Pediatric refractory urgency, neuropsychiatric disorders linked

Key Points

San Francisco-Children who do not respond to treatment for urgency fre-quency syndrome (UFS) may have underlying neuropsychiatric disorders that need treatment before UFS symptoms can be resolved.

That's the take-home message from research led by Israel Franco, MD, associate professor of urology at New York Medical College, Valhalla. Dr. Franco analyzed pediatric patients seen for UFS over a 1-year period. He found that 56% of patients who did not respond to aggressive conventional treatment had a history of a neuropsychiatric disorder or had a first-order family member with neuropsychiatric problems. Among children who responded to conventional treatment, just under 11% had neuropsychiatric disorders.

"If there is a clear-cut history of a neuropsychiatric disorder in the syndrome mix, these children will be very difficult to treat," Dr. Franco told colleagues at the 2007 American Academy of Pediatrics Section on Urology meeting here. "There is not really much we can do for these children, except treat the underlying neuropsychiatric issue."

However, Patrick H. McKenna, MD, professor and chair of urology at Southern Illinois University School of Medicine, Springfield, hesitates to blame UFS on neuropsychiatric problems. While there may be a subset of refractory patients with underlying neuropsychiatric disorders, his program has successfully managed the majority of these patients with a comprehensive approach.

"This is a difficult group of patients, but few require medication with our approach," Dr. McKenna said.

In his own practice, UFS patients represent a small subgroup, most of whom are male. Male patients with UFS have the largest percentage of anatomic abnormalities (most commonly, posterior urethral valves) in the practice.

Dr. McKenna refers the small percentage of these patients who have clear neuropsychiatric problems to a behavioral psychiatrist. After behavioral therapy, most patients return to complete the UFS treatment program. The program combines treatment of anatomic problems, management of neuropsychiatric problems, and training of pelvic muscles through computer games. Medication rarely is required.

No anatomic abnormality

"Dr. McKenna appears not to be clear on the fact that these patients had all failed conservative therapy, which includes biofeedback," Dr. Franco said.

"There were no anatomic abnormalities in these children, as is the common finding in children who develop de novo urgency and frequency. The common link among these patients-both boys and girls who were refractory to conventional therapy-was that they had an underlying neuropsychiatric problem without any anatomic abnormality.

"Our findings are matched by other studies that indicate the incidence of incontinence is two to three times higher in children who have neuropsychiatric problems in large population studies," he added. "At issue here is not the treatment modality, but the fact that if one determines that there is a neuropsychiatric problem, the way one may approach such a patient is clearly going to change."

Dr. Franco started with 326 patients who had been seen within the previous year for frequency or urgency. Of this group, 126 had adequate follow-up, 18 of whom had urinary tract infections and were eliminated, leaving 108 patients with UFS.

In the UFS group, 83 patients responded to treatment with a bowel regimen, anticholinergics, alpha-blockers, or combination therapies. Among the 25 non-responders, 14 patients (56%) had autism, attention deficit disorder or attention deficit hyperactivity disorder, anxiety, depression, or a first-order relative with a neuropsychiatric disorder.

Pediatric urologists have long recognized that children who have attention deficit hyperactivity disorder or other neuropsychiatric problems are more difficult to treat, Dr. Franco said. The surprise was finding that more than half of children who failed to respond to treatment also have some sort of neuropsychiatric problem either in their own history or in their immediate family history.

Imipramine (Tofranil) is useful in treating refractory patients, especially for daytime wetting, Dr. Franco added. But some parents prefer not to admit to neuropsychiatric problems in the family due to the social stigma that can be attached to mental illness.

"We know these neuropsychiatric problems have a genetic component," Dr. Franco said. "We now routinely ask the parents if they are on medication or have a history of underlying problems. Some parents are very cooperative on this issue, and some fight us tooth and nail."

Parents who have undergone neuropsychiatric treatment are more amenable to treatment for their children, he added, while those who have not been treated or who deny the existence of neuropsychiatric conditions in their families are more resistant to the idea.