
==== Front
Investig Clin Urol
Investig Clin Urol
ICU
Investigative and Clinical Urology
2466-0493
2466-054X
The Korean Urological Association

39249923
10.4111/icu.20240137
Original Article
Pediatric Urology
Comparative analysis of health-related quality of life between children with bladder and bowel dysfunction versus lower urinary tract dysfunction and healthy controls
https://orcid.org/0000-0003-0230-8933
Ikeda Hirokazu
https://orcid.org/0000-0001-7979-2044
Ono Takahiro
https://orcid.org/0009-0004-9770-9696
Oyake Chisato
https://orcid.org/0009-0004-2148-4793
Oonuki Yuta
https://orcid.org/0000-0003-3852-5219
Watanabe Yoshitaka
https://orcid.org/0009-0001-5389-4015
Watanabe Tsuneki
Department of Pediatrics, Showa University Yokohama Northern Hospital, Yokohama, Japan.
Corresponding Author: Hirokazu Ikeda. Department of Pediatrics, Showa University Yokohama Northern Hospital, 35-1 Chigasakichuo, Tsuzuki Ward, Yokohama 224-0032, Japan. TEL: +81-45-971-1151, FAX: +81-45-972-7601, ihirokazu@med.showa-u.ac.jp
9 2024
16 8 2024
65 5 494500
23 4 2024
05 6 2024
04 7 2024
© The Korean Urological Association
2024
The Korean Urological Association
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Purpose

This study aimed to compare health-related quality of life (HRQoL) between children with bladder and bowel dysfunction (BBD) and lower urinary tract dysfunction (LUTD) alone and healthy controls based on self-report forms and parent-proxy report forms.

Materials and Methods

In this retrospective study, clinical records were reviewed. Children with LUTD, with or without bowel dysfunction, and healthy children were included in this study. The dysfunctional voiding scoring system and Rome IV Diagnostic Criteria were used to assess lower urinary tract symptoms. The Rome IV Diagnostic Criteria was also used to evaluate bowel symptoms. The Pediatric Quality of Life Inventory 4.0 (PedsQL) questionnaire was administered to investigate pediatric HRQoL.

Results

Of the total 252 children (mean age, 7.3±2.1 years) who participated in this study, 78 were classified into the BBD group and 174 into the LUTD group. Compared with the control group, the BBD group had significantly lower total PedsQL scores (p<0.001) and psychosocial healthy summary scores (p<0.001). The BBD group had significantly lower emotional functioning scores than the LUTD group (p=0.023). Children with BBD who presented with fecal incontinence (FI) had a significantly lower social functioning score than those without FI (p=0.023).

Conclusions

Children with BBD who present with FI are at higher risk of decreased psychosocial HRQoL, and they require special emotional support. These findings underscore the need for effective treatment and follow-up to improve the HRQoL of children with BBD who presented with FI.

Graphical Abstract

Behavioral problems
Fecal incontinence
Quality of life
Urinary bladder diseases
Urinary incontinence
==== Body
pmcINTRODUCTION

According to the International Children’s Continence Society, bladder and bowel dysfunction (BBD) is a clinical syndrome characterized by coexistent functional constipation and lower urinary tract dysfunction (LUTD) without anatomic or functional abnormalities [1]. LUTD can present as incontinence, abnormal urinary frequency, urgency, hesitancy, straining, weak stream, intermittency, and dysuria. Bowel dysfunction is commonly characterized by primary constipation or encopresis [12]. Globally, BBD is common among children and causes psychosocial and behavioral problems [345]. BBD is associated with a low health-related quality of life (HRQoL) [6]. The psychological effect of BBD symptoms can further influence the self-esteem and self-image of patients and their families [6]. Thus, to develop diagnostic and treatment strategies, disease- and condition-specific HRQoL must be investigated [789]. Several HRQoL studies have been conducted in children with LUTD [81011]. However, only few studies have focused on HRQoL in children with BBD. Thus, more studies on BBD with complex symptoms should be conducted [789]. This study aimed to compare the HRQoL of children with BBD and LUTD with that of healthy children.

