Clinical Insights From A Spinning Top Deformity Case: A Functional Perspective For Pediatric Pelvic Health Therapists

If you work with pediatric bladder and bowel dysfunction, you know how often a diagnosis or imaging finding becomes the focal point of a child. Sometimes this overshadows the functional behaviors that truly drive clinical decision-making. A recent case discussion inside our Kids Bowel and Bladder Professional Village (our private Facebook community with biweekly clinical meetups) highlighted this perfectly.

A 9-year-old girl presented with a radiologic finding of a “spinning top deformity,” but as the therapists in our community quickly recognized, the most meaningful insights came not from the imaging but from the child’s symptoms and functional patterns.

This blog reviews the case as presented and discussed in the Village, emphasizing clinical reasoning, pelvic floor function, and the therapeutic approach that ultimately matters more than the diagnosis.

The patient was a 9-year-old girl whose mother reported a longstanding history of urinary tract infections, essentially her entire life. Over the past few years, the infections increased in frequency and severity, often accompanied by fevers and headaches. This led to a referral to pediatric urology.

A Voiding Cystourethrogram (VCUG) was performed, revealing normal bladder contour and capacity, no vesicoureteral reflux, and no anatomic abnormalities of concern. However, the radiologist noted a spinning top deformity with a posterior urethra.

To many providers, this terminology becomes the primary clinical talking point. But for therapists evaluating bladder and bowel dysfunction, the child’s behavior and voiding patterns provide the most clinically relevant information.

During the pelvic health evaluation, the child was engaged, communicative, and able to describe her experiences in detail. She explained that when she went to the bathroom, she often had to wait (sometimes for an unknown amount of time) before urine would begin to flow. When it did, she would void only a small amount. After leaving the bathroom, she frequently felt the need to return shortly afterward.

She also described episodes of sudden, overwhelming urgency. In these moments, she would drop into a squat and “freeze,” dribble a small amount, and then hurry to the bathroom to finish voiding. These behaviors  indicated staccato voiding, pelvic floor overactivity, and incomplete emptying.

Her bowel habits added another layer to the clinical picture. She had bowel movements every other day, but they were large, dry, and painful, consistent with significant constipation. She was also on prophylactic Cefdinir due to recurrent UTIs.

No developmental delays or neurological concerns were present. Her history and functional symptoms were much more consistent with pelvic floor dysfunction than with a structural abnormality.

While a spinning top deformity may sound alarming to families, it is almost always a functional finding in children. The “spinning top” shape occurs when the bladder contracts against a pelvic floor or external urethral sphincter that does not fully relax.

This can create:

• Increased intravesical pressure
• Intermittent, staccato urinary flow
• Incomplete emptying
• Post-void dribbling
• Heightened urgency

In this case, the imaging simply reflected the physiology already evident from the child’s symptoms. Her pelvic floor was not releasing effectively during voiding, and her voiding mechanics were compensatory rather than coordinated.

This reinforces the importance of prioritizing functional assessment over isolated imaging findings.

Constipation played a central role in this child’s presentation. A constipated colon can increase pressure on the bladder, and cause tightening and shortening of  the pelvic floor, and creates a chronically inflamed and bacteria-rich environment around the perineum.

Residual urine from incomplete emptying becomes a bacterial reservoir, increasing the risk of infection. This is particularly impactful in children who already have pelvic floor difficulty.

During the case discussion, I emphasized that many providers underestimate stool burden. While ultrasound can measure rectal diameter,  KUB x-ray offers a more complete picture by assessing stool throughout the colon. This is especially valuable in chronic, complicated cases.

Addressing constipation aggressively is a non-negotiable component of management. Without it, voiding dysfunction often persists regardless of pelvic floor retraining.

For this girl, strengthening exercises were not indicated. Her pelvic floor was already “on” too often. The goal was to improve her awareness of resting tone and teach her to access full relaxation during voiding.

Surface EMG and biofeedback were ideal tools for this case. These modalities help children visualize what their pelvic floor muscles are doing and distinguish between activation and release. Establishing baseline resting tone and building awareness around “on versus off” were key first steps.

One strategy we discussed in the KBB Professional Village involved coordinated breathing following the initial voiding attempt for a second void.. The child would be instructed to raise her arms while inhaling, then lower them while exhaling, encouraging diaphragmatic descent and pelvic floor relaxation. Leaning forward with a soft abdomen and exhaling through pursed lips would help maintain low, steady pressure to facilitate a second void.

This approach often enables children to achieve more complete bladder emptying without straining, reducing post-void residual and decreasing infection risk.

The case generated meaningful insight among therapists in our community. This case underscores the importance of evaluating a child’s functional patterns rather than relying solely on imaging terminology.

Key points include:

• A spinning top deformity is typically a functional finding related to pelvic floor overactivity.
• Thorough understanding of the child’s voiding behavior is crucial for appropriate treatment planning.
• Constipation frequently contributes to urinary dysfunction and must be addressed to ensure improvement.
• Surface EMG and biofeedback are useful tools for teaching pelvic floor relaxation in children however treatment can be done without it!
• Coordinated breathing strategies can support more complete bladder emptying.
• Collaboration among therapists, urologists, and families enhances clinical outcomes.

Our KBB Professional Village community thrives on cases like this – complex, nuanced, and clinically rich. With biweekly discussions, members gain insight not only from the case presenter but from collective reasoning and shared experience.

If this case resonated with you and you want to deepen your understanding of more pediatric bladder, bowel, and pelvic floor dysfunction cases like this one, I invite you to sign up for Peds Level 1 – Treatment of Bowel and Bladder Disorders.

This course provides a comprehensive foundation in:

• Pediatric pelvic floor assessment
• Relaxation strategies when you don’t’ have SEMG of biofeedback
• Surface EMG and biofeedback
• Bladder and bowel defecation dynamics
• Clinical reasoning
• Real case studies like the one described here

You’ll walk away with clarity and practical tools you can implement immediately. Plus, once you’ve registered, you’ll be eligible to join the KBB Professional Village immediately to gain invaluable insights from a rich community of pediatric pelvic therapists leading the way in treating this underserved population. We look forward to seeing you in The Village!