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Glicia Estevam De Abreu1, Ana Paula Dias Souto Schimitz1, Ubirajara Barroso1*1center For Urinary Disorders In Childhood (Cedimi), Bahia School Of Medicine And Public Health, Salvador, Bahia, Brazil Association between a constipation scoring system adapted for use in children and the dysfunctional voiding symptom score
Autor: Glicia Estevam De Abreu1, Ana Paula Dias Souto Schimitz1, Ubirajara Barroso1*1center For Urinary Disorders In Childhood (Cedimi), Bahia School Of Medicine And Public Health, Salvador, Bahia, Brazil

Introduction: A presumed association between more severe lower urinary tract symptoms (LUTS) and more severe functional constipation (FC) remains unconfirmed. Since the Rome IV criteria do not quantify FC, an adult constipation scoring system was modified and adapted for use in children.

Objectives: To assess the correlation between FC severity as determined by the modified constipation scoring system and LUTS severity in children/adolescents, and to assess the correlation between this modified scoring system and the Rome IV criteria.

Study design:  A cross-sectional study including 5- to 17-year-old patients with LUTS, with or without FC. Patients with neurological and/or anatomical abnormalities of the genitourinary and/or gastrointestinal tract were excluded. Girls with Dysfunctional Voiding Symptom Score (DVSS) ≥6 and boys with DVSS ≥9 were diagnosed with lower urinary tract dysfunction (LUTD). Patients with at least two positive Rome IV criteria were considered constipated. The severity of FC according to the adapted constipation scoring system was classified as mild for scores of 1-10, moderate for scores 11-20 and severe for scores 21-30.

Results: Of 128 patients with LUTS, 71 (55.5%) were female. LUTD was detected in 107 patients (83.6%) and was more common in girls. FC was present in 80 patients (62.5%). Constipated children had higher constipation scores and DVSS, with both scores increasing with the severity of FC. Correlation was moderate between the constipation score and the DVSS (þ=0.5, p<0.001) and was strong between positivity for a greater number of Rome IV criteria and the constipation score (þ=0.7, p<0.001). Most of the constipated patients had mild or moderate FC, while in 30 non-constipated patients the constipation score indicated mild FC.  

Discussion:  Patients from a specialist center are more likely to have more severe medical problems, and this may have influenced the correlation between the scores. The modifications made to the constipation scoring system require a future validation study. Nevertheless, this study provides new data on urinary dysfunction and its association with FC, and highlights the need to investigate occult bowel symptoms that could affect the treatment of urinary dysfunction. Conclusion: The intensity of FC as measured by the modified constipation scoring system correlated with the severity of the urinary symptoms in children/adolescents with LUTS/LUTD. In constipated patients, there was a correlation between the modified constipation scoring system and the Rome IV criteria. In non-constipated patients, the constipation scoring system identified symptoms/signs of bowel dysfunction not picked up by the Rome IV criteria. Finally, constipation score modified for use in children and adolescents could be important for research purpose and particularly having a prognostic importance.

Keywords: constipation; modified constipation scoring system; lower urinary tract dysfunction; Dysfunctional Voiding Scoring System; children.

Figure 1.

       
Frequency of bowel movements 1-2 times per 1-2 days 2 times per week Once per week Less than once per week Less than once per month Minutes in the toilet to defecate 0.     Less than 5 minutes 1.     5-10 minutes 2.     10-20 minutes 3.     20-30 minutes 4.     More than 30 minutes
Painful evacuation effort Never Rarely Sometimes Usually Always Type of assistance   0.   No assistance   1.   Stimulative laxatives   2.   Digital assistance or enema
Feeling incomplete evacuation Never Rarely Sometimes Usually Always Unsuccessful attempts for evacuation per 24 hours Never 1-3 3-6 6-9 More than 9
Abdominal pain Never Rarely Sometimes Usually Always Duration of constipation        0.   Less than 1 year 1-3 years3-5 years5-7 yearsMore than 7 years  

