08/02/2002 Archives of Disease in Childhood. (v87,2) Pp. 151-155.

Investigation of daytime wetting: when is spinal cord imaging indicated?

E Wraige & M Borzyskowski. Guys Hosp, Dept Paediat Neurol, Newcomen Ctr, London SE1 9RT, England

Background: Most children with daytime wetting have detrusor instability. A minority have neuropathic
vesicourethral dysfunction. The commonest cause is spina bifida, which may be closed, Clinical features suggestive
of closed spina bifida include cutaneous, neuro-orthopaedic or lumbosacral spine x ray abnormalities, impaired
bladder sensation, and incomplete bladder emptying. MRI is the ideal method for detecting spinal cord abnormality,
It has been suggested that MRI spine is an unnecessary investigation in children with daytime wetting in the absence
of cutaneous, neuro-orthopaedic, or lumbosocral spine x ray abnormalities.

Aim: To clarify indications for magnetic resonance imaging (MRI) of the spine in children with voiding dysfunction.

Methods: Retrospective study of children with voiding dysfunction referred from the Guy's Hospital neurourology
clinic for MRI spine between April 1998 and April 2000. Clinical notes and results of investigations, including
urodynamic studies and MRI spine were reviewed.

Results: There were 48 children (median age 9.1 years). Closed spina bifida was detected in five, of whom four had
neuropathic vesicourethral dysfunction confirmed by urodynamic studies. Impaired bladder sensation and incomplete
bladder emptying were more frequent in these children than in those with normal MRI spine. One child with spinal
cord abnormality had no cutaneous, neuro-orthopaedic, or lumbosacral spine x ray abnormalities.

Conclusion: Spinal cord imaging should be considered in children with daytime wetting when this is associated with
impaired bladder sensation or poor bladder emptying, even in the absence of neuro-orthopaedic, cutaneous, or
lumbosacral spine x ray abnormalities.

Introduction:

If your child has Encopresis (soiling) or hard, large or difficult bowel movements, these issues must be managed first
to have any hope of success with daytime bladder problems and likely even with bedwetting. If this is true see your
pediatrician and/or check out the Clean Kid Manual page at this website.

The purpose of this behavioral intervention for daytime training is to stretch the bladder and increase your child's
bladder capacity. There are three levels of intervention going from least intense to most intense. You can enter at
any level you choose. If this is not successful after one month, then go to your child's physician and discuss the
possibility of a prescription for an antispasmodic medication (e.g., Ditropan or its generic, oxybutynin). Take your
records with you! Continued use of your Urine Collection Device (UCD) will help to verify if there is an improvement
in bladder capacity with this prescription and your child's physician will be impressed by your record keeping.

The normal development of bladder and bowel control occurs in the sequence: bowel-asleep, bowel-awake, bladder-
awake, and bladder-asleep. The child has to develop (learn) an awareness of fullness cues arising from the bladder
or bowel and to connect them with the proper response of sphincter muscle contraction to temporarily prevent
evacuation. For soiling or bowel accidents some children overlearn holding which can lead to constipation and
fear/avoidance of voiding which only complicates the problem and can make treatment very difficult. The child has
to go to the proper site, relax, and "let go" to void. This is a delicate point and often leads to lots of conflict between
parent and child. This is much more true for soiling (Encopresis) than wetting accidents. Soiling accidents requires
a more strategic, complex approach, which is addressed in the "Clean Kid Manual" available from this site. If soiling is
present, and this includes "leakage", "stains", or "tire tracks" which you thought were just due to improper wiping, the
chances of bladder control will be substantially reduced! You must look very closely for any signs of bowel accidents.
If soiling or Encopresis is present, it MUST be treated first before addressing bladder control! Examine the Clean Kid
Treatment page on this site and the many other pages that deal with Encopresis. This page will be limited to
strategies for reducing daytime bladder accidents or diurnal enuresis. Recent research suggests that training for
both bedwetting and daytime bladder control at the same time is more effective than either alone.

Most children succeed with traditional bladder training methods. However, the best source available for toilet training
is a book entitled, "Toilet Training in Less Than a Day" by Nathan H. Azrin and R.M. Foxx (New York: Simon and
Schuster, 1974). The techniques are demanding, and intense, but rewarding. This page will draw heavily on the
contributions of Dr. Azrin.

