Voiding problems, also called dysfunctional voiding, are very common in children. Dysfunctional voiding can range from very mild problems to severe problems, which cause damage to the kidneys.

Types of voiding dysfunction
Difficulties with urination may range from mild frequency or burning with urination to severe day and nighttime urinary leakage.

Overactive bladder
This is a very frequent problem that can start anytime during childhood. The bladder is hyperactive and tries to empty frequently, often without warning. Often children do not feel the need to void until the bladder is actually trying to empty. As a result, the child with this problem may run to the bathroom, have many accidents and try to hold himself/herself to prevent leakage. You may ask the child to void and they will tell you they do not need to void then two seconds later it is an emergency. This problem may, in some cases, be related to urinary tract infections, constipation, stress at home or use of caffeine. In most cases, the problem improves with time. Trying to have the child void every 2 hours is often helpful.

Uncoordinated voiding
In some cases, a child with an overactive bladder learns to hold onto urine and then cannot empty the bladder properly. This may lead to infections, more wetting and, in severe cases, kidney damage. The child may also hold onto feces and be constipated with periodical soiling of underwear.

Frequency-urgency syndrome of childhood
Some children develop a sudden problem with needing to go to the bathroom frequently, as often as every 10 minutes. These children were fine prior to developing this problem. They usually are able to sleep through the entire night without going to the bathroom or wetting the bed. The problem tends to go away on its own, but may last for months or a year or longer. These children typically are normal in every way, but just feel as if they need to void with little or no urine in the bladder.

Infrequent voiding
Some children are brought to our attention because they get urinary tract infections and the family notices that they go to the bathroom only 2 or 3 times per day. Holding the urine in for long periods can allow germs to get into the bladder and start an infection. Urination helps prevent infection by flushing out the bladder. These children need to void 6 times per day even if they do not feel the need to do so.

Testing
Children with wetting problems are examined, their urine is checked for infection and they may be asked to urinate into a machine that checks how fast they urinate (called a uroflow machine). We may even place patches (3 stick-on) similar to those used in heart monitoring to the pelvic muscles at the area around the rectum in order to allow direct assessment of the pelvic floor muscles. An ultrasound of the kidneys and bladder may be ordered to check for any abnormalities. A bladder x-ray (VCUG) may also be recommended in some cases. Children who have had urinary tract infections may need both of these tests. We look for blockage (obstruction) in the kidneys, reflux (urine from the bladder ascending back up into the kidneys), bladder size and how well the bladder empties.

Treatment of voiding dysfunction
If the problem is mild and the ultrasound or x-rays are normal, we may recommend simply to observe your child and wait for the problem to go away on its own. If other problems are found, these will be treated separately. If the symptoms are severe, we may recommend medication, depending on the age of the child

Overactive bladder
If your child is young and has no other problems with the urinary tract, we may recommend a watch and wait approach to see if the problems goes away on its own. It may help to avoid caffeine, to encourage your child not to delay urination and to treat constipation if present. If the problem persists, we may recommend treatment with medication. The most common drugs used are Ditropan and Detrol. Ditropan and Detrol help reduce bladder contractions to allow the bladder to fill further without trying to empty. They are given 2 or 3 times per day. Side effects may include: red face, dry mouth, constipation, drowsiness, reduced sweating which may lead to severe overheating in the summer, blurred vision and personality changes. Most children tolerate Ditropan and Detrol without serious problems, but reducing the dose may help if side effects occur. If any problems occur with one of these medicines, you should stop it and contact our office. If effective, we usually continue the medicine for up to 6 months and then stop it and see how your child does without it.

Uncoordinated voiding
If your child has reflux or frequent infections, these will be treated (see our other sections). If your child does not empty his/her bladder we may recommend that he/she urinate twice in a row to more completely empty the bladder. In rare cases, we may ask you and your child to learn how to empty the bladder with a catheter on a routine basis (intermittent catheterization) for a while.

This usually needs to be done 4 or 5 times per day and we will give you specific instructions on how to do it. Sometimes we will recommend biofeedback training. Biofeedback uses a special machine that can help teach your child how relax their urinary sphincter to allow them to empty their bladder.

Frequency-urgency syndrome
If your child has these symptoms and all our tests are normal, we usually recommend waiting until the problem stops on its own. In many cases medicine is not effective for this problem.

Infrequent voiding
If your child has urinary tract infections and does not urinate frequently, we will recommend that he/she be encouraged to go to the bathroom more often. Since the bladder may be overstretched in people who do not empty it very often, your child may say that he/she does not have to go as often as necessary. Therefore, it is likely that you will have to encourage your child to go "by the clock" for a while until he/ she develops a habit of urinating more frequently (at least every 3-4 hours during the day).