Voiding Dysfunction in Children
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.
What causes voiding dysfunction in children?
Voiding dysfunction can be the result of numerous causes:
(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
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,
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.
- Behavioral problems or poor habits
What are the symptoms of voiding dysfunction?
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
- Urinary hesitancy, dribbling, intermittent urine flow and/or straining at
- 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
Are there different types of voiding dysfunction?
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
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.
What is the difference between voiding dysfunction and overactive bladder?
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
How is voiding dysfunction diagnosed?
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.
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:
-- to identify obstructions in the
urinary pathway and the capacity of the bladder
Renal and bladder ultrasound
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
How is voiding dysfunction treated?
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
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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