Monday 21st July to Sunday 27th July marks World Continence Week 2021. Davina Richardson, Children’s Specialist Nurse at Bladder & Bowel UK, talks about an overactive bladder in children and young people.
Many children and young people experience bladder problems, but these are often poorly understood. They may be associated with behavioural difficulties or emotional problems but are rarely caused by them. It is more likely that any behaviour and/or emotional issues are the result of the bladder problems. Often these reduce or go away when the underlying bladder issue is treated.
Understanding bladder problems in children and young people
To understand the causes of many bladder problems, it helps to understand how the bladder works. The bladder wall has a layer of muscle in it that should reman relaxed, soft and stretchy while the bladder is filling. There is also a circular ring of muscle at the base of the bladder that should remain contracted (squeezed so it is closed) during bladder filling.
The kidneys are constantly producing urine and it is collected in the bladder. When the bladder is about half to two thirds full it should start to send messages to the brain to alert the individual that they are going to need to use the toilet. As the bladder continues to fill those signals become stronger. Young children who have not been toilet trained for long, may need the later stronger signals to notice that they need the toilet and are therefore less able to wait to pass urine. However, if the bladder is working correctly, older children will become aware of the signals earlier so have more time to get to the toilet.
When the individual goes to the toilet, a complex control mechanism allows the bladder wall to know it is time for the muscles to tighten and squeeze to push the urine out. At the same time, the circular muscle at the base of the bladder relaxes and opens to allow the urine out. The bladder can then fully empty before the bladder wall relaxes again and the circular muscle contracts and closes the bottom of the bladder. This mechanism allows us to pass urine in a socially acceptable time and place.
While there are different underlying causes for bladder difficulties in children and young people, for most there is no problem with the way the bladder has been constructed. The most common bladder condition in children and young people is called bladder overactivity.
Children and young people with an overactive bladder often appear to leave it to the last minute to go to the toilet. Adults may understandably perceive this as laziness, naughtiness or the child being too engrossed in what they are doing and leaving it too long. However, ‘urgency’ to get to the toilet is usually caused by the bladder wall contracting (twitching or tightening) suddenly and unexpectedly before the bladder is full. This happens with no warning and results in an unexpected and urgent need to get to the toilet. If the circular muscle at the base of the bladder recognises that the bladder wall is tightening, it may respond by relaxing and urine may then leak.
The urgency may be associated with frequency, which is the need to pass urine more than seven times a day in children over four years old . Additionally, children and young people with overactive bladder may have bladders that hold less urine than is expected for their age and physical size. This is because the bladder is used to emptying more frequently than it should, so it is never holding as much as would be expected if the bladder were working well.
Many children and young people who have this problem will ‘dance’, fidget, hold their groin or suddenly crouch and put their heel into their perineum. They are often unaware of what the are doing and if asked if they need the toilet will usually say no. They will usually then try to get to the toilet quickly just a few minutes later. This is because the movements that adults recognise as an indication that the child needs the toilet appear to be subconscious in the child.
Did you know an overactive bladder can occur at night?
Bladder overactivity can occur at night as well as during the day. If it does the child or young person may wake more than once a night to use the toilet. If they are unable to wake to bladder signals they may have bedwetting. Overactive bladder is a common cause of bedwetting.
The reason why an individual has developed overactive bladder may be unclear. It can happen as result of a previous urinary tract infection and it is commonly associated with constipation. However, the problem does not always go away when the urinary tract infection or constipation has been treated.
Many children and young people with bladder issues respond by reducing their fluid intake in the hope that drinking less will make the problem better. Unfortunately, strong urine can irritate the lining of the bladder and make the problem worse. Fizzy drinks and ones with caffeine in can also irritate the lining of the bladder.
Assessments for children and young people
Children and young people who are experiencing problems with bladder leakage, frequency or urgency should be offered an assessment of their bladder and bowels to try to work out the cause of the problem and identify the appropriate treatment for them. If constipation or a urinary tract infection is present, this should be treated. Ensuring that children are drinking plenty of water-based drinks each day is also helpful for many. Primary school aged children should be having about 1.5 litres of water-based drinks a day; teenage girls should have about 1.5-2.5litres a day and teenage boys should have about 2-3litres a day. Regular toilet visits may also help. However, many children do need specialist assessment, support and medication.
Where can I find more information?
If you are a young person with a bladder or bowel problem, or parent of a child with an issue, then do speak to the GP or school nurse, who should be able to provide more support or referral to an appropriate service.
For general advice and support please complete our Bladder & Bowel UK confidential helpline enquiries web form.