Pediatric Incontinence and Pelvic Floor Dysfunction

“What's wrong with children?”

By Dawn Sandalcidi, PT, RCMT, BCB-PMD

As pelvic health physiotherapists it would be safe to say most of you are treating adults with bladder and bowel dysfunction and pelvic pain. I was in the same place when I was approached over 30 years ago from an urologist to take care of his pediatric patients. My reply: “What’s wrong with children?” I will never forget the whirlwind of learning since that day.

According to the National Institute of Diabetes and Digestive and Kidney Diseases, by 5 years of age, over 90% of children have daytime bladder control (NIDDK, 2013) What is life like for the other 10% who experience urinary leakage during the day?

Bed-wetting is another pediatric issue with significant negative quality of life impact for children and their caregivers, with as much as 30% of 4 year-olds experiencing urinary leakage at night (Neveus, 2010). Children who experience anxiety-causing events may have a higher risk of developing urinary incontinence, and in turn, having incontinence causes significant stress and anxiety for children (Austin, 2014; Neveus, 2010).

Having bowel dysfunction such as constipation is also a contributor to urinary leakage or urgency, and with nearly 5% of pediatric office visits occurring for constipation (Thibodeau 2013, NIDDK, 2013), the need to address these issues is great.  As pediatric bladder and bowel dysfunction can persist into adulthood, pelvic rehabilitation providers must direct attention to the pediatric population to improve the health in our patient populations.

Children suffer from many diagnoses that affect the pelvic floor including (Austin et al, 2014);

·         Voiding dysfunction

·         Constipation

·         Enuresis (Bedwetting)

·         Encopresis

·         Daytime urinary incontinence

·         Urinary urgency and frequency

·         Vesicoureteral reflux (Backflow of urine into the kidney)

·         Pelvic pain (yes pelvic pain!)

The most common diagnoses I treat are voiding dysfunction and constipation. Pediatric voiding dysfunction is defined as involuntary and intermittent contraction or failure to relax the urethral striated sphincter during voluntary voiding. (Austin et al, 2014); The dysfunctional voiding can present with variable symptoms including urinary urgency, urinary frequency, incontinence, urinary tract infections, and vesicoureteral reflux. Frequently constipation is a culprit or cause. (Austin et al, 2014; Hodges S. 2012); Managing constipation can have a very positive effect on voiding dysfunction as you may have likely seen in your adult patient population.

 

“How do I work with the pediatric population?  I only treat adults!”

Many therapists tell me they are not comfortable working with children however I would like to challenge you to open yourself to the Joy of the pediatric pelvic health world!

Some common questions I am asked are:

·         Can I use biofeedback with children?

·         Do we complete internal assessments on pediatric patients?

·         How do I talk to a child?

·         How do we teach kids so they can understand?

·         Do kids have the ability to learn strengthening versus relaxation

·         How do you teach a child to become aware of their pelvic floor and coordinate it?

 

If you have pondered these questions let’s delve in. I see children as young as 4 who have been able to master biofeedback and recite back to me how their pelvic floor works with bowel and bladder function! Children are so eager to please and they love working with animated biofeedback sessions. The research supports the potential benefit of biofeedback training for children with pelvic floor dysfunction (DePaepe et al. 2002, Kaye 2008, Kajbafzadeh 2011, Fazeli 2014). The children are engaged and learn how to isolate their pelvic floor muscles (PFM) from accessory muscles through positioning and breathing. The exercises are fun and easy to do. We also can’t forget the core! What a wonderful opportunity we have to educate the younger population on these vital muscles in addition to proper diet and bowel and bladder habits! Many of your adult patients suffered from childhood bladder problems.

It is not typical to complete an internal pelvic muscle assessment on children, as that would not be appropriate. Teenagers may be the exception to this if there is a reasonable clinical goal in mind for utilizing internal assessment or treatment and with physician and parent approval.

Talking to kiddos is just like talking to a grandchild, niece or nephew. When they look at you funny you learn to rephrase things to make sense to them. I always recommend being up to date on the most recent Disney or other animated film to connect with them. My favorite was Frozen and I could teach them to ‘Let it go!”

