(646) 355-8777

Herman & Wallace Blog

Functional Gastrointestinal Disorders (FGID) in the Pediatric Population

For over 25 years my practice has had a focus on children suffering from bloating, gas, abdominal pain, fecal incontinence and constipation. Functional Gastrointestinal Disorders (FGID) are disorders of the brain -gut interaction causing motility disturbance, visceral hypersensitivity, altered immune function, gut microbiota and CNS processing. (Hyams et al 2016). Did you know that children who experience chronic constipation that do not get treated have a 50% chance of having issues for life?

The entire GI system is as amazing as it is and complicated. Its connection to the nervous system is fascinating, making it a very sensitive system. In her book GUT, Giulia Enders talks about Ninety percent of the serotonin we need comes from our gut! The psychological ramifications of ignoring the problem are too great (Chase et el 2018). Last year an 18-year-old patient of mine had to decline a scholarship to an Ivy League University because she needed to live at home due to her bowel management problem.

Unfortunately, FGID conditions can lead to suicide and death. Over 15 years ago my children’s pediatrician told me about an 11-year-old boy who hung himself because he had encopresis. In 2016 a 16-year-old girl suffered a cardiac arrest and died because of constipation.

The problems with children are different than for adults and need to be addressed with a unique approach.

How do physical therapists treat pediatric FGID?

  • Have a solid foundation in the gastrointestinal system
  • Coordinate muscle functions from top to bottom!
  • Identify common childhood patterns
  • Learn treatment techniques and strategies to address the issues specifically

Study and understand gastrointestinal anatomy, physiology, function and examination techniques. The entire GI system is as amazing as it is complicated. Its connection to the nervous system is fascinating, making it a very sensitive system. Ninety percent of the serotonin we need comes from our gut! The psychological ramifications of ignoring the problem are too great.

What do the Pelvic Floor Muscles (PFM) have to do with it?

Encopresis leads to a weak internal/external anal sphincter and pelvic floor muscles and constipation leads to pelvic floor muscles that can’t relax. Confused? When the Rectal Anal Inhibitory Reflex or RAIR fails from bypass diarrhea the sphincter muscles relax, and feces leaks out. This constant leakage leads to weak sphincter and pelvic floor muscles. When it happens on a regular basis most children don’t feel it, however their peers smell it and life changes.

My course, Pediatric Functional Gastrointestinal Disorders, teaches how to coordinate the muscle function based on the tasks required.

How did this start?

One painful bowel movement can lead to withholding for the next due to fear of the pain happening again. The muscles of the pelvic floor then tighten to hold the poop in. This actually does not make the muscle strong but instead makes it confused. The muscle then is controlled by the consistency of poop being too hard and painful to let out or too loose and not able to hold in.

Managing functional GI disorders is a process. It takes the bowel a long time to re-train and it requires patience and skill to know how to do it. Many therapists and patients themselves get frustrated and compliance fails. This is mostly due to lack of knowing how to titrate medications and give the bowel what it needs (other than proper nutrition that is!) It's like retraining a person to walk after a stroke, the brain needs to relearn normal bowel sensations.

Most families don’t realize how severe constipation can be. It is an insidious problem that gets ignored until it is too late.

Typically, what I hear from parents is their child was diagnosed with constipation and was advised to take a daily laxative. So, which one is the best one? How do they all work? Once leakage occurs again the laxative is discontinued as we think the bowel must be empty and this medication is causing the leaks which is counterproductive. Now the frustrating cycle of backing up or being constipated begins again. The constipation returns, the laxative is restarted, the loose stool leaks out and the laxative is stopped and that is the REVOLVING DOOR or what I refer to as children riding the “Constipation Carousel”. The bowel is an amazingly beautiful, smart but also sensitive organ that does not like this back and forth and therefore will not learn how to be normal. In the meantime, they experience distended abdomens and dysmorphia ending up in eating disorder clinics. I had an 11-year-old girl taking Amitriptyline for abdominal pain all because of a pressure problem in the gut not knowing how to work the pelvic floor with the diaphragm and her core.

