Dawn Sandalcidi PT, RCMT, BCB-PMD is known as the go-to expert in the field of pediatric pelvic health. She has been practicing for 40 years this May and has concentrated on the pediatric pelvic floor for 29 of those. When it comes to pediatric pelvic floor issues, there is so much more than bedwetting, and often the practitioner needs to look beyond the pelvic floor.

Despite the growing number of pelvic rehab specialists treating men and women with PF dysfunction, children in this patient population remain woefully under-served. This can cause undue stress for the child and family, as well as the development of internalizing and externalizing psychological behaviors. Many of the techniques used in pediatric pelvic therapy can be translated to the adult population. The question is ‘who’s the driver?’ In pediatrics, it is typically a bowel issue.

The Standard American Diet involves food that is high in calories, saturated fats, trans fats, added sugars, and sodium. It is also lacking in the intake of essential nutrients for the body like fiber, calcium, potassium, and vitamin D. This lack of dietary fiber can cause issues with the digestive tract as well as the colon leading to constipation. Bowel dysfunction including constipation can contribute to urinary leakage and urgency (1). Constipation accounts for approximately 5% of visits to pediatric clinics (2) proving that there is a need for practitioners to know how to treat these pediatric issues.

Dawn focuses much of her pediatric knowledge on her two courses: Pediatric Incontinence and Pelvic Floor Dysfunction (PEDs) and Pediatric Gastrointestinal Disorders (PEDsG). Pediatric pelvic floor basics are covered in PEDs, including instruction in anatomy, physiology, development of normal voiding reflexes and urinary control, and learning how to talk with child patients. Biofeedback and ultrasound (which Dawn fondly calls jelly belly) are also covered and can be helpful as less invasive procedures for children.

PEDsG goes beyond the pelvic floor and opens up the door to look at the big picture of the whole child. Dawn shares that almost 80% of her kiddos with chronic constipation present with diastasis rectus abdominus. They can also have hyperextension in the thoracic spine, and the rib cage is postally rotated – where the kids don’t know how to bring it down.

Dawn is also on the threshold of writing a pediatric pelvic pain course that she expects to be ready later this year. Pediatric pelvic pain is becoming more prevalent, and it can’t be treated the same way as in adults. Dawn explains that “children don’t understand, so we’re actually creating a pediatric pain neuroscience protocol. It is a bio-psycho-social approach, and we use fun things.”

Research tells us that 15% of kids per year will outgrow bedwetting. Children who suffer from bedwetting can feel ashamed and embarrassed, have self-esteem issues, or even act out. There are 5 basics of where you start with a pediatric patient that are taught in PEDs. Dawn also shares 5 basics in her e-book, BEDWETTING BOOTCAMP(3):

1. Avoid things that can irritate the bladder
2. Avoid drinking anything just before bed
3. Drink throughout the day
4. Empty your bladder throughout the day
5. Avoid constipation and straining

Everything in Pediatric Incontinence and Pelvic Floor Dysfunction builds into Pediatric Gastrointestinal Disorders, and everything in PEDsG builds into Pediatric Pelvic Pain. The more practitioners who learn about the pediatric pelvic floor means that more kids get treated and the fewer adults that will have pelvic floor dysfunction. To learn more about treating pediatric pelvic health register for one of Dawn Sandalcidi’s upcoming courses:

Pediatric Incontinence and Pelvic Floor Dysfunction: August 27-28th

Pediatric Gastrointestinal Disorders: May 14-15, November 12-13

References:

1. Sandalcidi (Spring 2018). Paediatric incontinence and pelvic floor dysfunction. Journal of Pelvic, Obstetric and Gynaecological Physiotherapy, 122, 5–8.
2. 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.
3. Dawn Sandalcidi PT, RCMT, BCB-PMD. BEDWETTING BOOTCAMP Frustrated by Bed Wetting? The 5 Ways to Speed Starting Up Dry Tonight! www.kidsbowelbladderPMD.com. https://cdn.fs.teachablecdn.com/YfP5rUfiRtOJxXZSZUso

This is the second installment in our 3 part pediatric blog series written by Amanda Moe DPT, PRPC treats women, men, and children with disorders of the pelvis and pelvic girdleAmanda enjoys assistant teaching with the Herman & Wallace Pelvic Rehabilitation Institute in her free time as well as working out, practicing yoga, and spending time with her family. You can find Amanda online at www.pelvicphysicaltherapyandmore.com and on Instagram @amandampelvicpt.

