Bladder and Bowel Control Problems in Older Children

My nephew both wets and soils himself regularly, while both awake and

asleep. The problem: He is 7 years old, and it's getting worse.

Neither his parents, grandparents or doctors have been able to get to

the bottom of this (excuse the expression). Even when he announces

the need to go, we have mere minutes to get him to a bathroom. He can

tell us exactly when his accidents occurred, so he's feeling 'the

urge.' He just doesn't say or do anything about it until it's too

late, especially when he's focused on something else (i.e. with a

game, activity, T.V. program, etc.)

Though toilet training was difficult, he actually showed better

control when he was younger. There were long stretches without an

accident when he was five. Now, he needs to change sometimes twice

daily. This leads us to believe the problem is not physical. Neither

his mom nor dad have great parenting skills, and they are in the

middle of an unpleasant divorce. His mom works much of the day, but

my parents, with whom they live, are both excellent and responsible.

They are the primary caregivers at the time. We wonder if anxiety

may have something to do with it. Neither of his two sisters have had

similar problems.

He is reminded regularly to go to the bathroom. My father even wakes

him every two hours to go at night, but that only keeps the sheets

dry. The overall problem remains … and gets worse. He

has begun counselling recently, but am unsure if this matter is being

addressed by the therapist.

Cleaning-up is a tremendous chore. Of course, when he soils or wets

himself at school, his peers notice and make the expected unkind

remarks. We need to get this fixed.

Is there any helpful research available on children with similar

problems? What programs and/or treatments have been successful in

dealing with this unpleasant and difficult problem?

Request for Question Clarification byhummer-ga

Hi hypertyper,

My heart goes out to your family because I know exactly what you are

going through – it is not fun! We experienced the same type of

behaviour with one of our family members about 15 or 20 years ago. The

parents were at their wit's end – they tried everything that anybody

and everybody suggested. Like you, it seemed to get worse as time went

on – the mother even distinctly remembered commenting to a friend when

"Jon" was not yet 2 yrs old, that potty training was going to be

easier with Jon than it had been with his older brother. But they

never did find out why the train went off the track, all's they know

is they had a major problem on their hands. As the child got older and

bigger, he ate more and the soiling became larger also. It could

happen at any time, and as you say, more than once per day. Finally,

when he was in about 4th grade I think, a pediatrician referred them

to a psychiatrist (not a pshychologist or therapist) after confirming

with a Barium Enema that there was nothing physically wrong. The

entire family (brother too) saw the psychiatrist once per month for

two years – Jon was never singled out as the "problem" and he never

went alone to any of the sessions. All the members always shared in

the therapy. It consisted of behaviour modification, but never

directly around bathroom habits. It had more to do with getting up

early for school (Jon was always a late riser and missed the bus alot)

and other day to day things that he was responsible for. Anyway, the

soiling just stopped – the family hardly noticed, really, as they were

all concentrating on other things. I don't know how long it took — I

suspect that just getting the attention off of the problem went a long

way in fixing it. Jon was also put on Ritalin for awhile, but I don't

know how much that contributed to resolving the problem. He wasn't

hyper, he just had trouble sticking to the task at hand. He'd start

many projects at the same time and move from one to the other, not

really concentrating on one thing long enough to finish it. If we

asked Jon today about it, I'm sure he would still have no idea why he

soiled (he's a fine young man in university). It's probably a very

complicated syndrome that has really no hard and fast answers. I can

only recommend seeking a family psychiatrist who will see the whole

family, instead of singling out just the one little guy – he feels bad

enough as it is.

Anyway, when I saw your question, I just had to write and let you know

that you are not alone, that there is a light at the end of the tunnel

and to wish you all well. I'm not going to post this as an answer in

the hopes someone else can help you more directly, but if by chance

this is what you were looking for, please let me know and I'll post it

as an answer.

Very sincerely,

hummer

Request for Question Clarification byhummer-ga

Hi, it's hummer again,

I've been thinking about you and thought I'd add a bit to my previous

post. I hadn't mentioned anything about the bed wetting before because

he 'will' outgrow it on his own. It's possible that he inherited the

'problem' – I bet at least one of his parents had been a bed wetter

too. Anyway, if you can afford it, I would suggest buying some

disposable pants that are specially made for the purpose. That way, he

wouldn't have to be awakened during the night (sleep is so important

for children) and he could do sleep-overs as well. And here is the

thought that came to me just today: again, if you can afford it, he

could wear the special pants to school and every time he goes out

anywhere. The last thing he needs is to be teased and ridiculed by his

peers – do everything in your power to make him feel good about

himself and keep his self esteem up. I know the pants won't make the

reason he is soiling himself go away, but they sure will help to ease

some of the tension (less laundry!).

