Kathleen Kieran, MD, MSc, MME
Associate Professor of Urology, University of Washington
Department of Urology, Seattle Children’s Hospital
Lusine Ambartsumyan, MD
Associate Professor of Pediatrics, University of Washington
Director, Gastrointestinal Motility Program
Division of Gastroenterology and Hepatology, Seattle Children’s Hospital
Bowel and bladder dysfunction (BBD) in children is associated with decreased quality of life, impaired emotional and psychological well-being, and increased family and parent stress.1-8 While prevalence rates for BBD vary from 5.9%-18.7%1-5, it remains underdiagnosed and undertreated, and accounts for approximately 40% of referrals from primary care physicians to pediatric urology and gastroenterology at some SCH clinic sites.
Bladder and bowel health are closely linked, with well-documented associations between lower urinary tract (LUT) dysfunction and functional constipation (FC) or fecal incontinence (FI).10-12,14-18 More than half of children with LUT symptoms fulfill Rome III criteria for functional defecation disorders13; of children with FC and FI, approximately 22% experience urinary incontinence (UI),16 11%-42.1% have increased frequency of urinary tract infections (UTIs), and others report increased frequency and urgency.12,15,17 Effective treatment of constipation is associated with an improvement in LUT symptoms and reduction in diagnosed UTIs in multiple studies,15,19-21 although the exact physiologic mechanisms remain unknown. The relationship between rectal pressure and impaired bladder emptying may predispose patients with fecal retention to UI and UTIs.22 In addition, patients with FC and FI have abnormal voiding dynamics that may predispose them to urgency, urge UI, UTIs, and vesicoureteral reflux.
The complex interaction between the bowel and bladder underscores the need for a multidisciplinary approach to the child with BBD. Nonetheless, management can be initiated in the primary care setting. The International Children’s Continence Society (ICCS) advocates optimizing elimination habits by encouraging regular voiding (approximately every 2 hours), taking in adequate water (hydration is best assessed by urine color—ideally light yellow), and addressing gastroenterologic concerns.23 Medications are not considered first-line therapies. Bowel movements should be at least daily, and ideally should be soft enough to pass without straining (Bristol stool scale Type 4-6). Achieving this can be challenging for some children: in addition to hydration, adequate fiber intake and scheduled toilet sitting are encouraged. Obstructive sleep apnea (OSA) has also been associated with voiding issues, and otolaryngologic evaluation should be considered in overweight children and those who snore.24 Engagement of parents and caregivers (e.g. schoolteachers, babysitters) is critical for success. The complexity of elimination issues dictates that weeks, if not months, of behavioral modification are necessary to achieve subjective and objective improvement. Families adherent to initial behavioral modification techniques for 3-4 months without clinical improvement should be referred for specialist evaluation.
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- Rajindrajith S, Devanarayana NM, Weerasooriya L, et al. Quality of life and somatic symptoms in children with constipation: a school-based study. J Pediatr. 2013;163(4):1069-72 e1.
- Thibodeau BA, Metcalfe P, Koop P, Moore K. Urinary incontinence and quality of life in children. J Pediatr Urol. 2013;9(1):78-83.
- van Dijk M, Benninga MA, Grootenhuis MA, Last BF. Prevalence and associated clinical characteristics of behavior problems in constipated children. Pediatrics. 2010;125(2):e309-17.
- von Gontard A, Baeyens D, Van Hoecke E, et al. Psychological and psychiatric issues in urinary and fecal incontinence. J Urol. 2011;185(4):1432-6.
- Wolfe-Christensen C, Manolis A, Guy WC, et al. Bladder and bowel dysfunction: evidence for multidisciplinary care. J Urol. 2013;190(5):1864-8.
- Wolfe-Christensen C, Veenstra AL, Kovacevic L, et al. Psychosocial difficulties in children referred to pediatric urology: a closer look. Urology. 2012;80(4):907-12.
- Wyndaele M, De Winter BY, Pelckmans P, Wyndaele JJ. Lower bowel function in urinary incontinent women, urinary continent women and in controls. Neurourol Urodyn. 2011;30(1):138-43.
- McGrath KH, Caldwell PH, Jones MP. The frequency of constipation in children with nocturnal enuresis: a comparison with parental reporting. J Paediatr Child Health. 2008;44(1-2):19-27.
- Soderstrom U, Hoelcke M, Alenius L, et al. Urinary and faecal incontinence: a population-based study. Acta Paediatr. 2004;93(3):386-9.
- Combs AJ, Van Batavia JP, Chan J, Glassberg KI. Dysfunctional elimination syndromes–how closely linked are constipation and encopresis with specific lower urinary tract conditions? J Urol. 2013;190(3):1015-20.
- Burgers R, de Jong TP, Visser M, et al. Functional defecation disorders in children with lower urinary tract symptoms. J Urol. 2013;189(5):1886-91.
- van Ginkel R, Benninga MA, Blommaart PJ, et al. Lack of benefit of laxatives as adjunctive therapy for functional nonretentive fecal soiling in children. J Pediatr. 2000;137(6):808-13.
- Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics. 1997;100(2 Pt 1):228-32.
- Loening-Baucke V. Prevalence rates for constipation and faecal and urinary incontinence. Arch Dis Child. 2007;92(6):486-9.
- Kasirga E, Akil I, Yilmaz O, et al. Evaluation of voiding dysfunctions in children with chronic functional constipation. Turk J Pediatr. 2006;48(4):340-3.
- Benninga MA, Buller HA, Heymans HS, et al. Is encopresis always the result of constipation? Arch Dis Child. 1994;71(3):186-93.
- Erickson BA, Austin JC, Cooper CS, Boyt MA. Polyethylene glycol 3350 for constipation in children with dysfunctional elimination. J Urol. 2003;170(4 Pt 2):1518-20.
- Hagstroem S, Rittig N, Kamperis K, et al. Treatment outcome of day-time urinary incontinence in children. Scand J Urol Nephrol. 2008;42(6):528-33.
- Borch L, Hagstroem S, Bower WF, ewt al. Bladder and bowel dysfunction and the resolution of urinary incontinence with successful management of bowel symptoms in children. Acta Paediatr. 2013;102(5):e215 20.
- Ambartsumyan L, Siddiqui A, Bauer S, Nurko S., Simultaneous urodynamics and anorectal manometry studies in children: insights into the relationship between the lower gastrointestinal and lower urinary tracts. Neurogastroenterology & Motility 2016;28(6)924-33.
- Chang SJ, van Laecke E, Bauer SB, et al. Treatment of daytime urinary incontinence: a standardization document from the International Children’s Continence Society. Neurourol Urodyn 2017;36(1):43-50
- Basccom A, Penney T, Metcalfe M, et al. High risk of sleep disordered breathing in the enuresis population. J Urol 2011;196(4 suppl):1710-3.