Friday, 26 February 2016

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. 

Friday, 19 February 2016

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. 

Friday, 12 February 2016

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.

Friday, 5 February 2016

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.