Friday, 25 March 2016

Bladder Control - The Color of Urine

During the first appointment to my office I ask the child to drink enough water that he or she will be able to pee at least two or more times. I do an ultrasound of the bladder and rectum before and after each void. The child is instructed to pee into a Uroflow device that measures peak flow rate, voiding time, and the volume of pee voided. The post-void ultrasound allows me to assess bladder emptying. Together with a good history, the data allows a very good non-invasive assessment of bladder function.

The kidneys are responsible for maintaining the water balance in the body. When the child is dehydrated the kidneys make very little urine. Once a child is optimally hydrated and the body has all the water necessary for health, the kidneys make urine as fast as the child drinks water.

Almost every child with day or night time wetting has a bladder capacity that is smaller than average. Most have a bladder capacity that is less than half of average and some have a bladder capacity that is only a quarter or a third of average. Once optimally hydrated, a child with a very small capacity might pee as often as four or more times over the course of an hour. 

Most children with day and night time wetting have borderline or poor hydration. These children do not drink very much for a variety of reasons that make sense to either the child or the adult caregivers. Parents often limit drinking in the evening. Children self limit drinking at school to avoid either voiding too often or to minimise the risk of daytime wetting. 

The urine in a child who is dehydrated is dark yellow (concentrated). The kidneys have a limited ability to concentrate the urine. In a dehydrated state, without enough water in the body, the kidneys are not able to promptly and optimally excrete all of the waste products that have built up after the food is metabolized by the body. 

The urine in a child who is well hydrated is clear (dilute). Once optimally hydrated, the water that a child drinks is quickly made into urine. The kidneys can dilute the urine to make almost pure water.

Once every month or so, a well-hydrated child in the office comments that there is something "wrong" with the colour of their urine. The child tells their parents that the pee is "white." This implies that until this moment, he or she has never seen dilute (clear) urine. This implies that their hydration has always been poor or borderline. 

I routinely point out and discuss the dark urine voided by children who attend my office. I recommend that children drink enough water early in the day so that their urine is clear (dilute) before lunch.  

Friday, 18 March 2016

Bladder Control - An Enema Every Second Day for Nine Years!

A 12.5 year old girl with a history of developmental delay was referred for constipation and for day and night wetting.

At about the age of 3 years, once walking, she stopped pooping regularly and after five days without a poop the parents attended an emergency department and the girl was treated with an enema. She continued to poop infrequently and with the advice of a local physician, the parents treated her with an enema every two days. The girl and the parents accepted this intervention and nine years later the girl was still wearing a pull up by day and night and the parents continued to treat her with alternate days enemas.

A few times a year the girl told her parents she needed to poop, and she used a conventional toilet. By day at home, she wore underwear and voided attentively without any wetness in her underwear. At her school for children with disabilities, she wore a pull up and changed this promptly if she wet even a small amount, and she otherwise voided attentively at school. She wet every night.

I knew the ultrasound of her pelvis would tell an interesting story. What does a rectum look like, when courtesy of an enema, the rectum has emptied faithfully every two days for nine years?

The rectum looked normal. The diameter was only 19 mm. I hardly ever see a rectal diameter under 25 in my office and mostly I see diameters in the thirties and forties on the first visit.

This story fascinated me. Enemas are mostly given intermittently, often in an emergency department. At home, enemas are usually only used intermittently when tummy pain or another constipation symptom becomes too problematic. Occasionally I see a child with a history of an enema every 3 to 7 days, used intermittently and only as necessary. Routine treatment with an an enema is uncommon and usually only offered in neurologically devastated children who are bedridden or in ambulatory children with a neurogenic bladder.

The good news for this child is that the alternate day enemas insured that her rectum was not “stretched” with a consequent loss in muscle tone, and that her rectal function was preserved. She will be able to have normal daily bowel movements. Since the girl was attentive to bladder signals and had a history of intermittent (albeit uncommon) attentiveness to bowel signals, the child was clearly ready for the transition to normal movements in the toilet and to wear underwear by day. The child can be cured and she can achieve normal social control of her bladder and bowel. 

The “sort of” bad news was that she had alternate day enemas for 9 years. But, was this really bad? I would never prescribe regular enemas in this situation, but I commonly see children with a chronic history of withholding poop for a week or more and in these children I tell the parents that treatment will “control” but might not “cure” the constipation. Which is better? Poor control and a rectum that is “stretched” with the result that the constipation can only be controlled, or very good control with alternate day enemas and the ability to cure the constipation? Interesting question. Of course this is an oversimplified question. The correct answer is that physicians need to teach parents how to prevent constipation in the first place and that their are good alternatives to enemas that also preserve bowel function.