Sincerely,

hummer



One thought on “Bladder and Bowel Control Problems in Older Children

  1. Hello, hypertyper-ga!

    You are truly a wonderful person to care so much for your nephew!

    And what great parents you have to be watching over him at this

    stressful time, getting up at night to help him stay dry, and to help

    him overcome this problem. Between all of you, he has much love and

    support. I have every confidence you will find a solution to this.

    The following sources may help you in finding some direction and

    hopefully, a solution to the problem.

    An article titled “Help available for kids with constipation, soiling

    problems,” by Becky Soglin. Pacemaker (May/June 2000), University of

    Iowa Healthcare website at

    http://www.uihealthcare.com/news/pacemaker/2000/mayjune/02childhoodconstipation.html

    offers some possible answers for bowel control problems. An excerpt

    follows:

    “Although rarely life-threatening, defecation problems, particularly

    soiling, can cause both physical and social problems such as low

    self-esteem for children, according to Vera Loening-Baucke, MD, a

    pediatrician with Children's Hospital of Iowa.”

    "Many parents have trouble determining that children who soil

    themselves may also be constipated," she said. "A hard stool may be

    stuck in the bowel and loose stool leaks out around it."

    “Usually, the constipation has an unknown but not serious cause.”

    “It's important to recognize that children are not intentionally

    soiling even though it may appear that way," Loening-Baucke said.

    "Children simply don't have the control. Successful treatment involves

    parent-child cooperation to get results."

    The University of Iowa has a special clinic to help treat children

    of all ages with bowel control problems. The UI Encopresis Clinic

    “focuses on treating patients with encopresis-fecal incontinence in

    the presence of organic or neurologic disease-and provides

    comprehensive treatment for other pediatric constipation and

    defecation problems.”

    Lack of exercise and low fiber diets are a common cause of

    constipation (with resultant leaking stools). Laxatives and high

    fluids can help.

    ** “However, especially for older children, it may take a while to

    resolve the problems.”…"Many years of problems can't be solved

    overnight," Loening-Baucke said. "It takes time to help patients

    retrain their bowels, many months, sometimes years."**

    Contact information: “Parents who want more information about

    treatments for children with defecation problems may call the

    toll-free UI Health Access phone number and ask for Dr. Vera

    Loening-Baucke, or call the UI Encopresis Clinic at 319-384-7888.”

    A webpage from the “Tri-state Incontinence Support Group” with the

    heading, “Help For Children With Soiling Problems – Encopresis,” at

    http://tis-group.org/top_soil.html has several links to helpful

    articles.

    “Many parent wrongly assume that children will have an easier time

    gaining bowel control compared to bladder control. For many children

    reliable bowel control comes long after bladder control. Also many

    children have problems with soiling that continue or start long after

    they appear to have mastered the basics of bowel control. The

    incidence of childhood encopresis [bowel incontinence] in the general

    population has been estimated at 20%.”

    Also read “Childhood Problems with Bowel Control,” by Jeffrey Brown,

    MD. Child (June/July 1990) at http://tis-group.org/soil_ch.html

    Another helpful article is “Your Child and Encopresis,”by Susan

    Poulton, RNC, ARNP, CNS II and Jeanne Torrens, RN, MSN, CNS II.

    (Updated Fall 2001 by Joni Bosch, PNP,Center for Disabilities and

    Development) at http://www.medicine.uiowa.edu/uhs/enco.cfm.

    The Children’s Medical Center at University of Virginia has numerous

    links to articles dealing with encopresis. Excerpts from “What is

    Encoprosis and What Causes It?” at

    http://hsc.virginia.edu/cmc/tutorials/constipation/encopre.htm,

    follow:

    “When somebody suffers from encopresis it means that he or she can't

    control their bowel movements and so they pass bowel movements in

    their underwear. Sometimes people use the words "soiling" or "fecal

    incontinence" to mean the same thing.”

    “In most cases, encopresis is not primarily a behavioral problem –

    children with encopresis do not have their accidents out of spite or

    because they are lazy. Rather, many behavioral problems develop

    because of the encopresis, and once the encopresis is treated, many of

    the behavioral problems may resolve.”

    “With constipation and painful bowel movements, children may not

    completely empty themselves when they go to the bathroom. Over a long

    period of time the large intestine slowly fills with stool and

    stretches out of shape. As the large intestine stretches larger and

    larger, liquid stool from the small intestine begins to "leak" around

    the more formed stool in the colon. In the beginning, this leakage is

    usually small amounts that streak or stain the underwear and most

    parents just assume their child isn't wiping him or herself very

    well.”

    “As the intestine stretches further, the amount of leakage increases

    so that eventually children begin having "accidents" – they pass whole

    bowel movements in their underwear! This is called encopresis. Because

    the accidents consist of stool that is "leaking" through the intestine

    and not getting completely digested, they are usually very dark and

    sticky, smell very badly, and they have to scraped off the skin and

    clothing.”

