What Is Voiding Dysfunction?
Voiding dysfunction is a broad term that covers a variety of symptoms, including urinary frequency, urgency, and incontinence (having urinary accidents or leaking) in otherwise healthy children without an underlying neurological condition. These symptoms occur independently of urinary tract infections (UTIs); however, a significant portion of children with voiding dysfunction may also have UTIs.
A broader term, bowel and bladder dysfunction (BBD), is used when the child also has constipation or fecal incontinence (poop accidents) associated with the urinary symptoms listed above.
Causes of Voiding Dysfunction or Bowel and Bladder Dysfunction
Voiding dysfunction results from problems in bladder storage, bladder emptying, or both. Bowel dysfunction is a disturbance in the gastrointestinal tract that disrupts normal storing or eliminating stool. These two issues are grouped together because they usually coexist.
Constipation contributes to urinary symptoms because of the direct pressure placed on the bladder. The nerves that go to the bowel and bladder are also associated; therefore, constipation is often the underlying cause of voiding dysfunction.
Common Types of Voiding Dysfunction
Normally, children urinate five to seven times each day. A child who is suffering from urinary frequency will urinate more than eight times during the day time. If your child has urinary frequency during the night, and they are waking up to urinate, this is called nocturia.
The sudden and unexpected urge or need to urinate is called urinary urgency. This is a frequent complaint of children who suffer from overactive bladder (OAB).
The involuntary or accidental leakage of urine is called urinary incontinence. Leakage can be continuous (leaking all day and night), intermittent (periodically during the day or night), only at nighttime (nocturnal enuresis), or stress-induced (leakage with coughing, laughing, sneezing, etc).
Sometimes girls will say they experience damp underwear (from urine leakage) 5 to10 minutes after using the bathroom. This is called vaginal voiding. With vaginal voiding, urine backflows into the vagina and as your child stands up and walks around after using the bathroom, the urine will slowly leak out and wet her underwear.
A burning or painful sensation when urinating.
Urinary Tract Infection (UTI)
A urinary tract infection can have any of the following symptoms:
- urinary frequency
- urinary urgency
- sudden onset of wet accidents or an increase in accidents
- back or abdominal pain
If these symptoms are associated with fever and your child becomes very ill, we are more concerned about the infection reaching the kidney, causing a kidney infection (pyelonephritis). It is important to remember that some children may not complain of any specific symptoms, and may only report abdominal pain.
Voiding dysfunction can contribute to UTIs when children are not emptying their bladders regularly or completely. This leads to urinary retention (stasis) in the bladder, and causes a build-up of bacteria. Some children who have UTIs and voiding dysfunction may also have vesicoureteral reflux (VUR), a condition where urine travels back up from the bladder, through the urinary tract and into the ureters or kidneys.
Girls who experience urinary incontinence or leaking may also experience vaginal infections (vaginitis). The condition may become recurrent if their incontinence is not well controlled.
Constant moisture and irritation from urine accidents, or leaking into their underwear, can cause the vaginal area and bottom to become red, inflamed, painful, and itchy, similar to a diaper rash that occurs in babies. When this happens, girls will sometimes complain that it “burns” to urinate, and you may suspect they have a UTI. The burning is from the urine coming into contact with the red, inflamed skin and causing pain. This is not necessarily from a true bladder infection.
Nocturnal Enuresis (Bedwetting)
Bedwetting refers to urinary incontinence that only occurs while your child is asleep, regardless of whether it happens overnight or during naptime. Bedwetting is considered normal up until age 5, and it can run in families. Even if your child only has accidents at nighttime, their normal daytime voiding habits should also be evaluated during the initial examination.
Children who have the feeling of needing to urinate, but are unable to go despite trying to void, may be dealing with urinary retention. Affected children may have a distended bladder and complain of pain.
Children may urinate, but feel they did not completely empty their bladder and will need to use the bathroom again a short while later.
Constipation can contribute to urinary symptoms, and plays a big role in voiding dysfunction management. The definition for constipation can vary widely, but in pediatric urology, if your child is having any one or multiple symptoms described above, and is NOT having a daily, soft bowel movement, we describe them as “constipated,” and want to treat them for this. The goal is to have a soft bowel movement at least once per day. If your child is pooping every other day, or only poops a few times a week, we will need to address this.
How Is Voiding Dysfunction Diagnosed?