No two children are the same and no two colons are the same. Laxatives need to be titrated to the specific needs of your child’s colon and motility of their colon not their age or body weight.

The success in getting children to have regular bowel movements of normal consistency without any fecal leaks is based not only teaching how to titrate laxatives but also how to sense urge, become aware of the pelvic floor muscles and learn how NOT to strain to defecate, retrain the core and diaphragm with the ribcage and integrate developmental strategies for function. Teaching Interoception- what my body feels like when I have an urge- is an important part of this course. This is especially important for those children born with anorectal malformations or congenital problems such as imperforate anus or Hirschsprung’s Disease.

In this class we use visceral techniques, manual therapy techniques, sensory techniques and neuromuscular reeducation and coordination to retrain the entire system.

Come and explore the amazing gut with me and learn how to improve the health and well-being of your patients, in Pediatric Functional Gastrointestinal Disorders!


1. Hyams, JS, et al. Childhood Functional Gastrointestinal Disorders: Child/Adolescent. Gastroenterology volume 150, 2016;1456-1468.
2. Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical features and rome IV. Gastroenterology 2016;150:1262-1279
3. Robin SG, Keller C, Zwiener R, et al. Prevalence of Pediatric Functional Gastrointestinal Disorders Utilizing the Rome IV Criteria. J Pediatr 2018; 195:134.
4. Koppen IJN, Vriesman MH, Saps M, Rajindrajith S, Shi X, van Etten-Jamaludin FS, Di Lorenzo C, Benninga MA, Tabbers MM. Prevalence of Functional Defecation Disorders in Children: A Systematic Review and Meta-Analysis. J Pediatr. 2018 Jul;198:121-130.e6. doi: 10.1016/j.jpeds.2018.02.029. Epub 2018 Apr 12.
5. Zar-Kessler C, Kuo B, Cole E, Benedix A, Belkind-Gerson, J. Benefit of pelvic floor physical therapy in pediatric patients with dyssynergic defecation constipation. 2019 Dig Dis https://doi.org/10.1159/000500121/
6. Chase J, Bower W, Susan Gibb S. et al. Diagnostic scores, questionnaires, quality of life, and outcome measures in pediatric continence: A review of available tools from the International Children’s Continence Society. J Ped Urol (2018) 14, 98e107

Continue reading

Pediatric Incontinence and Pelvic Floor Dysfunction - An Overview

“What's wrong with children?”

As pelvic health physical therapists we take care of people suffering from bladder and bowel incontinence and/or dysfunction as well as pre-natal/ post-partum back pain, weak core muscles and pelvic pain. I was approached over 30 years ago by a urologist to take care of his pediatric patients. My reply: “What’s wrong with children?” It’s been a whirlwind of learning since that day!

Pediatric pelvic floor dysfunction is common and can have significant consequences on quality of life for the child and the family, as well as negative health consequences to the lower urinary tract if left untreated.

pediatric defecatory positioningAccording to the National Institute of Diabetes and Digestive and Kidney Diseases, by 5 years of age, over 90% of children have daytime bladder control (NIDDK, 2013) What is life like for the other 10% who experience urinary leakage during the day?

Bed-wetting is also a pediatric issue with significant negative quality of life impact for both children and their caregivers, with as much as 30% of 4-year-olds experiencing urinary leakage at night (Neveus, 2010). Children who experience anxiety-causing events may have a higher risk of developing urinary incontinence, and in turn, having incontinence causes considerable stress and anxiety for children (Austin, 2014; Neveus, 2010).

Additionally, bowel dysfunction, such as constipation, is a contributor to urinary leakage or urgency. With nearly 5% of pediatric office visits occurring for constipation (Thibodeau 2013, NIDDK, 2013), the need to address these issues is great!  And, since pediatric bladder and bowel dysfunction can persist into adulthood, we must direct attention to the pediatric population to improve the health of all our patients.
Children suffer from many diagnoses that affect the pelvic floor including (Austin et al, 2014);

  • Voiding dysfunction
  • Enuresis (Bedwetting)
  • Daytime urinary incontinence
  • Urinary urgency and frequency
  • Vesicoureteral reflux (Backflow of urine into the kidney)
  • Pelvic pain (yes pelvic pain!)

