Dysfunctional voiding

self-cathing key


blue_sc_func How do you talk to families about dysfunctional voiding?
I tell them, “This is what I do all day. I have a clinic all day for this!” Just to give them that reassurance that they’re not the only one. It’s not something that they’re doing wrong, because sometimes they’ve heard that message by the time they get here. The parents have gotten frustrated, feeling like the kids are lazy, they just don’t want to do it. Often times the kids have had that negative message, and sometimes it’s good for the parents to hear us say it’s not their fault.

Other things the kids worry about: is there something really wrong with me? Lots of times during the teaching I’ll actually draw pictures of the bladder and the kidneys, so that they understand how this whole process works. Because I feel like if they don’t really know how it works, they won’t understand the treatment – “Why do you want me to go to the bathroom every couple of hours? If I don’t feel like I need to go, why do I need to go?”

Pam Kelly, PNP, Clinical Coordinator, Urodynamics and Voiding Improvement Program


blue_sc_func What strategies do you use to address dysfunctional voiding?
I often put the kids on an every two hour schedule for going to the bathroom. One of the big issues is that some kids don’t want to go to the bathroom at school, because it’s not clean, or there’s no doors, or there are other people in the bathroom and they don’t feel comfortable, or the teachers are going to be mad if they’re not back to class in time. So I provide a lot of support around that, either by writing letters to the school nurses to allow kids to use the nurses’ bathroom where they have a little more privacy, or by helping get parents to negotiate that with the teachers. The teachers have their agendas also, and they’re trying to weed out who’s just going to the bathroom because they want to get out of class, and who really has an issue. So I help the parents talk to teachers and offer to talk to them directly to let them know, “Even though there’s no physiologic disorder right now, this is a real issue, and this child needs regular toileting in order to re-establish a regular pattern for their bladder, which is all out of whack at this point.”

They might also need medications, they might need biofeedback. Biofeedback involves exercises to strengthen the pelvic floor muscles, but I tell the kids it’s Wii with your bum muscle – they all get it and they love it! Often over time the muscle has gotten so used to holding that it gets into this mode of peeing a little bit then clamping back up and there’s urine still left, and they don’t really know how to relax it. Biofeedback helps them learn how to control that muscle.
The other component is management of constipation. I’ll treat their constipation with laxatives and dietary counseling. Some of the kids that are more complicated should go to GI. Another nurse practitioner that used to work here went to the GI program, so I feel like I have an in: “I have another kid for you!” “Send them in!” So we send kids back and forth, and we work together really well to give a whole treatment plan to the families.

Pam Kelly, PNP, Clinical Coordinator, Urodynamics and Voiding Improvement Program

blue_sc_func Why might a dysfunctional voider need to catheterize?
We may have done some other diagnostic tests, other urodynamic testing to check, is there any problem with the contractility of the bladder? Is there some other underlying problem that’s causing this? And we’ve also done behavioral modification at the same time. Once we get to that point and we notice that this child is not able to empty their bladder despite all the things that we’ve done, that’s when we bring up the concept of self-catheterization. For some kids we may suggest biofeedback, where they learn how to tighten their pelvic floor and relax their pelvic floor muscles and over time sometimes they’re able to bring that contractility and tone back to the bladder. However, the biofeedback training is a longer process. For some kids, especially given a history of reflux or any potential for kidney damage, we would go to the catheterization quicker, because the idea is to maintain the health of the kidneys and the bladder and prevent any further infection.

Pam Kelly, PNP, Clinical Coordinator, Urodynamics and Voiding Improvement Program


blue_sc_func When can a dysfunctional voider stop catheterization?
We ask the children to see if they can urinate first and measure the amount of urine left in the bladder afterwards, and record that in a voiding diary. This measurement gives them (and us) an idea of how they’re progressing and possibly how soon they might be able to come off the catheterization program. We initiate this protocol in children who have residual urine in the range of a couple of hundred milliliters. Over time (and it may not occur immediately) the average residual urine will tend to decrease, and eventually the catheterizations can be stopped when the residual urine approaches zero.

Stuart Bauer, MD, Department of Urology


If it’s someone who’s not able to empty their bladder, we usually just leave it open-ended: “Let’s try it, come back in a couple of months, see how you’re doing. Do a voiding diary to see if there’s been any improvement.” I don’t usually give them a specific time as to how long they’re going to be cathing. Sometimes the kids themselves want to know that there’s going to be an endpoint, but it’s just about refocusing: “Let’s see how this goes, and see how your voiding diaries are, and then check back to see how it’s going, and we’ll see how long we have to do it.”

Diane Manning, RN, Department of Urology