    A link to another article titled “What are the Symptoms of Chronic

    Constipation” at http://hsc.virginia.edu/cmc/tutorials/constipation/symptoms.htm

    also mentions **bladder control problems** associated with lack of

    bowel control.

    “The bladder sits right in front of the rectum so if the rectum

    becomes enlarged and is chronically filled with stool, there may be

    less room for the bladder to expand with urine. This may cause a

    number of urinary problems. Many children with chronic constipation

    seem to have small bladder capacities and seem to have to urinate more

    often than usual. In some children, constipation may cause recurrent

    bladder infections, bedwetting, urinary dribbling, or difficulty

    starting their stream.”

    “In older children, long-standing constipation can be associated with

    leakage or smearing of stool in the underwear. As the large intestine

    gets stretched larger and larger, liquid stool from the small

    intestine begins to "leak" around more formed stool in the large

    intestine. In the beginning, the leakage is usually very small and

    most parents just assume their child isn't wiping his or herself very

    well. As the large intestine stretches further, the amount of leakage

    increases so that eventually children begin having "accidents" – they

    pass whole bowel movements in their underwear! This is called

    encopresis. Since these accidents represent "leaking" of soft stool

    through the colon, children don't usual feel the "accidents" happening

    – rather, they just happen.”

    Another indication that constipation (leading to loss of bowel

    control) and incontinence can often be linked can be found in the

    article “Pediatric Incontinence” at

    http://www.sevenhillsurology.com/pedscauses.html

    “Some of the same factors that contribute to nighttime incontinence

    may act together with infrequent voiding to produce daytime

    incontinence. These factors include:”

    “Pressure from a hard bowel movement (constipation)”

    “How Do We Treat Encopresis?” at

    http://hsc.virginia.edu/cmc/tutorials/constipation/encotreat.htm

    provides a comprehensive overview of the steps taken to help overcome

    bowel control problems. Since it is very lengthy, and full of

    information, I will avoid excerpts and suggest you read it in full.

    A very comprehensive article called “Incontinence” by the Tri-state

    Incontinence Support Group at http://tis-group.org/child.html#group

    offers a wealth of information with numerous links to articles,

    medical centers that treat incontinence, and even ***camps*** for

    children with incontinence.

    One article on the page, titled “Diurnal Enuresis,” examines some of

    the reasons for poor urinary control:

    “Your normal school age child has long been potty trained but he or

    she continues to wet his/her pants. Repeated trips to the doctor find

    no obvious physical problem. You have a behavior problem, right? Don’t

    be so sure. Many a child who has long mastered the basics continues to

    have accidents, or leakage – Diurnal enuresis. Many will show no gross

    medical problem. We have seen medical articles that believe that 'at

    least 1% of healthy children have chronic daytime incontinence after'

    five years of age. That is a significant number. Unfortunately most

    articles deal with this problem only as a side note.”

    “Daytime problems are harder for everyone involved. Even parents who

    accept that bedwetting is not the child's fault often believe that wet

    pants during the day are at best a sign of carelessness and at worst a

    deliberate act of defiance.”

    “We feel that many of these problems have a physical cause and while

    some are "functional" very few are behavioral. Problems have many

    causes including stress, emotional trauma, too lax training, too rigid

    training, developmental delays, bladder infections, a small bladder,

    an over active bladder, and many more. All the problems that can cause

    bedwetting also often cause daytime wetting. In fact, many bedwetters

    also have problems with daytime control as well.”

    “Keeping the Child Dry” at http://tis-group.org/where.html offers

    excellent supportive advice for parents, and suggestions for

    disposable and reusable protective undergarments for older children.

    As the article says, “Children need to know that they are not alone.

    They should know that one of the most famous presidents of the United

    States (FDR) had to wear diapers. They need to know that many

    otherwise normal children have these problems and many of them wear

    diapers. Tell them how many medical problems secondarily cause bladder

    or bowel problems. If a parent or friend has/had a similar problem

    tell the child. Most bedwetting children have at least one close

    relative who has or had the problem. We have heard many reason why the

    children aren't told and all of them are lame.”

    Camp links:

    Camp Kirk http://www.campkirk.com/

    “Camp Kirk is a small residential camp which welcomes children ages

    6 to 13 with learning disabilities, ADD, ADHD and those with bladder

    and/or bowel control delays. It offers a nurturing and accepting

    community where everyone can develop socially, emotionally and

    physically, It is a place where children can make friends, have fun

    and develop a sense of belonging without fear of being ostracized or

    ridiculed. The camp program is varied, well structured and, for the

    most part non-competitive. It focuses primarily on social skills and

    on raising self-esteem.”

