What is voiding dysfunction?

Voiding dysfunction is a broad term use to describe a voiding (urination) pattern that is abnormal for the child's age. A normal bladder stretches easily as it fills with urine. It does not contract or increase in pressure as it fills. As the bladder contracts during normal voiding, the external urethral sphincter muscle should completely relax so that the urine released from the bladder flows smoothly, completely, and without interruption. A problem in bladder filling or emptying is called a voiding dysfunction.

Voiding dysfunction can be the result of numerous causes:

• Behavioral problems or poor habits (eg, infrequent voiding, poor toileting habits, having too much fun or being too busy to break to go to the bathroom, being fearful of urinating due to a past painful urinary tract infection, attention deficit disorder, psychological or emotional stressors)
• Congenital (born with) problems in the physical anatomy of the urinary tract
• Acquired problems in the physical anatomy of the urinary tract (such as those caused by tumors or trauma)
• Central nervous system diseases and conditions that affect the urinary tract (eg, cerebral palsy, epilepsy, multiple sclerosis, other abnormalities of the brain or spinal cord that affects the nerves that control bladder or urinary sphincter function)
• Endocrine or kidney diseases that affect the urinary tract (eg, diabetes, chronic kidney disease)
• Genetic diseases that affect the urinary tract (eg, Ochoa syndrome, Williams syndrome)
• Infections or irritations that affect the urinary tract (eg, urinary tract infections, urethritis, pinworms, foreign body)
• Other causes can include stress incontinence (the involuntary loss of urine during activities such a coughing, or sneezing), giggle incontinence (see next page for definition), and delayed nighttime bladder control.

Signs and symptoms of voiding dysfunction include:

• Incontinence (urine leakage) during the day and/or night - often is the first sign noticed by parents that there is a problem
• Increase in urinary frequency and/or urgency (the need to void immediately)
• Urinary hesitancy, dribbling, intermittent urine flow and/or straining at urination
• Pain in the back, flank or abdomen
• Recurrent urinary tract infections
• Blood in the urine
• Infrequent urination - three or fewer voids in a 24-hour period
• Constipation and fecal soiling

Yes. Some of the more common types include:

Daytime wetting (also called diurnal enuresis): Daytime wetting can consist of either small urine leaks that spot or dampen underwear to the complete soaking of undergarments. Wetting occurs more commonly in the afternoon, as most children are anxious about wetting in school and work hard to stay dry.

Giggle incontinence: This is the complete emptying of the bladder that occurs with vigorous laughter or giggling.

Urge syndrome: This is frequent attacks of the need to void (at least seven times a day) countered by hold maneuvers, such as squatting. Urine loss is mild, represented by a dampening of undergarments.

Bedwetting (also called nocturnal enuresis): This is when a sleeping child cannot control his/her urination at night. This problem begins to be considered abnormal after the age of five.

Overactive bladder is a condition in which the large bladder muscle (detrusor) contracts involuntarily, causing symptoms including urinary frequency, urgency and or/or urge incontinence. Urinary incontinence is the involuntary leakage of urine. Urinary incontinence can range from the occasional leakage of urine to a complete inability to hold any urine and can be one symptom of overactive bladder.

If your child is experiencing a voiding problem, he or she will be referred to a pediatric nephrologist and a behavioral psychologist. Other members of the team might include pediatric urologists, pediatricians, family practice physicians, and nurse practitioners.

• Medical and social histories. The doctor will take a history of your child's voiding patterns and may ask you to create a voiding diary (to track frequency and volume). In addition, the doctor will ask about your child's bowel function (frequency, volume, caliber, staining, abdominal pain). A social history will be taken that includes such questions as how wetting affects the child, the child's school performance, presence of attention deficit disorder, history of problems with sensory stimulation (such as avoiding loud noises or certain touch stimuli).

• Physical and neurology exam. The doctor will then conduct a thorough physical exam, including examination of the back, rectum and genitalia (for anatomic abnormalities). The neurologic exam will include careful attention to the lower extremities, including tone, strength, sensation, and reflexes.

• Lab tests. A urinalysis, urine culture, and blood test (ie, serum creatinine level) are conducted to gain an initial view of kidney function.

• Other specialized tests. Certain radiologic and urodynamic tests (a test that provides details of bladder storage and emptying functions) may be ordered to help confirm the diagnosis and to document treatment effects. Other tests that may be ordered include:

Renal and bladder ultrasound -- to identify obstructions in the urinary pathway and the capacity of the bladder

Magnetic resonance image of the lower spine -- to identify any spinal cord abnormalities

A voiding cystourethrogram -- is a special type of x-ray to evaluate for possible vesicoureteral reflux (the backward flow of urine from the bladder to the kidneys). This test is most often conducted in children with a history of urinary tract infections.

A radionuclide cystogram -- is an alternative to a cystourethrogram; uses less radiation but pictures have lower resolution

A renal scan -- to determine the function and/or extent of damage to the kidneys

Treatment options are based on the underlying cause of the voiding dysfunction, severity of symptoms, and findings from the physical, laboratory, and medical test results. Treatment may consist of one or more of the following approaches. Your doctors will discuss which specific method(s) will be tried with your child.

Managing constipation. Proper management of constipation through the use of enemas, laxatives, and dietary fiber intake can reduce urinary wetting and urinary tract infections. Parents are encouraged to keep an elimination diary on the child. Over time, the stool softeners can be removed and the child remains on a high fiber intake.

Eliminating bladder irritants. Your doctor may recommend increasing your child's water intake to dilute the urine and eliminating caffeine, carbonated beverages, citrus juices, and chocolate - products thought to irritate the bladder and may make voiding uncomfortable for your child.

Treating urinary tract infections (UTI). A short course of antibiotics can be used in children with recurrent urinary tract infections.

Incorporating behavioral interventions. Behavioral interventions are tools and techniques children and their parents can use to gain control over voiding dysfunction. The goals of behavioral interventions are to help your child remain continent and empty the bladder effectively.

For nocturnal enuresis, an alarm system that rings when the bed gets wet can help the child respond to bladder sensations at night. The majority of research on bedwetting supports the use of urine alarms as the most effective treatment. Urine alarms are currently the only treatment associated with persistent improvement. The relapse rate is low, generally 5 to 10 percent, so that once a child's wetting improves, it almost always remains improved.

With daytime wetting and other types of voiding dysfunction, techniques such as increased water consumption, scheduled voiding (pee every 2 to 4 hours), high fiber intake, and Kegel exercises (contraction/relaxation) to strengthen pelvic floor muscles can be helpful. Relaxation and biofeedback may be used to help your child learn to relax as they void.

For some children, behavioral interventions are an adjunct (used in addition) to medications and other treatment methods. In other cases, these interventions are the primary treatment method. The behavioral interventions tried with your child will be individually tailored to his/her problems. They provide a means for helping your child learn to manage these problems independently.

Using anticholinergic medications. Anticholinergic medications, such as oxybutynin (Ditropan) or hyoscyamine (Levbid), are helpful in children with urge syndrome.

Surgery. Sometimes, though rarely, surgery is needed to correct an underlying anatomical problem that is the cause of the voiding dysfunction.

Miscellaneous treatment methods.

• If a young girl's genitalia is inflamed due to wetting, avoid soaping the area. Apply emollient creams. Soaking in baking soda and water may be helpful.
• Watches that quietly beep or vibrate can be purchased to remind your child that it is time to void.

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. For additional written health information, please contact the Health Information Center at the Cleveland Clinic (216) 444-3771 or toll-free (800) 223-2273 extension 43771 or visit www.clevelandclinic.org/health/.

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