Just as Mora from @PracticallyPerfectPT mentioned in the previous blog post, Big Issues for Tiny Humans, pelvic health specialists treat pelvic floor and pelvic girdles for all humans of all ages. This blog post aims to introduce why pre-teens and teenagers could need pelvic floor therapy for pee problems!

Pelvic girdle-related dysfunction in young children often manifests as bowel or bladder complaints such as constipation, poo leakage (fecal incontinence or encopresis), and day or nighttime pee leakage (incontinence or nocturnal enuresis). Young children can be potty-trained with NO pee or poo complaints for several years then suddenly develop these very same symptoms in the pre-teen or teenage years! Occasionally there is a cause for the change in pee or poo symptoms such as trauma, the birth of a sibling, moving to a new city, divorce, or other changes in family situation. However, oftentimes there isn’t a signifying event attributed to the onset of these symptoms—which is where assessment and treatment from a skilled Pelvic Physical Therapist (or Occupational Therapist) may be beneficial! 

Pediatric Pelvic Physical/Occupational Therapy

Pelvic Physical and Occupational Therapy in pre-teens and teenagers focuses on a whole-body assessment and treatment. Specifically, the Pediatric Pelvic Therapists will look at pelvic girdle influences on bowel and bladder complaints such as:

• Pelvic muscle tension
• Pelvic muscle strength
• Pelvic muscle coordination
• Abdomino-pelvic pressure management
• Load transfer 
• Breathing
• Pelvic girdle strength
• Core coordination and strength
• Bladder and bowel habits
• Food and fluid contributors

Common Urinary Complaints in Pre-Teens and Teenagers

Potty-training regression can occur and is commonly seen in Pediatric Pelvic Therapy. Below is a list of other pee problems commonly seen in pre-teens and teenagers (often addressed in Pelvic Therapy). 

• Strong urge to pee (urinary urgency)
• Frequent peeing
• Chronic UTI’s
• Urinary stream changes
• Nighttime bedwetting (nocturnal enuresis)
• Daytime leakage (urinary incontinence)
• Leakage with activity or sport (stress urinary incontinence or SUI)

Urinary leakage during sport or physical activity (SUI) can commonly arise in the pre-teen and teenage years. A recent systematic review determined that SUI occurs in 18-80% or an average of 48.58% of adolescent female athletes (7). While stress incontinence is common in women after childbirth, it doesn’t have to be considered “normal” for women OR children. This is where Pediatric Pelvic Therapy comes into play to determine the factors (such as those listed above) that are impacting a child's leakage during sport or activity!

The Lower Urinary Tract (LUT) symptoms listed above and specifically daytime pee leakage are prevalent in 10–17% of children (2, 4, 8). Gastrointestinal (GI) dysfunction such as constipation is commonly associated with these LUT dysfunctions in pre-teens and teenagers. Research has shown constipation in 22-37.5% of children with LUTS (3, 5) with an additional study reporting that greater than 50% of children with LUT symptoms had some type of functional defecation disorder (1). This is why Pediatric Pelvic Therapists often address the GI system when pre-teens and teenagers present with pee problems!

To learn more about the GI systems in adolescents and how these symptoms influence pee problems in Pediatric Pelvic Therapy, check out Dawn Scandalcidi's interview on Friday! Herman & Wallace also offers two pediatric courses featuring assessment and treatment of urinary and bowel functioning:

• Pediatric Incontinence and Pelvic Floor Dysfunction Remote Course - August 27-28th
• Pediatric Functional Gastrointestinal Disorders Remote Course - May 14-15th and November 12-13th 

