June 14, 2016
The following paragraphs represent a few observations and experiences I’ve had from my time treating children with incontinence, specifically bed wetting, that I hope will be helpful in providing perspective to children with this condition and their families . . .
In treating children with bed wetting, I have come to realize that most kids with this condition and their parents suffer in silence . . .
I can’t tell you how many times a mom has broken down in my clinic feeling awful that she did not know there was help for her child, feeling guilty and ashamed that she had not done something sooner. Parents may have been told or had the impression that their child was simply going to outgrow it, suffered unnecessarily for several years before they received help. Typically, only 15% of kids outgrow these conditions per year, leaving the other 85% to suffer in silence if left untreated.
Parents don’t talk about their children wetting the bed to each other . . .
As a mom of three young boys, I have spent many hours with other moms sharing the trials and tribulations of raising children, in addition to comparing notes on our kids’ developmental milestones.
“When did your child sleep through the night?” “When did they start walking?” But we never asked each other the question, “When was your child potty-trained?” or “Does your child still wet the bed?”
One of my children’s friends wet the bed at our house while attending a sleep over. What is telling about this event is not that it occurred, but that we had been very close to this child and their family for several years without knowing that they had such a problem. I will never forget how that child looked and how embarrassed he felt. If only his mom would have told me, I could have helped set this youngster up for success and avoided this humiliating experience. If I had known, I could have made the following precautions . . .
Not giving liquids just before bed with the other kids
Provided privacy to change into pull-ups before bed with discretion
Tell the children exactly where to sleep
Dispose of the pull-up early the next morning
These measures would have provided a more comfortable experience for this child.
The impact of bed-wetting on families is devastating . . .
I’m seeing an early elementary school child who was successful with potty-training during the day, but continued to wet the bed at night. As an older child, she is feeling isolated from her friends and shameful as she keeps wetting her bed. She cannot go to sleep-overs, nor invite friends to spend the night at her house, or go to overnight camps through school or summer camps. Her parents are frustrated and feel as if they have failed her because she not only missed the milestone of potty-training, but is beginning to miss the social milestones of a young girl. To say nothing of the constant changing of bed linens, increased laundry and the cost of pull-ups!
My goal as a physical therapist is to prevent these horrible experiences and let all children experience the joy of sleeping over at a friend’s house, going to an overnight camp without anguish, or missing out entirely on milestone events of being a child. I also want to spread the word that these children and their families are not alone! There is help and it should not be viewed as a shameful event!
I look forward to continuing to treat this wonderful population who has been so under-served in our health care system. This topic should no longer be seen as hopeless, but one that is treatable!
The International Children's Continence Society (ICCS) position statement on bed wetting is: “Not only is treatment (for bed wetting) justified, but is mandatory."
I couldn’t agree more!
Lori Lukban, MSPT
March 8, 2016
Constipation, Constipation, Constipation
By Dawn Sandalcidi, PT, PCMT, BCB-PMD
Is that not the most common and dismissed thing we see in pelvic floor dysfunction? I have decided that I want my tombstone to read “DON'T EVER BE CONSTIPATED!”
Did you know there was a teenage girl in Great Britain who died of constipation?
I had a teenager in my practice that had a bowel movement (BM) once every 3 weeks and the only sensation she had to become aware it was time to empty was goose bumps. Did you know that 50% of the weight of feces is bacteria? Is that something you really want sitting around inside of your body?
When people hear me speak they occasionally comment that all I talk about is constipation. Well amen! That means I got my point across, however, it’s more than just my soapbox. It's real. Approximately 95% of my patients present with constipation and it is the single most challenging aspect to convince parents that constipation is a large contributing factor if not the CAUSE of their urinary or fecal incontinence.
