Bladder Control - Factors that Influence Bladder Size in Children

Bladder Size in Children

The size of the child influences the size of the bladder. More precisely, the volume of the pelvis influences the size.

The bladder volume of a newborn infant is only about 50 ml. By one year the growth of the child is such that the volume is 130 ml, and by two years the volume is 175 ml. Thereafter, the bladder increases slowly by about 30 ml (one oz) per year of age. In a six year-old child in grade one the volume should be 275 ml. At ten years the volume should be 335 ml.

Bowel health has a major influence on bladder size. The bladder is designed to push a liquid out of a hole. The muscles of the bladder are not suited to push solid poop out of the way. The poop in the rectum therefore competes for space at the narrow bottom of the pelvis. The optimal bowel pattern to achieve an average size bladder is to poop every day in the morning after breakfast and a second time later in the day. The poop must be soft enough for the bladder to push out of the way.

Personality modifies how a child responds to the early signals of a full bladder. There is a spectrum of attentiveness to the early bladder signals. Some children are very attentive and never hold their pee past full. These children void more frequently at smaller volumes. Some children are not very attentive and tend to hold their pee past full and then race to pee and they might be damp or wet before they reach the bathroom. The "Attentive Voiders" present with smaller bladder volumes for size and bowel health. Perhaps there is a "muscle memory" situation that develops to account for this.

Pelvic size, bowel health, and personality are the major modifiers of bladder volume.

There are a number of other modifiers that might intermittently play a role.

The rate of bladder filling is a factor. A faster filling rate triggers the need to pee at a smaller volume. A faster filling rate happens when a child has a larger than usual amount of water or juice to drink and the kidneys are quickly making pee to excrete the excess fluid. think of how often some children need to pee after drinking a big pop at the movie theatre. 

Changes in the emotional state can modify bladder volume. Children who are excited (positive or negative) or anxious pee more often.

Cold temperature plays a role. The bladder empties at a smaller volume when the ambient temperature is low.

The sound of rushing water (taps, waterfalls, river noise) can trigger the need to pee.

Drinking water fast can trigger the need to pee. 

Bladder Control - Children who are “Rule Followers.”

A six year-old boy was referred for bedwetting. The boy wets every night.  He pees 7 times a day including at the prescribed time during morning kindergarten. Mom described him as a “rule follower” and scored him 9 out of 10 on the “perfectionist” scale.

This boy is an Attentive Voider. He does not hold his pee past full. His mother does not see holding postures, he does not need reminders to pee, he is not in a rush to pee, and he is always dry without even minor daytime dampness.

This boy is also a "rule follower." Many elementary school teachers request that a child only pee at break times. This message from a respected adult authority figure can have a strong impact on the behaviour of a young child. Likely this boy will only pee at scheduled breaks at school and he might be reluctant to ask to leave class to pee.

The combination of an Attentive Voider and a Rule Follower means that he will not drink much at school. Attentive voiders do not like the feeling of an overfull bladder or they are not prepared to risk daytime wetting, not even a few drips. Rule Followers restrict their trips to the bathroom to the scheduled breaks.  These children learn to self limit their fluid intake to allow them to stay attentive to the signals and to follow the rules.

Some of these children learn to pre-emptively pee at every break to make sure they are never overfull. These children also learn to pee before they get on the school bus.

Since they do not drink much at school, these children end up with very solid stool. The stool presses on the bladder and compromises bladder capacity. Children with a smaller bladder need to pee more often after they drink and since this might oblige them to leave class to pee, they learn to drink even less.

The body has healthy rules that should be followed and that are much more important than arbitrary rules about bathroom breaks at school. Paying attention to a bladder signal is an important rule. Holding the pee to wait for a break is not a healthy practice. Parents should empower their children to routinely leave class to pee and never to hold their pee to wait for a scheduled break. 

Bladder Control - Teaching a Child to "See" Himself Holding the Pee

I assessed a six year-old boy with day and night wetting. He holds his pee to the last minute when playing and Mom reminds him to pee when she sees the typical postures. He often denies he needs to pee when Mom reminds him. Sometimes an argument develops. 

Mom advised that he recently started to cooperate when she asked him to pee. The way Mom reported this made me think she had intervened to gain the cooperation and I asked her to explain how this came about. She went on to relate, “I explained what he looked like when he was holding his pee.” With words and some acting skills the Mom demonstrated the typical holding postures culminating in the inevitable race to the bathroom. 

