Dysfunctional Elimination Syndrome

Voiding Dysfunction/Constipation

Urination is a complex function and often misunderstood.  It involves the coordination of two completely different muscle systems.  The bladder is smooth muscle and stores urine (up to several ounces depending on the age of the child) and the sphincter muscle (which we can control) keeps the urine from leaking out.  Once the bladder is full, it signals the brain to be emptied.  The sphincter muscle must then relax, and the bladder muscle contracts so urine can flow.

Voiding Dysfunction



Voiding Dysfunction


Few things are more distressing to a family than having a child who is continuously wet.  The child suffers the ridicule of his classmates, the odors are offensive, the laundry mounts, and the child agonizes over his helplessness in bringing the end to the seemingly intractable problem. It becomes increasingly difficult for the child to hold back such a powerful bladder and he may be seen, at times, doubled over with lower abdominal cramps arising from the bladder or wetting himself despite his best efforts to hold it back. If the family can take any comfort from any of this, perhaps it comes form the realization that the problem is common and that children generally outgrow it.  In the meantime, however, the agony continues and there exists a small subgroup of these children who actually damage their urinary tract in the process.  These are legitimate reasons to want to get to the bottom of this problem quickly and bring it under control.

Although there are some children who are wet from purely anatomical causes, the bulk of those afflicted are wet because they have acquired an abnormal pattern of urination in which the various parts of the urinary tract are not working together in a coordinated manner.  Fortunately, that pattern can be changed into a normal one with a proper training program.

The purpose of this primer is to enlighten the family as to the mechanisms of normal and abnormal voiding so that they can take part in the training program in an informed way.  Once the reason for the problem is recognized, the battle is half won.

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The pattern of abnormal voiding behavior seen in children can be quite variable.  Some children hold the urine for extensive periods, overstretching their bladders, yet when they finally do urinate, they urinate with perfectly normal coordination.  Other children have difficulty relaxing the sphincter during urination and void against the sphincter, straining the bladder muscle extensively in the process.  The outcome is inefficient voiding.  All of these abnormal voiding patterns may also be associated with constipation.  These patterns collectively are referred to as dysfunctional elimination syndrome (DES).

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Infection occurs commonly with voiding dysfunction.  The normal bladder is remarkably resistant to infection under ordinary circumstances because of its ability to wash out and thus eliminate bacteria with every urination.  If, however, urine is held too long or is incompletely discharged, bacteria may increase.

The high pressure generated by muscles straining against themselves may break down the one-way mechanism of urine flow which normally prevents urine from going back up into the kidneys from the bladder.  It may also impede the flow of urine from the kidneys into the bladder.

Urination occurs then, not because we voluntarily contract the bladder, but rather because we release the bladder, while it is under tension, by relaxing the sphincter.  So fundamental to urination is the cooperation between bladder and sphincter that the activity is carefully coordinated by the nervous system through a reflex arc centered in the base of the brain.  Newborn infants do it automatically.  What then goes wrong in children with voiding dysfunction?

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Although an individual cannot willfully contract his bladder muscle, he can willfully contract his sphincter muscle.  In some respects, it is simple to stop urination than it is to start it.  As infants grow into children and become more aware of their bladders they are overcome with the desire to control their bladders and not wet themselves every time the bladder reflex is ready to kick off.  They learn to do this very early in life by overriding the normal tendency of the sphincter to relax; they forcibly contract their sphincter instead, thus preventing any urine from escaping.

This forced contraction of the sphincter to hold urine back is a normal reaction of children to prevent wetting and is not particularly harmful provided that the child uses those few moments to get to the bathroom where he can relax the sphincter and let the urine escape.

If, however, the child continues to maintain his sphincter contracted against a straining bladder, an unhealthy situation develops in which the two muscles strain against one another.  Over time, the bladder wall may reach two to three times its normal thickness because of enlargement of its muscle fibers which now stand out like the muscles of weight lifters.

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Although voiding dysfunction appears to be an acquired disorder (i.e., they are not born with it), the cause is not always clear.  In general, these children tend to be bright, busy, even hyperactive at times.  Because proper voiding requires relaxation above all else, it is understandable that a busy child, anxious to get back to play, may not take the time to perform the act of urination as conscientiously as he should.  Furthermore, any social or family pressures may interfere with proper relaxation.

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In most instances, voiding dysfunction can be diagnosed by the characteristic history of holding the urine back until the last minute, voiding explosively or intermittently, or involuntary wetting.  The history often begins around the time of potty training as a child first begins to exert voluntary control over urination.

