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Helping Children With
Dysfunctional Voiding
Amanda Berry
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hildren with dysfunctional voiding symptoms account for a significant number of visits
to pediatric urologists and can be
quite time consuming to manage. Symptoms, which can
include urinary urgency, frequency, and incontinence, are
often confusing to parents and
teachers who may label the child
as immature or lazy. Health care
providers may dismiss the problem as something the child will
eventually outgrow. Children
who wet frequently become
socially isolated and develop
low self-esteem (Hagglof, Andren,
Bergstrom, Marklund, & Wendelius,
1998). In addition to the social
consequences associated with
wetting, children with dysfunctional voiding are at increased
risk for urinary tract infections
(UTIs) and potential renal damage. According to Hagglof et al.
(1998), self-esteem is generally
restored when wetting problems
are overcome.
There are limited data
regarding the incidence of urinary urgency, frequency, and
wetting in children. Parents may
underreport these symptoms or
feel that their child is simply too
busy to stop what they are doing
Amanda Berry, MSN, RN, CRNP, is
Pediatric Nurse Practitioner, DOVE
Center, Division of Urology, Children’s
Hospital of Philadelphia, Philadelphia,
PA.
Note: CE Objectives and Evaluation
Form appear on page 201.
Children with dysfunctional voiding display a variety of symptoms
including urinary urgency, frequency, and incontinence. Urinary tract
infections and vesicoureteral reflux are not uncommon in this population. An accurate diagnosis of the underlying voiding dysfunction
guides treatment, which may include a combination of behavioral,
biofeedback, and medical interventions. Nurses play a key role in
helping children and families understand the nature of voiding problems, implementing treatment regimens, monitoring progress, and
keeping children on track. Various types of dysfunctional voiding in
children, their evaluation, and management strategies are described.
in order to void. In a study of 7year-old Swedish schoolchildren,
20% reported needing to get to a
bathroom quickly. Additionally, it
was reported that 6% of girls and
3.8% of boys continued to have
problems with daytime wetting at
this age (Hellstrom, Hanson,
Hannson, Hjalmas, & Jodal, 1990).
Upadhyay et al. (2003) found that
half of children with dysfunctional voiding symptoms had a history
of urinary tract infections.
Children who develop recurrent UTIs are at greater risk of
kidney damage particularly if
reflux is present. Failure to correct the underlying dysfunctional voiding problem results in
poorer outcomes after surgical
correction of reflux. In many
cases, correction of voiding dysfunction brings about complete
resolution of reflux. Children
with dysfunctional voiding are at
greater risk for UTIs and repeated
antibiotic use.
The goals of this article are to
describe (a) subtypes of dysfunctional voiding, (b) key components of a history and physical
examination, (c) diagnostic testing, (d) treatment modalities for
UROLOGIC NURSING / June 2005 / Volume 25 Number 3
various types of voiding dysfunction, and (e) nursing roles in the
management of dysfunctional
voiding.
Definitions of Dysfunctional
Voiding
Dysfunctional voiding refers
to an abnormality in either the
storage or emptying phase of
micturition and is associated
with urgency, frequency, incontinence, and UTIs. It is important
to distinguish dysfunctional
voiding from enuresis. With
enuresis, there is normal voiding
with complete expulsion of urine
at a socially less acceptable time
or place. Enuresis occurs more
frequently at night (nocturnal),
can occur during the day (diurnal), and is usually self-limiting.
Dysfunctional elimination
syndrome refers to children who
have problems with both bowel
and bladder control. Significant
bowel problems take the form of
chronic constipation, fecal retention, stool withholding, and
encopresis. However, even a low
level of constipation can impact
urinary symptoms. The association between lower urinary tract
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dysfunction, infections, and constipation has long been recognized; however, bowel issues are
often unrecognized or overlooked
(O’Regan,
Yazbeck,
Hamberger, & Schick, 1986).
Developing Continence
Voiding during infancy
occurs frequently, reflexively,
and without voluntary control.