Constipation can result from PFM dysfunction. Rectal distension with constipated feces is known to increase the risk of colonization of the urethra and perineum with uropathogens, irritate the bladder and cause over activity of the detrusor, and increase the virulence of the fecal bacteria (Reddy, Redman 2003). 52% of constipated children presented with abnormal voiding parameters. Rectal dilation seen on US was associated with abnormal voiding parameters. (Chung 2014). Stool backed up in the rectum may cause pressure on the bladder or reflex relaxation of urinary sphincters. As a result, 1 in 3 children with encopresis also have bedwetting and 1 in 5 also have daytime dribbling or urinary frequency. (Griffin, et al 1999.) Constipation is more common in children with overactive bladder (OAB) than in those without urinary symptoms (Veiga 2013)
So what is normal?
On the Bristol Scale we encourage patients to have a Type 4 stool consistency that is like a ripe banana. The goal for our patients with comorbidities of constipation and daytime or nighttime urinary leakage is a daily BM of type 3-4 consistencies without straining. To support his goal we encourage the use of the squatty potty, diaphragmatic breathing, ILU massage and other visceral techniques to retrain the bowel. It’s important to help the parents understand the importance of regular bowel movements and it may take the bowel 6 months to 1 year to retrain. That doesn't necessarily mean the child will need therapy that long but that they will get backed up and relapse easily if they don't maintain their bowel program.
Miralax is frequently prescribed for constipation. Parents often discontinue it as their child has stools that are too loose and they experience fecal incontinence. This then causes more constipation and the vicious cycle continues. Please request permission from your referral source to titrate the Miralax until you have a formed stool.
Constipation is so common and a critical component to the success of your treatment. Education and demystifying it will lead to a very positive outcome.
1. Chung KL, Chao NS, Liu CS, Tang PM, Liu KK, Leung MW. Abnormal voiding parameters in children with severe idiopathic constipation. Pediatr Surg Int. 2014 Jul;30(7):747-9.
2. Griffin, G., Roberts, SD., Graham, G. How to resolve stool retention in a child. Underwear soiling is not a behavior problem. 1999 Jan;105(1)159-61, 165-6, 172-3.
3. Koppen IJN, von Gontard A, Chase J, Cooper CS, Rittig CS, Bauer SB, Homsy
Y, Yang SS, Benninga MA. Management of functional nonretentive fecal incontinence in children: recommendations from the International Children’s Continence Society. J of Ped Urol (2015)
4. Koppen IJ, Di Lorenzo C, Saps M, Dinning PG, Yacob D, Levitt MA, Benninga MA. .Childhood constipation: finally something is moving! Expert Rev Gastroenterol Hepatol. 2015 Oct 14:1-15.
5. Reddy, PP., Redman, JF. The management of childhood voiding dysfunction. J Ark Med Soc. Mar.2003;99(9):295-8.
6. Veiga ML, Lordêlo P, Farias T, Barroso C, Bonfim J, Barroso U Jr. Constipation in children with isolated overactive bladders. J Pediatr Urol. 2013 Dec;9(6 Pt A):945-9.
March 3, 2016
The Psychological Effects of Bedwetting, Daytime Urinary and Fecal Incontinence
By Dawn Sandalcidi, PT, PCMT, BCB-PMD
A regular referring pediatrician called me one morning to tell me about an 11-year-old boy who hung himself secondary to fecal incontinence and persistent teasing by his siblings and peers. Her comment to me was “If his parents only knew about the services you offer this child’s life may have been spared.” That was over 10 years ago and to this day I still get emotional just thinking about it.
Children who suffer from constipation with or without encopresis (fecal incontinence), daytime urinary leakage, nighttime leakage or bedwetting suffer tremendously. The psychological test scores of these children are abnormal at the time of diagnosis however the interesting piece is that once their bowel and/or bladder issues are resolved, their psychological test scores return to normal. (Hinman 1986, Sureshkumar, 2009; Joinson 2007.)
It is clear that these disorders CAUSE psychological disturbances rather than the reverse being true. Can you imagine having such angst as a child AND parent dealing with poor self-esteem, embarrassment, shame, anxiety (I could go on) which can develop into oppositional defiance disorders, internalizing and externalizing psychological behaviors?
