Urology Clinic Hospital for Sick Children Please read the following information and have the child follow the bladder retraining protocol included. Information on bladder retraining, urinary tract infections and urinary frequency can also be found on the About Kids Health portion of the Hospital for Sick Children website at www.sickkids.ca Bladder control Proper bladder control or continence should never be taken for granted. Bladder control is a complicated process, which requires normal brain, spinal cord and pelvic nerve function. Bladder control is a bodily process that can be changed by behaviour. Just as behaviour can be learned correctly, it can be learned incorrectly or be affected by many other factors in a child s life and social environment. Lower Urinary Tract Dysfunction some abnormality related to the manner in which children use their bladder. Usually, children with Lower Urinary Tract Dysfunction will have one or more of the following: 1. incontinence wetting accidents and / or damp underwear. This may occur during the day and/ or night, sporadically, continuously, or only during certain activities. 2. urinary tract infections 3. frequency peeing a lot 4. urgency have to go right away, can t hold their pee, but not necessarily ending with peeing or incontinence. While Lower Urinary Tract Dysfunction is generally not medically harmful, it can be. It may also cause psychological stress or problems, and is also a social inconvenience. Therefore, Lower Urinary Tract Dysfunction should not be ignored. What causes Lower Urinary Tract Dysfunction? Infrequent voiding (less than 6-7 times per day) is the most common cause of Lower Urinary Tract Dysfunction and is often closely linked with constipation. Painful bowel movements can cause a child to avoid peeing. Both infrequent voiding and constipation increase the risk of developing urinary tract infections.
Infections and some types of foods (caffeine, citrus juices, pop) may cause urethral and / or bladder irritability. Lower Urinary Tract Dysfunction may also be related to a learned inability to hold on to or to store urine in the bladder. This is linked with frequency, urgency, and also incontinence. How is Lower Urinary Tract Dysfunction treated? The mainstay of treatment for children with Lower Urinary Tract Dysfunction is a bladder behaviour retraining program. This includes: establishing more frequent urination, increasing water intake, and avoiding constipation. Most issues can be addressed through teaching the child to stop (and take the time) to go (and empty the bladder on a defined schedule). We call this: stop and go. BLADDER RETRAINING / TIMED VOIDING: It is important to get your child on a voiding schedule. Infrequent voiders need to be reminded to use the bathroom at least every 2 hours, whether they feel the need to pee or not. Children who have frequency should be asked to try and hold for a few moments longer, gradually increasing the time between voids. REMEMBER, it takes time to get back to good toileting habits / routines.be PATIENT and provide your child with plenty of positive support. When should a paediatric urologist see your child? Parents and caregivers can manage many issues relating to voiding dysfunction after seeing their paediatrician or family doctor. If, after fully following a bladder retraining program, and writing down the exact times for your child s stop and go throughout the day using the included voiding diary over 10-14 day period, your child continues to have urinary tract infections or wetting accidents, an appointment should be scheduled with paediatric urology. QUESTIONS? Call the Urology Nurse Practitioners Abby Varghese, RN(EC), NP-Paeds Katharine Williams RN(EC), NP-Paeds 416-813-7654 xt 202135 416-813-7654 xt 227109 abby.varghese@sickkids.ca katharine.williams@sickkids.ca
BLADDER RETRAINING CHART Monday Wake Up Mid Morning Lunch Mid Afternoon Late Afternoon Dinner Before Bed Tuesday Wednesday Thursday Friday Saturday Sunday Children should pee approximately every 2 hours. Encourage them to pee on the above schedule and use stickers or mark in when they went. Even if they pee in-between the scheduled times, children should be encouraged to pee on the schedule to retrain the bladder. Remind your child to pee by indicating it is time to use the bathroom, not by asking them if they have to go. Vibrating watches are available through www.bedwettingstore.com and www.pottymd.com and www.forgettingthepill.com
Bladder Retraining How does the bladder work? A baby does not decide when to empty, or void, his bladder; when it is full, the bladder empties. As children grow, they learn to control their bladders. Good bladder control means that the brain and the bladder work together. The bladder tells the brain that it is getting full, and the brain decides to find a bathroom and empty the bladder. Most children are able to control their bladders completely by the age of 7 years, but some children need more help. Poor bladder control can result in: urinary frequency, when a child needs to void many times during the day urinary urgency, which is a sudden, almost uncontrollable need to void urinary incontinence, when a child voids without meaning to. If your child cannot control his bladder, he may have accidents (wetting) during the day and at night. This can be embarrassing