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UNJ June 2005-193.ps 5/18/05 3:36 PM Page 193 Helping Children With Dysfunctional Voiding Amanda Berry C 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 193 C O N T I N U I N G E D U C A T I O N UNJ June 2005-194.ps C O N T I N U I N G E D U C A T I O N 5/18/05 3:36 PM Page 194 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 194 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 UROLOGIC NURSING / June 2005 / Volume 25 Number 3 UNJ June 2005-195.ps 5/18/05 3:36 PM Page 195 Figure 1a. Normal Voiding: The Bladder Contracts and the Urethral Sphincter Relaxes Figure 1b. Discoordinated Voiding: The Bladder Contracts and Urethral Sphincter Is Active C O N T I N U I N G E D U C A T I O N 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 UNJ June 2005-196.ps C O N T I N U I N G E D U C A T I O N 5/18/05 3:36 PM Page 196 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 196 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 UROLOGIC NURSING / June 2005 / Volume 25 Number 3 UNJ June 2005-197.ps 5/18/05 3:36 PM Page 197 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- 197 C O N T I N U I N G E D U C A T I O N UNJ June 2005-198.ps C O N T I N U I N G E D U C A T I O N 5/18/05 3:36 PM Page 198 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 198 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 UROLOGIC NURSING / June 2005 / Volume 25 Number 3 UNJ June 2005-199.ps 5/18/05 3:36 PM Page 199 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 199 C O N T I N U I N G E D U C A T I O N UNJ June 2005-200.ps C O N T I N U I N G E D U C A T I O N 5/18/05 3:36 PM Page 200 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. 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