Children's Hospital Colorado

Voiding Dysfunction

What is voiding dysfunction?

Holding and releasing urine is a very complex process. Urination involves the coordination of two different systems: the bladder (involuntary control) and the sphincter (voluntary control).

The bladder muscle relaxes as it fills to allow storage of urine. When the bladder has reached 50% capacity, a signal is sent to evacuate the bladder. During the time of bladder filling, the sphincter muscle is in a state of contraction, holding the urine back. It is not until the sphincter is relaxed that the bladder contracts to empty.

During normal development, children become more aware of their bladders. This maturation process allows the ability to control their bladder and prevent wetting. Children learn to override the normal tendency of the sphincter to relax by contracting their sphincters, thus staying dry. This is a normal reaction of a child to prevent wetting and allows a child time to get to a bathroom. However, an unhealthy situation occurs when a child continues to maintain a contracted sphincter against a full or straining bladder (holds for long periods of time). This, in essence, sets up two muscles working against each other. Over time, the muscle will become to large, with the bladder wall reaching two to three times its normal thickness because of muscle fiber enlargement. In severe cases, damage to the kidneys can occur.

What causes voiding dysfunction?

The exact cause is unknown, but there is a behavioral component to the change in the bladder caused by excessive holding and increased bladder irritation.

Who gets voiding dysfunction?

Voiding dysfunction can occur in males and females, most commonly in the ages of 4 to 16.

Voiding dysfunction is often a learned behavior by children who hold their urine all day. Children begin the pattern or behavior for many reasons, including not wanting to stop what they are doing to use the restroom, voiding infrequently because of discomfort with voiding or a social environment that discourages them from using the bathroom. No matter what the reason, the outcome is the same, an inability to relax the sphincter muscle to allow urine to flow out without interruption and allow complete bladder emptying.

After the holding process has been learned, it is difficult to change. A child usually begins holding without symptoms. After a period of time, the bladder muscle becomes strong as it resists against the sphincter (control mechanism). The bladder will eventually overcome the tight sphincter muscle and will empty on its own at an undesirable time.

What are the signs and symptoms of voiding dysfunction?

Symptoms include daytime wetting or leaking of urine, nighttime wetting when previously dry, recurrent urinary tract infections, pain with voiding without evidence of a urinary tract infection, urinary urgency, urinary frequency, stopping and starting urine flow and/or straining to void or hesitancy to void.

What tests are used to diagnose voiding dysfunction?

A child must be potty trained in order to diagnose dysfunctional voiding. Often uroflow tests and bladder scan are performed to diagnose dysfunctional voiding.

The uroflow is a test that provides information about the urine flow and how the bladder and sphincter muscle work together. The test simply requires that your child voids into a special toilet.

A bladder scan, performed after the uroflow, evaluates the amount of urine left in the bladder after voiding. An abdominal X-ray may also be performed to identify any stool burden contributing to the condition. Further evaluation of the urinary tract is done on an individual patient basis.

How do doctors at Children's Colorado make a diagnosis?

A voiding diary can be very useful for identifying voiding dysfunction. This should include how often and how much your child is voiding. Filling out a list of fluid intake over several days (called an intake diary) can also be helpful. This information allows your child's healthcare provider to more clearly understand your child's habits and to diagnose the cause of their symptoms.

How is voiding dysfunction treated?

Treatment usually begins with placing your child on a strict bowel and bladder program to establish a timed voiding schedule. This means that the bladder should be emptied before the urge to go to the bathroom. Every two hours during the day is a good place to begin. The goal of a voiding schedule is to break old habits and learn healthy ones. The new habits allow control and consistent emptying of the bladder.

Constipation can also play a role in voiding dysfunction, so it's always important to ensure good fiber intake and daily stools. Some children may require further testing, medications or other treatments to help with improving dryness.

It is very important to remember that the behaviors that have created bladder instability often begin long before any symptoms are identified. Therefore, it will likely take time to reverse the habits and changes which have occurred. It takes dedication and commitment to ensure that treatment is followed closely.

Why choose Children's Colorado for your child's voiding dysfunction?

Our Bedwetting and Enuresis (BE) Program was created to specifically address children with wetting issues and dysfunctional voiding by using behavioral modifications and motivating techniques to help children attain success. Watches and alarms are given to the children in clinic to establish independence during this regimen.

  • Patients keep voiding diaries to record their progress.
  • Letters are written for schools to ensure compliance during classroom hours.
  • Hints are also given to children to learn how to relax their pelvic floor during urination.
  • Incentive programs are a useful method to promote compliance with the bowel and bladder program prescribed for children in the BE Program. Reward systems are discussed and established for patients and their parents. In addition, prizes are given in clinic if patients bring voiding diaries to follow-up appointments.

We work closely with the Gastroenterology Department to address any constipation issues that may be contributing to the dysfunctional voiding, as well with a clinical psychologist to help with the motivation and resistant behaviors that can accompany dysfunctional voiding. Our group is committed to helping you and your child attain success with the interventions and improve bladder function and eliminate leaking of urine, irritated voiding and/or recurrent UTIs, which are all symptoms of dysfunctional voiding.

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