To revise the clinical guideline for childhood urinary tract infections (UTIs) of the Korean Society of Pediatric Nephrology (2007), the recently updated guidelines and new data were reviewed. The major revisions are as follows. In diagnosis, the criterion for a positive culture of the catheterized or suprapubic aspirated urine is reduced to 50,000 colony forming uits (CFUs)/mL from 100,000 CFU/mL. Diagnosis is more confirmatory if the urinalysis is abnormal. In treating febrile UTI and pyelonephritis, oral antibiotics is considered to be as effective as parenteral antibiotics. In urologic imaging studies, the traditional aggressive approach to find primary vesicoureteral reflux (VUR) and renal scar is shifted to the targeted restrictive approach. A voiding cystourethrography is not routinely recommended and is indicated only in atypical or complex clinical conditions, abnormal ultrasonography and recurrent UTIs. 99mTc-DMSA renal scan is valuable in diagnosing pyelonephritis in children with negative culture or normal RBUS. Although it is not routinely recommended, normal scan can safely avoid VCUG. In prevention, a more natural approach is preferred. Antimicrobial prophylaxis is not supported any more even in children with VUR. Topical steroid (2-4 weeks) to non-retractile physiologic phimosis or labial adhesion is a reasonable first-line treatment. Urogenital hygiene is important and must be adequately performed. Breast milk, probiotics and cranberries are dietary factors to prevent UTIs. Voiding dysfunction and constipation should be properly treated and prevented by initiating toilet training at an appropriate age (18-24 months). The follow-up urine test on subsequent unexplained febrile illness is strongly recommended. Changes of this revision is not exclusive and appropriate variation still may be accepted.
Anti-Bacterial Agents ; Catheters ; Child ; Cicatrix ; Constipation ; Diagnosis ; Female ; Follow-Up Studies ; Humans ; Hygiene ; Milk, Human ; Nephrology ; Phimosis ; Probiotics ; Pyelonephritis ; Technetium Tc 99m Dimercaptosuccinic Acid ; Toilet Training ; Ultrasonography ; Urinalysis ; Urinary Tract Infections* ; Urinary Tract* ; Vaccinium macrocarpon ; Vesico-Ureteral Reflux

Coexisting voiding and bowel dysfunction in children are common in the clinic. The idea that overactive bladder (OAB) and constipation arise from one single pathophysiology has been reinforced in many studies. In Korea, a nationwide multicenter study conducted in 2009 showed that overall prevalence of OAB in children, 5-13 years of age, was 16.59% and this number has increased more recently. The initial step to manage coexisting fecal retention and OAB in children is to characterize their bowel and bladder habits and to treat constipation if present. Although diagnosing constipation in children is difficult, careful history-taking using the Bristol Stool Form Scale, and a scoring system of plain abdominal radiography, can help to estimate fecal retention more easily and promptly. Non-pharmacological approaches to manage functional constipation include increasing fluids, fiber intake, and physical activity. Several osmotic laxatives are also effective in improving OAB symptoms and fecal retention. Additionally, correction and education in relation to toilet training is the most important measure in treating OAB with fecal retention.
Child* ; Constipation ; Education ; Humans ; Korea ; Laxatives ; Motor Activity ; Prevalence ; Radiography, Abdominal ; Toilet Training ; Urinary Bladder ; Urinary Bladder, Overactive*

Coexisting voiding and bowel dysfunction in children are common in the clinic. The idea that overactive bladder (OAB) and constipation arise from one single pathophysiology has been reinforced in many studies. In Korea, a nationwide multicenter study conducted in 2009 showed that overall prevalence of OAB in children, 5-13 years of age, was 16.59% and this number has increased more recently. The initial step to manage coexisting fecal retention and OAB in children is to characterize their bowel and bladder habits and to treat constipation if present. Although diagnosing constipation in children is difficult, careful history-taking using the Bristol Stool Form Scale, and a scoring system of plain abdominal radiography, can help to estimate fecal retention more easily and promptly. Non-pharmacological approaches to manage functional constipation include increasing fluids, fiber intake, and physical activity. Several osmotic laxatives are also effective in improving OAB symptoms and fecal retention. Additionally, correction and education in relation to toilet training is the most important measure in treating OAB with fecal retention.
Child* ; Constipation ; Education ; Humans ; Korea ; Laxatives ; Motor Activity ; Prevalence ; Radiography, Abdominal ; Toilet Training ; Urinary Bladder ; Urinary Bladder, Overactive*

