Continence Foundation Board Member and physiotherapist Dr Janet Chase was working at the Mercy Hospital for Women when her interest in women’s health increased.
“You only have to be involved for about five seconds to realise incontinence is a very big issue” she says. Patients would often tell her: “I’ve always had these issues ever since I was a child”.
As a mother of young children at the time, this raised a question for Janet: “Why aren’t we treating the children?” Guidelines from the International Children’s Continence Society state that childhood incontinence should only be treated by someone who has specialised in women’s health or has a postgraduate qualification in the treatment of continence and pelvic floor rehabilitation. Janet ventured into paediatrics as she realised there was no one else for children to see.
If toilet training has not succeeded, children are classified as faecally incontinent when they are four years old but not urinary incontinent until five years old. These age milestones help to determine if the child is slow to mature, or if there is underlying dysfunction. If the child has a condition which requires multidisciplinary input, Janet may be brought in to work with parents of children as young as two or three.
A commonly held belief is that all children who experience incontinence have a congenital or neurological disorder or have experienced significant trauma. However, normally developing healthy kids can also have issues with incontinence.
The biggest misconception is that children will grow out of incontinence. While some childhood incontinence will indeed improve with maturation, others don’t and if untreated, incontinence can cause damage to the upper urinary tract and kidneys. Psychologically, incontinence is associated with a lower quality of life, lower self-esteem, and associated behavioural comorbidities.
Continence physiotherapists may see patients from a minimum of two to three months to some years. When children soil themselves, they may pretend it hasn’t happened because of the shame they experience, so Janet initially engages the child with age-appropriate education and removing blame and guilt from both the child and the parents. The treatment plan will usually involve a full medical history, an assessment of the child, including signs and symptoms, bladder and bowel function, and a behavioural assessment. If there is bowel dysfunction, laxatives and a toileting program will be introduced.
How the child uses their muscles to empty their bowel will also be assessed. If the presenting problem is urinary incontinence, uroflowmetry, ultrasounds, bladder charts and non-invasive urodynamics can be employed to measure frequency and volume. Treatment can involve employing a toileting regime, where Janet teaches the child how to empty bladder to completion. “For most children, it’s not just about the pelvic floor but about the child’s abdominal muscles and the way they breathe so that they are able to relax”, says Janet.
Additional support may include pharmacological help from a GP or paediatrician, or neuromodulation with non-painful Transcutaneous Electric Nerve Stimulation (TENS) or Inferential Current (IFT). Continence guidelines state that if there is no improvement within six months of seeking professional assistance, treatment should be reassessed, and further consultation should be sought with a urologist or paediatrician.
For Janet, working as a continence physiotherapist is very rewarding. Children who were once shy and quiet wearing damp underwear can leave the course of treatment with a renewed confidence and sense of self.