From age 6 to 12 months, bladder
capacity increases and voiding
frequency decreases. Between
the ages of 1 to 2 years, the child
has conscious sensation and is
able to feel fullness in the bladder. Many in this age group are
able to postpone voiding briefly
by contracting the sphincter.
Volitional voiding typically
occurs between the ages of 2 and
3, when the child is able to initiate voiding by relaxing the pelvic
floor and inhibit voiding through
the cerebral cortex. By age 4,
bladder volume has increased
and a child is generally able to
remain dry for 2 to 3-hour intervals and void 5 to 8 times per day
(Bloom, Seeley, Ritchey, &
McGuire, 1993).
A fully toilet-trained child
has the ability to stop and restart
the flow of urine, to initiate voiding by relaxing the external urethral sphincter, even in the
absence of an urge to void, and to
cortically inhibit a bladder contraction. Mastery of toileting
skills occurs long after a child is
removed from diapers. It is during this time that a child is most
vulnerable to developing a dysfunctional
voiding
pattern
(Bakker & Wyndaele, 2000). Pain
associated with toileting, which
may be brought on by constipation, local irritation, or a urinary
tract infection, can cause a
regression of toileting skills in
young children. This can lead to
the development and persistence
of dysfunctional voiding habits.
Bladder control in children
with motor, behavioral, and cognitive disabilities may not
progress along the same timeline
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as that for children without disabilities. Thus, bladder awareness and motor skills necessary
to toilet may be delayed in these
children. In a study of 601 children with cerebral palsy, Roijen,
Postema, Limbeek, and Kuppevelt
(2001) found 80% of those with
spastic hemiplegia or diplegia
achieved control by age 6, while
only half of those more severely
affected with tetraplegia had control by the same age. Children
with Down syndrome and its
associated hypotonia are often
delayed in acquiring toileting
skills due to limitations with
mobility and cognition. Toilet
training disabled children is a
long-term challenge and success
may be realized in one small step
at a time.
Types of Voiding Disorders
A child’s bladder capacity
can be estimated as the child’s
age in years, plus two ounces. A
normal bladder stores urine at
low pressure (< 5cm H2O) until at
least half of expected bladder
capacity is reached. Afferent
nerves then signal the brain of a
need to urinate. Normal emptying occurs as a result of coordination between the bladder muscle contracting and the external
urethral sphincter sustaining
relaxation long enough for the
bladder to empty completely (see
Figure 1a). Bladder contraction is
not completely voluntary, as one
can exert control over sphincter
activity. One type of dysfunctional voiding involves discoordination between bladder and
sphincter during voiding, as
shown in Figure 1b.
Urge incontinence. This is
the most common form of functional incontinence in children
and has been well studied
(Bauer, 2002; Lettgen et al., 2002;
Schulman, Quinn, Plachter, and
Kodman-Jones, 1999; van Gool,
Vijverberg, & de Jong, 1992). Urge
incontinence is characterized by
frequent voiding and urgency
accompanied by hold maneuvers
or posturing such as leg crossing,
dancing, squatting, or crouching
in a position to press their heel
into the perineum (Vincent’s
curtsy) to prevent urinary leakage. Urodynamic (UDS) assessment reveals uninhibited detrusor contractions relatively early
in bladder filling and increased
pelvic floor activity at the point
of urgency. Findings reflect a
bladder storage problem and a
normal voiding phase. It has
been suggested that immaturity
of the central inhibition of the
sacral micturition center is
responsible for detrusor instability, or the inability to inhibit bladder contractions (Hoebeke &
vande Walle, 2002).
Bladder-sphincter dyssnergia. Bladder-sphincter dyssnergia
is a disturbance in the voiding
phase characterized by bursts of
pelvic floor and sphincter activity during voiding, coinciding
with a rise in bladder pressure
and a decrease in urine flow
velocity (van Gool et al., 1992).
The flow may be staccato in
nature and there is often a post
voiding residual urine (PVR) in
the bladder. If the amount of
residual urine is significant, the
child may void frequently, often
returning to the bathroom shortly
after voiding. It may appear that
the child has a reduced bladder
capacity; however, bladder
capacity and the filling phase are
usually normal.
