Potty Problems: Number 1

I'll try a slightly different format for this one--kind of like Dear Abby. This is a real letter to me from a friend and former mom in my practice, and my actual answer to her (we used facebook!). I changed names (other than mine) to protect the innocent. As always please remember that the purpose of this blog is to provide you with more information and insight into how I personally think about health and illness. I am not trying to personally diagnose or treat your child. For that you need to discuss the problem with your medical professional. Other sources of information on the web could include www.uptodate.com/patients, or childrenshealth.org.

Hey Stephanie

I wanted to pick your brain a little. I hope you don't mind but I really trust your care for little ones and miss you as the girls' doctor.

So, our little sweetheart is a big three old, 40 lbs, 42 inches. She is potty trained day and night but has a huge problem holding her potty. When she has to go, she has to go NOW or potty comes out, she cries that she can't hold it, etc. At her well child in May I brought it up but she tested clear for urine and blood sugar. Took her in again in August b-cuz it has gotten worse but again nothing wrong with her urine. The doc here says she is just big for age and her bladder has not caught up. What do you think? My mommy intuition is telling me there is something else going on.

Please let me know your thoughts. Wish we could come up to MI and see you. It is very hard having new doctors for my girls.

Thanks, Sweetheart's Mom


Hi Mom:
Interesting problem. And a tough one to sort out. What I can tell you is what is usually the problem in this situation, and what else to look for.

The bladder is designed to be in a relaxed (empty) state. So when it gets stretched it has the tendency to spasm a little and give you the urge to urinate. If it gets overstretched, the problem will be worse, and the person will wet. Good bladder habits involve emptying the bladder regularly, or the bladder will stay kind of stretched out and having little spasms at unpredictable times.

Commonly there is a point in potty training where a child wants to experiment a bit with how long they can "hold it." Certainly the desire to not interrupt play, or stubbornness about doing what mom or dad want can play a part in "holding." You know how that looks--the bottom is wiggling, feet are moving, sometimes the hand is holding the urine in--but the child says "but I don't have to go." Maturity involves the child knowing themselves and how long it takes to get to the bathroom as well as the bladder physically being able to handle a fuller state.

So when there is a problem like you describe it is BY FAR most commonly resolved with a behavioral approach. Small, immature bladder or not, the behavioral method is most likely to work and doing testing is hardly ever helpful. And, thankfully, there is physically RARELY anything wrong (and if there is, behavioral approaches are usually best!).

What I normally tell a parent in your situation is that you have to go back to potty training (but now it's RE-training). The bladder needs to be emptied at regular intervals. It will have a harder time producing spasms that way and make accidents less likely. At first, the intervals need to be close enough together to capture the accidents (keep her dry). Set a kitchen timer, or your digital watch for 60-90 minutes. When it beeps you tell Sweetheart that the timer says it's time to sit on the potty.

Initially you might say something like "Sweetheart, we are proud of you and you must be so proud of yourself when you go potty like a big girl, and keep your underpants dry. We think there is a way we can help you get even better at staying dry. The doctor said there is a special way you can do that and we want to tell you how that will work..."

You might need rewards at this stage (something little--a sticker, a cracker), or praise might be enough. Sitting on the potty might have to be timed, or enough distraction provided to get her to relax and actually urinate (read a short book, listen to a song, sing a little song). She might have to think about whether all the urine actually came out.

When this becomes successful in controlling accidents, you attempt to increase the intervals to a more normal level of frequency. That's what I call "potty manners." Potty manners are going potty at regular, convenient times in the day (Pick some of the following: when you get up in the morning, before meals--combine with handwashing before eating, or after a meal, before leaving the house, before or after a nap, as soon as you arrive at a large store where the bathrooms are inconveniently located, as soon as you get to a friends' house--so you know where the bathroom is, bedtime, before you go outside, before you leave in the car on a trip, when you stop for gas, etc.). The point of potty manners is to normalize going potty throughout the day so there is a good habit and little resistance, and to keep the bladder empty.

When you are working on potty manners, EVERYONE makes a show of doing it too. For example, "Sweetheart, it's time for everyone to go potty before lunch, do you want to go potty first, or should I go?

Pitfalls in potty retraining:
1. Letting your child know how important this is to YOU, and how disappointed YOU are when they don't succeed is a pitfall. If your child realizes how they can use this to manipulate you, you'll have a tough time. Bowel and bladder control are something your child should be proud of, for themselves, for growing up. You should be happy for her as she achieves control. ("You must be so happy that you stayed dry on your playdate!).
2. Offering big tangible rewards is a pitfall. The beautiful Halloween costume hanging in the bathroom that she can have if she stays dry all day will quickly become something unattainable to her, or something she decides (after looking at it all the time) that she doesn't really have to have. Potty rewards seem to work best if they are tiny tokens of success (stickers, sugarless gum, a cracker), OR if there is an element of surprise (the potty prize box has 4 or 5 little but exciting rewards in it, and at each success the child opens the box and gets to choose--the key is that after the child chooses, the parent exchanges out some of the items, so the child never knows what will be in the box).
3. Constipation is a pitfall. Being really constipated makes it hard to empty the bladder, so it's constantly partly full. The bladder stays stretched out and spasming off and on, and accidents keep happening. This situation can lead to bladder infections too--and if this is part of your problem, then you should go back to the pediatrician. Stools should be daily and soft in consistency. Stools should not be huge, plugging the toilet. Nor should they be round balls or dry logs with cracks in them.
4. Not being consistent is a pitfall. Training is the key word here.

So what if I am wrong? The big sign would be that you can't get her to be dry even if you reduce the intervals down to 45" to an hour (assuming she is compliant with going potty then). The amount of urine that comes out doesn't necessarily help decide anything. Sometimes the bladder will spasm and just produce a little squirt, and sometimes it releases it all. If it all just doesn't work, the next step would be back to the pediatrician with a discussion of all the effort you put in behaviorally--and consideration of limited testing (maybe just an ultrasound, to stay noninvasive) and possibly a urology referral. But this, again, is hardly ever necessary, and even at the urologist's office you might get similar advice.

I hope I'm not missing anything, since my advice has been somewhat generic--so let me know if there are important details that I haven't considered. Also--you didn't tell me what happens at night (pull-up?).

Would you mind if I used my answer to you on my blog? I'll take out all personal info from you--but I think this might be a good one to post for others since it comes up so often.

I miss you too! Nice to hear from you.

Stephanie

Stephanie
Thank you so much for getting back with me in regards to Sweetheart's potty problem.
We are going to do the re training like you suggested and hopefully it will get her back on track. She has been potty trained since the spring and still could use reinforcement for keeping dry and making it to the potty on time.
I took her diapers away at night about a month ago and she does good but I wake her up before I go to bed and she also wakes up 1-2 times to go. She has also had her share of night time accidents. I will start rewarding her for staying dry at night.
You absolutely can use the question for your blog! I truly appreciate your wisdom. Thanks a bunch.
Have a great long weekend.
Thanks
Sweetheart's Mom

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