Neuromodulation in Pediatrics

Voiding dysfunction, sometimes referred to as dysfunctional elimination syndrome (DES), is encountered commonly in the pediatric population. It represents a constellation of symptoms that affect urinary storage or emptying. Common symptoms include recurrent urinary tract infections, nocturnal or diurnal enuresis, urgency, urge incontinence, posturing, frequency, urinary dribbling, infrequent voiding, weak or intermittent stream, and pelvic pain. The advent of clean intermittent catheterization, evolution of urodynamic testing, and refinement in surgical techniques for urinary incontinence changed the traditional approach to managing this subset of patients. With this change came a great understanding of the pathophysiology of many disorders that can affect children primarily. A team approach with expertise in different therapeutic modalities, including pharmacologic, behavioral modification, and biofeedback, provides for the highest success rate. A common challenge, however, lies in children resistant to conventional therapy, causing significant distress to caregivers, patients, and their families. In the last few decades, in an effort to solve this problem, several nonconventional therapeutic modalities have emerged with promising results. They share a common objective of restoring bladder and bowel function to as normal as possible based on the current understanding of the various neural pathways that connect the central with the peripheral micturition reflexes to correct inefficient bladder habits, uncoordinated sphincter activity, and bladder storage problems. This article highlights neuromodulators that have been used in the pediatric population.