Scientific Letter
Vaginal reflux: A forgotten cause of diurnal incontinence in prepubertal girls
Reflujo vaginal: una causa olvidada de incontinencia diurna en niñas prepúberes
M. Fernandez Ibieta
, G. Zambudio Carmona, I. Martinez Castaño, M.J. Guirao Piñera, J.I. Ruiz Jimenez
Corresponding author
Sección de Urología Pediátrica, Servicio de Cirugía Pediátrica, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
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Fernandez Ibieta, G. Zambudio Carmona, I. Martinez Castaño, M.J. Guirao Piñera, J.I. Ruiz Jimenez" "autores" => array:5 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Fernandez Ibieta" "email" => array:1 [ 0 => "mfndezibieta@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Zambudio Carmona" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Martinez Castaño" ] 3 => array:2 [ "nombre" => "M.J." "apellidos" => "Guirao Piñera" ] 4 => array:2 [ "nombre" => "J.I." "apellidos" => "Ruiz Jimenez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Sección de Urología Pediátrica, Servicio de Cirugía Pediátrica, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reflujo vaginal: una causa olvidada de incontinencia diurna en niñas prepúberes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 748 "Ancho" => 950 "Tamanyo" => 77916 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 1. Double outline in the late voiding film of the VCUG that shows a partially filled bladder with a superimposed round outline (more radiopaque) corresponding to the vagina.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Most cases of daytime incontinence in prepubertal girls have a functional aetiology, although a neurogenic dysfunction must always be ruled out. Vaginal reflux (VR) or intravaginal urination has been recognised as a cause of urinary incontinence with post void dribbling in prepubertal girls.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2</span></a> The reverse flow of urine into the vagina can sometimes be perceived in a retrograde voiding cystourethrogram (VCUG), even in a standing position. This finding, which is frequent in prepubertal girls,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> may be asymptomatic or accompanied by symptoms such as diurnal incontinence and recurrent vulvovaginitis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> Incontinence is characterised by loss of urine in the daytime (accompanied by enuresis in some cases) usually soon after urinating (post void dribbling) due to the progressive emptying of the vagina.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present 3 cases of VR that showed the usual clinical features of exclusively diurnal incontinence.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Case 1. Girl, 7 years of age, with overweight and symptoms of diurnal incontinence consisting of post void dribbling without enuresis. She reported occasional urgency and 3–4 episodes a year of afebrile urinary tract infection (UTI). We performed an ultrasound and a VCUG, with normal results. A uroflowmetry and urodynamic assessment were performed and showed no signs of pathology (coordinated urination without residual urine, no overactivity, correct voiding). Two filling cystometries were performed, the second of which (with the patient in a seated position) revealed a leakage that had not been detected in the first one. At first we considered the possibility of sphincter deficiency and we performed a magnetic resonance imaging study of the lumbosacral spine that showed no abnormalities. We reassessed the patient, reviewed the imaging tests, and found signs of VR in the VCUG (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). This finding led to the prescription of urotherapy, and the symptoms resolved in 6 months.