Back to school: A to Z with No problem with Pee!

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Fiona McMahon PT, DPT

It’s back to school time! Many of us look back at this time fondly. Reminiscing about the joy of picking out new notebooks, meeting new friends, and trying to put together a perfect back to school look (any 90’s kids remember the Delia*s catalog?) But if you are a kid or a parent dealing with a kid with urinary accidents, the idea of going back to school can be downright terrifying. In this blog, we will go through the causes of urinary incontinence as well as treatments. Here’s the thing, if you only have time to just skim this blog, I want you to know this: Urinary accidents are not your fault, nor your child’s and there are solutions out there to help improve accidents. So keep your and your kiddo’s heads up. It can get better.

In the spirit of back to school, we will start off this blog with some definitions. We can classify bladder accidents in many different ways, which can be helpful when it comes to selecting a course of treatment. Here are ways the medical community may classify your child’s incontinence

Intermittent versus Continuous: Intermittent applies to children who are having discrete individual episodes of incontinence, rather than continuous loss of urine from the bladder. The latter is more suggestive of neurological or anatomical impairment and does require a physician’s attention right away.

Intermittent incontinence can be further classified as primary or secondary. Primary incontinence occurs in children over 5 who have never achieved continence, whereas secondary incontinence occurs in kiddos who have had continence previously for a period of 6 months or more.

Urge Incontinence: Occurs when when a child has a sudden urge to urinate and cannot make it to the potty in time. It is a type of intermittent incontinence.

Stress Incontinence: Occurs when kiddos lose continence with activities like coughing, laughing, and sneezing. It is a type of intermittent incontinence.

Eneuresis or Nighttime Incontinence as the name would imply, this is intermittent urinary incontinence that occurs at night.

So here’s the thing, your child may experience just one type of incontinence or they may experience many types, (i.e. urge, stress, and bedwetting). Regardless of the type of incontinence your child is experiencing, they are not alone. Bedwetting is experienced in nearly 5%-10% of 7 year olds and daytime incontinence is experienced by 5-15 percent of kiddos between 5- 9 years old. It can be helpful to share this fact with your kiddo when they feel alone and isolated. Let them know that there may be several people in their class experiencing the exact same symptoms.

What Causes Incontinence in Kiddos?

In most kiddos, it is rarely one thing exclusively. One of the most common causes of incontinence at BBPT is constipation. The rectum and the bladder are neighbors sandwiched between two relatively immobile bones, the pubic bone in front and the sacrum in back. When a child, or an adult is constipated the rectum can become distended, like a big ol’ balloon. When the rectum is full of poo it squishes the poor little bladder leaving very little room for pee to collect before a child has to go. Furthermore, all that junk in the pelvic floor reduces the feeling that it’s time to go until it is much too late. Even a child that is pooping daily may be constipated. How can that be you may ask? Well, kiddos that are constipated may actually be incompletely evacuating resulting in a build up of stool in the abdomen. Signs besides bowel frequency that your child may be constipated include, abdominal pain, large painful bowel movements, itchy tushes, or even poo accidents. If you are still unsure, some doctors may do an abdominal x-ray to confirm the presence of large amounts of backed up poo in the abdomen

The pelvic floor is another huge player in urinary issues. The pelvic floor refers to the group of muscles between the pubic bone in front and the tailbone in the back. These muscles help regulate the flow of pee and poo out. Sometimes these muscles are too loose to hold everything in. Often times they actually may be too tight, which can lead to constipation, incomplete urination, and believe it or not, these muscles may also be too weak to hold in waste during play!

We see other factors linked to pediatric incontinence. Keep in mind these factors are correlated with incontinence and may not be necessarily causal. Kinda like a chicken and the egg situation. One may have caused the other or one may have no effect on the other. With correlations, it is often impossible to tell. Here are factors found in the research that have been linked with urinary incontinence in kiddos:

  • Younger age
  • Male sex
  • Black race
  • History of urinary tract infection (UTI)
  • Family history of bed wetting.
  • Difficult infant temperament
  • Early toilet training before 2 years
  • Late toilet training after 36 months
  • Attention-deficit Hyperactivity Disorder
  • Stressful life events

What to do About Pee Accidents

We have established that having urinary accidents as a child is pretty common. So the first thing to do, and I’m serious here, is remind yourself and your kiddo that you are not alone and that it is not your fault. Keep saying it until it sinks in. Potty issues can come with the extra burden of guilt and shame. Let it go. It is no longer serving you or your kiddo.

Now, it’s time to get the ball rolling. Although childhood incontinence has a 15% spontaneous cure rate every year after age 7, it leaves out a whopping 85% of kiddos who deserve being able to play and go to fun activities like sleepovers without fear of accidents.

First, get yourself a proactive doctor who will screen for UTI’s. They often don’t show up the same way in kiddos as they do for adults. UTIs can cause incontinence and left untreated, they can be dangerous.

Then get yourself to a qualified pelvic floor physical therapist who has experience working with kids. A qualified pelvic floor physical therapist has the ability to assess the muscles of the pelvic floor in a non-invasive manner to see if weakness or tightness could be a potential culprit. They also are qualified to assess the abdomen to determine if backed up poo from constipation is worsening accidents. Based on what they find, they will taylor a program to help fix any potential barriers your child could be facing on their way to continence.

Things to do now:

  1. Explore Irritants: Certain foods can irritate the bladder and cause accidents. Check out this list {HERE} to explore potential bladder irritants. Keep in mind, not everything irritates everyone. What I would suggest is a blander day followed by a day where you add back in a potential offender. Bladder irritants usually cause irritation within 2 hours, so if you don’t see anything in that timeframe, that item is most likely off the hook.
  2. Schedule the Potty: Kids are so scheduled these days but we need to add potty breaks to the agenda. Having your child attempt to urinate, whether she wants to or not can help. I suggest starting at once every hour during the day and gradually increasing the interval as they succeed. There are watches like the WOBL watch that can help kiddos out, but I also find teachers to be extremely helpful getting a kiddo to visit the bathroom regularly.
  3. Pee at the transition times: This one is from my clinical experience. Make sure your kiddo goes to the bathroom immediately before leaving camp or school. The on the way home accidents are usually the last to clear up . So nip it in the bud ahead of time.
  4. Drink water! But not to close to bed: Your child should be drinking enough water to keep his stool soft and his urine dilute. Dehydration can worsen bladder irritation and constipation, which can in turn worsen incontinence. Just stop water intake 2 hours before bed.
  5. Manage Constipation: Give your kiddo enough time to poo and make sure her diet is varied so her stools are formed but not pellets. If you struggle with this, come see us.

Wrapping it up:

One more time for the people in the back. You are working so hard. I never met a family who is not trying everything for their kiddo. Incontinence is tough, but with PT and support it can get better. If trying these steps is not working for you, come see us.

 

Check out Amy’s book Heal Pelvic Painwhich includes a chapter on the pediatric pelvic floor.

Baird D, Seehusen D, Bode D. Enuresis in children: a case based approach. American Family Physician. 90(8) 2015

Maternik M, Krzeminska K, Zurowska A. The management of childhood urinary incontinence. Pediatr Nephrol (2015) 30:41-50

Vasconcelos M, East P, Blanco et al. Early behavioral risks for childhood and adolescent daytime urinary incontinence and nocturnal enuresis. J Behav Pediatric. 2017; 38 (9): 736-42

Von Gontard A, Kutwertz-Bröking. The diagnosis and treatment of enuresis and functional daytime incontinence. Dtsch Arztebl Int 2019; 116 279-85

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