Overactive Bladder in Children - An Overview

Introduction:

Overactive bladder is different from bedwetting in that bedwetting occurs in children below three years of age and is normal. When urinary incontinence (lack of voluntary control over urination) occurs in children who have been toilet-trained and are above three to four years of age, this condition is called enuresis. Enuresis can affect the self-esteem of both the child as well as parents and can be frustrating. Parents need to be supportive as enuresis is not under the child’s control.

What Are the Types of Enuresis?

One or more types of the following enuresis may be present in a child.

• Daytime (Diurnal) Enuresis: Wetting occurs during the day.

• Nighttime (Nocturnal) Enuresis: This is the most common type and is called bedwetting which occurs at night.

• Primary Enuresis: This type occurs when the child has not gained full control over toilet training.

• Secondary Enuresis: Secondary enuresis occurs with a period of dryness followed by a period of wetting.

At Which Age Does Bladder Control Occur?

Bedwetting occurs in children under the age of three. They slowly gain control over their bladder after three years but this can vary. Overactive bladder is diagnosed when a child is five or six years old. Though night wetting may persist, about 90 percent of children gain control over urine during the daytime by five years of age.

How Does the Urine Move Out of the Body?

The urinary system is involved in producing, storing, and moving urine out of the body. This system comprises two kidneys, two tube-like structures called ureters, one urinary bladder, and a urethra through which urine exits the body. Kidneys are involved in filtering the waste products from the blood and moving it into the bladder through ureters. An intricate system of nerves sends signals from the brain and spinal cord to the bladder and vice versa to release urine in a controlled manner. Urine exits the body in the following ways:

• When the urinary bladder is about half to two-thirds full, signals are sent to signal the individual that it is time to urinate. Individuals who are trained in toilet training perceive these signals in the earlier stages so that they have sufficient time to reach a comfortable place to urinate.

• When the bladder’s filling increases, strong signals are sent. Young children can perceive only the late signals and hence they are unable to wait to pass urine. But, older individuals who are well toilet-trained perceive the signals at an earlier stage and have sufficient time to reach the restroom.

• Once the individual is ready to urinate, the bladder begins emptying by relaxing the soft, stretchy layer of muscle in the bladder. The circular ring of muscle at the bottom of the bladder relaxes so that urine is released. Once the bladder is emptied, the circular ring of muscle contracts, and the bladder starts filling once again.

• A simple reflex operates in newborn babies and infants which enables them to release urine when there is increased pressure in the bladder. With age, the holding capacity of the bladder increases, and children can gain control over the mechanism of urinating.

• Around two to three years of age, the children can gain control over the sphincter (a ring of muscle that surrounds an opening in the body enabling it to open and close when needed) and pelvic floor muscles (group of muscles in the base of the pelvis or hip) so that they can withhold the urine until they reach the restroom. This control increases with age as the brain matures and by seven years of age, 90 % of the kids stop bedwetting at nighttime.

What Are the Reasons for Overactive Bladder in Children?

Neurologic causes present at birth which can affect the brain and spinal cord can have an impact on the coordination between the urinary bladder and the sphincter. Other reasons include:

• Change in routine.

• Too busy with other activities.

• Illness.

• Anxiety.

• Drinking fizzy, carbonated drinks and increased intake of caffeinated beverages.

• Uncontrolled spasm (involuntary movement of the muscle) of the bladder muscles.

• The muscles around the point of exit (urethra) may be affected.

• Urinary tract infections.

• Consumption of allergic foods.

• Withholding urine for long periods.

• Constipation.

• Structural abnormalities in the urethra or the urinary bladder.

• Less capacity of the bladder.

• Not emptying the bladder completely while urinating.

• Obstructive sleep apnea (a condition in which there are frequent episodes of partial or complete obstruction of the upper airway which hinders breathing during sleep).

• Damage to the nerves disables the child to recognize a full bladder.

A condition called daytime urination syndrome or pollakiuria may also be involved in the overactive bladder in children. Children with this syndrome tend to urinate as frequently as every five to ten minutes or around 10 to 30 times a day. Pollakiuria is common in children around three to eight years of age and the frequent act of urinating is present only during the daytime. There may be no other symptoms and is believed to be due to stress. The issue resolves on its own after two to three weeks.

Can Hormonal Changes Cause Overactive Bladder in Children?

Anti-diuretic hormone (ADH) is responsible for the constriction of blood vessels and helps kidneys to regulate the amount of water and salt in the body. ADH hormone is produced more at night and retards the production of urine. Insufficient ADH production can increase the production of urine at night which causes an urge to urinate frequently.

