Bladder Dysfunction and Urine Control in Children

Constipation is one of the most common causes for bladder dysfunction in children. Constipation is when a child may have:

• Fewer than two bowel movements a week
• Stools that are hard, dry and small and may be painful or difficult to pass

This problem is very common in children, especially with picky eaters who avoid high fiber foods. Problems with bowel movements and bladder function are often linked and is known as bladder bowel dysfunction (BBD). These reasons link both problems:

• The rectum is behind the bladder. When there is a large amount of stool in the rectum, it can push on the bladder. The bladder can't hold as much urine in this case. This pressure can cause urinary frequency.
• The pelvic floor muscles control both the bladder sphincter and anal sphincter. Children who feel pain when they have a bowel movement will tend to hold in their stool. This action, in turn, holds in urine by tightening the bladder sphincter, which can cause urinary infrequency.

How is Bladder Dysfunction Diagnosed?

Complete health history: the healthcare provider will begin by asking many questions about your child's health. Expect to be asked about:

• Birth history, medical conditions, developmental milestones, age of potty-training (how smooth or difficult it was), any house or school stressors (parent's divorce/separation, moving, birth of a new sibling, etc.) 
• You will be asked questions about your child's bathroom habits such as how often they go, if and when they have wetting accidents, how often they have bowel movements, observations of holding (e.g., squatting, leg crossing, holding genitals if there are triggers for accidents (like laughter or coughing)

Physical exam: your child will be examined in the office. The healthcare provider will examine the abdomen, back and genital area. It helps to let your child know what to expect of this type of exam in advance. During the exam, the doctor will be looking for abnormal physical signs that could lead to bladder dysfunction such as:

• Girls may have labial adhesions or scarring which can cause wetting accidents soon after using the bathroom. 
• Boys may have scarring or narrowing in their urethra which can cause a slow stream or a burning sensation. 
• An anal fissure (a tear in the rectal tissue) or rectal prolapse is a sign of severe constipation. 
• A large, hard lump in the abdomen may be from stool. 

Tests: the healthcare provider may ask you to take notes of bathroom habits, collect a urine sample, or suggest imaging tests to help make a diagnosis.

• You may be asked to keep notes in a bladder/bowel diary at home. This is a way to keep track of when your child urinates and passes stool. This will help form a diagnosis and determine treatment options.
• A urine specimen may be collected during the doctor's visit. This is done to test for a urinary tract infection, sugar in the urine (for diabetes) and to see other elements of the urine.
• Your child may need a kidney/bladder ultrasound and/or abdominal x-ray. These may be used to find stool in the bowels and help manage constipation, if present.
• Your child may be asked to urinate in a toilet that has a sensor at the bottom (uroflow). This test checks the quality of the urinary stream. A bladder ultrasound may also be used to check how well the bladder is emptying.

High-Fiber Dietary Changes: Offer meals with many fruits, vegetables, and whole grains.

• Products are available to increase daily fiber intake, such as "Fiber Gummies". 
• For the short-term, your care provider may recommend a bowel cleanse.

If your child does not have constipation or does not respond to constipation treatment, other treatments will depend on your child's diagnosis.

Children who void infrequently or seem to wait until the last moment to go, may have urgency and wetting accidents. Creating a timely bathroom schedule can help.

Scheduled Voiding: with this method, you help your child follow a daily schedule of going to the bathroom which can retrain the bladder and sphincter muscles.

• Your healthcare provider may suggest a bathroom schedule for your child of every 2 to 4 hours, whether they have to go or not.
• If your child is old enough to wear a programmable watch, it can be set to vibrate or make a sound to help stay on schedule in school.

If your child has frequency of urination, or going too much, they may have daytime accidents when a bathroom isn't nearby. Children in this case may have an overactive bladder (a bladder that holds less than it should and it must be emptied very often).

Medication for Overactive Bladder: can help your child's bladder to hold more urine, for longer.

• Examples of these medications include oxybutynin and tolterodine.

Medication for Giggle Incontinence:
Examples of these medications include oxybutynin or methylphenidate (Ritalin).

Some children may have problems with the way their bladder contracts, and the way their sphincter relaxes. In this scenario certain pelvic floor exercises can help.

Pelvic Floor Exercises: different exercises help different problems.

• "Quick flicks" are useful when a child has the "gotta go" feeling too often. The exercise is done by squeezing and then relaxing the sphincter and pelvic floor muscles as quickly as possible, several times, when they feel the urge to go. This sends a message to the nervous system and back to the bladder to stop squeezing. As the bladder stops squeezing and starts relaxing, the "gotta go" feeling should lessen. 
• "Kegels" help strengthen the pelvic floor muscles. Kegels are done by squeezing and relaxing the pelvic floor muscles many times each day. Children can do this while they urinate to start and stop the flow, and gain control. Pelvic floor muscles help support the bladder and other organs. Exercising them can make them stronger and help reduce leaking. 
• Your healthcare provider can explain pelvic floor exercises and which type will help best.

Biofeedback Therapy: may be offered in your child's doctor's office. It teaches children how to control their sphincter and pelvic floor muscles.

• Biofeedback therapy uses video games that interact with electrode skin patches placed over the sphincter area. After a few sessions, your child will be able to recognize and control these muscles.

Children with leaking accidents just after using the bathroom (post-micturition dribbling) may be girls with labial adhesions and/or are overweight. In this case, the child will be asked to spread her legs when seated to release more urine. Weight loss may also help. If there are adhesions, a two-week course of estrogen cream can heal the area.

With a clear diagnosis, you can work with your child's healthcare provider on a helpful treatment plan.