Bed wetting can be an extremely frustrating problem to have, for kids and their parents. Why does it happen? What might be causing it? How can physio help?
Pediatric pelvic health physiotherapy is an integral part of the care team for children that are experiencing persistent bed wetting aka nocturnal enuresis. Many children go through daytime potty learning, and just seem to never really quite get the night-time down pat. For others, they breeze through daytime and night-time dryness, and then at some point the night-time problems start and just get worse over time. If you are struggling with potty learning check out our blog.
So why does bed wetting happen?
Bed wetting can in some instances simply be a result of a deep sleeper and an immature bladder. These are kids that will eventually just grow out of it. Many children, however, fit into the “underlying contributing factors” category. Our ability to be continent (hold our urine) at night can be impacted by a number of factors. Here we will go through two main issues:
- Daytime urinary dysfunction
Often times we think of constipation as children going days on end without bowel movements, having extreme difficulty evacuating the bowel, tears, and an overall dramatic experience (which definitely may be the case). BUT some of the time constipation looks like multiple bowel movements a day, quick trips to the washroom, and stool being evacuated without having an actual sensation of the “I need to poop”
The question is how does constipation impact bed wetting? During appointments we take the time to sit down and draw out the relationship (clients get signed copies to take home because the artistic talent is top notch!) – but imagine that the bladder is a balloon, and the abdomen is like a Tupperware container. If the bowel is a long skinny balloon that also fits into the container there is only a certain amount of space in there. When we start to stuff the bowel with some extra stool, it will take up more space in the container. This will leave less space for the bladder, and it will get squished before it can send a signal of “I’m full go pee!” resulting in bed wetting. Biggest take away?
Really the child has no signal that they need to go!
Daytime Urinary Dysfunction
When a parent comes with their child for an appointment and the only reason is “bed wetting” there is a good chance that it isn’t JUST bed wetting. In order for the problem to be strictly nocturnal enuresis, it needs to be present in the absence of any daytime abnormalities. Many children that come in have several daytime issues going on, and often the parents don’t even realize it! Here are a few things that often come up during discussions with children:
- decreased urinary frequency during the day (<4x/day)
- increased urinary frequency during the day (>7x/day)
- leaking urine during the day
- altered sensation to void (not sensing the urge to go, or having the urge and being unable to go)
- voiding difficulties (feeling the urge to go and not being able to)
We struggle especially with school aged children as we often don’t know what their bathroom habits are! Our society tends to significantly limit our bathroom involvement with our kids after they have potty learned, even though they may need parent support until age 5 to ensure they are building positive bowel and bladder hygiene routines!
If you have a child that is holding their bladder all day, you can imagine that might impact night-time dryness. If they are having any sort of daytime dysfunction, the night-time wetting will have difficulty resolving independently, since our kids are sleeping (hopefully!) at night, the greatest impact we can have on bed wetting is by working on the daytime dysfunction and/or constipation!
Ultimately, bed-wetting in many instances is not something that the child is wanting to do or has control over (despite what many of our friends and relatives will tell us). If you have a child that is wetting at night at any age, it may be worth it to think about some of these factors. When in doubt, give us a shout!
Haylie has been practicing pelvic health and focused in prenatal and post-partum care since graduating from the U of S MPT program in 2011. She officially added to her practice pediatric pelvic floor therapy in 2017. Haylie has been advocating for treatment for women, ensuring appropriate and effective care throughout pregnancy and post-partum, and helping all expecting and post-partum moms ultimately brought her to open her family-friendly clinic since opening in 2014. She now adds to this education and treatment provision her knowledge and experience in pediatric pelvic health providing workshops and presentations in addition to assessment and treatment. At Warman Physio clients are encouraged to bring their infants and children to treatment. Haylie was recognized as YWCA Women of Distinction for Health & Wellness in 2017, the ABEX Young Entrepreneur Award Recipient in 2018, and a finalist in the 2019 SABEX and WMBEXA Awards.
Many people are aware that physiotherapy can help with injuries from sports or car accidents, but did you know there is physio that can help with your bladder problems? Not just any physiotherapist can assist you with your leaky bladder, we need to take a little bit of extra training to become a Pelvic Health Physiotherapist (PHPT). Depending on the courses that have been taken, PHPT can treat a variety of pelvic floor disorders including urinary incontinence.
There are a few different types of incontinence that pelvic health physiotherapy can address including stress urinary incontinence (leaking with cough and sneeze), urge urinary incontinence (leaking when rushing to the washroom), mixed urinary incontinence (a mix of stress and urge) and functional urinary incontinence (leaking due to other limitations).
In years past incontinence was an issue associated with an elderly woman who had likely had children at some point, and now we recognize that it is an issue not only in women, but men and children as well!
In some instances the leaking starts as just a small amount and only with certain activities, and in some instances it is a large amount and seeming to be all the time!
