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Tags >> Pediatric Incontinence
Jul 01, 2014

This post was written by H&W instructor Dawn Sandalcidi, PT, RCMT, BCB-PMD. Dawn's course that she wrote on "Pediatric Incontinence" will be presented in in South Caroline this August.


Dawn Sandalcidi

Years ago when my oldest daughter was 4 years old and in Pre-school I received an urgent call at the office that she had an accident. Immediately my head began to race, “What hospital is she in?” “What did she break?” Then the director informed me she wet her pants. I collapsed in my chair with a huge sense of relief and I began to ponder “Did she have an ‘accident’ or did her bladder leak?


Merriam-Webster defines an accident as:


Jun 26, 2014

In Turkey, the rate of daytime urinary incontinence (DUI) was studied in primary school-aged children. A questionnaire was completed by parents of 2164 students. The Dysfunctional Voiding and Incontinence Symptoms Score Questionnaire was utilized and includes 14 questions about daytime and nighttime symptoms, voiding and bowel habits, and quality of life.


The population studied included approximately half boys and girls, with nearly half living in rural versus urban settings, and of a mean age of 10 years old. The overall prevalence of DUI was 8% (8.8% in girls, 7.3% in boys), and decreased with increasing age in this study population of children in 1st through 8th grades. 57.8% of those who did experience involuntary loss of urine were wetting less than 1x/day, 26.6% were wetting 1-2 times/day, and 15.6% were wetting greater than 2x/day. Urge incontinence was reported in nearly 59% of the children with DUI.


Independent risk factors for DUI included age, maternal educational level, family history of daytime wetting, urban versus rural setting, history of constipation or urinary tract infection (UTI), and urinary urgency. The authors conclude that "…educational programs and larger school-based screening should be carried out, especially in regions with low socioeconomic status." In this study, one of the strategies used to increase the survey response rate was to send medical and public health residents to the schools to speak about the study on 2 occasions.


Despite the numbers of therapists who have previously trained with educators such as faculty member Dawn Sandalcidi in her coursework for pediatric bowel and bladder function, the number of therapists focusing on pediatric pelvic health remains small while the need is great. Therapists who wish to expand community reach to pediatric urologists and pediatricians, and to serve the children who may unfortunately become adults who have bowel and bladder dysfunction, have the opportunity to attend the Pediatric Incontinence and Pelvic Floor Dysfunction continuing education course in Greenville, South Carolina this August.

Jun 23, 2014

This post was written by H&W instructor Dawn Sandalcidi, PT, RCMT, BCB-PMD. Dawn's course that she wrote on "Pediatric Incontinence" will be presented in in South Caroline this August.


Dawn Sandalcidi

I will never forget the morning I was called by one of my referring pediatricians to tell me an 11-year-old boy with fecal incontinence hung himself because his siblings ridiculed him. If you ever ask me why I do what I do, I will tell you so that nothing like that would ever happen again.


When we think of pediatric bowel and bladder issues we primarily focus on the physiologic issue itself and treating the underlying pathology. I think it is imperative to teach a child that she/he did not have a leak but their bladder or bowel had a leak. It makes the incident a physiological problem and not a problem of the child.


Jun 09, 2014

The goals of a recent research article were to determine the degree to which lower urinary tract symptoms (LUTS) are related to quality of life (QOL) and also the reliability of parents to accurately report on QOL disturbance in children who have urinary incontinence (UI). Outcomes tools utilized in the study include the Dysfunctional Voiding Symptom Score (DVSS) and the Pediatric Urinary Incontinence QOL tool (PIN-Q). Parents of forty children ages 5-11 (10 males and 30 females) and diagnosed with non-neurogenic daytime wetting completed the outcomes tools and responded to open-ended questions about incontinence and QOL. All children had daytime wetting, more than 50% of them had recurrent urinary tract infections (UTI's), and 89% reported urinary urgency.



According to the National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), night-time wetting affects 30% of children who are 4 years of age, with the condition resolving in about 15% of children each year. Additionally, wetting at night persists in about 10% of 7 year-old, 3% of 12 year-olds, and 1% of 18 year-olds. A summary handout about Urinary Incontinence in Children is available here.