The first step is to see you and your child in the clinic to discuss their typical voiding habits, and fill out a questionnaire about their history. Your child will also need a physical exam that includes looking at the genitalia for any possible anatomical issues that may be contributing to their symptoms.
We use a helpful tool called a voiding history diary to more fully understand your child’s voiding habits. This tool allows you and your child to keep a record of each time they urinate, for a couple of days, while also recording if they have any accidents (damp from leaking or full wet accidents) and if they have a bowel movement.
Sometimes we recommend diagnostic testing to rule out potential issues or infections. These tests may include:
Urinalysis (UA) and/or Urine Culture
A urinalysis is conducted for each potty-trained child who comes into the clinic. This test requires the child to urinate into a sterile cup so that we can test their urine. We do this to screen for infection, which may be contributing to their symptoms, and to screen for other possible abnormalities in the urine. If the urine shows an infection, it will be sent to a lab for a urine culture to determine the exact organism that is growing, and how to best treat it with an antibiotic.
If constipation seems to be a significant factor in your child’s voiding dysfunction symptoms, an x-ray may be recommended. An abdominal X-ray can show the amount of stool in your child’s bowels and will also allow us to look at their spine for any possible defects.
Renal Ultrasound (RUS)
This test is most often ordered when your child is experiencing recurrent urinary tract infections (UTIs), especially if they are associated with fever. A renal ultrasound can further evaluate your child’s kidneys, urinary tract, and bladder for any underlying anatomical issues. We also order this test whenever a child has continuous leaking throughout the day and nighttime or if your child has confirmed blood in their urine that is not related to an infection.
Voiding Cystourethrogram (VCUG)
During this test, a catheter is inserted into your child’s urethra and contrast dye is injected into the bladder while taking X-ray images. It is more invasive than a simple X-ray or RUS, so it is reserved for children who have recurrent febrile UTIs or have abnormalities on their renal ultrasound. A VCUG exam looks for urine refluxing up into the ureters and kidneys.
This is a noninvasive test that is done in the office to calculate the rate at which your child’s urine is flowing. Your child will need to have a full bladder, and they will urinate on a special toilet. Sometimes, we also attach electrode pads to see how the sphincter muscles work when urinating.
Children with recurrent nocturnal enuresis (bedwetting), or symptoms that could indicate obstructive sleep apnea (OSA), may benefit from a sleep study. Symptoms of obstructive sleep apnea include: loud snoring, constant pauses of breathing during sleep, restlessness during sleep, possible coughing or choking, mouth breathing, and bedwetting. Some children are at an increased risk for OSA, including those who are overweight or obese, have Down syndrome, or have neuromuscular diseases.
How Is Voiding Dysfunction Treated?
All patients being evaluated for voiding dysfunction will need to implement some behavioral changes, which we will tailor to your child’s symptoms and issues. Behavioral changes may include:
- Timed voiding (having your child urinate every 2 hours)
- Double voiding (having your child urinate, count to 10, and then urinate again)
- Proper positioning on the toilet (need to have feet firmly planted on the ground or on a stool, and lean forward so they are able to relax)
- Backwards toilet sitting (or wide-legged toilet sitting) for girls experiencing vaginal voiding
- Avoid bladder irritants, including caffeine, carbonated beverages, tea, and citrus juices, especially if your child complains of urinary frequency. These beverages can worsen their symptoms.
- Stay hydrated and drink lots of water
Medication may be added to your treatment plan, depending on your child’s symptoms (including constipation) and any anatomical issues that may be found in the examination and testing process. Your child may benefit from medications used for overactive bladder (urinary frequency) or nocturnal enuresis (bedwetting) after behavioral therapy and/or alarm therapy have been used. Occasionally, if there is an issue with recurrent febrile UTIs, the urologist may prescribe antibiotics to help prevent infections during treatment.
Sometimes children need to undergo biofeedback, which is a program where the child learns to control and relax his or her pelvic muscles and urinary sphincter while playing a video game. This will allow the child to void more efficiently and, over time, improve their urinary symptoms.
Children with psychological or behavioral issues can struggle more than others with nocturnal enuresis (bedwetting), daytime urinary incontinence, and fecal incontinence (poop accidents). The most common psychological condition/behavioral issue seen with voiding dysfunction is attention deficit hyperactivity disorder (ADHD), but children with oppositional defiant disorder (ODD), anxiety, and depression may also have issues with voiding dysfunction.