LP is an 11 year old girl who I have followed for four years for day and night wetting, recurrent urinary tract infection, and constipation and soiling.

At the first appointment at age 7, I reviewed all the basics of good bladder health, bladder friendly bowel health, optimal hydration, and the importance of careful genital hygiene to reduce the risk of bladder infection.

After the first few follow up appointments, I realized that this would be a very slow journey for LP.  Changing behaviour is always challenging and for four years this was impossible for LP.

LP has ADHD and Oppositional Defiant Disorder and she is on medications for both these problems. Her mother is single and LP is the fourth of five children. Currently she has an 18 year old sister, 16 year old sister, 13 year old brother, and an 8 year old brother.  The boyfriend of the eldest sister lives in.  Over the years, Mom has had a partner on and off.  Mom has always worked.  For several years, Mom drove a school bus and now she works in a warehouse.  Mom’s work has usually meant that there is no adult supervision in the mornings before school. There is only one bathroom in the home. There is not enough money to go around. I am fairly certain that Mom could not afford prescriptions and that there were times when antibiotics were not be taken for the infections. Whenever I obtain samples of stool softeners, I save them up for her and for other families who are financially strapped.

LP did not improve very much.  There were visits with some improvement and visits when she was back at square one. There were many times when I wondered whether the visits were helpful at all. Mostly, I felt as if my main role was as a sympathetic ear for Mom to commiserate with.

Last fall, push came to shove at school. Her behaviour was worse than usual. Soiling is a longstanding intermittent problem and the poop accidents were worse as well. The school chose to focus on the soiling. LP and Mom arrived in my office to ask if I had an  answer for the school request that she wear a “diaper” in class.  Ouch.

“L,” I said, “I’m really worried for you.” I paused for a minute, and then repeated this with slightly different words. I think I repeated this about three or four times.

I felt sad and defeated as I spoke with her, and I’m sure I must have looked that way.

I reviewed all the basics for the umpteenth time but LP didn’t need to hear this.  She was a bright girl and I’m sure that she could have repeated the basics back to me years ago.

By the time she left, I could see that something about my manner had hit home. She looked a bit frightened. At the time I wondered if she were worried that I might give up on her.

LP returned two weeks ago with a remarkable story.  She was pooping every day  in the morning at school.  She had not had a poop accident for almost two months. She was dry by day and she had even had some dry nights.  She was a different girl.  To me she seemed older.

I congratulated her and asked her what she had done to make such an amazing difference.

“I do body scans now.”

“Body scans,” I asked?

“Yes. My Mental Health Worker suggested that I do body scans. Between classes I do a body scan to find out if I need to poop or pee.  If the class is busy, I leave the class and find a quiet spot to do the body scan. If my body needs to pee or poop I go to the bathroom.”

The Mental Health Worker was new and  clearly LP had connected well with her.

LP went on to tell me that her drawings were better now.  I asked LP how this related to the body scans and improvement, and she replied, “Now that I don’t feel the pee and the poop all the time, my drawings are better.  My school work is a lot better.”

I congratulated her. Not only did she turn a huge corner, but very quickly she had also realized how much a difference that a relaxed bladder and bowel can make to her ability to focus on routine tasks, personal or school related.  The improved ability to draw meant a lot to her.  This means LP is much more likely to sustain this change.  She understands the value of her new behaviour.

From now on, “body scan” will be jargon that I will use to help the children connect with their bladder and bowel.

AT is a 6.5 year old boy who I first saw at 4 years of age for constipation and soiling.

His bowel health is no longer a problem. He poops every day, either after lunch at home or after school, and he has not had soiling for years.  He still wets the bed and we are waiting for him to mature a bit more before we start a bedwetting alarm.

His daytime bladder control is usually very good but during December of his grade one school year he had problems with daytime wetting.  Over that month he needed a change of clothes several times a week, but only at school.  At home he was dry.  He had enjoyed good daytime bladder control for a long time and the first few months of grade one were fine. Clearly something changed in December.

His Dad is a terrific bladder and bowel detective and he had the answer ready before I asked.  ”It was the fire alarm,” Dad reported. “My son was in the bathroom when the fire alarm went off, and he refused to use the bathroom after that.”

This is the second grade one child in six months that came to my office with the same story. Bathrooms are not built to muffle sounds. The walls, porcelain fixtures, tiles, and metal all reflect and accentuate the sound. I can imagine this would be a scary experience for lots of early elementary aged children.  Time and a lot of reassurance from Dad was necessary before the boy felt confident enough to use the school bathroom again. By January he was back into a normal routine.