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Because voiding dysfunction is basically a lack of coordination between the bladder and sphincter, the key to treatment centers on a voiding retraining program.  Fortunately, the normal reflex which coordinates bladder and sphincter is so strongly ingrained in the nervous system that all that is required is to stop the voluntary overriding of the sphincter and allow the system to go back to its normal function.  However, this may not be easy.  The pattern of tightening the sphincter may, by now, be well established in the child and the thickened bladder muscles may be particularly difficult to hold back.  Nonetheless, with proper attention to a bladder retraining program, the abnormal pattern of voiding can be broken and the normal pattern restored.

Bladder retraining is based on the principle of taking all the pressure off the bladder to allow its strained muscles to recover.  To do this, two important principles are incorporated into the bladder retraining program:

1. Frequent voiding
2. Complete voiding

The time of voiding should be determined in advance and one should rigidly adhere to the schedule.  Generally, a voiding schedule of every 2 hours during the day is selected and marked on a voiding calendar or diary (Example Diary), and the child should then be sent to the bathroom at the appointed time without regard to his perception of whether or not he needs to void.

This voiding routine is effective, however, only if the bladder is emptied completely.  The stretched smooth muscle of the bladder will empty the bladder completely if released and allowed to do so without interruption.  But if contraction of the sphincter occurs during voiding, interrupting the stream and the bladder contraction, the bladder contraction may be lost.  The bladder, though still not empty, may not be under the tension it was at the beginning of urination and thus possibly may not be started again.  The child is likely to announce that he has finished and is ready to go out and play again, even though his bladder is still half full.

In general, if a child voids every 2 hours and empties his bladder completely, he will keep the pressure in his bladder down to a level where the muscles will recover and normal function will be restored.

The expenditure of time and energy to normalize voiding in these children can be exhausting to the parents and child alike, and there is a decided tendency to quit these training sessions in favor of simpler or less time consuming approaches.  The parents will often tell the child to do this himself or else rely on medication to correct the problem.  The result of such short cuts is inevitably failure.  There is no substitute for the discipline required in voiding by the clock, concentrating on a continuous stream at every void, and maintaining careful records in a voiding diary.  Progress can be slow at times, but only with proper dedication to the effort can success be achieved.

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Q. Will surgery be required?
A. This is a problem in coordination not an anatomical disease; thus, the primary disorder is not amenable to surgery. Consequences of voiding dysfunction, however, may require surgery.

Q. How long is treatment required?
A. This varies depending on the specific type of voiding dysfunction present and the secondary changes that may have occurred. Usually, improvement is evident quickly, but complete reversal of the basic abnormal habit pattern takes months. Generally, the family should be expected to commit 6 months to 1 year to the retraining program.

Q. Do relapses occur?
A. Relapses are common during the early treatment phase and are usually due to a lapse in following the retraining program vigorously. Once a pattern of normal voiding is established, however, it is usually durable.

Q. Will my child outgrow this?
A. Yes. In fact, many children will finally outgrow the problem and acquire the necessary coordination spontaneously, even without treatment. This may take some time, however, and significant psychological and even organic urinary tract damage may occur in the interim. Thus, aggressive, early treatment seems justified.

Q. My child seems to have to go to the bathroom every 15 minutes. How will a program of voiding every 2 hours help this?
A. Most children’s bladders will hold 2 hours of accumulated urine without any difficulty. If he has to void more often that this, it is usually due to one of two problems. The first is that he may not be emptying his bladder when he goes but instead is just squeezing a little off the top so that he quickly fills back up to capacity. The other possibility is that the bladder has been strained to the point it has gone into spasm and will not stretch.

Q. My child can’t seem to feel the need to urinate. The urine just runs out without his seeming to realize it. Does he have something wrong with his ability to feel?
A. Probably not. We feel sensations because of the change in pressure on pressure receptors. Push your eyeglasses up over your forehead and leave them there. After a while you will no longer notice them because there is no longer any change in pressure upon the scalp. You feel the bladder full because it feels different from an empty bladder. If the bladder stays full all the time, this sensation of fullness gets lost. Usually, as the bladder begins to empty more effectively, the normal sensation of empty and full begins to return.

Modified from:  Parents Primer to Normal and Abnormal Voiding in Children National Kidney Foundation of Texas.