Once a pre-school child starts to hold their pee during compelling play activities, they also start to lose touch with the early signals of bladder fullness. The signals fade away in a  manner similar to how "background noise" disappears. 

One psychological reason for this common phenomenon is that these children are in the Early Childhood phase of development, a time of egocentricity when the children only see the world through their own eyes and limited knowledge. They are not yet able to "see themselves" through the eyes of their peers or parents.

Once a child matures into Middle Childhood, the next psychological phase of development, they learn that they are part of a group (family, church, class, team) and that what other people think (parents, teachers, peers) has a value. 

This Mom helped her boy to "see himself" and this worked because he was far enough along towards Middle Childhood that he could learn this important concept. In my experience this is possible in about 20% of grade one children and about 50% of grade two children. By the end of grade three about 90% of children will have matured into Middle Childhood and are able to "see themselves" through the eyes of others. 

Bowel Health - Didn't Poop for "99 days."

There is not much room at the bottom of the pelvis in a pre-school or an early elementary school-aged child. The bladder and the bowel are situated side-by-side at the bottom in the most narrow part of the pelvis. The bones don't move. The bladder is affected by the pressure of the stool. The bladder cannot push solid poop out of the way. Solid stool pressing into the bladder compromises bladder control (holding postures, urgency, daytime dampness) and reduces the bladder size (peeing frequently, waking up to pee at night, bedwetting).

Once a child is at least six years of age they are able to answer questions about their pee and their poop. I routinely ask the child questions about how often they poop. One of the questions I ask is, "Do you poop every day or are there some days you do not poop." Most of the children I see respond that they do not poop every day. If they miss days, a follow up question is whether they miss one day at a time or more than one day. If more than one day, I ask if they might ever go more than two days, and so on until the child settles on their best estimate of how many days they might miss in a row.

A six year-old recently told me he could go "99 days" without a poop. Most children at his age do not really understand big numbers. This child was telling me in his own words that he missed many many days in a row. 

Most children only miss one or two days at a time. An every other day pattern is very common. Missing two days at a time means only two poops a week and this is also common. About once a month I talk with a family with a child who can miss a week of poops. About once or twice a year I hear a credible story that fits with going two weeks without a a poop. Going more than two weeks without a poop is rare. I have only heard this from a few families over my professional lifetime. 

Bedwetting - Dryness Due to Dehydration is Not Healthy

A nine year-old boy was referred for bedwetting. He wet every night.

The only time the boy had ever had a dry night was during a trip with some cousins. His cousins were mean-spirited and they teased him about the bedwetting. The boy felt terrible about the teasing. He decided on his own to stop drinking at 4 PM and this allowed dryness for the last four nights of the trip.

Dryness due to dehydration was an acceptable temporary solution for this boy. I don't blame him for doing what he could to stop the teasing and to bolster his self esteem.

However, dryness due to dehydration is not the right solution.

Hydration is an important fundamental of good health. One of the major goals in my clinic is dryness with the ability to drink as much as desired in the evening.

My goal is always HEALTHY DRYNESS.

My hydration recommendations for children who wet the bed are to drink at least one ounce per year of age in the evening hours before bed. Children should hydrate well early in the day. I recommend that children wake up and catch up with their daily hydration by drinking 40% of their daily needs before lunch (about 20 ounces in an early elementary school-aged child). 

Bladder Control - The Color of Urine

During the first appointment to my office I ask the child to drink enough water that he or she will be able to pee at least two or more times. I do an ultrasound of the bladder and rectum before and after each void. The child is instructed to pee into a Uroflow device that measures peak flow rate, voiding time, and the volume of pee voided. The post-void ultrasound allows me to assess bladder emptying. Together with a good history, the data allows a very good non-invasive assessment of bladder function.

The kidneys are responsible for maintaining the water balance in the body. When the child is dehydrated the kidneys make very little urine. Once a child is optimally hydrated and the body has all the water necessary for health, the kidneys make urine as fast as the child drinks water.

Almost every child with day or night time wetting has a bladder capacity that is smaller than average. Most have a bladder capacity that is less than half of average and some have a bladder capacity that is only a quarter or a third of average. Once optimally hydrated, a child with a very small capacity might pee as often as four or more times over the course of an hour. 

Most children with day and night time wetting have borderline or poor hydration. These children do not drink very much for a variety of reasons that make sense to either the child or the adult caregivers. Parents often limit drinking in the evening. Children self limit drinking at school to avoid either voiding too often or to minimise the risk of daytime wetting. 