MATERIALS AND METHODS

1. Design and study population

This retrospective observational study was conducted at Showa University Yokohama Northern Hospital from April 2018 to March 2022. The study was approved by the Institutional Review Board of Showa University (approval number: 2023-012-A) and Tokyo Seitoku University (approval number: 15-4). The participants provided informed consent. This study enrolled patients exhibiting lower urinary tract symptoms, with or without accompanying bowel dysfunction, including those reporting daytime urinary incontinence (DUI) at least twice weekly. Patients aged 5–14 years with functional DUI and/or enuresis, with or without bowel dysfunction, including constipation and/or fecal incontinence (FI), in accordance with the Rome IV Diagnostic Criteria were included [12]. The participants were either self-referred or referred by general practitioners (indicative of a self-initiated visit; primary healthcare) or physicians from district or university hospitals (tertiary healthcare). Patients with neurogenic bladder diagnoses, developmental disorders, developmental delays (intelligence quotient <70), and congenital anomalies of the urogenital tract were excluded.

The parents completed the dysfunctional voiding symptom scoring (DVSS) questionnaire [13] and keep a 48-hour bladder and bowel diary for their children. Both children and their parents completed the Pediatric Quality of Life Inventory 4.0 (PedsQL) questionnaire. All participants completed the voiding diary and DVSS and PedsQL questionnaires, with consent from both guardians and children. If a questionnaire was incomplete or had missing responses, a physician or nurse intervened to complete the questionnaire, thereby preventing any missing data.

The control group included 999 children who had normal development, voluntary control of lower urinary function, and were within the same age range. The participants were recruited from an urban and a rural elementary school. To recruit healthy controls, the PedsQL questionnaire was disseminated schoolwide. The distribution targeted 1,120 children and their guardians, and responses from 999 children and 467 consenting guardians were used.

2. Assessment

1) DVSS

The DVSS [13] comprises a 10-item scale that qualitatively and quantitatively assesses the presence and severity of voiding dysfunction lasting for at least a month in pediatric patients. It Japanese version was administered to the participants.

2) PedsQL Generic Core Scale

The PedsQL Generic Core Scale [14], Japanese version [15], was administered to the patients, their caregivers, and healthy controls. Children independently completed the self-report forms. The attending physician provided assistance to any child who had difficulty comprehending the questions. Using the DVSS and Rome IV Diagnostic Criteria, children with LUTD were classified under the LUTD group and those with DUI combined with defecation disorders under the BBD group.

3. Data analysis

Data were statistically analyzed using JMP Pro 13 (SAS Institute Japan). The unpaired t-test was used to compare differences in the physical health summary, psychosocial health summary, and overall PedsQL scores between the BBD and LUTD groups and the healthy control group. The magnitude of differences was determined as the effect size (mean BBD or LUTD group/mean healthy controls) with 95% confidence intervals. The effect sizes were classified as small (0.20–0.49), medium (0.50–0.79), and large (0.80) [16]. Data are presented as means and standard deviations. All p-values of <0.05 were considered significant.

RESULTS

In total, the study included 252 children aged 5–14 years (mean age, 7.3±2.1 years) who presented with LUTD, with or without bowel dysfunction (165 boys and 87 girls). Among them, 78 patients (31.0%) were classified into the BBD group based on the DVSS and Rome IV Diagnostic Criteria. The BBD group included 46 boys and 32 girls, with a mean age of 7.4±2.1 years. The LUTD group included 119 boys and 55 girls, with a mean age of 7.3±2.0 years. No significant difference in age, sex, or proportion of patients with LUTDs was found between the two groups (Table 1).

1. Comparison of the child self-reported PedsQL scores between the BBD and LUTD groups and the healthy control group

The BBD group had significantly lower mean overall PedsQL scores (77.3±15.3 vs. 83.6±12.6; p<0.001; effect size, 0.42), mean psychosocial summary scores (75.1±16.6 vs. 83.4±13.2; p<0.001; effect size, 0.41), emotional functioning scores (68.5±20.7 vs. 76.2±18.7; p<0.001; effect size, 0.41), and social functioning scores (77.1±20.1 vs. 88.2±15.9; p<0.001; effect size, 0.68) than the healthy control group (Table 2). However, no significant differences were found in the physical health summary and school functioning scores. The mean PedsQL overall score did not significantly differ between the BBD and LUTD groups. However, the BBD group had a significantly lower emotional functioning score than the LUTD group (68.5±20.7 vs. 74.4±21.7; p=0.023; effect size, 0.28). Thus, children with LUTD combined with bowel dysfunction have a significantly impaired psychosocial quality of life (QoL) related to emotional functioning.