Resources

1. Burgers R, de Jong TP, Visser M, Di Lorenzo C, Dijkgraaf MG, Benninga MA. Functional defecation disorders in children with lower urinary tract symptoms. J Urol. 2013 May;189(5):1886-91. doi: 10.1016/j.juro.2012.10.064. Epub 2012 Oct 30. PMID: 23123369.
2. Kajiwara M, Inoue K, Usui A, Kurihara M, Usui T. The micturition habits and prevalence of daytime urinary incontinence in Japanese primary school children. J Urol. 2004; 171(1):403–7. [PubMed: 14665943] 
3. Loening-Baucke V. Prevalence rates for constipation and faecal and urinary incontinence. Arch Dis Child. 2007; 92(6):486–9. [PubMed: 16857698] 
4. Malykhina AP, Brodie KE, Wilcox DT. Genitourinary and gastrointestinal co-morbidities in children: The role of neural circuits in regulation of visceral function. J Pediatr Urol. 2017;13(2):177-182. doi:10.1016/j.jpurol.2016.04.036
5. Muhammad S, Nawaz G, Jamil I, Ur Rehman A, Hussain I, Akhter S. Constipation in Pediatric Patients with Lower Urinary Tract Symptoms. J Coll Physicians Surg Pak. 2015 Nov;25(11):815-8. PMID: 26577968.
6. Neveus T, von Gontard A, Hoebeke P, Hjalmas K, Bauer S, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. J Urol. 2006; 176(1): 314–24. [PubMed: 16753432] 
7. Rebullido TR, Gómez-Tomás C, Faigenbaum AD, Chulvi-Medrano I. The Prevalence of Urinary Incontinence among Adolescent Female Athletes: A Systematic Review. Journal of Functional Morphology and Kinesiology. 2021; 6(1):12. https://doi.org/10.3390/jfmk6010012
8. Sureshkumar P, Jones M, Cumming R, Craig J. A population based study of 2,856 school-age children with urinary incontinence. J Urol. 2009; 181(2):808–15. discussion 815–806. [PubMed: 19110268] 

This week The Pelvic Rehab Report is featuring faculty member (and senior TA) Mora Pluchino, teaching assistant Amanda Moe, and faculty member Dawn Sandalcidi on the topic of pediatric issues from infancy through adolescence. Our first guest blogger, Mora Pluchino, PT, DPT, PRPC has published two books. The first of which is titled The Poop Train: Helping Your Child Understand Their Digestive System. This is a rhyming, kid-friendly book to help children understand how their poop is made. It has resources in the back to help parents and caregivers manage a child's digestive system for optimal function including proper voiding positions, ideas for activities to help voiding, fiber recommendations, fiber-filled food options, and belly massage instructions. Her second book, Practically Perfect Pelvic Health 101: A Visual Tour of the Pelvic Floor is a visual tour of the pelvic floor to help all genders and all ages understand general pelvic health. You can find Mora online at https://www.practicallyperfectpt.com/ and on Instagram @practicallyperfectpt.

As a pelvic health specialist, I treat the pelvic floors for all humans of all ages. I am frequently asked the question “Why would a child need pelvic floor therapy?” The response is “So many reasons!” 

Colic, gastroesophageal reflux disorder (GERD), and constipation are the top reasons for visits to a pediatrician in the first year (Indrio Et Al, 2014). As the mother of a child that struggled with all of these things, I can attest to the quality of life impact these diagnoses can create. A pelvic health specialist can help caregivers to manage these conditions with manual therapy, gross motor development assistance, and other infant care ideas to help manage the infant’s gastrointestinal system for better comfort and function.

Sillen (2001) reports that the neonatal bladder is controlled by neuronal pathways connecting with the cerebral cortex. The neonatal bladder function is characterized by small, frequent voids of varying volumes (Sillen 2001). Preterm infants had slightly different results thought to be due to an immature nervous system and this interrupted voiding disappeared for most as the children approached potty training age (Sillen, 2001). Still, infants born prematurely may be more at risk for pelvic floor issues!

What does this mean? There is a certain point in every child’s life where the bladder function, nervous system, and cognitive awareness match up. Ideally, this allows them to learn to hold and then void waste on a toilet. When toddlers are seen for pelvic floor issues, it is usually due to problems that arise during the potty training phase if they haven’t carried along with another pelvic floor issue from infancy. Pediatric pelvic floor issues, if not addressed early on, can continue on into preschool and elementary-aged children. 

Pediatric Incontinence and Pelvic Floor Dysfunction, instructed by Dawn Salicidi, reviews the basics of pediatric pelvic floor treatment. Pediatric pelvic floor issues can be divided into three categories: storage, voiding, and “other.” Storage issues include things like: increased or decreased voiding frequency, continuous incontinence, intermittent incontinence, enuresis, urgency, nocturia, constipation, and encopresis. Voiding dysfunctions present with hesitancy, straining, weak stream, intermittency, and dysuria. Other pediatric pelvic floor issues include symptoms like excessive holding, incomplete emptying, post micturition dribble, spraying, and pain in the bladder/ urethral/ genital areas. 