Pediatric pelvic floor dysfunction is common and can have significant consequences to quality of life for the child and the family, as well as negative health consequences to the lower urinary tract if left untreated.

 

“How do I treat it?”

In the literature on pediatric bowel and bladder dysfunction you will often come across the word "Urotherapy". It is by definition a conservative based management based program used to treat lower urinary tract (LUT) dysfunction using a variety of health care professionals including the physician, Physical Therapists, Occupational Therapists and Registered Nurses (Austin 2014)

Basic Urotherapy includes education on the anatomy and function of the LUT, behavior modifications including fluid intake, timed or scheduled voids, toilet postures and avoidance of holding maneuvers, diet, bladder irritants and constipation. Parents may not be as aware of their children’s voiding habits once they are cleared from diaper duty after successful potty training occurs. This program needs to be tailored to the patients’ needs. For example a child with an underactive bladder needs to learn how to sense urge and listen to their body and a child who postpones a void needs to be on a voiding schedule. Urotherapy alone can be helpful however a recent study (Chase, 2010) demonstrated a statistically significant improvement in uroflow, pelvic floor muscle electromyography activity during a void, urinary urgency, daytime wetting and reduced post void residual (PVR) in those patients who received pelvic floor muscle training as compared to Urotherapy alone. This is great news for all of us who are qualified to teach pelvic floor muscle exercise!

The International Children’s Continence Society (ICCS) has now expanded the definition of Urotherapy to include Specific Urotherapy (Austin et al, 2014). This includes biofeedback of the pelvic floor muscles by a trained professional who is able to teach the child how to alter pelvic floor muscle activity specifically to void. Cognitive behavioral therapy and psychotherapy are always important to assess.

Functional PFM exercises combined with Urotherapy is a safe, inexpensive, and effective treatment option for children with pediatric voiding dysfunction.

Do bladder and bowel problems cause psychological problems or is the reverse true?

I will never forget the morning I was called by one of my referring pediatricians to tell me an 11-year-old boy with fecal incontinence hung himself because his siblings ridiculed him. If you ever ask me why I do what I do, I will tell you so that nothing like that would ever happen again.

When we think of pediatric bowel and bladder issues we primarily focus on the physiologic issue itself and treating the underlying pathology. I think it is imperative to teach a child that she/he did not have a leak but their bladder or bowel had a leak. It makes the incident a physiological problem and not a problem of the child.

It is not always apparent how much the child is suffering from issues with self-esteem, embarrassment, internalizing behaviors, externalizing behaviors or oppositional defiant disorders. Dr. Hinman recognized theses issues years ago (1986) and commented that voiding dysfunctions might cause psychological disturbances rather than the reverse being true. Dr. Rushton in 1995 wrote that although a high number of children with enuresis are maladjusted and exhibit measurable behavioral symptoms, only a small percentage have significant underlying psychopathology. In other more recent studies(Joinson et al. 2006a, 2006b, 2008, Kodman-Jones et al, 2001)  it was noted that elevated psychological test scores returned to normal after the urologic problem was cured.

I frequently get testimonials from my patients. I would say the common denominator is the child and/or parental report that the child is “much better adjusted,” “happier”, “come out of his shell”, “more outgoing”, “making friends.” As a side note -- they’re happy they don’t leak anymore.

Therapists are increasingly learning about and treating pediatric patients who have pelvic floor dysfunction, yet there are still not enough of them to meet the demand. There are children and parents out there who need your expertise and passion!

 

 

 

 

 

 

 

 

 

References:


Austin, P., Bauer, S.B., Bower, W., et al. The standardization of terminology of lower urinary tract function in children and adolescence: update report from the standardization committee of the international children’s continence society. J Urol (2014) 191.

 

Chase J, Austin P, Hoebeke P, McKenna P. The management of dysfunctional voiding in children: a report from the standarisation committee of the international children’s continence society. 2010; J Urol183:1296-1302.

 

Constipation in Children. (2013)retrieved June 9, 2014 from http://kidney.niddk.nih.gov/kudiseases/pubs/uichildren/index.aspx

 

DePaepe H., Renson C., Hoebeke P., et al: The role of pelvic- floor therapy in the treatment of lower urinary tract dysfunctions in children. Scan J of Urol and Neph 2002; 36: 260-7.