2. Comparison of the parent-proxy-reported PedsQL scores between the BBD and LUTD groups and the control group

The BBD group had significantly lower parent-proxy-reported overall PedsQL scores than the healthy group (80.6±14.7 vs. 85.5±13.4; p=0.005; effect size, 0.36). The BBD group had a lower psychosocial health summary score (78.6±16.7 vs. 85.2±13.2; p=0.002; effect size, 0.48), emotional functioning score (75.7±19.9 vs. 84.5±14.9; p<0.001; effect size, 0.57), and social functioning score (78.3±22.8 vs. 86.5±17.4; p=0.005; effect size, 0.45) than the healthy control group (Table 3). However, no significant differences in the overall PedsQL scores or scores of various domains were found between the BBD and LUTD groups. Parents of children with BBD are aware of the decline in psychosocial QoL, particularly in terms of emotional well-being and social engagement. However, they may not completely recognize school life challenges or the full extent of emotional impairment in children with LUTD accompanied by bowel dysfunction.

3. Comparison of the child self-reported PedsQL scores based on age, sex, presence of nocturnal enuresis, and FI in the BBD group

The overall PedsQL and subdomain scores were analyzed in relation to the characteristics of patients in the BBD group, which included age (≤9 or >9 years), sex, presence of nocturnal enuresis (NE), and FI (Table 4). No significant differences in the mean overall PedsQL or subdomain scores in terms of age, sex, and presence of NE were found between the two groups. However, children with FI had significantly lower average scores in the social functioning domain of the PedsQL (68.2±24.0 vs. 80.8±17.8; p=0.023).

DISCUSSION

Children with BBD may experience emotional and psychological distress [16], including anxiety and depression [17]. Moreover, younger children may experience difficulties in providing valid self-report and completing the questionnaires. Because PedsQL has several advantages, the HRQoL of children with BBD was investigated using the PedsQL 4.0 Generic Core Scale scores, self-reports, and parent-proxy reports [14].

Varni et al. [18] used the PedsQL to assess HRQoL in 10 physician-diagnosed disease clusters, including cancer, diabetes, and asthma. Their patients with these diseases, except those with diabetes cluster, had significantly lower physical summary scores than healthy children. Thus, patients with BBD were more likely to present with bowel disorders, such as chronic constipation and FI, than those with LUTD and healthy controls. However, no significant decrease in physical function scores was found in the BBD group.

Compared with the control group, the BBD group had significantly lower psychosocial summary scores and emotional and social functioning scores. Behavioral difficulties, such as low self-esteem, social isolation, and social interaction difficulties may occur in children with BBD [16,17]. In a Dutch study of >1,500 children with BBD symptoms [19], 12 (25%) of 47 had strength-and-difficulty questionnaire scores within the high clinical range on one or more difficulty scales. In that study, the BBD group was more likely to experience emotional and social difficulties than the normal group.

Equit et al. [20] reported that patients with LUTD and FI had significantly lower HRQoL scores than those with LUTD alone. Results showed that the pediatric urinary incontinence QoL score of children with FI was significantly lower than that of children without FI. According to Bower [21], the HRQoL of children with NE and all DUI and FI symptoms was more impaired than that of children with these symptoms individually. Furthermore, children with frequent FI had a significantly lower HRQoL than those with infrequent FI [22]. The HRQoL of children with FI was lower than that of children with constipation alone [23]. Based on these results, an association was found between the frequency and severity of FI and a lower HRQoL. Moreover, FI is the primary cause of low HRQoL. In another study, children with FI have higher rates of internalization issues, such as anxiety and depressive symptoms [22]. In the comparison of the healthy psychosocial domain of patients with BBD with and without FI, the social functioning scores of children with BBD with FI were significantly lower than those without FI.

Based on the study findings, the pathophysiology of BBD and possibility of decreased emotional quality and HRQoL should be explained to parents during their first visit. Based on parent-proxy reports, the BBD group had significantly lower total PedsQL, psychosocial summary, and emotional and social functioning scores than the healthy control group. However, the decline in school functioning scores observed in child self-report forms was not reflected in the parent-proxy report forms. This discrepancy indicates that parents may overlook the reduction in QoL experienced by children with BBD during their school life. Consequently, the potential decline in the quality of school life among children with BBD should be proactively explained, and appropriate parental support should be provided to ensure a comfortable school experience for these children.