The most common diagnoses I treat are voiding dysfunction and constipation. Pediatric voiding dysfunction is defined as involuntary and intermittent contraction or failure to relax the urethral muscles while emptying the bladder. (Austin et al, 2014); The dysfunctional voiding can present with variable symptoms including urinary urgency, urinary frequency, incontinence, urinary tract infections, and vesicoureteral reflux. Frequently, constipation is a culprit or cause. (Austin et al, 2014; Hodges S. 2012); Managing constipation can have a very positive effect on voiding dysfunction.
 

“What do we do to teach the pelvic floor (Kegel) muscles to work?”

Common questions I am asked include:

  • Can I use biofeedback with children?
  • Do we complete internal assessments on pediatric patients?
  • How do we teach kids so they can understand?
  • Do kids have the ability to learn strengthening versus relaxation?
  • How do you teach a child to become aware of their pelvic floor and coordinate it?

If you have pondered these questions, let’s delve in! I see children as young as 4 who have been able to master biofeedback and recite back to me how their pelvic floor works with bowel and bladder function! Children are so eager to please and they love working with animated biofeedback sessions. The research supports the potential benefit of biofeedback training for children with pelvic floor dysfunction (DePaepe et al. 2002, Kaye 2008, Kajbafzadeh 2011, Fazeli 2014). The children are engaged and learn how to isolate their pelvic floor muscles (PFM) through positioning and breathing. The exercises are fun and easy to do. We also incorporate the core! What a wonderful opportunity we have to educate the younger population on these vital muscles as well as proper diet and bowel/bladder habits!

It is not typical to complete an internal pelvic muscle assessment on children, as this would not be appropriate.

“How do I treat it?”

In the literature on pediatric bowel and bladder dysfunction you will often come across the word "Urotherapy". It is, by definition, a conservative management-based program used to treat lower urinary tract (LUT) dysfunction. (Austin 2014)

Basic Urotherapy includes education on the anatomy, behavior modifications including fluid intake, timed or scheduled voids, toileting postures and avoidance of holding maneuvers, diet, avoiding bladder irritants and constipation. Parents are often not aware of their children’s voiding habits once they are cleared from diaper duty after successful potty training occurs.

Urotherapy alone can be helpful however a recent study (Chase, 2010) demonstrated a much greater improvement in those patients who received pelvic floor muscle training as compared to Urotherapy alone.

The International Children’s Continence Society (ICCS) has now expanded the definition of Urotherapy to include Specific Urotherapy (Austin et al, 2014). This includes biofeedback of the pelvic floor muscles by a trained professional who can teach the child how to alter pelvic floor muscle activity specifically for voiding. Cognitive behavioral therapy and psychotherapy are also important and can be a needed in combination with biofeedback in specific cases.

As you can see, PFM exercise combined with Urotherapy is a safe, inexpensive, and effective treatment option for children with pediatric voiding dysfunction.

Do bladder and bowel problems cause psychological problems or is the reverse true?

When we think of pediatric bowel and bladder issues, we primarily focus on what is happening to cause the bowel or bladder leakage and treat it accordingly. It is imperative to teach a child that she/he did not have an “accident”, but their bladder or bowel had a leak. It makes the incident a physiological problem and not something they did. See my blog post on “Accident” for more information.

It is not always apparent how much the child is suffering from issues with self-esteem, embarrassment, internalizing behaviors, externalizing behaviors or oppositional defiant disorders. Dr. Hinman recognized theses issues years ago (1986) and commented that voiding dysfunctions might cause psychological disturbances rather than the reverse being true. Dr. Rushton in 1995 wrote that although a high number of children with enuresis are maladjusted and exhibit measurable behavioral symptoms, only a small percentage have significant underlying psychopathology. In other more recent studies (Joinson et al. 2006a, 2006b, 2008, Kodman-Jones et al, 2001) it was noted that elevated psychological test scores returned to normal after the urologic problem was cured.

