Six months pregnant with her second child, Michelle Boyd* was at a pelvic physiotherapy appointment for prevention of postpartum bladder issues when she learned that the exercises she was doing to strengthen and relax her pelvic floor might also help kids with their own potty problems. Boyd’s seven-year-old son still needed Pull-Ups at night and she was desperate for him to stop wetting the bed.
She’d tried everything over the years, from giving him oral laxatives to help with underlying constipation to an underwear-attached sensor that would trigger an alarm in the middle of the night when he started to pee. “I didn’t know what else to do,” she says. The family’s paediatrician finally told her to stop exhausting herself with all the nightly wakings and laundry and just keep her son in training pants until he stopped wetting on his own. But Boyd’s physiotherapist had another idea. She suggested Boyd look into pelvic physiotherapy for kids.
Over the last few years, the importance of pelvic health for mothers—and the lasting effects that pregnancy and childbirth can wreak on women’s bodies—has become common knowledge. More recently, paediatric pelvic physiotherapy has become an emerging treatment for children with bladder and bowel dysfunctions that can lead to constipation, daytime or nighttime incontinence, and urinary tract infections, among other problems. “Paediatric pelvic health issues are common but often ignored,” says Catherine MacGillivray, a paediatric-trained pelvic health physiotherapist based in Calgary.
According to the Canadian Paediatric Society, 10 to 15 percent of five-year-olds, and six to eight percent of eight-year-olds, experience bedwetting. Daytime accidents, defined as those accidents that occur after a child has had consistent bladder control, are less common, but about one of four children who wet the bed at night also wet themselves during the day.
When should you seek help?
If any aspect of toilet learning has become a struggle, it’s a good idea to talk to your child’s health provider. (Typically, it’s a concern only around age four for daytime or nighttime accidents and six or seven for bedwetting.) Your doctor may refer your kid to a medical urologist or physiotherapist. Joana Dos Santos, a medical paediatric urologist at The Hospital for Sick Children and Kindercare Pediatrics and an assistant professor of paediatrics at the University of Toronto, says 40 percent of her practice (roughly 3,000 kids every year) focuses on bowel and bladder dysfunction. For those cases that don’t improve after six months of regular medical bladder retraining and constipation management—about 10 to 20 percent—she will refer them to a pelvic physiotherapist. “Some children will have difficulty relaxing the pelvic floor muscles and may benefit from medication and/or need alternative therapies, such as pelvic floor physiotherapy,” says Dos Santos.
How does paediatric pelvic physiotherapy work?
Many kids need extra support with toilet training and constipation. Your child’s family doctor will often recommend scheduling routine bathroom breaks, eating a high-fibre diet (more fruits and veggies) and fewer processed foods, and drinking more water—even taking oral laxatives to get things moving. A physiotherapist, on the other hand, specializes in pelvic health education and retraining of the bladder and bowels, using many different techniques. After an initial assessment, which often includes a look at your kid’s bathroom diary, treatment may include fun toilet games to address anxiety around pooping, breathing techniques and learning pelvic muscle exercises (sort of like Kegels). A therapist may also try biofeedback using special stickers that are placed on your child’s butt cheeks and abdomen and are connected to a video game, so they can try to do things like make a fish jump or a bird fly by pushing and pulling the muscles in their perineum. Unlike pelvic physio in adults, there is no internal component to the treatment.
There is growing evidence that paediatric pelvic physiotherapy works. A study published in the European Journal of Physical and Rehabilitation Medicine showed that, in combination with standard medical care, abdominal and pelvic floor muscle retraining was beneficial for curing incontinence, bedwetting and urinary tract infections in children diagnosed with “dysfunctional voiding.”
Could it be something more serious?
Bladder and bowel issues are extremely common in otherwise-healthy children, but a physician or physiotherapist can identify red flags related to a medical condition, such as an infection, a defect in the urinary tract, emotional stress or other more concerning problems. A sudden onset of incontinence for a previously potty-trained child, such as more frequent and urgent peeing, could be a sign of diabetes. Difficulties peeing, on the other hand, could be due to a physical obstruction in the bladder, though this is quite rare.
Not just a laundry problem
A study in the journal European Urology found that bedwetting has significant negative effects on school-aged kids and that successful treatment boosted self-esteem and even athletic abilities. “The impact on the family and the child’s mental health and quality of life is so important,” says MacGillivray.
Boyd’s son is now eight and has been doing his pelvic floor physiotherapy for more than a year. His treatment plan included a bed-wetting diary, changes to his diet, regular bathroom breaks, “dream wakings” before his typical accident times and lots of pelvic floor muscle training exercises. Since starting, bedwetting incidents decreased from up to five times a week to once a week at the most.
“I explained to him that this was the same set of exercises I needed to do when I had his brother and that he didn’t do anything wrong,” says Boyd. “It’s also encouraging for him to think, I learned how to do this, so I can do other things. Now he’s looking forward to having sleepovers and going to sleep-away camp, which he couldn’t do if he was still regularly having accidents.”
Is your previously potty-trained kid suddenly having regular accidents?
Regressions are normal for children during stressful events, including setbacks with potty use or starting to have accidents at school. “What I see often is kids going to kindergarten or grade one and they don’t want to pee or poo at school—and the pandemic has exacerbated that a little bit because everyone’s more germophobic,” says Joanne Vaughan, a paediatrician in Toronto. “What I hear over and over again is that ‘the bathrooms are so gross.’ So they hold it all day, and then they get into this cycle of bowel and bladder dysfunction.”
Janice Heard, a community paediatrician in Calgary, agrees that while bathroom regressions during the pandemic haven’t been studied, it’s not surprising to see young kids having more wetting incidents, especially when there’s been such a drastic change in their routine. “It can be a reflection of their anxiety. They feel like there’s a loss of control, and toileting is one of the only things that children have all the control over and parents don’t.”
If you’re noticing regressions, your kid may just need more emotional support; also, try getting them to stick to a toileting schedule, drink plenty of water and eat enough whole grains, fruits and vegetables. It also can’t hurt to talk to their doctor if you or your child is bothered by it and there isn’t any improvement over time.
*Names have been changed