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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.

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“I Still Feel Wet!” - A Cry for Help

When my 6 year old daughter ran to the bathroom 3-4 times before she got on the school bus every morning, I wasn’t too concerned, but I definitely took note. The day she was in tears and wouldn’t get off the toilet because she felt like she was still wet, I got worried (although slightly intrigued). No matter how much she wiped, she still felt wet. When she stood up, she felt like she was going to pee herself, making my sweet-natured girl slip into hysterics. After eliminating small amounts of urine 8 separate times in 3 hours and saying it burned, I assumed she had a urinary tract infection (UTI). A simple urine test ruled out UTI or diabetes (thankfully!). So then, what was my daughter’s diagnosis? The pediatrician simply referred to it as “a phase;” however, I had researched the symptoms before the visit.

In 2014 Arlen et al. described a condition called “phantom urinary incontinence.” This refers to the situation when children experience the sensation of being wet (a presumptive urinary incontinence) when they are objectively dry. They considered 20 children (18 females, 2 males) referred to their pediatric urology clinic over a 5 year span, all who were all diagnosed with phantom urinary incontinence (PUI). The authors evaluated the concomitant diagnoses found among the boys and girls in the study. Lower urinary tract symptoms were present in 95% of the subjects. Associated bladder symptoms were found as well, with urgency in 75% and frequency in 50% of the children. Vaginitis occurred in 72% of the girls. Parents reported obsessive-compulsive disorder or obsessive-compulsive disorder personality traits in 70% of the children. In order to treat these patients, dietary modifications, timed voiding, and a bowel regimen were implemented to manage symptoms. A follow up at 14.4 months revealed 90% of the children’s bowel-bladder dysfunction improved and PUI resolved. The authors concluded children compliant with a rigid bladder-bowel regimen experience relief of their “phantom” incontinence as well as lower urinary tract symptoms, and a majority of PUI patients have obsessive-compulsive traits.

Oliver et al., (2013) studied how psychosocial comorbidities and body mass index relate to children with lower urinary tract dysfunction. Data on 358 patients with lower urinary tract dysfunction between 6 to 17 years old was collected, and the subjects’ parents completed questionnaires screening for lower urinary tract symptoms, stressful life events, and psychological comorbidities. Obesity was present in 28.5% of the children, 22.9% had a recent stress in life, and 22.9% had a psychiatric disorder. Under and overweight children, children with a recent life stressor, psychiatric disorder, or both, as well as the younger-aged children all had lower urinary tract symptom scores significantly higher than healthy weight subjects, those without psychosocial comorbidities, and older subjects. The results encourage screening for psychosocial issues and obesity in pediatric patients with lower urinary tract dysfunction.

Having read the research, I knew a life stressor was likely contributing to my daughter’s symptoms. I had already advised her to sit on the toilet every 1-2 hours, don’t let her bladder get too full, wipe gently from front to back, stop bubble baths, and wear looser pants. To conclude our $76 session, the doctor prescribed almost verbatim what my daughter had heard from me at home. Although thankful it wasn’t something more serious, I am curious what the diagnosis code is for “a phase” and when it will end.


Arlen, AM, Dewhurst, LL, Kirsch, SS, Dingle, AD, Scherz, HC, Kirsch, AJ. (2014). Phantom urinary incontinence in children with bladder-bowel dysfunction. Urology. 84(3):685-8. DOI: http://dx.doi.org/10.1016/j.urology.2014.04.046 Oliver, J.L., Campigotto, M.J., Coplen, D.E. et al,. (2013). Psychosocial comorbidities and obesity are associated with lower urinary tract symptoms in children with voiding dysfunction. The Journal of Urology. 190:1511–1515. DOI: http://dx.doi.org/10.1016/j.juro.2013.02.025

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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.

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Pediatric Enuresis: Neurogenic or Just Nervous?

When my almost 4 year old still wets his bed in the middle of the night, my first reaction is frustration; but, I learned that gets us nowhere fast, so now I just roll with the punches. Usually the culprit is my stubborn son’s simple refusal to go the bathroom before bed. When enuresis is secondary to neurogenic disorders or anxiety disorders, caregivers need to have even more patience with children.

