Unpacking Pediatric Dysfunctional Voiding: An Insightful Case Study

As pediatric pelvic floor therapists, addressing dysfunctional voiding in children is paramount in our specialized field. In this blog post, you will gain insight and strategies tailored to the unique needs of your young patients struggling with dysfunctional voiding.

Dysfunctional voiding  can be misdiagnosed or overlooked, especially when symptoms are intermittent. From understanding the underlying causes to implementing evidence-based interventions, we’ll explore the multifaceted nature of this condition.

We’ll also investigate an intriguing case study of a 6 year old girl who presented to therapy with dysfunctional voiding. You’ll explore the clinical thought process to determine the most effective therapy approach for her.

By leveraging the latest research and therapeutic approaches, you can empower yourself to make a significant impact on the lives of children and families in your pelvic floor therapy practice.

Join me as we explore this crucial aspect of pediatric pelvic floor therapy, striving towards optimal urinary health for our young patients.

Dysfunctional voiding (DV) refers to the habitual contraction of the urethral sphincter during voiding, occurring in the absence of a neurological disorder. Children with DV exhibit abnormal voiding patterns for their age, typically experiencing irregularities during the voiding phase while maintaining normal storage capabilities. Some physicians may still call this “The Hinman Syndrome”.

Dysfunctional voiding may indicate varied flow patterns on uroflow study, demonstrating a range from staccato, to intermittent, or to continuous flow. This can result in inefficient bladder emptying, discomfort, and potential complications.

The etiology of DV is multifactorial, involving components such as:

• Delayed Maturation: Some children may experience delays in the maturation of bladder control, leading to incomplete coordination between the bladder and sphincter muscles.
• Toilet Training Challenges: Inconsistent or premature toilet training can disrupt normal voiding patterns.
• Learned Behaviors: Withholding urine due to fear of pain or reluctance to use unfamiliar bathrooms can result in uncoordinated sphincter muscles.
• Sensory Processing Issues: Children with sensory sensitivities may struggle with bladder awareness and coordination.
• Stress and Anxiety: Emotional factors can lead to habitual holding behaviors.
• Comorbidities: Constipation, UTIs, and anatomical abnormalities can exacerbate symptoms.

Without treatment, children with DV face risks of recurrent UTIs, vesicoureteral reflux (VUR), and kidney damage. Understanding the developmental trajectory of DV is crucial, as early sphincter contraction or poor bladder-sphincter coordination can lead to complications like urinary retention and overflow incontinence.

Therapeutic interventions for DV encompass non-pharmacological and, in severe cases, pharmacological methods.

Urotherapy, focusing on bladder rehabilitation and education, is a cornerstone of treatment. This may involve fluid and voiding schedules, constipation management, and behavioral therapy. Muscle re-education, including pelvic floor muscle retraining and biofeedback, is essential for improving voiding coordination.

Collaboration with other healthcare professionals is important, especially for severe cases requiring interventions like clean intermittent catheterization or sacral neuromodulation. Tailor treatment plans based on individual responses and escalate interventions as needed.

Let’s take a look at the case study to frame the issue of dysfunctional voiding. We discussed this interesting case in the Kids Bowel Bladder Professional Village Zoom meeting, where clinicians bring their difficult questions and complex cases to discuss among my private online group.

Harper*, a 6 year old girl, presented with the sensation of daytime incontinence. According to her mother, she was not actually having urinary leakage. Harper never had damp or soaked underwear, but she frequently felt like she was leaking.

Harper had been standing all day at school because she felt like she was going to pee when sitting down. This constant urge resulted in urinary withholding, as she tightened her pelvic floor reflexively to prevent any “leakage”.

During the external visual assessment of her perineum, Harper presented with a normal anal wink. She also demonstrated difficulty with volitional pelvic floor contraction and an almost complete inability to relax as well.

We discussed this case via Zoom just after Harper’s first therapy appointment. I thought this case history was intriguing, but further testing and information would be needed to really hone in on her treatment progression.

1. Uroflow: A uroflow study would be another appropriate initial test to measure the quantity and rate of urine output.
2. OT Evaluation: Harper’s pelvic floor therapist mentioned that Harper has a tactile sensitivity to tags. This note would prompt me to request an occupational therapy evaluation to assess Harper for sensory sensitivities.
3. Interoception Assessment: An interoception assessment would be appropriate as well. I’d ask Harper, “What does it feel like when you have to go potty? Do you actually pee? Where do you feel it?”
4. Constipation Assessment– constipation could be a contributing factor to Harper’s bladder irritability. Pressure on the bowel can cause involuntary bladder contraction.
5. Bladder and Bowel Diary: A diary would indicate and help track when she gets urges to urinate and defecate. Is she getting bowel urges during the school day and then withholding?

During our Zoom meeting, one therapist asked me if establishing a voiding schedule would be appropriate for Harper. A voiding schedule would be ideal to implement, but because Harper has established such deep withholding patterns, this potentially may create a lot of contention and might not be helpful initially.

Instead, timed voiding would be the best habit change to start with, making sure she has minimally one additional void during her school day and providing her with a reward afterward. By also giving Harper the choice of where she would want to urinate, this would grant her a sense of control, something which could help tremendously in this situation where much of Harper’s world is out of her control,

Additionally, establishing consistent and adequate fluid intake would be necessary. According to Harper’s therapist, because this little girl was afraid to drink and urinate at school, she avoided drinking during the day. Instead, she overloaded fluid during the morning and night.

Let’s not forget the importance of patient and family education. Although Harper is too young to understand the implications of dysfunctional voiding and urine reflux, educating her parents is crucial. Remember, long term damage can occur to the urinary tract if this is not treated. You can read more about the dangers of reflux in my previous blog post.

Dysfunctional voiding is an habitual pattern in children that can and must be retrained! In my LIVE, virtual pediatric pelvic floor course, Peds Level 1, I dedicate an entire lecture to breaking down dysfunctional voiding and how you should treat it. On April 26-27, 2025, you’ll dive deeper into pediatric pelvic floor case studies, like Harper’s, with expanded opportunities for in-depth learning.

*patient’s name changed for privacy