AUA Summit - What are Bladder Control Problems in Children?
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What are Bladder Control Problems in Children?

Bladder control problems describe a range of problems with the way the bladder holds and releases urine. This is also commonly called bladder dysfunction or voiding dysfunction.  For children, there may be a problem with the way the bladder and urethra work together. A child may experience wetting accidents.

How Does the Urinary System Work?

The urinary system includes the organs that make, store and move urine out of the body. These include two kidneys, two ureters, the bladder and the urethra.

The kidneys are a pair of organs that filter waste products from the blood. Waste (urine) will then move from the kidneys to the bladder through tubes called "ureters". The bladder holds urine until the body gets rid of it through the urethra. The urethra opens at the end of the penis in boys and in front of the vagina in girls.

A complex network of nerves sends signals from the bladder to the spinal cord and brain, and back, letting the bladder store and release urine in a controlled way.

Healthy newborns and infants have a simple reflex that causes them to pass urine as the bladder fills. As infants grow, many things allow children to gain control over the act of passing urine. First, the bladder can simply hold more urine with age. By two to three years old, the child gains control over the sphincter and pelvic floor muscles and can hold back the flow of urine until they reach a toilet. As the brain matures, children gain more and more control over passing urine. By seven years old, 90 percent of children are able to stay dry while they sleep at night.

Symptoms and Causes

What are Common Symptoms of Bladder Control Probmes?

Children with bladder control problems may have a range of symptoms. Common problems are:

  • Daytime wetting: the loss of bladder control in children who have been toilet trained during awake hours. Daytime wetting affects up to 20 percent of four to six year-old children.
  • Frequency: when a child has to pass urine more than 8 times during awake hours.
  • Giggle Incontinence: urine leaks out by accident with laughter.
  • Hesitancy: trouble starting or taking a long time to start passing urine.
  • Holding maneuvers: the child does things to avoid going to the bathroom, such as squatting, leg crossing or holding the genital area.
  • Infrequency: when a child doesn't pass urine enough during awake hours (fewer than three times). This may be linked with holding maneuvers.
  • Intermittent urine stream: the flow of urine occurs in bursts rather than a normal continuous stream.
  • Post-void dribbling: leaks of urine that occur immediately from sitting position soon after going to the bathroom. This occurs mainly in girls and may be due to labial adhesions (a condition where the labia are fused together) or when the legs are tightly closed while passing urine.
  • Straining: trouble getting urine out (a child may have to push or strain to go).
  • Urgency: a sudden, unexpected need to pass urine.
  • Weak urine stream: the flow of urine is weak or slow.

How are Constipation and Bladder Control Problems Related?

Constipation is one of the most common causes for bladder control problems in children. In fact, up 80% of children who have bladder control problems do so because they are constipated.  Constipation is when a child has:

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


Why is it Important to Diagnose and Manage Bladder Control Problems in Children?

Wetting accidents in school-aged children can cause major stress. If left untreated, they can also lead to bladder and kidney problems in later childhood and adulthood. These problems include continued wetting accidents, poor bladder emptying, repeat urinary tract infections, kidney or bladder stones and, in severe and untreated cases, kidney failure.

Fortunately, most bladder control problems in children are from bad habits that can easily be changed with some patience and care.

How are Bladder Control Problems Diagnosed?

Complete health history: Your health care team (doctor, nurse practitioner or physician assistant), 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 home or school stressors (parent's divorce/separation, moving, new school, 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). You may be given questionnaires to answer that will help better understand their toileting habits.

Physical exam: your child will be examined in the office. The health care team 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, they will be looking for abnormal physical signs that could lead to bladder control problems such as:

  • Girls may have labial adhesions, which can cause wetting accidents soon after using the bathroom. 
  • Boys may have scarring or narrowing of the urethral opening, 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: your health care team 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 passes urine and passes stool. They may you to measure how much your child passes urine each time.  This will help form a diagnosis and determine treatment options.
  • A urine specimen may be collected during the 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 large amounts of urine in the bladder, kidney abnormalities or large amounts of stool in the bowels.  These findings may help determine a treatment plan or if other studies are needed.
  • Your child may be asked to pass urine in a toilet that has a sensor at the bottom (uroflow). This test checks how quickly urine flows.  Additionally, small sticky pads may be placed on the belly and bottom to see if the muscles are relaxing while your child is passing urine (EMG).  A bladder ultrasound may obtained before and after passing urine to check how well the bladder is emptying.


Treating Bladder Control Problems

Managing bladder control problems in children is often successful. The first step is to learn which type of bladder problem your child has.

If your child has constipation then helping your child to have regular bowel movements can, by itself, cure bladder control problems.

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 health care team may suggest 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. Some children with constipation that do not respond to increased fiber intake, may need medicine such as stool softeners or laxatives. 

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

Scheduled (timed) 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 doctor may suggest a bathroom schedule for your child of every two to four 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.
  • Your child’s teacher may be an ally.  Share your child’s bladder control problem with them.  Many times a teacher may be able to prompt your child to use the restroom.  You may need a doctor’s note.  This is usually easier to do in younger kids.

If your child has frequency of urination or going too much, they may have daytime accidents when a bathroom isn't nearby. In this case, your child may have an overactive bladder (a bladder that holds less than it should and must be emptied very often). This may be improved by avoiding bladder irritants such as artificial colors, spicy foods, carbonated drinks, sodas and caffeine and treating constipation.  If this doesn’t work, medication may be needed.

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

  • Examples of these medications include oxybutynin, tolterodine and mirabegron.

Medication for Giggle Incontinence include medications such as oxybutynin or methylphenidate.

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

Pelvic Floor Exercises include different exercises that may 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, many 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 pass urine 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. 
  • Training may be available in your doctor’s office or you may be referred to physical therapy (PT). Specially trained physical therapists are very helpful to determine which exercises are best and to ensure that your child understands how to do these exercises correctly. Ask your doctor if there is a physical therapist they suggest in your area.

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

  • Biofeedback therapy uses video games or other techniques 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-void 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 steroid or estrogen cream can help open the skin that has fused together.

With a clear diagnosis, you can work with your child's doctor on a helpful treatment plan.  Treatment of these issues requires a lot of work.  Be prepared to encourage your child during this journey to healthy bladder habits.

After Treatment

Can my Child Relapse After Treatment?

Some children may go back to their old habits and have wetting accidents again. Retry the strategies that helped in the first place. Sometimes it takes different strategies over time. Your child may develop another type of bladder control problem that causes symptoms. It is of great value to talk with your doctor if your child is having problems. There is hope, and there are many long-term solutions.

Updated August 2023. 

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