Here are the statistics:
· 20-30% of children with bedwetting fulfill the criteria for psychiatric disorders with a 2-4x higher rate as compared to non-wetting children; (von Gontard, Neveus 2006)
· Bedwetters who are punished by their parents exhibit depression and reduced quality of life (Al-Zaben 2014)
· Children who wet during the day and at night exhibit more fear and anxiety (van Gontard 2011, 2014).
· 20-40% of children with daytime incontinence fulfill the criteria for psychiatric disorders- (von Gontard, Neveus 2006)
· Daytime wetters tend to exhibit internalizing behaviors such as depression, anxiety and withdrawal and nighttime bed wetters tend be exhibit more externalizing behaviors such as aggression and acting out. (Kodman 2001).
· Children who postpone voiding exhibit more externalizing disorders-especially oppositional defiant disorder (ODD). More than 50% fulfill criteria for at least 1 psychological disorder(von Gontard et al 1998, Zink et al, 2008) and it affects the family (Lettgen et al. 2002)
· 30-50% of children with fecal incontinence fulfill the criteria for psychiatric disorders and exhibit both internalizing and externalizing disorders. (von Gontard, Neveus 2006)
Helping families who have kiddos with bowel or bladder leakage is not only a passion but also a privilege and an obligation!!
February 25, 2016
Is It An Accident?
By Dawn Sandalcidi, PT, PCMT, BCB-PMD
I do tend to have a few “soapbox” topics I like to discuss. If you have ever heard me speak, you have surely heard me say I don’t like the word accident. Merriam- Webster defines the word accident as a sudden event (such as a crash) that is not planned or intended and that causes damage or injury or: an event that is not planned or intended: an event that occurs by chance.
The latter is a great definition without any blame. However, have you ever used the word accident without a negative connotation? I remember when my eldest daughter was in preschool 20 years ago and I received a call stating that she had an accident. Immediately my heart began to race and I asked if she fell off the monkey bars, did she break anything? There was silence on the other end for a few seconds escalating my anxiety and then I heard “she wet her pants”. Whew! It was that moment I felt the word accident should not be used to refer to an incontinent event. Although by definition, it is true it leaves a child feeling shame and embarrassment. When we say did you have an accident the child becomes the responsible party when in fact is was the bladder or bowel. I prefer to ask children “Did your bladder/bowel have a leak?” Truly that is a more accurate question putting the responsibility for leak on the body part it involves.
February 10, 2016
UROTHERAPY- What is it??
By Dawn Sandalcidi, PT, PCMT, BCB-PMD
If you read any papers 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 track (LUT) dysfunction using a variety of health care professionals including the physician, PT’s, OT ‘s and RN’s.
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. This 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 demonstrated a statistically significant improvement in uroflow, PFM EMG activity during a void, urinary urgency, daytime wetting and reduced post void residual (PVR) in those patients who received PFM (Pelvic Floor Muscle) training as compared to Urotherapy alone. This is great news for all of us who are qualified to teach PFM exercise!
The International Children’s Continence Society (ICCS) has now expanded the definition of Urotherapy to include Specific Urotherapy. This includes biofeedback of the PFM by a trained experienced therapist who is able to teach the child how to alter PFM activity specifically to void. It also includes neuromodulation for many types of LUT dysfunction but most commonly with overactive bladder(OAB) and neurogenic bladder. Cognitive behavioral therapy (CBT) and psychotherapy are always important to assess (see Blog post on psychological effects of bowel and bladder dysfunction).
It truly does take a village to help this kiddos and I am honored to be a team player!
Chang SJ, Laecke EV, Bauer, SB, von Gontard A, Bagli,D, Bower WF,Renson C, Kawauchi A, Yang SS-D. Treatment of daytime urinary incontinence: a standardization document from the international children;s continence society. Neurourol Urodyn 2015;Oct 16. doi:10.1002/nau.22911
Ladi Seyedian SS, Sharifi-Rad L, Ebadi M, Kajbafzadeh AM. Combined functional pelvic floor muscle exercise with swiss ball and Urotherapy for management of dysfunctional voiding in children: a randomized controlled trial. Eur J Pediatr.2014 Oct;173(10):1347-53.