritis (IU) of childhood or urethrorrhagia is a common problem characterized by blood spotting in the underwear between voiding. A clear etiology has not been established and treatments vary. We postulate that idiopathic urethritis is a manifestation of underlying dysfunctional elimination syndrome (DES).
• Materials and Methods: During a 5-year period we reviewed the records of all children diagnosed with IU in our practice. In total 72 children fit the analysis criteria. There were 68 boys and 4 girls. All children presented with either gross blood per urethra or microhematuria. Children with active infection, immunodeficiency, neurogenic bladder, vesicoureteral reflux, infravesical obstruction, urethral trauma or other genitourinary anomalies were excluded. Evaluation included thorough history and physical examination, urinalysis and urine culture. Renal and bladder ultrasound, voiding cystourethrogram and uroflow/electromyogram/post-void residual volume were obtained in select patients. Study children were divided into 2 cohorts. The first cohort (group 1, 37 patients) was treated with traditional remedies using antibiotics, urinary analgesics and/or anticholinergics. The second cohort (group 2, 35 patients) was treated by bowel and bladder regimens, laxatives when necessary, and biofeedback and/or alpha-blockers when sphincter dyssynergia was identified.
• Results: A total of 13 patients in group 1 (35%) had a full response to treatment, 6 (16%) had a partial response and 18 (49%) failed to respond. A total of 29 patients in group 2 (83%) had a full response to treatment, 2 (6%) had a partial response and 4 (11%) had no response. It took an average of 12.1 months to respond fully in group 1, while in group 2 the same full response took an average of 5.2 months. Of the 18 children who crossed over from group 1 to group 2, 15 (83%) had a full response with an average response time of 7.3 months.
• Conclusions: Our data clearly reveal a higher cure rate when children with urethritis are treated according to DES guidelines. IU of childhood is a manifestation of underlying DES and should be treated as such.
  
  
• Editorial Comment
  The authors provide a new theory as to the etiology of idiopathic urethritis. This is a frustrating condition that leads to significant parental and patient anxiety and occasionally results in urethral stricture. In a previous era, patients were over-investigated and rarely was a significant cause discovered. Recently patients have been treated primarily with reassurance with some benefit but considerable skepticism.
  Hence, the advent of a new theory is welcome. The authors propose that dysfunctional elimination is the basic cause. This abnormal pattern of voiding leads to high velocity, turbulent flow in the posterior urethra that results in the hematuria and dysuria. They also demonstrate that treating these patients for dysfunctional elimination results in greatly improved resolution of symptoms.
  Although welcome, there are some questions about the validity of the theory. Symptoms in their patients were frequent. For example, approximately 40% had urgency/frequency, 20% had constipation and about 20% had infrequent voiding. However, if symptoms like these are actively sought, how many of their patients with undescended testes or hernias would also have these symptoms? Similarly, the treatment of dysfunctional elimination is much more involved than reassurance. Could the added attention and ongoing personal interest have helped in the reported resolution? Despite these questions, this is an important contribution and those of us caring for these children should strongly consider this possibility.

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