Sturm and Cheng (2016) published a review on the management of neurogenic bladder in the pediatric population. Central nervous system (CNS) lesions including cerebral palsy, spinal cord injury, and spinal malformations, as well as pelvic tumors or anorectal malformations, can all affect normal lower urinary tract function. Children with neurogenic bladder often have the condition because of a CNS lesion. This can affect the bladder’s ability to store and empty urine, so early intervention is essential and focuses on maximizing bladder function and avoiding injury to the upper or lower urinary tracts. With older children, the goals are urinary continence and independent bladder management.

Myelomeningocele surgical prenatal closure has had minimal effect on urinary tract function, and parents are encouraged to monitor urological changes because of the child’s risk for neurogenic bladder. Clean intermittent catheterization (CIC) has reduced the morbidity in patients with neurogenic bladder. Determining which children would benefit from initiation of CIC and when medical or surgical interventions should be implemented remains a challenge. Anticholinergics have proven effective on continence and bladder compliance either orally or, more recently, intravesical administration. Surgically, autologous augmentation using the ileum or colon has shown fatal complications like bowel obstruction and bladder rupture, particularly when bladder neck procedures are performed concurrently. Robotic versus open bladder neck reconstruction has been proving more favorable in recent studies. The authors concluded more research is needed for treatment, and the goals are preservation of the upper and lower urinary tracts, optimizing quality of life (Sturm and Cheng 2016).

Considering a different side of nerves, Salehi et al., (2016) studied the relationship between primary nocturnal enuresis and child anxiety disorders. They studied 180 children with primary nocturnal enuresis (referring to children >5 years old having no urine control 6 continuous months) and 180 healthy controls. A statistically significant difference was found between the two groups regarding the frequency of generalized anxiety disorder as well as panic disorder, school phobia, social and separation anxieties, maternal anxiety history, parental history of primary nocturnal enuresis and body mass index. The authors recommended any children with primary nocturnal enuresis should be assessed and treated for generalized anxiety disorder.

The seriousness of enuresis cannot be underestimated. When the cause is neurogenic, pharmacological or surgical intervention may be warranted and lifelong urologic management is needed, especially for a healthy transition into adulthood. As common as nocturnal bed wetting may be in school aged children, they should be monitored for the presence of any anxiety disorders that may be contributing to the disorder. Changing sheets may feel like a burden for parents, but the child with enuresis has a far greater weight to bear.

You can learn all about caring for pediatric patients by attending Pediatric Incontinence and Pelvic Floor Dysfunction with Dawn Sandalcidi, available twice in 2017.


Sturm, R. M., & Cheng, E. Y. (2016). The Management of the Pediatric Neurogenic Bladder. Current Bladder Dysfunction Reports, 11, 225–233. http://doi.org/10.1007/s11884-016-0371-6
Salehi, B., Yousefichaijan, P., Rafeei, M., & Mostajeran, M. (2016). The Relationship Between Child Anxiety Related Disorders and Primary Nocturnal Enuresis. Iranian Journal of Psychiatry and Behavioral Sciences, 10(2), e4462. http://doi.org/10.17795/ijpbs-4462

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Pediatric Voiding Dysfunction

As pelvic rehabilitation providers, it may be safe to assume a lot of us are treating adults with bladder and bowel dysfunction. Often we get questions from these patients about treatment for children with voiding dysfunction. How comfortable are we treating children for these problems and what would we do? Pediatric voiding dysfunction and bowel problems are common and can have significant consequences to quality of life for the child and the family, as well as negative health consequences to the lower urinary tract if left untreated. No clear gold standard of treatment for pediatric voiding dysfunction has been established and treatments range from behavioral therapy to medication and surgery.

A randomized controlled trial in 2013 that was published in European Journal of Pediatrics, explores treatment options for pediatric voiding dysfunction. Pediatric voiding dysfunction is defined as involuntary and intermittent contraction or failure to relax the urethral striated sphincter during voluntary voiding. The dysfunctional voiding can present with variable symptoms including urinary urgency, urinary frequency, incontinence, urinary tract infections, and abnormal flow of urine from bladder back up the ureters (vesicoureteral reflux).

