Any parent will tell you, the potty training years are stressful! There are millions of resources that tell you different information, and on top of that, work and school schedules make it almost impossible to stick to a solid routine. Every day on the streets of New York City I see frantic parents running to the nearest restroom dragging their child who is doing “the pee dance” because 10 minutes ago at home they “didn’t have to go.” At some point, the chaos ends, and children have a better awareness of their needs, but what about those children who don’t?

Almost all children experience wetting or soiling accidents for various reasons during these training years. By age 5, a child’s neuromuscular system is developed to have bowel and bladder control; however 10% of children from age 5 to 7 continue to have regular day and night time accidents. This trend continues with 3% of children age 12, and 1% of children age 18 .

Persistent wetting has emotional and psychological effects on both children and their parents. Parents report feeling frustrated, stressed, bothered, sad, and helpless when their children are not as physically capable as their peers to remain continent. Children can reports feelings of anxiety, embarrassment, and generally become less sociable . So, why does persistent wetting occur?

Children experiencing persistent wetting should be evaluated by a doctor for the following causes:
• A “Twitchy” or “overactive” bladder that signals frequent urgency sensations and premature voiding
• A weak outlet system that is unable to hold back urine during laughing, coughing, or straining
• Urinary tract infection
• Chronic constipation
• Structural abnormalities within the urinary system
• Neurological issues effecting the lower half of the body
• Psychological or emotional trauma

      Regardless of the cause, a root issue seen with most of the conditions above is “dysfunctional voiding” from weak, over active, or non-coordinated pelvic floor muscles. In addition to the immediate psychological effects, dysfunctional pelvic floor muscles can lead to improper development of the urogenital system with connections to chronic pelvic pain in their adolescent and adult life. So what can be done to improve the functioning of these muscles?

Pelvic floor physical therapy is a specialty within physical therapy that focuses on the strength and coordination of this vastly important muscle group. When working with pediatrics, the whole family is considered, and involved as a unit. It is NOT just about kegel exercises! Therapy is focused on creating a better awareness of this area of the body, improving the child’s interpretation of the various sensations experienced at different points in the voiding cycle, and developing the strength and coordination to allow more effective voiding habits. To accomplish this, first, keep a bladder diary to keep track of every time your child uses the bathroom, or has an accident, to find any patterns in their bladder symptoms, such as time of day and frequency. After that, “timed voiding” helps retrain the bladder to void only when in the bathroom by having your child use the bathroom every hour, then slowly increasing the time until it is more optimal.

Rewards and praise are excellent motivation for children to want to use the bathroom and let you know when they have to use it. Avoid negative feedback such as reprimands or “time outs” when an accident does occur, this is very discouraging and does not help improve confidence or self-esteem. Exercise consisting of leg and abdominal stretches help keep your child’s muscles more calm rather than tense, which applies added stress and compression to the bladder. And finally, educating your child about their pelvic muscles is key! Many parents find this topic taboo, or uncomfortable to talk about. This sends a message to children that they should dissociate themselves from feelings or sensations in this area rather than really paying attention and developing that complete mind body awareness. If you find this topic uncomfortable, remember, your pelvic muscles are not solely for sexual function, and that part of the conversation does not need be discussed until your child comes closer to puberty. Educate your child on the fact that they have control over this area of their body, they can squeeze those muscles, release those muscles, and push those muscles downward (this maneuver is referred to as “bearing down” and is done during bowel movements). Most of the time, children feel excited to learn they are in control of something since this is usually a rare occurrence in childhood. The more they are taking notice of these muscles and practicing using them, the stronger they will become. In physical therapy, their strength gains are monitored using biofeedback which uses external surface electrodes to quantify the strength of the muscle contractions.

For strengthening when the muscles have significant weakness, pelvic physical therapists engage the child in play activities that facilitate the use of these muscles. Activities include bouncing on therapy balls, negotiating obstacle courses, creating dances, and other full body physical activity that is fun for the child, all the while incorporating pelvic floor contractions in a safe and supportive environment. Training and educating children is more successful when it is fun and engaging. Parents are also instructed in activities they can perform at home as a family to further increase the child’s engagement, and provide effective parent involvement.

If your child is experiencing any of the symptoms discussed, there is hope. In a matter of 2 to 3 months, muscles can be trained to work at their full potential, and you, and your child can develop the confidence and peace of mind to overcome the struggle of persistent incontinence.