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.