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.