PROBLEMS WITH URINARY CONTROL
Symptoms of Voiding Problems
- Loss of Urinary Control (Enuresis)
- Frequent Urination
- Squatting/Squeezing To Prevent Urination
- Tendency Toward Constipation
- Recurrent Urinary Tract Infections
What Causes Incontinence (Enuresis)?
Enuresis is probably caused by many factors. Most children with enuresis have a developmental delay in their ability to hold urine. Not all children develop this ability at the same rate, and gaining bladder control may take longer in some children. Children who have only night wetting and have never had urinary tract infections rarely have structural abnormalities of the urinary tract to account for wetting. Recent studies suggest that these children produce more urine at night than other children. Some children will have wetting problems during the day and night. They may even have been perfectly dry for some period after toilet training. This is usually very different from night wetting. Reasons to explain this are urinary tract infections, structural abnormalities of the urinary tract or problems with bathroom habits. (Such problems include holding urine and bowel movements, infrequent or very frequent urination, insufficient time spent on the commode to empty bladder or eliminate stool, and painful bowel movements with straining.) Many children with severe problems will also be incontinent of stool, causing them to soil themselves.
The initial evaluation should include a thorough history and physical evaluation, a urine analysis and a urine culture to screen for infection. Further evaluation may be necessary to help determine the reason for a child’s wetting. Frequently the only test that may be done is a sonogram of the kidneys and bladder. The sonogram is a safe, non-invasive test to screen children for abnormalities in the urinary tract. X-rays are not usually indicated unless there is a history of urinary infections or an abnormality is discovered on the sonogram. Cystoscopy is rarely indicated and urethral stretching (dilatation) is not helpful.
How Common Is Enuresis?
Fifteen Percent of all 5-year-olds, 5% of all 10-year-olds, and 1% of all 15-year-old children occasionally wet themselves. This, therefore, represents a common childhood problem.
Is There a Cure for Enuresis?
Yes. For children who wet themselves at night and void normally during the day, patience and understanding are most important. A common sense approach includes voiding just before bedtime and encouraging success with a positive reinforcement (reward) program. Punishment should always be avoided. Treatment options that have proven to be effective include the enuresis-conditioning alarm and DDAVP nasal spray or tablets. Children with daytime urinary symptoms often respond to medication (bladder muscle relaxants). Many of these children have a tendency toward constipation; this should be treated vigorously with high-fiber diets, stool softeners, laxatives and even enemas if necessary. Timed-voiding by the clock every three to four hours during the day helps encourage regular bladder emptying. Occasionally, for severe problems bladder emptying may be improved by intermittent catheterization or behavior modification. Children with anatomic abnormalities will usually show improvement once the cause is addressed. Treatment may include surgery. Children with neurologic dysfunction (spina bifida, spinal cord injury) often require a combination of medication, intermittent catheterization and surgery.
Overactive Bladder and Voiding Dysfunction
Children may suffer from “overactive bladder” activity during the day. They will respond to this in a variety of ways. Some will run to the bathroom and be able to stay dry. Others may run to the bathroom but will lose urine on the way and dampen their underwear. Others will try to postpone urination in a very different, abnormal way. A normal adult can postpone urination without doing anything. They don’t need to tighten the muscles that hold urine back (the sphincter muscles). They can do this consciously, for example when they are involved in something they want to continue doing and they decide to wait. The bladder remains relaxed and will not try to empty. This postponement can also occur unconsciously. When they are ready to urinate, the bladder contracts and the muscles that hold back urine will simultaneously relax. The emptying of the bladder is low pressure because of the coordinated contraction of the bladder and relaxation of the sphincters. Infants urinate in a very healthy way. The bladder will automatically contract, as a reflex, and the sphincters automatically relax. This is very healthy because the bladder pressure needed to empty the urine is low. However, it’s not very sociable! Some children are able to postpone urination in the same way as adults, but many cannot. This can be due to many of the factors mentioned above, but it can also be due to “immaturity” of their nervous system so that they recognize the urge to urinate before they have developed the ability to postpone urination. They feel the sudden need to urinate, but are unable to keep their bladders from trying to empty. They learn to stay dry by blocking the flow of urine because they are unable to postpone urination. Some of these children will dance (“pee-pee dance”), others will stand very still and some girls will even sit down on the heel of their foot in order to put pressure on the urethra and block urine flow (“curtsy sign”). Obstruction and incomplete emptying are bad for the bladder and can lead to an overactive bladder. This pattern of behavior can become the only way these children are able to control their overactive bladders. This is a common cause of what we call voiding dysfunction. Voiding dysfunction is also very frequently associated with constipation. Normal, low-pressure, complete emptying of the bladder is one of the best defenses against urinary tract infection. Because they do not urinate normally, these children have a much higher rate of urinary tract infections. Fortunately, biofeedback training can be used to teach these children how to relax their bladder sphincters during urination and, along with management of their constipation, we can help them become dry and reduce the rate of urine infections.
The Role of Constipation in Overactive Bladder and Recurrent UTIs
There is a close association between constipation or fecal retention and an overactive bladder. One of the most important issues in management of overactive bladder is the correction of constipation and fecal retention. An understanding of normal bowel function is essential to understanding problems associated with overactive bladder. The stimulus and desire to have a bowel movement is initiated primarily by rectal distention (overstretching). Distention in the rectal wall will generate nerve impulses that cause relaxation of the muscle (the anal sphincter) that holds a stool in, allowing the stool to come out easily. In many children who have intermittent fecal soiling or fecal marks on their underwear, the involuntary relaxation of the sphincter will allow the stool to reach the anus, causing soiling of their underwear. When they sense the stool at the anal opening, they clamp down on the sphincter and the stool is pushed back in. Continuation of this chronic rectal sphincter tightening may persist during urination and inhibit or obstruct bladder emptying. Children can be taught to relax the pelvic muscles, allowing more normal, low-pressure bladder emptying to occur. The center for bladder control at PUA specializes in the diagnosis and treatment of disorders of urination and bowel control in children. We offer all of the most current means for diagnosing children with disorders of bladder and bowel function, and we are equipped to provide the necessary behavioral, medication and biofeedback methods to successfully treat them.