Copyright © 2009 by Amy Stein. Click here for terms of use.
The first thing you should know about pelvic floor disorders in children is that they are not unusual.
If your child experiences urinary or fecal incontinence, urgency, frequency, and/or retention—that is, doesn't fully empty the bladder or bowels, or has trouble doing so—then he or she is not alone. Twenty percent of pediatrician visits are for incontinence. Some five million children complain of bed-wetting. Fifteen percent of pediatric appointments with gastrointestinal specialists are for lower bowel dysfunction. Clearly, pelvic floor disorders in children are not uncommon.
For the most part, younger children—those under the age of 10—will infrequently suffer pelvic pain, although some might feel the abdominal or rectal pain associated with constipation or lower abdominal pain due to urinary retention. Older children and teenagers, however, may experience the pain of tightened muscles or pelvic weakness, signals of the same disorders adults experience. This is not surprising, for indeed, the maturing muscles and tissue and bones of these older kids are subject to the same musculoskeletal issues as can affect grown-ups. After all, children have the same pelvic floor muscles we have; the muscles may simply be underdeveloped, or the child may be using the muscles incorrectly.
But although millions of kids suffer from these problems, often with consequences for the whole family's quality of life, few kids get the help they need—help that addresses the real underlying problem. Without such help, the psychological impact on the child can be substantial and very painful, with long-lasting influence. This chapter is about making sure that doesn't happen to your children—or to any children you know and care about.
Children today are typically fully toilet trained by the age of four. Most of the problems that occur between the ages of 4 and 10 therefore tend to be problems of incoordination—that is, instead of relaxing the pelvic floor muscles in order to void, the kid tightens up and "holds it in." Frequently, it's because something exciting is going on that the child doesn't want to miss. Heading for the nearest bathroom seems like a waste of time and a distraction—a chore of secondary importance. In due course, the inevitable happens: the child leaks stool or wets himself; there is involuntary excretion.
Sometimes, the cause is deeper. If toilet training was undertaken when the child was not ready for it, it can sometimes turn into a power struggle. If the power struggle persists, the child will continue to use the refusal to go to the bathroom as a weapon in the struggle.
Young children may also have issues that focus on the toilet itself: they might not feel comfortable in a strange toilet, or in one that looks unclean to them. I've known kids to express fear about the toilet itself, particularly the "scary" flushing that seems both loud and mysterious.
Sometimes, emotional distress from other causes gets expressed as a struggle over use of the toilet, and the child "holds it in" as a way of dealing with the distress. Discord between parents, illness or loss of a family member, even the worries over money or job security or world events that parents unwittingly transfer to their kids can all find their way to the bathroom, with incontinence or urgency, frequency or retention as the result.
As with adults, injury may also have an impact. A small tumble can be a big problem for a small child—especially if it injures the back, sacroiliac joint, or tailbone, and it can cause a pelvic floor disorder that will precipitate the symptoms kids find so embarrassing. By the same token, these symptoms may signal physical, sexual, or psychological abuse.
A fairly common condition in young kids is vesicoureteral reflux, in which the urine flows backwards from the bladder to the kidneys; the normal path is from the kidneys to the bladder to the urethra, from which it is excreted into the toilet. The condition can either be caused by or lead to chronic urinary tract infections, and it can result in scarring of and possible permanent damage to the kidneys. In this case, exercises like those in Chapter 3 that teach the child how to let go and how to stretch as well as the advice in the "Tips for the Toilet" section in Chapter 7 can help avoid urinary tract infections and other complications.
Whatever the particular condition the child experiences, and whatever the cause, any instance of pelvic floor disorder in children can qualify as a major medical problem, one that may affect the child's behavior and emotional health as well as family life as a whole—even eventually lead to severe psychosocial issues. As with grown-ups, children may feel the symptoms as life-limiting. They become embarrassed, ashamed, and anxious, may lose self-esteem, and typically shy away from such normal childhood activities as sports, playing with friends, and after-school activities.
But unlike adults, even teenagers, not to mention young children, find it difficult to understand what is happening to them physically and how their physical condition connects to their unhappiness. They can't understand why they are different from their friends. It's tough on the kids, and it's tough on the parents as well.
How then should parents treat such disorders? The most important first step is to get a clear diagnosis of both the condition and, to the extent possible, the cause. For that, you will need to see a health-care professional—specifically, your child's pediatrician or a physical therapist trained in pediatric pelvic floor dysfunction.
But as with adults, as you read in the foreword to this book by Dr. Andrew Goldstein, it continues to be rare to find physicians who will consider musculoskeletal issues when they examine a patient—rarer still for physicians to prescribe the kind of natural healing advanced in this book. Unfortunately, giving a kid a pill may not be the answer for treating a problem of incontinence or retention; it doesn't always get to the root cause or address the source of the problem, and it can cause side effects and complications that can be further injurious to your child's health.
The solution to this dilemma? Make an appointment for your child with the pediatrician—and take this book with you. As a consumer of health-care services, you have the right to ask that musculoskeletal issues be addressed and that nonpharmaceutical therapies be considered. Your doctor may thank you in the end.