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Case 2. Girl, 9 years of age with diurnal incontinence and lower UTIs. She had received previous treatment with oxybutynin for suspected overactive bladder and showed no response to it. Uroflowmetry with electromyography revealed uncoordinated voiding, leading to the initiation of a biofeedback programme that had poor results despite improvement in the uroflowmetry tracings. It was decided to perform VCUG, which revealed VR (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Urotherapy specific to VR was initiated. Six months after starting treatment, the patient stopped having urine leaks.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Case 3. Girl, 7 years of age with sporadic dribbling and lower UTI. She had voiding postponement and decreased voiding frequency. Urotherapy was the only treatment prescribed. The patient did not show significant improvement by the following visit, so VCUG and ultrasound examinations were ordered, which revealed VR. There was evidence of low compliance with urotherapy, so we reinforced it with close monitoring by the nursing staff, stressing the importance of good toilet posture. The girl became asymptomatic after one year of followup.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Vaginal reflux may be the cause of incontinence in 12–15% of prepubertal girls with urine leakage.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,3–6</span></a> The diagnosis may be difficult if this possibility is not taken into account, requiring a multitude of diagnostic tests. It is common for voiding films taken during VCUG not to be examined in detail, as the emphasis is often placed on ruling out anatomical anomalies of the bladder and vesicoureteral reflux, and some paediatric radiologists are not familiar enough with VR. A bladder diary along with a structured history-taking usually reveals a pattern of incontinence, typically diurnal, post void dribbling (5–10<span class="elsevierStyleHsp" style=""></span>min after urination) of a small volume,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> but large enough to require changes of clothing or some form of protection (such as sanitary pads). The genital anatomy in VR is completely normal and urine reflux from the urinary meatus to the vagina occurs when the legs are not spread during urination, the labia majora pose a barrier to the free flow of urine from the meatus, forcing the urine to flow back into the vagina.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2–6</span></a> The habit of keeping the legs closed when sitting in the toilet obstructs the free flow of urine. Another factor that contributes to this reverse flow is the more horizontal vagina of prepubertal girls. This pattern is common in girls with an overactive bladder and “crossed legs” and in obese patients, and may play a role in recurrent vulvovaginitis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Once intravaginal reflux is identified, the treatment is satisfying. It consists of a urotherapy programme based on frequent or scheduled voidings, every 3<span class="elsevierStyleHsp" style=""></span>h, adapted to family and school life, with a correct toilet position spreading the legs and leaning forward, or straddled on the toilet in the position opposite to normal (facing the wall), devoting enough time to urination (one minute or “counting to sixty”),<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1–6</span></a> with double voiding to try to empty any residual urine.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-07-12" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernandez Ibieta M, Zambudio Carmona G, Martinez Castaño I, Guirao Piñera MJ, Ruiz Jimenez JI. Reflujo vaginal: una causa olvidada de incontinencia diurna en niñas prepúberes. Ann Pediatr (Barc). 2015;83:55–56.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 748 "Ancho" => 950 "Tamanyo" => 77916 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 1. Double outline in the late voiding film of the VCUG that shows a partially filled bladder with a superimposed round outline (more radiopaque) corresponding to the vagina.