Abbreviations:

BBD               Bladder and bowel dysfunction

DVSS             Dysfunctional Voiding Scoring System/ Dysfunctional Voiding Symptom Score

FC                   Functional constipation

IQR                 Interquartile ranges

LUTD             Lower urinary tract dysfunction

LUTS              Lower urinary tract symptoms

Introduction

Lower urinary tract symptoms (LUTS) are often associated with functional constipation (FC) and the condition is then referred to as bladder and bowel dysfunction (BBD) [1]. Constipated children have been found to be 6.8 times more likely to have lower urinary tract dysfunction (LUTD) compared to non-constipated children [2]. There is a consensus today that treating bowel dysfunction is a crucial step to ensuring the successful resolution of urinary dysfunction and in many cases this is the only treatment adopted [3,4].

Questionnaires have been used to identify BBD. These instruments were developed in response to the need for a more objective way of evaluating subjective complaints and to transform them into quantitative data. Various different questionnaires have been used to evaluate and quantify LUTS, with the original being the Dysfunctional Voiding Scoring System (DVSS) [5]. This instrument allows the presence of dysfunctional voiding symptoms to be detected, indicating whether LUTD is present, and quantifying the severity of each symptom using a Likert-type scale. In other words, patients scoring higher in this questionnaire are probably more symptomatic. For the evaluation of FC, the Rome IV criteria currently constitute the diagnostic instrument most widely used in pediatric clinics [6]. The presence of at least two of the criteria over a 1-month observation period is sufficient to characterize a child as having FC. Nevertheless, although the Rome criteria are able to identify the presence of the condition, this tool cannot be used to quantify the severity of bowel dysfunction. In adults, this information can be obtained using scores such as the constipation scoring system developed by Agashan et al. [7]. This is a widely used diagnostic tool that enables the severity of FC to be measured. This aids management of the dysfunction insofar as the choice of diagnostic tests and treatments is concerned, and when evaluating the patient’s response to the treatment provided.

Although the association between constipation and LUTD in children and adolescents is well known, it has yet to be established whether LUTD classified as more severe by the DVSS is associated with more severe FC, since, as previously mentioned, the Rome IV criteria do not quantify this bowel dysfunction.

Measuring the severity of FC in children and adolescents using a scoring system specifically modified for this age group could provide useful information on the role of this dysfunction and its severity on the presence and severity of urinary dysfunction. Furthermore, such a score could serve as a useful clinical guide on whether or not to request additional tests or adopt specific treatments in accordance with the intensity of the FC. Consequently, this would perhaps contribute towards a faster and more long-lasting response, since the treatment of FC in children can be frustrating due to the not uncommon risk of relapse [8].

Therefore, the objective of the present study was to conduct a preliminary analysis of a constipation scoring system adapted for use in children, evaluating whether there is a correlation between this modified constipation scoring system and the Rome IV criteria, and whether there is a correlation between the severity of FC, measured using that scoring system, and the severity of the urinary symptoms in children and adolescents with LUTS.

Materials and methods

Sample selection

A cross-sectional study was conducted with children and adolescents of 5 to 17 years of age attending an outpatient clinic for the diagnosis and treatment of urinary disorders in childhood and adolescence. The study was carried out between May 2017 and May 2018. Children and adolescents with LUTS, with or without FC, were included in the study. Patients whose DVSS, Rome criteria and modified constipation scoring system questionnaires were incomplete were excluded from the study, as were those with a diagnosis of neurological and/or anatomical abnormalities of the genitourinary and/or gastrointestinal tract.

