Minimum Urodynamics Enables Evaluation Without Catheters
To some physicians, urodynamics is synonymous with invasive bladder testing. Multichannel urodynamic studies, in which catheters are placed in the urethra and anus, can be enormously useful for diagnosing complex urologic issues, but can also be uncomfortable and scary for patients and families. Fortunately, it’s possible to use an array of noninvasive tests to evaluate many pediatric urinary problems — and Children’s Health℠, Children’s Medical Center Dallas uses an approach that enables us to diagnose and treat a majority of patients without catheterization.
“A lot of families worry that being referred to a urologist means that their child will undergo a painful test,” says Micah Jacobs, M.D., Pediatric Urologist at Children’s Health and Associate Professor at UT Southwestern. “We’ve dedicated ourselves to streamlining testing and making it as comfortable and noninvasive as possible, and most of our urologic evaluations are now relatively painless.”
Combining Tests to Improve Diagnosis
Children’s Health is home to one of the region’s highest volume pediatric urology departments, and we see referrals for patients with conditions ranging from nighttime wetting to spina bifida-related bladder issues. Our philosophy in bladder testing is to select diagnostics that can help evaluate patients while avoiding catheterization whenever possible.
“We’ll pick and choose tests that will help us understand each patient, without resorting to a full multichannel study unless it’s absolutely necessary,” Dr. Jacobs says.
Testing often begins with a uroflow test that assesses the speed at which urine leaves the body.
“Uroflow can tell us a lot about how someone is urinating, including if they’re interrupting their stream or if they’re not generating a good stream,” Dr. Jacobs says. “It also lets us gauge how the patient’s results compare to typical patients.”
We often pair uroflow with a post void residual test, where we use ultrasound to determine how much urine remains in the bladder after a patient urinates.
“That delivers important information about how efficiently someone is emptying their bladder, which can help us understand why they might be experiencing an issue like incontinence,” Dr. Jacobs says.
In some cases, our team will simultaneously perform an electromyography (EMG) test, where an adhesive electrode patch is placed on a patient’s bottom to monitor sphincter activity during urination. To keep this test painless, we do not use needle electrodes which are preferred by some providers elsewhere.
“EMG can help complete the picture,” Dr. Jacobs says. “For example, if uroflow shows the urine is coming out slowly or is being interrupted and the sphincter electrode is frequently triggering, we can determine that the patient is squeezing their sphincter while they urinate.”
Making Multichannel Studies as Comfortable as Possible
Of course, full multichannel studies are still necessary in certain cases, such as when initial testing suggests a bladder problem is related to neurological issues, or when a neurosurgeon refers a patient for pre-surgical evaluation related to conditions like tethered spinal cord. In those cases, we work to make the studies as comfortable as possible.
Our patients benefit from the fact that we focus only on children, which gives us the experience to know how to best prepare them for catheterization, and how to insert catheters in smaller patients in the least painful way. When necessary, we bring in child life specialists during the test, to help children feel more comfortable.
“Our urodynamics technician is wonderful and works with kids all day, every day, so she knows how to put children and families at ease,” Dr. Jacobs says.
The Children’s Health team is often asked if children can be sedated during the study. Dr. Jacobs and his colleagues avoid sedation in most cases.
“It’s hard to get good information when a child is sedated and it can also be counterproductive, because some kids get disoriented and consequently more scared than they might be otherwise,” Dr. Jacobs says.
Innovative Biofeedback Program
Once evaluation is complete, Dr. Jacobs and his colleagues match patients with the latest treatments including lifestyle modifications, medication, and rarely — surgery. Children’s Health is also home to a comprehensive pelvic floor training program called biofeedback for pediatric incontinence.
This program uses a computer game to teach children how to contract and relax pelvic floor muscles on command. Via sensors placed on their skin, children control game characters by activating their pelvic muscles.
“Kids come in for one biofeedback session a week for about six weeks, and we’ve seen it improve bladder control in many of the patients who try it,” Dr. Jacobs says.
This combination of streamlined testing and state-of-the-art care helps explain why Children’s Health’s urology department — led by Craig Peters, M.D. — draws patients from across our region, and why our outcomes are in line with other top centers.
“We have an incredibly skilled and collaborative team, and we’re constantly working together to improve every aspect of what we do, so we can give each child the best opportunity for an excellent outcome,” Dr. Jacobs says.
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