Voiding problems are very common in children. Also called dysfunctional voiding or difficulties with urination, voiding problems can range from mild to severe. Severe dysfunctional voiding can cause kidney damage.
Types of voiding dysfunction
Voiding problems range from mild problems like frequency of urination or burning during urination to more severe problems like daytime and nighttime urinary leakage.
Overactive bladder
Overactive bladder in children is a common problem that can start anytime during childhood. It occurs when the bladder is hyperactive and tries to empty frequently. This happens often without any warning, and children do not feel the need to urinate until the bladder is actually trying to empty. This sudden need to urinate may cause the child to run to the bathroom or to hold him or herself to try to prevent urine leakage. A child with an overactive bladder will likely have many voiding accidents. If you ask a child with this disorder to try to use the bathroom, he or she may say “I don’t have to,” but then minutes later, he or she has a bathroom emergency. Voiding dysfunction may be related to urinary tract infections, constipation, stress at school or at home, or drinking caffeine. In most children, overactive bladder improves with age. But in the meantime, try to have your child use the bathroom every two hours whether he or she thinks it’s necessary or not.
Uncoordinated voiding
Some children who have an overactive bladder will learn how to hold onto urine, but subsequently cannot properly empty the bladder. The inability to fully empty the bladder can lead to infections, more wetting, and even kidney damage. A child who suffers from uncoordinated voiding may also hold feces and become constipated, but will periodically soil his or her underwear.
Frequency-urgency syndrome of childhood
Frequency-urgency syndrome can develop suddenly, and children who suffer from it may need to go to the bathroom as often as every 10 minutes. Most children showed no voiding problems prior to starting with the need to frequently urinate, and they can usually sleep through the entire night without wetting the bed or getting up to use the bathroom. This problem usually goes away on its own, but it can last for months or even a year or longer. Children with this syndrome are typically normal in every way, but just feel as the need to urinate even when there is no or very little urine in the bladder.
We see some children because they get urinary tract infections and their caretakers notice that they go to the bathroom only two or three times per day. Holding urine for long periods can allow germs to get into the bladder, which can lead to infection. Urination helps prevent infection by flushing germs out of the bladder. Children should void at least 6 times per day even if they do not feel like they have to go.
Tests to diagnose voiding dysfunction
We examine children with voiding dysfunction, and then we check their urine for signs of infection. We may also ask them to urinate into a machine (called a uroflow machine) that will check how fast they urinate. We may even place skin patches to the pelvic muscles around the rectum so we can assess the pelvic floor muscles. We may also order an ultrasound of the kidneys and bladder to check for abnormalities or an X-ray of the bladder (called a VCUG). Children who have a history of urinary tract infections may need both of these imaging tests. During testing, we look for blockage in the kidneys, urine reflux (urine that flows from the bladder to the kidneys), bladder size, and how well the bladder empties when voiding.
Treating voiding dysfunction
If your child’s problem is mild and the results of the ultrasound and/or x-rays are normal, we may not offer treatment and may recommend a watch and wait approach because many problems go away on their own without treatment. If we find other problems, we will treat them separately. On the other hand, if your child’s symptoms are severe, we may recommend medication, depending on your child’s age.
Treating overactive bladder
If your child is young and doesn’t have any additional urinary tract problems, we may recommend a watch and wait approach in hopes that the problem will go away on its own. You may find that some lifestyle changes can help with the symptoms, such as having your child avoid caffeine, encouraging him or her not to delay urination, and treating constipation if it occurs. If the problem continues, treatment with medication may be an option. The most common drugs for overactive bladder in children are Ditropan and Detrol. These medications are given one to three times per day to help reduce bladder contractions, which allows the bladder to fill more fully without trying to empty. Side effects are possible, including red face, dry mouth, constipation, drowsiness, reduced sweating (which could lead to severe overheating during hotter months), blurred vision, and personality changes. Fortunately, most children tolerate these medications without serious problems, but if your child experiences side effects, you should contact his or her doctor. Your child’s doctor may recommend reducing the dose or stopping the medication altogether. If the medications work, we typically recommend continuing with them up to 6 months, at which point you can stop them and see how your child does without them.
Treating uncoordinated voiding
If your child has reflux in the urinary tract or frequent urinary tract infections, we will treat those issues first. If your child has difficulty emptying the bladder, we may recommend urinating twice in a row to try to empty the bladder more completely. In rare cases, we may ask you and your child to learn how to use a catheter to empty the bladder on a routine basis for a while. This is called intermittent catheterization.
Intermittent catheterization usually needs to be done four or five times per day. We will provide you with instructions about how to do it. In some cases, we will suggest biofeedback training. Biofeedback uses a machine that can help teach your child how relax the urinary sphincter in order to fully empty the bladder.
Treating frequency-urgency syndrome
If your child has the symptoms of frequency-urgency syndrome and all test results are normal, we typically recommend waiting until the problem resolves on its own because medication is not often effective.
Nerve Modulation
If your child has symptoms that do not respond with time, behavioral changes, or medications, we may recommend nerve stimulation/modulation therapy. This new and exciting therapy is now being offered by Beaumont Children’s Hospital Pediatric Urologists.
The Urgent PC Neuromodulation System is an effective method for stimulating confidence and urinary control in patients when more conservative therapies aren’t working. It can be performed in the doctor’s office.
Nerve modulation can be effective for overactive bladder and the symptoms associated with urinary urgency, urinary frequency and urge incontinence.
There are two major benefits of nerve modulation therapy.
The nerve modulation procedure is simple and provides percutaneous tibial nerve stimulation. The doctor inserts a slim needle electrode near the tibial nerve, which carries electric impulses from a hand-held stimulator to the sacral plexus. Treatment sessions last thirty minutes. After the initial 12 treatments, some patients may continue to need additional treatments to sustain relief of symptoms. The most common side effects are temporary, and they may include skin irritation or inflammation and mild pain at or near the stimulation site.
- Performance has been proven
Nerve modulation has a patient response rate of up to 80%. There have been documented reductions in leakage episodes and daytime and nighttime voiding frequency during and after treatment. The nerve modulation procedure produces statistically superior results when compared to validated sham therapy in a double-blind randomized controlled trial (RCT). Results were maintained at a three year mean follow-up when the initial procedure series was followed by maintenance therapy.
In a double-blind placebo study, 71% of patients responded positively to treatment with Urgent PC. (Positive response is defined as a greater than 50% reduction in voids per day.) According to this criterion, no patients in the placebo group were considered responders.