Urinary and Fecal Incontinence: A Training Program for Children and Adolescents 1616764600, 9781616764609

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Monika Equit · Heike Sambach Justine Niemczyk · Alexander von Gontard

Urinaryand Fecal Incontinence A Training Program for Children and Adolescents

Urinary and Fecal Incontinence

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Urinary and Fecal Incontinence A Training Program for Children and Adolescents

Monika Equit

Heike Sambach

Justine Niemczyk

Alexander von Gontard

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Library of Congress Cataloging-in-Publication Data is available via the Library of Congress Marc Database National Library of Canada Cataloguing in Publication Data Library and Archives Canada Cataloguing in Publication Equit, Monika, 1978– [Ausscheidungsstörungen bei Kindern und Jugendlichen. English] Urinary and fecal incontinence: a training program for children and adolescents/Monika Equit, Heike Sambach, Justine Niemczyk, Alexander von Gontard. Translation of: Ausscheidungsstörungen bei Kindern und Jugendlichen. Includes bibliographical references. Issued in print and electronic formats. ISBN 978-0-88937-460-7 (pbk.), ISBN 978-1-61676-460-9 (pdf), ISBN 978-1-61334-460-6 (epub) 1. Urinary incontinence in children. 2. Urinary incontinence in children Treatment. 3. Fecal incontinence in children. 4. Fecal incontinence in children Treatment. I. Gontard, Alexander von, author. II. Sambach, Heike, author. III. Niemczyk, Justine, author. IV. Title. V. Title: Ausscheidungsstörungen bei Kindern und Jugendlichen. English 618.92’62 C2014-902523-8 RJ476.I6E6813 2014 C2014-902524-6 English translation prepared by Octavia Harrison with assistance of Alexander von Gontard, Monika Equit, and Justine Niemczyk. © 2015 by Hogrefe Publishing http://www.hogrefe.com PUBLISHING OFFICES USA: Hogrefe Publishing, 38 Chauncy Street, Suite 1002, Boston, MA 02111 Phone (866) 823-4726, Fax (617) 354-6875; E-mail [email protected] Hogrefe Publishing, Merkelstr. 3, 37085 Göttingen, Germany EUROPE: Phone +49 551 99950-0, Fax +49 551 99950-425; E-mail [email protected] SALES & DISTRIBUTION Hogrefe Publishing, Customer Services Department, 30 Amberwood Parkway, Ashland, OH 44805 USA: Phone (800) 228-3749, Fax (419) 281-6883; E-mail [email protected] Hogrefe Publishing c/o Marston Book Services Ltd, 160 Eastern Ave., Milton Park, Abingdon, OX14 4SB, UK: UK Phone +44 1235 465577, Fax +44 1235 465556; E-mail [email protected] Hogrefe Publishing, Merkelstr. 3, 37085 Göttingen, Germany EUROPE: Phone +49 551 99950-0, Fax +49 551 99950-425; E-mail [email protected] OTHER OFFICES CANADA: SWITZERLAND:

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This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Table of Contents Preface  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

vii

Introduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

1

1  Theoretical Background Chapter 1: Incontinence During Childhood and Adolescence  . . . . . . . . . . . . . . . . . . . . . . . . .  1.1 Nocturnal Enuresis  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.1.1 Definition and Classification  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.1.2 Subtypes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.1.3 Prevalence  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.1.4 Differential Diagnoses and Comorbid Disorders  . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.1.5 Etiology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.2 Daytime Urinary Incontinence  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.2.1 Definition and Classification  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.2.2 Subtypes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.2.3 Prevalence  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.2.4 Differential Diagnoses and Comorbid Disorders  . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.2.5 Comorbid Psychological Disorders  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.2.6 Etiology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.3 Fecal Incontinence (Encopresis)  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.3.1 Definition and Classification  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.3.2 Subtypes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.3.3 Prevalence  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.3.4 Differential Diagnoses and Comorbid Disorders  . . . . . . . . . . . . . . . . . . . . . . . . . . .  1.3.5 Etiology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

5 5 5 5 6 6 8 10 10 10 11 12 12 13 14 14 14 15 16 18

Chapter 2: Assessment  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2.1 Standard Diagnostic Assessment  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2.1.1 History  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2.1.2 Development and Family History  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2.1.3 The 48-Hour Bladder Diary  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2.1.4 Physical Examination  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2.1.5 Sonography/Urine Analysis  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2.2 Extended Assessment for Complex Elimination Disorders  . . . . . . . . . . . . . . . . . . . . . . . . .  2.2.1 Uroflowmetry  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2.2.2 Bacteriology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2.2.3 Further Pediatric and Urologic Diagnostic Steps  . . . . . . . . . . . . . . . . . . . . . . . . . . .  2.3 Psychological Tests  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

21 21 21 22 22 23 23 23 23 23 23 24

Chapter 3: Treatment of Incontinence  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3.1 General Treatment Principles  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3.2 Treatment of Fecal Incontinence  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

25 25 25

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3.3 Treatment of Daytime Urinary Incontinence  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3.3.1 Urge Incontinence  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3.3.2 Voiding Postponement  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3.3.3 Dysfunctional Voiding  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3.4 Treatment of Nocturnal Enuresis  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3.5 Urotherapy as a Treatment for Complex Elimination Disorders  . . . . . . . . . . . . . . . . . . . . . .  3.5.1 Definition  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3.5.2 Scientific Evidence  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

26 26 27 27 27 28 29 29

2  Therapy Manual Chapter 4: Description and Structure of the Manual  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4.1 Development of the Manual  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4.2 Formal Aspects of the Training  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4.3 Contents of the Sessions  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4.4 Including the Parents  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4.5 Application as Individual Training  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4.6 Application to Adolescents  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

33 33 34 35 36 36 37

Chapter 5: Conducting the Individual Sessions  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5.1 Bladder Training Session 1: Introduction, Defining Problems and Goals  . . . . . . . . . . . . . .  5.2 Bladder Training Session 2: Anatomy and Physiology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5.3 Bladder Training Session 3: Pathophysiology of Wetting and Coping With Stress  . . . . . . .  5.4 Bladder Training Session 4: Drinking  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5.5 Bladder Training Session 5: Going to the Toilet, Hygiene, and Constipation  . . . . . . . . . . .  5.6 Bladder Training Session 6: Emotions, Body and Bladder Perception  . . . . . . . . . . . . . . . . .  5.7 Bladder Training Session 7: Knowledge Check, Goal Analysis, Outlook  . . . . . . . . . . . . . .  5.8 Bowel Training Session 1: Problem and Goal Analysis, Pathophysiology of Fecal Incontinence  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5.9 Bowel Training Session 2: Diet and Exercise  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

39 39 46 50 55 59 63 67

Chapter 6: Evaluation of the Treatment  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6.1 Sample  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6.2 Method  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6.3 Results  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6.4 Conclusion  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.5 Final Remarks  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

79 79 79 80 81 82

References  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

83

Appendix  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

91

70 75

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Preface Elimination disorders are common and stressful disorders for children and adolescents. Additionally, they are often associated with comorbid psychological disorders. Elimination disorders include nocturnal enuresis (nighttime wetting), daytime urinary incontinence (functional urinary incontinence) and soiling (fecal incontinence or encopresis). With specific evidence-based treatment methods, most children and adolescents can be treated successfully. These standard treatments, described in detail by von Gontard and Nevéus (2006), should be applied first. But there is a group of children and adolescents who do not respond to standard treatment and do not achieve continence. Generally, these children are affected by complex elimination disorders. What does this term comprise?

ital factors. These chronically incontinent patients usually exhibit these problems from early age onwards into adolescence and even adulthood. In these cases, incontinence is often associated with psychological strain, low self-esteem, hopelessness, and resignation. Moreover, problematic familial interaction can impede the treatment. Parents often show higher treatment motivation than children. These problematic parent–child relationships can result in oppositional behavior of the children and in escalating conflicts. On the other hand, some parents think they have made mistakes in their childrearing; they feel responsible for their children’s incontinence and have feelings of guilt. Sometimes parents also see the incontinence as a deliberate provocation and react with punishment, which leads to further dysfunctional interactions.

On the one hand, these are children suffering from multiple elimination disorders (any combination of nocturnal enuresis, daytime urinary incontinence, fecal incontinence, and constipation). On the other hand, these children are often affected by comorbid psychological disorders: 20–30% of children with nocturnal enuresis, 20–40% of those with daytime urinary incontinence, and 30–50% of children with fecal incontinence have at least one other psychological disorder (von Gontard, Baeyens, van Hoecke, Warzak, & Bachmann, 2011). These include predominantly externalizing disorders as attention deficit hyperactivity disorder (ADHD) or conduct disorders. If these disorders remain unnoticed or untreated, the compliance of the children as well as the treatment success will be decreased (Crimmins, Rathburn, & Husman, 2003).

All these groups of children have in common that they are resistant to standard treatment. This is especially stressful for children but also for parents. Therapy resistance despite of correct treatment is perceived as a personal failure. This manual was developed for these children. The aim was to offer an efficient and structured treatment within a limited number of sessions. The aim is to encourage children to actively restart their treatment and not to give up. Parents and children show a high acceptance of this clear and manageable therapy program consisting of 7–9 afternoon sessions.

Furthermore, subgroups of children without obvious risk factors is also more difficult to treat and more likely to encounter a relapse or have continuous incontinence as was shown in population-based longitudinal studies (Heron, Joinson, Croudace, & von Gontard, 2008). These relapses and persistent trajectories with continuing incontinence might be due to genetic and other congen-

The treatment described in this manual can be conducted in an outpatient setting. Inpatient or day-care treatment is not necessary for most children with elimination disorders. This way, the children stay in their social environment and train their newly acquired skills at home. The group training is meant to motivate children and adolescents and to invigorate them for a new “round” of treatment. Additionally, new opportunities and perspectives can evolve. Thereby, children learn to take responsibility for their elimination disorders themselves and not to transfer it to their parents. Parents are informed and supported, but they

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Preface

are not the main recipients of the treatment. They do learn, however, to return the commitment and responsibility needed for therapeutic success to their children. Many different components are combined in the group training, e. g., provision of information, psychoeducation, relaxation and body perception techniques, changing dysfunctional cognitions, and other elements of cognitive behavioral therapy. Therefore, it is far more than a mere training. The group format offers considerable advantages. Children learn that problems with incontinence are more common than they have thought. They see other children as also being affected by incontinence or as suffering from even more severe disorders. They learn to modify their own subjective views. They develop new coping strategies together with the other children in the group training. To avoid feelings of shame and embarrassment, the groups should be homogeneous regarding age and gender. Some of the training components have been adapted to the treatment of adolescents. If group training is not possible due to organizational or other reasons, the components can be offered in individual sessions as well. In individual treatment, a selection of components of the training can suffice. This manual has been developed over the course of many years at the specialized outpatient department for elimination disorders at Saarland University Hospital, Germany (Department of Child and Adolescent Psychiatry and Psychotherapy). Heike Sambach, a pediatric nurse and urotherapist, became aware of the need for special group training for children with therapy resistance. With great in-

novation, passion to experiment, and dedication she laid the foundation for this manual. In mutual cooperation, our group of authors further developed and completed the manual, which is therefore the result of creative teamwork. The manual is aimed at pediatricians, specialists of child and adolescent psychiatry, psychologists, nurses, urotherapists, and all other professionals treating children and adolescents with elimination disorders. The training program was designed to be of fun for the children (as well as the therapists). It should, therefore, be carried out in a relaxed and humorous way. The components of this manual are designed to be appealing and attractive for children and adolescents. We would like to express our gratitude to all the children, adolescents, and parents who gave us many insights over the years – and still do so every day. We wish to thank the editors of the Hogrefe publishing company, who responded very positively to our proposal of creating this manual and have assisted us throughout the whole process. Our thanks also go to Dr. Manfred Vogtmeier, Ms. Alice Velivassis, Mr. Robert Dimbleby, Ms. Juliane Munson, and our translator Octavia Harrison. We would be very pleased if our approaches were integrated extensively in all settings treating incontinent children and adolescents. June 2014

Monika Equit Heike Sambach Justine Niemczyk Alexander von Gontard

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Introduction Nocturnal wetting (nocturnal enuresis), daytime wetting (functional urinary incontinence), and fecal incontinence (encopresis) are categorized as elimination disorders. Elimination disorders are heterogeneous in their clinical signs and symptoms, i. e., many different kinds and subtypes can be distinguished. They are also heterogeneous with regard to their etiology. On the one hand, genetic factors can predominate (as in nocturnal enuresis). On the other hand, environmental factors can be more important (as in voiding postponement). And finally, they differ regarding type of treatment – in order to be effective, therapy has to be specific to each type of incontinence, which requires an exact diagnosis. In contrast to many other disorders in child and adolescent psychiatry and psychotherapy, elimination disorders can be treated quite effectively, resulting in high success rates. Most elimination disorders are functional in their pathogenesis, i. e., not caused by organic factors. Although psychological disorders can co-occur, the etiology of elimination disorders is not mainly psychogenic, as previously assumed, i. e., they are not due to intrapsychological or interpersonal conflicts and stressors. They are caused by a multivariate etiology with genetic dispositions, which are modulated by environmental factors. The aim of the treatment is always the achievement of continence, i. e., becoming completely dry or free from soiling. If children and adolescents become continent, there will be an improvement of psychological distress, self-esteem, and even behavioral symptoms. In order to attain this goal, simple but specific symptom-oriented treatment approaches are the most successful. These include counseling and components of cognitive behavioral therapy. When indicated, they can be combined with pharmacotherapy. Neither surgical interventions nor longterm psychotherapy are needed in most cases.

­ nother advantage is that in almost all cases outA patient therapy is possible – inpatient or day-care treatments are usually not necessary. According to our experience, they are needed only in exceptional cases and are mostly indicated by comorbid psychological disorders but not by elimination disorders themselves. In summary, with exact diagnosis and specific therapy most incontinent children and adolescents can be treated well in an individual outpatient setting combined with parental counseling. Elimination ­disorders treated that way can be considered “simple” disorders. Standard treatments for these uncomplicated disorders are described in detail in von Gontard and Nevéus (2006) and in von Gontard (2012a, 2012b). At our specialized outpatient clinic, we can witness every day that incontinence can be treated successfully through short and specific interventions – much to the relief of children and their parents. Unfortunately, in some children and adolescents treatment is not so successful. Despite optimal diagnosis and specific therapy, they will not respond to standard treatments. These are so-called complex elimination disorders. The program presented in this manual is aimed at children and adolescents who do not respond adequately to standard treatment. Besides therapy resistance, these complex elimination disorders are often characterized by comorbidities, i. e., they often coexist with other psychological disorders. These difficult-to-treat children and adolescents have often been neglected in the past because their treatment resistance sometimes leads to feelings of frustration and incompetence in therapists and doctors. Sometimes unnecessary and ineffective treatments, such as inpatient treatment, nonindicated medication, or a pause in therapy are suggested. This manual makes new therapy options available. It presents new topics and introduces a group for-

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2

Introduction

mat for therapy. The group setting gives children the opportunity to a step out of their isolation and to share their experiences with others. The following structure was chosen for this manual: The first part gives a short overview of the current state of research on elimination disorders. For even more detailed information, readers are referred to the literature on standard therapy (von Gontard & Nevéus, 2006; von Gontard, 2012a, 2012b). The second part is dedicated to the description of the group therapy itself. Following general informa-

tion on indication and procedures, every session is described in detail in a practical and clinically relevant way. There are 7 bladder training sessions for children with enuresis and urinary incontinence and 2 additional bowel training sessions for children with fecal incontinence (encopresis) and/ or constipation. The materials for the group therapy can be printed out (see Appendix).

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1  Theoretical Background

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

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Chapter 1

Incontinence During Childhood and Adolescence 1.1

Nocturnal Enuresis

1.1.1

Definition and Classification

According to both classification systems ICD-10 (WHO, 1993) and DSM-5 (APA, 2013), enuresis is defined as an involuntary voiding of urine in inappropriate places from the age of 5  years onwards after ruling out organic causes. According to the diagnostic criteria of ICD-10, wetting occurs at least either twice a month (age 5–7) or once a month (age > 7) for at least 3 consecutive months. According to DSM-5, wetting occurs twice a week or leads to social incapacitation for at least 3 consecutive months. According to the classification of the International Children’s Continence Society (ICCS), which is the gold standard in national and international research, enuresis (or nocturnal enuresis) is defined as any kind of wetting in discrete amounts while asleep (i. e., also during daytime naps) – independent of possible comorbid symptoms or assumed causes (Austin et al., 2014; Nevéus et al., 2006).

A minimum age of 5 years, a duration of 3 months, and a frequency of once per month is also required (Austin et al., 2014). 1.1.2 Subtypes

Nocturnal enuresis can be divided into different subtypes (Austin et al., 2014; Nevéus et al., 2006). See Table 1. Primary nocturnal enuresis (PNE) denotes nocturnal incontinence in children who have never been dry for more than 6 months. Two subtypes can be differentiated: 1. Primary monosymptomatic nocturnal enuresis (PMNE) refers to nocturnal incontinence without a dry interval longer than 6 months and no lower urinary tract symptoms, e. g., daytime incontinence, urgency, voiding postponement, or interrupted flow (see Section  1.2). Children with this type of nocturnal enuresis often wet large amounts of urine and are very difficult to wake up. During the day, no lower urinary

Table 1 Subtypes of nocturnal enuresis (according to von Gontard & Nevéus, 2006) Maximum dry interval  6 months

Primary nocturnal enuresis (PNE)

Secondary nocturnal enuresis (SNE)

No signs of bladder dysfunction during daytime

Primary monosymptomatic nocturnal enuresis (PMNE)

Secondary monosymptomatic nocturnal enuresis (SMNE)

Signs of bladder dysfunction during the day present*

Primary non-monosymptomatic nocturnal enuresis (PNMNE)

Secondary non-monosymptomatic nocturnal enuresis (SNMNE)

*  Daytime incontinence, urgency, holding maneuvers, interrupted flow, etc.

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6

Chapter 1

tract abnormalities exist. The micturition frequency is normal (4–7 times a day) and the amount of urine during daytime is appropriate for age. No urgency is present; the children do not show holding maneuvers, they can empty their bladder without any problems, and they do not soil. 2. Primary non-monosymptomatic nocturnal enuresis (PNMNE) refers to nocturnal incontinence without a dry interval longer than 6 months with disturbances of bladder function. For instance, these children can show urgency, voiding postponement, or interrupted flow. Children with secondary nocturnal enuresis wet during the night after a dry period of at least 6 months. Again, two subtypes are differentiated: 1. Secondary monosymptomatic nocturnal enuresis (SMNE) is defined as nocturnal incontinence after a dry period of at least 6 months without any signs of bladder dysfunction. 2. Secondary non-monosymptomatic nocturnal enuresis (SNMNE) describes nocturnal incontinence after a dry period of at least 6 months with signs of bladder dysfunction – as in PNMNE. The differentiation between monosymptomatic and non-monosymptomatic is more relevant for treatment. Disturbances of bladder function have to be treated first. Treatment is the same in primary as in secondary types. However, children with secondary nocturnal enuresis have a higher risk for comorbid psychological disorders, which, if necessary, have to be treated in addition to the incontinence. 1.1.3 Prevalence

Nocturnal enuresis occurs 2–3 more often than daytime urinary incontinence. The sex ratio is 1.5:1 to 2:1 (boys to girls). Depending on definition, prevalence rates are 43.2% in 3-year-old children and 20.2% in 4-year-old children. However, enuresis is not a formal diagnosis at this age (not until age  5 according to ICD-10, DSM-5, and ICCS). Of 5-year-old children, 15.7% are affected, of the 6-year-olds 13.1%. The prevalence rate decreases to 2.5% in children between 7 and 10 years of age. In adolescence, 1–2% still wet during the night and in adulthood 0.3–1.7%. Here the high

rate of spontaneous remission of nocturnal enuresis of approximately 13% per year becomes apparent (Hellström, Hanson, Hansson, Hjälmås, & Jodal, 1990; von Gontard & Nevéus, 2006). According to the large epidemiological Avon Longitudinal Study of Parent and Children (ALSPAC, Golding, Pembrey, & Jones, 2001), at the age of 7 ½ years 15.5% (of 8,269 children) wet during the night (Butler, Golding, Northstone, & ALSPAC Team, 2005). Most of these children wet approximately once a week (82.9%). According to DSM-IV, 2.6% fulfilled the criteria for nocturnal enuresis, thus wetted at least twice a week. In their study of 2,856 children with a mean age of 7.3  years, Sureshkumar and colleagues (2009) found a prevalence rate for nocturnal enuresis of 18.2%. Of these children, 12.6% had nocturnal enuresis with a frequency of 1–6 times per month, 3.6% of them wet every night. In an epidemiological study by two of the authors with 2,079 preschoolers (mean age of 6 years), a prevalence rate of 9.5% for nocturnal enuresis was found (Equit, Klein, Braun-Bither, Gräber, & von Gontard, 2013). Of these children, 2.7% wetted during the day at least once a month. In another population-based study of 1,391 6-year-old children, 13.4% showed daytime or nighttime wetting: 9.1% wetted at night and 4.4% during the day (von Gontard, Moritz, Thome-Granz, & Freitag, 2011). In general, PNE occurs more often than SNE, but until the age of 7, SNE appears as often as PNE (5.2%; Fergusson, Horwood, & Shannon, 1986). SNE occurs the most often at the age of 7 (5.1%). Further epidemiological studies show that monosymptomatic nocturnal enuresis (MNE) occurs twice as often (68.5%) as non-monosymptomatic nocturnal enuresis (NMNE, 31.5%; Butler, Heron, & ALSPAC Team, 2006). 1.1.4

Differential Diagnoses and Comorbid Disorders

1.1.4.1 Psychological Differential Diagnoses

Many children wet during the night without any psychological disorder. If additional psychological disorders exist, they are classified separately.