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1148 "Ancho" => 850 "Tamanyo" => 78643 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Case 2. Double outline of the bladder neck in the late voiding film. The image shows the presence of contrast medium in the vagina (posterior to the urethra).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pathophysiology of daytime urinary incontinence in children incont" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I. Chiang" 1 => "S. Shei-Dei Yang" 2 => "S.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 16 | 11 | 27 |
| 2024 October | 157 | 50 | 207 |
| 2024 September | 181 | 52 | 233 |
| 2024 August | 172 | 74 | 246 |
| 2024 July | 140 | 32 | 172 |
| 2024 June | 147 | 34 | 181 |
| 2024 May | 144 | 35 | 179 |
| 2024 April | 145 | 39 | 184 |
| 2024 March | 115 | 26 | 141 |
| 2024 February | 172 | 37 | 209 |
| 2024 January | 211 | 25 | 236 |
| 2023 December | 146 | 30 | 176 |
| 2023 November | 154 | 24 | 178 |
| 2023 October | 160 | 29 | 189 |
| 2023 September | 138 | 32 | 170 |
| 2023 August | 159 | 31 | 190 |
| 2023 July | 146 | 39 | 185 |
| 2023 June | 107 | 46 | 153 |
| 2023 May | 198 | 56 | 254 |
| 2023 April | 133 | 30 | 163 |
| 2023 March | 199 | 25 | 224 |
| 2023 February | 145 | 32 | 177 |
| 2023 January | 150 | 53 | 203 |
| 2022 December | 150 | 53 | 203 |
| 2022 November | 163 | 47 | 210 |
| 2022 October | 139 | 62 | 201 |
| 2022 September | 155 | 56 | 211 |
| 2022 August | 206 | 63 | 269 |
| 2022 July | 258 | 46 | 304 |
| 2022 June | 197 | 60 | 257 |
| 2022 May | 170 | 37 | 207 |
| 2022 April | 194 | 43 | 237 |
| 2022 March | 208 | 77 | 285 |
| 2022 February | 175 | 50 | 225 |
| 2022 January | 217 | 43 | 260 |
| 2021 December | 134 | 43 | 177 |
| 2021 November | 146 | 47 | 193 |
| 2021 October | 145 | 72 | 217 |
| 2021 September | 127 | 67 | 194 |
| 2021 August | 132 | 41 | 173 |
| 2021 July | 161 | 45 | 206 |
| 2021 June | 126 | 202 | 328 |
| 2021 May | 126 | 30 | 156 |
| 2021 April | 380 | 94 | 474 |
| 2021 March | 261 | 40 | 301 |
| 2021 February | 152 | 31 | 183 |
| 2021 January | 202 | 29 | 231 |
| 2020 December | 171 | 27 | 198 |
| 2020 November | 131 | 20 | 151 |
| 2020 October | 151 | 19 | 170 |
| 2020 September | 152 | 20 | 172 |
| 2020 August | 224 | 23 | 247 |
| 2020 July | 145 | 21 | 166 |
| 2020 June | 131 | 17 | 148 |
| 2020 May | 143 | 31 | 174 |
| 2020 April | 121 | 27 | 148 |
| 2020 March | 130 | 24 | 154 |
| 2020 February | 148 | 29 | 177 |
| 2020 January | 151 | 21 | 172 |
| 2019 December | 158 | 23 | 181 |
| 2019 November | 143 | 14 | 157 |
| 2019 October | 197 | 17 | 214 |
| 2019 September | 189 | 9 | 198 |
| 2019 August | 134 | 21 | 155 |
| 2019 July | 155 | 37 | 192 |
| 2019 June | 141 | 33 | 174 |
| 2019 May | 176 | 20 | 196 |
| 2019 April | 180 | 43 | 223 |
| 2019 March | 120 | 20 | 140 |
| 2019 February | 103 | 31 | 134 |
| 2019 January | 95 | 33 | 128 |
| 2018 December | 87 | 25 | 112 |
| 2018 November | 113 | 29 | 142 |
| 2018 October | 85 | 24 | 109 |
| 2018 September | 59 | 18 | 77 |
| 2018 August | 9 | 0 | 9 |
| 2018 July | 10 | 0 | 10 |
| 2018 June | 13 | 0 | 13 |
| 2018 May | 19 | 0 | 19 |
| 2018 April | 57 | 0 | 57 |
| 2018 March | 60 | 0 | 60 |
| 2018 February | 33 | 0 | 33 |
| 2018 January | 32 | 0 | 32 |
| 2017 December | 43 | 0 | 43 |
| 2017 November | 20 | 0 | 20 |
| 2017 October | 33 | 0 | 33 |
| 2017 September | 27 | 0 | 27 |
| 2017 August | 29 | 0 | 29 |
| 2017 July | 45 | 1 | 46 |
| 2017 June | 59 | 10 | 69 |
| 2017 May | 55 | 5 | 60 |
| 2017 April | 49 | 11 | 60 |
| 2017 March | 32 | 9 | 41 |
| 2017 February | 122 | 5 | 127 |
| 2017 January | 24 | 4 | 28 |
| 2016 December | 69 | 10 | 79 |
| 2016 November | 96 | 3 | 99 |
| 2016 October | 115 | 10 | 125 |
| 2016 September | 189 | 18 | 207 |
| 2016 August | 105 | 18 | 123 |
| 2016 July | 28 | 10 | 38 |
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