What Is Voiding Dysfunction?
Voiding dysfunction is a general term used to describe a condition relating to the urine bladder and the urethral sphincter which leads to a loss of control over the urination process in a child who has reached the age when normal control over urination may be expected. This is often referred to as daytime wetting.
There are a number of causes and contributing factors to voiding dysfunction.
- Habits such as not urinating at regular intervals, such as when at school, results in urine being retained in the body for long periods of time. This can result in an urgency to urinate which can cause leaking and often daytime bedwetting during naps. Forced controlling actions, as described below, are signs of this condition.
- Being too preoccupied playing or being with friends to stop and go to the bathroom is another cause. It is more frequently seen in boys.
- In the case of girls, a frequent problem is a fear of the consequences of asking to leave the class to go to the bathroom or the memory of painful urination due to urinary tract infection leading to reluctance to pass urine.
- Children with Attention Deficit Disorder (ADD) or Attention Deficit Hyper Disorder (ADHD) may not respond properly to the body signalling the need to urinate which can lead to voiding problems.
- Irregular sleep patterns or disturbed sleep can cause sleepiness during the day which in turn leads to irregular toilet habits and voiding dysfunction.
- The death of a loved one, parents separating, moving to a new home and other emotional and psychological stresses can disturb the mental equilibrium and lead to voiding problems.
Constipation: Constipation can affect urination patterns in children. Poor toilet habits such as resisting normal bowel movements for long periods, not emptying the bowels completely and the excessive passing of gas to relieve pressure and postpone going to the toilet are all contributing factors. The presence of hard, difficult to pass stools in the rectum may place abnormal pressure on the neck of the urine bladder making it difficult for a child to urinate. Also, in such cases, bacteria from the stools can pass into the urinary bladder resulting infection and irritation.
Urinary Tract Infections (UTI): Such infections can result in urgent needs to go to the toilet, leaking, and increased frequency of urination, besides a burning sensation when urinating and the presence of blood in urine. If such infections occur more than twice and if forced controlling actions are observed, the child should be checked for voiding dysfunction.
Uncontrolled Daytime Urination: A child will normally achieve a great deal of control over the passing of urine by the age of 3 and full control by the age of 4. Any wetting of clothes by a child over the age of 4 is not normal and should be checked to determine the cause. This does not apply to night time urination or bedwetting which is normally controlled after the age of 7.
Forced Controlling Actions: Forced holding actions and contortions such as crossing the legs, pressing the knees together, squatting down, standing on tip-toe and pressing the genitalia are often seen in children who are trying to control their urine flow for any length of time or who have an urgent need to go to the bathroom. If such actions continue over an extended period of time, it may result in the weakening of the bladder muscles and affect the functioning of the urethral sphincter.
Bedwetting: Bedwetting is normal in children of approximately 7 years. If the problem continues after that age, or if there is any bedwetting during the day, an examination to determine if there is voiding dysfunction exists is required.
Leaking Urine: A child who frequently leaks a small amount of urine before he or she is able to reach a toilet may have voiding dysfunction. An occasional incident is not abnormal but if it is a regular occurrence the amount of urine leaked will start to increase and could lead to complete daytime wetting.
Constipation: Children suffering from voiding dysfunction are often constipated. Bowel movements may not be regular and when they do occur the stools may be hard. In some cases treating constipation can result in a significant improvement over the voiding dysfunction problem.
Frequent Urine Infections: The longer urine is forced to remain in the body the more time bacteria in it will multiply. This results in infection. In addition, if a child is also constipated, the bacteria in the fecal matter may migrate to the urinary tract leading to Urinary Tract Infections (UTI).
A child suspected of suffering from voiding dysfunction should be taken to a medical facility that has the specialists to diagnose the condition. Generally, a team of doctors including a Paediatrician, Paediatric Nephrologist, a Paediatric Urologist and a Behavioural Psychologist will examine the child. Before voiding dysfunction is diagnosed, other possible reasons for similar problems will be checked for and eliminated. These include:
- Congenital problems of the urinary tract such as obstructing valves, double kidneys, reflux of urine and Ureterocele.
- Traumatic or acquired urinary tract problems such as genital or abdominal trauma, spinal trauma, insertion of urinary catheters and in rare cases, the presence of tumours.
- Disease of the central nervous system like epilepsy, multiple sclerosis, cerebral palsy and brain and spinal cord abnormalities.
- Diseases of the kidney or endocrine system such as diabetes mellitus, diabetes insipidus, and hormonal imbalances.
- Uncommon genetic conditions like Williams syndrome, Ochoa syndrome etc., infections like pinworms and urethritis and the presence of foreign bodies in the urinary tract.
With other possible causes removed, a diagnosis of voiding dysfunction can be confirmed by:
• Creating a medical, urination and social history: The medical history and symptoms will be recorded. The parents will be asked to keep a diary of the frequency of urination, the volume of urine and any leaks. Information will be collected on the child's bowel functioning including the frequency of movements, the volume of stools passed, the consistency and of signs of straining during the movements and abdominal pain. Typically the information is collected over a period of 5 days.
• A neurological and physical examination: A full neurological exam with a focus on the lower extremities will be conducted. A complete physical examination with special attention to the back, genitalia and rectum will be carried out.
• Tests: Besides the normal blood, urinalysis, urine culture and blood pressure, certain specialized tests may also be done. These include:
- A bladder and renal ultrasound scan to obtain a clear picture of the state of the urinary bladder and kidneys. Possible obstruction and issues requiring surgery may also be identified.
- Uroflow and urodynamics in which the child is asked to urinate into a special toilet or vessel which is used to collect data on the urine flow and volume with pressures on the bladder.
- A special type of X-ray called a voiding cystourethrogram (VCUG) will be used to look for any reverse flow of urine from the bladder to the kidneys and other bladder problems.
- Lower spine Magnetic Resonance Imaging (MRI) will identify any abnormalities of the spinal cord.
The treatment prescribed will depend on numerous factors including the severity of the symptoms and the results of all the tests that were conducted. One or more of the following options may be recommended:
- Eliminating bladder irritation
- Constipation management
- Appropriate treatment of urinary tract infections
- Using behavioural interventions, which are techniques and tools that parents and their children can use to gain control over voiding dysfunction. The objective is to help the child empty the bladder properly and so remain dry.
The doctor will discuss the specifics of the course of treatment with the parents.
Article by Dr. Sivasankar Jayakumar, MRCS, PGCME, FEBPS (UK)
Consultant Paediatric surgeon and Paediatric Urologist
Kauvery Hospital, Chennai