The 2013 study compared 60 children over one year who were diagnosed with dysfunctional voiding into two treatment groups. One group received behavioral urotherapy combined with PFM (pelvic floor muscle) exercises while the other group received just behavioral urotherapy. The behavioral urotherapy consisted of hydration, scheduled voiding, toilet training, and high fiber diet. Voiding pattern, EMG (electromyography) activity during voids, urinary urgency, daytime wetting, and PVR (post-void residue) were assessed at the beginning and end of the one year study with parents completing a voiding and bowel habit chart as well as uroflowmetry with pelvic floor muscle sEMG (surface electromyography) was administered to the child for voiding metrics.

All parents and children in both groups received education about urinary and gastrointestinal tract function as well as healthy bladder habits, effects of high fiber diet, scheduled voiding, and normal mechanics of toilet training. For the group that completed PFM exercises and education, they participated in 12 sessions (2x/week for 30 minutes) to learn the PFM exercises under the guidance of a single physical therapist. There was bimonthly follow up for both groups throughout the 12 months to ensure retention and application of the behavioral urotherapy.

The goal of the PFM exercises for the children was too restore the normal function of the PFM’s and their coordination with abdominal muscles. The exercises that the children completed, included exercises with and without a swiss ball. The exercises without a swiss ball included breathing with the diaphragm, Transversus Abdominus muscle isolation, hip adductor squeeze (isolation), bridging with PFM relaxation, and cat/camel to improve lumbopelvic coordination. Swiss ball exercises included seated PFM contraction and relaxation exercise with a seated lift and relax, supine bridge with roll out on the ball with PFM contraction, and supine swiss ball lift with the legs and pelvic contraction. (Pictures and more details about how the exercises were carried out in the article itself.)

The conclusion of the study was that the functional PFM exercises with swiss ball combined with behavioral urotherapy reduced the frequency of urinary incontinence, PVR (post void residue), and the severity of constipation in children with voiding dysfunction. The children in the combined group showed improvements with voiding pattern, reduced EMG activity during voids, reduced urgency, reduced daytime wetting, and improvements with more complete emptying with voids (reduced PVR).

The Functional PFM exercises are easy to teach and easy for children to complete. They are a safe, inexpensive, and effective treatment option for children with dysfunctional voiding. PFM exercises combined with behavioral urotherapy seems to be a logical treatment option for treating pediatric voiding dysfunction.

To learn more about pediatric bowel and bladder dysfunction and treatment for it consider attending Dawn Sandalcidi's Pediatric and Pelvic Floor Dysfunction course. The three opportunities in 2016 are Pediatric Incontinence - Augusta, GA April 16-18, Pediatric Incontinence - Torrance, CA June 11-12, and Pediatric Incontinence - Waterford, CT on September 17-18.


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.

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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.

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Pediatric Pelvic Floor: Training to Go

The day my son was born, my daughter had not defecated for 5 days, and her pain was getting pretty intense. My husband and his mom took her to Seattle Children’s Hospital for help, and they suggested using Miralax and sent them away. When they got back to my hospital room, my daughter was straining so hard it looked like she was about to give birth! Being physical therapists, my husband and I massaged her little muscles and told her to take deep breaths, and eventually she did the deed, yet not without a heart-breaking struggle. Little did I know then there is actually research to back up our emergency, instinctual technique.

Zivkovic et al (2012) performed a study regarding the use of diaphragmatic breathing exercises and retraining of the pelvic floor in children with dysfunctional voiding. They defined dysfunctional voiding as urinary incontinence, straining, weakened stream, feeling the bladder has not emptied, and increased EMG activity during the discharge of urine. Although this study focuses primarily on urinary issues, it also includes constipation in the treatment and outcomes. Forty-three patients between the ages of 5 and 13 with no neurological disorders were included in the study. The subjects underwent standard urotherapy (education on normal voiding habits, appropriate fluid intake, keeping a voiding chart, and posture while voiding) in addition to pelvic floor muscle retraining and diaphragmatic breathing exercises. The results showed 100% of patients were cured of their constipation, 83% were cured of urinary incontinence, and 66% were cured of nocturnal enuresis.