Constipation in children is a common health problem affecting 0.7% to 29.6% children across the world. Exact etiology for developing symptoms is not clear in children and the majority is considered to have functional constipation. Alteration of rectal and pelvic floor function through the brain-gut axis seems to play a crucial role in the etiology. The diagnosis is often a symptom-based clinical process. Recently developed Rome III diagnostic criteria looks promising, both in clinical and research fields. Laboratory investigations such as barium enema, colonoscopy, anorectal manometry and colonic transit studies are rarely indicated except in those who do not respond to standard management. Treatment of childhood constipation involves several facets including education and demystification, toilet training, rational use of laxatives for disimpaction and maintenance and regular follow-up. Surgical options should be considered only when medical therapy fails in long standing constipation. Since most of the management strategies of childhood constipation are not evidence-based, high-quality randomized controlled trials are required to assess the efficacy of currently available or newly emerging therapeutic options. Contrary to the common belief that children outgrow constipation as they grow up, a sizable percentage continue to have symptoms beyond puberty.
Axis, Cervical Vertebra ; Barium ; Child ; Colon ; Colonoscopy ; Constipation ; Enema ; Follow-Up Studies ; Humans ; Laxatives ; Manometry ; Pelvic Floor ; Puberty ; Rome ; Toilet Training

PURPOSE: We aimed to determine the ideal age for initiating toilet training and investigate the factors influencing the training. METHODS: The study population comprised 1,370 children aged 2-6 years, who visited the pediatric clinics in Jeonju, Iksan, and Gunsan. Their parents were given questionnaires in order to gather data about the types of diapers used, ages when toilet training was initiated and completed for each day and night, its adverse effects, and the educational level and employment and economic status of the mothers. RESULTS: The toilet training initiation age was low for those living in the country, having an elder sibling(s), and using cloth diapers, and for those whose mothers were employed and had a low economic status. The training completion age was 22.9 months when the training was initiated before the age of 18 months; this was lower than the training completion ages of 25.9 and 31.0 months when the training was initiated at the age of 18-24 months and after 25 months, respectively. However, the required durations in these cases were 8.4, 5.6, and 3.8 months, respectively. Encopresis and refusal occurred more often when the training was initiated before the age of 18 months than when initiated after this age. CONCLUSION: Toilet training should begin at least after the age of 18 months considering the developmental status of infants. It is recommended for the future researchers to develop specific guidelines regarding toilet training.
Aged ; Child ; Disulfiram ; Employment ; Encopresis ; Humans ; Infant ; Mothers ; Parents ; Surveys and Questionnaires ; Toilet Training

We compared the effects of bladder training and/or tolterodine as first line treatment in female patients with overactive bladder (OAB). One hundred and thirty-nine female patients with OAB were randomized to treatment with bladder training (BT), tolterodine (To, 2 mg twice daily) or both (Co) for 12 weeks. Treatment efficacy was measured by micturition diary, urgency scores and patients' subjective assessment of their bladder condition. Mean frequency and nocturia significantly decreased in all treatment groups, declining 25.9% and 56.1%, respectively, in the BT group; 30.2% and 65.4%, respectively, in the To group; and 33.5% and 66.3%, respectively in the Co group (p<0.05 for each). The decrease in frequency was significantly greater in the Co group than in the BT group (p<0.05). Mean urgency score decreased by 44.8%, 62.2% and 60.2% in the BT, To, and Co groups, respectively, and the improvement was significantly greater in the To and Co groups than in the BT group (p<0.05 for each). Although BT, To and their combination were all effective in controlling OAB symptoms, combination therapy was more effective than either method alone. Tolterodine alone may be instituted as a first-line therapy, but may be more effective when combined with bladder training.
Urinary Bladder, Overactive/*therapy ; Treatment Outcome ; Toilet Training ; Phenylpropanolamine/*therapeutic use ; Outcome Assessment (Health Care) ; Muscarinic Antagonists/therapeutic use ; Middle Aged ; Humans ; Female ; Cresols/*therapeutic use ; Combined Modality Therapy ; Benzhydryl Compounds/*therapeutic use ; Behavior Therapy/*methods