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Incontinence During Childhood and Adolescence Therefore, in general, the focus is more on identifying possible comorbid disorders. These should be diagnosed and treated in addition to the incontinence (see Section 1.1.4.2) – not on a differential diagnosis per se. However, the same possible organic causes as in daytime urinary incontinence have to be ruled out (see Section 1.2.4). 1.1.4.2 Comorbid Psychological Disorders

Children with incontinence often have high psychological stress and reduced self-esteem. Subjective distress, however, is often a consequence of incontinence and improves with successful treatment of incontinence (Hägglöf, Andren, Bergström, Marklund, & Wendelius, 1996). These subclinical symptoms usually do not need additional treatment. Manifest psychological comorbid disorders, however, should not be overlooked. Epidemiological studies have shown increased rates of 20–40% of psychological comorbidities in incontinent children (von Gontard, Baeyens, et al., 2011). Higher rates of up to 70% can be found in selected clinical populations, especially in children and adolescents referred to psychiatric clinics. In one clinical study, 40% of all children with nocturnal enuresis or daytime urinary incontinence had at least one further psychiatric diagnosis according to ICD-10 (von Gontard, Plück, Berner, & Lehmkuhl, 1999). Van Hoecke and colleagues (2006) compared children with nocturnal enuresis with nonwetting children and found significantly higher values for the incontinent children concerning externalizing and internalizing behavior as measured with the Child Behavior Checklist (CBCL; Achenbach, 1991). Furthermore, the total score of psychological symptoms as well as the subscale attention problems were increased for these children. In the ALSPAC, Joinson and colleagues (2007) examined frequencies of psychological problems in children with nocturnal enuresis, in children with combined daytime and nighttime wetting, and in continent children. There were significant differences in parental reports of psychological symptoms (such as anxiety, depressive symptoms, attention and behavioral disorders) between the three groups with a higher risk for wetting children. Moreover, children with combined wetting

7

had a higher risk of externalizing behavior problems compared to children with nocturnal enuresis only. In an epidemiological study of 2,079 preschool children, associations between nocturnal enuresis and anxious and depressive symptoms could be shown (Equit, Klein, et al., 2013). Of the children with nocturnal enuresis 17.8% were affected by clinically relevant anxious and depressive symptoms compared to 12% of the continent children. No significant differences, however, were shown between children with daytime urinary incontinence and continent children. The most common comorbid disorder of nocturnal enuresis is the attention deficit hyperactivity disorder (ADHD). Of the children with ADHD 20.9% also wet at night (Robson, Jackson, Blackhurst, & Leung, 1997). In contrast, in an epidemiological study with 1,136 children between 8 and–11 years old, 12.5% of the children with nocturnal enuresis additionally fulfilled the criteria for ADHD in comparison to only 3.6% of children without nocturnal enuresis (Shreeram, He, Kalaydjian, Brothers, & Merikangas, 2009). Comparably high prevalence rates of 10% in children with ADHD combined with nocturnal enuresis in primary care and up to 30% in tertiary care are described by Baeyens, Roeyers, D’Hase, and colleagues (2006). In a population-based study by von Gontard, Moritz, and colleagues (2011), the association between nocturnal enuresis and ADHD symptoms was analyzed. Nocturnal enuresis did not represent a risk factor for ADHD symptoms if other factors, such as developmental problems and psychosocial risk factors (e. g., divorce of parents), were controlled for. Children with nocturnal enuresis and ADHD are more difficult to treat, show lower compliance, and have lower success rates in therapies that ­require compliance. For instance, children with ADHD more often refuse to get up at night during alarm treatment than children with nocturnal enuresis without ADHD (Baeyens, Roeyers, Demeyere, et al., 2005; Crimmins et al., 2003). In a study by von Gontard, Plück, and colleagues (1999), the rate of comorbid disorders with PNE was 20%. Children who only wet at night without

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Chapter 1

symptoms of bladder dysfunction showed a very low rate (10%) of comorbid psychological disorders. Children with MNE were thus not more disturbed than nonwetting children. In children with signs of bladder dysfunction, such as urgency, the rate of psychological disorders was increased. Similar results have been published by Zink, Freitag, & von Gontard (2008), who examined 166 children between 5 and 16 years of age with daytime urinary incontinence and/or nocturnal enuresis. Overall, the rate of externalizing behavior problems was twice as high as the rate of internalizing symptoms. Children with daytime urinary incontinence showed significantly more externalizing behavior problems as well as comorbid psychological disorders than children with nocturnal enuresis only. Children with MNE had the lowest comorbidity. Children, who had been dry before and have relapsed, had a much higher risk for comorbid disorders. In one study, the rate of ICD-10 diagnoses was about 75% in children with secondary nocturnal enuresis (von Gontard, Plück, et al., 1999). These children especially need further assessment and therapy in addition to the treatment of nocturnal enuresis. Furthermore, many clinical and epidemiological studies indicate that the rate of stressful life events is significantly increased in children with SNE, particularly preceding the relapse. Parental separation/divorce was described as an especially stressful event in the life of children (Järvelin, Moilanen, Vikeväninen-Tervonen, & Huttunen, 1990). 1.1.5 Etiology 1.1.5.1 Genetics

Nocturnal enuresis can be considered a genetically determined maturation disorder of the central nervous system. The genetic predisposition is the same in primary and secondary enuresis. Genetics can be regarded as the most important etiological factor for the development of nocturnal enuresis, which has been shown by formal as well as molecular genetic analyses (von Gontard, Schaumburg, Hollmann, Eiberg, & Rittig, 2001). Empirical family studies show that 60–80% of all children with nocturnal enuresis have relatives with wetting problems. The prevalence of enure-

sis in children is 44% if one parent was affected and 77% if both parents were affected (Bakwin, 1961, 1973). In epidemiological studies, a positive family history was described as the most important etiological factor of enuresis. The attainment of dryness was delayed by 1.5 years if at least two first-degree relatives had wetted. Furthermore, children have a 3–4 time higher risk for relapse if they attain dryness after age 5 (Fergusson et al., 1986). The risk of nocturnal enuresis increases 5–7 times for 7-year-old children and 11.3 times if one parent or both have a history of enuresis (Järvelin, Vikevärnen-Tervonen, Moilanen, & Huttunen, 1988). Twin studies compared concordance rates of monoand dizygotic twins and showed significantly higher rates for monozygotic (46–68%) compared to dizygotic twins (19–36%) (Bakwin, 1973). Segregation analyses showed an autosomal dominant mode of inheritance with reduced penetration of 90% in 44% of the cases. This means that only one parent with possible enuresis genes would be sufficient to induce enuresis in a child (dominant inheritance; Arnell et al., 1997). Reduced penetration means that if the relevant gene exists, only 90% actually develop enuresis. In contrast, in only one third of the cases enuresis develops sporadically, i. e., no relatives are incontinent or have been affected by wetting. Linkage studies have identified different ‘loci’ on chromosomes 4, 8, 12, 13, and 22, on which possible genes for nocturnal enuresis could be localized (von Gontard, Schaumburg, et al., 2001). Thus, nocturnal enuresis is a predominantly genetic disorder influenced by environmental factors. The environmental impact is less in PNE as genetic factors lead directly to wetting (delay in getting dry). Children with SNE have an increased genetic disposition for relapse, which is activated by environmental conditions, e. g., stressful life events or psychological disorders. 1.1.5.2 Neurobiological Results

Neurobiological findings are comparable in PNE and SNE. Unspecific signs for involvement of the central nervous system are lower birth weight,

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Incontinence During Childhood and Adolescence lower body length, and delayed bone age. In one third of all children fine neurologic coordination disorders (soft-signs) were found that additionally emphasize the involvement of the central nervous system. Children with nocturnal enuresis show slower motor performance (von Gontard, Freitag, Seifen, Prukop, & Röhling, 2006) and exhibit a slightly higher rate of abnormalities in early acoustic evoked potentials (Freitag, Seifen, Pukrop, & von Gontard, 2006). In sleep studies with EEG monitoring, children with nocturnal enuresis revealed no abnormalities. Wetting is not an equivalent of dreaming, as wetting rarely occurs in rapid eye movement (REM) phases. Instead, wetting is independent of sleep stage and occurs in every non-REM phase (nondreaming phase). However, the majority of wetting episodes occur in the first third of the night (Nevéus, Läckgren, et al., 2000). Neurobiological factors of nocturnal enuresis are not located in the cerebral cortex, as measured by EEG, but in deeper brain structures. A full bladder can lead to wetting during the night if the micturition reflex is not inhibited (Nevéus, Läckgren, et al., 2000). This function, i. e., the inhibition of the micturition reflex, is mediated by the pontine micturition center in the brainstem. Additionally, wetting occurs when sensations of the full bladder are not registered and do not lead to arousal, which is regulated by the locus coeruleus. Both structures are anatomically close and functionally connected. Many parents of children with nocturnal enuresis report difficulties in waking their children up, which could be demonstrated in standardized waking trials. Wolfish, Pivik, & Busby (1997) showed that only 9% of enuretic children could be woken up by acoustic stimuli of up to 120 decibel. 1.1.5.3 Neuroendocrinological Results

Many children with PNE or SNE have increased urine production (polyuria) during the night as well as a shift of the circadian day-night rhythm of the antidiuretic hormone (ADH). Due to increased production of urine, the capacity of the bladder can be exceeded so that wetting results if the children do not awake (Nevéus, Läckgren,

9

et al., 2000). The amount of urine is regulated by ADH leading to a decreased production of urine. Usually, during daytime less ADH is secreted so that more urine is produced. During the night, ADH secretion increases, whereby less and more concentrated urine is produced. For some children with nocturnal enuresis, ADH secretion is the same during night and day (i. e., leading to nocturnal polyuria). Therefore, changes of the daynight rhythm can be associated with nocturnal enuresis (Norgaard, Pedersen, & Djurhuus, 1985; Rittig, Knudsen, Norgaard, Pedersen, & Djurhuus, 1989). These ADH hypotheses of enuresis do not apply to all children as many wetting children do not have polyuria. Other children are dry during the night despite polyuria because they wake up and go to the toilet. Furthermore, polyuria does not explain why children do not wake up during the night or do not suppress the micturition reflex (Hunsballe et al., 1995; Mattson, 1994; Nevéus, 2011). In summary, polyuria does indeed increase the risk of nocturnal enuresis, but it is not the main cause. Arousal difficulty or the lacking suppression of the micturition reflex are also needed to explain the pathophysiology of nocturnal enuresis. Polyuria and variations of ADH can therefore be considered additional aspects of general maturation delay of the central nervous system. 1.1.5.4 Psychosocial Factors

Two longitudinal Swiss studies of the 1950s and 1960s showed that potty training does not have an impact on becoming dry during the night. In the 1950s, 96% of all parents began potty training before their child reached the age of 1 year; in the 1970s training shifted to the median age of 19–21 months due to different child-rearing practices and the availability of disposable diapers. However, these differences did not have an impact on becoming dry during the night (Bloom, Seeley, Ritchey, & McGuire, 1993; Largo, Molinari, von Siebenthal, & Wolfensberger, 1996). In a longitudinal study of more than 8,000 children, Joinson et al. (2009) could demonstrate that children who began potty training at the age of two took longer to get dry during the day and had more relapses in bladder control during the day compared to chil-

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dren who began potty training with 15–24 months of age. However, no differences were found between these groups concerning the age of continence at night.

stressful life events, such as a separation or divorce, in the environment of 19% of the children (von Gontard, Plück, et al., 1999).

Psychosocial risks (e. g., stressful life events, existing psychiatric disorders) can trigger a relapse. Enuresis can lead to high psychological stress and decrease self-esteem. After successful therapy, subclinical psychological signs decrease. However, problems in self-esteem can reinforce already existent psychological disorders. Also, psychosocial risks and wetting can coexist without any causal relation, i. e., by chance. In a study by Sureshkumar and colleagues (2009) of 2,856 Australian children, associations were demonstrated between the existence of emotional stressors and mild nocturnal enuresis.

1.2

Daytime Urinary Incontinence

1.2.1

Definition and Classification

Children with PMNE do not exhibit a highly increased rate of psychological disorders or psychosocial risk factors. These results support the predominantly genetic-biologic etiology of PMNE. For children with PNMNE, emotional and behavioral symptoms are more common compared to healthy children or children with PMNE, however, these symptoms are less common than in children with daytime urinary incontinence (Zink et  al., 2008). Butler and colleagues (2006) compared children with MNE and NMNE in respect to abnormalities in micturition, voiding frequency, etc., but also in respect to psychological variables such as social anxiety, general anxiety, unhappiness/depression, and ADHD. Although the rates of psychological disturbances were higher in the group of children with NMNE, no statistically significant differences could be shown. The rate of stressful life events and preceding psychiatric disorders is increased in children with SNE and can function as a trigger for relapse. There are two main peaks for relapse: in infancy (2–3 years) and at preschool age (5–6 years). The most important life event was the separation or divorce of the parents (Järvelin et al., 1990). Fergusson and colleagues (1990) demonstrated that the risk for SNE was increased in children who were exposed to four or more stressful life events in a year. In one study, 75% of children with secondary enuresis had a comorbid psychological disorder. Additionally, 62% of the parents reported

According to the recommendation of the International Children’s Continence Society (ICCS), the term functional daytime urinary incontinence (or daytime incontinence) should be used for children who wet during the day after ruling out organic causes (Nevéus et al., 2006; Austin et al., 2014). This implies that a disorder of the bladder function is present resulting in involuntary passing of urine at an inappropriate place and time. Organic (i. e., not functional) urinary incontinence can be caused, for instance, by malformation (structural) or a disorder of bladder innervation (neurogenic). The term functional implies that no organic bladder dysfunction exists. Additionally, a duration of 3 months, a frequency of once per month, and a minimum age of 5 years is required for a diagnosis (Austin et al., 2014). 1.2.2 Subtypes

In functional daytime urinary incontinence, three common and several rare types can be differentiated. First we will describe the three common types urge incontinence, voiding postponement, and dysfunctional voiding: 1. Urinary incontinence with urgency is described as urge incontinence (overactive bladder). In most cases, it is due to genetic factors with an inherent dysfunction of the filling phase of the bladder. The bladder contracts spontaneously during the filling phase, which often leads to urgency and frequent micturitions (up to 20 times a day) with small amounts of urine. These contractions are not adequately inhibited by the central nervous system. The children try to suppress the urge by using holding maneuvers (e. g., pressing legs together, sitting on the heel, etc.). 2. Urinary incontinence in voiding postponement is an acquired disorder. It is characterized by postponing micturition habitually, so that wet-

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Incontinence During Childhood and Adolescence ting during daytime occurs despite holding maneuvers. The most important sign for this type is infrequent micturitions (less than 5 times a day). Children postpone micturition in typical situations, e. g., at school, during play, or while watching TV. The longer the voiding postponement persists, the stronger the urgency gets. These children use similar holding maneuvers as those with urge incontinence. Finally, when micturition cannot be postponed any longer, wetting occurs. 3. Dysfunctional voiding is defined by a lack of relaxation and paradox contraction of the urethral sphincter during micturition (i. e., it is a disorder of the emptying phase). It is an acquired coordinative dysfunction between detrusor and sphincter. The sphincter contracts during micturition instead of relaxing. The detrusor, therefore, pushes against the activated sphincter in order to achieve emptying. Children with dysfunctional voiding cannot urinate spontaneously. They need to strain to initiate micturition. As a result, the stream of urine is interrupted. When these main symptoms occur (straining, interrupted voiding), further assessment with uroflowmetry and EMG is indicated, as the risk of medical complications is the highest in this type of daytime urinary incontinence (Chase, Austin, Hoebeke, & McKenna, 2010). Rare types of daytime urinary incontinence include: 1. Stress incontinence is characterized by urine leakage during an increase of intra-abdominal pressure, e. g., when coughing or sneezing. Stress incontinence is rare in childhood but typical in adult women. The amounts of urine leakage are usually small. 2. Giggle incontinence is characterized by complete bladder emptying while laughing. The amounts of urine are very large. This disorder is inherited. 3. Underactive bladder (formerly lazy bladder syndrome) represents a rare type of daytime urinary incontinence. The detrusor is decompensated so that the bladder cannot spontaneously be emptied completely and high volumes of residual urine remain. Micturition is interrupted and abdominal pressure is needed to achieve bladder emptying. 4. Vaginal reflux is a rare subtype in girls.

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1.2.3 Prevalence

The prevalence rates of different subtypes of daytime urinary incontinence have not been studied in detail. The gender ratio is relatively balanced (1.5:1 for girls to boys). Sixteen percent to 47% of 3-year-old children and 2–12% of 4-year-old children wet during daytime, i. e., before the definitional age of the disorder. With increasing age, 25% of 5-year-olds, 2.9% of 6-year-olds, 3.6% of 7-year-olds, 4.0% of 8-year-olds, 3.0% of 10-yearold children, and less than 1% of adolescents are affected. The rate of daytime urinary incontinence increases in late adulthood, 12–18% of the 25– 64-year-olds wet and 9–23% of the over 65-yearolds (von Gontard & Nevéus, 2006). One epidemiological study showed a prevalence rate of 7.7% of daytime urinary incontinence in 7.5-year-old children (Joinson, Heron, von Gontard & the ALSPAC team, 2006). In the same ALSPAC with 10,819 children, the prevalence rate of daytime urinary incontinence for the age of 4.5 years was about 15.5% and decreased to 4.9% at the age of 9.5 years (Swithinbank, Heron, von Gontard, & Abrams, 2010). In the same ALSPAC, Heron and colleagues (2008) identified four trajectories of daytime wetting. Of all children 86% attained bladder control during daytime already at the age of 4.5 years and did not wet in later years. In 6.9% of the children, the attainment of bladder control during daytime was delayed. They still wetted at the age of 4.5 years. Wetting, however, decreased successively and disappeared at the age of 9.5  years. Daytime wetting persisted in 3.7% until the age of 9.5 years. Finally, 3.2% of the children experienced a relapse at the age of 6.5 years after a period of continence. Both of the latter trajectories are clinically relevant (i. e., the continuous wetters and the relapsers) – these children need special therapeutic attention. Sureshkumar and colleagues (2000) reported prevalence rates of 16.9% of daytime urinary incontinence in 7.3-year-old Australian children. According an epidemiological study of one of the authors and colleagues, 4.4% of 6-year-old preschoolers wet during daytime (von Gontard, Moritz, et al., 2011). There are hardly any prevalence rates available for the subtypes of daytime urinary incontinence. Urge

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incontinence occurs most often in girls. Voiding postponement is as common as urge incontinence, and in clinical studies more boys than girls are ­affected. Based on ALSPAC data, von Gontard, Heron, & Joinson (2009) analyzed the associations of daytime wetting and voiding frequency. The children’s median of age was 77 months. Of the 8,475 examined children, 10.4% still wetted during daytime. Of these children 35.7% went to the toilet less than 5 times per day (voiding postponement), 61.5% had 5–9 micturitions a day, and 2.8% went to the toilet 10 times or more per day (urgency). Prevalence rates for dysfunctional voiding range from 4.2–31% in clinical samples, however, no population-based dates exist (Hjälmås, 1995; H ­ oang-Böhm, Jüneman, Köhrmann, Zendler, & Alken, 1999; Hoebeke, van Laecke, van Camp, Raes, & Vande Walle, 2001). 1.2.4

Differential Diagnoses and Comorbid Disorders

Children with daytime urinary incontinence have higher rates of somatic disorders than children with nocturnal enuresis only. Therefore, the assessment and treatment of the underlying organic disorder is necessary. It is especially important to avoid lasting kidney damage from recurring infections of the lower urinary tract. The following causes of urinary incontinence can be differentiated: • structural (i. e., malformation and abnormalities of the urinary tract); • neurogenic (i. e., dysfunction of the innervation of the bladder); and • other physical diseases (i. e., diseases which result in an increased urine production, such as diabetes insipidus or mellitus, or urinary tract infections). In structural urinary incontinence malformations of the urinary tract exist, which require urological or surgical assessment. Malformations include those of the kidneys (renal agenesis: the complete missing of a kidney; double kidneys, renal pelvis distension) or malformations of the ureter (e. g., megaureter – enlarged ureter).

Vesicoureteral reflux (VUR, urine flowing back from the bladder through the ureter up to the kidneys) is a common differential diagnosis which can also be caused by increased bladder pressure (as in voiding postponement or dysfunctional voiding). In severe types of VUR, the renal pelvis is involved. In mild types, urinary tract infections can occur. VUR must always be assessed radiographically and should be referred to pediatric urologists or nephrologists. Mild types are treated conservatively with an antibiotic prophylaxis (long-term antibiotics), severe types often require surgery. The urethra can be affected by malformations such as posterior urethral valves, but a stenosis of the urethra has to be considered as well. Furthermore, abnormal outlets of the urethra have to be excluded in boys (hypospadias, epispadias). In neurogenic urinary incontinence the innervation of the bladder is disturbed (e. g., in spina bifida occulta). Individuals with spina bifida, a malformation of the vertebral arches, can show neural deficits of the lower extremities as well as of the bladder. Other rare neurogenic causes of incontinence are the tethered cord syndrome and tumors of the spinal cord. Therefore, the spine, asymmetries of the buttocks and lower extremities, reflex differences, and sensitivity deficits of the lower extremities should always be examined thoroughly. Urinary incontinence can rarely be due to other underlying diseases, such as diabetes mellitus or diabetes insipidus (lack of ADH). Another neurologic condition that can cause incontinence is sacral agenesis. 1.2.5

Comorbid Psychological Disorders

Children with daytime urinary incontinence have an increased rate of comorbid psychological disorders (von Gontard, Baeyens, et al., 2011). Joinsen, Heron, von Gontard, & ALSPAC team (2006) found increased rates for ADHD (24.8%), oppositional behavior (10.9%), and conduct problems (11.8%). In an epidemiological study of 1,391 preschool children, von Gontard, Moritz, and colleagues (2011) found a specific association of daytime wetting and ADHD. However, the risk for

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Incontinence During Childhood and Adolescence ADHD was not increased in children with nocturnal enuresis only or fecal incontinence. Children with urge incontinence have slightly increased psychological comorbidity rates. Of these children, 29–36% were affected by externalizing as well as internalizing disorders (Kuhn, Natale, Siemer, Stöckle, & von Gontard, 2009; Lettgen et al., 2002; von Gontard, Benden, Mauer-Mucke, & Lehmkuhl, 1999; Zink et al., 2008). Children with voiding postponement showed comorbid psychological disorders more often (53– 54%; Kuhn et al., 2009; von Gontard, Benden et al., 1999; Zink et al., 2008). Externalizing disorders are very typical – especially conduct problems with oppositional behavior. Kuhn and colleagues (2009) compared children with voiding postponement to children with urge incontinence. Children with these types of daytime wetting had significantly more behavioral problems, assessed with the Child Behavior Checklist (CBCL; Achenbach, 1991), than nonwetting controls. Children with voiding postponement had more behavioral problems in general and were at a higher risk for externalizing behavioral disorders than children with urge incontinence. Clinically, children with dysfunctional voiding can be differentiated into two groups: (1) children without any psychological disturbances and (2) children with a high degree of comorbid psychological disorders. 1.2.5.1 Comorbid Soiling

The frequency of soiling is increased in children with daytime and nighttime wetting. According to von Gontard and Hollmann (2004), 12% of children with enuresis/ daytime urinary incontinence also suffer from fecal incontinence. Children with daytime wetting are significantly more often affected by fecal incontinence than children with nocturnal enuresis (24.6% vs. 5.5%). In a study by Kuhn et al. (2009), 41% of the children with daytime urinary incontinence also had fecal incontinence compared to no children of the healthy controls. In children with combined elimination disorders (wetting during daytime/nighttime and

13

soiling), the rate of comorbid psychological disorders is increased (von Gontard & Hollmann, 2004). 1.2.5.2 Comorbid Somatic Disorders

All somatic disorders presented in Section 1.2.4, which have to be excluded, can also occur as comorbid disorders. Special attention should be paid to the vesicoureteral reflux and concomitant infections of the urinary tract (for detailed descriptions see von Gontard & Nevéus, 2006). 1.2.6 Etiology 1.2.6.1 Genetic Factors

Compared to nocturnal enuresis, genetic factors have not been studied in great detail in daytime urinary incontinence. Urge incontinence is the subtype with the greatest genetic disposition: One linkage analysis identified a gene region on chromosome 17 (Eiberg, Schaumburg, von Gontard, & Rittig, 2001). Voiding postponement and dysfunctional voiding are mainly acquired disorders, in which genetic factors presumably play a minor role. 1.2.6.2 Neurobiological and Neuroendocrinological Factors

Compared to nocturnal enuresis, neurobiological factors are less often examined in children with daytime urinary incontinence. However, studies do indicate higher neurological risks in children with daytime urinary incontinence. The rate of minor neurological abnormalities (soft signs) was 26% in children with daytime urinary incontinence and 14% in children with nocturnal enuresis. The rate of pathological EEGs was 25% for daytime incontinence and 13% for enuresis (von Gontard, Benden et al., 1999). Franco (2011) outlined that associations between neurobiological factors and daytime urinary incontinence are also present. Neuroendocrinological alternations have not been demonstrated in any type of daytime urinary incontinence.

