Management of Pediatric Bowel and Bladder Dysfunction in Primary Care

DENVER – Although pediatric patients with bowel and bladder dysfunction (BBD) are often referred to a pediatric urologist by their primary care provider (PCP), few are found to actually require specialty intervention, according to research presented at the American Academy of Physician Assistants 2019 annual meeting held May 18 to 22, 2019 in Denver, CO.

A team of researchers from Le Moyne College and Upstate Medical University in Syracuse, New York, conduced a retrospective study to characterize BBD referals to pediatric urology and to assess how many of these referrals could have been managed in a primary care setting.

The investigators reviewed new referrals to a tertiary care pediatric urology practice for patients aged 4 to 12 years. Primary outcomes included correct BBD diagnosis at time of referral, the initiation of bowel treatments before referral, and any required specialty interventions.

A total of 190 pediatric patients with diagnosed BBD were included in the analysis. The majority of referrals to urology practices were made by physicians; nurse practitioners and physician assistants also referred patients. Referrals were from pediatric practices (65%), family practices (32%), specialist offices (1.5), and hospitals (1.5%).

BBD was not diagnosed at referral for any of the patients included in the study; 64% of patients were referred to a urologist for symptoms of voiding dysfunction, 9.5% were referred for symptoms of nonvoiding dysfunction, and 26% were referred for dysuria.

Specialty intervention was found to be required for only 7% of referred patients. Constipation treatment was found to be initiated prior to referral in only 23% of patients; however, thoroughness of pre-referral work-up was the predictive factor for constipation treatment rather than recognition of lower urinary tract symptoms and constipation as features diagnostic of BBD. The investigators advise that constipation should be addresed in primary care, wtih documentation of the essential criteria of BBD (urinary inquiry, bowel inquiry, abdominal/genitourinary examination, and urinalysis and/or culture) prior to specialist referral.

“Characterization of referrals revealed a weakness at the primary care level that validates increased education with respect to the diagnosis and treatment of BBD,” the authors concluded. “When evaluating urinary symptoms, PCPs should consider a validated constipation screening instrument such as the Rome classification or Vancouver questionnaire.”

Reference

Fortin MP, Buczek JF, Becht LJ, et al. Bowel bladder dysfunction diagnosis and treatment: should primary care providers be doing more? Presentation at: The American Academy of Physician Assistants Annual Meeting; May 18-22, 2019; Denver, CO. Poster 270.