The study found that parents were reliable in reporting quality of life and symptoms in their children, as the outcomes scores completed were not different between them. (I would point out that nearly all parents involved were the patient's mothers; and it may be interesting to know more information about how the responsibility of managing urinary incontinence in children is shared among parents or caregivers.) Confirmed in the research was the knowledge that urinary dysfunction in children causes significant quality of life impact.


Mar 07, 2014


In 2011, H&W was thrilled to add a new course to our list of offerings. Pediatric Incontinence and Pelvic Floor Dysfunction was a much-needed addition to our pelvic floor courses. Despite the growing number of pelvic rehab specialists treating men and women with PF dysfunction, children in this patient population remain woefully under-served, which can cause undo stress for the child and family, as well as the development of internalizing and externalizing psychological behaviors. Dawn Sandalcidi, the author of this course, and Robin Lund, her co-instructor, sat down with Pelvic Rehab Report to talk more about this course and their work with children.


PRR: Dawn, you developed this course many years ago. What initially inspired you to write this course?

Dawn Sandalcidi

When I set out to create this course, there were no courses offered in pediatrics for pelvic health. There was also nobody doing any pediatric courses when I began this quest.

May 06, 2013

While the co-existence of fecal incontinence (FI) and constipation is well-recognized in the pediatric and geriatric population, the authors of this article suggest that the relationship is under-appreciated in the adult population. Samuel Nurko, MD, and Mark Scott, PhD, describe the association between pediatric functional fecal incontinence and constipation, stool retention, and incomplete evacuation. In adults, they point out, constipation may also be related to pelvic floor dysfunction and denervation. The negative impact on quality of life creates the need for these issues to be addressed more readily, both in adults and in children. 


The study mentioned above cites a prevalence of fecal incontinence in school-aged children of 1-4%. The majority of the research cited in the article report that this incontinence is related to underlying constipation. Factors that may contribute to childhood holding of stool or to rectal dysfunction include constipation early in childhood, painful bowel function, "coercive toilet training practices and social stressors", fecal impaction, and treatments involving anal manipulation. It has been surprising to me how many adult patients describe psychologically stressful childhood associations with bowel function. Fortunately, the psychological stress, low self-esteem, and decreased quality of life that is associated with childhood bowel dysfunction improves with successful treatment of the condition. Childhood behavioral issues including bullying, disruptive behavior, and social withdrawal also are noted to improve following improvement in fecal issues, suggesting that the terrible social impact of fecal incontinence may be to blame for some of the behavioral issues. 


In relation to the adult population, the authors state that while the coexistence of constipation and FI may not be known, constipation has been shown to be an independent risk factor for FI and incomplete emptying is associated with fecal incontinence.  In the patient who has poor emptying of the bowels, overflow can occur, and this type of leakage is then associated with constipation. It follows, then, that treatment of the constipation should improve the fecal leakage.  Three mechanisms are described regarding the pathophysiology of incontinence caused by constipation: overflow due to fecal impaction; post-defecation leakage caused by rectal stool retention from a rectal evacuatory disorder; and general pelvic floor weakness or denervation. Certainly, neurological or other disease conditions can cause bowel dysfunction, yet this article focuses on "functional" constipation not caused by such diseases. 


Clinically, patients who present with fecal leakage can have a difficult time understanding the relationship between constipation and fecal incontinence. Educating the patient about bowel health and function are critical in "selling" the self-management strategies that will form the foundation of the patient's recovery. If you are interested in learning more about bowel health and function, come to the 2A course that instructs the participant in common colorectal conditions, constipation, and fecal incontinence. If you have already taken the course, check out the Institute's new course on bowel dysfunction that includes a lab for anorectal balloon re-training. 

