Bladder Function Improvement Training (BFIT) Program

We work together with you and your child to develop an individualized treatment plan that meets your child’s specific needs. Your child will receive world-class clinical care combined with a compassionate approach to make them more comfortable during the process. We collaborate with patients and their families until a successful outcome is achieved, taking time at each visit to ensure all questions are answered.

Though not often talked about, trouble with urinating is a common problem, and families are not alone in dealing with these issues.

About 40 percent of pediatric urology visits are related to lower urinary tract disease (LUTD), or the condition that can lead to issues like nighttime wetting, daytime wetting and other urinary problems. Furthermore, 5 to 7 million children 6 years or older have reported issues with daytime wetting. Daytime wetting occurs in 10% of 5-to 6-year-olds, and 5% of 6-to 12-year-olds.

Lurie Children’s experts in bladder function work with patients until their symptoms are completely resolved.

Many children with dysfunctional voiding show poor pelvic floor muscle relaxation caused by “holding it.” It is a learned behavior that develops over time, leading to an abnormal urine stream and poor emptying of the bladder. While dysfunctional bladder emptying happens in the voiding phase, a child will often have symptoms when not voiding, such as wetting. In most children, voiding problems can be treated without surgery.

Signs that your child has dysfunctional bladder emptying include:

Frequent Urine Holding

• Urinating 3-4 or less times per day, or
• Habit of “waiting until the last minute” and having to run to get to the bathroom, or
• Holding behaviors: Behaviors that exhibit holding of urine. For example, female children will “curtsy,” or cross the legs and bend from the waist to avoid urinating, “Potty dance” or sitting on the heal.

Daytime Wetting

• This is defined as leaking of urine while the child is awake that occurs at least once per month for at least 3 months.
• Keep in mind that urine accidents can be normal up until the age of five.
• Typically, children age five or over may benefit from a consult with our team.

Nighttime Wetting

• Most children become dry overnight between the ages of 3 and 5 years. Nighttime wetting technically cannot be diagnosed until the age of 5 years.
• It is incredibly common – affecting one out of 5 children at age 5 years; this prevalence decreases with increasing age. In some cases, children overcome it on their own with age.
• In most cases, nighttime wetting is a “benign” condition, meaning patients usually have a normal urologic tract and otherwise normal urologic function.
• However, bedwetting is stigmatizing; it limits social opportunities like camp and sleepovers; it can decrease a child’s self-esteem; it can have a negative impact on family dynamics. The psychologic effect of bedwetting can be quite significant and warrants addressing this condition thoroughly.

Urinary Urgency or Frequency

• Frequency is defined as urinating eight or more times per day and interferes with daily activities (school, sports, etc).
• Urgency is defined as is a sudden and unexpected need to void.

Withholding Stool

• Constipation, or infrequent or hard-to-pass bowel movements, occurs in most patients with urinary issues. Studies have shown anywhere from about 30-90% of patients with urinary problems have a clinically significant degree of constipation.
• The combination of both bowel and bladder dysfunction is called “dysfunctional elimination syndrome.” Stools present in the intestine causes increased pressure and irritation on the bladder and can impair it. In some children, managing their constipation alone has helped eliminate wetting.

Urinary Tract Infections (UTIs)

• UTI is an infection of the urinary tract as determined by urine testing and symptoms. Some infections are located in the bladder (also known as cystitis) and others are also located in the kidney (also known as pyelonephritis).
• UTIs in children are not normal and should first be discussed with the primary care provider to see if any further testing or evaluation is warranted.
• Children with more than one UTI are appropriate to refer to a urologist for further evaluation (some directly seen by BFIT, some medical conditions they’ll need a urologist as well – most kids likely coming to BFIT).