Stress Urinary Incontinence
Usually occurs when intraabdominal pressures exceed the ability of our internal and external urethral sphincters to counteract these pressures on the bladder. This will happen most often during laughing, sneezing, coughing, lifting, or yelling. The muscles that control keeping urine in while the pressure around the bladder increases is our external urethral sphincters, a part of our pelvic floor musculature and they are under our control. When there is weakness in these muscle, possibly a problem with timing of the contraction of these muscles, or ‘bearing down’ vs ‘lifting up’, then some leakage can occur. Pelvic floor physical therapy can help by teaching techniques and strategies to get the best recruitment of the pelvic floor muscles and timing of the contractions with these increases in intraabdominal pressure.
Urge Urinary Incontinence
This leaking is associated with the increased urge to void without being able to make it to the bathroom in time. This may start with “photo finishes” and just making it to the washroom in time, to having the entire bladder empty at the first urge to void. Often a higher toned pelvic floor and/or overactive bladder may be the cause. Pelvic floor physical therapy can help by teaching strategies for retraining of the bladder reflex responsible for the urge to urinate or by helping to decrease a higher toned pelvic floor with manual therapy techniques to the lumbosacral spine or pelvic floor and breathing/relaxation exercises.
As it sounds, this is usually a combination of the first two: stress and urge urinary incontinence. Depending on what the assessment finds, various techniques and strategies can be utilized by the pelvic floor physiotherapist to help address the issues. Each individual will get their own unique program no matter what type of issue they are coming in with, but this type in particular can have some very unique features for each client!
Functional & Overflow Incontinence
Generally will have leaking occur when there are other factors at play. Mobility or cognitive issues that prevent a person from making it to the bathroom in time are the biggest culprits here. Physical therapists can help address mobility issues and provide manual therapy, teach exercises to help increase mobility, strength, balance as well as recommend certain mobility aids that can assist the client to reduce incontinence secondary to functional limitations. Often associated with the more elderly client, this can also affect younger individuals as well.
Urinary incontinence can also be due to overflow incontinence. The hallmark symptoms of this type of incontinence are frequent leakage of urine without the urge to void, or the inability to have normal volumes of urine. This is when the bladder remains full due to its inability to empty, which causes the urine to leak out when the bladder capacity is overfilled. This type of incontinence is not a form that physical therapy typically addresses and NEEDS to be medically investigated first as there are a variety of medical reasons that may be causing this type of incontinence!
We have talked about what to expect in a pelvic health appointment before, and with these appointments as with all our assessments we get a detailed subjective history, followed by a scan exam of the low back, as well as an internal assessment of the pelvic floor is usually required in order to fully appreciate what is causing the urinary incontinence. This will help the therapist to formulate a treatment plan that will be individual and specific to each person being assessed. If someone is experiencing urinary incontinence and wishing to have this addressed by a pelvic health physiotherapist, no physician referral is required.
Have you been struggling with urine leakage? Not sure if your symptoms could be part of a pelvic health issue? Please feel free to contact us and we will help chat you through what you are experiencing as best we can.
Maja Stroh is a physiotherapist that has a particular interest in pelvic health and perinatal care. She graduated from the U of S MPT program in 2009 and has been working with pelvic health populations since 2013. Maja’s interest in helping her clients and spending quality time with her family has brought her to Warman Physio where she will be providing services in the Warman location.
The Canadian Continence Foundation <www.canadiancontinence.ca>
We have mentioned before about the predicament with completing ‘kegels’ (or the contraction phase of the kegel alone is what most end up doing). This has an inherent potential impact on labor and delivery.
Now there is new research out of the European Journal of Obstetrics & Gynecology and Reproductive Biology about the impact that there can be had when removing what is often referred to as ‘coached pushing’ during labor and delivery in addition to a few other key factors.
At Warman Physio we want to set women up for the best success possible during labor and delivery, and know that knowledge is power!
So let’s run through some of the background here.
The Facts From the Research
An article in Return to Now outlined the results from EJOG in a thought-provoking post. There is an 85% reduction in 3rd and 4th degree tears (the ‘worst’ of the available 1-4 scale) when women are not coached to push during labor. The amount of severe vaginal tearing was reduced from 7% to 1% within the study.
The researchers completed a review to determine what the main contributing factors were for third and fourth degree tears, and implemented a series of measures to try and reduce these risks.
Some of the risks include a larger than average baby, baby being born ‘face-up’, forceps use, previous perineal tear history, as well as maternal age and weight
This program is referred to as STOMP (Stop Traumatic OASIS Morbidity Project) and implemented within the hospital unit by the midwives and OB GYN teams over the following year. This program includes laboring in different positions to deliver the baby such as squatting, kneeling, and standing, as well as breathing through contractions instead of pushing and applying counter pressure to the perineum during delivery of the baby.
A total of 3902 vaginal deliveries occurred during the 1 year following the launch of full STOMP implementation, with the most significant and immediate results occurring in the first 5 months.
