| Explanation and demystification | |
| The first step is a dialogue between the child and the therapist, about normal bladder/bowel function. It is important to get the child interested in its own condition. An essential part of this is to explain, using all images which can help. | |
| Diaries [51-53] | |
| Voiding and drinking diary: to promote a normal bladder work schedule, a bladder regime is often applied. This implies voluntary initiation of voiding on predetermined times with 1-3 hours intervals, and without previous urge, in order to practise voluntary control over the bladder. Another goal is to regain a normal rhythm of bladder emptying. Frequency/volume charts are filled in by the child, scheduled to follow the daily life of the child. Children with urge start with shorter intervals, gradually increasing them as soon as the urgency attacks disappear. Children with a hypo- or acontractile bladder have to learn to decrease the intervals | The defecation diary is used to teach the child to deal consciously with his bowel problem. These charts are used to teach the child how to obtain an appropriate liquid intake and a regular toilet visit. The schedule is adapted after evaluation at every consultation |
| Relaxation of Pelvic Floor Muscles [53-57] | |
| In children pelvic floor muscles almost never fail as emergency brake, except sometimes during imperative urge, or during uncontrolled laughing. However, the most common problem occurs in children when they are unable to relax the pelvic floor during voiding. In some cases, instructions and practise can remedy this problem, but in the more severe cases the treatment should focus specifically on the pelvic floor. Several programs exist with pelvic floor exercises and perception practice, tailored to suit children. A prospective evaluation reported a success rate of more than 80% in 42 girls with a history of recurrent UTI and urodynamically documented bladder sphincter dysfunction. The studies describe physiotherapy exercises in an excellent way and show definite improvement of signs and symptoms. Controlled studies on physiotherapy alone are still missing, as programs described are always compound packages of pelvic floor exercises, biofeedback and behavioural therapy. | |
| Biofeedback [51,54,56,7,58-64] | |
| Implies perception of filling phase or emptying phase. This is achieved through monitoring of these activites, in a way which is easy to follow by the child. The feedback loop enables the child to influence the process, provided cognitive capacities are developed normally. Numerous studies reported on the efficacy of this treatment in children | |
| Flow patterns will teach the child how to relax the pelvic floor during the voiding. The child sits on a toilet with a flow transducer, watching flow curve and EMG on-line on a computer display, trying to empty completely in one relaxed voiding. | Inflatable Balloons are used to learn correct perception and emptying |
| Neuromodulation [65-68] | |
| Transcutaneous and percutaneous neuromodulation delivered over either the sacral region, anogenital region or peroneal region of the ankle, has proven a useful adjunctive treatment in children with bladder overactivity. Intravesically stimulation can potentially improve detrusor contractility and enhance bladder emptying. Recent studies indicate its effectiveness in children with severe dysfunctional elimination syndrome refractory to maximum medical treatment. | |
| Clearly neuromodulation in children warrants larger, controlled and randomized studies, including studies about its use as first-line intervention and in children with combined bladder and bowel dysfunction. | |
| Reported changes on bladder function with neuromodulation include: significantly increased bladder capacity, decreased severity of urgency, improved continence, and decreased frequency of urinary tract infection. Significant improvement in urodynamic parameters of bladder compliance, number of involuntary contractions, and bladder volume at first detrusor contraction have also been noted. | |
| Level of evidence: 4 | |
| Grade of recommendation D | |
| Rules for application at home [53,63] | |
After evaluation of fluid intake and eating habits, rules for a fixed intake are made, including reminders, designed for use between the visits to the hospital. Information and rules for application at home can be used:
| Drink water, pay attention to your diet (a lot of fibres, vegetables and fruit) Sit 3 times a day on the toilet after each meal and I always pay attention to posture on the toilet and think of the relaxation exercises of the pelvic floor during straining |
| Toilet Posture [53,69,70] | |
| Children are advised to void sitting down on the toilet, with a small bench to support their feet. Thighs have to be spread; the back has to be hold straight, and tilted slightly forward. | A proper toilet posture for defaecation implies that the legs are spread and the feet supported, the knees should be higher than the hips. The back is slightly bent forward, which is the optimal position to reach perfect relaxation of the pelvic floor during straining. In children who can not reach the floor with their feet a small bench or support is placed under the feet. |