OUT-PATIENT BLADDER REHABILITATION

OUT-PATIENT BLADDER REHABILITATION

The basis for the bladder rehabilitation, whether unstable bladder or hypertensive sphincter, is voluntary start of voiding at predetermined times. Ability to start voiding, even without the desire to void is the first step to learn bladder control in regard to both continence and bladder emptying. It is emphasized that the child itself has to take over the responsibility of regular bladder emptying. Parents of small children are instructed to support the child in this responsibility. The goal is daytime continence like with in-patient rehabilitation.

Out-patient Rehabilitation Program

First visit

Education: How does the normal bladder function and what is wrong with the child’s balladeer? Draw pictures and describe the situation so that the child really understands.
Discuss the sitting (girls) or standing (boys) posture during voiding. Help the child to find the best position for relaxation of pelvic muscles during voiding.
Make a voiding schedule for the first week. The child should void at predetermined times during the first day once every hour. Then the intervals can be prolonged, but they should be frequent enough to avoid urgency. Daily routines of the family should not be changed and voiding schedule should be adapted to the other activities of the family. The goal to achieve is that the child additionally to first morning and bedtime voiding would void five times a day relaxed, with one go and completely without pushing.
Instruct the child how use the voiding protocol.

Second Visit

After one week repeat the instructions of the first visit and check the voiding protocol. After one-week concentration on predetermined regular and meticious voidings, the child should try to identify feeling of a very tiny desire to void and the feeling when the bladder is empty.

Third Visit

Three weeks after entry repeat the instructions of the first visit once again. Adjust gradually the voiding schedule to child’s own desire to void. The voiding should happen at the first desire to void and urgency should be avoided. Possibly the child needs voiding reminders, especially during the school hours like a couple of tape strips on the back of the hand; one should be taken off for each voiding at the school toilet. Contact the school nurse and/or teacher if problems are encountered during school hours. At home, after school, a small parking clock can remind the child about the voiding on regular intervals. The child should then ask himself one, two, three - do I have to ? And concentrate on the desire to void and then void at the smallest desire as soon as possible.

Forth and Fifth Visit

Five and seven weeks after entry evaluate with the child and the parents all the voiding protocols thoroughly looking for improvement. Final instructions are given based on progress made. If the improvement is satisfactory after 8 weeks the child will continue to void regularly by the first desire and will no longer need the voiding protocol. A pad test is repeated and if the child is not cured or has greatly improved the patient is a treatment failure in the outpatient bladder rehabilitation group.

Additional Aids for Out-Patient Bladder Rehabilitation

In children with detrusor-sphincter dyscoordination relaxing exercises including pelvic floor muscles should be practiced also in between voidings. The child should start the voiding in a relaxed mood, possibly a light pressure to the suprapubic area can help to initiate bladder emptying. The child is instructed to try to void in one portion and get out as much as possible. During the visit to outpatient clinic uroflowmetry can be used to check improvement (but should not be used as a biofeedback method) and the bladder emptiness should be checked with ultrasound.

Contact with the Child by Phone

The child should him - herself contact the urotherapist, if necessary, at certain hours a day during the intensive outpatient bladder rehabilitation. After eight weeks of therapy the child should continue the voiding program by him- herself without voiding protocol.