What Does This Mean?
We have seen before in a video demonstration how the uterus does it’s job to push a baby out, coached pushing is shown to lead to closure of the perineum on the descending baby. Allowing women to follow their instincts, without coached pushing, is proven to reduce severe perineal tearing. This will not eliminate all perineal tearing, but gives additional information into how we can best support mothers during labor and delivery.
Physiotherapists are uniquely positioned to assist with mothers during this phase of life, particularly pelvic floor physiotherapists.
Although seeing a pelvic health physiotherapist is not the standard of care here in Canada, there are many women choosing to see one prior to labor and delivery for a variety of reasons such as leaking, pelvic pain, pain with intercourse, and low back pain or sciatica among others. There is also a large trend to see women post-natally as well due to the same reasons in addition to injuries sustained during labor and delivery such as perineal tears.
How can Physiotherapy Help?
Pelvic floor physiotherapists, like those we have at Warman Physio, are able to provide prenatal evaluation of the pelvic floor muscles, coordination, and information on labor and delivery preparation activities. Many women will have been practicing kegels throughout their pregnancy since there still is a significant amount of mis-information regarding what is ‘best’… (remember, a tight pelvic floor isn’t really what we are going for, a functional pelvic floor is what we want!)
In Saskatchewan women are provided an immediate referral to physiotherapy if they have received a third or fourth degree tear (which is GREAT!), however, any woman who has been pregnant into the second trimester may benefit from seeing a pelvic floor therapist after delivering baby.
We have seen that in France, the standard of care is that every woman who has a baby is entitled to Pelvic Floor Physiotherapy appointments postpartum.
Reducing injuries during labor and delivery, and having research to support theoretical working knowledge is critical to advancing health and wellness for women of childbearing years.
Wonder if Physiotherapy can help you for labor and delivery? We recommend an appointment 32-34 weeks gestation. (For those with contraindications to a pelvic exam, we would complete various education and external assessment components).
Our Pelvic Health Therapists:
You’ve already read all about WHY pelvic health is also important for men, now let’s dive into a case study!
Case Study – Male Pelvic Health
CT is a 43 year old male seeking help because he is having problems with leaking urine whenever he does physical activity. He has also been experiencing consistent sharp/burning pains around his rectal area. In the beginning he was leaking only a few drops of urine and feeling slight discomfort in his pelvic floor… but after a few months CT is leaking his full bladder and his pain has greatly increased. He is afraid to participate in golf, fishing, and jogging because this is when he leaks the most urine.
During the pelvic assessment it is found that CT has a weak pelvic floor (2/5 strength), and a lot of tension/tightness of his pelvic floor muscles. He is educated that he needs to strengthen his pelvic muscles in order to close his urethra (tube which pee comes out), so that he does not leak before he is able to get to the bathroom, or when participating in golf, fishing, and jogging. CT also requires training in relaxation exercises, and stretches for his pelvic floor, which will decrease the tightness and therefore stop the pain that he has been experiencing.
After the assessment CT is sent home with a breathing exercise, several pelvic floor stretches, and a muscle strengthening exercise.
At the next session CT reports having decreased episodes of leaking and reduced pain in his pelvic area. During a follow up evaluation CT now has 3/5 pelvic strength and a decrease in muscle tension. The therapist manually releases his pelvic muscles and he is once again sent home with progressed pelvic floor strengthening exercises and stretches.
After a few more weeks and 2 or 3 more sessions CT is no longer leaking and feels no more pain and discomfort in his pelvic floor. He is educated to keep up with his exercise program occasionally to maintain strength and proper length of his pelvic floor.
Not all pelvic health issues will present the exact same, and as such there is no one-size fits all program that will work for everyone. Need help with your pelvic health complaint? Don’t hesitate to contact us or book an appointment. Not sure if your issues can be helped by a physiotherapist? Give us a call, or send a message, we are happy to help you sort through it.
Scott Golding is a Pelvic Health Physiotherapist that has a special interest in male pelvic health and rehabilitation. He is passionate about advocating and supporting men in their pelvic health journey. He has completed the U of S Level 1 and Pelvic Health Solutions courses for pelvic health Level 2, and 3 in addition to orthopedic and integration of pain science courses. He has been working with both women and men for pelvic health and orthopedic issues since graduating in 2016.
He is driven to provide excellent care in a safe and comfortable environment for his patients. Scott believes that pelvic floor health needs to be a fundamental aspect of a healthy life, as many individuals struggle in silence.
“My future goals include becoming a strong support and resource for men as it relates to pelvic, and general health. I want to help decrease and remove the stigma associated with male pelvic health and provide exceptional resources for men who need or are seeking help.”
Warman Physiotherapy & Wellness
105 Klassen Street
Warman, SK, Canada
2543 Dudley St
Saskatoon, SK, Canada
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