Instruments

The DVSS, translated and validated for use in Brazilian Portuguese, was used to evaluate the presence of LUTS and LUTD [5]. This instrument consists of ten questions, seven of which refer to urinary symptoms (questions 1, 2, 5, 6, 7, 8 and 9), two to bowel symptoms (questions 3 and 4) and one to stress-related social and family issues (question 10). For questions 1-9, scores were awarded on a Likert-type scale ranging from 0 to 3 in accordance with the presence and severity of the symptoms (0 = never or almost never; 1 = at least once a week; 2 = three times a week; and 3 = almost every day). For question 10, an answer of no received a score of 0 while an answer of yes was given a score of three. The presence of a score ≥ 6 in girls or ≥ 9 in boys was considered indicative of LUTD. The presence of urinary symptoms (DVSS items 1, 2, 5, 6, 7, 8 and 9) occurring more than once a week (a score ≥1) was considered positive for LUTS. Children and adolescents whose answers were positive only for items 3, 4 and 10 of the DVSS were considered to have bowel problems and/or to be under stress, without the presence of LUTS, and were not included in the study.

Bowel symptoms were evaluated using the specific Rome IV criteria for children and adolescents of 4 to 18 years of age. The Rome IV criteria for FC consist of the following six criteria evaluated over the preceding month: the presence of less than two bowel movements per week, at least one episode of fecal incontinence per week, holding maneuvers, pain or straining at defecation, a fecal mass in the rectum and feces that obstruct the toilet bowl. Children or adolescents with at least two positive Rome criteria were considered constipated [6].

The constipation scoring system, as proposed by Agachan et al. [7] and also referred to as the Cleveland Clinic Score, was used to evaluate the severity of bowel dysfunction. This questionnaire consists of eight questions on the clinical signs and symptoms associated with defecation. To adapt this questionnaire for use with the pediatric population, only the question related to the duration of FC was modified (Figure 1). A patient with a total score of 1-10 was considered to have mild constipation, while one with a score of 11 to 20 was judged to have moderate constipation, and a total score of between 21 and 30 was considered indicative of severe constipation.

Statistical analysis

Sample size was calculated using the Winpepi software program, version 11.65 design by Abramson Epidemiologic Perspectives & Innovations, Jerusalem, Israel [9], taking into consideration an expected prevalence of LUTD of 9.1% [10], an acceptable alpha error of 5% (α = 5%), a design effect of 5, and a 95% confidence level. The number of patients to be included in the study was calculated as 128. The categorical data were expressed as numbers and percentages and the continuous data as medians and interquartile ranges (IQR) after the normality of the data had been established using the Kolmogorov-Smirnov test. The chi-square test was used to analyze the associations between the presence of LUTD and sex, between LUTD and constipation, between the intensity of FC (no FC, mild FC, moderate FC and severe FC) and the presence or absence of FC diagnosed using the Rome IV criteria. The Mann Whitney test was used to evaluate the association between the presence of LUTD and the constipation scoring system score and between the presence of constipation and the DVSS score. Spearman’s rank correlation coefficient was applied to evaluate the correlation coefficient between the DVSS score and the constipation scoring system score and between the constipation scoring system score and the number of positive Rome IV criteria. The analysis was performed using the SPSS statistical software program version 21.0 designed by IBM (SPSS®), Chicago, Illinois, U.S.A [11]. P-values <0.05 were considered statistically significant (two-tailed test).

The study was submitted and approved by the Research Ethics Committee of the Bahiana School of Medicine and Public Health (registration number – 2637641) and the study was conducted in compliance with Resolution 466/12 of the Brazilian Ministry of Health’s National Health Council. All participants signed an informed consent prior to answering the questionnaires.

Results

A total of 128 children and adolescents with LUTS were recruited to the study, with 71 (55.5%) being female. LUTD was found in 107 children/adolescents (83.6%), the majority of whom were female. Table 1 lists the characteristics of the sample according to the presence or absence of LUTD. There was no statistically significant difference in median age between the children with LUTD and those without this dysfunction. Evaluation of the association between LUTD and FC showed that the majority of the children/adolescents had a combination of both dysfunctions. The median DVSS score for the entire study population was 11 (IQR 8-15), with the children/adolescents with LUTD having higher DVSS scores. The median constipation scoring system score for the entire sample was 8 (95%CI: 3-12), with individuals with LUTD having higher constipation scores compared to those without this urinary dysfunction.

