Weekly conferences among pediatric urologists at Monroe Carell Jr. Children’s Hospital at Vanderbilt often centered around a common theme. Though anecdotal, a subset of young patients seemed to share a common comorbidity: allergies.
“We felt that, in general, the children that came in for voiding dysfunction were more likely to have other associated allergies,” said Abby Taylor, M.D., M.P.H., director of medical student education for the Department of Urology at Vanderbilt University Medical Center.
Multiple pediatricians agreed it was worthy of further investigation. But studying the association would not be easy.
Lower urinary tract symptoms are heterogeneous and often subjective. Childhood allergies range from seasonal sniffles to deadly anaphylaxis. As for crosstalk between pediatric urologists and pediatric allergists?
“I wouldn’t say there’s none. I just think that it’s so unrelated that allergists don’t ask or talk about any voiding symptoms.”
A Careful Approach
Taylor and colleagues sought to design a study that could cut through that noise. First, they looked into historical accounts connecting allergies and urinary symptoms, which Taylor found dated back to the 1920s. They were encouraged to learn the association had earned some attention. Still, they found a dearth of contemporary pediatric data.
The team had to narrow their study population. They decided to enroll pediatric patients with lower-urinary-tract symptoms then narrowed down the definition of allergy.
“Seasonal allergies are non-descript, where a family may say they have them or a child may take an over-the-counter allergy pill every now and then,” Taylor said. “We needed to make this as scientific as possible. For that reason, we focused on food allergies, as they are a laboratory-diagnosed condition.”
Enrollment and Results
The researchers got Institutional Review Board approval for a case-controlled study and sent a pediatric urologist to the allergy clinic at Monroe Carell to enroll participants. Over a two-year period, 26 children with food allergies enrolled in the study. Another 57 children without food allergies enrolled as a comparator group.
Food allergies were confirmed among participants via positive skin pricks or serum IgE testing. All families filled out validated questionnaires to quantify lower urinary tract symptoms and to grade each child’s level of bladder dysfunction, if any.
“Our goal was to see if the kids with food allergies scored higher on the questionnaires than kids without known food allergies,” Taylor explained.
Four children with food allergies and 15 without had survey scores indicating dysfunctional elimination. With these small numbers, the researchers weren’t able to prove a statistically significant association, though Taylor says this does not change their line of thinking.
“The Gestalt is that we still have more kids that have listed allergies come in with voiding dysfunction, especially children with irritative voiding symptoms, such as burning and pain with urination,” she said.
“You’d have to do this study on a really, really big scale to prove an association. It would have to be multi-institutional. Food allergies are just not prevalent enough to do it any other way.”
Benefits to Patients
If the association became clear, patients could benefit from counseling before they arrive in the pediatric urology clinic.
“It might actually help from an allergy perspective; when the allergist sees patients, they could preemptively provide education about something the child is at higher risk for,” Taylor said.
“We could prevent some of the frustration of voiding symptoms by giving them educational tools that we typically provide only once a child is symptomatic. I see it as a kind of pre-urology counseling.”
Maintaining Bladder Health
A standard urotherapy is used to support children with voiding dysfunction.
“Timed voiding, where they are on a schedule, prevents them from holding their urine too long,” she said.
Another tactic is double voiding, where after the patient urinates, they take a minute or two to wash their hands and then sit back down to try again.
“Kids are in a hurry, so they don’t empty their bladder completely on the first void,” Taylor said.
For young girls, she recommends spread-leg voiding to help get every drop out.
“When they stand up, persistent drops of urine in the underwear can be quite irritating. For little girls, we can have them just sit backwards on the toilet to ensure that their legs are spread really far apart. We want to try to avoid any of it getting into the vagina.”
She also notes that voiding dysfunction can be intimately tied to constipation, so managing the latter can often help.
Support for Other Symptoms
On another front, Taylor and her team at Monroe Carell are also involved in several clinical trials that employ technology to manage nocturnal enuresis, or bedwetting. The team sees hundreds of new patients each year, many of whom might benefit. “There are nocturnal alarm systems, that either wake you up upon voiding to help retrain your system, or can even make the sphincter close. We’re involved in international trials to try to get FDA approval for some of these cutting-edge devices.”
