Wet pants and constipation
The relationship between the urinary tract and the lower gastrointestinal tract impacts urinary tract infections (UTIs) and urinary incontinence in children. It is not enough to treat UTIs with antibiotics and examine for reflux, said Yves Homsy, MD, FRCSC, FAAP, during his presentation "Wet pants, UTIs, and constipation: The relationship between bowel and bladder dysfunction." It is also crucial to investigate whether the child has any constipation issues.
That can be difficult, however, because constipation is somewhat relative. It means different things to different people, few of whom like talking about it. However, some children have a more sensitive urinary tract—a large mass of stool in the rectum pressing on the bladder leads to bladder problems ranging from UTIs to urinary incontinence and reflux, and the damage that can follow.
Key steps for diagnosing constipation include the following:
1. Examine the lower abdomen clinically—Once the child relaxes sufficiently, an empty sigmoid should not be palpable. If full, it feels like a little sausage in the left lower quadrant.
2. Use the Bristol Stool Form Scale (BSFS)—This tool (bit.ly/NIDDK-Bristol-scale) simplifies constipation conversations by assigning 7 numerical grades to corresponding images (grades 1-4 indicate retention). After children are aged 6 or 7 years, parents rarely know what their child’s stool looks like, but children can instantly identify which picture looks like their stool. The BSFS also can help families and caregivers track treatment progress.
3. Request a pelvic sonogram—In children aged younger than 12 years, rectal diameter measuring more than 3 cm indicates constipation or fecal retention.1 An abdominal x-ray, which pediatricians often request, is not a reliable diagnostic tool because it is prone to subjective interpretation with no validated objective parameters.
Together, these tools provide a fairly clear idea of the patient's status. Boosting compliance with treatment requires discussing a delicate subject with parents, who might feel embarrassed, guilty, or even insulted that one suspects their child may be constipated. Here again, the BSFS breaks the ice, eliciting giggles from children to get the discussion started.
Although bowel and bladder dysfunction are common problems pediatricians see, those who can get their patients to appreciate the importance of bowel management and commit to compliance see amazing results. This spares children numerous investigations, which can be painful and expensive, not to mention recurrent UTIs and the embarrassment of wetting because of an overfilled rectum as an unsuspected underlying cause.
1. Joensson IM, Siggaard C, Rittig S, Hagstroem S, Djurhuus JC. Transabdominal ultrasound of rectum as a diagnostic tool in childhood constipation. J Urol. 2008;179(5):1997-2002.