Description

• Bladder and bowel dysfunction (BBD) is the appropriate term that the International Children’s Continence Society has agreed upon to define combined bowel and bladder disturbance.
• Children’s symptoms can then be subcategorized as either lower urinary tract dysfunction and/or bowel dysfunction.
• 5 years is the minimum age for a child to be defined as having lower urinary tract symptoms (LUTS).
• 4 years is the minimum age for a child to have functional bowel dysfunction.
• Incontinence is the leakage of urine that is continuous or intermittent.
• Intermittent incontinence can occur during the day (daytime incontinence) or exclusively at night (enuresis).
• Dysfunctional voiding is defined as tightening of the pelvic floor muscles before completely emptying the bladder, which may leave a large amount of urine in the bladder.
• BBD also encompasses the underactive (“flaccid”) bladder, which is seen in children who postpone voiding and only empty a few times a day.
• Constipation has a major role to play in affecting the bladder’s ability to store urine and also affects the bladder’s ability to empty completely and in a timely fashion.
• Patients with BBD may experience daytime and/or nighttime incontinence.

Epidemiology

• 15% of 6-year-olds have abnormal voiding patterns. Children with BBD can have
  • Abnormal renal ultrasound (US)
  • Higher rates of urinary tract infections (UTIs)
  • A decreased ability to resolve vesicoureteral reflux (VUR)
• 89% of children who are treated for their constipation completely resolve their daytime urinary incontinence, and 63% resolve their nighttime incontinence.
• 50% of children with BBD may have had adverse childhood experiences.
• 16% of 5-year-olds complain of LUTS, whereas only 5% of children >14 years old complain of LUTS.

Risk Factors

• Recurrent UTIs
• Constipation

General Prevention

• Daily soft, formed bowel movements
• Timed voiding—goal between 5 to 7 times a day

Pathophysiology

• A child who is holding his or her stool and not having regular daily bowel movements has increased stool in the rectal vault.
• As stool builds up in the rectal vault (constipation), it begins to push on the bladder. This process causes decreased bladder filling.
• In addition, the rectal vault shares sensory input with the bladder in the same spot of the sacral spinal cord, and the full rectal vault can be confused at this level and trigger bladder spasms, leakage, and/or incomplete emptying of the bladder.
• As a child struggles to stay dry in the face of bladder spasms, he or she overcontracts the external sphincter of the bladder, has a hard time relaxing the external sphincter during voiding, and develops increased pressure during voiding. This increased pressure can be transmitted to the kidneys.

Etiology

The etiology of BBD is broad and can have multiple causes. Increased rectal volume will mechanically compress the bladder and decrease bladder capacity and cause urgency and frequency. This can also change the neural stimuli in the bladder and the pelvic floor muscles leading to decreased urge to evacuate, poor coordination of the sphincter and the bladder muscles, increased residuals, and decreased awareness of evacuation leading to stool and bladder accidents.

Commonly Associated Conditions

• ADHD
• Autism spectrum disorder