Now, if, despite your best efforts and after following our instructions, you get nowhere or there is a relapse to wetting,
you may be dealing with a special problem that may require more specialized attention. Again, if soiling was present,
then you must treat it first because it is likely contributing to the bladder problem.

If you are curious about the "why" of the diurnal enuresis coexisting with the Encopresis, the best behavioral medicine
account is that the cues of awareness for a full bladder become confused with or "hidden" in the cues deriving from an
overly full and distended colon. Therefore, taking care of the Encopresis and keeping the bowel more consistently
emptied out will allow the child to once again sense the cues for a full bladder to which he will now respond in the
appropriate manner. If you are lucky that is exactly what will happen, but more often than not a child with Encopresis
also is a very intense and busy child that got into trouble in the first place because he/she did not want to take the
time to toilet. Therefore, he or she tends to put off even the simpler act of voiding the bladder. Boys have it so much
easier than girls here, but they still delay too much. Boys are more at risk because of being more intense, busy, and
subject to ADHD. Getting mad won't help and you may even stimulate stubbornness and oppositional behavior! So,
be cool, be smart and consider the following three steps, which are given in an escalating fashion. You can do the
simplest thing first and escalate as needed or start with the most intense third step for shortening your intervention.
You know your child best as to what he or she can tolerate and what is most likely to work.

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"Play it again Sam, I":

If your child is competitive he/she will love this first, very simple approach. Purchase a specipan from your area
medical supply house or from the Store at this website where it is called a URINE COLLECTION DEVICE (UCD). This
device is provided free with the purchase of our DRY BED MANUAL. This is a plastic volumetric measuring container
which has a wide brim that allows it to be placed on the front portion of your toilet bowl. It is especially handy for girls
because it can be conveniently placed such that it will easily collect all of her urine and even allow bowel evacuation
at the same time, if properly placed. Be sure you get a specipan with etched volume markers on it and not just a
pasted label which will come off with rinsing or repeated use. Moms may recall this simple, inexpensive plastic
container from their hospital stay for child delivery! It is included with the Dry Bed Treatment Package. Have you
anticipated the author here?

Right, you introduce the specipan and your interest in seeing how much he or she can void. Counter intuitively,
you even encourage him to drink lots of fluids! This will help to create more "learning trials" of going to the right
place and voiding appropriately. You get him to compete within himself for how much he can void. Everytime he
(or you) goes emphasize the feeling of relief that accompanies emptying the bladder. You really do not need
extrinsic reinforcers! You use his/her own motivation (not yours). You recruit him/her and note that he or she is
not THE PROBLEM, but part of THE SOLUTION. Introduce and oversee or do the record keeping at the beginning
so he or she can see the results over time. This teaches discipline, looking long-range, and gives you something to
remind the child of should he/she relapse. He/she did it before and can do it again. Calculate an average at the end
of each week to help sustain interest and keep a weekly chart. CAUTION: You really don't want your child to exceed
500 cc of bladder capacity, although he/she could become an excellent candidate for long distance truck driving.
Loads exceeding this would result in an over-distension of the bladder which could lead to future problems.

When you see your child hopping around holding his or her crotch, resist the temptation to tell your child to go to the
bathroom as if he/she is an imbecile. Quite aside from damaging the ego, you are short-circuiting his/her awareness
and substituting your own. It's too easy! You want self-management as a goal. You want him or her to truly learn. That
requires some effort by your child. Engage your child, look at him quizzically and ask, "Gee Johnny what are you
doing"? Play dumb, let him/her figure it out! Don't make it easy! Of course, you could come up with many creative
challenges to tease (gently) and help your child toward his/her own insight or discovery. Hey, your child could be very
talented and gifted and still "not get it"! This is not a high IQ skill, it just has to get connected, right! Be patient and
persistent and you and your child will both win. You could even have fun at this. Figure out different ways to help him
or her to make the connection with you asking the right question, "Are your eyes yellow yet"? "Are your teeth floating"?
"Can you hold it any longer?" "What's yellow and mellow"? "Would you like a nice, big, tall glass of water"? Then, if
he/she does get it, remind him or her of "Oh how great it feels" after he or she does go. This is better than giving
the child money or a sticker as a reward. This is a form of "self-reinforcement". You could even make it all a family
joke and comment on your own relief at times after you void. Don't we all?