Is Constipation Linked to Overactive Bladder Dysfunction?

Constipation occurs when the child has less than two bowel movements a week or if the stools are dry, hard, small, difficult, and painful to pass. Constipation is common in children as they prefer few foods and might miss foods rich in fiber content. Bladder dysfunction related to bowel movements is termed ‘bladder bowel dysfunction’. This is because:

• The rectum (end portion through which solid waste leaves the body) is situated behind the bladder. A large amount of stools can create pressure or push the bladder and hence, the bladder is unable to retain the urine. This causes an increased urge to urinate.

• The muscles on the floor of the pelvis control both the anal and the bladder sphincters. Children with constipation may experience pain while passing stools and they tend to withhold the stools. This in turn causes the bladder sphincter to tighten and prevents the release of urine.

What Are the Signs and Symptoms of an Overactive Bladder?

The signs and symptoms include:

• Frequent use of the toilet (more than four to five times a day).

• May have the urge to urinate but do not pass urine. Instead, they dance around, jump from one foot to another or move around the toilet seat.

• Bed-wetting in the night even after five years of age.

• Frequent urinary tract infections.

• Increased daytime urination.

• Giggling or laughing can cause urine to leak.

How to Diagnose Overactive Bladder in Children?

Various diagnostic tests are as follows:

• History: A doctor might ask for the complete history such as the medical conditions, birth history, age of toilet training, toileting habits, frequency of bowel movements, urine leakage while giggling or laughing, and so on.

• Physical Examination: The healthcare professional may examine the back, abdomen, or genital area for any physical abnormalities such as any labial adhesions (front portion of the genital area in girls) or scarring that cause wetting after urination, scarring or a narrow urethra which can cause a burning sensation or a slow flow of urine in boys.

• Laboratory Tests: Urine samples may be collected and analyzed for the presence of any infections or the presence of sugar as in diabetes. Voiding tests measure the urinary volume and the flow rate (if any urine is left behind in the bladder after urinating). An ultrasound of the bladder may be taken to check for any structural abnormalities. A sensor called uroflow might be placed while urinating to check the quality of urine.

How to Treat Overactive Bladder in Children?

Overactive bladder gets corrected as the child grows with the development in the body’s alarm clock, stabilization of ADH hormone, increased capacity of the bladder, and so on. In children with prolonged complaints, the following treatment methods can be followed:

• Bladder Training: This method involves developing a fixed urinating schedule by the parents. Following a particular time to urinate, such as every two hours, enables the child to notice the signs to urinate. The schedule must be followed even if the child urinates or not. This leads to complete emptying of the bladder and prevents the rush to the restroom in a short duration. Bladder training exercises can help strengthen the bladder as well as the urethra.

• Medications: The pediatrician (child specialist) may prescribe antibiotics to get rid of urinary tract infections or suggest laxatives to ease the passage of stools in case of constipation.

Medications such as Oxybutynin can relax the bladder but can have side effects such as dry mouth and constipation. The symptoms can relapse with the stoppage of the medication. Drugs such as Desmopressin or DDAVP are prescribed to stimulate the production of ADH hormone. This drug is available as nasal drops, nasal sprays, or pills. Imipramine which targets both the bladder and the brain can prevent bedwetting in about 70 % of kids.

• At-Home Treatment: Parents should avoid giving caffeinated or fizzy beverages, as these can trigger the bladder. Foods such as cranberry juice, pumpkin seeds, diluted squash, and water can make the bladder healthy. Parents can be supportive by rewarding the child if they follow a disciplined toileting schedule instead of scolding or punishing them for wetting. The child must not be allowed to take liquids before bedtime and be asked to use the toilet 15 minutes before bed and also just before they hop on to the bed. They must refrain from any distractions so that they empty the bladder completely.

The kids must be encouraged to drink more water at regular intervals throughout the day to reduce infections. Sensors that detect moisture and raise an alarm can alert the child to use the restroom at night.

• Bio-feedback Training: With a therapist’s aid, bio-feedback training helps the children to focus and relax their bladder muscles when urinating.

Surgery is considered the last treatment option when other modes of treatment have failed.

What Are the Complications Of Overactive Bladder in Children?

The complications of an overactive bladder are:

• Kidney damage.

• Urinary tract infections.

• Incomplete emptying of the bladder.

Conclusion:

An overactive bladder can be frustrating as parents might think that their child is too lazy to use the restroom, doing it on purpose, and so on. This can be embarrassing for the parents as well as the child when they grow up. Pediatric urologists (experts in treating urinary diseases in children) can offer the needed support. Parents need to be supportive and understand that several treatment options are available to correct overactive bladder in children.