    Camp Brandon for Boys http://tis-group.org/brandon.html

    “Camp Brandon is a new summer sports camp targeting boys eight to

    eighteen years of age who have bedwetting or incontinence

    problems……Many children who have bedwetting or incontinence suffer

    from a poor self image. Camp Brandon claims to be a place where a

    bedwetting boy can "find sports and activities that he will enjoy plus

    he will feel a sense of satisfaction in developing new skills. He will

    also gain strength and confidence in a friendly atmosphere, while

    taking that first big step of living away from home." All this in an

    environment where he need not fear teasing from other campers.

    I am sure your pediatrician would have mentioned Irritable Bowel

    Syndrome if that was considered a possibility, but an article titled

    “Irritable Bowel Syndrome in Children” at

    http://www.healingwell.com/library/ibs/info2.asp may be worth reading.

    An article dealing with bedwetting and bowel control, written by the

    Child Care Centers Association of Victoria, Inc. at

    http://www.cccav.org.au/pageprotect/members/policy/bedwetting.html

    has an interesting excerpt:

    “Soiling which is not caused by an illness or disability is called

    encopresis. Children with encopresis may have other problems, such as

    short attention span, low frustration tolerance, hyperactivity and

    poor co-ordination. Occasionally, this problem with soiling starts

    with a stressful change in the child's life, such as the birth of a

    sibling, separation/divorce of parents, family problems, or a move to

    a new home. Encopresis is more common in boys than in girls.”

    “School-age children with soiling or bowel control problems should

    have a complete physical evaluation by a family physician or

    pediatrician. If no physical causes are found, or if problems continue

    after examination by a family physician, the next step is an

    evaluation by a child and adolescent psychiatrist. The child and

    adolescent psychiatrist will review the results of the physical

    evaluation and then decide whether emotional problems are contributing

    to the encopresis.”

    “Child and adolescent psychiatrists treat encopresis with a

    combination of educational, psychological and behavioral methods. Most

    children with encopresis can be helped, but progress can be slow and

    extended treatment may be necessary. Early treatment of a soiling or

    bowel control problem can help prevent and reduce social and emotional

    suffering and pain for the child and family.”

    Also read “Incontinence and Voiding Problems in Children.” University

    Childrens Hospital. UCI Medical Center at

    http://www.ucihealth.com/HealthcareServices/peduro11.htm for some

    possible

    direction.

    Now, for my own two cents……My daughter continued to wet her bed until

    she was about 8 years old. It occurred every night, and several times

    a night. I tried getting her up to go to the bathroom, and attaching

    bedwetting alarms to her underwear. Nothing worked. I wish I had tried

    protective undergarments at the time, but they didn’t have “older

    size” diapers at her age. Only later, did they invent pull-ups, which

    were a help. One strategy that helped me get back to sleep a bit

    sooner, was to put a waterproof mattress pad down, and then a second

    and third set of sheets already on the bed, protected by plastic. That

    way, I didn’t have to re-make the entire bed in the middle of the

    night, and disturb her sleep so much. I usually just cleaned her with

    a warm, wet washcloth and put her back into dry pajamas. However, I

    must say……those disposable youth diapers mentioned on

    http://tis-group.org/where.html seem worth a try. It should provide

    your nephew and your parents some much needed sleep until you get this

    under control. I also remember my daughter being ashamed that she

    couldn’t spend the night at a friend’s house for many years. Aahh…that

    is where the love of an adult is so important by helping them maintain

    their self-esteem!

    My second suggestion would be to have your nephew bring some

    disposable, child-size diapers to school in an opaque plastic bag in

    his backpack, or arrange for the school nurse to allow him to use a

    special, private bathroom in the school where he can store the

    pull-ups and some cleaning supplies, like pre-moistened cleaning

    cloths. This would avoid a lot of embarassment for him. My daughter

    occasionally wet her pants at school, and I arranged to send clean

    underpants and pants for her to change into discreetly in the

    bathroom.

    Also, my son, from about 8-10, refused to even have a bowel movement

    at school, and would come home with excruciating headaches. I am

    telling you this just to reassure you that many children have a host

    of urinary and bowel problems, some of which disappear with age, and

    others which need an extra measure of help from parents and doctors to

    find a solution.

    And here is my last word! It drives me nuts when doctor’s say they

    have no idea what the problem may be! I managed to find several

    sources of possible causes, and I am not a doctor. What is the problem

    with doctors these days? I have seen so many people, of all ages, with

    all conditions, leave the doctor’s office with no helpful advice or

    hope…..until somehow, they manage to find it on their own, or run in

    to someone with a similar problem.

    That’s where I end this……More power to all of us for helping one

    another out when doctor’s seem unwilling to go the extra mile.

    My best wishes to you…..and admiration for you and your parents for

    loving this little boy so much! And also, my fellow researcher,

    hummer-ga, is to be greatly admired for expressing such care and

    concern.

    umiat-ga

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