Lazy bladder syndrome. This
syndrome can result from longstanding voiding postponement.
It is characterized by infrequent
and incomplete voiding, very little urge to void, and a larger than
normal bladder capacity. The
detrusor
muscle
becomes
hypoactive and the use of
abdominal muscles and straining
may be noted on voiding.
Wetting in this group of children
is due to overflow (Schulman,
1999; van Gool et al., 1992).
Diurnal enuresis. This term
describes children who wet but
exhibit normal bladder filling, an
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Figure 1a.
Normal Voiding: The Bladder Contracts and
the Urethral Sphincter Relaxes
Figure 1b.
Discoordinated Voiding: The Bladder
Contracts and Urethral Sphincter Is Active
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Source: Reprinted with permission of the publisher, PottyMD LLC. Reprinted from Smith, 2004
age-appropriate storage capacity,
and a normal voiding phase.
These children are generally not
upset by their wetting and may
exhibit other immature behaviors. Age, maturity, and the
child’s motivation to be dry
should be assessed. In younger
children, central inhibition of
bladder contractions may not yet
be mastered. Behavior and oppositional problems are more common in school-age children with
diurnal enuresis (Kodman-Jones,
Hawkins, & Schulman, 2001;
Lettgen et al., 2002; van Gool et
al., 1992).
Vaginal voiding. Vaginal
voiding is characterized by dribbling a small amount of urine
after voiding. It is not associated
with urgency, although many
girls feel the need to return to the
bathroom when their panties feel
wet. Vaginal voiding occurs as a
result of a few teaspoons of urine
flowing back into the vagina during voiding and then dribbling
from the vaginal vault when
child stands up or becomes
active. It is more common in
heavy-set girls and those who do
not spread their legs while voiding. The condition can usually be
remedied by having the child
pull her panties down to her
ankles and spread her legs while
voiding. Sitting backwards or
straddling the toilet helps position the pelvis so the urine
stream is directed down into the
toilet rather than back into the
vagina.
Giggle incontinence. In the
pediatric population, giggle
incontinence usually refers to
urine leakage associated with
laughter. A detailed history often
reveals some degree or history of
urgency and dampness at other
times as well. In these cases,
there is usually some underlying
bladder instability and treatment
with an anticholinergic may be of
benefit (Chandra, Saharia, Shi, &
Hill, 2002). An entity rare in chil-
UROLOGIC NURSING / June 2005 / Volume 25 Number 3
dren, giggle micturition, or
enuresis risoria, refers to the
complete loss of urine associated
with laughter, rather than just
leakage. History is usually negative for urgency or dampness at
any other time. Anticholinergics
are generally ineffective, but
some benefit has been derived
from methylphenidate (Ritalin®),
based on the suggestion that the
condition is central in nature and
related to cataplexy (Sher &
Reinberg, 1996).
Problems Associated with
Dysfunctional Voiding
Urinary tract infections. UTIs
are among the most common bacterial infections in children,
occurring in 3% of girls and 1%
of boys by age 11. Hellstrom et al.
(1990) found that 30% of girls
with dysfunctional voiding
symptoms (leaking, urgency, frequency, posturing) had a previous UTI. Upadhyay et al. (2003)
found a higher incidence of chil195
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dren with dysfunctional voiding
and UTIs as well. In a study of
children with severe dysfunctional voiding, van Gool et al.
(1992) found 90% to have recurrent UTIs.
Dysfunctional voiding patterns lead to UTIs in several
ways. Children who void infrequently and those who do not
empty the bladder to completion
have urine stasis in the bladder.
If bacteruria is present, infection
can result as the bacteria flourish
in the bladder. Urotherapy aimed
at improving bladder emptying
can prevent further UTIs
(Herndon, Decambre, & McKenna,
2001).
