By Lee Vander Loop
CP Family Network Editor
Perhaps nothing is more important to a child as he or she grows older as the ability to control their bowels and bladder. With successful “potty training” comes freedom to move into the wider world, such as school or day care. It is a major developmental milestone for any child. For a child with cerebral palsy, it can be monumental.
Children with cerebral palsy frequently suffer from urinary incontinence and constipation, which can result in bowel leakage. Both of these functions are controlled by muscles, so the degree of muscle tone or strength in a child with cerebral palsy will in large part dictate how able they are to control their toilet functions.
Toilet training is expected to be obtained by the chronological age of five in non-disabled children, and by the cognitive age of five for a child with a developmental disability. Children with moderate to no level of learning disability or mobility issue were able to achieve a level of continence at age three, according to a 2006 hospital study. The study recommended that regular toilet training for these children should start around then.
In children with more severe developmental and mobility challenges, the study determined that the probability of continence is extremely diminished after the age of eight. For these children, incontinence products and external collection devices are available. Also, some studies have shown that intermittent catheterization combined with medication may also be a good option for some older children.
Types of Incontinence
- Stress Incontinence – Occurs during activities such as coughing, sneezing, or exercise.
- Urge incontinence – Involves strong, sudden urges to urinate flowed by bladder contraction and involuntary loss of urine.
- Fecal/Bowel incontinence – The inability to control the passage of stool.
- Overflow incontinence – Occurs when the bladder cannot empty completely.
- Mixed incontinence – Involves multiple types of incontinence.
The inability to control the release of urine is called bladder incontinence, or neurogenic bladder. The bladder and sphincter work in harmony to control urine storage and release. The sphincter is a group of circular muscles around the opening of the bladder and must be able to squeeze to prevent urine leakage. The bladder wall muscle (detrusor) must stay relaxed so the bladder can expand. In many children with cerebral palsy this group of muscles may be weak.
Incontinence can take the form of bed-wetting, uncontrolled urination during physical activities, or slow leaking of urine throughout the day.
The first step is to get a full evaluation from a urologist, which is a doctor who specializes in urinary issues. The doctor will want details about your child’s incontinence, so it’s a good idea to keep a three-day diary of out-puts, including amount, time of day, stressors, activities, meals, foods, liquid intake and anything else you think might be helpful.
Common Tests for Bladder Incontinence Include:
- Uroflowmetry to look at lower urinary tract functions.
- EMG to look at the pelvic floor.
- Cystometry – a moderately invasive test and dependent on a cooperative child, cystometry in children evaluates the bladder muscle called the detrusor that contracts to squeeze out urine and then relaxes.
- Urine test – the doctor will also test the urine for signs of a urinary tract infection, which can also cause bladder incontinence. Repeated infections can lead to a condition vesicoureteral reflux, where urine travels backward into the kidneys. Another source of infection occurs when the bladder doesn’t empty completely, leaving a small amount of urine in the bladder that can collect bacteria. A 1993 London study suggests that children with cerebral palsy have increased incident of lower urinary tract symptoms.
Medical treatments for incontinence may include special exercises, biofeedback, prescription drugs, surgery, or surgically implanted devices to replace or aid muscles.
Basic to all these other strategies, however, is proper toilet posture. The child needs to be able to sit securely on the toilet or the potty chair. Buttock support, foot support and comfortable hip abduction are necessary to enable a sitting posture that keeps the child relaxed and prevents activation of abdominal muscles and the simultaneous co-activation of pelvic floor muscles. A therapist trained in muscle re-education can help a child learn this posture and other techniques necessary for relaxed voiding to completion.
After physical issues such as anatomical abnormalities or pelvic floor dysfunction have been ruled out, most children can be successfully treated with urotherapy and muscle training.