Friday, 11 March 2016

Bladder Control - Daytime Wetting that Happens in "Waves."

A 7 year-old girl came had daytime wetting that came in “waves.”

She stopped wearing a day and night diaper at 2.5 years. She tended to hold her pee to the last minute. Mom saw holding postures and she often needed to remind her daughter to pee. Her daughter was often in a rush to get to the bathroom but she made it on time and was usually either dry or had only minor drips in the underwear. 

Daytime wetting sufficient to change her clothes was not common. Mom reported that this degree of wetting came in “waves.” During the “waves” her daughter needed to change her clothes every day for several days up to a week.

The two common causes of intermittent daytime wetting that comes in “waves” are bladder infection and a change in the bowel health with solid poop pressing on the bladder.

She did not have any history of bladder infection and she did not have more specific symptoms of bladder infection during the “waves.” Her urine did not have infection when I checked.

Mom reported that her daughter had “severe” constipation at 18 months of age. Mom recollects “painful” and “traumatic” poops. The pain settled down and Mom presumed her bowel health was good. However, when I asked her daughter about her current poop pattern, she related that she only pooped twice a week and sometimes she went up to a week without a poop! Her poops were hard, up to two inches wide, and she routinely pushed, but she did not complain of any pain, and never talked about her poops with her Mom.

The family followed my instructions to achieve Bladder Friendly Bowel Health and by her follow up visit several months later she was pooping every day and the holding postures, urgency, and minor daytime dampness was gone. She had not experienced any "waves." 

This child has likely had poor bowel health since the age of 18 months. The “waves” of daytime wetting likely developed during those times when her bowel health was worse than usual.

The Mom had no idea about how infrequently her daughter pooped. At the follow up visit she told me, “We were lucky that she had the daytime wetting.” Otherwise they would never have realised the seriousness of the chronic bowel problem.

Besides “waves,” another word that families often use to describe the problem is “spurts.” Both words relate to water and are appropriate figures of speech to describe the problem.

Friday, 4 March 2016

Bladder Control - Aggressive Toy Truck Behaviour as a Response to an Overfull Bladder in a Toddler.

A 3.5 year-old boy who was referred for voiding frequently. He stopped wearing a day diaper at about 3 years of age and since then he peed as often as every 15 minutes. Mom mentioned that the prior night he needed to pee 5 times during a 45-minute dinner at a local restaurant. He was mostly dry at night but only because he routinely woke up to pee between 2 and 5 AM. Holding postures and urgency were not common and daytime wetting was only once every three weeks. There were no other symptoms to suggest urine infection and his urine tests at the family doctor and in my office did not show infection. Mom told me he pooped every day, later in the day, and he pushed to poop. He doesn’t drink much.

This is the story of a boy who is more attentive to bladder signals than most of his peers and who has a small bladder capacity. In the absence of bladder infection, a small bladder capacity is usually due to the presence of hard or pasty poop that presses into the bladder. The pelvis in a child is not very big. The bones of the pelvis are a shaped like a funnel and the bladder and the bowel are compressed side-by-side into the most narrow portion at the bottom. The bladder is "at the mercy" of solid stool and cannot push the poop out of the way.

He arrived as a happy well-behaved boy and he cooperated to drink enough water that his bladder filled up five times over the two hours in my office. He played in the room where I talked with Mom for the first three voids and in each case his personality changed as his bladder filled up and then progressed to an overfull situation. He had a big red truck, which he manoeuvred around on the floor.

The following sequence of events played out in response to his overfull bladder. He stopped using the truck and stood up. He touched his groin with his hand (signal that bladder is full). Then he resumed playing. Within a minute he was aggressive with the truck. On the first occasion he kicked the truck. After the display of aggression and Mom’s comment to “play nice,” he stood up, touched his groin, and announced that he needed to pee. I pointed out to Mom that the behaviour change was a response to an overfull bladder and she didn’t believe me, but when the same sequence played out the second time (this time he ran the truck into the wall) and third time (he ran the truck into the exam table), she understood my observation was correct. Part of my job is helping parents to recognise the signs of an overfull bladder in their child.

Children would rather play than pee and the decision to ignore a full bladder is real easy, but the brain does not ignore the increasing bladder filling and the brain signals are often expressed with a personality change that is unique for every child.

No one should ever ask a toddler, pre-school, or early elementary school-aged child to hold his or her pee. Parents should make sure to build in lots of opportunities to pee to prevent an overfull bladder. 

A full bladder or bowel is not the only event that can trigger a change in behaviour. Lack of sleep and a low blood sugar are other possible triggers.

When the behaviour of a child changes, a parent should consider asking the child to pee.