Pediatric pelvic health requires the knowledge and skills used for treating adults with the additional abilities to relate to the child and their caregivers to help them manage and improve their symptoms. There is no age limit on the benefits of pelvic floor treatment!

Join us on Wednesday for the next installment of the pediatric pelvic floor three-part series: Pee Problems in Pre-Teens and Teens by Amanda Moe, DPT, PRPC. Amanda has written a book, Pelvic PT for ME: Storybook Explanation of Pelvic Physical Therapy for Children. You can find Amanda on Instagram @amandampelvicpt. The series will conclude on Friday with an interview with long-time faculty member, Dawn Sandalcidi PT, RCMT, BCB-PMD. Dawn Sandalcidi is a trailblazer in the field of Pediatric Bowel and Bladder Disorders and can be found on Instagram @kidsbowelbladder.

References:

• Indrio F, Di Mauro A, Riezzo G, et al. Prophylactic Use of a Probiotic in the Prevention of Colic, Regurgitation, and Functional Constipation: A Randomized Clinical Trial. JAMA Pediatr. 2014;168(3):228–233. 
• Sillén U. Bladder function in healthy neonates and its development during infancy. J Urol. 2001 Dec;166(6):2376-81. 

Most people spend their days alternating between sitting and standing, changing positions constantly. How many of us take the time to think about the position of our coccyx, ilia, or sacrum? The coccyx typically is minimally weight-bearing in sitting, about 10%, just like the fibula. However, it can become a major pain generator if the biomechanics of the ilia, sacrum, and femoral head positions are not quite right.

Coccydynia and Painful Sitting is a course that can be related to all populations that physical therapists treat. A lot of patients will state “my pain is worse with sitting” which can mean thoracic pain, low back/sacral pain, and even lower extremity radicular pain.

Coccyx pain patients often have more long-standing pain conditions than other patient types. For the most part, the medical community does not know what to do with this tiny bone that causes all types of havoc with patient pain levels. Lila shares that "Sometimes treating a traumatic coccydynia patient seems so simple and I am bewildered as to why patients are suffering so long - and other times, their story is so complex that I wonder if I can truly help."

Lila Abbate discussed this in her past blog, Case Studies in Coccyx Pain. She wrote that "The longer I am a physical therapist, the more important the initial evaluation has become. Our first visit with the patient is time together that really helps me to create a treatment hypothesis. This examination helps me to put together an algorithm for treatment.

I hear their story and repeat back their sequence of events in paraphrase. Then I ask if there is any other relevant information, no matter how small or simple, that they need to tell me? Some will say, I know it sounds weird, but it all started after I twisted my ankle or hurt my shoulder (or something like that). I assure them that we have the whole rest of the visit together and they can chime in with any relevant details."

Determining the onset of coccyx pain will help you gauge the level of improvement you can expect to achieve. Coccyx literature states that patients who have had coccyx pain for 6 months or greater will have less chance for resolution of their symptoms. However, none of the literature includes true osteopathic physical therapy treatment, so I am very biased and feel that this statement is untrue."

The remote course Coccydynia and Painful Sitting is very orthopedically-based which takes Lila Abbate's love of manual, osteopathic treatment and combines it with the women’s health internal treatment aspects so that practitioners are able to move more quickly to get patients back on the path to improved function and recovery. The course looks at patients from a holistic approach from the top of their heads down to their feet. In taking on this topic, the course hones basic observation skills, using some of Lila's favorite tools: the Hesch Method, the Integrated Systems Model, and traditional osteopathic and mobilization approaches.

This course is designed to spark your orthopedic mindset, encouraging the clinician to evaluate the coccyx more holistically.

• What are the joints doing?
• How does it change from sitting to standing? Standing to sitting?
• What is the difference from sitting upright to slump activities?

Working through the basics and the obvious with failed results takes practitioners to the next step of critical thinking about how the patient presents, what seems to be lacking, and how to correct them biomechanically to achieve pain-free sitting?

This remote course provides 5.5 contact hours and the registration fee is $175. The 2022 scheduled course dates are:

• April 9
• June 5
• October 16
• December 3

Practitioners who have taken Sacroiliac Joint Current Concepts, Bowel Pathology, Sacral Nerve Manual Assessment and Treatment, Yoga for Pelvic Pain, or Ramona Horton's Mobilization of the Myofascial System courses may be interested in attending this course.