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14

Chapter 1

1.2.6.3 Psychological Factors

Children with urge incontinence show the lowest rate of comorbid psychological disorders and familial stress of all daytime wetting children. Comorbidity rates were significantly increased in children with voiding postponement (Kuhn et al., 2009). Children with daytime wetting and additional oppositional defiant disorder had higher rates of interaction problems within the family. Moreover, parents of children with daytime urinary incontinence reported a lower quality of life for their children compared to parents of healthy controls, especially for children with voiding postponement (Natale, Kuhn, Siemer, Stöckle, & von Gontard, 2009). In ALSPAC, Joinson and colleagues (2008) demonstrated that problematical temperament traits of children and maternal anxiety/depression are risk factors for daytime wetting at school age (as well as for soiling). Therefore, children with voiding postponement and their families need an intensive psychological assessment and, if comorbid disorders are present, psychotherapy. As already mentioned, the empirical data for dysfunctional voiding is limited. According to clinical reports, two groups can be differentiated. One group consists of children and families with low psychosocial risks and stress, in which the dysfunctional voiding represents an acquired behavior. The second group includes children with severe psychological disorders, e. g., physical abuse or deprivation. In these cases dysfunctional voiding can be a symptom of the underlying psychological disorder needing further psychotherapeutic and psychiatric treatment.

1.3

Fecal Incontinence (Encopresis)

1.3.1

Definition and Classification

According to ICD-10 (WHO, 1993) and DSM-5 (APA, 2013), encopresis is defined as intentional or involuntary passage of feces in inappropriate places from the age of 4 after ruling out organic causes. A duration of 3 months (DSM-5) or 6 months (ICD10) and a frequency of once per month are required.

The current Rome-III classification criteria (Rasquin et al., 2006), provided by pediatric gastroenterologists, define functional gastrointestinal disorders in children and adolescents (age 4–18) in detail and have become the gold standard in clinical practice and research. Please see von Gontard and Nevéus (2006) for a detailed overview. In this manual, the terms encopresis and fecal incontinence are used synonymously. 1.3.2 Subtypes 1.3.2.1 Functional Constipation With Fecal Incontinence (Encopresis With Constipation)

The terms encopresis with constipation or functional constipation with fecal incontinence can be used as synonyms when constipation and soiling appear at the same time (Nevéus et al., 2006). Children with functional constipation have two or fewer defecations per week. Functional constipation can, of course, occur without incontinence according to the Rome-III criteria (Rasquin et al., 2006). Further criteria are large fecal masses, an increased diameter of the rectum, hard stools, and painful bowel movements. In this type of fecal incontinence, soft and watery stool can also occur. Most children soil during the day. Soiling during the night is the exception (Benninga, Buller, Heymans, Tytgat, & Taminiau, 1994). Of these children 50% report painful defecation, abdominal pain, and frequently reduced appetite. A reduced sensitivity of the rectum is associated with the ability of the rectum to comprise larger fecal masses. Stool retention is indicated by stool masses as well as by an increased rectum diameter in the ultrasound (Joensson, ­Siggard, Rittig, Hagstroem, & Djurhuus, 2008; Klijn, Asselman, Vijverberg, Dik, & DeJong, 2004). Passage time through the colon (colon transit time) is prolonged but can normalize after successful therapy (Bekkali et al., 2009). A paradoxical contraction of the external anal sphincter during defecation is the most common finding in manometric examinations.

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Incontinence During Childhood and Adolescence 1.3.2.2 Nonretentive Fecal Incontinence (Encopresis Without Constipation)

Children with this subtype soil without any symptoms of stool retention or constipation. Defecation frequency is normal, mostly daily; stool consistence and volumes are normal. Soiling frequency is lower than in children with fecal incontinence and constipation (Benninga et al., 1994). Also, the children have less abdominal pain and painful defecation. Appetite as well as colon transit time are normal. Palpating the abdomen and ultrasound assessment show normal results. Defecation dynamics (examined with the help of manometry) can be abnormal. 1.3.2.3 Toilet Refusal Syndrome

Children with toilet refusal syndrome use the toilet regularly for micturition but not for defecation and insist on being given a diaper when wanting to defecate (Christophersen & Edwards, 1992; Taubman, 1997). Toilet refusal syndrome is common in infancy and usually temporary. It is diagnosed when it persists for more than a month. Constipation and painful bowel movement often appear in combination with toilet refusal syndrome (Blum, Taubman, & Nemeth, 2004; Taubman, 1997). Blum and colleagues (1997) found no association between toilet refusal syndrome and behavioral problems. However, a trend toward a more difficult temperament is given in children with toilet refusal syndrome. In a recent study, both constipation and behavioral disorders (such as oppositional defiant disorder) were associated with toilet refusal syndrome (Niemczyk, Equit, El Khatib, & von Gontard, 2014). 1.3.2.4 Toilet Phobia

Toilet phobia is a specific phobic disorder. Children are anxious about using the toilet, e. g., they have anxiety about falling into the toilet or that a monster or animals could come out of the toilet. Similar to other specific phobias, children with toilet phobia demonstrate avoidance behavior as they refuse to use the toilet for defecation and for micturition. This rare type of phobia has not been

15

described often. Early potty training (Bellmann, 1966) and aversive potty training (Krisch, 1985) can be associated. 1.3.2.5 Slow Transit Constipation

Slow transit constipation is characterized by a genetically determined prolonged transit time of the stool through the gastrointestinal tract. Chronic, therapy-resistant constipation and fecal incontinence, as well as soft stools, are typical signs (Cook et al., 2005; Hutson et al., 2004; Shin, Southwell, Stanton, & Hutson, 2002). 1.3.3 Prevalence

Of all children 1–3% are affected by fecal incontinence during childhood (Bellmann, 1966). There is no spontaneous remission as with nocturnal enuresis. The sex ratio is 1:2 to 1:4 (girls to boys; Bellmann, 1966; Joinson, Heron, Butler, von Gontard, & the ALSPAC team, 2006). According to Joinson, Heron, Butler, and colleagues (2006), 1.4% of 7-year-old children soil at least once a week and 5.4% less than once a week. About half of the school children with soiling have never been continent; the other half has relapsed (Bellmann, 1966). The peak for a relapse is at the age of about 6–7  years (Benninga et  al., 1994; Heron et  al., 2008; Largo, Gianciaruoso, & Prader, 1978). In a population-based study in the Netherlands, van der Wal and colleagues (2005) found prevalence rates of 4.1% for 5–6-year-old and 1.6% for 11–12-year-old children. In the ALSPAC, Heron and colleagues (2008) reported prevalence rates of 4.8% in boys and 3.1% in girls at the age of 5.5 years and at least 3.6% in boys and 2.1% in girls at the age of 9.5 years. The prevalence rates of this study are relatively high because rare soiling was included. Soiling occurs predominantly during the day. Prevalence rates for soiling during the night range from 2.7% (Bellmann, 1966) to a maximum of 30% (Benninga et al., 1994). Four different trajectories of bowel control and fecal incontinence could be identified in the ALSPAC. Of the studied children (between 4.5 and 9.5 years of age) 89% had always been continent

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16

Chapter 1

and attained age-appropriate bowel control, 4.1% had a delayed attainment of bowel control, 2.7% had persistent soiling, and 4.1% had a relapse after a continent period (Heron et al., 2008). There is hardly any data available on the subtypes of fecal incontinence. Of all children with constipation 70–90% soil, whereas 20–70% of all children with fecal incontinence have constipation (von Gontard & Hollmann, 2004). In their review, van den Berg and colleagues (2006) refer to results of a study by Roma-Giannikou and colleagues (1999). According to the latter study, constipated children have a higher risk for fecal incontinence than nonconstipated children (25% vs. 0.4%). In contrast, a Brazilian study did not find any comparable differences (de Araújo Sant’Anna & Calcado, 1999). 1.3.4

Differential Diagnoses and Comorbid Disorders

1.3.4.1 Somatic Differential Diagnoses

Somatic differential diagnoses must be ruled out in every case, which makes a full pediatric examination mandatory. In most cases, fecal incontinence with constipation is a functional disorder; only in approximately 5% of cases, constipation occurs due to somatic causes. In fecal incontinence without constipation, organic causes are responsible for only 1% of cases. These two subtypes of fecal incontinence have different comorbidities and etiologies as outlined in the following paragraphs. Somatic Causes of Fecal Incontinence With Constipation

Fecal incontinence with constipation can have anatomical causes such as anal fissures. These can cause painful defecation, due to which children can develop fecal retention and constipation. Infectious diseases in the anogenital areas (e. g., abscesses, dermatitis) can also cause fecal retention due to associated pain. Furthermore, congenital anorectal malformations (e. g., anal stenosis) or strictures, as well as congenital types of intestinal dilatation (idiopathic megacolon) can be a cause of constipation.

Metabolic causes such as electrolyte shifts (e. g., hypokalemia, hypermagnesemia, hypophosphatemia, hypocalcaemia) can evoke constipation. Also, genetic diseases such as mucoviscidosis or chronic diseases such as coeliac disease can be associated with constipation. Endocrinological causes, such as diabetes mellitus and hypothyroidism, have to be ruled out as well. Many drugs (anticholinergics, antidepressants, neuroleptics, antihypertensive drugs, opiate, iron, chemotherapeutic substances, and anticonvulsants) have constipation as a possible side-effect. The most important differential diagnosis, the ruling out of possible neurogenic causes, require special attention. Constipation can occur in children with cerebral palsy, spina bifida, or tethered cord syndrome. Hirschsprung’s disease is a neuropathic cause of constipation, with segments of the bowels not adequately innervated. Main symptoms are constipation, failure to thrive, anemia, small volumes of stool, extended abdomen, and growth retardation. A surgical removal of the affected segment of the bowels is curative. In most of the cases (80%), the disease is recognized before the age of 4 (i. e., the definitional age of encopresis). Somatic Causes of Fecal Incontinence Without Constipation

Diarrhea (infectious or functional) can result in soiling because the child cannot control defecation. Postoperative soiling can occur if the function of the rectum is affected. As a neurogenic cause, spina bifida has to be considered. 1.3.4.2 Psychological Differential Diagnoses

Psychological differential diagnoses are not of clinical relevance. Fecal incontinence (encopresis) has a very high rate of comorbid psychological disorders, which have to be diagnosed and treated. 1.3.4.3 Comorbid Psychological Symptoms and Disorders

Many children with fecal incontinence report psychological strain and are affected by subclinical psychological symptoms. Bellmann (1966) com-

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Incontinence During Childhood and Adolescence pared 45 boys with fecal incontinence to 73 healthy children. Boys with fecal incontinence more often showed symptoms such as reluctance to eat, negativism, stealing, anxiety, disturbed self-esteem, low frustration tolerance, inhibited and active aggression. Benninga and colleagues (1994) found a clearly increased rate of clinically relevant behavioral problems (according to the CBCL) in children with soiling (44.2%) compared to healthy controls (10%). According to Joinson, Heron, Butler, and colleagues (2006), children with fecal incontinence are more frequently involved in bullying (both as victims and perpetrators). Children with fecal incontinence with constipation suffer from low self-esteem but take part in social activities equally often (Bongers, van Dijk, Benninga, & Grootenhuis, 2009). Cox and colleagues (2002) did not find reduced self-esteem in children with fecal incontinence but significantly more internalizing and externalizing disorders as well as school problems. Children with fecal incontinence show significantly higher rates of psychological disorders than children with nocturnal enuresis or daytime urinary incontinence (von Gontard, Baeyens et al., 2011). Of children with fecal incontinence 30–50% suffer from psychological disorders. According to Joinson, Heron, Butler, and colleagues (2006), children with frequent soiling (at least once a week) were significantly more often affected by separation anxiety (4.3%), social phobia (1.7%), specific phobia (4.3%), generalized anxiety (3.4%), depression (2.6%), ADHD (9.2%), and oppositional defiant disorder (11.9%) than children with less frequent soiling. The comorbid psychological disorders encompass internalizing as well as externalizing disorders. Psychological comorbidities are the same for fecal incontinence with and without constipation. As already mentioned in Section 1.2.6.3, difficult temperament as well as maternal anxiety and depression represent risk factors for soiling at school-age (Joinson et al., 2008). The association between fecal incontinence and sexual abuse is controversial. Studies show higher rates not only of fecal incontinence in boys and girls with a history of sexual abuse but also of additional physical and psychological symptoms. A retrospective study compared 466 children after

17

sexual abuse, 429 children with externalizing disorders, and 641 controls (Mellon, Whiteside, & Friedrich, 2006). Sexually abused children and children with externalizing symptoms had the same rate of soiling (each approximately 10%). However, only 2% of healthy children had fecal incontinence. Sexualized behavior was much more typical after sexual abuse than fecal incontinence. Children with intellectual disability or specific genetic syndromes associated with intellectual disability (e. g., Fragile X syndrome, Prader–Willi syndrome) soil more often than normally intelligent children (Backes et al., 2000; Joinson, Heron, Butler, et al., 2006; von Gontard, Didden, Sinnema, & Curfs, 2010; Equit, Piro-Hussong, Niemczyk, & von Gontard, 2013). 1.3.4.4 Comorbid Somatic Disorders

Physically disabled children with normal intelligence can also have higher rates of fecal incontinence, e. g., children with spinal muscular atrophy (von Gontard, Laufersweiler-Plass, Backes, Zerres, & Rudnik-Schöneborn, 2001). 1.3.4.5 Comorbid Wetting

High comorbidity also exists between soiling and wetting (von Gontard & Hollmann, 2004). About one third of all children with fecal incontinence additionally suffer from daytime or nighttime wetting, independent of the subtype of fecal incontinence (with or without constipation). Benninga and colleagues (1994) examined children between 5 and 17 years with fecal incontinence and found prevalence rates of 14% for additional daytime wetting and 20% for nighttime wetting. Loening-Bauke (1997) reported slightly higher comorbidity rates. In her study, 29% of 234 children with fecal incontinence and constipation had daytime urinary incontinence and 34% had nocturnal enuresis. Through the successful treatment of fecal incontinence with constipation, in 89% of cases daytime wetting and in 63% nighttime wetting disappeared. Van Ginkel and colleagues (2003) reported high comorbidity rates between fecal incontinence without constipation and daytime and nighttime wetting (46% and 40%).

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18

Chapter 1

1.3.5 Etiology 1.3.5.1 Genetic

Genetic factors play an important role in the etiology of fecal incontinence and especially in the etiology of constipation. Bellman (1966) demonstrated a higher risk for boys to develop fecal incontinence if their fathers had a history of fecal incontinence. Of 25 boys with fecal incontinence, 15% of their fathers, 1% of their mothers, and 9% of their brothers had a history of soiling. No relatives were affected in control children. The genetic disposition for developing constipation is even higher. In 234 children with fecal incontinence with constipation, 15% of the relatives had suffered from fecal incontinence and 26% from constipation (Loening-Baucke, 1997). Benninga and colleagues (1994) reported even higher rates: 42% of children with fecal incontinence with constipation had relatives who had constipation. In children with fecal incontinence without constipation this rate was only 15% (Benninga et al., 1994). Hence, genetic factors seem to mainly affect the phenotype of constipation and the phenotype of fecal incontinence only secondarily. This was also shown in the twin study by Bakwin and Davidson (1971). The authors could demonstrate that the concordance rate of constipation was 70% in monozygotic and only 18% in dizygotic twins. Furthermore, the risk of constipation was 46% if both parents had been affected, and lower if only one parent had been constipated (40% vs. 19% in father vs. mother). 1.3.5.2 Neurobiological Results

The enteric nervous system of the gastrointestinal tract can be regarded as an independent nervous system. Connections exist between the enteric nervous system and the central nervous system, which predominantly send afferent information from the gastrointestinal tract to the central nervous system. These close connections can be a reason for central nervous system involvement in functional gastrointestinal disorders. Children with fecal incontinence frequently show unspecific EEG abnormalities. Somatic-sensory evoked potentials triggered by electric or pressure stimulation in the rectum are abnormal. Functional imaging demon-

strated an activation of the central nervous system by local intestinal factors in adults with irritable bowel syndrome (Mayer, Naliboff, & Craig, 2006). In a neurophysiologic study, Becker and colleagues (2011) showed altered emotion processing through event-related potentials in children with fecal incontinence – in contrast to controls and children with ADHD. Children with fecal incontinence with constipation had the most intense reactions to emotional stimuli. 1.3.5.3 Functional Gastrointestinal Findings

Many functional gastrointestinal findings have been associated with fecal incontinence (with and without constipation). Often, causal associations are not clear, i. e., they could be either cause or consequence. For instance, altered secretion of gastrointestinal hormones in children could both be a primary cause or a secondary consequence of fecal incontinence. Studies on defecation dynamics (with manometry) have demonstrated a nonphysiological, paradox contraction of the external anal sphincter during defecation, i. e., children do not relax but contract the muscle during defecation. However, it is unclear whether this is a predisposition for the development of fecal incontinence/constipation or a consequence of repeated soiling and fecal retention (von Gontard & Nevéus, 2006; von Gontard, 2012a). The normal process of defecation proceeds in several steps: Fecal masses dilate the rectum, a feeling of urge to defecate is perceived, pressure increases, and the external and internal sphincter are relaxed. Additionally, the anorectal angle is altered through the relaxation of the pelvic floor muscles facilitating stool passage. Defecation is initiated by the increase of abdominal pressure. If defecation is not possible, the external anal sphincters are contracted. The relaxation of the internal anal sphincter decreases and the fecal masses can be accommodated again due to the plasticity of the rectum. As a result, wall tension and the urge to defecate decrease. The rectum of children with fecal incontinence with constipation can absorb greater fecal masses

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Incontinence During Childhood and Adolescence before an urge to defecate is initiated (Voskuijl et al., 2006). Also, soiling and stool smearing occur more often because the anal canal is shortened due to the accumulation of stool in the rectum (Claßen, 2007). Furthermore, children with fecal incontinence with constipation have an extended colon transit time (Benninga et  al., 1994; Benninga, ­Voskuijl, Akkerhuis, Taminiau, & Buller, 2004), which is associated with reduced peristalsis and an extended stay of stool within the colon. Water is absorbed, whereby the stool consistence becomes increasingly harder. Newly produced stool passes between the old, hard fecal masses and leads to soiling. This is also the reason why children with constipation have soft to fluid stool. In fecal incontinence without constipation, the colon transit time is only slightly prolonged, but the defecation dynamics are similarly altered (Benninga et al., 2004). Pathophysiology and etiology are not clarified for nonretentive incontinence (Bongers, Tabbers, & Benninga, 2007). 1.3.5.4 Theoretical Learning Factors

Models of learning theory add to the understanding of physiological changes in the etiology of fecal incontinence with constipation. It is assumed that chronic constipation can develop from an acute constipation due to painful defecation, which is a common disorder in young children. In addi-

19

tion to somatic triggers, such as anal fissures, unspecific psychological factors, such as stressful life events, are relevant. Cox and colleagues (1998) have framed the most differentiated theoretical model of learning for constipation. Acute constipation is triggered by a variety of somatic or psychological factors, leading to painful defecation. Children start to avoid bowel movements as a consequence of the anticipated pain. Even during defecation they attempt to retain stool. These behaviors enhance fecal retention: Fecal masses accumulate in the rectum and stool hardens. Through this habitual avoidance of defecation, chronic constipation develops. With increasing fecal masses, the colon expands and a megacolon may develop. Sensitivity decreases, i. e., the fecal masses are not perceived consciously. Peristalsis decreases as well, leading to an extended transit time. Thereby, more water is absorbed from the colon, which causes thickening and hardening of the fecal masses. Due to this retention, fecal incontinence may develop. Also, the altered anorectal angle and the postponement of defecation lead to soiling. Soiling can trigger intrafamilial conflicts and may lead to social isolation and stigmatization, which in turn can lead to intrapsychological conflicts and symptoms. For a discussion of other psycho- and familialdynamic models see von Gontard and Nevéus (2006).

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This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Chapter 2

Assessment This section outlines different diagnostic assessments. Standard diagnostic assessment, usually sufficient for uncomplicated types of nocturnal enuresis, daytime urinary incontinence, and fecal incontinence, is described first. For complex elimination disorders, additional assessment is necessary (i. e., extended assessment). Hoebeke and colleagues (2010) give an overview of the assessment of daytime urinary incontinence based on ICCS guidelines. More detailed descriptions of the diagnostic procedure can be found in von Gontard and Nevéus (2006).

2.1

Standard Diagnostic Assessment

2.1.1 History

As the first step, the detailed history of both parents and the child should be assessed for all elimination disorders (nocturnal enuresis, daytime urinary incontinence, and fecal incontinence) including the current symptoms, the developmental history, and family history. Initially, parents and child are asked for an open description of the presenting symptoms. Additionally, the context of the presentation should be clarified (Who has initiated the presentation? Which expectations do the parents, the referring physician, the children, etc. have of the clinic or practice?). Subsequently, specific elimination symptoms are explored (daytime and nighttime incontinence, soiling). Typical questions relevant for the different problems are listed below. Nighttime wetting: • Is the child dry during the night? If yes, since when?

• If the child wets during the night, information of the longest dry period is important. When did it occur and for how long? • How often per week does the child wet? • How often per night does the child wet (e. g., once, twice, or more)? • How large is the voided volume during sleep? • Can the child be woken up easily or is it difficult to wake him/her up? • Does the child wake up during the night to go to the toilet? Daytime wetting: • Is the child dry during the day? If yes, since when? • Has the child ever been dry during the day? If yes, for how long (days, weeks, months, or even years)? • Has there been a trigger for dry or wet periods? • How often does wetting occur presently per day/per week? • How large is the voided volume? • Are there specific situations in which wetting occurs more often (e. g., while playing, watching TV, with increasing tiredness)? • How often does the child pass urine during the day? • Does the child show voiding postponement (e. g., while playing, while watching TV), urgency, or holding maneuvers (sitting on the heel, crossing legs, etc.)? • How much does the child drink every day? • Does the child go to the toilet voluntarily or does he/she have to be asked to do so? • Does the child have problems while urinating (e. g., interrupted stream, straining)? • Has the child ever had urinary tract infections? If yes, how often and for how long? • Has the child been treated with antibiotics?