The urine in a child who is dehydrated is dark yellow (concentrated). The kidneys have a limited ability to concentrate the urine. In a dehydrated state, without enough water in the body, the kidneys are not able to promptly and optimally excrete all of the waste products that have built up after the food is metabolized by the body. 

The urine in a child who is well hydrated is clear (dilute). Once optimally hydrated, the water that a child drinks is quickly made into urine. The kidneys can dilute the urine to make almost pure water.

Once every month or so, a well-hydrated child in the office comments that there is something "wrong" with the colour of their urine. The child tells their parents that the pee is "white." This implies that until this moment, he or she has never seen dilute (clear) urine. This implies that their hydration has always been poor or borderline. 

I routinely point out and discuss the dark urine voided by children who attend my office. I recommend that children drink enough water early in the day so that their urine is clear (dilute) before lunch.  

Bladder Control - An Enema Every Second Day for Nine Years!

A 12.5 year old girl with a history of developmental delay was referred for constipation and for day and night wetting.

At about the age of 3 years, once walking, she stopped pooping regularly and after five days without a poop the parents attended an emergency department and the girl was treated with an enema. She continued to poop infrequently and with the advice of a local physician, the parents treated her with an enema every two days. The girl and the parents accepted this intervention and nine years later the girl was still wearing a pull up by day and night and the parents continued to treat her with alternate days enemas.

A few times a year the girl told her parents she needed to poop, and she used a conventional toilet. By day at home, she wore underwear and voided attentively without any wetness in her underwear. At her school for children with disabilities, she wore a pull up and changed this promptly if she wet even a small amount, and she otherwise voided attentively at school. She wet every night.

I knew the ultrasound of her pelvis would tell an interesting story. What does a rectum look like, when courtesy of an enema, the rectum has emptied faithfully every two days for nine years?

The rectum looked normal. The diameter was only 19 mm. I hardly ever see a rectal diameter under 25 in my office and mostly I see diameters in the thirties and forties on the first visit.

This story fascinated me. Enemas are mostly given intermittently, often in an emergency department. At home, enemas are usually only used intermittently when tummy pain or another constipation symptom becomes too problematic. Occasionally I see a child with a history of an enema every 3 to 7 days, used intermittently and only as necessary. Routine treatment with an an enema is uncommon and usually only offered in neurologically devastated children who are bedridden or in ambulatory children with a neurogenic bladder.

The good news for this child is that the alternate day enemas insured that her rectum was not “stretched” with a consequent loss in muscle tone, and that her rectal function was preserved. She will be able to have normal daily bowel movements. Since the girl was attentive to bladder signals and had a history of intermittent (albeit uncommon) attentiveness to bowel signals, the child was clearly ready for the transition to normal movements in the toilet and to wear underwear by day. The child can be cured and she can achieve normal social control of her bladder and bowel. 

The “sort of” bad news was that she had alternate day enemas for 9 years. But, was this really bad? I would never prescribe regular enemas in this situation, but I commonly see children with a chronic history of withholding poop for a week or more and in these children I tell the parents that treatment will “control” but might not “cure” the constipation. Which is better? Poor control and a rectum that is “stretched” with the result that the constipation can only be controlled, or very good control with alternate day enemas and the ability to cure the constipation? Interesting question. Of course this is an oversimplified question. The correct answer is that physicians need to teach parents how to prevent constipation in the first place and that their are good alternatives to enemas that also preserve bowel function.

Bladder Control - Daytime Wetting that Happens in "Waves."

A 7 year-old girl came had daytime wetting that came in “waves.”

She stopped wearing a day and night diaper at 2.5 years. She tended to hold her pee to the last minute. Mom saw holding postures and she often needed to remind her daughter to pee. Her daughter was often in a rush to get to the bathroom but she made it on time and was usually either dry or had only minor drips in the underwear. 

Daytime wetting sufficient to change her clothes was not common. Mom reported that this degree of wetting came in “waves.” During the “waves” her daughter needed to change her clothes every day for several days up to a week.

The two common causes of intermittent daytime wetting that comes in “waves” are bladder infection and a change in the bowel health with solid poop pressing on the bladder.

She did not have any history of bladder infection and she did not have more specific symptoms of bladder infection during the “waves.” Her urine did not have infection when I checked.