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Constipation is difficult to define but includes painful passage of stools, inability to pass stools, or infrequent and large stools (BRISTOL STOOL CHART).  Infrequent stools are typically defined as going 3 or more days without having a bowel movement.  Sometimes constipation presents as stool leakage in the underwear (encopresis).

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Although many things, such as family tendencies, stress, and some medications can contribute to constipation; diet is often the main problem.  Inadequate fiber and fluid intake, as well as excessive milk and dairy products can cause constipation.  When stools move too slowly through the bowel, excess water is absorbed by the body, making the stool hard.  Over time, the rectum can stretch and the urge to move the bowels can be decreased.  This can result in what might appear to be diarrhea, where liquid stool leaks around the hard stool and can cause the child to have leakage of stool into the underwear.

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Constipation is the most common associated problem seen in children with various bladder problems, including day and nighttime wetting and urinary tract infections.  With severe constipation, the bowel presses on the bladder and can interfere with normal bladder function.  There is also close association between the muscles that control both urine and bowel function.  Sometimes, correcting the constipation alone results in improvement in bladder function and a reduction in the number of urinary tract infections.

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Diet is the key in treating and preventing constipation.  A diet that is high in fiber and provides enough liquid is important.  Fiber is a natural laxative, and is found primarily in fruits, vegetables, and grains.  Since fiber increases the water in the stool, making it soft, bulky, and easier to pass; adequate fluid intake is needed (at lease 4-6 cups a day).  For children ages 3-15, add 5 to the child’s age to determine the number of grams of fiber recommended per day.  For example, a 7-year old needs 7+5 = 12 grams of fiber each day.  You may want to gradually increase fiber intake over a 2-week period to reduce abdominal fullness sometimes associated with a high fiber diet.  It is also helpful to limit foods that are constipating, including dairy products such as cheese and milk.  A high fat diet tends to slow down the bowel and can contribute to constipation.

In addition to diet, exercise is also helpful in preventing constipation.  Encourage regular activities and limit time watching TV.  Set a good example for your child by exercising yourself and planning family activities, such as a weekly walk in the park.

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Encourage your child to establish a regular bowel pattern by sitting on the toilet for 5-10 minutes after meals, especially breakfast.  A warm beverage, such as cocoa or hot apple cider, may help stimulate a bowel movement.  There needs to be adequate time to sit on the toilet and relax.  Sometimes a young child can relax better if a small stool is placed to support the feet.  A diversion, such as a book, can help a child sit and relax for a few minutes.  A timer may be helpful if your child resists sitting on the toilet.  Positive reinforcement may help the child cooperate with the program.  Do not force your child to sit on the toilet.  Encourage your child not to ignore the urge to have a bowel movement.  This can be a problem if the child has had hard, painful stools, and tries to hold back stools because fear of pain.

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Sometimes medication is needed if a child is very constipated and needs “cleaned out” before dietary changes are going to work.  What type of medication and length of time needed is individually determined.  Stool softeners and lubricants make the stool soft and easier to pass, but do not stimulate the bowel to move the stool through more quickly.  Examples of stool softeners and lubricants include docusate sodium (Colace), mineral oil, and Kondremul.  Laxatives are used to irritate the bowel and help the stool move through faster.  Common laxatives include bisacodyl (Dulcolax), senna (Senokot), and Milk of Magnesia.  Other medications work by adding bulk to the stool as fiber, such as polycarbophil (FiberCon, Fiberall), or psyllium (Metamucil).  A new laxative that acts by pulling water into the bowel and making stool easier to pass is MiraLax.  Children can become dependent on laxatives if they are given on a regular basis, so they should not be used long-term.  Ideally, constipation should be managed with diet on a long-term basis.

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Fruits and vegetables, especially raw with the skin on, are good fiber sources.  Some examples are prunes, figs, dates, raisins, peaches, apricots, pears, and apples.  A whole orange instead or orange juice is a better breakfast choice, providing 3.8 grams instead of less than 0.5 grams in juice.

Beans, peas, cauliflower, celery and broccoli are examples of high fiber vegetables.  Bran is an excellent fiber source, found in some “natural” cereals, bran flakes, bran muffins, shredded wheat, graham crackers, oatmeal, brown rice and whole wheat bread.  Try to choose a cereal with 5 grams of fiber per serving, or mix a high fiber cereal with another cereal your child enjoys.  Popcorn is a good snack for children over 4 years old.

Foods with no fiber include dairy products, meats, poultry, fish, eggs, fats, and sugars.  A good diet should include a variety of foods with sufficient fluid and fiber.

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