Functional Pelvic Floor Disorders: Concurrent Bowel and Bladder Symptoms

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We gastroenterologists find ourselves referring children with functional constipation to urologists for comorbid enuresis. Similarly, our urologists often send patients who have urinary incontinence without any congenital anomalies to gastrointestinal clinic for constipation and encopresis. In this issue of the Journal of Pediatric Gastroenterology and Nutrition, the article “Childhood Bladder and Bowel Dysfunction Questionnaire” reminds readers that functional urinary incontinence, constipation, and fecal incontinence frequently occur together in the same patient (1). A majority of children with lower urinary tract symptoms evaluated at a tertiary referral center fulfilled diagnostic criteria for a functional defecation disorder (2). Successful treatment of constipation resulted in improved day and nighttime urinary incontinence (3).
We congratulate the authors for identifying the need for simultaneous assessment of functional pelvic floor disorders to aid in accurate diagnosis and treatment. This is the first combined bowel and bladder questionnaire to be completed by caregivers of children 5 to 12 years of age. We hope that it will inspire efforts to streamline a therapeutic approach. Early diagnosis and treatment of functional constipation and enuresis is crucial to successful defecation and micturition remediation. The bladder and bowel dysfunction questionnaire will assist clinicians caring for children with these disorders, and should prompt early referral to specialists for a multidisciplinary approach. Indeed, it is an unstated conclusion that a team approach, including gastroenterologist, urologist, psychologist, and physiotherapist, may be the most efficient way to manage care for school-age children with dysfunctional voiding and defecation.
Acquisition of toileting skills depends on a child's ability to recognize parents’ approval for desirable behaviors, and enjoy a sense of pride and accomplishment. When incorrect behaviors provoke disapproval from parents, it threatens the child, and the child may lose confidence in the process of toilet learning (4). Sometimes parents blame and punish rather than praise and help children with toilet learning, resulting in poor outcomes (5). Functional disorders of elimination result from physical or emotional difficulties the child experiences, such as painful defecation or shame and guilt. In school-aged children defecation and micturition require a conscious decision to relax the pelvic floor muscles and simultaneously increase intra-abdominal pressure. Pelvic floor muscle contractions and relaxations are entirely under the school-aged child's control. Bowel and bladder dysfunction shares a common physiology: maladaptive use of pelvic floor muscles, the puborectalis and levator ani. Avoiding defecation or micturition requires a purposeful decision to increase pelvic floor muscle tone above resting pressures.
If constipation, retentive fecal incontinence, and urinary incontinence may arise from physical and/or emotional discomfort, then a multidisciplinary clinic incorporating physical and psychological evaluation and treatment possibilities makes sense. Treatment of pelvic floor dysfunction includes education for the child and parents about the causes for symptoms. It is important for clinicians to provide an expectation for symptom resolution and to instruct parents to help children rather than blame and punish. If the patient and family believe there will be symptom resolution, there is a greater chance for success (6). Treatment may include cognitive-behavioral training in those old enough to cooperate, with the goal of teaching children to use the conscious part of their brains to change maladaptive pelvic floor habits. Physiotherapists use biofeedback for pelvic floor retraining. Behavior modification includes advice for regular toilet sitting, and rewards for desirable behaviors.
There are many successful multidisciplinary clinics for complex problems. Examples of multidisciplinary clinics involving gastroenterologists include feeding teams (gastroenterologist, psychologist, speech or occupational therapist, dietician), aerodigestive teams (otolaryngologist, pulmonologist, gastroenterologist), functional pain clinics (gastroenterologist, psychologist, pain rehabilitation physician), and cystic fibrosis clinics (pulmonologist, gastroenterologist, dietician).

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