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22

Chapter 2

Soiling: • Does the child soil? If yes, how many times per week? • Since when? • If the child soils, how large is the stool quantity? • How often does the child have bowel movements? • Does the child have regular bowel movements or is he/she sometimes constipated? • Is defecation painful for the child? • What is the consistency of the stool? • How much does the child drink per day? • Is the child on a balanced diet? Previous treatments: • Which types of treatment have been conducted so far and where? • Which kinds of therapy (surgical, pharmacological, or other) have been conducted so far and were they successful? • Which kinds of treatment attempts have the parents tried (e. g., waking the child up during the night, lifting the child, restriction of liquid intake, rewards, punishment)? If alarm treatment has already been used, exact details are important: • When did the alarm treatment begin and for how long has it been used? • Has it been used regularly? • Why was it stopped? • Has medication been used? If yes, which one? In which doses and for how long? • Have surgical procedures been carried out? If yes, which? In case of fecal incontinence, ask exactly if and which laxatives have been given, for how long, and in which doses. Also, be sure to gather information regarding previous diagnostic and therapeutic steps. Comorbid psychological disorders: After the exploration of the wetting and soiling symptoms, questions regarding other psychological disorders should be asked (e. g., Are there

other aspects of your child’s behavior you are worried about?). Ask explicitly whether symptoms of externalizing disorders, such as conduct problems and ADHD as well as emotional (internalizing) disorders, are present. 2.1.2

Development and Family History

As the second step, the standard child psychiatric history (course of pregnancy, birth, early child development, etc.) as well as the family history should be assessed. The family history of wetting, voiding problems, and further elimination disorders (parents, siblings, other relatives) is very important. In addition to history, questionnaires should be employed to gather relevant information efficiently within a short time. Questionnaires are important for gaining information about psychological symptoms. For example, questionnaires for fecal incontinence (von Gontard, 2012a), enuresis, and urinary incontinence (von Gontard, 2012b), as well as the following psychological instruments can be very useful: CBCL/4-18, Youth Self Report (YSR), Teacher’s Report Form (TRF; Achenbach, 1991), Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997), Behavior Assessment System for Children-Second Edition (BASC-2; Reynolds & Camphaus , 2004). 2.1.3

The 48-Hour Bladder Diary

The 48-hour bladder diary (von Gontard & Ne­ véus, 2006) is a useful addition to the history and provides important objective information of which sometimes neither the parents nor the child are aware. In this diary, parents are asked to record the micturition times, voided volumes, fluid intake, as well as wetting and soiling episodes of the child. The bladder diary should always be filled out because it can provide essential information on the child’s drinking and micturition habits in the course of the day. It is invaluable for specific treatment to recognize non-monosymptomatic types of enuresis or voiding postponements.

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Assessment 2.1.4

Physical Examination

A pediatric and neurologic examination should be performed in every child. In general, all organ systems should be examined. Especially, the abdomen should be palpated (for signs of stool masses). Also, the genital region should be examined as well as the anal region (for signs of malformations and infections), the spine (for signs of spina bifida occulta), the buttocks, and the lower extremities (for asymmetries, which could indicate tethered-cord syndrome). During the neurological examination, attention should be paid to differences in reflexes or sensitivity of the lower extremities, which could be signs of neurogenic bladder dysfunction. Furthermore, “fine” neurologic signs (so-called soft signs, e. g., quality of motor movement, coordination, balance, etc.) should be noted because they offer indications to central coordination problems. 2.1.5

Sonography/Urine Analysis

If possible, a sonographic examination of the abdomen, kidneys, rectum, as well as the bladder should be carried out routinely to exclude malformations of the kidney and the lower urinary tract. Increased rectal diameter can be a sign of stool retention and constipation. Also, bladder wall thickness and increased post-void residual urine can be measured. Furthermore, a urine dipstick analysis is needed to rule out infections of the urinary tract.

2.2

Extended Assessment for Complex Elimination Disorders

History, bladder diary, questionnaires, physical examination, sonography, and urinalysis should be carried out routinely in every child – as outlined above. The following diagnostic steps are optional but should always be carried out if indicated:

2.2.1

23 Uroflowmetry

Uroflowmetry measures the urinary stream during micturition. If uroflowmetry is combined with a pelvic floor EMG (electromyogram: measurement of muscle activity), coordination between detrusor and sphincter can be evaluated, which enables a differentiated diagnosis of detrusor and sphincter during micturition. The examination is essential if dysfunctional voiding is suspected (Hoebeke, Vande Walle, van Laecke, & van Gool., 1999). 2.2.2 Bacteriology

If an infection of the urinary tract is suspected, especially in children with daytime wetting, further urine examinations (sediment, microbiologic tests) are needed. An antibiotic treatment should be initiated only after the urine has been examined bacteriologically. 2.2.3

Further Pediatric and Urologic Diagnostic Steps

Noninvasive urodynamic measurements are sufficiently reliable to diagnose most functional voiding symptoms (Ramamurthy & Kanitkar, 2010). The following assessments should only be carried out if they are indicated: Radiographical examination: Radiograms are not necessary on a regular basis and should only be recommended, when, for example, a vesicoureteral reflux or urethral stenosis is suspected (e. g., micturition cystourethrogram). Other specialized diagnostics: Scintigraphic examinations can be necessary in cases of renal dysfunctions (e. g., caused by scars). Urodynamic examinations: If organic urinary incontinence is suspected and diagnostic information is not sufficient, full urodynamic examinations with intravesical pressure measurement may become necessary. They should be carried out by expert pediatric urologists only.

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24

Chapter 2

Further urologic examinations: Any other urological examination should be carried out only if indicated, e. g., cystoscopy.

2.3

Psychological Tests

tion disorders is increased in children with intellectual disability (e. g., Järvelin et al., 1988; Laecke et  al., 2001; Yang, Meng, & Chou, 2010), frequency or type of wetting/soiling is not related to IQ in children with normal intelligence.

Psychological tests are not necessary with most of the children and should be carried out only with special indication. Although the rate of elimina-

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Chapter 3

Treatment of Incontinence In the following chapter, methods for the treatment of incontinence are described. A detailed description of treatment steps and interventions can be found in von Gontard and Nevéus (2006) or in von Gontard (2012a, 2012b). For the treatment of complex elimination disorders, intensive urotherapy has proven to be effective (see Section 3.5).

forms of ADHD, should be treated first (through psychotherapy or pharmacotherapy) to improve the compliance of children with further treatment.

3.1

Psychoeducation of the parents and the child is the basis for all subsequent interventions. It provides information about the type of incontinence, possible causes, comorbidity, and pathogenesis. Along with the most important diagnostic steps, therapy planning and changes in the diet and in drinking habits are discussed.

General Treatment Principles

If comorbid elimination disorders (urinary and fecal incontinence) are present, fecal incontinence with or without constipation is always treated first. Generally, the therapy of fecal incontinence or constipation leads to a reduction of wetting. Subsequently, any kind of wetting during daytime will be treated because daytime urinary incontinence represents a peripheral disorder of the bladder function. In children with (NMNE), similar bladder dysfunctions are existent except that these children do not wet during daytime. If these bladder dysfunctions (as in daytime urinary incontinence) are treated adequately, nighttime wetting will stop for many children. If nocturnal enuresis persists, treatment of nighttime wetting itself is indicated. While the treatment order of combined elimination disorders is very clear, additional comorbid psychological disorders are treated according to clinical indication. A symptom-oriented treatment of soiling and wetting, however, should always be carried out. After successful treatment of incontinence, children feel better, their self-esteem increases, and sometimes even conduct problems are reduced. Manifest comorbid psychological disorders (e. g., emotional disorders) can be treated simultaneously with incontinence. Other disorders, e. g., severe

3.2

Treatment of Fecal Incontinence

The main treatment approach of fecal incontinence is regular toilet training. Children are asked to sit on the toilet 3 times a day for 5–10 minutes after the main mealtimes. The aim of toilet training is not necessarily to achieve micturition or defecation but the regulation of defecation behavior. It is not completely clear which mechanisms lead to the success of this training. On the one hand, the emptying reflexes, which are mostly active after food intake (so-called gastrocolic reflexes), are regulated by developing the habit of emptying the stool into the toilet. Additionally, operant elements such as praise, attention, positive experience of the toilet times, and feelings of success are effective. Thus, toilet training is the basic therapy for all types of fecal incontinence (von Gontard & Nevéus, 2006) and is significantly more efficient compared to pharmacological treatment alone or biofeedback treatment (Borowitz, Cox, Sutphen, & Kovatchev, 2002). It is the main treatment component for fecal incontinence without constipation. In the treatment of fecal incontinence with constipation, toilet training is combined with laxatives. Tabbers and colleagues (2011) named four

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26

Chapter 3

steps for the treatment of constipation: education, disimpaction, prevention of re-accumulation of feces, and follow-up. Burgers and colleagues (2013) give an overview of treatment of constipation in children with lower urinary tract symptoms. Toilet training reduces the risk of constipation in chronic types of toilet refusal syndrome and slowly accustoms the children to going to the toilet. The parents should document the procedure of the toilet training on a chart; an additional documentation by the children is optional. For most children, toilet training with simple reinforcements is sufficient. In case of lack of treatment success or relapses, further cognitive behavioral treatment elements can be added. Outpatient treatment programs with a multimodal approach have proven to be effective. The group training described in the second part of this book is such a multimodal approach. Pharmacological treatment is only indicated in case of fecal incontinence with constipation. The initial emptying of colon and rectum fecal masses (disimpaction) is differentiated from the long-term maintenance treatment with the aim of preventing re-accumulation of feces. There are three options available for disimpaction: oral, rectal and, on rare occasions, surgical disimpaction. For oral disimpaction, polyethylene glycol (PEG) is the first choice laxative. It is an osmotic laxative that binds water molecules, softens the stool, and activates defecation. The required doses are much higher than in maintenance treatment. In severe and chronic constipation, oral disimpaction is not sufficient. Usually, rectal enemas containing phosphate are necessary. Information on the required doses can be found in von Gontard & Nevéus (2006). Please note that Bekkali and colleagues (2009) demonstrated that oral disimpaction with PEG can be as effective as rectal disimpaction with enemas. If children prefer oral disimpaction, this should be tried first. In rare cases of very severe constipation with megacolon, even rectal enemas may not be sufficient. In these cases, children should be referred to specialists in pediatric gastroenterology or surgery. Frequent and antegrade enemas or, on vary rare occasions, surgical evacuation may be necessary.

After the disimpaction, maintenance treatment starts immediately. Toilet training and laxatives are the two relevant components of the treatment, which have to be carried out simultaneously. Again, PEG is the laxative of choice. The effectiveness of the drug depends on sufficient liquid intake. If the children do not drink enough, a drinking schedule may be established. In exceptional cases (e. g., intolerance of PEG), lactulose may be administered. The effectiveness of the fecal incontinence treatment is dependent on the regular treatment over a long period of time. In summary, in fecal incontinence without constipation, toilet training is sufficient and no laxatives should be used. Fecal incontinence with constipation requires a treatment with both laxatives and toilet training.

3.3

Treatment of Daytime Urinary Incontinence

In this section, basic modules for treatment of daytime urinary incontinence are presented. An exact diagnosis of the subtype of urinary incontinence is necessary for a successful therapy. At the beginning of the treatment, detailed psychoeducation with the provision of information and counseling of children and parents is indicated. 3.3.1

Urge Incontinence

First-line treatment of urge incontinence consists of detailed psychoeducation and takes a cognitive approach. Children are instructed to perceive urgency and to go to the toilet immediately at the first signs of urge. They are asked to note in a voiding chart whether their underwear was dry or wet (e. g., using symbols such as a flag or a laughing smiley for dryness, a cloud or a sad smiley for wetting). Clinical experience has shown that this method can reduce wetting within a few weeks in one third of the children. Hagstroem and colleagues (2010) showed that 30% of all children with urge incontinence became dry through urotherapy in combination with programmed watches that reminded

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Treatment of Incontinence them to go to the toilet regularly. Pharmacological treatment with anticholinergics was not necessary. However according to clinical experience, for twothirds of the children additional pharmacological treatment with an anticholinergic (such as Oxybutynin, Propiverine, Tolterodine, or Trospium) is necessary. The drugs lead to a reduction of bladder contractions. The parasympathetic innervation is inhibited and sensitivity decreases. Thereby, the bladder can store more urine and does not contract so easily, reducing urgency and frequency. 3.3.2

Voiding Postponement

In addition to psychoeducation, the treatment of voiding postponement consists of a cognitive behavioral approach. The children are instructed to go to the toilet at least 7 times a day and note each micturition in a voiding chart. Through this timed voiding, micturition frequency is increased and postponement behavior is reduced. It is often necessary to combine the approach with positive reinforcement, especially in children with low compliance or oppositional behavior. Reminders to go to the toilet with programmed watches (or cell phones) can be helpful. Although only children with urge incontinence were included in the study by Hagstroem and colleagues (2010), timed voiding is especially suitable  for children with voiding postponement. 3.3.3

Dysfunctional Voiding

In dysfunctional voiding, biofeedback is the treatment of choice. In biofeedback, electromyograms (EMG) are used to present either uroflow or pelvic floor contractions acoustically or optically (curves are show on a screen). Child-appropriate animations are available. Biofeedback training with uroflow and EMG can only be conducted at the clinic or practice. However, EMG biofeedback programs are available for home use. The children receive a portable biofeedback device with which they can train to relax the muscles of the pelvic floor at home. The biofeedback training is an effective, noninvasive treatment

27

of dysfunctional voiding (Desantis, Leonard, Preston, Barrowman, & Guerra, 2011). Chase and colleagues (2010) described this treatment approach according to the ICCS standards.

3.4

Treatment of Nocturnal Enuresis

After successful treatment of fecal incontinence and daytime urinary incontinence, treatment of nocturnal enuresis can begin. In MNE, therapy can be initiated immediately. Nevéus and colleagues (2010) described the treatment standards of MNE according to the ICCS criteria. In NMNE daytime lower urinary tract symptoms need to be treated first. As the first step, the children are asked to fill out a calendar or chart for 4 weeks, depicting wet and dry nights with symbols (sun or smiley are common symbols for dry nights, clouds for wet nights). This is to set a baseline. Already through this simple intervention, the frequency of wet nights is decreased in many children within 4 weeks. Approximately 15% of children achieve dryness by charts alone (Devlin & O’Cathain, 1990). Following simple interventions, alarm treatment is the method of choice. The exact mechanisms of this treatment have not been clarified. It is, however, a highly operant behavioral method, leading to dryness in 60–70% of children with low relapse rates. Some children learn to sleep through the night, whereas others wake up and go to the toilet when the bladder is full (nocturia). The alarm devices should be explained and demonstrated to children and parents. They should be informed that it is important to use the alarm regularly every night over a longer time period not exceeding 16 weeks. The parents are asked to document the course of the alarm treatment in special protocols. Initial success is attained, when the child achieves a minimum of 14 consecutive dry nights. Alarm treatment can then be stopped. If a relapse occurs (two wet nights per week), the treatment is reinstituted. Reinforcement of the alarm treatment with additional behavioral interventions is only indicated if simple alarm treatment is not sufficient. The child receives positive reinforcement through different

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28

Chapter 3

kinds of rewards (e. g., material reinforcement, action reinforcement, or tokens that can be traded in later). The goal is to reinforce the cooperation and compliance of the child, which he/she can influence voluntarily, and not dryness itself. Apart from reward programs, baseline calendars in and of themselves can offer reinforcement during alarm treatment. If dry nights are recorded in a calendar with special symbols (e. g., sun, smiley), the attention of parents and child is shifted to the already attained success. In arousal training (van Londen, van Londen-Barenstein, van Son, & Mulder, 1993, 1995), the children are instructed to turn off the alarm within 3 minutes, go to the toilet, and then reset the alarm. When the child succeeds, he/she receives two tokens. If the goal is not reached, the child has to pay one token back. Through this procedure, motivation and participation can be increased. Arousal training is easy to carry out and very effective. However, it should be modified for younger children. They receive a token when they are successful, but they do not have to pay a token back if they are not. This could be frustrating and demotivating for them. Overlearning, another reinforcement technique, can be used to stabilize treatment effects (Morgan, 1978). Children are offered larger amounts of liquids in the evening as soon as they have reached the initial success of 14 consecutive dry nights. If the child sleeps through the night with increased fluid intake, it can be assumed that he/she has reached sufficient control over his/her bladder (Grosse, 1986). If the child awakes during the night, he/she sufficiently perceives the full bladder. Dry-bed training (Azrin, Sneed, & Foxx, 1974) is a complex training program combining alarm treatment with further operant approaches. The aim of this training is that the child learns to perceive and differentiate different filling states of the bladder and to prevent wetting through self-control mechanisms. This training can lead to fast initial dryness with a smaller relapse rate. However, the training requires strong commitment. Also, in recent meta-analyses, dry-bed training was not more effective than alarm treatment alone. The in-

dication of dry-bed training has been restricted to treatment resistant cases. A detailed description of this approach can be found in von Gontard and Nevéus (2006). Although alarm treatment and combined behavioral interventions represent the first choice treatment of nocturnal enuresis, there are specific indications for pharmacotherapy with desmopressin (e. g., short-term dryness for school excursions; lack of motivation for alarm treatment; familial risk factors making alarm treatment impossible). Treatment with desmopressin is therefore the second choice. Desmopressin inhibits urine production at night, which leads to a clear reduction of wet nights. However, most of the patients experience a relapse after discontinuing medication (Kwak, Lee, Park, & Baek, 2010; van Kerre­ broeck, 2002). The likelihood of a relapse after desmopressin is 9 times higher than after alarm treatment (Lister-Sharp, O’Meara, Bradley, & Sheldong, 1997). It is important to inform parents and children about rare but severe side effects of desmopressin, i. e., hyponatremia and water intoxication. A combination of desmopressin and alarm treatment is not effective and therefore not recommended. If either alarm or desmopressin treatment fails, the ICCS recommends switching over to the other mode of treatment (Nevéus et al., 2010). The use of anticholinergics in the treatment of MNE is not recommended in general because nocturnal enuresis represents a disorder of the central nervous system and not of the bladder (Yucel, Kol, Guntekin, Baykara, 2011). In coexisting symptoms of urgency (i. e., non-monosymptomatic nocturnal enuresis), the combination of alarm treatment and anticholinergics can be very useful.

3.5

Urotherapy as a Treatment for Complex Elimination Disorders

As shown so far, effective treatments for all types of incontinence are available. However, certain subgroups of children either show a chronic course or suffer a relapse. These children often experience psychological distress, feel inferior to other children, are unhappy, and try to hide their prob-

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Treatment of Incontinence lem. Due to treatment failure, resignation and demotivation are common. For these children, special, intensive urotherapy can be useful. 3.5.1

Definition

According to the ICCS definition, urotherapy includes all nonsurgical, nonpharmacological treatments for lower urinary tract malfunction (Nevéus et al., 2006). Standard urotherapy is distinguished from special urotherapy. Standard urotherapy consists of the following components (Nevéus et al., 2006): 1. information on bladder dysfunction and demystification; 2. instruction concerning regular voiding habits; 3. counseling concerning fluid intake and prevention of constipation; 4. documentation of symptoms and voiding habits; 5. regular support and follow-up. Specific urotherapy contains selected treatment components depending on subtype of incontinence (i. e., alarm treatment for nocturnal enuresis, biofeedback for dysfunctional voiding). Bladder training (also continence training) is regarded part of urotherapy and contains a combination of different treatment components, including providing information, psychoeducation, and counseling. In addition, relaxation techniques, biofeedback as well as components of cognitive behavioral therapy and body-related therapies can be used (i. e., Sambach, Equit, El Khatib, Schreiner-Zink, & von Gontard, 2011; KgKS – Konsensusgruppe Kontinenzschulung im Kindes- und Jugendalter e. V., 2010). 3.5.2

Scientific Evidence

The concepts of bladder training and urotherapy originate from Scandinavia and go back to the late 1980s. Until now, only few studies on bladder training have been conducted. (Bachmann et al., 2007, 2008; Bower, Yew, Sit, & Yeung, 2006; Hellström, Hjälmås, & Jodal, 1987; Hoebeke et  al., 1996, 2011; Kruse, Hellström, & Hjälmås, 1999;

29

Mattson, Brännstörm, Eldh, & Mattson, 2010; Mulders, Cobussen-Boekhorst, de Gier, Feitz, & Kortmann, 2011; Sambach et al., 2011; Vijveberg, Elzinga-Plomb, Messer, van Gool, & de Jong, 1997). A study of children between 8 and 12 years of age with NMNE, urge incontinence, or dysfunctional voiding (Bachmann et al., 2007) showed an improvement of daytime wetting in 64% of the children and an improvement of nighttime wetting in 18–52% of the children (inpatient vs. day-care ­setting) six months after bladder training. In this study, children were treated in matched groups of two a­ ccording to age and sex. The training included information on bladder and kidney functions, self-instruction training, bladder diary as well as fluid intake and pelvic floor exercises with biofeedback. Long-term effects of this program could also be confirmed (Bachmann et al., 2008). In another study of 122 children (5–15 years of age) with daytime urinary incontinence or micturition disturbances, Mulders and colleagues (2011) conducted a different urotherapeutic training in eight sessions. The training included information on urinary tract functions, healthy micturition behavior and fluid intake, keeping a bladder diary, sitting position on the toilet, examination of micturition behavior via uroflowmetry as well as support and motivation by the urotherapist. These urotherapeutical interventions led to symptom reduction or even a disappearance of symptoms in 78% of the patients. Mattson and colleagues (2010) treated 200 children between the age of 3 and 14 years in urotherapeutical group trainings. The participants received information on anatomy and on pathophysiology of the bladder dysfunction, physiotherapeutic exercises for straining and relaxation of the pelvic floor as well as instructions for correct micturition behavior. In a follow-up examination one year later, 40% of children showed a complete success and 34% a significant improvement. In a study by the authors (Sambach et al., 2011), 31  children with complex elimination disorders between 6 and 14 years of age received outpatient group training in groups with 2 to 4 children. This training was conducted in 6 sessions and con-

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30

Chapter 3

tained contents similar to the one presented in Chapter 4 and Chapter 5 of this manual. As a result of the bladder training, not only the frequency of wetting decreased significantly but also comorbid psychological problems, especially internalizing symptoms. Most of the studies described here are not randomized controlled studies. The comparability of their results is limited as the concept of urotherapy often contains different interventions. Furthermore, the samples of the studies differ in the subtypes of incontinence, which also could influence success rates. Overall, relatively high success rates (5–92%) are reported for urotherapy (Hoebeke, 2006). Therefore, this intervention has to be regarded as an effective supplement or alternative in addition to the standard methods of treatment. Yet, there still is a great need for research, especially for randomized controlled studies. There is only limited scientific evidence on bowel training with psychotherapeutic elements. Stark and colleagues (1990) conducted a group program with 18 children, aged 4–11 years, who suffered from fecal incontinence with constipation. In 6 sessions, specific topics were discussed with the children and, in parallel sessions, with their parents using behavioral methods. The sessions included information on the association between soiling and constipation, disimpaction with enemas, the introduction of a high-fiber diet, regular toilet habits as well as reinforcement schedules for desirable behavior. Through this training, soiling frequency was reduced by 83% – 16 of the 18 patients did not soil any longer. Also, in a follow-up examination 6 months later, the treatment effects remained stable. Van Dijk and colleagues (2007) introduced a behavioral intervention program for children with

chronic constipation between the age of 4 and 8 years and 8 and 18 years, respectively. This program consisted of 12 sessions with 5 topics called know (psychoeducation), dare (reduction of anxiety of defecation), can (administration of laxatives and acquisition of strategies), will (reinforcement of appropriate behavior), and do (introduction of routines). Most sessions were conducted in individual settings with children and parents together. Kuhl and colleagues (2010) conducted group training with 37 children with retentive fecal incontinence and their parents in two separate groups. One group of children received the standard program where information on the physiology of soiling, pharmacotherapy, high-fiber diet and liquid intake, sitting position on the toilet, and strategies for relapse-prevention were discussed. The second group received additional education, assignments, and reinforcement schedules for increasing liquid intake. The second group showed a significant reduction in soiling frequency as well as a significant increase of daily liquid intake compared to the group treated with the standard program only. The described programs only refer to the treatment of fecal incontinence with constipation and constipation without fecal incontinence. Treating children with nonretentive fecal incontinence with similar programs is recommended because these children may also profit from some of the interventions (e. g., regular toilet training). All in all, behavioral programs for the treatment of fecal incontinence are effective but should be accompanied by a laxative treatment in case of existing constipation. In the following section the development and structure of the therapy manual will be outlined and each session of the training will be described in detail.

