By: Laura Cornwell, MD
Children with neurocognitive disorders such as
cerebral palsy, who have differences in brain and nerve function, sometimes also experience other body function differences. This may include difficulty with urination control, also called voiding dysfunction. Read more about this connection and tips that can help manage toileting challenges.
What is voiding dysfunction?
"Voiding dysfunction" means urination problems that continue after a child has been
toilet-trained for 6 or more months. Voiding dysfunction is common in
all children: including as many as
20% of school-age children.
Common symptoms of voiding dysfunction include:
Daytime
urine leakage or accidents
Nighttime urine leakage or accidents (nocturnal enuresis or bedwetting)
Continued need for diaper
Stool (poop) accidents
Frequency: Needing to pee often, more than once every 2 hours
Urgency: Needing to pee urgently, or having sudden need to urinate without much warning
Difficulty starting to pee and maintaining a urinary stream
Feeling of incomplete urine emptying
Why are children with neurocognitive disorders more likely to have voiding dysfunction?
The bladder is a muscle in the body meant to hold urine, and the sphincter is a muscle that controls the exit of urine. These muscles must work together for urine to be stored and emptied. Many patients with a neurocognitive disorder have different muscle movement of one or both muscles.
It is common for children with neurocognitive abnormalities to have voiding dysfunction challenges that can last many years. However, there are common conditions that can also contribute to bladder control symptoms.
How UTIs can affect voiding dysfunction
Urinary tract infections (UTIs) can worsen voiding dysfunction. UTIs are usually more common in children with more severe neurological diseases, including those who are unable to walk or speak.
The constipation connection
It's also important to know that constipation can worsen voiding dysfunction in all children. Even when kids seem to have regular bowel movements without difficulty or pain, they can have hard or large stools sitting in their gut that push on the bladder and make urinary symptoms worse. Constipation is very common in children with neurocognitive abnormalities, so regular attention to bowel movements is very important to help urination issues.
What can I do to improve voiding dysfunction in my child with a neurocognitive abnormality?
Some children may have less common or bothersome symptoms, while others may cause them daily bother and stress. For some children, symptoms may improve as they grow and mature, while for others with more significant neurological differences symptoms may worsen over time.
Many voiding dysfunction symptoms can be improved with changes in toileting habits, such as:
Managing constipation
One reliable strategy to help voiding dysfunction is to pay closer attention to bowel movements.
The bladder works best if the intestine, located right next to it, is passing soft stools at least daily. Ideal stool should have only slight form, similar to mashed potatoes or soft serve ice cream. Stools that are more solid, have cracks or chunks often take longer to leave the body and push against the bladder in a way that can cause voiding dysfunction. Constipation is also one of the most common causes for UTIs in children.
Simple diet changes and over-the-counter medications can help bowel movements.
- Changes in diet: The best things to eat and drink to help bowel movements are water, vegetables and beans with fiber. Prunes and flaxseed oil are popular natural laxatives for families. Other "P" fruits can also help help stools- including peaches, pears, pineapples. Important foods to
stay away from include fresh (bright yellow) bananas or frequent cow's milk.
Many children who have voiding dysfunction are also at an age where picky eating is common, making diet changes hard for parents. When dietary changes do not create regular, soft stool as described above, medications are often needed.
- Constipation medication: The most commonly recommended medication for children with constipation is polyethylene glycol powder, which is available over-the-counter. This medicine is preferred because it stays inside the intestines, gently pulls water to make stool looser, and should not cause cramps or pain. It can be mixed into water, any liquid, or pudding/cream-like foods. The correct amount can be different for each child depending on their size. The amount given can be increased or decreased for soft stool, which will usually occur around 24 hours after given.
Many other over-the-counter medications are also available for children to assist with bowel movements if needed. Talk with your child's pediatrician about different options. Sometimes a
gastroenterology consultation can help, especially if over-the-counter medicines do not seem to be helpful.
Reward systems & other toileting techniques for voiding dysfunction
If your child can follow directions, you can make goals with them on how to help their urine control. A reward system and words of encouragement can be very helpful! Punishment should be avoided. Common strategies include:
Timed urination. Set a timer or reminder to ask your child to urinate every 2-3 hours. This is to prevent accidents or urinary urgency from waiting too long between bathroom visits
Double urinating. When your child urinates, have them go again after waiting 1-2 minutes to ensure better emptying.
Relaxation techniques. When your child is at the toilet, ensure they look relaxed and are not rushing their urination. Legs should be apart and if possible, flat on a stool or the ground. Elbows can rest on the top of the legs and deep breathing can help get urine out. Boys should be asked to sit to help urinate better until their urination issues improve.
When these approaches do not seem to help
There are other therapies or medications a pediatric urology care provider may recommend to help symptoms. Your
pediatrician is a great place to start if you are ready to pursue new options for your child.
If your child is not able to follow directions
For children who are the most disabled, they often remain in diapers. The main strategy for children who are diaper-dependent is regular hygiene to prevent rashes or wounds from wetness. Usually, there is low chance for urine-related complications like organ injury or infections.
Children who require regular use of a wheelchair may be more likely to have kidney stones, difficulty emptying their urine, or
urinary tract infections. If these occur, you will need to meet with a
pediatric urologist to lower the chance of complications.
What to do if your child is having difficulty peeing or holds in urine for long periods.
"Urinary retention" is when there is difficulty starting a urine stream despite the bladder being full. In children with a neurocognitive abnormality, parents will see no wet diaper or urination for 8 hours or more. This can be due to multiple causes.
Common causes of urinary retention
One common reason for urinary retention to happen is if your child has a large amount of
stool next to the bladder. Other common causes are genital discomfort or some medications (most commonly seizure medications or muscle relaxers).
How to help your child when they have trouble peeing
If your child is having difficulty urinating, you may want to try to place your child's bottom in a tub of warm water for 10 or more minutes. If this is unsuccessful, a rectal suppository or enema (over-the-counter) can help a child pass a large stool and urine at the same time. If your child is uncomfortable or seems sick, they should be evaluated emergently, preferably in an urgent or emergent care setting.
Remember
Pediatric urologists and their partner nursing providers are experts in the management of voiding dysfunction in all children. This is a common problem faced by many children and parents;
you are not alone! If you are interested in getting one-on-one advice and treatment for your child, help is available. Ask your pediatrician, neurologist, or physiatrist about your child's symptoms and whether or not they may benefit from a referral.
More information
About Dr. Cornwell
 Laura Cornwell, MD, is an assistant professor of urology and pediatric urologist at the University of Louisville and Norton Children’s Hospital in Louisville, Kentucky. She has special interests in improving perioperative experiences for children undergoing urological surgery and in understanding and improving the management of patients with urological kidney diseases. She completed her urological training at SUNY Upstate University Medical Center and pediatric urological training at Rady Children’s Hospital. Within the American Academy of Pediatrics, she is a member of the Section on Urology.
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