Dysfunctional Voiding

By Philip E. Gleason, MD

 

In children, the bladder is a largely automatic or reflexic organ. Bladder distention promotes spontaneous voiding both through the day and night. Development of urinary control through the day and night often occur spontaneously between the ages of 2-5. The toilet training process itself represents ongoing maturation of the bladder, brain, and CNS ability to control the bladder. For example, if you are driving home in rush hour traffic and feel the need to urinate, the brain inhibits the bladder and controls urination until you reach home and urinate at that time. Occasionally, if the bladder is very full, you may not be able to make it home and may have to stop at the gas station or rest area. Nevertheless, you are in fact able to control the bladder. This process of obtaining brain and CNS control of the bladder can be difficult for children. Oftentimes, the bladder will continue to act in a somewhat hyperactive and hypersensitive manner similar to the automatic bladder of infancy. In addition, toilet training also occurs at a point in time at which children are beginning to expand their interests and, quite frankly, find more interest and fun in playing with their friends, playing outside, or watching a video etc. Thus, when they feel the need to go to the bathroom, they will typically try to put that off as long as possible so they don't have to interrupt or miss what they are involved in. A short cut that children use to try to hold on to their urine when they are having difficulties controlling the bladder is to tighten the pelvic muscles or the external urinary sphincter to try to hold on to the urine within the bladder when they feel the need to void. They will typically cross their legs, squat, squirm, hold themselves, or perhaps even keen down and sit on their heel in an attempt to avoid urinating. This can, however, ultimately lead to problems with emptying the bladder because of failure of the muscles to relax when they do go to the bathroom. Thus, these "bad habits", ultimately predispose to difficulties with daytime wetting and accidents as well as predilection for urinary tract infections (UTI's). Further, UTI's in and of themselves, may exacerbate the bad habits and the voiding problems. It can then sometimes become a relatively difficult and vicious cycle.

If dysfunctional voiding represents bad habits of urine control and urinating, then the treatment for the day time wetting and UTI's associated with dysfunctional voiding would be to try to improve or normalize good voiding habits. The first step is typically trying to resume a routine, normal urinating pattern. This is an easy statement to make, but a relatively difficult concept to convey to young children as they really don't quite understand what you are talking about. It can really take a lot of patience on your part and work to try to help them work and improve their voiding habits. Unfortunately, even sometimes when they are making some improvement, they will have an acute flare up of wetting or develop a UTI and this, in fact, sets the whole process back more or less to the beginning and you have to start all over again. Therefore it can really be frustrating and require a lot of patience; both for the child and on the parent's part. Nevertheless, we typically try to encourage children to void every 2-4 hours. The bladder can certainly hold that amount of urine in a safer manner. Even if the children don't feel that they have void or are more or less putting it off, we encourage them to go ahead and try to void on a very routine schedule with the idea being that they will probably be surprised how much they are able to urinate even when they state that they don't feel they have to go or deny the need to void.

I typically recommend having children void when the arise in the morning, in the middle of the morning, at lunchtime, in the middle of the afternoon, at suppertime, in the evening, and again at bedtime. When they do void, I typically encourage the children to relax and to just take a few minutes to empty the bladder rather than attempting to rush into and out of the bathroom as quickly as possible so they don't miss anything. Oftentimes, when they do this, they will only partially empty the bladder (just enough ti get rid of the feeling that they have to urinate) and then leave the bathroom with a partially full bladder. This then causes troubles afterwards because the bladder is only partially empty, it will not take very much time for it to fill up again and they will have to go fairly often. In addition, the urine left over in the bladder will again predispose them to developing UTI's. We encourage the children to have a very smooth, steady urine stream when the urine is hitting the toilet water. I typically encourage them to avoid stopping and starting the urine stream as that often indicates poor relaxation of the external sphincter muscles. We really encourage them to try to empty the bladder completely.

While children are working on improving their voiding habits, we sometimes use medication called anticholinergic medication to try to help relax the bladder and help facilitate ladder control even when they are having some problems with it. We can often use medications such as Levsin or Ditropan to try to accomplish this. In addition, as mentioned above, if they develop UTI's, that oftentimes serves as a set back. We typically place the children on preventative antibiotics such as Septra or Nitrofurantoin, etc, to help prevent infections while they are again working on improving their voiding habits. Often we will continue the medications for perhaps a 3-6 month period while the children are trying to make progress with their voiding and then, hopefully, allow discontinuation of the medication just to follow the children with improved voiding. If they have really been able to make improvements in their voiding schedule and avoid some of the problems of dysfunctional voiding, then hopefully they will no longer have difficulties with wetting or infections, and not require or need the medication any further. Ultimately, it is the improvement of voiding habits which really gets at the heart of the problem which is the bad habits. Until those can be controlled and improved, it is very difficult to make progress. While the medications will help, they will not ultimately correct the problem.

 

© 2005-2010, Dr. Philip E. Gleason, MD