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2  Therapy Manual

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Chapter 4

Description and Structure of the Manual Urotherapy is often conducted as individual therapy. However, group treatment offers many additional advantages. In group training, children have the opportunity to share their problems with each other. They feel less isolated and can find a way to become continent together with other children. As a result, children often feel relieved and gain more self-esteem and motivation. The general aims of group training are to increase treatment compliance, to provide information and, to improve social skills. Group dynamics play a major role in reaching successful outcomes.

4.1

Development of the Manual

Over the past years, the German Konsensusgruppe Kontinenzschulung im Kindes- und Jugendalter e. V., (KgKS, 2010) has developed a manual for a group training with children and adolescents with daytime urinary incontinence only. This manual is meant for the exclusive use by professional urotherapists. Materials developed by Heike Sambach as well as her experiences from working at the Saarland University Hospital were integrated into the manual of the KgKS. A group training especially for complex and therapy-resistant elimination disorders (both fecal and urinary incontinence) was developed at the same time at Saarland University Hospital (Equit, Sambach, Niemczyk, & von Gontard, 2013). This group training is the basis for the one presented in this book. The group training in this manual was developed for children and adolescents with complex elimination disorders. It differs from the KgKS manual mentioned above in both content and material. It is especially suitable for the treatment of daytime in-

continence, non-monosymptomatic nocturnal enuresis, combined wetting (daytime and nighttime) as well as soiling. The first 7 sessions are about bladder training. There are two optional sessions on bowel training for children and adolescents with fecal incontinence or constipation. Additionally, balanced nutrition (in optional Session 2) and drinking (Session 4) are covered. We have also adapted all treatment components for adolescents. In summary, the current manual includes both bladder and bowel training and encompasses a wider range of group therapy techniques than its predecessors. Use is encouraged for all specialists treating children with incontinence. Since the German version of this manual was received with great enthusiasm and many international professionals have requested it, the authors decided to publish an English version. This version, presented in this book, was modified minimally to adapt to specific cultural customs and terms used in English-speaking countries. The authors have chosen the term training program instead of group therapy for this program because similar names, such as bladder training and bowel training, were used in previous literature for similar concepts. However, the present program is far more than a pure training. Rather, it is a group therapy integrating multiple psychotherapeutic elements. In addition to providing information and psychoeducation, it contains cognitive behavioral interventions, e. g., perceiving and dealing with emotional states, stress management, relaxation techniques, homework, etc. The exercises the children are asked to do at home often consist of self-monitoring to improve the perception and awareness of their own behavior. In the following passages, the terms training/group training and therapy/group therapy are used synonymously.

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34

Chapter 4

The goal of this manual is to enable pediatricians, specialists of child and adolescent psychiatry, psychologists, nurses, urotherapists, and many other professionals working in outpatient settings, practices, clinics, or counseling services to offer additional treatment for children and adolescents with complex elimination disorders. Figure 1 shows the treatment steps of elimination disorders used at the Department of Child and Adolescent Psychiatry, Saarland University Hospital, Germany. After initial consultation, history, and extensive assessment (see Chapter 2), standard interventions are initiated, as described in Chapter 3. For most of the children and adolescents this standard treatment is sufficient. If only little or no success can be observed after several weeks, participation in the group training is discussed with patients and parents. Depending on the child’s ­motivation, age, and other external factors (e. g., availability of a group of children with same age and sex) children are treated either in a group or individual setting. Standard treatment should be continued during bladder and bowel training. The treatment of comorbid psychological disorders should be continued as well (e. g., treatment with stimulants in children with ADHD). About 4 weeks after bladder and bowel training, therapist, patient, and parents meet for a follow-up. They reflect on and check whether treatment topics have been transferred successfully into everyday life and whether frequency of incontinence

Initial Consultation History Assessment

has been reduced. Further treatment options are initiated based on the child’s motivation. After the end of bladder and bowel training, if indicated, there will be further individual outpatient contacts for follow-up and further counseling. Thus, bladder and bowel training is embedded within a complete treatment program.

4.2

Formal Aspects of the Training

Group sessions should be conducted by two therapists simultaneously, if possible. Children should be grouped together (2–4 children) based on same sex and similar age. The sessions should be carried out as described in Chapter 5. Between 7 and 9 sessions (depending on whether elements of bowel training are included) take place with one session per week or every other week. Each session lasts 90 minutes. The room chosen for group treatment should be big enough to offer enough space for role playing, relaxation exercises, and other group activities. Recurring components such as the opening round, the drinking ritual, and homework are meant to structure the sessions, establish emotional security, and provide familiarity. Two characters, Tom and Emily, the Peeing Prince and Princess, guide the children through the treatment. They serve as characters the children can identify with and enable them to perceive their own problems and to accept and freely discuss them. In addition, many medi-

Group training 7–9 sessions (90 min)

Standard therapy

Lack of treatment success

Further therapy recommendations

Follow-up meeting Individual training 2–4 sessions (45 min)

• Success • Motivation • Transfer Check

Figure 1 Course of treatment and setting of the bladder and bowel training.

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Description and Structure of the Manual cal and behavioral interventions can be explained much better with these two characters. In every session the children receive worksheets for homework that should be completed for the next session.

4.3

Contents of the Sessions

All sessions have a similar structure, which helps therapists and children to orient themselves and leads to greater transparency and increases comprehension. Table 2 gives a short overview of the topics and goals of the individual sessions. In Session 1, children get to know each other, define their problem and their goals. By filling out questionnaires, they explore their symptoms in de-

35

tail and learn to differentiate between diverse aspects of their problem. Because of the group format, the children might speak more openly and are possibly less ashamed. The therapists should not exert any pressure but show understanding and praise their openness. An atmosphere should be created in which children feel comfortable and are willing to deal with their problems. In Sessions 2 and 3, children receive psychoeducation on anatomy, physiology, and pathophysiology of the lower urinary and intestinal tract. This is done with the help of attractive and age-appropriate materials for children. Therapists should ensure that children understand and can repeat all processes because they will be important for subsequent sessions. Psychoeducation alone can sup-

Table 2 Overview of topics and goals of group therapy Session

Topics

Goals

1

Why am I here and what do I want to learn?

Get to know each other, build up motivation, reflect problems

2

How do food and fluids get through our body?

Provide information on anatomy and physiology (“from mouth to bladder/bowel”)

3

How does wetting happen? What has stress got to do with it?

Provide information on the pathophysiology of wetting, perceive and counteract stress

4

Why is drinking so important?

Provide information on drinking, understand the importance of drinking, optimize drinking habits

5

When should I go to the toilet? What is hygiene? What does constipation have to do with wetting?

Learn to void regularly, provide information on body hygiene, illustrate the connection between bowels and bladder

6

How do I feel when I have wetted? How can I learn to feel and relax my bladder?

Perceive and self-reflect emotions, increase bladder and body perception

7

What do I know about me and my bladder? Have I achieved my goals? What comes next?

Check knowledge, recognize success and ­relapse, build motivation for further treatment

1 (optional)

How do soiling and constipation happen?

Reflect on problems, provide information on the pathophysiology of fecal incontinence and constipation, introduce toilet training

2 (optional)

What is a healthy diet? Do I exercise enough?

Reflect on eating and exercise habits, provide information on a healthy diet, raise motivation to be physically active

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36

Chapter 4

port treatment and increase the children’s motivation because it provides a clear explanation of their problem and helps them realize that they are not to be blamed for their symptoms. The topic of stress is discussed in Session 3. Children learn how a negative mood and anger can affect their symptoms. As part of their homework they are asked to self-monitor and write their observations down. This will help to train their ability to perceive negative feelings. Session 4 is about the topic of drinking. Children are playfully introduced to healthy and age-appropriate drinking behavior. Questionnaires are used to explore their drinking habits. Self-monitoring supports the transfer of learned contents into everyday life. In Session 5, healthy voiding habits are discussed and the children are informed about hygiene and bowel management. Session 6 deals with emotions and bladder perception. Children learn to identify, to reflect, and to relate emotions to their own behavior. In the second part of this session, bladder perception is trained by using body-focused exercises. Finally, in Session 7 the initial goals, as defined in Session 1, are reviewed. A final quiz helps to reinforce learned information. The children reflect on their treatment progress and are motivated for further therapeutic steps. The two additional sessions focus on fecal incontinence. As in bladder training, children receive information on the pathophysiology of soiling and constipation and learn about a healthy diet as well as further prevention and treatment strategies. Again, questionnaires, exercises, charts, and protocols help the children to reflect on their problem and to increase self-perception.

4.4

Including the Parents

This group training is mainly directed at the children. Nevertheless, it is important and essential that parents are included in the treatment. In preliminary counseling (before training begins), parents are informed about the contents of the pro-

gram and are instructed on how they might help their children between sessions. At the end of each group session, participants receive homework which should partly be done together with their parents. Homework consists of, for instance, a profile of the child, tests for checking up on what he/she has learned, and various self-monitoring assignments and protocols. Therefore, the children should show their homework to their parents and ask them for help if needed. Self-monitoring assignments and protocols (e. g., stress calendar, emotion homework, toilet training, drinking diary) should also be done together with the parents since they might be too complicated for young children. Parents may also help with tests. Doing homework together not only informs the parents about the content of the sessions, it also promotes a positive parent-child relationship because of the time spent together and shared feelings of success when homework was completed. Some weeks after finishing the training, a follow-up meeting with parents and child should take place, in which the treatment success is outlined and further interventions for stabilization of achieved goals are discussed.

4.5

Application as Individual Training

This manual is not only designed for group training but can also be used for individual training. There are different indications for an individual setting: • Due to a small number of patients a group cannot be provided. • The child is not in school yet. • The child is very anxious or too ashamed in front of other children. • The child refuses to participate in group therapy. • Comorbid psychological disorders are too pronounced (e. g., conduct problems or ADHD). Individual training should be carried out by one therapist in 2–4 sessions, each lasting 45 minutes. Contents can be adapted to the child’s knowledge and the number of sessions can be adapted to in-

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Description and Structure of the Manual

37

Table 3 Possible structure of individual training Session

Topics

1

Goal and problem analysis, anatomy and physiology, pathophysiology of wetting

2

Drinking and voiding habits, hygiene

3

Bladder perception and emotions

4

Pathophysiology of soiling, prevention and treatment, healthy diet

dividual needs. See Table 3 for a possible structure of the sessions. For preschoolers a short program is recommended because they cannot fill out worksheets. Furthermore, they rely more on verbal and visual explanations of the therapist. For very young children the amount of information should be reduced and facts should be explained in simple words and backed up with practical exercises. If children are very anxious, a parent or another trusted person may be present.

4.6

Application to Adolescents

Bladder and bowel training is generally designed as a group treatment for children aged 6–12 years. However, adolescents between 13 and 16  years with different problems of incontinence have been treated with a slightly modified program. Topics

such as hygiene, puberty, relationships, etc., were added to the program (see Session 5) and materials were adapted accordingly. When using this program with adolescents, therapists and group members should be of the same sex. Anatomy and physiology of the intestinal and lower urinary tract can be discussed in more detail than with children. Physical and psychological changes during puberty should receive special attention. Social interactions and peer relationships should also be discussed in more detail because adolescents often perceive this area as problematic. Thus, alternative behavior strategies in difficult situations (e. g., wetting in the presence of friends or at school) should be discussed or practiced during role play. In the following chapter, single group sessions are outlined in detail. At the end of each session, a modification for adolescents is given.

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This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Chapter 5

Conducting the Individual Sessions 5.1

Bladder Training Session 1: Introduction, Defining Problems and Goals Topics

• Who are the Peeing Prince and Princess? • Why am I here and what do I want to learn? Goals

• Get to know the group and the characters Emily and Tom • Build up motivation through teamwork and goal setting • Reflect on the soiling/wetting problem • Improve self-perception Topic/Activity

Duration

Materials/Worksheets (see Appendix)

Welcome and get to know each other

10 min

• Small ball (e. g., tennis ball)

Setting up group rules

10 min

• Bladder Training Material: Group Rules • Pencils

Introduction of the characters

10 min

• Bladder Training Material: The Story of the Peeing Prince and Princess

Introduction of the comfy book and the drinking ritual

5 min

• Folder for each child • Bladder Training Worksheet 1: My Comfy Book (Cover) • Bladder Training Worksheet 2: Introduction • Drinks (water, juice mixed with water) • Cups

Opening round

5 min

• Bladder Training Material: Mood Barometer • Toy Figures (such as Playmobil®)

Problem and goal definition

20 min

• Bladder Training Worksheet 3: Problems and Goals • Bladder Training Material: Emotion Cards Tom or Emily (version for boys or girls) – several copies, already cut out • Glue

History and problem evaluation

15 min

• Bladder Training Worksheet 4: Questionnaire

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40

Chapter 5 Topic/Activity

Duration

Materials/Worksheets (see Appendix)

The 3 Golden Rules

10 min

• Bladder Training Material: The 3 Golden Rules (large print-out) • Bladder Training Worksheet 5: The 3 Golden Rules

Closing round and homework

5 min

• Bladder Training Worksheet 6: My Profile

Please note: Examples and suggestions on how to verbalize instructions are included in the description of the training. They are given in gray boxes. 5.1.1

Welcome and Get to Know Each Other

For each session, a room large enough for various relaxation and perception tasks should be used. There should be a big table. At the beginning of the first session, children and therapists sit around the table. Drinks (water or juice mixed with water) and cups should be placed in the middle of the table. The therapists welcome the children and introduce themselves and their occupation. This is followed by a get-to-know-each-other game. “Now we are going to play a game to get to know each other. It goes this way: I will take the ball and say, ‘My name is … I enjoy eating … (name your favorite food).’ Then I will throw the ball to someone else and will ask a question, e. g., ‘What are your hobbies?’ This person catches the ball, says his/her name, and answers my question. Then, he/she asks another question (he/she can also repeat a previous question, e. g., about hobbies or a favorite food) and throws the ball to another child. We will do this until we’ve got to know each other a little more. Do you have any questions? (short pause) … OK then, let’s start!”

5.1.2

Group Rules

An important aspect of the first session is the development of group rules. For this purpose, the sheet called Group Rules (Bladder Training Ma-

terial: Group Rules) is put in a place where all participants can see it (e. g., in the middle of the table). Explain to the children that it is important to have rules for the group that all participants respect so that they can all reach their goals. Ask the children which rules would help them to participate actively in the training. It is also very useful to refer to general rules of conduct, which some of the children may already know from school. Many children come up with rules themselves, e. g., letting others finish when speaking or not laughing at others. List all rules on the sheet. Ask the children whether someone can think of additional rules that are important to him or her. Add them to the sheet. Rules During Bladder and Bowel Training

The therapists should pay attention that the following rules are mentioned and should add them to the list of group rules if necessary: • We let each other finish speaking! • We raise our hands before we talk! • We do not laugh at anyone! • We listen to others and do not interrupt them! At the end, have all participants, including the therapists, sign the sheet with the group rules and hang it up where everybody can see it. Optionally, a rewarding system can be used if there are children with behavioral disorders in the group (e. g., ADHD or conduct problems) or if the children are agitated. At the end of each session, every child receives praise or a small reward if he or she has adhered to all the rules.

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Conducting the Individual Sessions 5.1.3

Introduction of the Characters Emily and Tom

In the next part of the session, the characters of the group training are introduced, Tom and Emily – the Peeing Prince and Princess. The characters accompany the children throughout the training and often occur in the material. Both of them have incontinence and serve as figures to identify with. Read the story of Tom and Emily to the participants (Bladder Training Material: The Story of the Peeing Prince and Princess). “I’d like to tell you the story of two friends who will accompany us during the next weeks. Sit comfortably on your chair, take a deep breath, and listen. You can close your eyes if you like… (short pause) In a faraway country, where the sun shines for the longest time, kings and queens still reign. Emily and Tom also live there. They are the children of King George II and Queen Rose I. They live in a huge castle with many rooms, huge windows, a well, and hundreds of servants. Although they live in such a magnificent castle, Emily and Tom are just two normal children. They do the same things as you and I, even though they are called Prince and Princess. Tom is 10 years old, enthusiastic at playing soccer and loves building castles and ships. But his most favorite thing to do is making fun of his sister. Emily is only 7 years old. She loves giving tea parties for her dolls and meeting with her girlfriends. Both go to school. Tom is in 5th grade and Emily in 2nd grade. Both love to play tricks on their parents. As you can see, they are actually two normal children. Yet, the royal children have a minor problem. Every morning, Emily wakes up in a sea full of pee. She always wonders, ‘Where does it come from?’ and ‘Maybe I’m ill?’ By now, she has become so embarrassed that she takes the sheets off in the morning and hides them in her closet. Of course, the servants notice this and tell her mother. When she finds out, the queen always gets angry with her daughter. Emily is also

41

afraid of sleeping over at her friends’. Some times her friends feel upset because they believe Emily does not like them. But what is even worse: Sometimes even at daytime Emily is not able to get to the toilet quickly enough because she has such an urge. It does not matter where she is, she cannot hold her pee, which then goes into her pants. She is also annoyed that she has to go to the toilet at least 20 times a day and that her pants are still wet. Tom always laughs at Emily and says that she is still a baby. But today he is quiet because he has experienced himself that it is not so easy to control his body. Just last week, while sitting on his Prince’s toilet, he noticed that his underpants were soiled with poo. He could not explain where it came from. Sometimes Tom is so involved in his knight-computer game that he does not get to the toilet in time. Then some drops of pee go into his pants. Tom does not tell his parents that because he is too ashamed and does not want them to think that he’s still a baby. He hides his underpants and thinks, ‘Nobody will notice!’ However, Mom and Dad do know about their children’s problems. Dad does not believe that it is serious at all. He also wetted in his bed when he was a little prince. Mom is annoyed because of all the washing and the smell. Also, she cannot stand her children hiding their underpants or sheets. As you can see, sometimes things go wrong even with royal children. Therefore, Tom and Emily have decided to do something about it together with us. They want to learn how peeing and pooing happen and what they can do against wetting and soiling!” Discuss the story with the children. Taking turns, the children can say what they liked or did not like about the story or they could talk about their own experiences. Of course, some children might not want to talk about the story or their expe­riences because it is a very painful topic. This should be accepted by everyone, as written down in the group

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42

Chapter 5

rules. In order to initiate a discussion, you might use the following questions: • How did you like the story? Did you like it? Why (not)? • Do you know the problems Emily and Tom are experiencing? • Do you sometimes feel like them? • Emily does not want to sleep over at her friends’ because of her peeing problem. What things do you not want to do because of your peeing or pooing problem? • How do your parents react? • What do you not like about wetting or soiling? • Is there something positive in the story (e. g., no punishment by the parents)?

their Comfy Book. Each session they will receive new worksheets for the book. Tell them that it is called the Comfy Book because it will help them to learn how to deal with their bladder and bowel problems, and, as a result, they will soon feel more comfortable. Ask the children to write down their name and age on the cover and read the introduction to them. The children may take the folder home but should bring it to every session.

5.1.4

5.1.5

Introduction of the Comfy Book and the Drinking Ritual

Give each child a folder, the cover page (Bladder Training Worksheet 1), and the introduction (Bladder Training Worksheet 2) of the Comfy Book. Explain to the children that the folder will become

Next, introduce the drinking ritual. Explain that regular drinking is very important and pour water into the cup of every child. Children are allowed to refill their cups and to go to the toilet anytime. The ritual will be repeated at the beginning of each session. Opening Round

Put the mood barometer (Bladder Training Material: Mood Barometer; see Figure 2) in the middle of the table and place different toy figures next to it. Ask the children to take a figure and put it in the place on the barometer that best represents

Mood Barometer

Stimmungsbarometer

Figure 2 This page may be reproduced by the purchaser for personal/professional use. From M. Equit, H. Sambach, J. Niemczyk, & A. von Gontard: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents © 2014 Hogrefe Publishing Mood barometer.

