Bladder Bowel Dysfunction in Children

+ Timed Voiding

Timed voiding is a peeing schedule that children use while awake. This schedule facilitates regular voiding every 2-3 hours. The schedule mandates that kids should pee “by the clock” whether they feel like they need to go or not. The premise is that through regular emptying of the bladder, the abnormal holding cycle or urinary frequency habits will be decreased. 30-60% of children will show improvement of symptoms with timed voiding alone. Response is improved with better compliance (>60% of children resolved completely with the use of a watch with a timer which reminds them to go).

The use of a timed voiding chart is helpful for facilitating children to keep track of their voids. As well the chart often can be used to diffuse the tension created between care-givers and children over going to the bathroom. Children are often motivated with use of stickers or special pens to fill out the chart and they gain ownership over their voiding problem.

+ Double Voiding

Double voiding is where a patients voids to completion and then after several seconds attempts to void again. The premise of double voiding is to ensure that patients relax their pelvic floor and empty their bladder completely. Residual urine not emptied out of the bladder can cause problems with urinary leakage and recurrent infections.

One technique is to void to perceived completion. Count "5 Mississippis" and try to pee again. Often their pelvic floor will relax as they are couting.

+ Voiding Position

As toilets are not generally built for pediatric patients often children are not in a good position to empty their bladder appropriately. Children should have a footstool or solid surface to place their feet on to help relax their pelvic floor and separate their legs. Boys should be instructed to free their penis completely before voiding. Girls should be encouraged to keep their legs separated to prevent vaginal voiding or pooling of urine in the vagina during voiding.

+ Constipation

The prevalence of constipation in the pediatric population have been reported between 1% to 30%. As a result, up to 1/3 of children can be affected by difficulties having bowel movements. In one study of patient with urinary incontinence and constipation, up to 60-90% of incontinence was improved with the treatment of the constipation alone.

Treatment of constipation includes the use of a high-fiber diet, appropriate water intake and occasional the addition of a laxative medication.

Recommended fiber intake for adults is between 25-35 grams per day. A child’s fiber need is based on the child’s age: 10 grams plus the child’s age (for example for an 8 year old child, the recommended fiber intake is 10 + 8 = 18 grams of fiber per day).

A common dietary fiber supplement are Bran Buds 1/3 cup provides 44% of daily fiber. An appropriate stool softener used in children is polyethylene glycol (such as Restorolax or Miralax).

A moderate dose is approximately 0.5-0.8g/kg/day. This dose may be modified depending on the degree of constipation.

• 1 tablespoon is approximately 15 grams
• 1 capful is approximately 17 grams
• 1 packet is 17 grams
• 1 teaspoon is approximately 4 gram

+ Biofeedback and Pelvic Floor Rehabilitation

Biofeedback is the concept of building a patient’s self-perception of bladder contraction and bladder floor relaxation. Just like a physiotherapist is used to help patients rehabilitate after a muscular injury, pelvic floor physiotherapists or nurse continence advisors can help children re-learn and re-train their pelvic floor muscles to relax and contract in real time which allows them to void appropriately. Usually this is used for children 5 years and older.

Resolution rates for urinary symptoms are between 75-80% with use of biofeedback.

Currently, biofeedback is available through a referal to BC Children's Hospital nurse continence advisor.This is a time commitment as often the sessions are done weekly or bi-weekly initially until the child begins to develop control.

Routinely children will also be given home exercises to re-inforce the biofeedback sessions.

+ Antimuscarinic Medication

Treatment of voiding dysfunction with medication is generally reserved for refractory cases or to allow children to attain a normal voiding cycle. For most children this is not used as a long-term solution. Pharmacologic therapy is used to treat uninhibited bladder contractions and help the bladder relax. A commonly used medication for children is oxybutynin (0.3mg/kg 2-4xs/day). Response rates vary from 13-30% depending on the patient's symptom profile.

+ Neuromodulation

Neuromodulation is not used routinely for patients with dysfunctional voiding.

However, it can used for children that continue to refractory symptoms despite behavoir modification and medication. The premise is the nerve stimulators affect the nerve signals to the bladder. Neuromodulation techniques include transcutaneous electrical nerve stimulation (TENS). Often TENS patches are placed over the sacrum to stimulate the nerves to the bladder. This is an intensive therapy. It involves roughly 20 minutes of stimulation twice per day for 6-12 months. Response rates are 10-50%. Currently pediatric TENS is not available in Vancouver. Other neuromodulation techniques include peripheral tibial nerve stimulation and Interstim (implanted electrodes in the sacrum).

+ Accupuncture and Hypnosis

Although not used routinely for management of dysfunctional voiding. Patients have had improvement with the use of accupunture and hypnosis. The mechanisms are not well understood.

+ Botox

Intravesical (in the bladder) Botox injection is not currently approved for routine use for non-neurogenic refractory overactive bladder in children.

In the first clinical trial of incontinent children 67% of children showed a full response in children who were refractory to other therapies. 5% of children had transient urinary retention associated with the injection.