This study had several limitations. First, the quasi-experimental design precluded a random assignment component. Second, the lack of previous reports on PedsQL scores in children with BBD prevented us from identifying clinically significant differences and standard deviations. Therefore, the sample size was not calculated before study initiation. Third, the diagnoses of BBD and LUTD were determined using symptom questionnaires, such as the DVSS, rather than physician confirmation using data from bladder and bowel diaries. Finally, specific pediatric characteristics that influence these outcomes were not examined. Thus, the unique psychological stressors experienced by children with BBD must be elucidated. Therefore, these children should be interviewed to learn more about their friendships and school experiences.

CONCLUSIONS

Children with BBD present with a significant decrease in psychosocial QoL. Children with BBD who experience FI are at higher risk of decreased psychosocial QoL and require emotional support. These findings underscore the need for effective treatment and follow-up to improve the HRQoL of children with BBD who experience FI.

ACKNOWLEDGMENTS

We want to thank the staff of Edanz Group (www.edanzediting.com/ac) for critically reviewing the draft of the manuscript.

Table 1 Demographic characteristics of the patient population

Characteristic	Patients with BBD	Patients with LUTD	CTRL	
Number of patients	78	174	999	
Age (y)				
	Mean±SD	7.4±2.1	7.3±2.0	9.6±1.5	
	Range	5–13	5–13	6–13	
Sex				
	Female	32	55	474	
	Male	46	119	525	
Type of LUTS				
	DUI only	21 (26.9)	45 (25.9)	-	
	Combined DUI+NE	57 (73.1)	129 (74.1)	-	
Presence or absence of FI				
	FI (+)	26 (33.3)	7 (4.0)	-	
	FI (-)	52 (66.7)	167 (96.0)	-	
DVSS	10.8±3.1	8.0±2.8	-	
Values are presented as number only, mean±standard deviation, range, or number (%).

Only p-values of <0.05 are shown.

BBD, bladder and bowel dysfunction; LUTD, lower urinary tract dysfunction; CTRL, control; SD, standard deviation; LUTS, lower urinary tract syndrome; DUI, daytime urinary incontinence; NE, nocturnal enuresis; FI, fecal incontinence; DVSS, dysfunctional voiding symptom scoring.

Table 2 Comparison of the child self-reported PedsQL scores between the BBD and LUTD groups and the healthy control group

Measure	Control group (n=999)	BBD group (n=78)	p-value (BBD vs. control)	Effect size (BBD vs. control)	LUTD group (n=174)	p-value (LUTD vs. control)	Effect size (LUTD vs. control)	p-value (BBD vs. LUTD)	Effect size (BBD vs. LUTD)	
Total score	83.6±12.6	77.3±15.3	<0.001	0.42	80.1±14.0	0.014	0.27	0.097	0.19	
Physical health summary	85.2±14.8	84.2±16.2	0.773	0.06	87.0±14.0	0.071	0.12	0.201	0.18	
Psychosocial health summary	83.4±13.2	75.1±16.6	<0.001	0.41	78.7±15.7	0.001	0.35	0.112	0.23	
Emotional functioning	76.2±18.7	68.5±20.7	<0.001	0.41	74.4±21.7	0.060	0.09	0.023	0.28	
Social functioning	88.2±15.9	77.1±20.1	<0.001	0.68	80.1±15.9	<0.001	0.51	0.206	0.17	
School functioning	84.7±13.7	79.7±18.2	0.041	0.36	81.7±16.5	0.073	0.21	0.486	0.12	
Values are presented as mean±standard deviation.

PedsQL, Pediatric Quality of Life Inventory 4.0; BBD, bladder and bowel dysfunction; LUTD, lower urinary tract dysfunction.

Table 3 Comparison of the parent-proxy-reported PedsQL scores between the BBD and LUTD groups and the control group

Measure	Control group (n=467)	BBD group (n=78)	p-value (BBD vs. control)	Effect size (BBD vs. control)	LUTD group (n=174)	p-value (LUTD vs. control)	Effect size (LUTD vs. control)	p-value (BBD vs. LUTD)	Effect size (BBD vs. LUTD)	
Total score	85.5±13.4	80.6±14.7	0.005	0.36	81.7±14.1	0.507	0.08	0.689	0.08	
Physical health summary	86.2±19.9	86.3±16.0	0.314	0.01	85.5±20.5	0.788	0.04	0.847	0.04	
Psychosocial health summary	85.2±13.2	78.6±16.7	0.002	0.48	80.8±14.6	0.417	0.14	0.425	0.11	
Emotional functioning	84.5±14.9	75.7±19.9	<0.001	0.57	79.0±18.6	0.211	0.17	0.318	0.17	
Social functioning	86.5±17.4	78.3±22.8	0.005	0.45	80.4±20.7	0.588	0.10	0.696	0.10	
School functioning	84.6±14.2	81.9±16.9	0.320	0.19	82.9±14.9	0.733	0.06	0.899	0.06	
Values are presented as mean±standard deviation.

