Frequent urination

The Pediatric Insider

© 2011 Roy Benaroch, MD

For November, I’m concentrating my writing chops on National Novel Writing Month. Fun! So I’m re-running revised versions of some classic posts. And by classic, I mean “old.” This one was originally from October, 2008—and it has been, consistently, the most-viewed “medical” article I’ve ever posted. Who would have guessed? Enjoy!

Here’s a question from AB: “Our daughter who is almost 5 years old has started a habit of wetting her pants at least once a day. She only wets a little each time and it doesn’t seem to bother her at all – she never tells us that it happened or complain about wet panties. We’ve talked to her continuously about not wetting her pants and tried all types of incentives and punishments, but nothing seems to make her stop. Could this be a medical problem? Or could it be some other behavioral issue such as an attention getter (She has a little brother who is 20 months old)? If this is only behavioral, what are your suggestions that we can use to help her stop?”

I doubt this represents a “medical” problem—she isn’t dribbling continuously or even that frequently, just once or a few times a day. And it doesn’t sound like it’s very likely to be a neurologic problem if she’s running around and otherwise acting normally. However, just to be safe, she does need to see her pediatrician for a simple urine dipstick test for infections or (far, far less likely) diabetes.

The most likely diagnosis for what’s going on is a very common problem among children called “dysfunctional voiding.” I’ve written about this before, but it comes up so often that it’s worth covering again in more detail. First, though, you should probably stop with any kind of incentive or punishment—that’s not going to get you anywhere, and may prolong the problem by making the accidents an attention-getter.

What is dysfunctional voiding?


Dysfunctional voiding is a term for an abnormal pattern of urination. The symptoms can include wetting during the daytime, urinating very frequently, rushing to the bathroom, or sometimes pain with urination. Some children who have these symptoms squat down on their heels, cross their legs or hold themselves between their legs to keep from wetting. Sometimes, children with dysfunctional voiding also start to ignore the urge to have a bowel movement.


How does dysfunctional voiding develop?


For many different reasons, children start holding their urine for a long time. They may be reluctant to stop doing fun activities for a bathroom break, or they might be embarrassed at school to ask for a hall pass. Kids who feel that the bathroom at school is dirty will sometimes hold their urine all day long! Once a child starts holding urine, the bladder wall becomes thicker and less able to empty completely. After a while, children begin to lose the sensation that their bladder is filling until it almost overflows. Though dysfunctional voiding may start because of habits, it does become a physical problem once the body begins these adaptations. Fortunately, these physical changes can be reversed by following good voiding habits.


Dysfunctional voiding with constipation


Children with dysfunctional voiding may also have constipation. When a child is constipated, the rectum may be full of hard stool and can irritate the bladder and keep it from holding as much as it should. Constipation makes the wetting problem worse. You cannot treat the problems of dysfunctional voiding unless you fix the constipation, too.


How is dysfunctional voiding treated?


The most important part of treated is regular bowel and voiding habits. These must be used together in order for this condition to be treated successfully Changing your child’s habits can take a long time. At school, children may need to be reminded to go to the bathroom.

Medicine is not usually needed to help with dysfunctional voiding. Sometimes, a stool softener can help with the constipation that often accompanies dysfunctional voiding.

Timed voiding schedules are a big help. Your child should urinate during the daytime every 2 hours (some children may need to go more often). This schedule will help train your child to empty the bladder before it gets full and begins to leak. It’s a good idea to use a kitchen timer to go off at set intervals, so a parent doesn’t have to be the “bad guy” enforcing trips to the bathroom. Make sure that the bathroom breaks aren’t perceived as a punishment, and that any fun activity that was interrupted for a bathroom break will continue when the child comes back—and doesn’t rush!


How to urinate correctly


It is very important for your child to relax when urinating. Relaxing helps the bladder to empty completely.

  • Girls should remove pants or tights completely off of one leg so that they can spread their legs far apart.
  • Girls should sit way to the back of the toilet and lean forward. Alternatively, girls can sit backwards on a toilet, facing the tank.
  • While establishing good habits, boys should be encouraged to sit to urinate. This prevents rushing.
  • Breathe deeply.
  • Relax the muscles of the head, arms, body and legs.
  • Feet should be on the floor or a footstool, not dangling.
  • Imagine urine flowing (turn water on in the sink).
  • Allow plenty of time for urination. The process of relaxing to empty the bladder takes time. Plan to spend 3-5 minutes in the bathroom.
  • For younger kids, it can be especially helpful to bring a toy. An electronic game that is only used while sitting on the toilet will keep kids sitting for a long time!

Dysfunctional voiding is a common problem encountered in a pediatrician’s office. There are no expensive tests or medicines that need to be used. It’s a matter or re-training good habits. The best way to handle this is with relaxation and good humor—you can’t force it. Fortunately, children who have developed dysfunctional voiding habits can quickly reverse this problem with some gentle support and simple steps.

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