Voiding Dysfunction

Voiding dysfunction is a broad term which encompasses many urinary symptoms that are not caused by a neurologic issue. It involves inconsistent coordination of the bladder muscles and urethra. There are several ways that this occurs. One way has a lack of coordination between the bladder and the urethra resulting in the muscles in the urinary tract not being able to relax all of the way. The muscles in the pelvic floor can also become overactive when a child attempts to use the bathroom. Some children may not void as often as they should and may not be able to empty completely due to an overly full or distended bladder.

When the muscles become overactive or fail to relax all of the way, the child with this condition suffers an abnormality in filling, storing, and emptying urine. These symptoms include:

• Urinary incontinence (giggle incontinence, urge incontinence)
• Urinary frequency
• Urinary urgency
• Underactive bladder
• Pain with urination (dysuria)
• Urinary tract infections

Children with voiding dysfunction may tighten their pelvic floor muscles as their bladder contracts, thus not completing emptying their bladder. This subsequently can lead to the various symptoms listed above. Voiding dysfunction is extremely stressful to the both the child and parent.

• Infrequent urination. Some children tend to hold their urine during activities in fear of missing out.
• Inadequate urination. Some children do not empty their bladder completely and do not take enough time or adequately relax their pelvic muscles to ensure the bladder is completely emptied.
• Uncontrolled bladder contractions. Some children will feel a sudden urge to need to use the restroom immediately.
• Constipation. This can have a major impact on voiding function as the same nerves that innerve the bowel innervate the bladder. There is also a physical correlation anatomically. If there is a significant amount of stool in the rectum, this can cause bladder contractions as well as inhibit the bladder from completely emptying.

• Thorough history and physical exam to rule out any neurologic cause.
• Urine analysis to ensure no urinary tract infection or other medical condition.
• A renal/bladder ultrasound may be used to ensure no anatomic abnormalities.
• A uroflow/EMG study may be used in the evaluation to understand how well the child is voiding and relaxing his or her pelvic muscles during urination.

The majority of patients with symptoms related to voiding dysfunction can be treated conservatively with healthy bowel and bladder habits.

• Adequate fluid intake throughout the day.
• Avoid bladder irritants (specifically caffeine, carbonated (“fizzy”) beverages, colored or dyed beverages, citric acid and chocolate.
• Timed voids every 2-3 hours. This is to encourage bladder emptying on a regular schedule and promote healthy bladder cycling. This would also discourage withholding.
• Proper voiding techniques. In order to prevent vaginal voiding (backwash of urine into vagina), girls are encouraged to fully remove underwear at the toilet so the legs can be maximally abducted. Using a step stool under feet while urinating relaxes the pelvic floor muscles and allows adequate emptying of the bladder.
• Double voiding after each void. Have the child urinate, wait a few seconds (can have child say the alphabet or count) then have the child urinate again. This will help ensure complete emptying of the bladder.
• Avoiding constipation with a daily soft stool is recommended. Increasing the amount of fiber and healthy fruits and vegetables, as well as increasing water intake may be sufficient. Some children require a gentle stool softener to help achieve a soft stool daily.

Other treatment options:

• Biofeedback: This is a pelvic floor therapy that helps children retrain their pelvic floor muscles to relax appropriately during voiding.
• Medications: Anticholinergics are medicines that help relax the bladder and may prevent uninhibited bladder contractions that cause urgency, frequency, and incontinence. Alpha-blockers are medicines that help relax the muscles in the bladder neck and sphincter and may help with complete urine elimination.