FC, as detected by the Rome IV criteria, was present in 80 of the participants (62.5%). Evaluation of the intensity of constipation, measured using the constipation scoring system, showed that constipated children had a higher median score compared to non-constipated participants.  Likewise, the median DVSS score was higher in children with FC (Table 2).

Evaluation of the intensity of constipation, measured using the constipation scoring system, showed that 111 children/adolescents had constipation, with 71 having mild FC, 39 moderate FC and 1 severe FC. The median DVSS scores increased as a function of the severity of constipation (Table 3).

Investigation of the correlation between the constipation scoring system scores and DVSS scores showed that the children and adolescents with more intense LUTS also had more severe constipation (þ = 0.5; p<0.001) (Figure 2).

Since this was the first time that this constipation scoring system adapted for use in children and adolescents was used, the system was applied to all the patients irrespective of whether they had FC or not. The objective of this methodology was to observe the congruence between this new instrument and a positive diagnosis of constipation made using the Rome IV criteria. Findings showed that a greater number of positive Rome IV criteria corresponded to a higher constipation scoring system score (þ=0.7, p<0.001). In relation to the constipated patients, the majority had mild to moderate FC. When the 48 patients without FC were analyzed, 30 of them (62.5%) were found to have mild constipation, although they had not been diagnosed with FC when the Rome IV criteria were applied (Table 3).

Discussion

The Rome criteria were not originally designed to identify the severity of FC. Nevertheless, the results of the present study show that a higher constipation score was associated not only with the presence of FC diagnosed according to the Rome IV criteria, but also with the number of positive answers to those criteria. In other words, a greater number of positive Rome IV criteria was associated with more severe FC. This shows that in constipated patients, there is a correlation between this new diagnostic instrument and the Rome IV criteria for FC as well as with the intensity of constipation. More importantly, the findings of this study show a correlation with the severity of urinary symptoms, since children with higher DVSS scores, reflecting LUTD, had constipation scores that were also higher, i.e. in children and adolescents with more intense LUTS, FC is also more severe.

To the best of our knowledge, this is the first study to evaluate the severity of FC in association with the severity of urinary symptoms. The association between LUTS and FC has been widely studied; however, no studies have yet been conducted using a score to determine the severity of FC and its implication in urinary function. In adults, scores are widely used to quantify FC, since they improve the evaluation process and the selection of treatment for this dysfunction [12,13]. Nonetheless, there are few data in the literature correlating the number of positive Rome criteria and the severity of FC. Using only the Rome IV criteria, the pediatrician has to evaluate the severity of FC based on the clinical context. Since this is a subjective evaluation, erroneous interpretations may be common, contributing towards delaying the diagnosis of FC, which may reflect on the child’s response to treatment or could even compromise the treatment of other associated dysfunctions such as LUTD.  

Most of the children and adolescents with LUTD participating in the present study had constipation scores indicative of mild to moderate constipation. Even the non-constipated children had some of the signs/symptoms included in the modified constipation scoring system, being consequently diagnosed with mild FC. In this respect, the use of a constipation score modified for use in children and adolescents, particularly in patients with another associated functional disorder such as LUTD, may be valuable, since it would allow a broader investigation of the bowel disorder to be conducted. By classifying FC as mild, moderate or severe, this score may serve as a guide for clinicians, particularly those working in primary healthcare, in their initial approach to diagnosing and treating FC. This diagnostic instrument may be particularly useful in cases involving urinary disorders, since it will allow investigation of the bowel disorder to be broadened. Signs and symptoms not dealt with in the Rome IV criteria may be present and, as widely agreed in these cases, the treatment of LUTD cannot be disassociated from treatment of the underlying FC [7]. Furthermore, the use of the constipation score in children can avoid tests such as a digital rectal examination having to be performedor having to expose the child to ionizing radiation such as in abdominal radiographies, particularly in children with only one positive Rome criteria. In spite of the important role of the digital exam, in our country it has the stigma of being invasive. In addition, rectal examination could be traumatic, particularly in very young children or suspicion of sexual abuse cases. Some authors have been advocating use of ultrasound to access rectal diameter even though true value of this measure in the diagnosis of FC remains unclear [14,15].