I frequently get testimonials from my patients. I would say the common denominator is the child and/or caregivers report that the child is “much better adjusted,” “happier”, “come out of his shell”, “more outgoing”, “making friends.” As a side note -- they’re happy they don’t leak anymore.
You can learn more about treating pediatric patients in my courses,

Pediatric Incontinence and Pelvic Floor Dysfunction and Pediatric Functional Gastrointestinal Disorders.


Austin, P., Bauer, S.B., Bower, W., et al. The standardization of terminology of lower urinary tract function in children and adolescence: update report from the standardization committee of the international children’s continence society. J Urol (2014) 191.
Chase J, Austin P, Hoebeke P, McKenna P. The management of dysfunctional voiding in children: a report from the standarisation committee of the international children’s continence society. 2010; J Urol183:1296-1302.
Constipation in Children. (2013)retrieved June 9, 2014 from http://kidney.niddk.nih.gov/kudiseases/pubs/uichildren/index.aspx
DePaepe H., Renson C., Hoebeke P., et al: The role of pelvic- floor therapy in the treatment of lower urinary tract dysfunctions in children. Scan J of Urol and Neph 2002; 36: 260-7.
Farahmand, F., Abedi, A., Esmaeili-dooki, M. R., Jalilian, R., & Tabari, S. M. (2015). Pelvic Floor Muscle Exercise for Paediatric Functional Constipation.Journal of Clinical and Diagnostic Research : JCDR, 9(6), SC16–SC17. http://doi.org/10.7860/JCDR/2015/12726.6036
Fazeli MS, Lin Y, Nikoo N, Jaggumantri S1, Collet JP, Afshar K. Biofeedback for Non-neuropathic daytime voiding disorders in children: A systematic review and meta-analysis of randomized controlled trials. J Urol. 2014 Jul 26. pii: S0022-5347(14)04048-8.
Hinman, F. Nonneurogenic neurogenic bladder (the Hinman Syndrome)-15 years later. J Urol 1986;136, 769-777.
Hodges SJ, Anthony E. Occult megarectum:a commonly unrecognized cause of enuresis. Urology. 2012 Feb;79(2):421-4. doi: 10.1016/j.urology.2011.10.015. Epub 2011 Dec 14.
Hoebeke, P., Walle, J. V., Theunis, M., De Paepe, H., Oosterlinck, W., & Renson, C. Outpatient pelvic-floor therapy in girls with daytime incontinence and dysfunctional voiding. Urology 1996; 48, 923-927.
Joinson, C., Heron, J., von Gontard, A. and the ALSPAC study team: Psychological problems in children with daytime wetting. Pediatrics 2006a; 118, 1985-1993.
Joinson, C., Heron, J., Butler, U., von Gontard, A. and the ALSPAC study team: Psychological differences between children with and without soiling problems. Pediatrics 2006b; 117, 1575-1584.
Joinson, C., Heron, J., von Gontard, A., Butler, R., Golding, J., Emond, A.: Early childhood risk factors associated with daytime wetting and soiling in school-age children. Journal of Pediatric Psychology2008; e-published.
Kajbafzadeh AM, harifi-Rad L, Ghahestani SM, Ahmadi H, Kajbafzadeh M, Mahboubi AH. (2011) Animated biofeedback: an ideal treatment for children with dysfunctional elimination syndrome. J Urol;186, 2379-2385.
Kaye JD, Palmer LS (2008) Animated biofeedback yields more rapid results than nonanimated biofeedback in the treatment of dysfunctional voiding in girls. J Urol 180, 300-305
Kodman-Jones, C., Hawkins, L., Schulman, SL. Behavioral characteristics of children with daytime wetting.  J Urol 2001;Dec(6):2392-5.
Neveus, T, Eggert P, Evans J, et al. Evaluation of the treatment for monosymptomatic enuresis: a standarisation document from the international children’s continence society. J Urol 2010; 183: 441-447
Rushton, H. G. Wetting and functional voiding disorders. Urologic Clinics of North America, 1995; 22(1), 75-93.
Seyedian, S. S. L., Sharifi-Rad, L., Ebadi, M., & Kajbafzadeh, A. M. (2014). Combined functional pelvic floor muscle exercises with Swiss ball and urotherapy for management of dysfunctional voiding in children: a randomized clinical trial. European Journal of Pediatrics, 173(10), 1347-1353.
Thibodeau, B. A., Metcalfe, P., Koop, P., & Moore, K. (2013). Urinary incontinence and quality of life in children. Journal of pediatric urology, 9(1), 78-83.
Urinary Incontinence in Children. (2012). Retrieved June 9, 2014 from http://kidney.niddk.nih.gov/kudiseases/pubs/uichildren/index.aspx
Zivkovic V, Lazovic M, Vlajkovic M, Slavkovic A, Dimitrijevic L, Stankovic I, Vacic N. (2012). Diaphragmatic breathing exercises and pelvic floor retraining in children with dysfunctional voiding. European Journal of Physical Rehabilitation Medicine. 48(3):413-21. Epub 2012 Jun 5.

