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Voiding Dysfunction

A voiding dysfunction includes all the problems which interfere with the normal filling and emptying of bladder in children. Overactive bladder is one of the most common type of voiding dysfunction which results in sudden urge to urinate.

Children often signal the urge to urinate using non-verbal methods (such as squatting, crossing their legs, peculiar peeing dance) to attract your attention. Although this is normal in smaller children when they are being toilet-trained, if the behavior continues into the later years of childhood, then it can be a cause for concern.

Voiding dysfunction mainly results in frequent trips to the toilet by the affected child. The urge to urinate may arise every 10 to 390 minutes or even less. Every time such children urinate, only a small amount of the urine is expelled or the urge to urinate will return after a short while.

The bladder is a muscular spherical organ which is mainly responsible for storing the urine before expelling it out of the body. Once the bladder becomes full from the urine coming in from the ureter connecting it with the kidney, the bladder muscles contract and expel the collected urine out through the other end (urethral opening).

In case the bladder becomes overactive or irritable, it will contract involuntarily, regardless if the bladder is completely full or not. It is important for parents and family to understand that this is an involuntary action by the bladder and the child should not be blamed for it.

Constipation is another disorder which causes symptoms of voiding dysfunction. Mild to moderate level of constipation can cause the child to put undue pressure for defecation which pushes the bladder and causes an urge to urinate frequently.

There are several factors which are needed to be known by the doctor to diagnose overactive bladder, such as:

  • Medical history

  • Physical evaluation

  • Urine culture test and urinalysis

  • Renal/bladder ultrasound tests

  • Urine flow study

  • Post void residual

A bowel/voiding diary is also asked to be maintained by the patient in some cases. This helps the doctor to check the frequency of urination and the decrease in storage ability of the bladder.

Mostly, in case there is no additional abnormality, overactive bladder conditions are resolved on their own as the child grows up. Certain medications are prescribed in such conditions to relax the bladder muscles.

Treatment of the frequent urinating urge can help to improve the affected child’s quality of life immensely.

What is the cause of voiding dysfunction in children?

Voiding dysfunction is the result of several causes, including:

  • Poor habits – Poor toilet training, infrequent urinating habit, avoiding timely urination when normal urge comes, UTI related pain, stress, etc.

  • Congenital (birth) defects – This affects the structure of the urinary tract.

  • Acquired factors – Tumor or trauma causing damage to bladder anatomy.

  • Central nervous system disorders – Those diseases that affect the urinary tract, such as epilepsy, cerebral palsy, multiple sclerosis, etc apart from any abnormality in the brain or spinal cord.

  • Endocrine/Renal diseases – Those that affect the urinary tract, such as chronic kidney disease, diabetes, etc.

  • Genetic mutation – Hereditary diseases that affect the urinary tract, including Williams syndrome, Ochoa syndrome, etc.

  • Infections/irritations – Those that affect the urinary tract, such as UTI, pinworms, foreign bodies, etc.

  • Other causes – Stress incontinence and delayed bladder control in the night are also some of the known causes of voiding dysfunction.

What are the signs and symptoms for recognizing voiding dysfunction?

These are the commonly seen signs and symptoms of voiding dysfunction:

  • Incontinence – Involuntary leakage of urine from the vagina.

  • Infrequent urination – Higher or lower frequency of urination.

  • Urinary hesitancy – Dribbling and intermittent flow of urine.

  • Pain – In the abdomen, flank or back.

  • Recurring UTI

  • Hematuria – Blood in the urine.

  • Constipation/fecal soiling

What are the types of voiding dysfunctions?

A commonly seen type of voiding dysfunctions is:

  • Diurnal enuresis – Also called as ‘daytime wetting’, it is caused when the urine leaks in less quantity and slowly. This condition often recurs in the afternoon.

How is voiding dysfunction diagnosed?

In case bladder control (voiding) problems are noticed in the child, it is advised to consult an experienced pediatric nephrologist and behavioral psychologist. A whole team of medical experts are required to properly diagnose voiding dysfunction.

The diagnosis of a suspected case of voiding dysfunction includes:

  • Medical history – A look at the patient’s medical history helps to exclude any other disorder which may cause similar symptoms. A voiding diary which tracks the frequency and volume of urination may also be advised to be maintained. Apart from this, the other aspects of the child’s behavior are also taken into account.

  • Physical and neurological evaluation – A thorough physical examination is advised then. Neurological tests may show reflex action and muscle tone/strength in the lower extremities.

  • Laboratory tests – Urinalysis, blood test and study of urine culture are required to determine the functioning level of the kidneys.

  • Other tests – Urodynamic and radiological tests are also advised in some cases. These help to view the emptying functions and the bladder storage capacity clearly.

  • Renal and bladder ultrasound – This helps to identify blockage in the urinary pathway and capacity of the bladder.

  • MRI of lower spine – This helps to rule out spinal cord abnormalities.

  • VCUG – Voiding cystourethrogram is useful to detect VUR (vesicoureteral reflux) in children with history of UTI.

  • Radionuclide cystogram – Alternative test in place of cystourethrogram.

  • Renal scan – This helps to view the level of functioning and damage in the kidneys.

How is voiding dysfunction treated?

The treatment of voiding dysfunction is determined according to the main cause of the condition in the particular case, the symptoms and their severity, lab results and medical test results.

Treatment may include a single or multiple procedures, such as:

  • Constipation management – Laxatives, enemas and increase of dietary fiber can effectively help treat constipation. This helps to prevent UTI and urinary wetting. A regular log of the urinary and bowel activity of the child helps to measure the success of the treatment.

  • Treating bladder irritants – Increased water intake is advised by doctors to help dilute the urine significantly. The doctor will also advise to avoid intake of caffeine, fizzy drinks, chocolate and any other food which can cause irritation in the bladder.

  • Treatment of UTI – Antibiotics administered for a short period of time helps to prevent UTI from recurring.

  • Behavioral guidance – These are special tools and techniques that are designed to help children and parents cope with the difficult times of voiding dysfunction. These are aimed to teach the child better control over voiding (urinating).

For nocturnal bedwetting problems, special alarms that go off when the bed is wet by the child in sleep helps to control urination in a remarkably better way at night.

There are several techniques used to treat daytime voiding dysfunction in children. Increased water consumption, Kegel exercises, scheduled urinating, and higher intake of dietary fiber can help with these conditions.

In some cases, anticholinergic medications have been found to have significant increase in control over infrequent urge to urinate.

Surgery is advised in rare cases when an anatomical problem is the cause of voiding dysfunction.

Other methods of treating voiding dysfunction.

In case a girl’s genitalia is inflamed from wetting, it is advised to avoid soaping the area. Apply emollient cream instead. Soaking in a mixture of baking soda and water may also help.

Watches with alarms can help children to urinate at set intervals.

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