Mom reported that her daughter had “severe” constipation at 18 months of age. Mom recollects “painful” and “traumatic” poops. The pain settled down and Mom presumed her bowel health was good. However, when I asked her daughter about her current poop pattern, she related that she only pooped twice a week and sometimes she went up to a week without a poop! Her poops were hard, up to two inches wide, and she routinely pushed, but she did not complain of any pain, and never talked about her poops with her Mom.

The family followed my instructions to achieve Bladder Friendly Bowel Health and by her follow up visit several months later she was pooping every day and the holding postures, urgency, and minor daytime dampness was gone. She had not experienced any "waves." 

This child has likely had poor bowel health since the age of 18 months. The “waves” of daytime wetting likely developed during those times when her bowel health was worse than usual.

The Mom had no idea about how infrequently her daughter pooped. At the follow up visit she told me, “We were lucky that she had the daytime wetting.” Otherwise they would never have realised the seriousness of the chronic bowel problem.

Besides “waves,” another word that families often use to describe the problem is “spurts.” Both words relate to water and are appropriate figures of speech to describe the problem.

Bladder Control - Aggressive Toy Truck Behaviour as a Response to an Overfull Bladder in a Toddler.

A 3.5 year-old boy who was referred for voiding frequently. He stopped wearing a day diaper at about 3 years of age and since then he peed as often as every 15 minutes. Mom mentioned that the prior night he needed to pee 5 times during a 45-minute dinner at a local restaurant. He was mostly dry at night but only because he routinely woke up to pee between 2 and 5 AM. Holding postures and urgency were not common and daytime wetting was only once every three weeks. There were no other symptoms to suggest urine infection and his urine tests at the family doctor and in my office did not show infection. Mom told me he pooped every day, later in the day, and he pushed to poop. He doesn’t drink much.

This is the story of a boy who is more attentive to bladder signals than most of his peers and who has a small bladder capacity. In the absence of bladder infection, a small bladder capacity is usually due to the presence of hard or pasty poop that presses into the bladder. The pelvis in a child is not very big. The bones of the pelvis are a shaped like a funnel and the bladder and the bowel are compressed side-by-side into the most narrow portion at the bottom. The bladder is "at the mercy" of solid stool and cannot push the poop out of the way.

He arrived as a happy well-behaved boy and he cooperated to drink enough water that his bladder filled up five times over the two hours in my office. He played in the room where I talked with Mom for the first three voids and in each case his personality changed as his bladder filled up and then progressed to an overfull situation. He had a big red truck, which he manoeuvred around on the floor.

The following sequence of events played out in response to his overfull bladder. He stopped using the truck and stood up. He touched his groin with his hand (signal that bladder is full). Then he resumed playing. Within a minute he was aggressive with the truck. On the first occasion he kicked the truck. After the display of aggression and Mom’s comment to “play nice,” he stood up, touched his groin, and announced that he needed to pee. I pointed out to Mom that the behaviour change was a response to an overfull bladder and she didn’t believe me, but when the same sequence played out the second time (this time he ran the truck into the wall) and third time (he ran the truck into the exam table), she understood my observation was correct. Part of my job is helping parents to recognise the signs of an overfull bladder in their child.

Children would rather play than pee and the decision to ignore a full bladder is real easy, but the brain does not ignore the increasing bladder filling and the brain signals are often expressed with a personality change that is unique for every child.

No one should ever ask a toddler, pre-school, or early elementary school-aged child to hold his or her pee. Parents should make sure to build in lots of opportunities to pee to prevent an overfull bladder. 

A full bladder or bowel is not the only event that can trigger a change in behaviour. Lack of sleep and a low blood sugar are other possible triggers.

When the behaviour of a child changes, a parent should consider asking the child to pee. 

Bladder Control - Getting up to Pee from the Dinner Table

When a child gets up to pee from the dinner table, some parents might presume this is a tactic to delay sitting down or to avoid eating what is offered. This is not the case. Getting up to pee happens because of the Gastro-Colic Reflex.

Whenever a person eats, the brain automatically initiates the Gastro-Colic Reflex. Gastro means stomach and Colic refers to the colon, the last part of the intestine. When food enters the stomach the brain automatically instructs the muscles in the intestine to contract and to move the variously digested contents further down through the intestine to make room for the newly ingested food.

Stool is stored in the rectum, the final part of the colon, until the person poops. The Gastro-Colic Reflex causes the poop in the rectum to be pushed lower down.

The bladder is located at the bottom of the pelvis and the rectum comes down the left side of the pelvis beside and below the bladder.

