What is Bladder Dysfunction?

Bladder dysfunction is a term used for a range of problems with the way the bladder holds and releases urine. 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, allowing the bladder to store and release urine in a controlled way.

Newborns and infants have a simple reflex that causes them to urinate with pressure on the bladder. As infants grow, several things allow them to gain control over the act of urinating. First, the bladder can simply hold more urine with age. By 2-3 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 urinating. By 7 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 Dysfunction?

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

  • Daytime wetting: the loss of bladder control in grown children during awake hours. Daytime wetting affects up to 20 percent of 4 to 6-year-old children.
  • Frequency: when a child has to urinate more than 8 times during awake hours.
  • Giggle Incontinence: urine leaks out by accident with laughter.
  • Hesitancy: difficulty starting or taking a long time to start urinating.
  • 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 urinate enough during awake hours (fewer than three times).
  • Intermittent urine stream: the flow of urine occurs in bursts rather than a normal continuous stream.
  • Post-micturition dribbling: leaks of urine that occur immediately from sitting position soon after going to the bathroom. This occurs primarily in girls. with either labial adhesions or when urinating while moving their legs.
  • Straining: difficulty getting urine out (a child may have to push or strain to go).
  • Urgency: a sudden, unexpected need to urinate.
  • Weak urine stream: the flow of urine is weak or slow.

How are Constipation and Bladder Dysfunction Related?

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.

Diagnosis

Why is it Important to Diagnose and Manage Bladder 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 for adults. For example, poor bladder emptying, repeat urinary tract infections, kidney or bladder stones and kidney failure are long-term problems that may result from childhood bladder dysfunction.

Often, bladder problems in children are from a bad habit that can easily be corrected.

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.

Treatment

Treating Bladder Dysfunction

Managing bladder dysfunction 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 treating it by helping your child to have regular bowel movements can, by itself, cure bladder dysfunction.

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.

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 dysfunction that causes symptoms. It is very important to talk with your healthcare provider if your child is having problems. There is hope, and there are many long-term solutions.