Continue reading

Bedwetting: Facts and Myths

How often have you heard that bedwetting was behavioral or caused by deep sleep and your child would outgrow it? 15% of children per year will “outgrow” bedwetting. What if your child is in the percentile at the end of that range?

Facts:

  • Bedwetting affects 15% of girls and 22% of boys
  • 5 - 7 Million US children
  • Boys are 50% more likely than girls to wet the bed
  • 10% of 6 year olds continue to wet
  • Spontaneous cure rate 15% per year thereafter
  • 1-3% of 18 year olds still wet their beds
  • Less than 50% of all bedwetting children have bedwetting alone, without also experiencing daytime urinary leakage or constipation
  • Bedwetting is genetic – if one parent was a bed wetter the child has a 40% chance of wetting the bed and if both parents were bedwetters the percentile goes up to 77%

Myths:

  • Your child is lazy
  • Your child is doing this to get attention
  • Your child is just a deep sleeper
  • You must wait to grow out of it

Research from the International Children’s Continence Society (ICCS) is a great resource for exploring the research on this topic and other pediatric voiding issues. www.i-c-c-s.org

What causes Bedwetting?

There are many philosophies discussed in the research. Here are some listed below:

  1. Hormone deficiency- our bladders empty about every 2-3 hours during the day however at night we can hold over 8 hours! This happens because our bodies produce an antidiuretic hormone when we sleep to slow kidney function and produce less urine to empty into the bladder. If this hormone is not being produced, the kidneys produce as much urine at night as they do during the day. In this case, it's good that the bladder empties out in our sleep, otherwise our bladders would be dangerously large and possibly reflux urine backward into the kidneys. Clearly not behavioral!!
  2. Dr. Steven Hodges has researched and written extensively on the topic of constipation causing pressure from the rectum against the bladder making it irritable during sleep. His research has supported the fact that once the bowel is cleaned out daily the bedwetting episodes diminish. See It’s No Accident by Dr. Hodges or visit https://www.bedwettingandaccidents.com for more information on this topic. Again, a physiological cause of bedwetting versus behavioral.
  3. Sleep Disturbance and Nasal Airway Obstruction. Dr. Neveus and colleagues reported that 43.5% of children with snoring or obstructive sleep apnea became dry after adenotonsillectomy. Dr. Kovacevic also found increases in antidiuretic hormone seen in responders post-operatively.

 

Take Home Message

  1. Active treatment for bedwetting should begin at age 6
  2. The impact of bedwetting is mainly psychological and may be severe
  3. Children with bedwetting have abnormal psychological test scores, however once the bedwetting is resolved the test scores return to normal
  4. “Treatment is not only justified but mandatory”
    -ICCS Standardization document 2010

 

There is help!

At Physical Therapy Specialists we specialize in bedwetting, urinary leakage, constipation and other voiding issues in children. Let us eliminate the need for your family to suffer through this very treatable condition!