The following post comes from Dawn Sandalcidi PT, RCMT, BCB-PMD author and instructor of the Pediatric Incontinence and Pelvic Floor Dysfunction course, and the more recent follow-up course, Pediatric Functional Gastrointestinal Disorders. Dawn has developed a pediatric dysfunctional voiding treatment program in which she lectures on nationally. She has further studied pediatric conditions in post graduate work at Regis University. Dawn has published articles in the Journal of Urologic Nursing, the Journal of Manual and Manipulative Therapy, and the Journal of Women’s Health Physical Therapy.

Growing up, I was blessed to be around children with Cerebral Palsy (CP), which stimulated my desire to become a physical therapist, a career that I love more now than when I started nearly 38 years ago!

Did you know….

The incidence of Cerebral Palsy in Nepal is estimated to be over 60,000. The Self -Help Group for CP estimate that 80% of children (and adults) also present with bowel and bladder leakage which significantly affects their quality of life and leads to infections and other medical complications. Additionally, a recent pilot study revealed an incidence of urinary leakage in school children aged 10-16 years at 73%, as compared to 6-13% in developed countries. This has shown me a clear and meaningful need to help CP kids in Nepal who are tragically affected.

Pictures from http://www.cpnepal.org/about.html

Through a partnership with the University in Nepal, I will be training Nepali Physical Therapists how to treat children with bowel and bladder issues. Nepal currently does not have any trained providers - this training will provide sustainability as these providers will be able to treat multiples of children with bowel bladder issues, in addition to strategies for prevention. The plan is also to visit several villages with a Self-Help Group for Cerebral Palsy children to educate families and caregivers how to manage incontinence and constipation in these children.

I need your help to accomplish this!

I will be donating a 3-day training for PT’s and several caregiver trainings for this project. With your help I can secure needed supplies, bring physical therapists from remote villages to the course and help with travel expenses.

The Prometheus Group has generously donated an entire biofeedback system with pediatric animation to the hospital, but additional lead wires and electrodes are needed to run the system.

What’s needed?

• Supplies for treatments
• Electrodes for 1 child $4.60 x 100 =$460
• Additional lead wires and adaptors - $340 per set – 2 sets per year= $680.00
• Airfare and Travel Expenses (Hotel, etc.) to help offset the costs of - $3,750.00

My goal is to raise approximately $6,000 to help improve the quality of life for these children.
Your Support Will Make a Great Impact:

• $50 will help pay for electrodes for 10 children
• $150 will bring a physical therapist from a remote region to the course
• Any $ amount will help me educate the therapists in Nepal to sustain the program and treat thousands of children = PRICELESS

A donation of any size will make a difference and will be tremendously appreciated. Please consider donating an amount that feels comfortable to you and know that you are impacting the health, well-being and quality of life for Nepalese children.

This is a personal mission - I’m asking for a personal donation (which unfortunately is not tax-deductible) to help me make a difference in the lives of these children. My hope is to train the physical therapists in Nepal who will in turn continue to train others. Training the trainers is the most sustainable way for me to begin this grass-roots process.

I need to be funded by February 29!

3 Options for donations
1. Venmo @Dawn-Sandalcidi- no fees
2. https://fundly.com/nepal-2020-1 (fees apply)
3. Mail a check directly (no fees) to:
 3989 E. Arapahoe Rd #120
 Centennial, CO 80122

Thank you so much for your consideration!
Dawn Sandalcidi

“What's wrong with children?”

As pelvic health physical therapists we take care of people suffering from bladder and bowel incontinence and/or dysfunction as well as pre-natal/ post-partum back pain, weak core muscles and pelvic pain. I was approached over 30 years ago by a urologist to take care of his pediatric patients. My reply: “What’s wrong with children?” It’s been a whirlwind of learning since that day!

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

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 also a pediatric issue with significant negative quality of life impact for both 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 considerable stress and anxiety for children (Austin, 2014; Neveus, 2010).

Additionally, bowel dysfunction, such as constipation, is a contributor to urinary leakage or urgency. With nearly 5% of pediatric office visits occurring for constipation (Thibodeau 2013, NIDDK, 2013), the need to address these issues is great!  And, since pediatric bladder and bowel dysfunction can persist into adulthood, we must direct attention to the pediatric population to improve the health of all our patients.
Children suffer from many diagnoses that affect the pelvic floor including (Austin et al, 2014);

• Voiding dysfunction
• Enuresis (Bedwetting)
• 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 muscles while emptying the bladder. (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.
 