As a limitation of the present study, there is the fact that the study population consisted of children and adolescents receiving care at a specialist center; therefore, this is a particular population with more severe medical problems, and this may have had an effect on the correlation between the scores. Another limitation is that this score has yet to be validated in children, a procedure that will be the subject of a future study. Indeed, despite the favorable preliminary findings with the scoring system modified by our research group, it is crucial that a broader study be conducted that may confirm the external validity of this adaptation, since its application in the general population could have different results. Nevertheless, this study provides new data on urinary dysfunction and its association with FC, particularly on the association between the severity of LUTS and FC. These findings also serve as a warning on the need for a more thorough investigation of occult bowel symptoms, which, if not identified, could have a negative effect on the treatment of urinary dysfunction. Furthermore, the constipation score could be important for research purpose making articles comparable and studies reproducible, having a prognostic importance, since higher scores can be associated with worse outcome.

Conclusion

Urinary symptoms in children and adolescents with LUTS increase in severity as a function of the severity of FC. Furthermore, in constipated patients, a correlation was found between the modified constipation scoring system and the Rome IV criteria. In the children and adolescents who were not constipated, the constipation scoring system was able to identify signs and symptoms of bowel dysfunction that were not picked up by the Rome IV criteria. Finally, constipation score modified for use in children and adolescents could be important for research purpose and particularly having a prognostic importance.

Acknowledgements:

Funding: None

Conflicts of interest: None.

References

Table 1. Characteristics of the sample according to whether lower urinary tract dysfunction was present

  Without LUTD With LUTD p-value
  n = 21 n = 107  
Sex, n (%)           Female              Male   6  (28.6) 15 (74.2)   65  (60.7) 42  (39.2) 0.007*
Age (median; interquartile range) 6 (4-11) 8  (6-11) 0.052 **
Constipated (Rome IV criteria), n (%) 5 (25) 75 (70.1) <0.001 *
Constipation scoring system adapted for use in children (median; interquartile range) 3 (1-6) 9 (4-13) <0.001 ***

*Chi-square test; ** Mann Whitney test.

LUTD: lower urinary tract dysfunction; n: number; DVSS: Dysfunctional Voiding Scoring System.

Table 2. Constipation scoring system adapted for children and the Dysfunctional Voiding Scoring System as a function of Rome IV criteria positivity

Scores Median (interquartile range) Rome IV negative n=48 Rome IV positive n=80 p-value *
Constipation scoring system 2.5 (0-4) 10 (8-14) <0.001
DVSS 8.0 (5-11) 12.5(10-16) <0.001

* Mann Whitney test; n: number; DVSS: Dysfunctional Voiding Scoring System.

Table 3. The intensity of functional constipation measured using the constipation scoring system as a function of the Dysfunctional Voiding Scoring System and the Rome IV criteria

  No FC n= 17 Mild FC n= 71 Moderate FC n= 39 Severe FC n= 1   p-value
DVSS, median (interquartile range) 8 (6-11) 10 (7-15) 13 (10-18) 16 (16-16) 0.001*
Rome IV criteria negative,  n (%) 16 (33.3) 30 (62.5) 2 (4.2) 0 (0.0)   <0.001**
Rome IV criteria positive, n (%) 1 (1.3) 41 (51.3) 37 (46.3) 1 (1.3)  

*Kruskall Wallis test; ** Chi-square test.  DVSS: Dysfunctional Voiding Scoring System.

                                      Constipation scoring system

Figure 2.

Figure Legends:

Figure 1: Box showing theconstipation scoring system adapted for children

Figure 2: Correlation between the constipation scoring system adapted for children and the Dysfunctional Voiding Scoring System (DVSS)

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