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Conducting the Individual Sessions their current mood. Afterwards, every participant may report how he/she feels and what he/she expects from group training or what he/she wants to learn. A similar opening round, asking the children about how they (and their bladder and bowels) feel, will be conducted at the beginning of each session. 5.1.6

Problem and Goal Analysis

Hand out Bladder Training Worksheet  3 (Problems and Goals) and spread the emotion cards (Bladder Training Material: Emotion Cards Emily or Tom; see Figure 3) on the table. The children work through the first two questions on the worksheet on their own. They are asked to name their

Emotion Cards Emily

Gefühle

happy glücklich

proud stolz

surprised überrascht

afraid ängstlich

ashamed beschämt

angry wütend

disgusted eklig

problem and estimate how serious it is on a scale from 1–10. Show and explain the emotion cards to the children. Then ask them to choose the emotion card that best describes the emotion associated with their problem and glue it into the box next to the third question. In the second part of the worksheet, the children are asked to name the goals they want to reach during the training. Pay attention that the children name clear, positive goals (e. g., “I want to become dry” instead of “I don’t want to wet any longer”). Again, ask them to glue the equivalent emotion card into the box on the worksheet. When the children have worked through the worksheet, discuss the results with them. Ask the children to talk about his/her problem and goals. If a child is too ashamed to read out the answers, recall the group rules or ask another child to answer. Make sure that the group accepts it if a child does not want to talk about his/her problems and goals in front of the other children. Praise the participants for their openness. 5.1.7

cheerful fröhlich

sad traurig

Figure 3This page may be reproduced by the purchaser for personal/professional use. From M. Equit, H. Sambach, J. Niemczyk, & A. von Gontard: Emotion cards Emily (version for girls). Urinary and Fecal Incontinence: A Training Program for Children and Adolescents © 2015 Hogrefe Publishing

43

History and Problem Evaluation

Ask the children to complete Bladder Training Worksheet 4 (Questionnaire). Read the questions out loud and let one or two children answer the questions. The questionnaire serves for history taking and to check how the children perceive their problem. If there is not enough time to answer all questions, the remaining ones can be done as homework. 5.1.8

The 3 Golden Rules

Cover the sheet The 3 Golden Rules (Bladder Training Material: The 3 Golden Rules; see Figure 4) with an blank sheet so that only the three questions at the top are visible and put it on the table or hang it up. Read the first question and collect the answers and ideas of the children. Lay the first picture open and discuss the solution with the children. The children may report their experiences, e. g., what they are already doing right. Continue with the remaining questions.

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44

Chapter 5 Questions for the 3 Golden Rules

1. When should you go to the toilet? The children should learn to go the toilet as soon as they have a feeling of urgency (there is pressure in the abdomen or it’s tickling). This will relieve their bladder. 2. How often should you go to the toilet every day? The children should go to the toilet approximately 7 times a day to empty the bladder. 3. How should you go to the toilet? Children should urinate in a relaxed way and take their time so that the bladder is emptied completely. Hand out Bladder Training Worksheet  5 (The 3 Golden Rules) to the children for their Comfy Book.

5.1.9

Closing Round and Homework

At the end of each session, there is a short closing round when the children tell how they feel and how they liked the session. Do this with the children and then hand out Bladder Training Worksheet 6 (My Profile) as homework. Ask them to bring it to the next session. 5.1.10 Modification for Adolescents

Using this session with adolescents, attention should be paid on how the participants get to know each other because feelings of shame can be greater in adolescents. Therefore, make sure to address age-appropriate topics during the introduction game and opening round, e. g., favorite music or soccer team. The characters of the Prince and Princess should not be emphasized as

Bladder Training Worksheet 5

The 3 Golden Rules

When? WANN?

How WIEoften? OFT?

How? WIE?

Too Zu spät! late!

Spüre dieyour Blase Feelfrüh, earlywenn on that voll istisund in to bladder fullgehe and go Ruhe zur Toilette! the toilet relaxed.

Gehe 7 toilet Mal Go to the 7zur times a day. Toilette!

Lass Zeitand Take yourdirtime und mache Blase empty yourdie bladder in einem in oneMal go.leer!

Based on KgKS, 2010. Reprinted with permission from Pabst Science Publishers, © 2010. Figure 4 This page may be reproduced by the purchaser for personal/professional use. From M. H. Sambach,rules. J. Niemczyk, & A. von Gontard: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents © 2015 Hogrefe Publishing The 3Equit, golden

Based on KgKS, 2010. Reprinted with permission from Pabst Science Publishers, © 2010.

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Conducting the Individual Sessions much because they serve as identification figures for younger children. Feel free to have an age-appropriate discussion with the adolescents instead of reading the story  of the “Peeing Prince and Princess.” The following questions may be very helpful: • How do you like being in this group? Are you embarrassed? • How do you cope with your problem? Do you talk openly about it or do you try to hide it? • What tricks and excuses do you use? • What difficulties do you experience in everyday life because of your wetting (soiling) problem? • How do your parents cope with the problem?

45

• What are you expecting from this group training? Adolescents should not be forced to talk but may say something if they feel like it. If no adolescent wants to talk at the beginning, consider reporting experiences of other wetting adolescents and talk about shame openly. Bladder Training Worksheet  4 (Questionnaire) can be filled out during this discussion. During the work on The 3 Golden Rules, it is relevant how much adolescents already know about going to the toilet. Read the three questions aloud and wait for the answers of the participants. Add discussion points which have not been mentioned.

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46

5.2

Chapter 5

Bladder Training Session 2: Anatomy and Physiology Topics

• How do food and fluids get through our body? Goals

• Provide information on anatomy and physiology (“from mouth to bladder/bowels”) • Check the children’s knowledge Topic/Activity

Duration

Materials/Worksheets (see Appendix)

Welcome and drinking ritual

5 min

• Drinks

Opening round

5 min

• Bladder Training Material: Mood Barometer • Toy figures

Discussion of homework

10 min

• Bladder Training Worksheet 6: My Profile filled out by the children

How food and fluids get through the body – Part 1

10 min

• Bladder Training Worksheet 7: How Do Food and Fluids Get Through Our Body? (version depends on sex of the children)

How food and fluids get through the body – Part 2

35 min

• Inside-my-body picture already prepared with the help of: ––Bladder Training Material: Instructions for the ­Inside-My-Body ­Picture ––Bladder Training Material: Templates for the ­Inside-My-Body ­Picture ––Colored drawing paper, foamed rubber, hook and loop fastener (such as Velcro®)

Game: What’s my name?

15 min

• Bladder Training Worksheet 8: Body Picture (version depends on sex of the children) • Pencils • Bladder Training Material: Game Cards for What’s My Name? – already cut out

Closing round and homework

10 min

• Bladder Training Worksheet 9: Maze • Optional: children’s books of your choice about anatomy

5.2.1

Welcome and Drinking Ritual, Opening Round, and Discussion of Homework

Welcome the children to the group and have everyone drink water or juice mixed with water. Ask the children to report events of the last week with

the help of the mood barometer (Bladder Training Material: Mood Barometer). Everyone should say how they feel right now using the mood barometer. You may ask the following questions to prompt the children: • Has something special happened since the last session?

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Conducting the Individual Sessions • If so, how did you feel then? • Are there any news about your bladder (bowel) problem? Then have the children present their profiles, which they filled out as their homework. Everyone may ask the presenting child questions. 5.2.2

The Way Food and Fluids Get Through the Body – Part 1

In this session, the children should work out which organs are involved in drinking, eating, and going to the toilet, i. e., how food and fluids get through the body. Hand out Bladder Training Worksheet 7 (How Do Food and Fluids Get Through Our Body?) with a body shape (depending on the sex of the child either a male or female body) and ask the children to draw the gastro-intestinal and urinary tracts as they think it looks. “Today, we want to have a look at what’s happening in our bodies when we drink, eat, and finally have to go to the toilet. Maybe you already know some things about it. I will hand out a worksheet  with our “Peeing Prince and Princess”. Please draw the way food and fluids get through the body and how they eventually leave as pee and poo. It is not important that your drawing is correct but that it shows how you imagine it to be.” The drawings are neither commented nor discussed, but put aside and looked at again after the following exercise. 5.2.3

The Way Food and Fluids Get Through the Body – Part 2

In a next step, the group will work out how food and fluids get through the body with the help of the inside-my-body picture (Bladder Training Material: Instructions for the Inside-My-Body Picture). Distribute the organs you made of foamed rubber on the table and put the picture of the body shape next to it. Quickly review each organ so that the children know what they are. Then ask the

47

children which organ is first when food and fluids travel through the body. When a child names the right organ, explain the organ’s function and have the child attach the organ to the right spot of the body. Begin like this: “You have just drawn how you think food and fluids go through your body and how then urine and feces are produced. Now let’s have a look at it together. There are different organs that are involved in this process on this table. Does anyone of you know where the journey of food and fluids begins?” If a child says mouth or points to it, explain that food and liquid first pass the lips. Solid food is chewed in the mouth. Have the child attach the mouth in the right place on the body. Continue this way until all steps of the passage through the body have been discussed and all organs are at the right places. “Where do food and fluids go once they’re in the mouth? … Right, they go into the esophagus. The esophagus looks like a long hose. While swallowing, the epiglottis (a small flap inside your throat) closes the wind pipe to your lungs so that water and pieces of food do not get in it and you do not choke. Where do water and pieces of food get to next? – The stomach. In the stomach, water and food are mixed up. From the stomach they go to the – small intestine, right. The small intestine is about 10 feet (~3 meters) long and rolled up like a fire hose. In the small intestine important nutrients which we need to survive (e. g., vitamins) are taken out of the food and transported into the blood. Nutrients in the blood travel through the entire body so that every cell of the body receives some of them. But what happens to the food that is left in the small intestine and which the body does not need? … It moves into the – colon, right. The colon is only about 5 feet (~1.5 meters) long, but it is much thicker than the small intestine. There, water is extracted from the food, which also goes into the blood and travels through the body as the nutrients do. When this is done, only solid leftovers remain which cannot be

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48

Chapter 5

used by the body. What do we call these leftovers? Yes, exactly, feces (or poo). After a long way through the body, digested food is released through the rear and ends up in the toilet. Do you remember where the water and nutrients are? Yes, exactly, they travel in the blood to all cells of the body. The blood supplies the whole body with nutrients, but it also takes back food residues – like some kind of garbage removal. Therefore, every once in a while the blood has to be cleaned. Does anyone know where this cleaning happens? … Yes, the kidneys clean the blood – they are a kind of washing machine of the body. Every human being has two kidneys. During cleaning, the garbage is filtered out of the blood. What do we call the result of the cleaning? Urine (pee), exactly! The pee goes from the kidneys through the ureter (a tube) into the bladder, where it is collected. The bladder looks like a balloon. And what happens to the bladder when it’s full with pee?… Exactly, then you have to go to the toilet. The pee goes from the bladder into the toilet through the urethra (a tube).

the picture on the worksheet and the inside-mybody picture should help the children find the ­answers. When the name of the organ has been found, ask the children to write it next to the organ on the worksheet. Bladder Training Worksheet 8 – Version for Boys

Body Picture Please fill in the blanks.

So, now we know how food and water travel through our body and how many organs are involved in it. It’s a long way from the mouth to the exit!” Following this exercise, ask the children to take out the pictures they drew earlier and compare them to what you just discussed. 5.2.4

Game: What’s My Name?

In order to consolidate knowledge on anatomy and the function of the digestive organs play the game What’s My Name? Before playing the game, hand out Bladder Training Worksheet 8 (Body Picture; either male or female version; see Figure 5) and explain that it shows all organs that are involved in digesting food and fluids. Place the game cards (Bladder Training Material: Game Cards) on the table. Explain that each card describes the function of an organ. Have the children take turns drawing a card, read the card out aloud, and ask the others to guess which organ it could be. Both

Figure 5This page may be reproduced by the purchaser for personal/professional use. From M. Equit, H. Sambach, J. Niemczyk, & A. von Gontard: Body picture (version for boys). Urinary and Fecal Incontinence: A Training Program for Children and Adolescents © 2015 Hogrefe Publishing

5.2.5

Closing Round and Homework

Quickly recap today’s session by saying that the children learned how food and fluids travel through the body. Explain that they will review what they learned today on Bladder Training Worksheet  9 (Maze) and that they should complete it as homework together with their parents (parent–child homework). If there is still some time left at the end of the session, the children may read and look at the books about anatomy. Therefore, it is useful to have a selection of books dealing with body functions available.

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Conducting the Individual Sessions 5.2.6

Modification for Adolescents

In the session with adolescents, omit Bladder Training Worksheet 7. Instead, functions of the organs can be described more in detail. For girls,

49

the position of the genitals (womb, vagina) in the urinary tract (between urethra and anus) should be pointed out. You can also mention physical changes during puberty.

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50

5.3

Chapter 5

Bladder Training Session 3: Pathophysiology of Wetting and Coping With Stress Topics

• How does wetting happen? • What has stress got to do with it? Goals

• Provide information on pathophysiology of wetting • Recognize, perceive, and counteract stress Topic/Activity

Duration

Materials/Worksheets (see Appendix)

Welcome and drinking ritual

5 min

• Drinks

Opening round

5 min

• Bladder Training Material: Mood Barometer • Toy figures

Discussion of homework

5 min

• Bladder Training Worksheet 9: Maze filled out by the children

Knowledge test

10 min

• Bladder Training Worksheet 10: Body Quiz

How does wetting happen?

10 min

• Balloons

Bladder stories

25 min

• Bladder Training Material: Bladder Stories

Stress

15 min

• Bladder Training Worksheet 11: My Stress Worksheet • Balance (scale with two plates) and marbles

Homework: My stress calendar

5 min

• Bladder Training Worksheet 12: My Stress Calendar

Relaxation techniques or closing round

10 min

• Gymnastic mat, armchair, blankets, pillows • Relaxation technique for children (e. g., from Lite, 2011)

5.3.1

Welcome and Drinking Ritual, Opening Round, and Discussion of Homework

Welcome the children and go through the drinking ritual with them. Then the opening round follows with the help of the mood barometer (Bladder Training Material: Mood Barometer). Ask the children to tell everyone how they feel, what has happened since the last session, and how their bladder (bowel) problem has been. Afterwards,

have the children present their homework and ask them to name organs that are involved in the digestion of food and fluids. 5.3.2

Knowledge Test

Test the children’s knowledge of their body with the help of Bladder Training Worksheet 10 (Body Quiz).

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Conducting the Individual Sessions

“Today we want to start with a small quiz. Try to answer the questions on the worksheet. We will then discuss your answers.” Give the children 10 minutes to work through the 6 multiple choice questions on the worksheet. Explain that only one answer for each question is correct and that they should mark the letter next to the correct answer. All letters put together will give them a new word. When the time is up, ask the children to name their answers in turns. Have them write the letter for each answer on the lines at the bottom of the worksheet. Friend is the word they are looking for. 5.3.3

How Does Wetting Happen?

Session 3 focuses on the age-appropriate communication of the pathophysiology of wetting, i. e., what happens inside the body – especially inside the brain and bladder – when it comes to wetting. “We already know what happens inside the body when we have eaten and drunk something and which organs are involved in the digestion. Next, we’ll learn about what goes on when wetting happens. You already know that the bladder looks like a balloon. This is a balloon. Imagine that this is your bladder. (take out a balloon) What happens when we drink a lot? … Yes, exactly, the bladder fills up. Urine goes from the kidneys through the ureter into the bladder. I’ll blow up the balloon to show how it fills up. (blow up the balloon and hold it with the open end towards the floor) Does the pee (the urine) always flow out the bladder immediately? … No, at the bottom of the bladder there is a muscle – here where I have my fingers – that takes care that large amounts of pee can go into the bladder without any of it flowing out. The muscle is called bladder gate. As you can see, I can hold the balloon shut with my two fingers so that no

51

air comes out. This is the same in your bladder. When the bladder fills up, the bladder gate remains closed. And when the bladder gets really full, what happens then? Does the bladder burst like a balloon that has too much air? … No, the bladder doesn’t burst. Through the nerves, which look like telephone cables, the bladder sends a signal to the brain. Just like this: ‘Hi brain! I’m full and need to empty! Please go to the toilet!’ After that, the brain sends a signal to the body to go to the toilet. Then the detrusor, which is a muscle surrounding the bladder, contracts and the bladder gate opens. And so, pee flows into the toilet. However, it can happen that the bladder sends the signal too late or that the brain does not receive the message because it’s occupied with other things, e. g., playing. What happens then? … Yes, the detrusor contracts, the bladder gate opens, and the pee flows out. And if you were not able to get to the toilet in time, the pee goes right into the pants. You can see it well with this balloon: When I relax my fingers, which is like the bladder gate opening, the air flows out, just like pee goes out of the bladder (hold on to the balloon with one hand and slowly relax the fingers that hold the balloon closed).”

5.3.4

Bladder Stories

In the next part of the session, the children may tell their own bladder story. Hand out the sheets with the bladder stories (Bladder Training Material: Bladder Stories). Explain that the stories show different situations of wetting (see Figure 6 for two of them). Each bladder story illustrates a different subtype of incontinence (urge incontinence, voiding postponement, dysfunctional voiding). Look at the stories together with the children and ask them which of the stories shows what they experience. Then ask the children to tell their own bladder story. The goal of this exercise is that the children understand their personal story.

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52

Chapter 5 Children with voiding postponement often wet during play or while watching TV because in these situations bladder and brain do not work together due to distraction. These children hold back until the bladder overflows because they are afraid to miss something important. Bladder Stories 1 or 4 illustrate this subtype.

Helpful Questions for Choosing the ­Appropriate Bladder Story

In which kind of situations do you wet? How does your bladder tell you that it’s full? What happens in your head? What does your bladder do then? Bladder Story 1

Du musst noch You’ve got to etwas wait. I’mwarten. playing Ich right spielenow. gerade so schön. I’m full. Ich bin voll, Could you to kannst dugo mal the aufstoilet? Klo?

But I can’t Ich kann nicht hold the pee any mehr halten! longer!

3+5=8 7+2=9

Warum hast Why didn’t you du wait a little nicht longer? gewartet?

Ich möchte But I want to zukeep Endeon playing! spielen!

Zu spät! Too late! Na toll!

Mist, ich schaffe es nicht!

Oh nein!

Hilfe, schnell, ich muss zur Toilette!

Schade, zu spät!

Schnell, ich kann nicht mehr!

3 + 7 + 5 = 4 + 2 = 9 + 6 = 3 + 7 = 8 =

3 + 7 + 5 = 4 + 2 = 9 + 6 = 3 + 7 = 8 =

3 + 7 + 5 = 4 + 2 = 9 + 6 = 3 + 7 = 8 =

Bladder Story 3

This page may be reproduced by the purchaser for personal/professional use. From M. Equit, H. Sambach, J. Niemczyk, & A. von Gontard: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents © 2014 Hogrefe Publishing

Open Los, mach dein your gate, Tor auf, Pipiblase! bladder! I’ve got Ich tomuss! pee!

I‘m Ich drücke pressing ganz fest! really hard!

Das macht That’s no keinen fun. Spaß!

Ich kann I can’t! nicht, It’s es tooist so schwer! difficult!

Ich sehe doch,dass du musst!

Gehst du bitte auf Toilette?

Philipp hört die Blase nicht

?

Ich muss mich entleeren!

Hallo?! Hello?! I’m Ichnot binempty noch yet!leer! nicht

This is Das dauert taking a long aber lange! time!

Wieso? Ich muss doch gar nicht, Mama.

Schnell, ich kann nicht mehr!

Nein!

Das dauert mir zu lange!

Figure 6 This page may be reproduced by the purchaser for personal/professional use. From M. Equit, H. Sambach, J. Niemczyk, & A. von Gontard: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents © 2014 Hogrefe Publishing Bladder stories.

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Conducting the Individual Sessions

53

Bladder Training Worksheet 11

Children with urge incontinence can tell their story  with the help of Bladder Story  2. In this story, the bladder calls the brain before it is full. This happens because the detrusor already presses actively. In most cases, the urge is so strong that the children are not able to get to the toilet in time. Bladder Story 3 is appropriate for children with dysfunctional voiding. In this condition, both muscles (detrusor and sphincter) do not work together as they should. When the detrusor presses, the sphincter contracts and does not let go of the urine. The result is that the bladder is not emptied completely while on the toilet and that the child wets later on. In addition to voiding postponement, Bladder Story 4 shows a child refusing to go to the toilet. At this point, you can ask further questions such as, “Does it ever happen that your mom tells you to go to the toilet but you don’t go?” and “Do you wet right afterwards?”

My Stress Worksheet What stresses you? Write everything down in the box! ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________

Where do you notice stress in your body? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Do your wetting and stress have something to do with each other?

 Yes. When I’m stressed, I wet more often.  No. They have nothing to do with each other.  I don’t know. I’ve never paid attention to it.

What are your comfy activities? Write them into the suns!

5.3.5 Stress

Another important part of this session is to discuss how stress arises and how it is associated with wetting. Coping strategies are worked out as a group. Hand out Bladder Training Worksheet  11 (My Stress Worksheet; see Figure 7). The goal of this worksheet is to find out what the children already know about stress. First, ask the children what causes them stress and to write everything down in the first box. If the children know body reactions to stress (e. g., being tired, headache, maybe also wetting) they can write them down as well. The third question is aimed at helping the children recognize the connection between wetting and stress. Explain that some children wet more often when they experience stressing factors. Before completing the last part of the worksheet, take out a balance with two plates and demonstrate what happens if there is too much weight on the stress side and too little on the other side (the balance becomes unbalanced). Feel free to talk about your own stressful experiences (e. g., much to do at work, housework, an argument with someone,

Figure 7This page may be reproduced by the purchaser for personal/professional use. From M. Equit, H. Sambach, J. Niemczyk, & A. von Gontard: MyUrinary stress worksheet. and Fecal Incontinence: A Training Program for Children and Adolescents © 2014 Hogrefe Publishing

etc.) and place a marble on one plate for each experience. Next, tell the children that stress can be counteracted with the help of nice, relaxing activities, such as reading a book, going out for a walk, listening to music, meeting friends, etc. For each comfy activity, i. e., stress-reducing activity, place a marble on the other plate so that both sides balance out. In the next step, ask the children to write down their comfy activities on the worksheet. “Now, you have described quite well what stress means to you and what stresses you out. Everyone is stressed at some point and you cannot always avoid stressful situations. Therefore, it is important that you find activities that balance out your stress (as we have just seen with the

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54

Chapter 5

scale). We call these balancing activities comfy activities. Comfy activities are good for you and your body because they relax you. Can you think of some comfy activities you already do or would like to do? Write them into the suns on the worksheet.”

5.3.6

as the story of Angry Octopus from Lite (2011). For this exercise, the children lie down on gymnastic mats or make themselves comfortable  on chairs or armchairs. They can take off their shoes and put their legs on a chair if they like. Guide the children through the exercise according to the instructions. If there is some time left at the end, carry out a short closing round by recapping the content of today’s session.

Homework and Relaxation Exercise

Hand Bladder Training Worksheet 12 (My Stress Calendar) to the children and explain that it is a stress calendar that they should fill out together with their parents. Every day for the next week, they should write down stressful situations and comfy activities that helped them cope with them. Today’s session ends with a relaxation exercise. Use a progressive muscle relaxation exercise, such

5.3.7

Modification for Adolescents

In general, the structure and content of this session can be kept the same for adolescents. Experience has shown that adolescents remember pathophysiology better as well if it is described as a dialogue between bladder and brain. Homework can be completed by the adolescents without the help of their parents, but, of course, they may help.

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Conducting the Individual Sessions

5.4

55

Bladder Training Session 4: Drinking Topics

• Why is drinking so important? Goals

• Reflect on drinking habits • Understand the importance of drinking • Optimize fluid intake Topic/Activity

Duration

Materials/Worksheets (see Appendix)

Welcome and drinking ritual 5 min

• Drinks

Opening round

5 min

• Bladder Training Material: Mood Barometer • Toy figures

Discussion of homework

5 min

• Bladder Training Worksheet 12: My Stress Calendar filled out by the children

Drinking game

10 min

• Bladder Training Material: Drinking Game (large printout) • Dice and game pieces

Drinking questionnaire

5 min

• Bladder Training Worksheet 13: Drinking Questionnaire

Why does your body need water?

