Bladder dysfunction

Introduction 

Bladder dysfunction refers to abnormalities in either the filling and/or emptying or the bladder which may be associated with urinary incontinence. The most common types of bladder dysfunction are overactive bladder, voiding postponement and dysfunctional voiding.

Children should be dry during the day by the age of 4 years. Normal voiding frequency is between 4 to 7 times per day.

Bladder dysfunction is very commonly associated with constipation. Constipation however mild, must be treated first, often resulting in resolution of the child’s bladder dysfunction symptoms. If the constipation is not addressed, any intervention to treat bladder dysfunction will be unsuccessful. See Constipation pre-referral guideline.

Attempting to treat nocturnal enuresis when daytime symptoms are present will generally be unsuccessful.

Behavioural difficulties (especially attention deficit hyperactivity disorder) should be addressed prior to managing bladder dysfunction.

Pre-referral screening

Bladder and Bowel diaries:

• Bladder – measure and document fluid intake and urinary output over 24 hours including all episodes of incontinence on 2 occasions
• Bowel – measure and document fluid intake, and stool type and frequency over 7-14 days including any soiling
• Download the Bladder and Bowel diary sheet (PDF).

Renal tract ultrasound – include on request form pre and post void volumes, bladder wall thickness and rectal diameters:

• Expected bladder capacity in mL = (age +1) x 30 (adult = 400 mL)
• Post void residual volumes - < 20 mL (under 6 years) or < 10mL (6 years and over) is considered normal
• Normal bladder wall thickness < 1 cm (> 1cm is abnormal and requires referral to rule out neurogenic bladder)
• Normal rectal diameter < 3cm (if > 3 cm highly suggestive of constipation)

Mid-stream urine – rule out Urinary tract infection.

Pre-referral management

• Diagnose and treat constipation – refer to Constipation guideline
• Ensure child is meeting expected daily fluid requirements. Fluid intake should be evenly spread across the day, starting on waking.

• Timed toileting – the child needs to toilet regularly throughout the day and when they get symptoms of bladder fullness/urge. This should be roughly every 2-3 hours. On school days, toileting should be timed to occur during breaks
• Consider referral to Paediatric Continence Physiotherapist
• In children with nocturnal symptoms only, please see Enuresis in Children - Clinician Assist WA.

When to refer

• Children with ongoing bladder symptoms and a history of constipation who have been compliant with constipation treatment for at least 6 months and are no longer reporting symptoms of constipation.
• Children with ongoing symptoms despite three months of recommended fluid intake and time toileting, with no history of neurodevelopmental disorder, behavioural problems or untreated constipation.
• Abnormalities on Renal US suggesting possible neurogenic bladder require urgent referral to the Department of General Paediatrics for investigation and confirmation prior to Urology Referral.
• Children with neurodevelopmental disorders should be referred to Specialist Continence and Toilet Training - Therapy Focus (previously called PEBBLES). 

How to refer

• Routine non-urgent referrals from a GP or a Consultant should go to the Central Referral Service.
• Routine non-urgent referrals from private hospitals go to the PCH Referral Office (Fax: 6456 0097 or email PCH.Referrals@health.wa.gov.au).
• Urgent referrals (less than seven days) go to the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456 222 to discuss referral with Paediatrician on call.

Essential information to include in your referral

• Duration and type of symptoms
• Presence of daytime incontinence
• Presence of night-time incontinence
• Presence of constipation
• Treatments and therapies trialled
• Results of Renal ultrasound and MSU
• Completed bladder and bowel diaries
• Growth parameters. 

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