“What do we do to teach the pelvic floor (Kegel) muscles to work?”

Common questions I am asked include:

• Can I use biofeedback with children?
• Do we complete internal assessments on pediatric patients?
• 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) through positioning and breathing. The exercises are fun and easy to do. We also incorporate the core! What a wonderful opportunity we have to educate the younger population on these vital muscles as well as proper diet and bowel/bladder habits!

It is not typical to complete an internal pelvic muscle assessment on children, as this would not be appropriate.

“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 management-based program used to treat lower urinary tract (LUT) dysfunction. (Austin 2014)

Basic Urotherapy includes education on the anatomy, behavior modifications including fluid intake, timed or scheduled voids, toileting postures and avoidance of holding maneuvers, diet, avoiding bladder irritants and constipation. Parents are often not aware of their children’s voiding habits once they are cleared from diaper duty after successful potty training occurs.

Urotherapy alone can be helpful however a recent study (Chase, 2010) demonstrated a much greater improvement in those patients who received pelvic floor muscle training as compared to Urotherapy alone.

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 can teach the child how to alter pelvic floor muscle activity specifically for voiding. Cognitive behavioral therapy and psychotherapy are also important and can be a needed in combination with biofeedback in specific cases.

As you can see, PFM exercise 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?

When we think of pediatric bowel and bladder issues, we primarily focus on what is happening to cause the bowel or bladder leakage and treat it accordingly. It is imperative to teach a child that she/he did not have an “accident”, but their bladder or bowel had a leak. It makes the incident a physiological problem and not something they did. See my blog post on “Accident” for more information.

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 caregivers 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.
You can learn more about treating pediatric patients in my courses,

Pediatric Incontinence and Pelvic Floor Dysfunction and Pediatric Functional Gastrointestinal Disorders.

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.

When my 6 year old daughter ran to the bathroom 3-4 times before she got on the school bus every morning, I wasn’t too concerned, but I definitely took note. The day she was in tears and wouldn’t get off the toilet because she felt like she was still wet, I got worried (although slightly intrigued). No matter how much she wiped, she still felt wet. When she stood up, she felt like she was going to pee herself, making my sweet-natured girl slip into hysterics. After eliminating small amounts of urine 8 separate times in 3 hours and saying it burned, I assumed she had a urinary tract infection (UTI). A simple urine test ruled out UTI or diabetes (thankfully!). So then, what was my daughter’s diagnosis? The pediatrician simply referred to it as “a phase;” however, I had researched the symptoms before the visit.

In 2014 Arlen et al. described a condition called “phantom urinary incontinence.” This refers to the situation when children experience the sensation of being wet (a presumptive urinary incontinence) when they are objectively dry. They considered 20 children (18 females, 2 males) referred to their pediatric urology clinic over a 5 year span, all who were all diagnosed with phantom urinary incontinence (PUI). The authors evaluated the concomitant diagnoses found among the boys and girls in the study. Lower urinary tract symptoms were present in 95% of the subjects. Associated bladder symptoms were found as well, with urgency in 75% and frequency in 50% of the children. Vaginitis occurred in 72% of the girls. Parents reported obsessive-compulsive disorder or obsessive-compulsive disorder personality traits in 70% of the children. In order to treat these patients, dietary modifications, timed voiding, and a bowel regimen were implemented to manage symptoms. A follow up at 14.4 months revealed 90% of the children’s bowel-bladder dysfunction improved and PUI resolved. The authors concluded children compliant with a rigid bladder-bowel regimen experience relief of their “phantom” incontinence as well as lower urinary tract symptoms, and a majority of PUI patients have obsessive-compulsive traits.

Oliver et al., (2013) studied how psychosocial comorbidities and body mass index relate to children with lower urinary tract dysfunction. Data on 358 patients with lower urinary tract dysfunction between 6 to 17 years old was collected, and the subjects’ parents completed questionnaires screening for lower urinary tract symptoms, stressful life events, and psychological comorbidities. Obesity was present in 28.5% of the children, 22.9% had a recent stress in life, and 22.9% had a psychiatric disorder. Under and overweight children, children with a recent life stressor, psychiatric disorder, or both, as well as the younger-aged children all had lower urinary tract symptom scores significantly higher than healthy weight subjects, those without psychosocial comorbidities, and older subjects. The results encourage screening for psychosocial issues and obesity in pediatric patients with lower urinary tract dysfunction.