15 min

• Bladder Training Worksheet 14: Why Does Your Body Need Water?

Golden rule for drinking and 10 min healthy drinks

• Bladder Training Worksheet 15: Information on Drinking

Making a drinking clock

15 min

• Paper plates, marker pen, pictures of drinks (from magazines etc.), clock hands made of colored drawing paper, brass fastener • Alternatively use paper cups and labels

Mixing cocktails, closing round, and homework

20 min

• Bladder Training Worksheet 16: Healthy Cocktails • Drinks (juices, water, tea), fruits, sugar (for the rims of the glasses), cocktail glasses, straws • Bladder Training Worksheet 17: My Drinking ­Schedule

5.4.1

Welcome and Drinking Ritual, Opening Round, and Discussion of Homework

Welcome the children and have everyone drink water or juice with water. Ask the children to report events from the past week with the help of the

mood barometer (Bladder Training Material: Mood Barometer). Discuss last week’s homework, the stress calendar, with them and ask the children to report when they had stress and whether they used comfy activities to reduce their stress. Remind the children of the connection between stress and wetting.

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56 5.4.2

Chapter 5 Drinking Game and Drinking Questionnaire

Place the drinking game (Bladder Training Material: Drinking Game; see Figure 8) in the middle of the table. Have each child pick a game piece and place it on the start field. Make sure that each child has a full cup to drink. Explain the game: “Today we will learn more about why we have to drink and what and how much we should drink. Let’s start today’s session with a drinking game. We will take turns rolling the dice. The number on the dice shows you how many steps you have to take with your game piece. The picture on the board where you stop tells you what you need to do. The one who gets to the goal first, wins the game! The youngest child may begin. Let’s go!” Have the children roll the dice and carry out the actions as outlined in the box.

Rules of the Game

Drop: “It starts to rain and you get wet. Take a large sip from your cup.” Thunder cloud: “There’s a thunder storm and everybody gets wet. Everybody has to drink.” Sun: “The sun is shining and everybody stays dry. Nobody has to drink.” Umbrella: “Quick! Get under the umbrella! Unfortunately, the umbrella is only large enough for 6 people. We will count and the person who says 7 has to drink.” Tom/Emily: „The Peeing Prince and Princess take your turn. Choose two other players to have a drink.” For a larger group or with adolescents you can use a variation of the game called Attention Please! The participants take turns rolling the dice. The number on the dice determines the action (see box below).

Drinking Game

Finish

Start Figure 8 This page may be reproduced by the purchaser for personal/professional use. From M. Equit, H.game. Sambach, J. Niemczyk, & A. von Gontard: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents © 2014 Hogrefe Publishing Drinking

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Conducting the Individual Sessions Variation of the Game: Attention Please!

1: The player takes a large sip. 2: The person on the right takes a large sip. 3: The person on the left takes a large sip. 4: The player chooses two other players who have to drink for him/her. 5: The player skips his/her turn, i. e., has to do nothing. 6: Everybody has to put their hands as quickly as possible on his/her bladder. The one who is last has to drink. After playing the drinking game, give each child Bladder Training Worksheet 13 (Drinking Questionnaire) and explain that they will write down information about their current drinking. Go through the questions one by one and have the children answer them in turns. Ask the children to write down their answers. 5.4.3

Why Does Your Body Need Water?

Hand out Bladder Training Worksheet 14 (Why Does Your Body Need Water?). Explain that the sentences tell why our bodies need water but that the sentences are missing words. Go through the worksheet and discuss with the children why the body needs water. Have the children write down the words to complete the sentences. The complete sentences are given in the box below. A worksheet with the answers is included in the materials. It might be useful to use this version with young children. Why Does Your Body Need Water? It needs water …

• So that your kidneys can clean the blood much better. • So that your body can digest the food better. • For tear drops. • So that your body can cool down by sweating when it’s hot or during exercise. • So that the blood can flow better through the body. • So that your body can protect mouth and nose against viruses and germs.

5.4.4

57

Drinking Rules, Healthy Drinks, and Making a Drinking Clock

In this part of the session, the children will learn how much they should drink every day and when they should drink it. Hand out Bladder Training Worksheet 15 (Information on Drinking) and go through it with the children. Talk about healthy drinks (water, juice mixed with water, and unsweetened tea) and why they shouldn’t drink so many unhealthy drinks (too much sugar). Make sure to point out the Golden Rule of Drinking: approx. 7 cups with 7–10 oz. (~ 200–300 ml) each day; one cup every 2–3 hours. In order to help the children remember to drink regularly, have them make a drinking clock. Give the children each a paper plate with the numbers 1–12 written on them so that they look just like a clock. Have the children glue pictures of glasses, cups, or bottles next to the times on the clock when they should drink. Help the children attach the arms of the clock (already prepared from colored drawing paper) with brass fasteners and review with them when and how much they should drink every day. When Should You Drink?

• At breakfast/in the morning • At school (two cups or a small bottle) • During lunch • In the afternoon (two cups or a small bottle) • During supper Instead of making the clock, you could also hand out 7 paper cups to each child and ask them to label them with the times of the day they should drink them. 5.4.5

Mixing Healthy Cocktails, Closing Round, and Homework

At the end of the session, have some fun with mixing healthy cocktails! Mix a few of the recipes listed on Bladder Training Worksheet 16 (Healthy Cocktails) from ingredients you should provide in advance. These tasty drinks and nice glass decorations may motivate the children to drink more.

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58

Chapter 5

Hand the worksheet  to the children and explain that they should try these cocktails at home as well. End the session with a short closing round and hand out the drinking schedule on Bladder Training Worksheet  17 (My Drinking Schedule) as homework. Ask the children to complete the chart during the next week and remind them to pay attention to their drinking habits and to drink enough every day.

5.4.6

Modification for Adolescents

Most of the content of this session can be kept. However, building the drinking clock may be omitted because adolescents might perceive the activity as childish. Alternatively, discuss with them ideas on how to remember to drink regularly (e. g., set an alarm on the cell phone or move bracelets from one arm to the other for every finished cup.)

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Conducting the Individual Sessions

5.5

59

Bladder Training Session 5: Going to the Toilet, Hygiene, and Constipation Topics

• When should I go to the toilet? • What is hygiene? • What does constipation have to do with wetting? Goals

• Learn to empty bladder and bowels regularly • Provide information on body hygiene • Illustrate the connection between bowels and bladder Topic/Activity

Duration

Materials/Worksheets (see Appendix)

Welcome and drinking ritual

5 min

• Drinks

Opening round

5 min

• Bladder Training Material: Mood Barometer • Toy Figures 

Discussion of homework

5 min

• Bladder Training Worksheet 17: My Drinking Schedule filled out by the children

When is it most important to go to the toilet?

10 min

• Board or flipchart, pencils • Bladder Training Worksheet 18: When to Go to the Toilet

Perception exercise

10 min

• Blank pieces of paper and pencils • Ultrasound or cups for measuring urine

How should I go to the toilet?

10 min

• Bladder Training Worksheet 19: How to Go to the Toilet

Hygiene

15 min

• Bladder Training Worksheet 20: Prevent Your Bladder From Getting Sick (version for boys or girls) • Body care products (pH-neutral soap, shower gel, toilet paper, etc.)

Constipation

20 min

• Bladder Training Worksheet 21: How Does Constipation Happen? • Bladder Training Worksheet 22: What to Do Against Constipation

Closing round and homework

10 min

• Bladder Training Worksheet 25: Perception Exercise (see Section 5.6.3)

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60 5.5.1

Chapter 5 Welcome and Drinking Ritual, Opening Round, and Discussion of Homework

Session 5 starts, as usual, with the welcome ritual; everyone drinks something and shares any news in the opening round. Then discuss the homework with the children. In the last lesson the children were taught to make sure to drink at least 7 cups per day and to write down all the drinks they had in a drinking schedule. Every child may now show his/her drinking schedule and explain on which days he/she has drunk enough fluids and whether there have been problems to do so.

5.5.2

When Is It Most Important to Go to the Toilet?

The first main topic of Session 5 is the necessity of going to the toilet regularly. Ask the children when they think they should go to the bathroom to pee. Collect the answers on a board or flipchart and add any missing answers to the list. Hand out Bladder Training Worksheet 18 (When to Go to the Toilet) and go through the different items. The goal is that the children learn, when it is most important to go to the toilet. When to Go to the Toilet

• Before going to bed at night • After waking up in the morning • Before going out to play • Before watching TV • When I have wetted • Every time I need to go

“Now that we know when it is important to go to the toilet, we will practice noticing how full our bladder is. Rub your hands together so that they get warm and then put them on your lower belly, just where your bladder is. Now, close your eyes and try to feel your bladder. What do you think? How full is your bladder – completely full, a little full, or completely empty?” Give each child a sheet of paper and ask them to draw their bladder and how full they think it is right now. If you have ultrasound available, check the children’s answers with the machine. If ultrasound is not available, ask the children to go to the toilet and measure their urine in a cup to see if they were right. This exercise can be repeated again later in today’s session. 5.5.4

How Should I Go to the Toilet?

The next part of the session is about peeing properly. Hand out Bladder Training Worksheet  19 (How to Go to the Toilet; see Figure 9) and talk about the rules for going to the toilet. Next, tell the children that you will act as if you’re going to the toilet and that you will make mistakes. Ask them to watch out for your mistakes and explain that you will talk about them later. Have a chair ready that will be your toilet. Pretend that you are going to the toilet and make mistakes while doing so (e. g., run to the bathroom, sit tensed, hurry through it, clean yourself from back to front, do not wash your hands, etc.). Ask the children to name the mistakes they saw you make. 5.5.5 Hygiene

5.5.3

Perception Exercise

The following exercise will help the children learn to estimate how full their bladder is. First the children will estimate how full their bladders are and then they will get a chance to check whether they’ve estimated correctly.

The next component of Session 5 is teaching personal hygiene. Discuss daily personal hygiene with the children, how to clean the body and especially how the genital region should be washed and cared for. Feel free to have different personal care products ready for demonstration (e. g., pH-neutral soap or shower gel, moist toilet paper, etc.).

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Conducting the Individual Sessions

61

Bladder Training Worksheet 19

How to Go to the Toilet

1. Go to the toilet relaxed!

2. Sit down relaxed!

3. Empty your bladder completely!

4. Take your time!

5. Clean yourself from front to back!

6. Flush the toilet!

7. Wash your hands!

8. Dry your hands!

Figure 9This page may be reproduced by the purchaser for personal/professional use. M. Equit, H. Sambach, J. Niemczyk, & A. von Gontard: How goIncontinence: toFromthe toilet. Urinary to and Fecal A Training Program for Children and Adolescents © 2014 Hogrefe Publishing

Explain that the bladder can get sick, which is called a bladder infection. This is very uncomfortable (itching or pain when urinating) but can easily be prevented if the children follow certain rules for hygiene. Hand out Bladder Training Worksheet 20 (Prevent Your Bladder From Getting Sick) and discuss the content. Note that the versions for boys and girls consider gender specific aspects of personal hygiene. 5.5.6

Constipation, Wetting, and Prevention

The last topic today is constipation, how it comes about, and how it is connected to wetting. “We have just learned a lot about how important it is to go to the toilet to pee, what the best

way is to do it, and how to wash yourself properly so that your bladder doesn’t get sick. Now let’s discuss a topic which is sometimes connected to wetting: constipation. Who knows what constipation is? Has anyone of you already had constipation? What was it like?” Ask the children to share their experiences with constipation. Possibly, some children in the group suffer from fecal incontinence and constipation and can tell a lot about this issue. Next, describe how constipation happens with the help of Bladder Training Worksheet 21 (How Does Constipation Happen?; see Figure 10). “Let me tell you a bit about constipation and how it happens. I’m sure all of you had times when you knew that you had to go to the toilet to poo but you didn’t want to because you wanted to continue playing. Or maybe some of you have felt pain when trying to poo and you had to press hard. Have a look at the worksheet. The first picture shows how poo is collected in the bowels. The bowel gate (a muscle just like the bladder gate) is kept shut so that no poo can get out. If you keep the bowel gate shut, more and more poo is collected and your colon gets bigger and bigger. Over time it gets very difficult for the bowels to let go of the poo because the poo becomes really hard and pooing hurts even more. The second picture shows how large the colon gets. So, if there’s a lot of poo in the bowels and it is so hard that it can barely get out, then this is constipation. Having constipation can hurt a lot. Do you have an idea, why one might wet because of constipation? … Exactly, when the bowels are full, it can put pressure on your bladder so that it cannot hold the pee any longer. And you already know what happens then. The bladder gate opens and pee goes into the pants.” After talking about what happens in the bowels when constipated, discuss factors that can lead to constipation and write them on the board (holding maneuvers, not taking time on the toilet, not enough

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Chapter 5

fibers in the food, too much white bread, too much chocolate, too much fat, too few fruits and vegetables, too little to drink, not enough sports and exercise, too much sitting, etc.). Then, hand out Bladder Training Worksheet 22 (What to Do Against Constipation) and discuss with the children how they can prevent constipation. 5.5.7

Homework and Closing Round

At the end of the session, you can repeat the exercise for bladder perception (see Section 5.5.3) including the checking of the estimates. Ask the children to do this exercise 2–3 times per day at home. They should note the estimated filling of

their bladder either by drawing it on a sheet of paper or by using Bladder Training Worksheet 25 (Perception Exercise; see Section  5.6.3). Do a short closing round to end the session. 5.5.8

Modification for Adolescents

The focus of the session for adolescents should be on the perception exercise and hygiene. The two topics of when and how to go to the toilet (Bladder Training Worksheets 18 and 19) can be discussed in less detail and the adolescents should be asked what they already know about it. Finally, changes during puberty should be mentioned (e. g., hygiene during menstruation) and elaborated on in more detail.

Bladder Training Worksheet 21

How Does Constipation Happen?

Verstopfung constipation Darmtor bowel gate

Darmtor bowel gate

Figure 10 This page may be reproduced by the purchaser for personal/professional use. From M.does Equit, H. Sambach, J. Niemczyk, & A. vonhappen? Gontard: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents © 2014 Hogrefe Publishing How constipation

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Conducting the Individual Sessions

5.6

63

Bladder Training Session 6: Emotions, Body and Bladder Perception Topics

• How do I feel when I have wetted? • How can I learn to feel and relax my bladder and pelvic floor? Goals

• Perceive and self-reflect emotions • Increase bladder and body perception Topic/Activity

Time

Materials/Worksheets (see Appendix)

Welcome and drinking ritual

5 min

• Drinks

Opening round

5 min

• Bladder Training Material: Mood Barometer • Toy figures

Discussion of homework

5 min

• Perception Exercise (conducted at home by the ­children)

Emotions

35 min

• Bladder Training Worksheet 23: Emotions • Bladder Training Material: Emotion Cards Tom or Emily (multiple copies, already cut out) • Pencils, glue • Bladder Training Worksheet 24: Emotion Homework

Body and bladder perception

20 min

• Bladder Training Material: Series of Pelvic Floor ­Exercises • Trampoline, massage balls, tennis balls, grain ­pillows, gymnastics mat, gymnastics ball, stop watch • Bladder Training Worksheet 25: Perception Exercise • Ultrasound or cups for measuring urine

Relaxation

15 min

• Blankets • Relaxing music • Relaxation exercise

Closing round and homework

5 min

• Bladder Training Worksheet 24: Emotion Homework

5.6.1

Welcome and Drinking Ritual, Opening Round, and Discussion of Homework

Welcome the children with a drink and an opening round. This session focuses on the perception and reflection of emotions and on the perception of the

body and especially the bladder. First, discuss the homework from the last session. The children had been asked to do the perception exercise multiple times per day, noting down their estimated filling states of their bladder. Ask them to report in turn whether their estimates where right and whether their wetting has decreased since the last session.

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Chapter 5

5.6.2 Emotions

Before the session starts, place the emotion cards on a table  (Bladder Training Material: Emotion Cards Emily or Tom) where the children cannot see them. Ask them to name emotions they know and in which situations they experience them (e. g., “I’m sad when my friend doesn’t go to the same class I do” or “I get angry when my sister doesn’t let me play with her” etc.). If the children cannot think of any emotions without help, have them look at the emotion cards on the table. Ask them to identify the emotions and to think of situations in which one might feel them. Then have the children work out how emotions feel in the body e. g., “When I’m angry, I get tense,” “When I’m sad, I/my arms/my legs feel heavy,” “When I’m excited, I’ve got butterflies in my stomach,” “When I’m ashamed, I turn red and I feel hot,” etc. Have the children choose one card that matches their current emotional state and explain why they feel that way at the moment and how they notice this feeling in their body. Distribute Bladder Training Worksheet 23 (Emotions) and ask them to glue their emotion card on the first page. Before they fill out the second page of the worksheet, tell a story about wetting. “Imagine that you are invited to a friend’s birthday party. You drink a lot of the tasty juices and lemonade that they have there. Because you’re playing fantastic games all afternoon you don’t notice that your bladder gets really full and that you have to go to the bathroom. At some point, your bladder cannot hold the pee any longer and it goes into your pants. You try to hide that your pants are all wet, but the other children notice it and some make fun of you. … How do you feel? … And what do you think could help you feel better? … Are you familiar with that kind of situation? … Has something like that already happened to you?” With the help of this or a similar story, discuss emotions, thoughts, alternative thoughts (e. g., “This could happen to anybody”), as well as be-

havior to deal with the situation (e. g., going to the friend’s mother immediately and asking for new pants). Then have the children act out the story in a role play. Some of the children take the role of making fun of the child that has wetted. The other children take his/her side and try to comfort and help the child. Ask the children to pick an emotion card that shows how they feel when they have wetted and ask them to glue it on the second page of Bladder Training Worksheet  23. Then have them write down things that could help them in a situation like that and a comfy sentence that could help them feel better (e. g., “Never mind, I will change my clothes now and then no one can see anything” or “This also happens to others – it’s not the end of the world!”). As homework, ask the children to complete Bladder Training Worksheet 24 (Emotion Homework) together with their parents every night before going to bed. They should write down the situations in which they felt comfortable or uncomfortable during the day, which emotions they experienced, and what exactly happened to cause the emotions. Doing this will help the children perceive emotions and to understand the connections between wetting and their emotions.

5.6.3

Body and Bladder Perception: Series of Pelvic Floor Exercises

The second focus of this session lies on improving body and bladder sensation. For that purpose, set up a larger room before the session begins with the items needed for the pelvic floor exercises (see Bladder Training Material: Series of Pelvic Floor Exercises). In summer this exercise can be conducted outside. Before and after each exercise have the children estimate the filling state of their bladder using the perception exercise from Session 5 (see Section 5.5.3). Ask them to note down the estimates of how full their bladders are on Bladder Training Worksheet 25 (Perception Exercise; see Figure 11).

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Conducting the Individual Sessions

65

Bladder Training Worksheet 25

Perception Exercise

Hey bladder, how do you do? Please tell me, how full are you?

feel your bladder and note down on the worksheet how full you think your bladder is. Do the same after each exercise. There are four different exercises: jumping on a trampoline, massaging your feet, rolling back and forth on a ball, and an exercise arching your back. You will do each exercise for one minute and I will tell you when to stop. Choose one exercise to start with and then go to the next one. If you have to go to the toilet in between, do so, but don’t forget to check how much urine (pee) actually came out and whether it’s as much as you thought!” Series of Pelvic Floor Exercises

Figure 11 Based on KgKS, 2010. Reprinted with permission from Pabst Science Publishers, © 2010. This page may be reproduced by the purchaser for personal/professional use. Perception exercise. From M. Equit, H. Sambach, J. Niemczyk & A. von Gontard:

Urinary and Fecal Incontinence: A Training Program for Children and Adolescents © 2014 Hogrefe Publishing

Based on KgKS, 2010. Reprinted with permission from Pabst Science Publishers, © 2010.

“As you can see, we have prepared special exercises for you. The different exercises will help you to feel your body and your bladder better and to train the muscles of your pelvic floor. The muscles arranged around the bladder belong to the pelvic floor. First, we want to do an exercise together so that you feel where the pelvic floor actually is. Sit down on the floor and put one hand on the lower belly, right where your bladder is. Now sit on your other hand. Cough a few times. Can you feel with your hands that something in your body is moving? … That’s your pelvic floor! Now, we want to do some exercises to train your pelvic floor because it will help you feel and control your bladder. Before each exercise try to

1. The children jump on a trampoline and notice the filling state of their bladder before and after. Bladder sensation increases due to the exercise. 2. Place massage balls in different sizes, grain pillows, and tennis balls on the floor. Have the children roll their left and right foot (without shoes) back and forth over them. This activates the reflexes of the pelvic floor. 3. Have the children lie face up on a large gymnastics ball and roll back and forth on it. Have them repeat the exercise facing down. This helps to stretch the abdominal muscles. 4. Have the children get down on their hands and knees on a gymnastics mat. Make sure their hips are right above their knees and their shoulders above their hands. Ask them to arch their backs up like a cat, moving their heads down. Then ask them to arch their backs down like a pot-bellied pig, lifting their heads up. This exercise helps to relax and loosen the muscles of the lumbar vertebrae and the muscles of the pelvic floor. Have the children do each exercise for about one minute. After the children have completed the exercises, ask them to go to the toilet. If possible, let them use cups into which to pee or, if available, the measuring instrument for uroflowmetry, or determine the amount of urine with the help of ultrasound.

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Chapter 5

This will give the children feedback about the actual filling state of their bladder and allows them to compare it with what they had estimated. 5.6.4

Relaxation Exercise

Session 6 ends with a relaxation exercise. Ask the children to come together and to make themselves comfortable either on mats or blankets. Play relaxing music and carry out a relaxation exercise, e. g., Angry Octopus (Lite, 2011) or Bubble Riding (Lite, 2008). 5.6.6

Closing Round and Homework

emotions they already know and collect their answers on a board or a flipchart. Discuss with them how to recognize human emotions (facial expressions, gestures, postures, way of talking and other behavior) and find examples for the different emotions with them (e. g., anger: angry looks, tense posture, etc.). In addition, talk about why negative emotions are important (e. g., fear: warning against danger, anger: something unjust has happened, etc.). When talking about emotions during/after wetting, make sure to ask the group to think about where they perceive the emotions in their bodies and what their thoughts are in that moment.

Modification for Adolescents

If the birthday party situation seems inappropriate to most of the participants, have them act out a situation or problem of their choice (e. g., wetting during sports class at school). Be sure to respond to the different emotional perceptions of the actors (depending on their role) and have them test alternative behaviors than holding back pee.

The topic of emotions should be discussed with adolescents in greater detail than with the children. Introducing the subject, ask them which

The pelvic floor exercises should not be altered because the perception of the pelvic floor is also crucial for adolescents.