Farahmand, F., Abedi, A., Esmaeili-dooki, M. R., Jalilian, R., & Tabari, S. M. (2015). Pelvic Floor Muscle Exercise for Paediatric Functional Constipation.Journal of Clinical and Diagnostic Research : JCDR, 9(6), SC16–SC17. http://doi.org/10.7860/JCDR/2015/12726.6036

Fazeli MS, Lin Y, Nikoo N, Jaggumantri S1, Collet JP, Afshar K. Biofeedback for Non-neuropathic daytime voiding disorders in children: A systematic review and meta-analysis of randomized controlled trials. J Urol. 2014 Jul 26. pii: S0022-5347(14)04048-8.

Hinman, F. Nonneurogenic neurogenic bladder (the Hinman Syndrome)-15 years later. J Urol 1986;136, 769-777.

 

Hodges SJ, Anthony E. Occult megarectum:a commonly unrecognized cause of enuresis. Urology. 2012 Feb;79(2):421-4. doi: 10.1016/j.urology.2011.10.015. Epub 2011 Dec 14.

 

Hoebeke, P., Walle, J. V., Theunis, M., De Paepe, H., Oosterlinck, W., & Renson, C. Outpatient pelvic-floor therapy in girls with daytime incontinence and dysfunctional voiding. Urology 1996; 48, 923-927.

 

Joinson, C., Heron, J., von Gontard, A. and the ALSPAC study team: Psychological problems in children with daytime wetting. Pediatrics 2006a; 118, 1985-1993.

 

Joinson, C., Heron, J., Butler, U., von Gontard, A. and the ALSPAC study team: Psychological differences between children with and without soiling problems. Pediatrics 2006b; 117, 1575-1584.

 

Joinson, C., Heron, J., von Gontard, A., Butler, R., Golding, J., Emond, A.: Early childhood risk factors associated with daytime wetting and soiling in school-age children. Journal of Pediatric Psychology2008; e-published.

 

Kajbafzadeh AM, harifi-Rad L, Ghahestani SM, Ahmadi H, Kajbafzadeh M, Mahboubi AH. (2011) Animated biofeedback: an ideal treatment for children with dysfunctional elimination syndrome. J Urol;186, 2379-2385.

 

Kaye JD, Palmer LS (2008) Animated biofeedback yields more rapid results than nonanimated biofeedback in the treatment of dysfunctional voiding in girls. J Urol 180, 300-305

Kodman-Jones, C., Hawkins, L., Schulman, SL. Behavioral characteristics of children with daytime wetting.  J Urol 2001;Dec(6):2392-5.

 

Neveus, T, Eggert P, Evans J, et al. Evaluation of the treatment for monosymptomatic enuresis: a standarisation document from the international children’s continence society. J Urol 2010; 183: 441-447

 

Rushton, H. G. Wetting and functional voiding disorders. Urologic Clinics of North America, 1995; 22(1), 75-93.

Seyedian, S. S. L., Sharifi-Rad, L., Ebadi, M., & Kajbafzadeh, A. M. (2014). Combined functional pelvic floor muscle exercises with Swiss ball and urotherapy for management of dysfunctional voiding in children: a randomized clinical trial. European Journal of Pediatrics, 173(10), 1347-1353.

Thibodeau, B. A., Metcalfe, P., Koop, P., & Moore, K. (2013). Urinary incontinence and quality of life in children. Journal of pediatric urology, 9(1), 78-83.
 

Urinary Incontinence in Children. (2012). Retrieved June 9, 2014 from http://kidney.niddk.nih.gov/kudiseases/pubs/uichildren/index.aspx

Zivkovic V, Lazovic M, Vlajkovic M, Slavkovic A, Dimitrijevic L, Stankovic I, Vacic N. (2012). Diaphragmatic breathing exercises and pelvic floor retraining in children with dysfunctional voiding. European Journal of Physical Rehabilitation Medicine. 48(3):413-21. Epub 2012 Jun 5.