Hoebeke and vande Walle
(2002, p. 2) describe how urge
syndrome or detrusor instability
can lead to urinary tract infections. “The opening of the bladder neck during unstable bladder
contractions is the main cause of
UTI. During a severe unstable
contraction, the bladder neck is
opened and urine is pushed into
the urethra to the level of the urethral sphincter. After some seconds, the contraction subsides
and the urine returns from the
proximal urethra to the bladder,
carrying bacteria from the colonized urethra.” The authors suggest that management of detrusor
instability is key to preventing
UTIs.
Vesicoureteral reflux. Various
studies have shown that 35% to
50% of children with vesicoureteral reflux have voiding dysfunction (Koff, 1992; Snodgrass,
1998; Upadhyay et al., 2003).
Children with a dysfunctional
voiding pattern use the external
urethral sphincter to delay or
interrupt urination. This inappropriate response, as well as
unihibited bladder contractions,
can lead to increased intravesical
pressure and the development or
persistence of reflux. A history
that includes voiding behavior
should be obtained from all children with reflux. In many cases,
reflux resolves with treatment of
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Table 1.
Elimination History for Child with Dysfunctional Voiding
Parent’s Perception of Problem
Why is your child being seen today?
Timing
When did the problem start?
Frequency
How often does the problem occur?
Day wetting
Night wetting
UTI
Voiding History
Frequency of voiding
Is urgency demonstrated?
Are hold maneuvers used?
Pain with urination?
Quality of stream
Degree of wetting
Where does wetting occur?
# Times per day or Every __ hours
Continuous/Interrupted
Forceful/Weak
Dampness/Soaked
Home/School/Play
Motivation
Does child willingly void when directed?
Is child bothered by wetting?
Does child willingly change when wet?
Bowel History
History of constipation?
History of soiling?
Frequency of BMs
Quality of BMs
Quantity
Abdominal pain?
Pain with defecation?
If yes, how often?
# times/day or # times/week
Loose/Soft/Firm/Hard, Pebbly
Large/Small
voiding dysfunction (Herndon et
al., 2001; Palmer et al., 2002;
Snodgrass, 1998). Failure to
address the voiding dysfunction
results in slower resolution of
reflux and poorer surgical outcomes (Capozza et al., 2002).
Associated bowel dysfunction-constipation. Constipation
is a common but often unrecognized entity in children with
dysfunctional voiding. Dohil,
Roberts, Jones, and Jenkins
(1994, p. 57) state, “The close
proximity of the bladder and urethra to the rectum, and the similar innervation (S3-S4) of the urethral and anal sphincters, make it
likely that abnormalities in one
system may affect the other.” A
rectum full of stool can place
pressure on the bladder neck
which may cause or sustain
detrusor instability. Furthermore
it may interfere with central inhibition, and may compress the
bladder resulting in a decreased
functional capacity. With persistent stool in the rectum, there is
likely to be a greater colonization
of fecal bacteria on the perineum,
increasing the likelihood of periurethral colonization and UTIs in
young girls. Aggressive treatment
of constipation can lead to near
complete resolution of day and
night wetting, and urinary tract
infections
(Loening-Baucke,
1997). Failure to identify and
manage constipation in a child
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Table 2.
Diagnostic Tests for Children with Dysfunctional Voiding
Screening for
Diagnostic Test
Nursing Implications
Urinalysis of first morning void
Renal disease, polyuria
Obtain specimen before child has
anything to eat or drink.
Urine culture
Infection
Instruct family in obtaining a clean
voided specimen.
Renal and bladder
ultrasound (RBUS)
Obstruction, bladder capacity,
ability to empty
Child should drink at least 16 oz of
water prior to test so full bladder
images can be obtained.
Flat plate X-ray of abdomen (KUB)
Constipation
Constipation, or excessive stool in
the colon, can be present in child
with daily BMs.
Uroflowmetry with EMG, and post
void bladder scan
Flow rate, pelvic floor relaxation,
bladder emptying
Optimum results are obtained when
child has full bladder and is feeling
urge to urinate.
Voiding cystourethrogram (VCUG)
Posterior urethral valves,
vesicoureteral reflux
Prepare child for catheterization and
the need to void during study.
Antibiotic prophylaxis for 2-3 days
after catheterization.