At the end, conduct a short closing round and remind the children of their emotion homework before saying goodbye. 5.6.7

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Conducting the Individual Sessions

5.7

67

Bladder Training Session 7: Knowledge Check, Goal Analysis, Outlook Topics

• What do I know about me and my bladder? • Have I achieved my goals? • What comes next? Goals

• Check knowledge • Recognize success and relapse • Build motivation for further treatment Topic/Activity

Duration

Materials/Worksheets (see Appendix)

Welcome and drinking ritual

5 min

• Drinks

Opening round

5 min

• Bladder Training Material: Mood Barometer • Toy figures

Discussion of homework

5 min

• Bladder Training Worksheet 24: Emotion Homework completed by the children

Final quiz

20 min

• Bladder Training Material: Final Quiz

Goal analysis

15 min

• Bladder Training Worksheet 26: Goal Analysis • Bladder Training Material: Emotion Cards Emily or Tom (multiple copies, already cut out)

Outlook

15 min

• Bladder Training Worksheet 27: How to Go From Here

Important things to know

10 min

• Bladder Training Worksheet 28: Remember!

Closing round: certificates and feedback

15 min

• Bladder Training Material: Certificate (filled out)

5.7.1

Welcome and Drinking Ritual, Opening Round, Discussion of Homework

After welcoming the children with a drink and after the opening round, review the emotion homework. Additionally address the connection between negative and positive emotions and wetting or being dry during daytime or nighttime.

5.7.2

Final Quiz

The children play the final quiz (Bladder Training Material: Final Quiz). The quiz consists of 15 multiple-choice questions and their answers. If you like, project the pages of the quiz with the help of a projector. Alternatively, you can print the questions. The children play in one team and should answer the questions in turns. If a question cannot

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68

Chapter 5

be answered, one of 4 wild cards can be used. When the group has completed the quiz, all participants receive a prize (small toy, candy, or something similar). 5.7.3

Goal Analysis

Next, the children should evaluate the personal goals they named at the beginning of the bladder training. Have them take out Bladder Training Worksheet  3 (Problems and Goals; see Section  5.1.6) which they completed in Session  1 from their folder. Hand out Bladder Training Worksheet 26 (Goal Analysis; see Figure 12) ask the children to complete it as well. Comparing the answers on the worksheets, help each child work Bladder Training Worksheet 26

Goal Analysis What was your goal at the beginning of bladder training?

_______________________________________ Have you achieved your goal? Tick one number. 1

2

3

4

5

6

7

8

9

10

Yes

Glue the appropriate emotion cards into the boxes. How do you feel today?

5.7.4 Outlook

Talk about further treatment options and plan a follow-up meeting of the group (after about 3 months) if so desired. Next, it is useful for the children to think about personal plans. Hand out Bladder Training Worksheet 27 (How to Go From Here) and explain that they should think and write about things to keep in mind in order to stabilize their success, how their parents can help them in daily life, and any expectations they have for themselves. 5.7.5

_______________________________________ _______________________________________

No

out how he/she has benefited from this group training. Have emotion cards (Bladder Training Material: Emotion Cards Emily or Tom) ready for the children to glue into the small boxes on the worksheet.

Important Things to Know

Give Bladder Training Worksheet  28 (Remember!) to the children for them to take home. Explain that it summarizes the most important tips on hygiene, going to the toilet, pooing (defecation), and drinking. If there is still some time left, go through the worksheet with them.

What’s your bladder doing?

5.7.6

Did you like the bladder training? Why? _________________________________________________________________ _________________________________________________________________ What did you not like? What could we do better? _________________________________________________________________ _________________________________________________________________

Figure 12 This page may be reproduced by the purchaser for personal/professional use. From M. Equit, H. Sambach, J. Niemczyk, & A. von Gontard: Goal analysis. Urinary and Fecal Incontinence: A Training Program for Children and Adolescents © 2015 Hogrefe Publishing Based on KgKS, 2010. Reprinted with permission from Pabst Science Publishers, © 2010.

Based on KgKS, 2010. Reprinted with permission from Pabst Science Publishers, © 2010.

Closing Round: Certificates and Feedback

This bladder training ends with the handing out of the certificates (Bladder Training Material: Certificate)! Do the ceremony with some pomp and circumstance if you feel that it is appropriate. When handing out the prepared and signed certificates, thank each child for participating and praise him or her. Tell the children that their Comfy Book is now complete and that they can go back to it any time to review information and to remember things they learned. If the children want, they can give feedback and say what they liked or did not like about the group training. Do the same and give feedback to the group. And then it’s time to say goodbye!

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Conducting the Individual Sessions 5.7.7

69

Modification for Adolescents

plement what they have learned into their everyday life.

This session can be carried out the same way with adolescents. If the final quiz is too simple, prepare harder questions on puberty, hygiene, etc. During goal analysis, stress how the adolescents can im-

The training for adolescents can be completed without handing out certificates. Instead, give them positive feedback on their behavior during group treatment and their achievements.

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Bowel Training The following two sessions are optional and cover the topics of fecal incontinence, constipation, and diet. Include these sessions if children have fecal incontinence or problems with constipation in addition to wetting. We recommend inserting the first additional session after Session 3 (about the pathophysiology of wetting and coping with stress). The second additional session should be conducted after Session 5 (about going to the toilet, personal hygiene, regulation of the intestine). If you carry out this additional session, you can talk in less detail about the

5.8

regulation of the intestine (or leave it out) in Session 5 as it will be dealt with in the additional session. If bowel training is carried out with children with fecal incontinence only, less relevant aspects of bladder training can be presented in less detail or can be left out completely (e. g., pathophysiology of wetting in Session 3). Other contents (problem and goal analysis in Session 1, anatomy of the intestinal tract in Session 2, coping with stress in Session 3, going to the toilet and personal hygiene in Session 5) should be adapted to the topic of fecal incontinence and be complemented with topics of the bowel training.

Bowel Training Session 1: Problem and Goal Analysis, Pathophysiology of Fecal Incontinence Topics

• Why am I here and what do I want to achieve? • How do soiling and constipation happen? Goals

• Reflect on problems • Provide information on pathophysiology of fecal incontinence and constipation • Introduce toilet training Topic/Activity

Duration

Materials/Worksheets (see Appendix)

Welcome and drinking ritual

5 min

• Drinks

Opening round

5 min

• Bladder Training Material: Mood Barometer • Toy figures

Discussion of homework

5 min

• Completed worksheet from the previous session

History and evaluation of the problem

20 min

• Bowel Training Worksheet 1: Questionnaire

Problem and goal analysis

15 min

• Bowel Training Worksheet 2: Problems and Goals • Bladder Training Material: Emotion Cards Tom or Emily (version for boys or girls) – several copies, already cut out

How does soiling happen?

20 min

• Bladder Training Material: Inside-My-Body Picture, rubber band • Bowel Training Worksheet 3: How Does Soiling ­Happen?

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Conducting the Individual Sessions Topic/Activity

Duration

71

Materials/Worksheets (see Appendix)

Optional: What is constipation?

10 min

• Bladder Training Worksheet 21: How Does Constipation Happen?

Toilet training

5 min

• Bowel Training Worksheet 4: Toilet Training

Homework and closing round

5 min

• Bowel Training Worksheet 5: Toilet Training – Chart for Parents

5.8.1

Welcome and Drinking Ritual, Opening Round, and Discussion of Homework

At the beginning of each session welcome the children as usual with the drinking ritual and the opening round. Next discuss the homework from the previous session. Present this session after Session 3 (Pathophysiology of Wetting and Coping with Stress) because they complement each other. 5.8.2

History and Self-Evaluation of the Problem

Begin the session with the following explanation: “In the last sessions you’ve learned how food and fluids get through the body and leave it as poo or pee. You’ve also heard how wetting happens. Today Tom and Emily will tell you why poo sometimes goes into your pants. We’d like to know when and why this happens to you. Therefore, I’m handing out a worksheet for you to complete. Then we will talk about your answers as a group.” Hand out the questionnaire on soiling (Bowel Training Worksheet 1) and ask the children to fill it out. Then, go through the worksheet and ask the children to answer in turn. Doing this will help the children realize that the others have similar problems. It is also important to ask whether they experience pain during defecation. This is an indication for constipation.

5.8.3

Problem and Goal Analysis

Next, hand out Bowel Training Worksheet 2 (Problems and Goals) and put the emotion cards (Bladder Training Material: Emotion Cards Emily or Tom) in the middle of the table. Talk with them about their emotions when they have soiled and let them choose their emotion card to glue on the worksheet. Psychological stress is assessed by the rating scale on the worksheet. At the bottom of the worksheet, the children can draw or write about how they would feel once they have reached their goals. 5.8.4

How Does Soiling Happen?

For this exercise, place the inside-my-body picture (Bladder Training Material: Instructions for the Inside-My-Body Picture) so that everyone can see it. Hand out Bowel Training Worksheet 3 (How Does Soiling Happen?; see Figures 13a and 13b) on psychoeducation. Ask the children to explain how food gets from the mouth to the rectum with the help of the inside-my-body picture. Have the group correct wrong answers, if necessary. Then continue like this: “Great, now you already know a lot about how we digest our food. Let me tell you how soiling happens. Food travels through the body, nutrients are absorbed, and waste is turned into feces (or poo) in the colon. At the end of the colon, just down there (point to the end of the insidemy-body picture), is the bowel gate. You can see it in the first picture on the handout. The bowel

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gate is a circular muscle that closes the bowels. If we need to defecate (poo), the bowel gate opens and the feces come out. The bowel gate is similar to a real gate in that it can be opened and closed. If the poo does not come out, a lot of feces gather in the colon. What happens then? (For younger children leave this part out) Now, take a look at the second picture on the worksheet. If there is a lot of poo, the colon expands and gets bigger (demonstrate with the rubber band). When that happens, the poo cannot move through the bowels very well and you feel it less. (For younger children continue here) The poo gathers and presses against the bowel gate. What do you think happens next? … Yes, exactly, the bowel gate opens and poo gets out. And where does it go if you’re not sitting on the toilet? … Exactly, right into your pants!”

5.8.4

Optional: What Is Constipation?

This section is optional and should used if some of the children in group have constipation. Hand out Bladder Training Worksheet  21 (How Does Constipation Happen?; also used in Session 5). “Some of you have mentioned that your bowel movements hurt and that you have to press hard. This is called constipation. Take a look at the first picture on the worksheet. There, you can see how feces gather in the colon at the bowel gate. If the bowel gate does not open and the poo remains inside for some time, water is taken out of the poo and it becomes hard. To get it out, you have to press hard and this can hurt a lot. Sometimes liquid feces (poo) get passed the hard poo and go into your pants. And because your bowels are expanded, you don’t even notice it.”

Bowel Training Worksheet 3

How Does Soiling Happen? (1)

5.8.5

esophagus Speiseröhre stomach Magen Dünndarm small intestine Dickdarm colon Darmtor bowel gate

Next, hand out the worksheet  on toilet training (Bowel Training Worksheet  4) and explain that toilet training is important because it gives the bowels a regular schedule and makes pooing easier. Right after having eaten, the body is more ready to poo than at other times. If the children do not know yet how toilet training works, go through the worksheet with them. Explain that they should go to the toilet and try to poo after their main meals (breakfast, lunch, supper). Make sure to also discuss how to do it. The children should sit on the toilet in a relaxed manner, take their time (at least 10 minutes), and bring something to play or to read with them so that the toilet sessions are less boring. 5.8.6

Figure 13a This page may be reproduced by the purchaser for personal/professional use. From M. Equit, H. Sambach, J. Niemczyk, & A. von Gontard: How soiling happen? (front of© worksheet) Urinary does and Fecal Incontinence: A Training Program for Children and Adolescents 2014 Hogrefe Publishing

Toilet Training

Homework and Closing Round

Hand Bowel Training Worksheet 5 (Toilet Training – Chart for Parents) out as homework. Explain that they have to give the chart to their parents, who will fill it out over the next week (see Figure  14). Close today’s session with a short

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Conducting the Individual Sessions

73

Bowel Training Worksheet 3

How Does Soiling Happen? (2)

1

2

4

3

5 Illustration based on Alexander von Gontard (2010). Figure 13b This page may be reproduced by the purchaser for personal/professional use. From M. Equit, H. Sambach, J. Niemczyk, & A. von Gontard: Urinary and of Fecalworksheet) Incontinence: A Training Program for Children and Adolescents © 2015 Hogrefe Publishing How does soiling happen? (back

Illustration based on von Gontard (2010)

Bowel Training Worksheet 5

Toilet Training – Chart for Parents Toilet training: 3 times a day for 5 to 10 minutes after the main meals

Midday

In the morning

Date: __________________

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Child sent (g) Child went on his/ her own (!) Pants: clean () smeared (r) wet (¨) soiled (×) Bowel movements: urine (~) stool (+) Child sent (g) Child went on his/ her own (!) Pants: clean () smeared (r) wet (¨) soiled (×)

In the evening

Bowel movements: urine (~) stool (+) Child sent (g) Child went on his/ her own (!) Pants: clean () smeared (r) wet (¨) soiled (×) Bowel movements: urine (~) stool (+)

Figure 14 This page may be reproduced by the purchaser for personal/professional use. From M. Equit, H. Sambach, J.– Niemczyk & A. von Gontard: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents © 2014 Hogrefe Publishing Toilet training chart for parents.

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74

Chapter 5

round and have the children say goodbye to each other. 5.8.7

Modification for Adolescents

The structure of this session can be kept the same for adolescents. When completing the worksheets, establish, as in previous sessions, an open and honest atmosphere that will make the participants comfortable. Social aspects should be taken into

consideration, also, e. g., the kind of negative consequences they experience because of their problem. The discussion of constipation as well as the vicious cycle (Levine, 1991; see Bowel Training Worksheet 3) that can develop (decrease in sensitivity and peristalsis during the accumulation of feces, new stool passes old feces and leads to soiling) can be more detailed than with the children. Homework (toilet training chart) should be completed by the adolescents themselves. This should increase their self-dependence and self-efficacy.

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Conducting the Individual Sessions

5.9

75

Bowel Training Session 2: Diet and Exercise Topics

• What is a healthy diet? • Do I exercise enough? Goals

• Reflect on eating and exercise habits • Provide information on a healthy diet • Raise motivation to be physically active Topic/Activity

Duration

Materials/Worksheets (see Appendix)

Welcome and drinking ritual

5 min

• Drinks

Opening round

5 min

• Bladder Training Material: Mood Barometer • Toy figures

Discussion of homework

5 min

• Completed worksheet from the previous session

How can constipation and soiling be prevented?

15 min

• Flip chart, board etc., pencils • Bowel Training Worksheet 6: Rules for a Healthy Bowel

Healthy diet

30 min

• Bowel Training Worksheet 7: Eating Questionnaire • Bowel Training Worksheet 8: Food Pyramid • Bowel Training Material: Food Pictures (already cut out) • Bowel Training Material: Food Pyramid Template (large print-out) • Glue • Bowel Training Worksheet 9: Healthy Recipes • Optional: snacks

The importance of exercise

25 min

• Bowel Training Worksheet 10: Exercise Questionnaire • Bowel Training Worksheet 11: Schedule for My Hobbies • Pencils • Bowel Training Worksheet 12: Balloon Games • Balloons, clothes, sheets

Homework and closing round

5 min

• Bowel Training Worksheet 13: Healthy Belly Quiz

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76

Chapter 5

5.9.1

Welcome and Drinking Ritual, Opening Round, and Discussion of Homework

Welcome the children with the drinking ritual and opening round. Discuss last week’s homework with them. 5.9.2

How Can Constipation and Soiling Be Prevented?

Today you will discuss with the children what can be done against soiling or constipation. “Today, we want to learn about what helps against constipation or soiling. You already know how constipation or soiling happen. Can someone explain it to me again? … (Let the children answer and let the group help if necessary)… Yes, very good. What do you think helps against constipation or soiling? Have you already tried something?” Let the children report what they know about this topic and/or what they have already tried themselves. Write their answers on the board or flipchart and emphasize the most important ones. If necessary, add the following points: Rules Against Constipation and Soiling

• Sufficient fluid intake • Healthy diet • Toilet training • Treatment with laxatives (if indicated) Hand out the worksheet with rules for a healthy bowel (Bowel Training Worksheet  6) and go through it with the children. However, the focus of this session lies on the topics diet and movement because drinking and toilet training were discussed in previous sessions. 5.9.3

Healthy Diet

Hand out the questionnaire on eating habits (Bowel Training Worksheet 7), have the children complete it, and discuss their answers with them emphasiz-

ing their eating habits. Then give the children the worksheet with the food pyramid (Bowel Training Worksheet 8; see Figure 15) and explain it: “Our food can be grouped into different categories. This is shown by the different colors in the pyramid (yellow, green and red). The pyramid shows how much of each food group you should eat every day. At the base of the pyramid are the drinks. Remember! Drinking 7–10 cups of healthy drinks every day is important for your digestion. Foods in the green group have many carbohydrates and vitamins your body needs. They are also very good for your digestion and prevent constipation. Therefore, you may eat a lot of these foods every day. Foods in the yellow group have important nutrients, but they also have fat. That means you should not eat too much of them, but not too little either! Foods in the red group have a lot of sugar and fat. If you eat too much of them, you will harm your body and gain weight. Eat only 1–2 servings of them per day. That is about 1–2 handfuls.” Hang up the large print-out of the food pyramid template or put it on the table  (Bowel Training ­Material: Food Pyramid Template). Quickly run through the food pictures (Bowel Training Material: Food Pictures) so that all children know what they are, shuffle them, and put them on the table upside down. Ask the children to draw cards taking turns and to add them to the right food groups on the pyramid. Depending on the time you have available, this game can be played several times. At the end of this section, give the children the worksheet  with healthy recipes (Bowel Training Worksheet 9) and ask them to try them out at home. If you like, have a few of the foods ready as a healthy snack (be sure to ask about food allergies). 5.9.4

The Importance of Exercise

In this section you will talk about the importance of exercise for a healthy bowel. First, ask the chil-

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Conducting the Individual Sessions

77

Bowel Training Worksheet 8

Food Pyramid 1 serving = 1 handful

Butter

Käse

Tomate

Oil, Butter, Candy: 1 to 2 times per day

Dairy Products and Eggs: Fisch 3 times per day (milk, cheese, yogurt) Meat and fish: 2 to 3 times per week

Kartoffeln

Fruit and Vegetables: 4 to 5 servings per day Whole Grain Products: 5 servings per day (bread, noodles, rice, potatoes, cereal) Drinks: 7 cups per day with 7–10 oz. each (~ 200–300 ml) mainly water, juice mixed with water, or unsweetened tea

Figure 15 This page may be reproduced by the purchaser for personal/professional use. From M. Equit, H. Sambach, J. Niemczyk, & A. von Gontard: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents © 2014 Hogrefe Publishing Food pyramid.

dren to fill out an exercise questionnaire (Bowel Training Worksheet 10) and then discuss the answers with them.

the group. After that, give each child a copy of this worksheet so that they can try out the other games at home.

Quickly review the rules for a healthy bowel (Bowel Training Worksheet 6; passed out earlier), explaining that physical activity can prevent constipation and support a healthy digestion because it keeps the bowels in motion.

5.9.5

Hand out the hobby schedule (Bowel Training Worksheet 11) and ask the children to fill in their hobbies and activities for every day of the week. Then go through the worksheet with them and ask them to highlight the activities in green that involve a lot of movement (e. g., sport, playing outside). Ask them to mark the other, quiet, activities (e. g., watching TV, playing video games, reading) in another color. Let them compare the rates of their active and passive hobbies/activities and explain that it is important for the children to have at least 2–3 green activities per week. At the end of this section, play one of the balloon games (see Bowel Training Worksheet  12) with

Homework and Closing Round

Hand out the Healthy Belly Quiz (Bowel Training Worksheet 13) as homework. The answer to the question about Emily’s favorite food is pineapple. Do a short closing round and say goodbye to the children.

5.9.6

Modification for Adolescents

Adapt today’s session so far that you find out what adolescents already know about a healthy diet and include only new aspects in psychoeducation. If there is enough time, prepare some of the recipes together with the adolescents. Treat the topic of exercise age appropriately.

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

This document is for personal use only. Reproduction or distribution is not permitted. From M. Equit et al.: Urinary and Fecal Incontinence: A Training Program for Children and Adolescents (ISBN 9781616764609) © 2015 Hogrefe Publishing.

Chapter 6

Evaluation of the Treatment The previous version of the bladder and bowel training presented in this manual has been evaluated for effectiveness in an explorative study (Sambach et al., 2011). The effectiveness of the bladder and bowel training in small groups on wetting and soiling frequency as well as problematic behavior was evaluated. The results of the study are presented in this section.

functions. 12 children (38.7%) had comorbid fecal incontinence. 6 children only had daytime wetting (daytime urinary incontinence). 51.6% of the children had additional comorbid psychological disorders, e. g., ADHD, ODD, and transient tic disorder.

6.1 Sample

All children were diagnosed according to current international standards. This included a developmental and family history, assessment of child psychopathology (Child Behavior Checklist; Achenbach, 1991), diagnosis according to ICD-10, and a 48-hour bladder diary. Additionally, a pediatric and neurological examination, a urinalysis, ultrasound of the urinary tract, and uroflowmetry (EMG of the pelvic floor if indicated) were carried out. The respective therapist recommended the participation in this study if the child had not responded to standard therapy.

31 children with a mean age of 9.16 years (range: 6–14 years) were included in the study. Of these children 19 (61.3%) were boys. Patients with pervasive developmental disorders, intellectual disability, psychosis, severe physical illness, as well as organic urinary incontinence were excluded. Before group training, all children had already been treated for a longer period with standard, evidence-based therapy (e. g., voiding charts, reinforcement system, alarm treatment; von Gontard, 2012a, b; von Gontard & Nevéus, 2006) without improvement of incontinence. These children were a therapy-resistant subgroup with complex daytime urinary incontinence. The majority of the children (77.5%) had nocturnal enuresis; in one child (3.2%) secondary nocturnal enuresis (SNE) was diagnosed. Only in two children (6.5%) with primary nocturnal enuresis (PNE), the symptoms were monosymptomatic (neither lower urinary tract symptoms nor daytime wetting or soiling). 22 children (71%) had primary non-monosymptomatic nocturnal enuresis (PNMNE). The child with SNE also had a non-monosymptomatic subtype. These children have additional daytime bladder and bowel dys-

6.2 Method

Group training was conducted by a urotherapist and a child psychiatrist. The training was performed in groups of 2–4 participants of same age and gender. There were 6 weekly sessions with 90 min each. In contrast to the training outlined in this manual, group training consisted of only 6 sessions instead of 7–9. Thus, topics such as healthy diet, drinking, and bowel management were dealt with in less detail. In order to evaluate the effectiveness of the training, 2 questionnaires were sent to the parents 3  months after the training: the Child Behavior Checklist (CBCL; Achenbach, 1991) and a questionnaire on treatment success (wetting/soiling frequency before and after training, etc.). Treat-

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Chapter 6

ment effect was evaluated according to ICCS criteria (Nevéus et al., 2006): no response (symptom reduction