Having read the research, I knew a life stressor was likely contributing to my daughter’s symptoms. I had already advised her to sit on the toilet every 1-2 hours, don’t let her bladder get too full, wipe gently from front to back, stop bubble baths, and wear looser pants. To conclude our $76 session, the doctor prescribed almost verbatim what my daughter had heard from me at home. Although thankful it wasn’t something more serious, I am curious what the diagnosis code is for “a phase” and when it will end.

Arlen, AM, Dewhurst, LL, Kirsch, SS, Dingle, AD, Scherz, HC, Kirsch, AJ. (2014). Phantom urinary incontinence in children with bladder-bowel dysfunction. Urology. 84(3):685-8. DOI: http://dx.doi.org/10.1016/j.urology.2014.04.046 Oliver, J.L., Campigotto, M.J., Coplen, D.E. et al,. (2013). Psychosocial comorbidities and obesity are associated with lower urinary tract symptoms in children with voiding dysfunction. The Journal of Urology. 190:1511–1515. DOI: http://dx.doi.org/10.1016/j.juro.2013.02.025

How often have you heard that bedwetting was behavioral or caused by deep sleep and your child would outgrow it? 15% of children per year will “outgrow” bedwetting. What if your child is in the percentile at the end of that range?

Facts:

• Bedwetting affects 15% of girls and 22% of boys
• 5 - 7 Million US children
• Boys are 50% more likely than girls to wet the bed
• 10% of 6 year olds continue to wet
• Spontaneous cure rate 15% per year thereafter
• 1-3% of 18 year olds still wet their beds
• Less than 50% of all bedwetting children have bedwetting alone, without also experiencing daytime urinary leakage or constipation
• Bedwetting is genetic – if one parent was a bed wetter the child has a 40% chance of wetting the bed and if both parents were bedwetters the percentile goes up to 77%

Myths:

• Your child is lazy
• Your child is doing this to get attention
• Your child is just a deep sleeper
• You must wait to grow out of it

Research from the International Children’s Continence Society (ICCS) is a great resource for exploring the research on this topic and other pediatric voiding issues. www.i-c-c-s.org

What causes Bedwetting?

There are many philosophies discussed in the research. Here are some listed below:

1. Hormone deficiency- our bladders empty about every 2-3 hours during the day however at night we can hold over 8 hours! This happens because our bodies produce an antidiuretic hormone when we sleep to slow kidney function and produce less urine to empty into the bladder. If this hormone is not being produced, the kidneys produce as much urine at night as they do during the day. In this case, it's good that the bladder empties out in our sleep, otherwise our bladders would be dangerously large and possibly reflux urine backward into the kidneys. Clearly not behavioral!!
2. Dr. Steven Hodges has researched and written extensively on the topic of constipation causing pressure from the rectum against the bladder making it irritable during sleep. His research has supported the fact that once the bowel is cleaned out daily the bedwetting episodes diminish. See It’s No Accident by Dr. Hodges or visit https://www.bedwettingandaccidents.com for more information on this topic. Again, a physiological cause of bedwetting versus behavioral.
3. Sleep Disturbance and Nasal Airway Obstruction. Dr. Neveus and colleagues reported that 43.5% of children with snoring or obstructive sleep apnea became dry after adenotonsillectomy. Dr. Kovacevic also found increases in antidiuretic hormone seen in responders post-operatively.

Take Home Message

1. Active treatment for bedwetting should begin at age 6
2. The impact of bedwetting is mainly psychological and may be severe
3. Children with bedwetting have abnormal psychological test scores, however once the bedwetting is resolved the test scores return to normal
4. “Treatment is not only justified but mandatory”
   -ICCS Standardization document 2010

There is help!

At Physical Therapy Specialists we specialize in bedwetting, urinary leakage, constipation and other voiding issues in children. Let us eliminate the need for your family to suffer through this very treatable condition!