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"Play It Again Sam, II":

Check your child's pants every hour for even the littlest bit of dampness or whenever you become aware of an
accident. Have the child clean him/herself up and put on clean underpants, but insist on him/her smelling them
first and commenting on how nice and fresh they smell. Even invite the child to squash them against her/her face!
Beforehand you could have added cologne, a sachet to the drawer, etc. No mention or disgust needs to be made
about the dirty underwear that you have tossed temporarily into the bathtub. Then, the child is to wash out his/her
underclothes using the "clean smell test" developed by the author of this site (this is optional, many modern day
parents are reluctant to do this). Basically, after sudsing and rinsing out the underpants, however many times, when
the child is finally able to draw the offending piece of underwear right up to their nose or within one inch away with a
good healthy sniff, they can cease repeating the cleaning sequence. You celebrate the GOOD SMELL and hang
the clean underwear up to dry. During this period, or, forever thereafter, have the child smell fresh herbs, clothes
dried out of doors, etc. Emphasize "good smell consciousness". Emphasize delight, not disgust. Why even mention
offensive body smells? Pick a fight and you will get a fight and resentment. They already know it, will never admit it,
and why rub it in? If you insist on a confession of "badness" and win, you lose!

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"Play It Again Sam, III" or Positive Practice Trials:

Actually, part II above and this section on positive practice trials go very well and can be implemented together. But,
positive practice trials are very demanding and time consuming. You should not undertake them unless you are
willing to make the commitment--read on.

Simply, initially, you have the child practice toileting awareness and pretending to go over and over again. Use lots
of imagination and spontaneity in doing this! After an accident and the clean smell test take the child out into the
living room. Practice or imagine that you are watching his/her favorite TV program, but keep the TV off. Then,
dramatically and suddenly say, "Oh my gosh, your bladder is very full, it wants to burst, it hurts"! "What are you
going to do"? Be dramatic, make it crazy and fun. He/she is to walk, not run, to the bathroom, lift the toilet lid
(adapt for a girl), unzips, aims, and fires (pretend on the latter if the child is sensitive to observation). Meanwhile,
the child (with your help) expresses great joy and relief over emptying the bladder out (pretend). Then, you go to
the kitchen and you pretend this or that, but, "Oh my gosh,...." Then, you go to the child's bedroom and pretend to
be playing and, "Oh my gosh,...." Then, you both go out into the back yard, even if this means really putting on
heavy winter clothes. You go to the remotest part of your huge estate or cattle ranch (modify as needed) and "Oh
my gosh,....". Then, you both get into the car and pretend that you are just going to go somewhere and "Oh my
gosh,...." Then, you both go out to the workshop or down into the basement and "Oh my gosh,...." Get it! Do it 10
times, the whole sequence, without compromise! We want the child to form a habit and "go on automatic". Get more
serious as you go along, always emphasize the child's coming to recognize the full bladder and then walking calmly
to the bathroom. You can lessen the frequency of positive practice trials after the first accident or, periodically, you
can "freshen up" this positive practice trial awareness/response sequence at anytime or anywhere during the day
just two or more times as it spontaneously occurs to you in the daytime.

One thing that upsets some parents about positive practice trials is that the child really enjoys this togetherness and
the time doing the positive practice trials! Darn it, they just don't seem to be taking this seriously enough. That
typically wears off after a time and the seriousness of the program goal of bladder continence will not be lost. You
will have brought all the elements of successful training together and you can feel justified and rewarded as a parent
as the child gets control over his own body.

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If none of these behavioral steps worked, go see your child's physician for consideration of an anti-spasmodic
medication such as Ditropan (oxybutynin) and monitor its effects for increasing bladder capacity using the UCD
from our Store.

Good luck! E-mail DrC@www.encopresis.com and let us know what you think or how you fared with your child.
Don't be surprised if you get Dr. Collins himself ... and even it you don’t, he will get back to you!