and frustrating for your child and for you. What is bladder retraining? Learning to follow a bladder routine can help make your child's voiding habit more regular. This can help your child in several ways: Your child may avoid wetting and stay dry for a longer time. Your child's feelings of having to void frequently and urgently may be less. A regular voiding habit can help prevent bladder infections. The following instructions are designed to guide you in helping your child retrain his bladder. Other family members may want to use some of these tips as well. Before you start bladder retraining Retraining your child's bladder takes time, understanding, and patience. Create a safe and supportive environment for your child. Together, you are developing strategies to overcome the problem. A relaxed, matter-of-fact approach will help. Tips for bladder retraining Your child should drink more fluids (liquids) during the day. Water is the best clear fluid that your child can drink. It helps to flush the kidneys and bladder naturally. As well as the milk and juice that your child normally drinks with meals, slowly increase the amount of water. Eventually, your child should drink 2 litres (eight 8-ounce glasses) of water during the day. Large amounts of fruit juices may irritate your child's bladder. Most fruit juices are acidic. They may cause burning and itching when voiding. Try limiting fruit juice or diluting it with water. You may need to ask your child's teacher to allow your child to drink more during the day. For example, ask the teacher if your child may keep a water bottle on his desk. Your child may need special bathroom privileges at school until he has
enough bladder control to go to the bathroom during regular school times. Ask the urology nurse or doctor for a school letter that explains this. Your child should drink most of his fluids between waking up and late afternoon (4:00 to 6:00). A large amount of fluid in the morning helps to make sure there is enough urine in the bladder. Drinking after 6:00 in the evening may make bedwetting worse. Your child needs to develop a regular voiding schedule. Encourage your child to try to void every 2 to 3 hours, whether he feels the need to or not. Your child should not hold urine for long periods of time. This may stretch the bladder muscles. You may want to have the voiding schedule match the breaks in your child's school day (morning, mid-morning/recess, noon, midafternoon) and afterwards (early evening, late evening) Your child should not eat or drink foods and drinks that contain caffeine. Caffeine may irritate the bladder and cause frequency and urgency in voiding. Common foods and drinks that contain caffeine are colas, Mountain Dew, tea, coffee, and chocolate. A high-fibre diet will help your child have a regular bowel routine and avoid constipation. If your child is constipated, it is more difficult for the bladder to fill up with urine. It is also hard to empty the bladder completely. Constipation is a major contributing factor in children who have urinary tract infections and/or incontinence. Foods that are high in fibre are fruits, vegetables, bran, cereals, whole wheat bread, rice, beans, and lentils. Bladder exercises can help to strengthen the muscles around the outlet of the bladder (the urethral sphincter). These exercises are known as Kegel exercises. To help your child understand this exercise and feel these muscles, ask him to squeeze a ball the size of your fist between his legs, right above his knees. When your child can feel these muscles, he should practice the Kegel exercises when he is not voiding. Your child should practice the Kegel exercises twice a day. To help your child remember, try doing them after something he does every day. For example, your child could do the exercises after breakfast and dinner, or after homework. A diary or calendar helps to reinforce your child's efforts to retrain the bladder and stay dry. You can use stickers or checkmarks to keep track of when your child voids. Help your child to make his own calendar. This will help your child develop a daily routine. The stickers and praise help reinforce your child's efforts to stay dry. The diary can also be used to keep track of your child's progress over a period of time, such as 6 months.
If you have further questions, please speak to your doctor or the urology clinic nurse. Key points Good bladder control means the brain and the bladder are working together. Learning to follow a bladder routine can help make your child's voiding habits more regular and avoid wetting. Retraining your child's bladder takes time, understanding, and patience. At SickKids: If your child has been referred to the urology program at SickKids for dysfunctional voiding (including recurrent urinary tract infections, incontinence, urinary frequency, or urinary urgency) and bladder retraining has been suggested, please: follow this bladder retraining information keep a voiding diary as described. If you have questions or concerns, please contact the Nurse Practitioners by calling the urology clinic at 416-813-6661. Health information for families from The Hospital for Sick Children www.aboutkidshealth.ca For information about copying or reproducing this material, contact: about.kidshealth@sickkids.ca (416) 813-5819 2004-2011 AboutKidsHealth.ca