PedsQL, Pediatric Quality of Life Inventory 4.0; BBD, bladder and bowel dysfunction; LUTD, lower urinary tract dysfunction.

Table 4 Comparison of the child self-reported PedsQL scores based on age, sex, presence of nocturnal enuresis, and FI in the BBD group

Measure	Young children (n=63)	Older children (n=15)	p-value (young vs. older)	Female participants (n=32)	Male participants (n=46)	p-value (female vs. male)	Enuresis: yes (n=57)	Enuresis: no (n=21)	p-value (enuresis: yes vs. no)	FI: yes (n=26)	FI: no (n=52)	p-value (FI: yes vs. no)	
Total score	76.2±15.9	81.9±11.8	0.236	77.9±14.9	76.8±15.7	0.823	77.2±16.6	77.4±11.2	0.588	72.5±18.2	79.6±13.2	0.125	
Physical health summary	83.6±16.1	86.7±16.7	0.246	82.1±18.0	85.6±14.9	0.376	85.0±16.6	81.9±15.2	0.324	81.1±19.7	85.7±14.0	0.541	
Psychosocial health summary	73.6±17.3	81.0±11.9	0.162	76.5±15.5	74.1±17.6	0.662	74.8±18.4	75.9±10.9	0.659	69.7±19.6	77.8±14.7	0.085	
Emotional functioning	66.6±20.9	76.3±18.8	0.097	70.0±17.7	67.4±22.7	0.750	68.9±21.6	67.1±18.4	0.604	62.7±21.1	70.6±19.8	0.153	
Social functioning	76.3±21.6	80.6±17.6	0.594	77.5±23.9	76.8±19.5	0.636	75.6±22.4	81.2±15.5	0.519	68.2±24.0	80.8±17.8	0.023	
School functioning	78.2±18.9	86.0±13.1	0.181	81.9±16.0	78.1±19.8	0.623	79.8±18.9	79.3±16.1	0.532	73.1±20.6	82.0±16.4	0.092	
Values are presented as mean±standard deviation.

Young children: aged 5–9 years, Older children: aged 10–14 years.

PedsQL, Pediatric Quality of Life Inventory 4.0; FI, fecal incontinence; BBD, bladder and bowel dysfunction.

CONFLICTS OF INTEREST: The authors have nothing to disclose.

FUNDING: None.

AUTHORS’ CONTRIBUTIONS: Research conception and design: Hirokazu Ikeda.

Data acquisition: Takahiro Ono, Chisato Oyake, Yuta Oonuki, and Tsuneki Watanabe.

Statistical analysis: Yoshitaka Watanabe and Tsuneki Watanabe.

Data analysis and interpretation: Hirokazu Ikeda and Yoshitaka Watanabe.

Drafting of the manuscript: Hirokazu Ikeda.

Critical revision of the manuscript: Hirokazu Ikeda, Yoshitaka Watanabe, and Tsuneki Watanabe.

Administrative, technical, or material support: Chisato Oyake and Takahiro Ono.

Supervision: Tsuneki Watanabe.