Urodynamic study (UDS)
Detrusor instability, bladder
emptying
Explain study ahead of time and
prepare child for catheterization.
Use videos to help distract/relax
child during study. Antibiotic prophylaxis for 2-3 days after catheterization.
with dysfunctional voiding is
likely to result in prolonged treatment and poorer outcomes.
Evaluation
A complete history and
physical examination are essential to determine the nature of
dysfunctional voiding, guide
treatment, and rule out neurologic or anatomic defects.
History. Key questions in a
voiding and stooling/bowel
movement history are shown in
Table 1. Instructions for the parents to monitor and complete a 3day voiding and stooling record
for the child may be sent home in
advance of the first office visit.
The child should also be questioned directly about voiding and
stooling. Prompting the child
through events in his or her day
may be helpful to assess voiding
frequency with questions such
as, “Do you pee before you go to
school?” “At school in the morning?” “Before/after lunch?”
“When you come home from
school?” “Around dinner time?”
“Before going to bed?” Urgency
can be assessed by asking if the
child can hold when a bathroom
is not immediately available. The
child should be directly questioned about bowel movements,
as parents are often unaware of
their child’s frequency or if the
child strains. Attempts should be
made to clarify discrepancies
between parental and child
responses.
The presence of any social,
emotional, and behavioral problems should also be assessed.
These may present as a consequence of wetting or may suggest
obstacles to effective behavior
UROLOGIC NURSING / June 2005 / Volume 25 Number 3
management. The child’s motivation, parental response to wetting, and expectations for treatment should also be determined.
Active listening and observing
the interaction between parent
and child can provide insight
into the family dynamics and
perspective on the problem.
Physical examination. A
focused physical examination
includes assessing the abdomen
for palpable stool in the colon,
suggestive of constipation. A rectal examination can provide further confirmation of constipation. The back is examined for
sacral malformation, hairy tuft,
or asymmetry of the gluteal
crease. Any of these clinical findings might suggest a neurogenic
cause for wetting related to
spinal dysraphism. The genitals
are examined assessing for exter-
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nal irritation and to rule out
meatal stenosis in boys or labial
adhesions in girls. A slow drip of
urine from the vagina and a history of constant dampness would
suggest an ectopic ureter. Urine
dripping from the vagina after a
girl has voided is suggestive of
vaginal voiding.
Diagnostic tests. Table 2 lists
common diagnostic tests along
with nursing implications to
assist in evaluating a child with
dysfunctional voiding. A voiding
cystourethrogram (VCUG) is not
routinely indicated for a child
with dysfunctional voiding.
However, the presence of a thickwalled bladder accompanied by
hydronephrosis on ultrasound
and/or a low velocity flow in a
boy would warrant further
workup with a VCUG to rule out
posterior urethral valves. A flat
plate X-ray of the abdomen (KUB)
is useful to assess for constipation, particularly if little is know
about the quality or frequency of
the child’s bowel movements.
Uroflowmetry provides critical information in the evaluation
of dysfunctional voiders in a noninvasive manner. The most meaningful results are obtained when
the child has a full bladder and
feels the urge to urinate. The
voiding profile and velocity of
flow indicate how well a child
sustains relaxation of the pelvic
floor muscles during voiding.
Pelvic floor relaxation can be
more accurately assessed when
electromyography is coupled
with uroflowmetry. A post void
bladder scan reveals how well a
child empties the bladder. The
uroflow and a PVR measurement
provide concrete information to
both the child and clinician during treatment.
Urodynamic assessment of
children with voiding dysfunction characterizes both the storage and emptying phase of urination. UDS facilitates an accurate
diagnosis and initiation of appropriate treatment. It is particularly
useful when an accurate history
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cannot be elicited, or when
empiric treatment has failed.
Testing provides visual information to provider, child, and the
family regarding detrusor instability, bladder capacity, bladder
compliance, pelvic floor activity
during voiding, and the bladder’s
ability to contract during voiding.
At our institution, only a few
children undergo urodynamic
testing, as a working diagnosis
can be drawn from an accurate
history and less-invasive methods of evaluation.