While many elementary aged children might be frightened by the alarm only a few would stop attending the bathroom for this.  This boy had a history of lots of toilet fears and anxieties.  At 4 years of age he didn’t like the sound of “poop splashing,” he put his hand over his ears to block out the “flushing noise,” and he was concerned about the “toilet plugging.”  The automatic flushing toilets were a real concern for him in kindergarten.  In the grade one bathroom, he is not comfortable with the urinals and he will only pee standing up in the cubicles and with the door closed.  If there are too many boys in the bathroom he won’t go in.

Anything that restricts access to a bathroom is a potential trigger for daytime wetting.

ZD is an almost 7 year old girl with daytime wetting that came in “waves.”

She stopped wearing a day and night diaper at 2.5 years and since then she had intermittent daytime wetting.  Mom sees holding postures and urgency every day, and she has minor pre-void dampness most days. Daytime wetting sufficient to change the clothes is not common and comes in “waves” where she will need to change her clothes every day for several days in a row or up to a week.

She does not have symptoms of bladder infection during the “waves,” she has never had a bladder infection, and her urine was normal when I checked. Bladder infection is one of the two common causes of intermittent daytime wetting. The other is a change in bowel health from baseline.

She had “severe” constipation at 18 months of age.  Mom recollects “painful” and “traumatic” poops. The pain settled down and Mom presumed her bowel health was good. However, ZD told me she only pooped twice a week and sometimes she went up to a week without a poop. Her poops were hard, up to two inches wide, and she routinely pushed.  But no pain, and therefore largely under the parental radar screen.

The family followed my instructions to achieve Bladder Friendly Bowel Health and at her follow up visit 2 months later she was pooping every day and the urgency and daytime dampness was gone.

ZD never recovered good bowel health after the “severe” constipation at 18 months of age, and the “waves” of daytime wetting were likely during those times when she went up to a week without a poop. The Mom didn’t know. At the follow up visit she told me, “We were lucky that she had the daytime wetting.”  Otherwise they would never have realized the seriousness of the chronic bowel problem.

JB is a 6.5 year old boy with day and night wetting.

He wets the bed every night and always has.

He pees about ten times a day on his own and with reminders from his parents. He has urgency and he wets enough to change every day. Mom sees holding postures and when she asks him to pee he sometimes denies he needs to pee. He is not lying. Children ignore the signals of a full bladder so often that the sensation becomes a form of “background noise.”  Other times however, he does recognize this, or at least he agrees with his Mom because she told me he sometimes “negotiates” to wait for a commercial if the TV is on. At kindergarten he did not want to pee because the other children would not stop the game and wait for him. Most children would rather “play than pee,” and some activities and situations are more compelling than others.

JB learned on his own to chose darker pants to wear at school during grade one, which implies an evolving social awareness, which is normal and desirable.

He has a long pasty poop every second or third day and he has a poop accident once a month.

On his third visit arrived with a full bladder and the pre-void pelvic ultrasound showed an empty rectum because he had pooped and emptied about an hour before his appointment. The rectum had an normal triangle shape under a bladder with nice curved shape. In the lateral view I could see that there was a pasty poop higher up under the bladder. He peed 141 ml. About half an hour he started to fidget with his typical “pee dance.” He denied that he needed to pee but Mom and I knew otherwise. I did another pelvic ultrasound. In the intervening half hour between voids, the pasty poop had moved down into his lower rectum and the bladder no longer had a nice curve.  The poop was pressing into the bladder and this time he only voided 46 ml. This was a beautiful demonstration of the effect of poop pressure on bladder capacity and bladder control.

AQ is a 10 year old boy with day and night wetting.

He wets the bed about two nights a week but he only wets his underwear or pajamas and not the sheets, which implies that he does not totally empty the bladder. He has never worn a pull up and he has always only wet this minimal amount. For about six months he has awakened to pee on his own between 10 PM and midnight and he has gone to the bathroom. He acknowledges that sometimes he wakes up but does not feel as if he needs to pee so he goes back to bed without voiding. I teach that whenever a child wakes up at night, for any reason, they should always pee. The sensation of a full bladder is very different lying down.

He has always had a problem with daytime wetting and he wets enough to change his clothes every day and he is otherwise routinely damp. Mom has always seen holding postures but she has NEVER seen urgency.  He fidgets and then is wet but he never runs to the bathroom. This implies that he has purposefully let out some urine in his underwear. He denies this.

He has a longstanding problem with constipation and soiling and he has a poop accident twice a week.

This boy has a very unique and uncommon story.  The story suggests that since he was a toddler he has purposefully let some urine escape into his clothes to let off some pressure and to allow him to continue with whatever activity is of interest at the time.  He denies this, but since Mom sees holding postures but she never sees urgency, this must be the case. He might not be lying when he denies that he lets the urine out. This behaviour could be so automatic that the sensation has become a kind of “background noise” and he has tuned this out.  I think the minimal amount of night time wetting is the asleep equivalent of what he does by day.