Al- Zaben FN, Sehlo MG. Punishement for bedwetting is associated with child depression and reduced quality of life. Child Abuse Negl. 2014
Hodges SJ, Colaco M. Daily enema regimen is superior to traditional therapies for nonneurogenic pediatric overactive bladder. Global Pediatric Health, 2016, 3: 1–4
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.
Treatment response of an outpatient training for children with enuresis in a tertiary health care setting. J Pediatr Urol. 2012.
Hodges SJ,Anthony EY::aunrecognizedof. Urology.2012 Feb;79(2):421-4. doi: 10.1016/j.urology.2011.10.015. Epub 2011 Dec 14.
Kovacevic L, Wolfe-Christensen C, Lu H, Toton M, Mirkovic J, Thottam PJ, Abdulhamid I, Madgy D, Lakshmanan Y. Why does adenotonsillectomy not correct enuresis in all children with sleep disordered breathing? J Urol. 2014 May;191(5 Suppl):1592-6.
Nevéus T, Leissner L, Rudblad S, Bazargani F. Acta Paediatr. 2014 Jul 15. doi: 10.1111/apa.12749. [Epub ahead of print]Orthodontic widening of the palate may provide a cure for selected children with therapy-resistant enuresis.
Hodges, Steve J. It’s No Accident-Breakthrough solutions for your child’s wetting, constipation, UTI’s and other potty problems. © 2012. Lyons Press, Guilford, Connecticut.

When my almost 4 year old still wets his bed in the middle of the night, my first reaction is frustration; but, I learned that gets us nowhere fast, so now I just roll with the punches. Usually the culprit is my stubborn son’s simple refusal to go the bathroom before bed. When enuresis is secondary to neurogenic disorders or anxiety disorders, caregivers need to have even more patience with children.

Sturm and Cheng (2016) published a review on the management of neurogenic bladder in the pediatric population. Central nervous system (CNS) lesions including cerebral palsy, spinal cord injury, and spinal malformations, as well as pelvic tumors or anorectal malformations, can all affect normal lower urinary tract function. Children with neurogenic bladder often have the condition because of a CNS lesion. This can affect the bladder’s ability to store and empty urine, so early intervention is essential and focuses on maximizing bladder function and avoiding injury to the upper or lower urinary tracts. With older children, the goals are urinary continence and independent bladder management.

Myelomeningocele surgical prenatal closure has had minimal effect on urinary tract function, and parents are encouraged to monitor urological changes because of the child’s risk for neurogenic bladder. Clean intermittent catheterization (CIC) has reduced the morbidity in patients with neurogenic bladder. Determining which children would benefit from initiation of CIC and when medical or surgical interventions should be implemented remains a challenge. Anticholinergics have proven effective on continence and bladder compliance either orally or, more recently, intravesical administration. Surgically, autologous augmentation using the ileum or colon has shown fatal complications like bowel obstruction and bladder rupture, particularly when bladder neck procedures are performed concurrently. Robotic versus open bladder neck reconstruction has been proving more favorable in recent studies. The authors concluded more research is needed for treatment, and the goals are preservation of the upper and lower urinary tracts, optimizing quality of life (Sturm and Cheng 2016).

Considering a different side of nerves, Salehi et al., (2016) studied the relationship between primary nocturnal enuresis and child anxiety disorders. They studied 180 children with primary nocturnal enuresis (referring to children >5 years old having no urine control 6 continuous months) and 180 healthy controls. A statistically significant difference was found between the two groups regarding the frequency of generalized anxiety disorder as well as panic disorder, school phobia, social and separation anxieties, maternal anxiety history, parental history of primary nocturnal enuresis and body mass index. The authors recommended any children with primary nocturnal enuresis should be assessed and treated for generalized anxiety disorder.

The seriousness of enuresis cannot be underestimated. When the cause is neurogenic, pharmacological or surgical intervention may be warranted and lifelong urologic management is needed, especially for a healthy transition into adulthood. As common as nocturnal bed wetting may be in school aged children, they should be monitored for the presence of any anxiety disorders that may be contributing to the disorder. Changing sheets may feel like a burden for parents, but the child with enuresis has a far greater weight to bear.

You can learn all about caring for pediatric patients by attending Pediatric Incontinence and Pelvic Floor Dysfunction with Dawn Sandalcidi, available twice in 2017.

Sturm, R. M., & Cheng, E. Y. (2016). The Management of the Pediatric Neurogenic Bladder. Current Bladder Dysfunction Reports, 11, 225–233. http://doi.org/10.1007/s11884-016-0371-6
Salehi, B., Yousefichaijan, P., Rafeei, M., & Mostajeran, M. (2016). The Relationship Between Child Anxiety Related Disorders and Primary Nocturnal Enuresis. Iranian Journal of Psychiatry and Behavioral Sciences, 10(2), e4462. http://doi.org/10.17795/ijpbs-4462