The Other “P” in Potty Training
When teaching our children potty training we are usually talking about “pee pee, poo poo and potties”, but what about the pelvic floor? Oftentimes we associate the pelvic floor with adult related conditions, including pregnancy and post-partum, incontinence, prolapse, etc. However, potty-aged children have fully developed pelvic floors as well, and this complex group of muscles actually plays a huge role in your child learning to maintain day and night time continence of both urine and feces.
Keep reading to find out more!
What is the pelvic floor?
The pelvic floor is a complex structure made up of sixteen muscles that connect to four boney areas on the pelvis; it also includes the tendons and ligaments that support these muscles and bones.
The pelvic floor has various functions; in children the primary functions of the pelvic floor include:
Bowel and bladder control
Support for internal organs
Stability, as these are the muscles that comprise the distal end of the “core”
How the pelvic floor works for continence:
In a toilet trained child and adult, the pelvic floor works with the bladder muscle to control holding and release of urine.
Our bladder muscle, called the detrusor, fills with urine and sends our brain the signal or “urge” that we need to urinate. If it is not time to urinate, the brain tells the pelvic floor muscles that control the sphincters to remain closed to prevent leakage. When it is time to urinate, the brain tells the pelvic floor muscles that control the sphincter to relax to release urine, while the bladder muscle simultaneously contracts to push urine out of the bladder. We need this synchronous and well coordinated process of properly timed contraction and relaxation of the pelvic floor to maintain urinary and fecal continence throughout all of our daily activities.
When the pelvic floor muscles are weak and/or too tight, we see symptoms that include urinary leakage and/or accidents at day and/or night, constipation, and/or fecal incontinence. When pelvic floor dysfunction is present, sphincter coordination and control is impaired, thus causing either leakage or inadequate emptying of the bladder.
When the pelvic floor muscles are weak and/or too tight, we see symptoms that include urinary leakage and/or accidents at day and/or night, constipation, and/or fecal incontinence. When pelvic floor dysfunction is present, sphincter coordination and control is impaired, thus causing either leakage or inadequate emptying of the bladder.
Pelvic floor dysfunction occurs when the pelvic floor muscles are not able coordinate contracting and/or relaxing appropriately, thus resulting in symptoms such as chronic constipation, straining to defecate, overactive bladder, urinary or fecal accidents, incontinence, and, sometimes, pelvic pain.
Pelvic Floor Dysfunction in Children:
If your child experiences urinary or fecal incontinence and/or constipation, please know that they are not alone! Children, like adults, can experience pelvic floor dysfunction. It is actually quite common, even if not commonly discussed. According to data gathered by the National Institute of Diabetes and Digestive Kidney Diseases, at least 10% of children lack daytime bladder control (NNIDK, 2013), and 10-20% of children ages 5-7 experience nocturnal enuresis (nighttime bedwetting), (AAP). Additionally, at least 15-20% of pediatric gastroenterologist visits are for constipation. Pelvic floor issues that are overlooked or not addressed can lead to impacts on a child’s comfort and quality of life. It sometimes goes beyond basic potty training for a child to learn and maintain full continence, at which point the pelvic floor must be considered.
In children, pelvic floor dysfunction most commonly presents with one or more of the following symptoms:
Chronic constipation (< 3 bowel movements per week, straining)
Stool holding behavior / pain with defecation
Frequent urinary accidents or incontinence
Overactive bladder (urinating > 8x per day)
Pelvic pain
Pelvic Floor Physical Therapy:
If your child is experiencing any of the above symptoms, and they are at least 4 years old, it is recommended to consider pelvic floor physical therapy to help your child master continence or treat constipation. A pediatric pelvic floor physical therapist will work with you and your child to help improve their pelvic floor function, thus improving bowel and bladder function, as well as help improve their confidence in maintaining continence. It would be wise to seek a pelvic floor therapist that also specializes in treating children, as they can also identify and treat any gross motor delays that may be contributing to the pelvic floor dysfunction. Pelvic floor physical therapy (PFPT) has been shown to effectively treat pediatric constipation and overactive bladder, without invasive treatments or medications. Specifically for constipation, PFPT is effective for treating pediatric constipation and lowering the amount of hospitalization visits or colonic clean outs (Zar-Kessler, Kuo, et al 2019).
What to Expect:
Your child will first be evaluated by a pediatric pelvic floor physical therapist with their caregiver present. The examination will be external only, as internal exams are only completed in adult patients. The physical therapist and caregiver will together visually observe the integrity of the child’s skin, anal reflex, and external pelvic floor contraction to determine the type of pelvic floor dysfunction. A thorough medical and developmental history will also be taken, and any indicated strength and gross motor assessments may also be performed. You may be asked to keep a bowel, bladder, and nutrition diary for your child over 1-2 weeks prior to your first follow up. At follow up treatments, your physical therapist will teach your child how to appropriately relax and contract the pelvic floor muscles and eventually teach them to coordinate the timing of this relaxation and contraction needed for continence or managing constipation. Exercises to improve postural, core, and hip strength, as well as balance or gross motor skills may also be incorporated. If it is indicated, a treatment called biofeedback may also be utilized to help with coordination of proper pelvic floor relaxation and contraction. Biofeedback is a painless, external treatment that has been shown to be effective in managing overactive bladder (Shim, Oh, 2023). One of the most important factors for success with PFPT is adherence to the home exercise program. We know “practice makes perfect”, and repetition of the exercises at home or anywhere toileting will occur is vital for your child to meet their continence goals. Your pediatric PT will work with you to design a custom and comprehensive home exercise program for your child to fit their unique needs and work within your daily routines.
Next steps:
If you are ready to get started but want to try a few things on your own at home first, check out our pelvic floor and potty training package, available here. This comprehensive at home program, created by our pediatric physical and occupational therapists, is designed to help your child navigate proper body mechanics and breathing needed for proper voiding and defecation, with the pelvic floor in mind. It also includes tips, tricks, and videos demonstrating a few basic exercises to get started with. Here you can also find potty training tips and readiness strategies. While this is a great way to get started, please note that this package does not take the place of 1:1 pelvic floor physical therapy. If after 3 weeks of trying the at home package your child continues to experience symptoms, incontinence, or discomfort, then it is time to schedule with our pediatric pelvic floor physical therapist. Dr. Karli’s schedule can be accessed here!
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