When the poop in the rectum is pushed along by the Gastro-Colic Reflex, the poop presses on the bladder. The increase in bladder pressure triggers a "bladder-is-full-signal" and this encourages the child to leave the table to pee.

Some of the children pee and poop in response to the signal but most children only pee. They likely could poop if they took the time to sit and relax, but most rush back to the dinner table.

This behaviour is frustrating for some parents and an understanding of why this happens might help some parents to be patient with this physiological behaviour.

I teach that a morning poop, great emptying, and soft stool is the goal for normal bowel health. Children who achieve this optimal pattern are much less likely to need to get up to pee at dinner. The rectum by then is emptier and the stool present is softer, and the resultant pressure on the bladder is less. 

Bladder Control in a Boy with Asperger's Syndrome

Recently I saw a 12 year-old grade 6 boy with Asperger's Syndrome (Autism Spectrum Disorder) for voiding frequently. The problem started in grade four.

During the summer before grade four the boy developed pinworms and he saw the worms moving in the poop. His memory of this image is strong and vivid. The event clearly made a strong impression.

Children with Autism Spectrum Disorder (ASD) are sometimes more intuitive about problem solving than other children of the same age. They see and solve problems in a unique manner based on their personal perspective. I listen carefully to these children.

With a careful and patient history the boy offered two important personal clues to the frequency problem. He reported that the frequency started right after the pinworm problem. He also reported that since the start of the frequency, the number of times that he needs to pee is related to how often he poops. If he does not poop very often he pees more frequently. If he poops more often, he pees less frequently.

Frequency implies a smaller bladder capacity. The most common causes are bladder infection, poop pressure on the bladder at the bottom of the pelvis, and personality considerations. There was no history or evidence of infection.

He had a longstanding history of constipation that started at four months of age. When frequency develops due to poop pressure it is a change in the pattern of pooping with less frequent movements and harder stool that triggers the change in the bladder size. His bowel health got worse after the pinworm infection. Perhaps he started to hold in his poop to avoid seeing the worms? He started to miss more and more days and finally the pressure of the poop was enough to change his bladder size and to result in the need to pee more often.

He also has personality considerations that modulated the response to the pressure signals of fullness in the smaller bladder and exacerbated the tendency to pee frequently. Mom scored him 10 out of 10 on the perfectionist scale. He has problems with anxiety. He sometimes has obsessive compulsive behaviours. Frequency is more common in children with anxiety, obsessive compulsive behaviours, and a perfectionist personality. Children with these features void more often because they are either very uncomfortable with the sensation of an overfull bladder or they are unwilling to suffer even a drop of pee in their underwear.

As a toddler the boy was "difficult" to toilet train. Whenever Mom tried him in underwear he "just wet" and carried on with his play activity. He did not try to hold his pee. He did not run to the bathroom. He just wet. Until Mom discovered him wet he was content to play in the wet clothes. He stayed in a daytime diaper until about age 4 years. This is a common story in a child with ASD. Interrupting an activity to go to the bathroom does not make sense to these children. They do not choose to hold the pee because they do not like the sensation of an overfull bladder. Rather than suffer this uncomfortable sensation or interrupt their play, they "just wet." The logic makes sense from their unique and valid perspective but is very frustrating for many parents. The boy still does not like the sensation of an overfull bladder. This is the reason he offered for why he pees so often. 

Bladder Control - School Fire Alarms and Daytime Wetting

Recently I assessed a 6.5 year old boy who I have followed intermittently for constipation and soiling since about four years of age.

His bowel health is no longer a problem. He poops every day, either after lunch at home or after school, and he has not had soiling for years. He still wets the bed and we are waiting for him to mature a bit more before we start a bedwetting alarm.

His daytime bladder control is usually very good but during December of his grade one school year he had problems with daytime wetting. Over that month he needed a change of clothes several times a week, but only at school. At home he was dry. He had enjoyed good daytime bladder control for a long time and the first few months of grade one were fine. Clearly something changed in December.

His Dad is a terrific bladder and bowel detective and he had the answer ready before I asked. “It was the fire alarm,” Dad reported. “My son was in the bathroom when the fire alarm went off, and he refused to use the school bathroom after that.

This was the second grade one child in six months who came to my office with the same story. School bathrooms are not built to muffle sounds. The walls, porcelain fixtures, tiles, and metal all reflect and accentuate the sound. I can imagine this would be a scary experience for many early elementary-aged children. Time and a lot of reassurance from Dad was necessary before the boy felt confident enough to use the school bathroom again. By January he was back into a normal routine.

