Mom told me that CV reduced the daytime wetting at school over the last year by not drinking while at school.  CV told me he limits what he drinks in the evening to help achieve dry nights.  Trying to achieve dryness by limiting fluid intake is never a good idea.  Good hydration is important.  Dryness do to dehydration is not healthy dryness.  

When he arrived I performed a pelvic ultrasound and his bladder contained only a few teaspoons of urine.  I asked CV to drink 12 oz of water and to tell me when he needed to pee.  He was my noon appointment and his only other fluid intake that day was a protein smoothie and 6 oz of orange juice at breakfast when he took his ADHD meds.  After about 75 minutes I asked him if he needed to pee and he told me that he didn’t feel full.  I suggested we do another pelvic ultrasound.  When he lay down on the table, he told me, “I feel a bit like peeing.”  For a boy who habitually holds his pee, this sounded to me like the signal of a full bladder.  Boys like CV blur the distinction of what is full.  They are always holding their pee. They are always past full. He voided 6 oz, his uroflow pee curve was a normal bell shape, and he emptied to leave only 6 ml (bit more than a teaspoon).  This data confirms that 6 oz is a full bladder for CV (normal for his age should be 13 oz).

I was very concerned about his bladder wall.  His bladder wall was thick and irregular and I measured the thickness at 7 mm (upper limit of normal is 5 mm, a healthy bladder should be about 3 mm).  A thick bladder wall is a concern.  Bigger is not better for the muscle in the bladder wall.  A thick bladder wall happens when the bladder is under pressure.  This can happen with a blockage in the urethra, which is ruled out by the normal uroflow pee curve, and the most common cause is chronically holding the pee in under pressure, which should be thought of as a self-induced blockage. The pee wants to come out but the child holds the pee.  I was worried because CV’s bladder wall was much thicker than usual for the boys I see who hold their pee.  The most likely reason was that he was still wetting by day at age 13 years and had been holding his pee in longer than the usual child.  

Mom had been worried about his daytime wetting for years and had repeatedly asked the pediatrician about the wetting, but the pediatrician had always told her he would “outgrow” the problem. Now, I hear this story a lot in children who wet the bed, but what bothered me about this boy was that he still had daytime wetting at age 13.  Daytime wetting sufficient to change the clothes while at school does happen in some grade one children but this becomes very uncommon by grade two.  The pediatrician either was inexperienced or did not listen to the Mom. This boy should have been referred to a specialist many years ago.  The thick and irregular bladder wall could have been prevented.  

The dry nights over the last year were due to dehydration.  His bowel health was poor.  His rectal diameter under the full bladder was 60 mm (normal should be less than 30 mm). We discussed bladder-friendly bowel health, the principlies of good bladder health, and the basics of good hydration.  He will likely need alarm therapy but first we need to improve his hydration and his bladder and bowel health. 

There are only two common causes of intermittent day and night wetting. One is bladder infection and the other is a change in bowel health with poop pressure on the bladder.  This Mom told me that her daughter has a bowel movement every morning and has always done so and on half the days she also poops a second time later in the afternoon.  I believed this mother.  She was able to describe the poop very well.  As well, when I performed a pelvic ultrasound at her first visit, the girl’s rectal diameter was only 16 mm under a full bladder and this can only happen with daily poops and excellent emptying.  So, without any evidence to suggest a bowel health cause, this pretty much had to be infection even if the story was not otherwise so convincing.  Intermittent discomfort with voiding and loss of bladder control that resolves with treatment with an antibiotic sounds a lot like infection to me!

I always teach the young doctors to treat the child not the lab test. This is a classic story of treating lab tests and ignoring the story.  I looked up the urine tests from the outpatient visits and the hospitalization.  The tests shows “mixed cultures,” “low colony count” cultures, and “negative” cultures.  Infection can be present in all of these situations.  With mixed cultures the child might have had redness (inflammation) in the genital area and some skin or poop bacteria from this area might have contaminated the specimen.  A low colony count culture means there was a bacteria but the number of bacteria grown was lower than a statistical cut off point.  Infection can be present and the culture negative if the urine specimen is dilute or if the child has been on an antibiotic in the preceding days.  

When I was a young fellow a local rancher told me that if you are standing outside a barn and you hear the door open, and then you hear a whinny and the clippity-clop sound of hooves on the ground, then you can be pretty sure, even if you cannot see what’s going on, that a horse has just left the barn.   In this case, if the doctors had listened to the Mom they would have realized this had to be infection.  

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.

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.

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.

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.