to allow evaluation, and therefore, several recordings are needed to obtain consistency.

Low rate continuous flow with extended flow-time can point to anatomical infravesical obstruction.31 Staccato and interrupted flow is seen in patients with dysfunctional voiding and underactive bladder.2 Normal continuous flow rate within expected time does not exclude urethral obstruction because no information is present on the pressure that the detrusor generates to produce this flow. Specific literature on this subject, other than expert opinion, is sparse.3, 32–34

11.2.5  Treatment

Medical treatment can be tried for an episode of 3 months by the specialist. Any treatment should start with explanation of bladder and sphincter function combined with explanation of the condition that is causing the LUTS.

In case of urge complaints and OAB, in the absence of constipation, antimuscarinics can be given. At this moment, oxybutynin is the only anticholinergic that is accepted for pediatric use although many also prescribe detrusitol.

Oxybutynin has a fast effect, within 30 min, that lasts for 6–8 h. This gives the opportunity to tailor medication to the urge complaints. Many children suffer predominantly from urge complaints in the late afternoon and early evening. In those cases, 1 dosage of oxybutynin around 3 pm can be sufficient to give relief of complaints. Thus, also the most important complication of oxybutynin treatment, constipation, can be prevented as much as possible. For daytime only complaints, dosage of oxybutynin is around 8 am and around 3 pm.A dosage in the morning and the evening, in most patients, gives no relief of complaints in the afternoon and early evening.

Oxybutynin causes no problems in the vast majority of patients but parents must be warned that,sometimes,central side effects like loss of concentration or psychological changes can occur that force to stop medication. Also, in high temperatures, temperature control can derange, even causing a heath stroke.

114 T.P.V.M. de Jong and M.A.W. Vijverberg

This is caused by a less effective transpiration due to the anticholinergic effect.We advise the parents, when possible, to interrupt medication with outside temperatures exceeding 30°C.

Much discussion exists around the use of chemoprophylaxis in patients with dilated upper urinary tracts and primary vesico-ureteric reflux. In our opinion, girls with recurrent UTI’s based on DV or UAB can really be depending on prophylaxis although good scientific evidence is not available. Preferably, we prescribe trimethoprim or nitrofurantoin MC 2 mg/kg/day in one gift. In girls with recurrent break-through infections we commonly use trimethoprim and nitrofurantoin alternating day by day. Girls with a low number of UTI’s can use self test strips at home (leucocytes and nitrite) and do self medication with nitrofurantoin MC 6 mg/kg/day in 3 or 4 gifts for 3 days. Nitrofurantoin MC should be prescribed in capsules or powder. Nitrofurantoin solution is not suitable for prophylaxis because all children will develop stomach complaints after several weeks or months.

For laxative therapy nowadays polyethylene glycols (PEGS) are preferred. Since constipation in children with LUTS does not always follow strictly the Rome III criteria for constipation but suffer mostly from a dilated rectum that they cannot feel, oral laxative therapy is not always successful. In those cases we use rectal water enemas comparable to those used in spina bifida patients.

After the 3 months run-in period, in boys with OAB and in girls with meatal anomalies, first step must be to think about the need to correct an urethral obstruction or do a meatus correction to get a normal urinary stream. Once this has been done the next step will be out-patient urotherapy.24,35

11.2.5.1  Standard Outpatient Urotherapy

Instructions are given about the bladder and sphincter function, proper voiding pattern, and the use of voiding charts and proper toileting position. Prophylactic antibiotics are continued and instructions are given for a regular defecation pattern with or without laxative therapy the child needs to sit on the toilet

116 T.P.V.M. de Jong and M.A.W. Vijverberg

adequate laxative and toileting therapy we have adopted rectal wash-out enema therapy for this group. The child is taught to take rectal enema with 20 mL tap-water/kg. First to weeks, daily enemas are taken, followed by 3 months of once every 2 days. When the child passes stools on the day that no enema is given, it can start doing it once every 3 days. Most children can stop the therapy after 12 months; some children remain depending on the enema therapy but, in general, keep performing it once a week or even less. Advantage of the enema therapy is that most children regain the feeling to discriminate between a distended or empty rectum.13,14,42

For therapy resistant patients some centers offer an intensive, hospitalized training program for 2 weeks that consists of daily training by biofeedback, wetting alarm, psychological support etc.43

When all these therapies fail, one should be aware of the possibility of structural anomalies of the bladder neck and urethra that need surgery to get cured.44

11.2.6  Giggle Incontinence, Incontinentia Risoria

It is well-known that directors of theatres dislike comic spectacles because of the fact that many seats are wet after such an event. Giggle incontinence can be a socially very debilitating condition for children. No good therapy exists. One can look specifically to the normal functioning of the pelvic floor and offer pelvic floor physical therapy to the children that appear to have insufficient strength. We are offering a training program that aims at awareness by a self-administered shock during moments of laughter.45,46 Success is approximately 60%. Ephedrine-like substances with an a-mimetic effect can sometimes reduce wet incidents. Prescription of 10mgephedrinewillreduceaccidentsfor4h.Methylphenidate, used in the treatment of ADHD, also acts on the bladder neck and can be tried.47 Even botulinum toxin injection into the detrusor muscle has been tried.48