Management
A stepwise approach to managing dysfunctional voiding gives
families one task to accomplish at
a time, thereby increasing compliance and the chance of success. The treatment plan may
consist of a combination of
behavioral and medical interventions.
Bowels. Management of constipation, or the clearing of an
excessive amount of stool from
the colon or rectum, is the first
step in treatment. Unfortunately,
history alone often does not
reveal constipation, as parents
may pay little attention to their
child’s bowel habits. Even children who move their bowels
daily can have stool present
throughout the colon.
An effective bowel regimen
consists of an initial cleanout
with a series of enemas followed
by daily administration of stool
softeners such as polyethylene
glycol without electrolytes (polyethylene glycol [MiraLax®]) or
lactulose
(Erikson,
Austin,
Cooper, & Boyt, 2003; LoeningBaucke, 1997). The child is
instructed to sit on the toilet after
meals to take advantage of the
gastrocolic reflex. To assist with
pelvic floor relaxation, the child’s
feet should not dangle, but rest on
a stool. Sitting time should be
close to 1 minute per year of age.
The goal is to produce at least one
soft bowel movement daily, and
progress should be recorded in an
elimination diary. Instruction in
adequate fiber intake should also
be given to the family.
Eliminate discomfort. Children
may postpone voiding or prematurely stop the flow of urine if there
is any discomfort associated with
urination. Girls with an inflamed
perineum may experience discomfort as urine runs over the
area. Baking soda sitz baths can
help soothe inflammation and a
barrier cream may be applied to
prevent further irritation. Water
intake should be increased to
keep the urine dilute and nonirritating.
Antibiotic prophylaxis. Children with recurrent urinary tract
infections may benefit from antibiotic prophylaxis even in the
absence of vesicoureteral reflux.
Recurrent infections can perpetuate a cycle of bladder instability,
painful urination, and incomplete bladder emptying, which
may result in further infections.
Sterilizing the urine can reduce
bladder irritability and painful
urination, facilitating relaxation
during voiding. If prescribing a
prophylactic antibiotic, it should
be for a short duration and discontinued after dysfunctional
elimination patterns have been
remedied. Antibiotics of choice can
include trimethoprim-sulfamethoxazole (Septra®) and nitrofurantoin
(Macrodantin®) which have little
effect on normal flora.
Large, well-designed studies
evaluating the effectiveness and
benefits of prophylaxis in children with recurrent UTIs are
lacking (Wald, 2004). Hellerstein
and Nickell (2002) identified
children with dysfunctional voiding to be at higher risk for breakthrough infections while on prophylaxis. The risks of long-term
prophylaxis include development of bacterial resistance, disruption of indigenous microflora,
and the elimination of asymptomatic bacteruria, which in some
cases can protect against more
virulent bacteria.
Behavior modification. A
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Table 3.
Fluid Recommendations Based on Weight
100 cc/kg for the first 10 kg of weight
50 cc/kg for the next 11 to 20 kg of weight
20 cc/kg for each additional kilogram of weight
voiding schedule is central to
bladder retraining for children
with dysfunctional voiding.
Children usually rely on the bladder to signal them to get to the
bathroom; however, many wet
before arriving on time. By voiding at regular intervals, about 2
hours apart, they have an opportunity to regularly empty the
bladder prior to the sensation of
urgency. The child must understand the importance of voiding
every 2 hours in the waking
hours, even if he doesn’t feel the
urge to do so. Ensuring adequate
hydration, by having the child
drink at least one 8 ounce cup of
water with each meal, can help
the child appreciate a feeling of
fullness in the bladder and
prompt regular voiding. Maintenance fluid recommendations,
based on weight, are displayed in
Table 3. A voiding chart or diary
should be used to remind the
child to void and to track
progress. An incentive chart with
token rewards earned for compliance may be useful with a reluctant child.