More recently, Farahmand et al (2015) researched the effect of pelvic floor muscle exercise for functional constipation in the pediatric population. Stool withholding and delayed colonic transit are most often the causes for children having difficulty with bowel movements. Behavioral modifications combined with laxatives still left 30% of children symptomatic. Forty children between the ages of 4 and 18 performed pelvic floor muscle exercise sessions at home, two times per day for 8 weeks. The children walked for 5 minutes in a semi-sitting (squatting) position while being supervised by parents. The patients increased the exercise duration 5 minutes per week for the first two weeks and stayed the same over the next six weeks. The results showed 90% of patients reported overall improvement of symptoms. Defecation frequency, fecal consistency and decrease in fecal diameter were all found to be significantly improved. Although not statistically significant, the number of patients with stool withholding, fecal impaction, fecal incontinence, and painful defecation decreased as well.

Parents may not be as aware of their children’s voiding habits once they are cleared from diaper duty after successful potty training occurs. To help prevent issues, keep the basics covered, such as making sure children are exercising regularly or being active, drinking plenty of fluids, and eating a diet that includes plenty of fiber. My daughter was only 26 months old when her constipation became a problem, so the stool softener was ultimately the way to go at that time, and everything worked out naturally over the next year. If she were still experiencing functional constipation, I would be delighted to know teaching her pelvic floor exercises (relaxation being the key aspect) and diaphragmatic breathing could be effective for keeping my crazy little girl regular in at least that area of her life!


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 J ournal of Physical Rehabilitation Medicine. 48(3):413-21. Epub 2012 Jun 5.
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

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How do we Apply Pelvic Rehabilitation to Pediatric Patients?

Therapists are increasingly learning about and treating pediatric patients who have pelvic floor dysfunction, yet there are still not enough of them to meet the demand. Many therapists I have spoken to are understandably concerned about how to transfer what they have done for adult patients to a younger population. Here are some of the more common concerns therapists express or questions they ask in relation to the pediatric population:

  • Can we use biofeedback with children?
  • Do we complete internal assessments on kids?
  • How do we change the way we talk to the children?
  • How much do we have to teach the parents to get the information across?
  • Why do we teach strengthening even if some of the kids mostly need relaxation or coordination?

Although each question deserves a longer answer, we can start with biofeedback, and the answer is a resounding “yes”. There is abundant research affirming the potential benefit of biofeedback training for children with pelvic floor dysfunction. And no, we do not typically complete an internal pelvic muscle assessment on children, as that would not be appropriate. Considering that pediatrics can refer to young adults up to age 18-21, there may be a reasonable clinical goal in mind for utilizing internal assessment or treatment. The words we use when we speak to children become very important. Herman & Wallace faculty member Dawn Sandalcidi (known as “Miss Dawn” to her younger patients) gives ample strategies for adapting our language in her continuing education course Pediatric Incontinence and Pelvic Floor Dysfunction. For example, Dawn emphasizes the importance of describing an episode of incontinence as a “bladder leak” and of pointing out to a child that his or her bladder leaked, rather than the child leaking. She also likes to encourage parents and school personnel to drop the term “accident” from vocabulary. In her 2-day course, Dawn also teaches therapists how to train children to become a “Bladder Boss”, and how to teach young patients about relevant anatomy.

The way we teach anatomy to kids is really important in making sure they “get” it. One study published in 2012Equit 2013 describes the results when children are asked to draw a urinary tract in a body diagram. Only half of the children drew a bladder and other organs, and nearly 43% of the children drew “anatomically incorrect pictures.” The authors point out that older children and the ones who had gone through group training for bowel and bladder were more likely to draw correct images. For the last question about teaching contract/relax exercises to children, I had an opportunity to ask Dawn this question recently when she was filming a pediatrics course for MedBridge Education. Her answer emphasized the importance of getting children to develop awareness of the pelvic muscles, and to improve their coordination as well as strength- concepts that participating in an exercise program can work toward.

If you would like to learn more about working with children, the next opportunity to take Dawn’s course is in Boston later this month.


Equit, Monika et al. "Children's concepts of the urinary tract". Journal of Pediatric Urology , Volume 9 , Issue 5 , 648 - 652

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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!!