Of course there certainly are health-care providers—physicians, nurse practitioners, and physical therapists—who specialize in bladder and bowel disorders and/or who routinely address musculoskeletal disorders of the pelvic floor in children as well as in adults. Such professionals may apply a variety of techniques and therapies to treat the child.
Among these is therapeutic massage to be applied by trained professionals only, who will also likely prescribe home exercises like the ones in this book. Biofeedback has also proven to be particularly effective with children, who tend to respond well to this form of therapy. It is simply a noninvasive tool for showing children how to use their pelvic floor and abdominal muscles correctly to help with proper elimination. The kids literally reeducate the muscles, reteaching them to be coordinated. It's a very effective therapy for pelvic floor dysfunction in children, but again, it requires health care providers fully trained in the technique.
Yes, there are things you can do at home to deal with your child's symptoms, mitigate his or her anxiety and embarrassment, and bolster his or her confidence.
First of all, as with adults, if the problem is tightness or muscle incoordination, as evidenced in bladder or bowel retention or constipation, children can benefit from the relaxation exercises of the End-the-Pain routine in Chapter 3.
The abdominal massage and the lower extremity massage described in Chapter 5 can also help with issues of constipation and bladder or bowel retention. (Note: the internal massage in that chapter is absolutely off-limits for children; it is for sexually experienced and mature adults only.) For the abdominal massage in the case of constipation, ask the child to demonstrate how he or she can draw the letters ILU on his or her belly. Guide the demonstration, making sure the child is not going too fast and is applying sufficient pressure. Many kids enjoy having their parent do the massage for them; it's relaxing.
If the problem is muscle weakness leading to urinary or fecal incontinence—that is, if the child leaks—try the strengthening exercises of Chapter 4. To be sure, Kegels can be difficult to explain to a young child; this is one area, in fact, where biofeedback can be particularly useful.
Whether the issue is tightened muscles or weak muscles, if you're starting a routine of exercises and massage from Chapters 3, 4, and 5, be sure first to check your child's symptoms against the lists at the beginning of each chapter to make certain you're following the appropriate routine. Also, be sure that the child does no more than the number of repetitions called for.
The problem with kids and exercise is getting them to do it—consistently. That is really a parenting issue rather than a health issue, and how you deal with it will depend on your own style and your approach to discipline as well as on the child's age and temperament. In some cases, you'll need to adapt the exercises. For example, you might use a bubble-blower or a toy whistle to assist with the deep-breathing exercise. To use the toy whistle, ask the child to take a deep breath, and as he or she exhales, slowly count with the child to see how long he or she can keep the sound going. It's helpful also to have the child practice this while on the toilet.
It's great for kids to take control of their own problems, but incentives—like verbal encouragement and praise or even a system of material rewards—may be needed to get them going and to help them stick with it. One form of encouragement is to make a game of the exercises. For example, keep a record of how many repetitions the child does, then suggest that he or she try to beat the number the next day. Offering a reward for doing so provides further encouragement.
Another good idea is to do the exercises with your child; this shows support and can be a bonding experience. Try filling out the Symptoms Monitor in Chapter 2 with the child so that you can both keep track of progress.
Sometimes, however, kids may respond more readily to a professional than to a parent, especially if a power struggle is part of the problem. In such cases, it's advisable that an objective health-care provider monitor the child's exercise program.
In addition to the physical exercises, a program of behavior modification may be warranted—especially if the child is having emotional problems, isn't sleeping well, is acting out with eating issues, and the like. For that, it makes sense to consult a child psychologist or other mental health professional.
Many parents find it helpful to set a voiding schedule—for example requiring the child to go to the bathroom every two to three hours, depending on the amount the child drinks, as a way of regularizing excretion patterns and getting the child used to heading for the toilet routinely. Make sure the child is comfortable on the toilet seat—at least the one at home. Child-sized toilet seats work well; kids don't feel they are falling in. Put a stool under the child's feet to raise the knees above the hips; this relaxes the pelvic floor, facilitates bowel movement, and can make the child feel safer and more secure. Make sure the child doesn't run off the toilet to get back to play; this may result in incomplete emptying.
Nutrition can also be a useful tool in dealing with kids' pelvic floor disorders. If the child suffers from constipation, it's important to make sure he or she drinks plenty of water and eats plenty of fiber-rich foods. You may have to be creative with the fiber-rich foods, experimenting till you find those your child likes—certain high-fiber cereals, for example.
If frequency or leaking is the problem, make sure the child's diet is free of bladder irritants like soda, chocolate, or acidic or spicy foods. If the issue is abdominal bloating or pain, try eliminating dairy products for two weeks and see if the symptoms improve; if so, it may be an indication of lactose intolerance. During this dairyless time, you'll need to find other, nondairy foods that supply calcium to the child's diet. Again, consult Chapter 6 for more details on what your child should and should not eat to help with his or her problem.
In addition, be sure the child engages regularly in physical activity—sports, physical games, and the kind of kinetic play that comes so naturally to children. It's a great way to increase cardiovascular fitness, control weight, and strengthen the core, and of course, it's good for every child's overall health and sense of well-being.