While many elementary aged children might be frightened by the alarm only a few would stop attending the bathroom for this. This boy had a history of other toilet fears and also some anxieties that were not related to the bathroom. At 4 years of age he didn’t like the sound of “poop splashing.” He put his hand over his ears to block out the “flushing noise.” He was concerned about the “toilet plugging.” The automatic flushing toilets were a real concern for him in kindergarten. In the grade one bathroom, he is not comfortable with the urinals and he will only pee standing up in a cubicle and with the door closed. If there are too many boys in the bathroom he won’t go in.

Anything that restricts access to a bathroom is a potential trigger for daytime wetting. Toilet-related anxieties are one of the common triggers.

Bladder Control - Duck Waddle Gait as a Cause of Urine in the Vagina

Recently I assessed a 6 year-old girl for day and night wetting. The main concern was the daytime wetting.

At her second visit, the pelvic ultrasound showed urine in her vagina.

Urine in the vagina is almost always due to what is referred to as Vaginal Reflux of Urine. Vaginal reflux is presumed to be due to voiding while sitting on the toilet with poor posture. If the thighs are pressed together, the urine cannot come out between the labia and the urine wells up behind the labia and emerges at the bottom. Some of the urine that wells up enters the vagina and then leaks out after voiding and this is a cause of daytime dampness.

Urine can also enter the vagina will while walking to the bathroom. This happens when girls employ the duck waddle gait on the way to the bathroom. In this gait, the knees and thighs are pressed firmly together and the lower legs splay out with each step. The awkward gait is reminiscent of the way a duck walks. These girls have invariably held their pee during a very engaging activity and then rather than accept a soaker, the girls duck waddle to the bathroom, which helps limit the amount of wetting.

To minimise vaginal reflux during a duck waddle gait, the child needs to stop holding the pee. The reasons why a child holds the pee need to be addressed. The three common factors are solid poop pressing on the bladder that limits bladder size and control, bladder infection, and personality/behaviour considerations.

To minimise vaginal reflux while voiding, there are two interventions.

The first intervention is for the child to sit with the correct posture. The child should sit comfortably in the middle of the toilet with the knees apart. An over-the-toilet seat is necessary in little girls who sink in or perch forward. The pants and underwear should be taken off or pulled right down to the ankles so that the knees can relax apart. There should be no clothes pulling the thighs together. The feet should be flat on the floor. A footstool is necessary for little girls.

The second intervention is to mop up any remaining pee behind the labia with some tissue. After voiding, the child should be instructed to hold some toilet tissue between the labia for enough time to sop up the remaining pee (ten or so seconds should do).

Some physicians recommend that a child sit backwards on the toilet to insure the labia spread apart but this is wrong! Sitting backwards on a toilet does not allow pelvic floor muscle relaxation, which is essential for good emptying.

Bladder Control - Annoying Behavior in an Eight Year-old Boy Who Holds His Pee

I recently saw an 8 year-old boy for bedwetting. He wet every night and had uncommon dry nights. Mom reported that he has always tended to hold his pee to the last minute and then race to the bathroom. She described his holding postures as “bouncing” or “jigging around.” When she asks him to pee in this circumstance he sometimes denies that he needs to pee. When he finally does race to the bathroom he has minor prevoid dampness but he doesn’t wet enough to change his clothes. The last time he had a soaker by day was in preschool.

Mom also reported that over the years she noted that when her son has an overfull bladder he is “annoying” to his brothers. “His behaviour changes in an unpleasant way." The bad behaviour/holding the pee pattern was common and whenever the parents noticed him pestering his brothers, whether they saw the holding postures or not, they routinely asked him to go pee. The bad behaviour resolved after he emptied his bladder. 

I see negative behaviour due to an overfull bladder on a regular basis in the children in my office and I am sure these scenarios are commonly played out at home and at school. My sense is that the majority of mothers and teachers notice the poor behaviour but do not make the connection with the overfull bladder. Next time you see a child with poor behaviour, consider asking them to go pee. 

Clinic Data

Recently I reviewed some basic clinic data. I wanted to know how many children referred for bedwetting "graduate" each year. 

To "graduate," a child needs to achieve the four basic goals.
1. confidently dry and not wearing a pull-up
2. able to wake up to pee
3. improved bladder capacity and close to or exceeding the average for age.
4. well hydrated and able to drink as much as desired in the evening and still dry at night. 