Biofeedback. Biofeedback
training can be beneficial to children with various types of dysfunctional voiding, recurrent
UTIs, and vesicoureteral reflux
(Chin-Peuckert & Salle, 2001;
Herndon et al., 2001). Children
who void in a staccato fashion fail
to empty the bladder completely,
or rely on the use of accessory
(abdominal) muscles to void,
receive training to gain conscious
control over the pelvic floor musculature. This control of voiding
can be initiated and sustained
through relaxation of the external
urethral sphincter. Biofeedback
has also been used to help children
learn to inhibit detrusor overactivity (Shafik, 1999; Yamanishi et al.,
2000). By teaching children to
contract the pelvic floor muscles
and the urethral sphincter, bladder
contractions can be inhibited.
The noninvasive use of EMG
patch electrodes near the perineum and on the abdomen, combined with verbal instruction and
an interactive visual display, help
the child to visualize and accomplish pelvic floor relaxation. A
uroflow and post void bladder
scan provide further input and
help gauge progress. Motivation
and willingness to participate are
important factors in patient selection for biofeedback. Children are
expected to practice exercises at
home, complete diaries, and comply with a voiding schedule for
maximum success. (Note: See the
article by J. Liberati in this issue
of Urologic Nursing for more specific information related to implementing biofeedback therapy.)
Anticholinergic medication.
For children who void at least
every 2 hours and empty their
bladder completely but continue
to have urgency and wetting, an
anticholinergic medication may
be indicated. Anticholingeric medications, such as oxybutynin
(Ditropan®) or tolterodine (Detrol®),
are often helpful to decrease uninhibited bladder contractions and
increase functional bladder
capacity. Optimum results are
achieved when the child is not
constipated and maintains a regular voiding schedule. It is beneficial to assess a flow rate and a
PVR while the child is taking
medication.
Psychological counseling.
When children fail to show
improvement with behavior mod-
UROLOGIC NURSING / June 2005 / Volume 25 Number 3
ification and/or medical management, it usually indicates problems with compliance due to comorbid factors such as poor motivation, attention deficit hyperactivity disorder, learning disabilities, sensory processing issues, or
problems within the family
(Kodman-Jones et al., 2001;
Lettgen et al., 2002). Family-centered psychological counseling
can be very beneficial in such
cases.
Nursing Roles
Management of children with
dysfunctional voiding takes time
and patience. Success depends
on patient compliance which is
facilitated when the child and
family have a good understanding of how the body works, the
nature of the problem, and the
need to perform certain tasks on a
daily basis. Nurses spend a great
deal of time with dysfunctional
voiders providing such education, coaching in biofeedback and
behavior modification techniques, and monitoring progress.
Many families need guidance in
organizing the tasks needed for
success and strategies to manage
setbacks. Intervention in school is
necessary to help staff understand the nature of a child’s voiding problem, and the need for a
strict voiding schedule and free
water drinking throughout the
day.
Summary
Children with dysfunctional
voiding can present with a spectrum of symptoms from wetting
with urgency and frequent or
infrequent voiding, to febrile urinary tract infections with complete day and nighttime dryness.
Therefore, it is important to
understand the subtypes of dysfunctional voiding so therapy can
be individualized. Patient history,
physical examination, and appropriate diagnostic testing help the
clinician make an accurate diagnosis and begin appropriate treatment. Treatment often involves a
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combination of bowel management,
regimented
voiding,
biofeedback training and, in some
cases, medications. Nurses play a
key role in identifying patients
with dysfunctional voiding and
in developing and implementing
management plans. Monitoring
progress and continued support
are critical to the success of
behavioral interventions that
help keep the child and family on
track. Elimination problems take
time, patience, and persistence to
overcome.
The prognosis for children
with dysfunctional voiding is
encouraging (Curran, Kaefer,
Peters, Logigian & Bauer, 2000;
Saedi & Schulman, 2003; Wiener
et al., 2000). Support of child and
family are critical and nurses play
a key role in monitoring progress,
and providing encouragement
and support.
Parents begin to see their
child as competent rather than
immature or lazy. Nurses reap
tremendous rewards in helping
children with dysfunctional voiding overcome such a frustrating
problem. •
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