Approval of the final manuscript: Hirokazu Ikeda, Takahiro Ono, Chisato Oyake, Yuta Oonuki, Yoshitaka Watanabe, and Tsuneki Watanabe.
==== Refs
1 Austin PF Bauer SB Bower W Chase J Franco I Hoebeke P The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children’s Continence Society Neurourol Urodyn 2016 35 471 481 25772695
2 Santos JD Lopes RI Koyle MA Bladder and bowel dysfunction in children: an update on the diagnosis and treatment of a common, but underdiagnosed pediatric problem Can Urol Assoc J 2017 11 1-2Suppl1 S64 S72 28265323
3 Sampaio C Sousa AS Fraga LG Veiga ML Bastos Netto JM Barroso U Jr Constipation and lower urinary tract dysfunction in children and adolescents: a population-based study Front Pediatr 2016 4 101 27752507
4 Shaikh N Hoberman A Keren R Gotman N Docimo SG Mathews R Recurrent urinary tract infections in children with bladder and bowel dysfunction Pediatrics 2016 137 e20152982 26647376
5 Özen MA Mutluer T Necef I Shabsog M Taşdemir M Bilge I The overlooked association between lower urinary tract dysfunction and psychiatric disorders: a short screening test for clinical practice J Pediatr Urol 2019 15 332.e1 332.e5
6 Bachmann C Lehr D Janhsen E Sambach H Muehlan H von Gontard A Health related quality of life of a tertiary referral center population with urinary incontinence using the DCGM-10 questionnaire J Urol 2009 182 4 Suppl 2000 2006 19695580
7 Kovacic K Sood MR Mugie S Di Lorenzo C Nurko S Heinz N A multicenter study on childhood constipation and fecal incontinence: effects on quality of life J Pediatr 2015 166 1482 1487.e1 26008173
8 Gladh G Eldh M Mattsson S Quality of life in neurologically healthy children with urinary incontinence Acta Paediatr 2006 95 1648 1652 17129976
9 Schast AP Zderic SA Richter M Berry A Carr MC Quantifying demographic, urological and behavioral characteristics of children with lower urinary tract symptoms J Pediatr Urol 2008 4 127 133 18631908
10 Bachmann C Lehr D Janhsen E Steuber C Gäbel E von Gontard A German version of the Pediatric Incontinence Questionnaire for urinary incontinence health related quality of life J Urol 2009 182 4 Suppl 1993 1998 19695623
11 Ikeda H Oyake C Oonuki Y Fuyama M Watanabe T Kyoda T Complete resolution of urinary incontinence with treatment improved the health-related quality of life of children with functional daytime urinary incontinence: a prospective study Health Qual Life Outcomes 2020 18 14 31964382
12 Drossman DA Hasler WL Rome IV---functional GI disorders: disorders of gut-brain interaction Gastroenterology 2016 150 1257 1261 27147121
13 Akbal C Genc Y Burgu B Ozden E Tekgul S Dysfunctional voiding and incontinence scoring system: quantitative evaluation of incontinence symptoms in pediatric population J Urol 2005 173 969 973 15711352
14 Varni JW Seid M Rode CA The PedsQL: measurement model for the pediatric quality of life inventory Med Care 1999 37 126 139 10024117
15 Kobayashi K Kamibeppu K Measuring quality of life in Japanese children: development of the Japanese version of PedsQL Pediatr Int 2010 52 80 88 19496977
16 von Gontard A Niemczyk J Weber M Equit M Specific behavioral comorbidity in a large sample of children with functional incontinence: report of 1,001 cases Neurourol Urodyn 2015 34 763 768 25111368
17 von Gontard A Baeyens D Van Hoecke E Warzak WJ Bachmann C Psychological and psychiatric issues in urinary and fecal incontinence J Urol 2011 185 1432 1436 21349549
18 Varni JW Limbers CA Burwinkle TM Impaired health-related quality of life in children and adolescents with chronic conditions: a comparative analysis of 10 disease clusters and 33 disease categories/severities utilizing the PedsQL 4.0 Generic Core Scales Health Qual Life Outcomes 2007 5 43 17634123
19 Wang R Van den Heuvel M Rickard M El-Bardisi Y Mistry N Koyle M Neurodevelopmental and psychiatric disorders in pediatric bladder and bowel dysfunction J Pediatr Urol 2021 17 450.e1 450.e6
20 Equit M Hill J Hübner A von Gontard A Health-related quality of life and treatment effects on children with functional incontinence, and their parents J Pediatr Urol 2014 10 922 928 24726201
21 Bower WF Self-reported effect of childhood incontinence on quality of life J Wound Ostomy Continence Nurs 2008 35 617 621 19018203
22 Bongers ME van Dijk M Benninga MA Grootenhuis MA Health related quality of life in children with constipation-associated fecal incontinence J Pediatr 2009 154 749 753 19150085
23 Rajindrajith S Devanarayana NM Weerasooriya L Hathagoda W Benninga MA Quality of life and somatic symptoms in children with constipation: a school-based study J Pediatr 2013 163 1069 1072.e1 23800401
