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Childhood Constipation and Bedwetting: The Pertinent Poop

In Pediatric Pelvic Health by Melinda FontaineLeave a Comment

By Melinda Fontaine, Clinic Director of PHRC Walnut Creek

Child: “Ms. Melinda, why did you choose to do what you do?”

Ms. Melinda: “Two reasons: I get to wear sneakers to work, and I get to laugh at potty humor forever!” 

Did you know that pelvic floor physical therapists also work with children?! I help all people pee and poop better and feel better, from age 5 to 95. Constipation affects a large percentage of the American population, including 29% of pediatric patients.1 Constipation in children can appear in a variety of ways.  Aside from infrequent, hard, or extra large poops, constipation may also present as frequent or loose poops. Does your child have less than three poops per week?  When they do poop, does the size of it threaten to clog your plumbing? If someone has been constipated for a while, the collection of poop expands the rectum, and can lead to recurrent large poops and recurrent clogged toilets. Sometimes the poop looks like rabbit pellets or a bumpy log with cracks in it. These poops indicate that the poop has been in the colon for too long and all the moisture has been sucked out of it until you are left with a hard dry solid mass. Some poops come out in small frequent poops that may even be loose, but there is a larger, less friendly poop remaining in the colon. This can be seen on an x-ray. 

Constipation can also lead to skid marks, itchy bottoms, or repeated trouble toilet training. Full rectums may also put pressure on bladders and lead to difficulty with bedwetting, urinary tract infections, frequent peeing, or belly pain.2 As if constipation wasn’t bad enough by itself, it can also set you up for increased incidence of anal fissures, hemorrhoids, and perianal scar tissue. In children with constipation and pelvic floor muscle dysfunction, over 80% had an acute or chronic anal fissure.1 children with constipation are also more likely to develop a pelvic pain condition. This tells me two things.  First, the cause of the constipation needs to be addressed swiftly to avoid other problems, and pelvic floor physical therapy addressing muscle dysfunction should be a part of the treatment plan. 

One cause of constipation is pelvic floor muscle dysfunction. The pelvic floor muscles are the gatekeepers; if they don’t open, then no poop shall pass. To open the pelvic floor muscles, they need to relax and lengthen. Sometimes, the muscles tighten and close instead. I can’t blame them. It may happen because they have had pain or injury in the past. Maybe there is a fear about the potty or a belief that it is dirty or shameful. It would be hard to relax in any of these situations. When poop is ready to come out, but the muscles won’t let it, people often hold their breath and strain to push it out. This can lead to a slew of complications, such as retention, hemorrhoids, fissures, continued constipation, etc. When the rectum is full of stool, it presses on the bladder and can cause bedwetting, frequent or urgent peeing, difficulty peeing, or accidents. 

As a parent, I know first-hand how awful it is when your kid is not well. Of course, you would do anything to help, and connecting with the right professionals and resources can be the first step. Pelvic floor physical therapists teach various methods to improve pooping in children in ways that are appropriate for their age. What can your kids expect in physical therapy? Talking, drawing, joking, playing, books, playdoh, and balloons. Sounds like fun.

 I make a point to talk openly and comfortably about all bodily functions because they are natural, and everybody does them. My goals are to reduce any anxiety or shame and to be very clear. This is where the talking, drawing, joking, and books come in to play. We can also get some work done by creating a plan for what to do at home or school when your body wants to pee or poop.2 What’s the best way to sit on a toilet? How long should you sit on a toilet? What should you do while you are sitting on a toilet? We can talk about what foods and drinks go into our bodies to make sure we have the right ingredients for good poops.2 What does a good poop look like? And we play games and do exercises to help us identify the muscles in our body.  Our games are really exercises for the diaphragm and pelvic floor. They help teach us what it feels like to relax and contract the muscles, so we can do it when we need to.3 These types of exercises in combination with medical care, help treat urinary incontinence, bedwetting, and urinary tract infections in children with dysfunctional voiding.4 If mature children would find it useful to use a biofeedback device to sense the activity in the pelvic muscles, we can do that, too. If you feel alone, you may just not have found the right resources yet. 

I am currently offering digital health appointments for patients who may live far from me or may not be able to come to the office during the pandemic. Here is the link to schedule

REFERENCES:

1. Sanchez-Avila MT, et al. Frequency and findings of the acquired anorectal disease in the pediatric population with chronic constipation. The Turkish Journal of Pediatrics 2018; 60: 547-553.

2. De Paepe H, et al. Pelvic-floor therapy and toilet training in young children with dysfunctional voiding and obstipation BJU International 2000; 85: 889-893.

3. De Paepe H, et al. The role of pelvic floor therapy in the treatment of lower urinary tract dysfunctions in children. Scandinavian Journal of Urology and Nephrology 2002; 36(4)

4. Zivkovic V. et al. Diaphragmatic breathing exercises and pelvic floor retraining in children with dysfunctional voiding. European Journal of Physical and Rehabilitation Medicine 2012; 48: 413-21.

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.

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