Problems with voiding (excreting urine), also known as dysfunctional voiding, are very common in children. When serious, they can result in damage to the bladder or kidneys.
Diagnosing Voiding Problems
Children with voiding problems need to be examined and their urine checked for infection. In addition, the child may be asked to urinate into a machine that measures how fast and how much urine they produce. Children with a history of infection should have an ultrasound of the kidneys and bladder, and may need other tests, such as a nuclear renal scan or bladder X-ray known as a voiding cystourethrogram (VCUG). Children with isolated bedwetting do not need any special studies beyond urinalysis. In relatively few cases, children may need further specialized studies, called urodynamic studies, to determine bladder capacity and function. If test results are normal and symptoms are mild, observation may be the best course of action.
Some children have an overactive bladder, which may cause a sudden and often uncontrollable need to urinate. In these cases, the bladder tries to empty frequently, often without warning. The child may run to the bathroom, have many accidents, or hold him or herself to prevent accidents. The child may also feel the urge to go but not be able to pass any urine. This condition can also be associated with urinary infection, constipation, stress or the use of caffeine.
In most cases, the problem improves with time, but can be treated with medications if the symptoms are bothersome to the child. Children with overactive bladder often benefit from medications that relax the bladder, such as oxybutynin. These can cause side effects such as dry mouth and constipation, but are safe and effective.
Dysfunctional voiding often starts as an overactive bladder, which results in the child learning to hold onto the urine when the bladder contracts. These children do not empty the bladder properly, and can develop infections, more frequent wetting and kidney damage in rare cases. Dysfunctional voiding is almost always associated with chronic constipation and fecal accidents, which must also be addressed in order to treat the bladder successfully.
Children with dysfunctional voiding can be helped by a program of timed voiding (going regularly every few hours) and double voiding (trying to urinate again just after finishing to ensure complete emptying of the bladder). In more severe cases, biofeedback training can be effective to help the child learn to relax the bladder outlet during emptying.
Urinary Urgency/Frequency Syndrome
Some children may suddenly develop a need to go the bathroom very frequently, even though there is no infection. They are often able to sleep through the night without any problems, or suppress the need to void when they are involved in play or other activities. Daytime urinary urgency/frequency syndrome tends to get better on its own after several weeks, but can also be treated with oxybutynin to relax the
A child's family may notice the child voids only two to three times per day (a normal child voids four to five times daily). Holding the urine for too long can allow bacteria to get into the bladder and cause infection. Urinating regularly prevents this by flushing out the bladder. Infrequent voiding, or "underactive bladder", can be treated with behavior modification, as well as timed and double voiding. Rarely, a catheter (tube) may have to be used a few times daily to empty the bladder until the child learns normal toileting habits.
Enuresis or Bedwetting
Some children make more urine at night than their bladder can hold, while others have an unstable bladder. In almost all children, bedwetting occurrences diminish by puberty. Nocturnal enuresis will almost always resolve on its own, but effective treatments are available. A bedwetting alarm can help cure children if used every night until the child is dry for at least two weeks. This may take a few months. There are also medications available, such as desmopressin and imipramine, but these are treatments rather than cures, and when the medication is stopped, the relapse rates are high. Imipramine in particular can have dangerous side effects, such as seizures and heart rhythm disturbances. It is therefore seldom used. Desmopressin may cause headache, abdominal pain and water intoxication, which can lead to seizures.
Whatever treatment is chosen, it is important to observe when and why the child does not wet the bed. While punishment does not work as a treatment, reward systems can be very helpful in treating children with bedwetting. Many parents set up a reward system, based on a calendar with stickers for each dry night, leading to a gift or other prize for a certain number of dry nights.