 


Al- Zaben FN, Sehlo MG. Punishement for bedwetting is associated with child depression and reduced quality of life. Child Abuse Negl. 2014
Hodges SJ, Colaco M. Daily enema regimen is superior to traditional therapies for nonneurogenic pediatric overactive bladder. Global Pediatric Health, 2016, 3: 1–4
Austin, P., Bauer, S.B., Bower, W., et al. The standardization of terminology of lower urinary tract function in children and adolescence: update report from the standardization committee of the international children’s continence society. J Urol (2014) 191.
Treatment response of an outpatient training for children with enuresis in a tertiary health care setting. J Pediatr Urol. 2012.
Hodges SJ,Anthony EY::aunrecognizedof. Urology.2012 Feb;79(2):421-4. doi: 10.1016/j.urology.2011.10.015. Epub 2011 Dec 14.
Kovacevic L, Wolfe-Christensen C, Lu H, Toton M, Mirkovic J, Thottam PJ, Abdulhamid I, Madgy D, Lakshmanan Y. Why does adenotonsillectomy not correct enuresis in all children with sleep disordered breathing? J Urol. 2014 May;191(5 Suppl):1592-6.
Nevéus T, Leissner L, Rudblad S, Bazargani F. Acta Paediatr. 2014 Jul 15. doi: 10.1111/apa.12749. [Epub ahead of print]Orthodontic widening of the palate may provide a cure for selected children with therapy-resistant enuresis.
Hodges, Steve J. It’s No Accident-Breakthrough solutions for your child’s wetting, constipation, UTI’s and other potty problems. © 2012. Lyons Press, Guilford, Connecticut.

Continue reading

Urotherapy - What is it?

The following post comes to us from long-time faculty member Dawn Sandalcidi PT, RCMT, BCB-PMD! Dawn is a figurehead in the world of pediatric pelvic floor, she teaches Pediatric Incontinence and Pelvic Floor Dysfunction (available three times in 2016) and she just completed the 2nd edition of the Pediatric Pelvic Floor Manual!! Today Dawn is sharing her insights an urotherapy for pediatric patients.

If you read any papers on pediatric bowel and bladder dysfunction you will often come across the word "urotherapy". It is by definition a conservative based management based program used to treat lower urinary tract (LUT) dysfunction using a variety of health care professionals including the physician, Physical Therapists, Occupational Therapists and Registered Nurses.

Basic urotherapy includes education on the anatomy and function of the LUT, behavior modifications including fluid intake, timed or scheduled voids, toilet postures and avoidance of holding maneuvers, diet, bladder irritants and constipation. This needs to be tailored to the patients’ needs. For example a child with an underactive bladder needs to learn how to sense urge and listen to their body and a child who postpones a void needs to be on a voiding schedule. Urotherapy alone can be helpful however a recent study demonstrated a statistically significant improvement in uroflow, pelvic floor muscle electromyography activity during a void, urinary urgency, daytime wetting and reduced post void residual (PVR) in those patients who received pelvic floor muscle training as compared to Urotherapy alone. This is great news for all of us who are qualified to teach pelvic floor muscle exercise!

The International Children’s Continence Society (ICCS) has now expanded the definition of Urotherapy to include Specific Urotherapy. This includes biofeedback of the pelvic floor muscles by a trained therapist who is able to teach the child how to alter pelvic floor muscle activity specifically to void. It also includes neuromodulation for many types of lower urinary tract dysfunction but most commonly with overactive bladder and neurogenic bladder. Cognitive behavioral therapy and psychotherapy are always important to assess (see blog post on psychological effects of bowel and bladder dysfunction).

It truly does take a village to help this kiddos and I am honored to be a team player!

 

To learn more about pediatric incontinence and pelvic floor rehabilitation, join Dawn Sandalcidi at one of her courses this year! Details at the following links:
Pediatric Incontinence - Augusta, GA - Apr 16, 2016 - Apr 17, 2016
Pediatric Incontinence - Torrance, CA - Jun 11, 2016 - Jun 12, 2016
Pediatric Incontinence - Waterford, CT - Sep 17, 2016 - Sep 18, 2016