I also determined the average number of visits and the average number of months from the first visit until graduation. 

The table below shows the data for the four years from 2011 to 2014. 

The clinic is open about 40 weeks a year, so we graduate about two children each week. The children take an average of 5 to 7 office visits to graduate and the journey to dryness takes an average of 8 to 14 months.  

Bladder Control - Children Who Continue to Play in Wet Clothes

Some children wet their clothes and they continue to play in the wet clothes. This behaviour is a source of concern and frustration for parents. 

In most of these children, the wetting has become so pervasive in their life, that they accept this as the usual and "normal" situation. 

The wetting is not their fault. Children who are always wet and who play in their wet clothes do not have control over their wetting. When wetting is not the fault of the child and when the wetting is routine, the child accepts that wetting and wet clothes are inevitable and they carry on with their play activities.  

This behaviour might be evident from the start of toilet training or might develop after daytime wetting is well established. 

When a parent discovers that their child is playing in wet clothes they usually either take the child to change or ask the child to change. When this becomes a regular event, the body language of the adult usually evolves from patient and and concerned to less and less patient and upset. Depending on the parent, the verbal language of the adult might become negative. Some parents eventually punish the child for this behaviour. I am careful to explain to these parents that the child has no control over the wetting and they should not be punished or blamed for this behaviour. 

To help the child and the parents with this problem, I explain that the child needs to learn to "value" dryness. When the parent notices wet clothes I ask them to insure that their body language is totally neutral. They should acknowledge the wetness and take the child to change into dry clothes. Next the parent should explain to the child the benefits of dry clothes in language the child can relate to. Dry clothes feel good. Dry clothes are clean. Then the parent should ask the child to advise them right away after wetting so that they can feel good and clean in the dry clothes. The parent should offer a reward for each and every time the child advises that they have wet their clothes. The reward needs to capture the attention of the child. If the language is neutral, the explanation consistent, and the reward attractive, the child will learn to value dryness and walking around in wet clothes will become less and less common. 

Bladder Control - Children Do Not Understand the Concept of a Half-full Bladder

Preschool and early elementary-aged children think about their bladder as either full or empty. Their brain development has not reached a stage when the idea of partially full makes any sense. 

This knowledge will help parents to understand the reasons for some common and frustrating voiding behaviours in their child. 

One common situation is when a parent suggests to their child that they should pee before they leave the house for a road trip. The child responds, "I don't have to pee." This might be true but the parent knows that a preemptive pee before the road trip is a good idea. So long as the child cooperates to pee this does not become a problem, but some children are reluctant to cooperate because the request does not make sense to them. "Why would Mom ask me to pee when there is no pee in my bladder?" If a child does not cooperate, this can lead to a confrontation and the parent might get upset. Confrontation and getting upset is never a good idea. 

Another common situation is when the parent asks their child to pee before they go to bed. 

The idea of "partially full" is an abstract concept for the child and abstract thinking comes later in childhood brain development. 

In children with daytime wetting who hold their pee, the child has lost touch with the early signals of fullness and has "blurred" the definition of full. For these children the bladder is therefore either empty or overfull. These children presume the bladder is empty even when they are doing the "pee pee dance."  

Bladder Control - Why Children Deny They Need to Pee.

Many parents tell me that their child denies that they need to pee even though the child is clearly posturing in a manner that indicates that they do need to pee. 

This can lead to a confrontation between the child and the parent. Many parents share that they are frustrated and that they get upset with these events. Confrontations and getting upset are never a good idea.

These children have a problem with daytime wetting and the parent would like to help the child to stay dry. The parent would like to be patient, does not want to precipitate a confrontation, and does not like getting upset. However, when the situation happens over and over again, many parents lose their composure over this issue. 

The usual story is that a child is engaged in a compelling play activity. The parent observes typical holding postures. There are many variations of the "pee pee dance." Mostly the children fidget, squirm, squeeze their thighs together, hold their groin area with a hand, tap their toes, or shuffle their feet. The parent knows that the child will either wet their clothes while playing or, that finally the child will disengage and run but wet on the way to the bathroom. 

As soon as a child starts to hold the pee on a regular basis they start to lose touch with the early signals of bladder fullness. Once a child is posturing and starts to deny they need to pee, they are not lying, they have actually lost touch with the early signals. 

