Saturday 19 December 2015

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.  

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