Jun 05, 2012

Pelvic floor muscle training has been found to be an effective approach for treating fecal incontinence in children following surgical correction for Hirschprung disease. This disease can cause severe constipation or intestinal blockage due to a lack of nerve cells in the large intestine that are responsible for creating contractions in the smooth muscles of the bowels. Most of the time, Hirschprung disease is identified and corrected in infancy, but it can also be treated in childhood and sometimes in the adult patient. There are several different types of "pull-through' surgical procedures that can be used to remove the diseased portion of the large intestine and attach a functioning portion of bowel to the anus. This type of procedure can injure tissues including the internal anal sphincter, creating the issue of fecal leakage or incontinence. 


A case series appears in the European Journal of Pediatric Surgery that reports on 24 cases of children who became incontinent following a Soave pull-through procedure for Hirschprung disease. 16 of the children were treated with 2 weeks of biofeedback training in the hospital followed by home program for pelvic muscle exercises, while 8 children served as a control group, receiving no therapy following the surgery. At baseline and at one year follow-up, measures were taken via anorectal manometry for resting anal canal pressure, squeeze pressure, and for rectal sensation. At one year post-surgery, the children in the treatment group were found to have significantly increased resting rectal pressure as well as squeeze pressure. Rates of fecal incontinence were significantly reduced with only 3 of the 16 children reporting occasional soiling after completing the pelvic muscle training.


This research is encouraging as biofeedback therapy is a non-invasive, inexpensive option for patients who have already been through a surgical procedure to correct a biological dysfunction. The International Foundation for Functional Gastrointestinal Disorders (www.iffgd.org) has a wonderful website with more information for rehabilitation providers and for patients, and they also have a website designed for kids and teens who have functional gastrointestinal issues. That website can be accessed at www.aboutkidsGI.org

Nov 23, 2011

Research about animated biofeedback and its effects on children who have elimination disorders appears in the December issue of the Journal of Urology. A report by Rueters can be accessed here, the PubMed abstract can be accessed here


Dr. Kajbafzadeh of the Tehran University of Medical Sciences in Iran led a study that involved a total of 80 children randomly assigned with 40 subjects in either Group A or Group B. The average age group was 8-9 years with more than 75% of the children being female. Group A received 6-12 sessions of animated biofeedback in addition to behavioral modification while Group B received behavioral modification only. The animated biofeedback used a computer program with images of dolphins or monkeys to get children to activate and relax the pelvic floor muscles. This type of training could then help the children understand how to relax the muscles with emptying the bowels or bladder, and to have active, more healthy muscles in general. Behavioral modification included education in hydration, high fiber diet, and scheduled voiding. At baseline, and at 6 and 12 months, data was collected regarding dysfunctional voiding scores, constipation and fecal soiling episodes/week, and uroflowmetry.


The results were very positive, with vesicoureteral reflux resolving in 7 of 9 children. (Vesicoureteral reflux occurs when urine moves from the bladder towards the upper urinary tract instead of flowing out of the urethra. This can create urinary tract infections (UTI), kidney scarring, and in severe cases, kidney failure.) 10 of 14 children did not have a return of UTI within 1 year from the start of the study. Bladder capacity and voided volume did not significantly change. The authors report that PVR (post-void residual, or how much urine is left in the bladder after voiding) improved as did urine flow. Within 12 months after treatment, children who reported fecal soiling at baseline were symptom-free, and 17 of 25 who had constipation were symptom-free. The control group also had improvements in symptoms but these were not as significant as in the group receiving animated biofeedback therapy. 


If you have a biofeedback unit (for surface EMG, or sEMG, one type of biofeedback) and know how to use it, you can apply this wonderful skill in the care of children who need your help. Many of the computer programs do have animations included in the software. If you would like to learn more about treating children who have bowel and bladder dysfunction, the Institute offers a course in pediatric pelvic rehabilitation with faculty member Dawn Sandalcidi. The next course is scheduled in May in Texas. Click here to see more information about the class.