Chang SJ, Laecke EV, Bauer, SB, von Gontard A, Bagli,D, Bower WF,Renson C, Kawauchi A, Yang SS-D. Treatment of daytime urinary incontinence: a standardization document from the international children's continence society. Neurourol Urodyn 2015;Oct 16. doi:10.1002/nau.22911
Ladi Seyedian SS, Sharifi-Rad L, Ebadi M, Kajbafzadeh AM. Combined functional pelvic floor muscle exercise with swiss ball and Urotherapy for management of dysfunctional voiding in children: a randomized controlled trial. Eur J Pediatr.2014 Oct;173(10):1347-53. I.J.N. Koppen, A. von Gontard, J. Chase, C.S. Cooper, C.S. Rittig, S.B. Bauer, Y. Homsy, S.S. Yang, M.A. Benninga. Management of functional nonretentive fecal incontinence in children: recommendations from the International Children’s Continence Society. J of Ped Urol (2015)
Koppen IJ, Di Lorenzo C, Saps M, Dinning PG, Yacob D, Levitt MA, Benninga MA. .Childhood constipation: finally something is moving! Expert Rev Gastroenterol Hepatol. 2015 Oct 14:1-15.

Continue reading

Learn Essentials Skills in Pediatrics from Dawn Sandalcidi PT, RCMT, BCB-PMD

The Pelvic Rehab Report had an opportunity to interview Dawn Sandalcidi, the creator and instructor of "Pediatric Incontinence and Pelvic Floor Dysfunction". Dawn has developed a pediatric dysfunctional voiding treatment program in which she lectures on nationally. Dawn has published articles in the Journal of Urologic Nursing, the Journal of Manual and Manipulative Therapy, and the Journal of Women’s Health Physical Therapy. Let's hear more from Dawn about her Pediatric Incontinence and Pelvic Floor Dysfunction course!

What essential skill does your course add to a practitioner’s toolkit?

Adding pediatrics to your practice truly allows you to treat the pelvic floor through the lifespan. If you are a pediatric therapist adding this most important specialty will complete the picture of your entire patient.

Will your course allow practitioners to see new/more patients?

There are so many therapists who tell me that while treating a parent they share a story about their child being a bed wetter or having incontinence. That has opened up many doors for including this population into my practice. Be careful though! Once the pediatricians, school nurses, pediatric urologists and GI docs know there is someone out there that can take care of kids you will be flooded with patients!!

Why did you develop this course?

I began treating pediatrics after having success with adult patients in a large urology practice over 25 years ago. One of the urologists called me and asked me to take care of this little girl who had already been operated on twice and was headed toward kidney transplants. My reply was "what is wrong with kids?????" So my journey began- observing surgery and learning how children developed pelvic floor dysfunction. This kiddo had vesicoureteral reflux or a back flow of urine form the bladder to the kidneys causing frequent infections and kidney damage. My goal in this course is to take the basic knowledge we have as therapists and apply it to a population of children who suffer terribly with urinary and fecal incontinence. The psychological side effects from incontinence are significant and we now have the tools to help!!

Continue reading

Was it an accident or was it a leak?? Dawn’s Soap Box

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:

  1. 1. An unforeseen and unplanned event or circumstance
  2. 2.An unexpected and medically important bodily event especially when injurious
  3. 3.Used euphemistically to refer to an involuntary act or instance of urination or defecation

Now lets think about that. How would you feel if someone approached you after noticing a smell or a wet spot and asked you “Did you have an accident?” My first thoughts are maybe shame, embarrassment, guilt or failure. “I” had an accident. Children feel without easily being able to express these emotions thus internalizing their feelings. This then can be expressed with inappropriate behaviors.

When I work with children, and adults for that matter, I frame the conversion with the physiology of the anatomical structure that is unable to do the job it is designed to do. I teach the children about their anatomy and bladder/bowel function and I am clear to let them know that their bladder and/or bowel had a leak, they did not. It takes ownership away from the person and places it on the body part that is currently dysfunctional. At that point we discuss we can re-train the body part to do the job they were designed to do. The kids become empowered that they will be able to become “The Bladder/Bowel Boss”.

To learn more about Dawn's course visit Pediatric Incontinence

Continue reading

Psychological Disturbances in Children with Elimination Disorders

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.