Conditions We Treat

• Dysfunctional Voiding
• Bedwetting (nocturnal enuresis)
  • This is defined as urine-related accidents occurring while a child who is at least five years old is sleeping. Most children will achieve nighttime continence on their own over time, but some therapies can help them to achieve this sooner.
• Problems with urination during the day (daytime urinary incontinence)
  • This is defined as involuntary leaking of urine or urine accidents while a child who has been toilet trained is awake.
• Recurrent urinary tract infections (UTIs)
  • A UTI is an infection of the urinary tract as determined by urine testing and clinic symptoms. Some infections are located in the bladder (also known as cystitis) and others are also located in the kidney (also known as pyelonephritis). Children with more than one UTI should consider consult with our team.
• Constantly having to urinate (urinary frequency)
  • This is defined as urinating eight or more times per day.
• Vesicoureteral reflux (VUR)
  • This is when urine moves backward from the bladder to the kidneys. Normally, pee flows from the kidneys down to the bladder. Children with VUR typically are also evaluated by one of our Urologists to help determine the treatment plan.

Often, children with urinary issues treated in the BFIT program endure no long-term consequences after treatment.

It is uncommon, but in some cases, children can develop kidney damage. Children may also struggle with self-esteem issues, though Lurie Children’s BFIT team is trained to consider and assist in resolving these issues.

Your first visit will include both you and your child. You will be asked to complete a three-day voiding diary (file is also available in Spanish) which provides important information about your child’s fluid intake and bathroom habits. If your child has had any testing done related to their bladder function, you should bring reports and CDs of that testing with you to your first visit. This may include copies of urine testing or ultrasound of kidneys or bladder. You can obtain the CDs from the facility that did the original testing.

Dysfunctional voiding is primarily diagnosed by reviewing a thorough patient history with emphasis on toilet habits. An ultrasound of the kidneys and bladder may be used to look for rare structural abnormalities. An abdominal x-ray may be used to evaluate for stool retention. Further evaluation may include pre-void and post-void ultrasounds to assess for residual urine. A uroflow with EMG test may be performed to evaluate the activity of your child’s pelvic floor muscles with voiding. This test may show poor pelvic floor muscle overactivity causing abnormal urine flow.

After the initial visit, follow-up visits may occur every 6-8 weeks, or more frequently, depending on the child’s needs. The number of visits needed depends on how quickly symptoms improve with management.

Treatments

Treatment for dysfunctional voiding involves a multi-pronged approach individualized for each child. The components of treatment include:

Behavior Modification

• Relaxation/Repositioning: Children are taught proper toilet positioning and techniques to promote pelvic floor relaxation to strengthen their ability to release urine in a relaxed and complete manner.
• Alarm Training: In alarm training, children with nighttime wetting are given a device to wear at night that includes a sensor that clips to their underwear attached to a speaker that attaches to their pajamas. When a child starts to wet at night, the alarm rings, waking up the child and parent, who will send the child to the bathroom. This alarm helps recondition the brain and bladder to communicate at night. With consistency and determination from parents and children in using this alarm, most patients see improvement within 3-4 months. Learn more about this approach with this video.
• Timed Voiding: Children with dysfunctional voiding may not receive strong messages that signal when the bladder is full and may need a schedule to re-train the bladder.
• Biofeedback: When repositioning and timed voiding do not improve pelvic floor function, biofeedback training is implemented on an age-appropriate level. This means teaching a child how to read their own body and understand how the body works.
  • Working with the Lurie Children’s expert pediatric physical therapists, information on a child’s voluntary contraction and relaxation of the pelvic floor feeds back to a computer program with videogame-like output. In other words, by squeezing and relaxing the pelvic floor, the child manipulates a character through a simple video game. Core strengthening is also incorporated. This teaches the child how to isolate and relax the pelvic floor muscles, which can help correct bedwetting and/or daytime wetting. These sessions last about 45 minutes, and children usually require 4-6 sessions. Families are taught how to complete exercises at home which is key to success. Learn more about biofeedback training.

Bowel Program

Children with dysfunctional voiding do not appropriately relax the pelvic floor muscle and these are the same muscles that control the release of stool. Learn more about preventing stool retention.

Antibiotics

Children with recurrent UTIs may be given low-dose preventative antibiotics.

Our Specialists

The BFIT program is managed by experienced pediatric providers that are specialized in treating urologic conditions: Kavita Hodgkins, MD; Reumah Ravoori, MMS, PA-C; and Lynn Freedman, APRN-NP.

Board-certified urologists and kidney disease specialists provide leadership for the program.