Jul 25, 2011

I recently had the opportunity to sit down for a chat with Dawn Sandalcidi, PT, faculty member and national leading expert in pediatric continence. In truth, she was indulging me with her vast experience and giving me tips and encouragement towards treating children who have incontinence. I, perhaps like many of you reading this, have taken Dawn's pediatric incontinence course, yet I have not yet launched a pediatric incontinence program. Until now. After I took her course a few years ago, I vowed that I would begin treating children with bowel and bladder issues. After all, how many times have you heard the response "ever since I can remember?" when you ask your adult patients how long they have dealt with their current pelvic dysfunctions?


I (kindly and respectfully) challenge us as pelvic rehabilitation specialists to dive further into the realm of helping children who no doubt have no one else to turn to for meaningful advice. If you already treat children, good on you! It has been my experience that it is very difficult to find a provider who can treat children as well as adults. Often I believe that we get so busy with our clinic caseloads that it feels overwhelming to begin another program. Like many other challenges, if you take the first step, the rest you can figure out with some helpful resources. 


If you have a biofeedback program, then you have all the special equipment you need. To begin a pediatric program, you might also like to acquire the Pediatric Pelvic Floor Manual  as it has age-appropriate educational tools.  Another great resource that Dawn recommends is the International Children's Continence Society website.  It has an immense amount of evidenced-based work as well as patient-friendly literature. Click here to find out when the next pediatric course will be taught by Dawn Sandalcidi, or contact the Institute if you would like to host a course. 


Perhaps if we all could treat the kids who need help with bowel and bladder function, we would hear fewer stories involving decades of struggle with pelvic floor issues. I have felt a little intimidated about beginning a pediatric program, yet I know that I have the tools, the education, and helpful experiences with adult populations. I hope this post will be encouragement for any of our readers who have thought about adding a pediatric program to your practice. As for me, I have some marketing to do. 

Upcoming Continuing Education Courses

Special Topics in Women's Health - Maywood, IL
May 30, 2015 - May 31, 2015
Location: Loyola University Stritch School of Medicine

Sacroiliac Joint Evaluation and Treatment - Middletown, CT
May 30, 2015 - May 31, 2015
Location: Middlesex Hospital

Pelvic Floor Level 2B - Seattle, WA (Sold Out!)
Jun 05, 2015 - Jun 07, 2015
Location: Swedish Medical Center Seattle - Ballard Campus

Pelvic Floor Level 3 - Atlanta, GA
Jun 05, 2015 - Jun 07, 2015
Location: One on One Physical Therapy

Visceral Mobilization of the Urologic System - Madison, WI
Jun 05, 2015 - Jun 07, 2015
Location: Meriter Hospital

Nutritional Perspectives for the Pelvic Rehab Therapist - Seattle, WA
Jun 06, 2015 - Jun 07, 2015
Location: Pacific Medical Center

Rehabilitative Ultra Sound Imaging: Orthopedic Topics - Baltimore, MD
Jun 12, 2015 - Jun 13, 2015
Location: Johns Hopkins Bayview Medical Center

Rehabilitative Ultra Sound Imaging: Women's Health and Orthopedic Topics - Baltimore, MD
Jun 12, 2015 - Jun 14, 2015
Location: Johns Hopkins Bayview Medical Center

Pelvic Floor Level 1 - Boston, MA (SOLD OUT!)
Jun 12, 2015 - Jun 14, 2015
Location: Marathon Physical Therapy

Pelvic Floor Level 2B - Derby, CT (SOLD OUT)
Jun 26, 2015 - Jun 28, 2015
Location: Griffin Hospital

Breast Oncology - Maywood, IL
Jun 27, 2015 - Jun 28, 2015
Location: Loyola University Stritch School of Medicine

Chronic Pelvic Pain - Arlington, VA
Jul 10, 2015 - Jul 12, 2015
Location: Virginia Hospital Center

Myofascial Release for Pelvic Dysfunction - Winfield, IL
Jul 17, 2015 - Jul 19, 2015
Location: Central DuPage Hospital Conference Room

Pediatric Incontinence - Houston, TX
Jul 18, 2015 - Jul 19, 2015
Location: Texas Children’s Hospital

Yoga for Pelvic Pain - Cleveland, OH
Jul 18, 2015 - Jul 19, 2015
Location: UH Case Medical Center - University Hospitals