Coping with Pediatric Bowel and Bladder Dysfunction
“The great majority of the children we see are going to be anatomically and neurologically normal,” says fellowship-trained pediatric neurologist Carlos Villanueva, MD, who works with the Bladder Dysfunction Clinic at Children’s Hospital & Medical Center in Omaha. “The reason they’re having accidents could be a delay in normal maturation or some behavioral form of dysfunction they acquire by voluntarily holding their bowel or bladder.”
In children who do have anatomic problems, Villanueva says the cause is often multi-factorial, making their cases particularly complex.
Villanueva says patients who are experiencing daytime urinary symptoms older than age 4, or who start having symptoms after more than 6 months of being dry, should be referred to the clinic. Children with nocturnal enuresis after the age of 5 who are emotionally upset about the issue and motivated to improve the condition should also be referred.
Initial treatment includes basic urotherapy (timed voiding, double voiding and hydration), bowel management and extensive education encompassing an explanation of the urinary system, behavior modification and how to complete a voiding diary.
“If they follow what we recommend initially – urotherapy and constipation management – about 45 percent of the patients we see have an improvement in symptoms,” says Tara Goesch, DNP, APRN-NP at Children’s. If problems persist, the investigation moves to the next level of studies, which can include:
● Renal ultrasound
● Noninvasive urodynamics, such as uroflow with electromyogram
● Invasive urodynamics studies
● Voiding Cystogram (VCUG)
In conjunction with escalating investigations for persistent dysfunctions are treatment options which may include:
● Alpha adrenergic blockers
● Behavioral therapy
● Biofeedback, a type of physical therapy that teaches pelvic floor muscle coordination
● Parasacral TENS (transcutaneous electrical neural stimulation) to stimulate the sacral nerves and help prevent voiding accidents and relieve constipation
● Sacral neuromodulation – equated to a “bladder pacemaker” for older children with persistent issues
● Percutaneous Tibial Nerve Stimulation, which involves sending a nerve impulse to the sacral plexus (which regulates control of bladder and pelvic floor muscles) by way of the posterior tibial nerve at the medial malleolus of the ankle
● Bladder or sphincter Botox treatments
In addition to diagnosis and treatment, the clinic specializes in comprehensive follow-up. “We follow them very closely because they need reassurance, retraining of poor habits, reinforcement of urotherapy strategies and ongoing support,” Dr. Villanueva says.
Educating parents and the child is a critical part of the treatment process. “It’s explaining to them – especially with bedwetting – it’s not because they’re lazy, it’s not that they don’t care. Their body just isn’t ready. Bedwetting is generally not behavioral. Negative reinforcement doesn’t work,” Goesch explains.