IN-PATIENT BLADDER REHABILITATION

Audiovisual documentation of the program and reassurance of non-invasiveness of bladder rehabilitation program are sufficient to motivate a child for a two-week hospital stay. It is important that the parents know that the primary aim of the training is daytime continence and it might not have influence on nighttime wetting. Nighttime wetting should be considered as a separate problem for which the child could start a dry-bed training program about six months after concluding the bladder rehabilitation program.

In-patient bladder training is based on three basic elements:

1. Learn relaxed voiding by using biofeedback information of uroflowmeter (in special cases with EMG or cystometry)
2. Void after first desire, and learn to separate between urgency and normal urge by wearing a detector pad.
3. Learn regular voiding habits by keeping a voiding protocol.

Intensive Training (1.5 days)

1. Day starts at 9.00 hrs when the trainer explains the normal bladder/sphincter function and the three steps of the training day explaining how they should help the child to learn normal bladder function. The child should understand the meaning of the steps and repeat them until he knows them by heart (learn how to void, learn when to void, learn how many times to void).
2. The child should drink at least 150 ml of fluid every hour and is sent to the toilet to void each hour by the urotherapist who asks: " think one-two-three, do you have to ?" The child should learn to concentrate of the first desire to void and go to the toilet immediately.
3. Every time the child has visited the toilet he notes it on the chart with a little flag.
4. The operation of the flowmeter is then instructed by showing different flow patterns of correct and incorrect voidings.
5. During the intensive training periods from 09.00 hrs to 12.00 hrs and from 14.00 hrs to 17.00 hrs each voiding is recorded with a uroflowmeter by displaying it on a computer scheme and making a printout for the child’s own voiding booklet.
6. The child should note type of desire he/she felt before each micturation on the flowmeter. He or she should learn to differentiate between the very strong desire to void associated with a small volume and a normal desire to void with larger volume.
7. The child wears a detector pad, which gives a signal by loss of urine. The child is instructed how to react to any involuntary loss of urine: a) call the urotherapist or nurse when the beeper beeps, b) try to finish the voiding on the toilet by doing the "5x20 exercise". This means sit on a chair count till twenty, and repeat the procedures five times, c) draw a rain cloud on the chart and put on dry detector pad.
8. Results are discussed with the child at 12.00 hrs and at 17.00 hrs. The child’s draws a shining sun on his chart after a successful training day.

Supervision Phase

After one and half days of intensive training, a less intensive supervision phase follows. The procedures are discusses with the child and repeated till he/she knows them by heart. No extra drinks are given any more and the child should participate in all activities of the ward and also attend the hospital school.

1. Start 09.00 hrs by asking the child to try to void in one go.
2. The trainer motivates the child to pay attention to his bladder sensations. He/she should think regularly: "one-two-three, do I have to ?" The staff helps the child to remember.
3. Instructions are given for the right posture on the toilet: a) sit upright on the toilet both feet sustained, b) relax the abdomen and wait till the voiding starts by itself without starting and c) listen the sound of voiding, it should be smooth and without interruptions.
4. The child should void two times before noon and three times during afternoon. At each time of voiding the child draws a flag in his booklet, notes his desire to void and check the pants for possible loss of urine with agreed symbols.
5. In case of involuntary loss of urine the child calls the urotherapist and acts like he did when the beeper beeped.
6. At 12.00 hrs at 17.00 hrs the urotherapist checks together with the child the booklet and the uroflow curves. Felicitations for a better performance than before and the shining sun in the booklet after a dry day will motivate the child to continue.
7. Training periods and trainer attendance:

1^st-4^th day: 09.00-12.00 and 14.00-17.00

4^th-5^th day: 09.00-17.00

6^th-13^th day: 09.00 until bedtime

The urotherapist is usually present on ward; bedside trainer attendance at 9.00 hrs, 12.00 hrs, 14.00 hrs and 17 hrs, the trainer is on call.

Practical Hints

If possible, two children with same kind of problems sex and age, should start in-patient rehabilitation together and they should share the room. Such an arrangement usually facilitates learning because of competition. It also helps the children to adjust themselves for the two weeks stay in a hospital ward. Visits of the family members are welcome in the afternoon and evenings.

After two weeks rehabilitation on ward the child continues the program at home. The parents should check the voiding protocol, which the child continues to keep independently for another six weeks. The child should keep contact by phone to the urotherapist at regular predetermined intervals until the six months follow-up point after entry.

© EUROPEAN BLADDER DYSFUNCTION STUDY IN CHILDREN (EBDS) PROTOCOL 68-72p

© 1999 Thinkquest team 28880