The role of the pelvic floor in the genesis of dysfunctional voiding in children

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Abstract

BACKGROUND: Pelvic organ evacuation dysfunction is observed in 17–22% of all pediatric urologic visits. Of these, 32% have dysfunctional urination, which means difficult urination due to the inability of external urethral sphincter and pelvic floor muscles to relax properly. Consequently, such abnormality can be accompanied by urinary incontinence and infectious complications. Timely diagnostics and proper understanding of the pelvic floor role in urination are essential for the effective treatment.

AIM: To improve treatment outcomes in children with pelvic evacuation dysfunctions through the implementation of transperineal sonography.

METHODS: The authors present their observational, single-center, and randomized trial. The main sample included 103 children with pelvic evacuation disorders who were consulted at N.F. Filatov Children's City Hospital in Moscow from 2018 to 2025. All children underwent transperineal sonography to examine their pelvic floor, triple uroflowmetry with assessment of the residual urine, and electromyography of the perineal muscles.

RESULTS: Children were divided into two groups by gender (58 girls and 45 boys). According to the findings obtained at three uroflowmetry examinations, urinary flow rate was decreased by 27%, in average, in boys, while in girls this parameter was at the lower norm limit. Intermittent or staccato urination was seen in all children in the studied group. An electromyography curve during urination showed the increased pelvic floor muscle activity. Moreover, ultrasound examination revealed the residual urine (from 10 to 30%) in the bladder of 53 children. Transperineal sonography in children with dysfunctional voiding has found a specific feature: virtually, no displacement of the urethra and bladder neck during functional tests, which was interpreted as manifestations of the paradoxic pelvic floor muscle activity. The increased puborectal loop size, anal canal width, and the decreased size of anorectal angle indicate anal sphincter hypercontractility. These findings correlated with transperineal sonography findings.

CONCLUSION: Transperineal sonography is a simple, available and non-invasive technique which demonstrates good diagnostic values in identifying dysfunctional voiding in children.

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About the authors

E. A. Markina

The Russian National Research Medical University named after N.I. Pirogov

Author for correspondence.
Email: katya.patrusheva.97@mail.ru
ORCID iD: 0000-0002-9107-2311
SPIN-code: 2454-4624
Russian Federation, Moscow

L. B. Menovschikova

The Russian National Research Medical University named after N.I. Pirogov; Filatov N.F. Children's City Hospital

Email: ludmilam-2205@yandex.ru
ORCID iD: 0000-0002-0780-9254

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Moscow; Moscow

Semen L. Kovarskiy

The Russian National Research Medical University named after N.I. Pirogov; Filatov N.F. Children's City Hospital

Email: sim3150@gmail.ru
ORCID iD: 0000-0001-6310-7110
SPIN-code: 9308-5014

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Moscow; Moscow

Z. Z. Sottaeva

The Russian National Research Medical University named after N.I. Pirogov

Email: scorpio140@yandex.ru
ORCID iD: 0000-0003-2522-904X
SPIN-code: 5275-0034

MD, Cand. Sci. (Medicine)

Russian Federation, Moscow

R. I. Dzhavatkhanova

Filatov N.F. Children's City Hospital; Russian Medical Academy of Continuous Professional Education

Email: d.risalat@gmail.com
ORCID iD: 0000-0003-4504-8414

MD, Cand. Sci. (Medicine)

Russian Federation, Moscow; Moscow

A. V. Lvova

Filatov N.F. Children's City Hospital; S.I. Spasokukotsky Moscow Centre for Research and Practice in Medical Rehabilitation, Restorative and Sports Medicine

Email: nas.lwowa199614@yandex.ru
ORCID iD: 0009-0002-0954-9115
SPIN-code: 8589-0349
Russian Federation, Moscow; Moscow

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2. Fig. 1. Anatomical location of the puborectalis. Borrowed from [11]: Zakharova IN, Guseva NB, Anikin AV, et al. Methods of studying the organs of the urinary system in children. A guide for doctors. Zakharova IN, Guseva NB, editors. Moscow: Masterskaya pechati idei; 2023. 598 p. (In Russ.) EDN: DCROWW

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3. Fig. 2. Urination mechanisms: a ― bladder at rest; b ― bladder at the moment of retention (decrease in the urethrovesical angle) and bladder at the moment of straining (increase in the posterior urethrovesical angle). Borrowed from [11]: Zakharova IN, Guseva NB, Anikin AV, et al. Methods of studying the organs of the urinary system in children. A guide for doctors. Zakharova IN, Guseva NB, editors. Moscow: Masterskaya pechati idei; 2023. 598 p. (In Russ.) EDN: DCROWW

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4. Fig. 3. Uroflowmetry with electromyography in a 6-year-old girl with complaints of difficult urination and urinary incontinence. The average flow rate is significantly reduced to 4.1 ml/sec. Intermittent urination is noted. Pelvic floor muscle activity is shown on electromyogramme.

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5. Fig. 4. Transperineal sonography (urethrovesical angle at rest, 116 degrees): proximal urethra (a); the line drawn through the bottom of the bladder (b); posterior urethrovesical angle (c).

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6. Fig. 5. Transperineal sonography (anorectal angle): anal canal (a); anorectal angle (b).

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