Lots of my pediatric clients with low muscle tone are toilet trained. But…they still have bladder accidents well after being trained. They are upset by this. Their parents and their teachers aren’t too happy either. They reach for the pencil they dropped, or lift up their backpack, and leak a little urine. Sometimes more than a little. They have no explanation. They didn’t ignore bladder urgency; they didn’t have any to begin with! They may have been to the bathroom an hour ago. By themselves. And they weren’t playing; they peed.
What is happening?
Well, for some of my little clients, it isn’t behavioral. It isn’t an infection. And it isn’t sensory processing. At least, not primarily.
They aren’t fully emptying their bladder the first time around.
One reason is that they are “all cleaned out”. They often have had constipation, and constipation usually contributes to problems with urinating. But sometimes, all that fullness actually helps them increase their intra-abdominal pressure as they contract their abdominal musculature while urinating. Increasing pressure helps them get more urine out when their bladder is less than about 40% full. With low muscle tone, core musculature is often weak and fatigues rapidly. Kids might not even contract the correct muscles, substituting their pelvic floor musculature instead. This could make it harder to pee, not easier. With poor sensory processing or poor postural control, the risk of incorrect muscle use is amplified. They are unable to sense residual urine pressing down, or their attention is diverted to remaining stable while sitting or standing.
If they do get control of their constipation and have easy regular bowel movements, their large intestines are empty or almost empty most of the day. If they get enemas, they are really and most sincerely cleaned out. This may make it more likely for them to have accidents. There is nothing to press against!
Another reason is that they don’t know how to use the modified Valsalva Maneuver. This is an action that every paraplegic is carefully taught to do before they leave inpatient rehab. Kids can use it too. The biggest difference is that children need to be taught the finer points of the technique and need to be occasionally viewed using it to be certain that they are doing it correctly. Asking them about their use is far less helpful, because their ability to explain and absorb information without demonstration is less than what we expect for an adult. And getting it wrong isn’t acceptable.
What is the Modified Valsalva Maneuver?
The child needs to be sitting to perform this move. They take a breath and hold it while bending forward for a few seconds, then breathe out through their pursed lips and bend forward a bit more. It can be repeated once, but many repetitions are more likely to make a child feel dizzy or nauseous. That isn’t recommended for any child.
Why does this work? It increases intra-abdominal pressure by lowering the respiratory diaphragm and forcing the weight of the chest and abdominal organs down toward the intestines. For kids who don’t have much abdominal muscle tone, it boosts their efforts at bladder emptying.