Some parents have trouble accepting this concept. They believe that because the child is posturing and because this happens so often and usually ends up with wet clothes, and because the parent has pointed this out so many times, that the child must know what is going on. They tell me their child is "lazy" or that the child is "stubborn" or that this is a "control" issue. No, No, and No. These children have lost touch with the early signals and actually do not not know they need to pee. 

The early bladder-pressure-signals fade away in a fashion similar to how "background noise" disappears. The noise is there but we no longer "hear" the sound. We have five senses and the brain can "accommodate" our perception to any of these senses and make the sensation go away. 

Another way to conceptualise this situation is that the inability of the child to realise they need to pee might be an inability to "multitask." The child is usually engaged in a compelling play activity that has used up all the "attentiveness" available for the child. The bladder signals cannot compete with the compelling play activity signals. 

Some children have learning problems and testing reveals that they have difficulties "processing" information. This is a common observation in children with Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD). Having a processing problem is similar to an inability to multitask. 

Some parents worry that there might be a nerve problem in their child. The nerves in these children are normal. The presence of the behaviour confirms that the brain-bladder nerve communication is intact. The holding postures are a consequence of an intact full bladder to brain communication. The nerves are OK but the child is not in touch with the signals. 

I explain this carefully to parents to help them understand the problem and in the hope that the explanation might help the parents to be more patient and to avoid confrontations with their child. 

Bowel Health - Poop in the overnight diaper or pull-up

When a toddler has poop in the overnight diaper or pull-up, this implies that the child withheld the stool all day and that the poop came out while the child was asleep (unconscious).

Stool withholding is a fundamental learned behaviour in children with constipation.  

When I hear a story about overnight poops that have persisted for many months, this usually implies that the child is "really good" at stool withholding. In my experience, this is often a sign of more serious constipation. 

Bladder Control - Large bladder in a 10 year-old boy.

Recently a ten year-old boy was referred for a "large bladder." The large bladder was discovered when an abdominal ultrasound was performed to look for a cause of tummy pain. The ultrasound showed that the top of the bladder was up to the belly button and the estimate of the amount of pee was about 500 ml (16 oz). 

The tummy pain story sounded like intestinal colic (spasms) due to constipation. The Mom confirmed that the boy had intermittent constipation. The boy reported he pooped about three days a week. Dad reported that the boy plugged the toilet with 90% of poops.  

The ultrasound in my office confirmed that the top of the bladder was at the level of the belly button. The boy peed about 525 ml (17 oz). 

The average size for a bladder in a ten year-old is about 350 ml. 

I see large bladders fairly often in my office. Constipation from infancy (first two years of life) is the most common cause of large bladder. When there is significant constipation during infancy, the tiny pelvis is so filled up with poop that there is no room for the bladder to expand. The bladder is literally "pushed up and out" of the pelvis. Once the bladder is above the pelvic bones, the bladder can expand. I often see a bladder that extends to just below the belly button. Occasionally I see a bladder that reaches the belly button. Once I saw a bladder that went above the belly button. The bladder is meant to fill up and stay in the pelvis.

This boy was unique in my experience because he did not have any bladder symptoms. He was late to toilet train because of the constipation, but once he stopped wearing his daytime diaper, he peed regularly on his own initiative, Mom did not see pee holding postures and she did not need to remind him to pee. The boy did not have urgency and he did not wet by day, not even minor dampness. He was dry at night and did not need to wake up to pee. This is the first child I have ever seen with a large bladder due to constipation and without any bladder symptoms! This makes me wonder if this is more common than appreciated. 

The main reason why this boy did not have bladder symptoms is because he did not drink very much and he never really filled his large bladder. The Mom convinced the boy to drink for the previous ultrasound and again for the visit to my office, but he otherwise he never drank very much and never likely filled up his bladder. 

His hydration story was terrible. The most water he drank during an entire day was about 180 ml (6 oz)!!! He did not drink anything at breakfast. Mom reports that sometimes he would take "a sip" of milk before school. His first drink of the day was a chocolate milk box at lunch. After school he had about 3 oz of water. At supper he had 3 oz of milk. In the evening he might have another 3 oz of water. Milk is good nutrition but poor hydration. The optimal amount of water for a boy his age is at least 50 oz of water. Yikes!! Very poor hydration. Perhaps the only times he ever filled his large bladder were for the two ultrasounds?

Not drinking is a classic strategy to minimise bladder symptoms and this boy was an expert at not drinking. He has obsessive compulsive and anxiety traits that likely played a role in his hydration, bladder, and bowel behaviours.