Written by Erin Teravest, PA
Process of micturition
Micturition is a complex, coordinated, timed organization between bladder storage and emptying. The urinary bladder, composed of smooth muscle fibers, acts in two ways: It functions to store urine by the relaxation of the detrusor muscle to allow for filling, or contracts to allow for the expulsion of urine. The urinary sphincter is a continuation of detrusor smooth muscle that converges to form a thickened bladder neck controlled by the autonomic nervous system, and a somatically controlled external component (striated muscle); both must relax to allow for the contracting bladder to expel urine. It is the striated muscle component of the external sphincter that a person has direct control over. Urine is stored through the process of bladder relaxation and simultaneous contraction of both the bladder neck (internal urinary sphincter) and the external urinary sphincter. Micturition occurs when the bladder neck and the external urinary sphincter relax and the bladder contracts, allowing for the unobstructed expulsion of urine. Potty training and bladder awareness allow for normal micturition to develop. These muscle groups function to support pelvic floor organs as well as assist in urinary and fecal continence.
Dysfunctional voiding occurs when the sphincter muscle forcefully contracts in a repetitive fashion and the two muscle systems strain against each other, causing a malfunction to occur. Typical chief complaints a clinician may see in practice include UTIs, enuresis, nocturnal enuresis, voiding postponement, gastrointestinal issues including chronic retentive constipation and encopresis secondary to the willful contraction of the pelvic floor muscle group as a whole.
The Department of Urology at Children's Hospital Colorado is focusing efforts on enhancing the care of patients with dysfunctional voiding. Forty percent of referrals to urology are diagnoses of dysfunctional voiding and/or stooling. The mainstay of treatment involves rehabilitation of bowel and bladder habits to improve overall health, which is often temporarily enhanced with medications as well. If conservative treatment with a bowel and bladder program either alone or in combination with medication management does not support success in a timely manner, or if families prefer non-pharmacological options to treatment, we can now offer an additional option for management. It's called pelvic floor rehabilitation (PFR) and is performed through the collaboration of the Urology Department and the Physical Therapy Program at Children's Colorado at the Anschutz Campus in Aurora.
Pelvic floor rehabilitation
Pelvic floor rehabilitation is a noninvasive treatment technique that uses electronic monitoring of normal automatic bodily functions, in this case the pelvic floor muscles, to train the voluntary control of those muscles using visual feedback. Patients learn to properly sequence their pelvic floor muscles using a visually stimulating video game. Unlike Kegel exercises, which primarily focus on strengthening the external urinary sphincter in response to stress urinary incontinence after childbirth, PFR assists patients in learning how to relax this overly tight muscle.
Specifically, with incontinence, patients learn how to identify, isolate, and target sensations and muscle groups associated with voiding and stooling. This allows them to better control the striated muscles associated with bladder and bowel control.
During the assessment period, a trained physical therapist will place gel-based external electrodes on the patient's abdomen and around the rectum. These electrodes are connected to a computer that records muscle activity. The patient sits to perform specific computerized programs (Urostym) for 20 to 30 minutes. These protocol programs calculate the muscle's fatigue point, which is essential to assess the pelvic floor's strength and determine the most effective rehab program for the patient. The patient plays a computer game to work on tightening and relaxing the muscles within the pelvic floor. Simultaneously, the patient works on relaxing the abdominal muscles at all times. This is especially important to gaining continence as use of accessory abdominal muscle with voiding has been shown to be a contributing factor in dysfunctional voiding.
Patients go home with pelvic floor exercises that help them reinforce the muscle rehabilitation and skills learned during the session in functional positions. The goal of PFR is for the patient to become aware of the muscles used for holding and releasing urine, promote muscle function and coordination, and minimize the use of accessory muscles to help them become continent of urine and stool.
Referral to pediatric urology
All patients suffering from dysfunctional voiding should be placed on a bowel and bladder program to promote overall good bladder and bowel habits. However, if there is no evidence of improvement within a two- to three-month period, then referral to pediatric urology is warranted. For further information or to refer a patient, please contact Children's Colorado's urology team at 720-777-3926 or Children's Colorado's physical therapy team at 720-777-6655.