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Endometriosis and adolescence

Recent research in The Journal of Pediatric and Adolescent Gynecology points to the alarming number of young women who present with pelvic pain who in fact also have endometriosis. Dr. Opoku-Anane and Dr. Laufer report that prevalence rates of endometriosis in an adolescent gynecology population have likely been underestimated (reported range of 25-47%) and that with advanced surgical methods the rates have been estimated to be as high as 73% in those who have pelvic pain. In their retrospective study, 117 subjects ages 12-21 completed laparoscopic examination for endometriosis. These subjects did not previously respond to non-steroidal anti-inflammatories or to oral contraceptives, and they were all referred for evaluation of chronic pelvic pain. In addition to collecting data about patient symptoms, the stage and descriptions of any endometrial lesions were documented.

A remarkable 115 of the 117 subjects (98%) presented with Stage I or II endometriosis as defined by the American Society for Reproductive Medicine guidelines. (Click here for the link to a detailed patient education document from the ASRM that describes endometriosis as well as staging.) The median age for onset of menarche in this population was 12 years old, and the median age of first symptoms reported occurred at age 13. Nearly 16% of the subjects also reported gastrointestinal complaints, menstrual irregularity in nearly 8%, and 76% of the participants reported a family history that included endometriosis, severe dysmenorrhea, and/or infertility. The authors of this research point out that advances made in surgical technique, both from a technological standpoint and a physician skill level, may be contributing factors in the increased rates of diagnosis of endometriosis.The authors also point out that it is yet unknown if early diagnosis and treatment will lead to improved outcomes in this population.

If you are interested in learning more about endometriosis in general, click here to follow the link to a free, full text article in PubMed Central. The article was first published in 2008, and even though advances in surgical diagnosis have been made, most of the information related to symptoms, medical treatment, and related risks remain significantly unchanged. In relation to etiology of endometriosis, one study that has set forth an environmental risk for endometriosis can be accessed here. Dr. C. Matthew Peterson, one of the researchers involved with the ENDO study, presented at the 2011 International Pelvic Pain Society meeting, and he encouraged all present to consider implementing strategies to minimize risks from chemicals in our daily lives. The Environmental Protection Agency offers advice towards protecting our health that can be accessed here. If environmental hazards are influencing the onset or progression of conditions such as endometriosis, it is in our best interest to reduce these risks. Consider not only the product exposure at home, but also at the workplace, and request less toxic products including cleaners when able.

In relation to pelvic rehabilitation, patients who present with pelvic pain or other pelvic health issues due to endometriosis often find relief when working with pelvic rehab providers. While surgery may be critical in reducing severe adhesions, maximizing tissue health and patient mobility and function is a job in which we can all actively participate. The evaluation and treatment of pelvic pain is instructed at various levels of depth in all of the main series courses as well as in many other courses offered at the Herman & Wallace Pelvic Rehabilitation Institute.

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Upcoming Continuing Education Courses

Nov 15, 2019 - Nov 17, 2019
Location: Banner Physical Therapy and Rehabilitation

Nov 15, 2019 - Nov 17, 2019
Location: Ability Rehabilitation

Nov 15, 2019 - Nov 17, 2019
Location: Huntington Hospital

Nov 16, 2019 - Nov 17, 2019
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Dec 6, 2019 - Dec 7, 2019
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Dec 6, 2019 - Dec 8, 2019
Location: Swedish Covenant Hospital

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Jan 10, 2020 - Jan 12, 2020
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Jan 17, 2020 - Jan 19, 2020
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Jan 17, 2020 - Jan 19, 2020
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Jan 17, 2020 - Jan 19, 2020
Location: Our Lady of the Lake Children's Hospital

Jan 24, 2020 - Jan 26, 2020
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Jan 24, 2020 - Jan 26, 2020
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Feb 1, 2020 - Feb 2, 2020
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Feb 7, 2020 - Feb 9, 2020
Location: FunctionSmart Physical Therapy

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

Feb 28, 2020 - Mar 1, 2020
Location: Inova Alexandria Hospital

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

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Mar 6, 2020 - Mar 8, 2020
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Mar 13, 2020 - Mar 15, 2020
Location: Sentara Therapy Center - Princess Anne

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