Urotherapy in this context is not to be confused with the “urotherapy” that claims to treat disorders by drinking urine. Standard, or conventional, urotherapy for children with voiding problems originated in Scandinavia in the 1980s. It describes a non-surgical and non-drug approach to treating lower urinary tract dysfunction and is defined as a bladder re-habilitation program with the goal of correcting filling and voiding problems. It usually involves education of the child and family, routine hydration, and regular voiding regimens and bowel programs. It may also include pelvic floor muscle awareness activities and biofeedback training
It’s recommended that initial steps in urotherapy should always involve education of the child and family regarding bladder and bowel dysfunction, timed voiding, adequate fluid intake, aggressive management of constipation and hygiene issues (changing of wet clothing, containment products, skin care and correct wiping technique after toileting), as well as treatment expectations and a timeline.
Toilet Training Methods
The Diagnostic Center, Southern California has developed an approach toward toilet training a child with developmental delays that it calls “habit training.” In this approach, a mental picture, signal or visual cue of a toilet becomes linked in the child’s mind with a need to void. The Center has a six-page hand-out that takes you through the steps and provides other good suggestions.
Another study, this one published in 2010 in the Journal of Urology concluded that wearing a programmable wrist watch was successful at helping many children manage daytime bladder control problems. The study also suggested that timed bathroom trips are a crucial part of urotherapy for daytime incontinence.
Drugs used to treat bladder or bowel incontinence target the muscles used in these functions. All have side effects. As of 2009, there were no approved drug therapies known to the International Children’s Continence Society. The ICCS recommends that alpha blockers and Botox may be considered alternatives only when other treatments, such as behavioral therapy, have failed, and then only with appropriate parental counseling.
There are a number of surgical interventions that treat incontinence caused by an underlying physical abnormality or disorder. The Mayo Clinic offers a comprehensive listing and descriptions of them.
Of note is a study conducted by the Women’s Specialty Center of Central Maine Medical Center that showed a procedure known as sacral neuromodulation which has the potential as a valuable tool in treating incontinence associated with CP.
The ability of a child to learn to control bowel function, like urinary function, depends on degree of muscle control and mental awareness of feelings to void. The age at which this happens will depend on the developmental age of the child and muscle tone.
Bowel function is controlled by muscles of the anus and sphincter. An inability to squeeze the sphincter tightly enough can lead to leakage. Chronic constipation, in which stool blocks the rectal passageway, can lead to damage to the muscle walls, worsening the ability to close tightly. So again, a child with muscle tone issues will likely have some bowel control issues.
The first step, of course, is a full medical evaluation by a specialist in bowel issues. These specialists are called gastroenterologists. They will rule out physical anomalies such as blockages, and make treatment decisions about surgeries and medications that might help.
Constipation affects many children with cerebral palsy. Laxatives are not recommended. Instead, dietary changes and making sure your child gets plenty of liquid is the first approach. A dietitian or your pediatrician can recommend other approaches to constipation.
Bowel retraining, consisting of exercises and biofeedback, can help a child strengthen those muscles and to become aware of the urge to defecate.
In some cases, the use of special fecal collection devices to contain the stool and protect skin from breakdown might be recommended. These devices consist of a drainable pouch attached to an adhesive wafer. The wafer has a hole cut through the center, which fits over the opening to the anus.
International Children’s Continence Society
http://www.i-c-c-s.org/ provides in-depth information on “The Management of Dysfunctional Voiding in Children” – A Report from the Standardization Committee of the International Children’s Continence Society. The society’s discussions resulted in guidelines on the assessment, non-pharmacological and pharmacological management of dysfunctional voiding. The final includes relevant research when available as well as expert opinion on the current understanding of dysfunctional voiding in children.
European Urology, Editorials, Twenty Years of Urotherapy in Children: Have We Learned?
Piet Hoebeke, Publ. online 4 January 2006 pgs 426-428
The Agency for Healthcare Research and Quality under the U.S. Department of Health & Human Services lists guidelines in the Management of neurogenic bladder in children. In: Guidelines on pediatric urology.
It’s the opinion of the International Children’s Continence Society that the most comprehensive programs incorporate continued elimination education, continued voiding diaries and exercises between possible biofeedback sessions
Secondary Conditions and Disability, Margaret A. Turk, The National Academies Press NAP