Bladder and Bowel Dysfunction

BLADDER AND BOWEL DYSFUNCTION
Dr G Nandhini
Consultant Pediatric Surgeon
Dr MEHTA’S CHILDREN,S HOSPITAL
Chennai.
BBD is used to describe children with abnormal lower urinary tract symptoms of
storage and/or emptying of both bowel and bladder .Bladder bowel
dysfunction(BBD), dysfunctional voiding & dysfunctional elimination syndrome refer
to a common but poorly characterized complex of symptoms typically including
urinary incontinence, dysuria, urinary tract infections (UTI), urinary frequency,
infrequent voiding , encoperesis , and constipation. The age of onset varies mostly
after the toilet training years ( 1-2 )years of age. This condition is emerging as major
issue in almost 30-40 % of the children attending outpatient department with lower
urinary tract symptoms.
Regular passage of urine and stool is very important for wellbeing of the child. Toilet
training is mandatory to ensure the same in the child by 1-1.5yrs of age once they
start to follow parental commands. If toilet training is not ensured at appropriate
age, it may lead onto both bladder and bowel disturbances leading onto, even grave
consequences on the urinary tract like recurrent febrile UTI, vesicoureteric reflux,
chronic kidney disease and failure to thrive.
Bladder dysfunction:
Children will have frequent urination as and when the urine comes to bladder during
first year of life. Beyond first year of life, children learn to hold urine voluntarily by
command.hence urine control and training them to pass urine in the toilet should be
initiated by 1 year of life. Day time urinary control is attained by 2 years and night
time urinary control by 5 years of age.
The function of the bladder is to store urine from the kidneys at low pressure and
empty efficiently at a socially acceptable time. This process involves integration of
activity from both brain and spinal cord. Bladder is overstretched when urination is
postponed voluntarily and this causes pain, frequency, urine leaks, recurrent urinary
tract infection etc. If the bladder is emptied at regular intervals, it is relaxed and the
system works fine.
A special note on various urine postponing maneuvers (Vincent curtsy) should be

identified early by the parents like - squatting with the heel pressed to the perineum,
standing on tip-toe with legs crossed ,pressing the glans to avoid incontinence etc.
History will reveal less intake of water & infrequent or postpontment of urination.
Clinically vincent curtsy can be identified. USG abdomen will show bladder wall
thickening when there is detrusor sphincter dyssynergia –ie sphincter is voluntarily
closed by the child when the detrusor is contracting to empty the bladder urine.
What can be done about it?

Bladder problems can often be treated quite easily, it’s all about helping the child
take command over his/her bladder. These are some basic strategies:
1) Go to the toilet regularly, every second hour or about six times per day (when
getting up from bed, mid-morning, lunch, mid-afternoon, late afternoon and
at bedtime).
2) Don’t rush to void urine and Give the bladder time to empty itself completely.
Sit with good support for both thighs and feet.
3) About 1-1.5 litre of water per day is appropriate.
4) Watch out for signs of constipation.
5) Explain to the child how the bladder functions. This will increase his/her
cooperation.
Bowel Dysfunction:
A standard pattern is seen for attainment of urinary and bowel continence. Normally,
the first to appear is night time bowel control and thereafter, day time bowel
control, day time urinary control and night time dryness, in that order by 5 years of
age .It is recognized that there is strong association between bladder and bowel
dysfunction. The bowel is present very closely behind the bladder, hence the bladder
will not be able to expand and hold urine well when a child has large amount of stool
loaded in the rectum.
Constipation is defined as hard stools with reduced frequency. Toilet training should
be initiated as early as 1 year to ensure smooth passage of stool atleast once a day.
Hard stools may cause pain, blood in the stools, fissure in the anus, recurrent
infection in the perineum. If it is not attended on time , it leads on to loaded rectum–
causing stool leak(encoperesis) unknowingly for the child (it is called spurious
diarrhea), running to corners to avoid stool, standing posture, flat sitting posture to
avoid passing stool. This reduces the appetite of the child and they fall sick
frequently. Hence habit constipation requires proper attention early.
What can be done about it?
Bowel problems can often be treated quite easily only at early identification. Later
stages need medical help for 6months to 1 year. These are some basic strategies:
1) initiate early morning habit of passing stools.
2) break the fear of passing stools in commode. make them Sit with good
support for both thighs and feet.
3) About 1-2 litre of water per day is essential.
4) good planning of diet every day with vegetables , fruits and nuts .
5) avoid milk intake more than 3 glasses a day.
6) active physical games will help in regulating bowel.
7) toilet visits should never be rushed or postponed .
Management of both bladder and bowel dysfunction should be given priority in

children. Children should be initiated on urotherapy, which includes simple behavior
modification and dietary management as detailed earlier - Failing which a pediatric
surgeon / pediatric nephrologist should be consulted for the same.

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BLADDER AND BOWEL DYSFUNCTION

A special note on various urine postponing maneuvers (Vincent curtsy) should be

What can be done about it?

Management of both bladder and bowel dysfunction should be given priority in

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