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. 

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