PURPOSE: To emphasize the significance of urethral abnormalities as the cause of vesicoureteral reflux in children. MATERIALS AND METHODS: Current literatures were evaluated and the data in my laboratories were added. RESULTS: Vesicoureteral reflux in boys which is more common in neonates and infants, has the tendency of quicker spontaneous resolution compared to girls in spite of its bilaterality and high grade. On the other hand, vesicoureteral reflux in girls, more commonly found after the first year of life, shows slower spontaneous resolution than boys although it shows lower grades when compared to boys. Such findings are attributed to sexual difference and the urethra is suspected to play an important role. The urethra influences the bladder function through sphincter to bladder reflex during the filling phase, and urethra to bladder reflex during the voiding phase. Cobb's collar which is an obstructive urethral lesion in males, is supposed to disappear after a short existence during fetal or neonatal period. However, if it causes severe obstruction or fails to disappear, it is suspected to result in the typical male type of vesicoureteral reflux caused by voiding dysfunction and increased intravesical pressure created by obstruction itself and urethral instability. Meanwhile, urethral abnormalities in girls such as mucosal web or female hypospadias causes vaginal voiding leading to dysfunctional voiding after toilet training and consequently results in vesicoureteral reflux through bladder instability, increased intravesical pressure and urinary tract infection as well as urethral instability. CONCLUSIONS: Since the meaning of surgery in vesicoureteral reflux, in view of kidney preservation, is becoming limited to the extent of recognizing the merit of surgical correction as merely discontinuing prophylactic antibiotics, studies of urethra in children with vesicoureteral reflux is another filed in (pediatric) urology which requires more active research and treatment.
Anti-Bacterial Agents ; Child* ; Female ; Hand ; Humans ; Hypospadias ; Infant ; Infant, Newborn ; Kidney ; Male ; Reflex ; Toilet Training ; Urethra ; Urinary Bladder ; Urinary Tract Infections ; Urology ; Vesico-Ureteral Reflux*

PURPOSE: Unstable bladder has been known to be one of the reasons for the genesis and persistance of primary vesicoureteral reflux(VUR) in children. And treatment of unstable bladder by anticholinergic agent may contribute to the resolution of primary VUR. We evaluated the effect of an anticholinergic agent(oxybutynin) on the resolution of primary VUR in children with different toilet training and voiding functions. METHODS: 152 children with persistant primary VUR after one year of follow up were randomly assigned to the oxybutynin group(n=59, oxybutynin 0.2 mg/kg twice daily) and the control group(n=93, no oxybutynin) at Ewha Womans University Mok-Dong Hospital from October 1996 to April 2002. The resolution rate of the VUR and the difference according to the status of toilet training and voiding dysfunction were analyzed. Statistical analysis was done by the Chi-square test and a P-value of less than 0.05 was considered as significant. RESULTS: VUR was resolved in 49.2%, improved in 20.3% and not changed in 30.5% in the oxybutynin group(n=59) which was not significantly different to 45.2%, 16.1%, 38.7% in the control group(n=93), respectively. In the non-toilet trained young children, VUR was resolved in 50.0%, improved in 23.5% and not changed in 26.5% in the oxybutynin group(n=34) which was not significantly different to 44.2%, 19.2%, 36.6% in the control group(n=52), respectively. In the toilet trained older children, VUR was resolved in 48.0%, improved in 16.0% and not changed in 36.0% in the oxybutynin group(n=25) which was not significantly different to 46.3%, 12.2%, 41.5% in the control group(n=41), respectively. In the toilet trained older children with no voiding dysfunction, VUR was resolved in 33.3%, improved in 11.1% and not changed in 55.6% in the oxybutynin group(n=9) which was not significantly different to 53.6 %, 10.7%, 35.7% in the control group(n=28), respectively. In the toilet trained older children with voiding dysfunction, VUR was resolved in 56.3%, improved in 18.7% and not changed in 25.0% in the oxybutynin group(n=16), which looked higher than 30.7%, 15.4%, 53.9% in the control group(n=13), respectively, but these were not significantly different either. CONCLUSION: Oxybutynin was not effective in the resolution of primary VUR in non-toilet trained young children and toilet trained older children. Oxybutynin showed slightly higher tendency of reflux resolution in toilet-trained older children with voiding dysfunction but the difference was not statistically significant. Judicious use of oxybutynin is required in selected older children with VUR and voiding dysfunction.
Child ; Female ; Follow-Up Studies ; Humans ; Toilet Training ; Urinary Bladder ; Vesico-Ureteral Reflux*

