Dysfunctional voiding means, the child does not empty the bladder normally. It may mean that the person waits too long to urinate, or passes urine very frequently or even tries to urinate when the muscles that prevent urination are still closed. The child’s symptoms will, therefore, vary accordingly.
These are often confusing to parents, their teachers at school, and even doctors, who may label the child as immature or lazy.
Typically they are seen has been so engaged in an enjoyable activity that they rush to the toilet only when the pressure is very high. They come back from school or play, with wetting of their underclothes or with fecal soiling of their underclothes. It may also be frequency and urgency to urinate, urinary tract infection, or even kidney damage. Lots of children with dysfunctional voiding also have problems with their bowel movement. Commonly it is dismissed as the problem that the child will eventually outgrow.
Quite often, these children become socially isolated and develop low self-esteem. Importantly, these children are at an increased risk for urinary tract infections, and potential renal damage.
In infants, the bladder fills and empties without control. Normally when the bladder fills up, the sphincter contracts. During urination, the sphincter muscles relax and the bladder contracts. As the child grows, this emptying of the bladder is stopped through the signals from the brain. This type of brain control of the bladder is what is termed as “toilet trained” or “potty trained”.
Generally, children gain control over bowel movement by age three, and bladder control by age four. During this period, that is, 3-7 years of age that for some reason, children develop the pattern of contracting their muscles at the same time that the bladder contracts (see the pictures below). Unfortunately, once children begin this, it is difficult to unlearn easily.
Constipation also occurs frequently in children with dysfunctional voiding. This may be because the same groups of muscle for urination also help control bowel movements. Children do not complain of constipation like adults. They are not even aware. It is suggested mainly by infrequent bowel movements, stool streaks in the underwear, or recurrent abdominal pain.
Types of Dysfunctional voiding
- Small bladders: These bladders hold less than the normal amount of urine for their age. This means that the bladder feels full even with a small amount of urine, and may even empty without the child wanting to urinate.
- Large bladders: Some children do not void frequently enough and the bladder holds a much larger quantity than normal amount of urine. Over a long period of time, these bladders become stretched out and flabby.
- Voiding against a closed sphincter: children are unable to relax the sphincter muscles when trying to urinate. Because the bladder generates high pressure against the kidneys, and it may force urine backward into the kidney, and may cause urine infection, and damage the kidneys.
- These may also be associated with constipation and has an additional adverse effect on bladder dysfunction.
A complete history and physical examination are essential to determine the nature of voiding dysfunction, plan treatment, and rule out neurologic or anatomic defects.
The presence of social, emotional and behavioral problems should be assessed, as these may be obstacles to effective behavior management.
This should include signs of fecal loading and constipation, spina bifida and other forms of neurogenic bladder. The urological examination should cover the genital region, the vagina, and signs of an ectopic ureter.
A 3-day bladder and bowel diary, blood and urine tests, ultrasound studies, a voiding cystogram (see the film below), with other tests as indicated, will be performed to identify and quantify the degree of the dysfunctional voiding.
The management of this child to return to normal may take anywhere from 6 months to 3 years to return to normal. This should be explained to the family, to ensure commitment and compliance over this period. There is no short cut too early recovery.
The details of management are in Urotherapy PIB.
The outcome for these children if properly managed is very good. Family support to the child is very critical. With good results, parents begin to see the child differently rather than lazy. The good outcome is a tremendous reward in overcoming such a frustrating problem.