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| Daytime Bladder Accidents (Diurnal Enuresis) Caution: The author of this site works closely with physicians whom he regards as his allies. For this page and our other services you should be aware that a medical disease may be contributing to your child's problem. If your child does not respond to the behavioral techniques recommended by us, then you should certainly see your physician to check for more rare possible medical causes (e.g., Hirschsprung's disease, diabetes, cancer, etc.). Next is a recent scientific abstract citing another rare possible cause: closed or occult spina bifida. Your physician will guide you through the detection process when and if he/she feels it is indicated (and your insurance company allows it). My treatment protocol below might also be tried in full as a possible "rule-out" to justify the more extensive diagnostic procedures. You should see results with my protocol within one month. 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. 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. 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 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. "Play
it again Sam, I": 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 overdistension 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? "Play
It Again Sam, II": "Play
It Again Sam, III" or Positive Practice Trials:
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. 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! Write bobpsy@yahoo.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
or an answering machine (He will get back to you!).
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