It is not always apparent how much the child is suffering from issues with self-esteem, embarrassment, internalizing behaviors, externalizing behaviors or oppositional defiant disorders. Dr. Hinman recognized theses issues years ago (1986) and commented that voiding dysfunctions might cause psychological disturbances rather than the reverse being true. Dr. Rushton in 1995 wrote that although a high number of children with enuresis are maladjusted and exhibit measurable behavioral symptoms, only a small percentage have significant underlying psychopathology. In more recent studies by Sureshkumar, 2009; Joinson 2007 it was noted that elevated psychological test scores returned to normal after the urologic problem was cured. Lettgen et al. 2002, Kuhn et al, 2008, van Gontard, 2012 all reported that children with urge incontinence are distressed by their symptoms but the family functioning is intact.

I frequently get testimonials from my patients. I would say the common denominator is the child and/or parental report that the child is “much better adjusted,” “happier”, “come out of his shell”, “more outgoing”, “making friends.” As a side note -- they’re happy they don’t leak anymore.

The International Children’s Continence Society (i-c-c-s.org) is filled with standardization documents that support the work we do to take care of kids with elimination issues. The work we do to take care of these kiddos in not only necessary but also mandatory to avoid these psychological disorders.

Read about Suzanne's Story

To learn more about Dawn's course visit Pediatric Incontinence

Read more about what Dawn does in PT in Motion

Continue reading

Upcoming Continuing Education Courses

Feb 1, 2020 - Feb 2, 2020
Location: Evergreen Hospital Medical Center

Feb 1, 2020 - Feb 2, 2020
Location: Ochsner Health System

Feb 7, 2020 - Feb 9, 2020
Location: FunctionSmart Physical Therapy

Feb 22, 2020 - Feb 23, 2020
Location: Pacific Medical Centers

Feb 22, 2020 - Feb 23, 2020
Location: Huntington Hospital

Feb 28, 2020 - Mar 1, 2020
Location: Inova Physical Therapy Center

Feb 28, 2020 - Mar 1, 2020
Location: University of North Texas Health Science Center

Feb 28, 2020 - Mar 1, 2020
Location: Novant Health

Feb 28, 2020 - Mar 1, 2020
Location: Rex Hospital

Feb 28, 2020 - Feb 29, 2020
Location: Rex Hospital

Mar 6, 2020 - Mar 8, 2020
Location: 360 Sports Medicine & Aquatic Rehabilitation Centers

Mar 6, 2020 - Mar 8, 2020
Location: Heart of the Rockies Regional Medical Center

Mar 6, 2020 - Mar 8, 2020
Location: University of Missouri-Smiley Lane Therapy Services

Mar 6, 2020 - Mar 8, 2020
Location: Princeton Healthcare System

Mar 6, 2020 - Mar 8, 2020
Location: Ochsner Health System

Mar 6, 2020 - Mar 8, 2020
Location: Spectrum Health System

Mar 7, 2020 - Mar 8, 2020
Location: Veterans Administration - Salt Lake City

Mar 7, 2020 - Mar 8, 2020
Location: GWUH Outpatient Rehabilitation Center

Mar 13, 2020 - Mar 15, 2020
Location: Sentara Therapy Center - Princess Anne

Mar 13, 2020 - Mar 15, 2020
Location: Thomas Jefferson University

Mar 13, 2020 - Mar 15, 2020
Location: Franklin Pierce University

Mar 14, 2020 - Mar 15, 2020
Location: Park Nicollet Clinic--St. Louis Park

Mar 20, 2020 - Mar 22, 2020
Location: Allina Hospitals and Clinics

Mar 20, 2020 - Mar 22, 2020
Location: Comprehensive Therapy Services

Mar 20, 2020 - Mar 22, 2020
Location: Shelby Baptist Medical Center

Mar 20, 2020 - Mar 22, 2020
Location: Tri-City Medical Center

Mar 20, 2020 - Mar 22, 2020
Location: PeaceHealth- St. Joseph Medical Center

Mar 20, 2020 - Mar 22, 2020
Location: Mount Saint Mary’s University

Mar 21, 2020 - Mar 22, 2020
Location: Banner Physical Therapy and Rehabilitation

Mar 27, 2020 - Mar 29, 2020
Location: Henry Ford Macomb Hospital