PURPOSE: Unstable bladder has been known to be one of the reasons for the genesis and persistance of primary vesicoureteral reflux(VUR) in children. And treatment of unstable bladder by anticholinergic agent may contribute to the resolution of primary VUR. We evaluated the effect of an anticholinergic agent(oxybutynin) on the resolution of primary VUR in children with different toilet training and voiding functions. METHODS: 152 children with persistant primary VUR after one year of follow up were randomly assigned to the oxybutynin group(n=59, oxybutynin 0.2 mg/kg twice daily) and the control group(n=93, no oxybutynin) at Ewha Womans University Mok-Dong Hospital from October 1996 to April 2002. The resolution rate of the VUR and the difference according to the status of toilet training and voiding dysfunction were analyzed. Statistical analysis was done by the Chi-square test and a P-value of less than 0.05 was considered as significant. RESULTS: VUR was resolved in 49.2%, improved in 20.3% and not changed in 30.5% in the oxybutynin group(n=59) which was not significantly different to 45.2%, 16.1%, 38.7% in the control group(n=93), respectively. In the non-toilet trained young children, VUR was resolved in 50.0%, improved in 23.5% and not changed in 26.5% in the oxybutynin group(n=34) which was not significantly different to 44.2%, 19.2%, 36.6% in the control group(n=52), respectively. In the toilet trained older children, VUR was resolved in 48.0%, improved in 16.0% and not changed in 36.0% in the oxybutynin group(n=25) which was not significantly different to 46.3%, 12.2%, 41.5% in the control group(n=41), respectively. In the toilet trained older children with no voiding dysfunction, VUR was resolved in 33.3%, improved in 11.1% and not changed in 55.6% in the oxybutynin group(n=9) which was not significantly different to 53.6 %, 10.7%, 35.7% in the control group(n=28), respectively. In the toilet trained older children with voiding dysfunction, VUR was resolved in 56.3%, improved in 18.7% and not changed in 25.0% in the oxybutynin group(n=16), which looked higher than 30.7%, 15.4%, 53.9% in the control group(n=13), respectively, but these were not significantly different either. CONCLUSION: Oxybutynin was not effective in the resolution of primary VUR in non-toilet trained young children and toilet trained older children. Oxybutynin showed slightly higher tendency of reflux resolution in toilet-trained older children with voiding dysfunction but the difference was not statistically significant. Judicious use of oxybutynin is required in selected older children with VUR and voiding dysfunction.
Child ; Female ; Follow-Up Studies ; Humans ; Toilet Training ; Urinary Bladder ; Vesico-Ureteral Reflux*

PURPOSE: The causes of encopresis are complex and multifactorial. Through application of new sophisticated techniques and armamentarium, it has been possible to find more specific aspects of the anorectal function in pediatric patients with refractory defecation disorders. However, quality research of which therapeutic option could be suitable, is still lacking. The current study was designed to assess outcome of treatment according to the treatment algorithm based on the clinical and physiologic findings. METHODS: 22 patients (15 boys, 7 girls) with encopresis were analyzed, retrospectively. For exclusion of the organic cause, barium contrast study and anoscopy were carried out in all cases. Patients were categorized and made treatment algorithm by using leading symptoms and findings of anorectal physiologic tests. Treatment outcomes were analysed in the basis of respective therapeutic options. RESULTS: Patients were categorized as constipation dominant group (n=15) and incontinence dominant group (n=7). Suggested etipathogeneses were as follows; fecal impaction and/or motility disorder (n=7), overflow incontinence (n=6), sensory defect of the rectum (n=4), puborectalis incoordination (n=3), anal hypertonia (n=2). Treatment options were as follows; conventional therapy (CT) only (n=7), CT plus biofeedback (n=9), CT plus balloon sensory retraining (n=4), and CT plus internal sphincterotomy or Nitroglycerine application (n=2). All patients were undertaken a toilet training and psychologic consultation. Regarding to the therapeutic outcome, 19 (86 percent) of overall 22 patients were improved in the mean period of 2.5 (range, 0.1-7) years follow-up. CONCLUSIONS: If therapy could be undertaken according to the optional algorithm based on the clinical and physiologic findings, it could be useful guide for clinical decision making to help the therapy. Moreover, through the combination therapy including medication, psychological consultation, and biofeedback treatment, encopretic children achieve acceptable outcome with a long-term compliance.
Ataxia ; Barium ; Biofeedback, Psychology ; Child ; Compliance ; Constipation ; Decision Making ; Defecation ; Encopresis* ; Fecal Impaction ; Follow-Up Studies ; Humans ; Nitroglycerin ; Rectum ; Retrospective Studies ; Toilet Training ; Treatment Outcome*