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I know how the story goes; Parents of grade school aged kids, waking up to kicks and stolen covers. The kids' beds are soiled and they're wearing different pajamas than you put them to bed in. Wetting the bed, AKA noctural enuresis, is an embarrassing problem for kids and creates a lot of extra clean up for parents. Who wants to do extra loads of laundry on top of an already packed week? So why does it happen? Yes, each case is very individual, but a huge puzzle piece when it comes to wetting the bed is pelvic floor dysfunction. This month, we go through some causes, treatments and troubleshooting for nocturnal enuresis.
Signs and symptoms of pelvic floor dysfunction in kids:
1) Healthy Bladder Habits in Kids
The first step in knowing if your child has good bladder habits is knowing norms per age group. Kids between ages 1 and 3 should void about 11 times per day. By age 4, the bladder capacity increases by 400%. Between the ages of 4-5 years old, children should void 6-8 times per day. By age 12, the norm decreases to 4- 6 times per day, closer to that of a grown adult. All too often, kids avoid going to the bathroom either because they don’t recognize the sensation of bladder fullness, or the fact that they don’t want to stop playing in order to void. LEGO LIFE, AMMIRITE?? Soon after potty training, understanding normal voiding frequency helps to differentiate between the two. Children who hold their urine too long can often develop pelvic floor hypertonicity, or excessive tightness. This means that they are frequently contracting these muscles in order to avoid going to the bathroom. Just like adults, increased pelvic floor tone can lead to urinary urge, frequency and incomplete emptying. The pelvic floor muscles need to relax and lengthen in order to completely empty the bowels and bladder. The bladder signals the brain that we have to go to the bathroom as it fills and stretches. Things that can stretch the bladder prior to appropriate fullness include posture, groin and abdominal tightness, and too much tone down below.
2) Constipation
This is a big one when it comes to pelvic floor dysfunction in kids. All of kids’ favorite foods are typically constipating: dairy, bananas, rice, cheese, pasta/bread products and processed foods such as chicken nuggets and hot dogs. It has been found that over 10% of children suffer from constipation. We know that in both pediatric and adult populations, constipation and bowel dysfunction can have a huge effect on bladder health. The pelvic organs sit very closely within the pelvic cavity. If you have stool sitting in the rectum, it takes up space within this cavity and could be causing pressure and therefore stretch onto the bladder, either signaling urinary urge or causing incontinence altogether. When we get the bowels more regular, the bladder has more room to wiggle and play. Think of the bladder as a toddler; it needs space to play and does not like to be nudged and pushed. Adequate hydration, and a balanced diet promote bowel regularity and good bladder health in the pediatric population.
3) Signs your kid may be constipated
If your child is wetting the bed, constipation is most likely at the root of the problem. Here are some tell-tale signs to look out for:
· Adult sized poops (that could clog the toilet!)
· Hard, pellet like poops (often a sign of dehydration)
· Fecal smearing or accidents (skid marks in the undies)
· Recurrent urinary tract infections (often a sign of incomplete emptying and too much tone in the pelvic floor muscles)
· Frequent and urgent peeing
· Abdominal pain or bloating
· Potty training difficulty (age 4 and over)
Tips and tricks for efficient bowel emptying in kids:
1) Voiding posture
The pelvic floor muscles are part of the deep core system. If kids are sitting on the toilet with their feet dangling, the core is on and activated. This can lead to closed sphincters and trying to push urine out of a “kinked hose”. It’s super important for kids to be to able to rest their feet while voiding, preferably with knees above hips, during bowel or bladder emptying. There are many potty training kits which include a stool and a toilet seat cover to make the toilet bowl smaller. An appropriate sized toilet seat decreases the stretch on the perineum (space between the rectum and vagina or scrotum) therefore making it easier to lengthen and relax the pelvic floor.
2) Bowel/abdominal massage
If you notice excess bloating in your child, the gastrointestinal system could be moving a little bit slower. Bowel massage is a great technique to coax the intestine's motility AKA how the bowels are moving the stool along the system. Work in clockwise circles with moderate but comfortable pressure from the right hip bone under the ribs to the left hip bone.
3) Voiding recommendations
In both adults and kids, we should not be holding our breath or using the Valsalva mechanism (think deadlifting 1000 lbs) while trying to empty. The muscles of our throat/glottis mimic that of the muscles of the pelvic floor. If we hold our breath and close off the glottis we are also squeezing our sphincters which can make it hard to empty the bowels. Try having your kid sing while they are voiding; this way you know they are breathing. Additionally, kiddos can squeeze a ball or toy against their belly while bending forward to help push the stool out.
Pelvic floor dysfunction in the pediatric population can affect potty training and bedwetting. If you notice any of the symptoms in your child, pelvic floor physical therapy can help! Please note that in the pediatric population, internal treatment and assessment is not performed. We can make great strides with dietary, activity and postural changes to aid in complete bowel and bladder emptying and focus on a lot on family education. If you are worried about your child or are noticing any of the above symptoms, feel free to reach out with any questions!
Health and Happiness, Dr. Carly & Dr. Katie