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Bedwetting and Developmental Delays

How the Urinary System Works in Kids with Developmental Delays

When Laura Johnson's* son Jacob* was diagnosed with Asperger's syndrome at age 4, no one told her it could be the reason he was having trouble potty training. Had she known then that sensory issues associated with his condition were to blame, she could have saved herself a lot of heartache.

"Training Jacob was very difficult," Johnson says. "At first, he showed no interest in trying. After countless videos and books, talking and bribing, he grew to absolutely hate sitting on the potty. He would sit there for half an hour and then get up and wet down his legs."

Although Jacob began reading when he was 3, he wasn't allowed to move up to a higher preschool class because he wasn't trained. "Being treated by family and educators as a worthless mother who would not properly potty train her child, when I spent the better part of two years of my life trying to, was pretty upsetting," she says.

Children with a developmental delay of any origin, if not too severe, tend to develop normal urinary control somewhat later than the usual age range, says Dr. Stanley Hellerstein, a pediatric nephrologist at Children's Mercy Hospital in Kansas City, Mo. He explains that parents of special needs kids may not be made aware of this when learning about their child's condition. "Everyone's usually so preoccupied with other aspects of the condition that they don't even think about discussing voiding issues," he says.

What is the Urinary System?

The urinary system consists of the kidneys, where urine is formed, and muscles, tubes and nerves that remove waste products from your body in urine. It consists of two kidneys, two tubes called ureters, the urinary bladder and the urethra.

Your kidneys are located just below your ribcage near the middle of your back on either side of your spinal column. They look like kidney beans about the size of your fist, and they filter waste from the blood. Water and other wastes form urine in tiny filters in the kidneys called nephrons.

The ureters are thin tubes about 10 inches long, connected to the pelvis of each kidney and extending down to the bladder. Urine travels down these tubes into the bladder. The walls of the ureters have a mucous layer, a muscular layer and an outer layer of connective tissue. Contractions of muscles in the ureter walls push urine through the ureters into the bladder.

Your urinary bladder is a balloon-like organ that expands as it fills with urine. It is located in your pelvis, attached to other organs and the pelvic bones by ligaments. As urine drains into the bladder from the ureters, the inner wall of the bladder expands and gets smoother. As urine empties out of the bladder, the inner wall retracts into many folds. Circular muscles called sphincters surround the neck of the bladder. They close tightly like a broad rubber band to keep urine from leaking out. When the sphincters relax, the muscles in the wall of the bladder contract to allow you to urinate.

The urethra is a tube connected to the bladder through which urine passes to the outside of your body.

How Does the Urinary System Work?

The main function of the urinary system is to remove waste from your body. The kidneys filter the blood to form urine. The urine travels down the ureters to the bladder, the bladder stores the urine until it is ready to be emptied, then expels the urine through the urethra.

Sensory nerve connections run from the bladder through the spinal cord to the brain. When urine is ready to be expelled from the bladder, a message is sent from the nerves in the bladder along this neural pathway telling you when it is time to urinate. You may first notice a sensation that you need to urinate when the bladder begins to fill with urine. The urge to empty your bladder intensifies as the bladder is progressively filled with urine.

When you're ready to go to the bathroom, the brain sends a message to the bladder muscles to tighten and the sphincter muscles to relax. This allows urine to flow out of the bladder and through the urethra to the outside of the body.

What Causes Incontinence in Children?

When we're babies, our bladders automatically empty once they become full. "Normal babies start out voiding essentially by reflex, regulated at the spinal level," says Dr. Lars Cisek, a pediatric urologist at Texas Children's Hospital. "Much like the reflex hammer tapping the knee, the bladder fills – that's the tap – and once perceived, the bladder contracts – that's the knee jerk."

As a child gets older and the nervous system develops, the reflex to empty the bladder is inhibited by input from the brain. This delays the knee jerk response and allows the bladder to fill and store more urine. The development of the nervous system also allows the child's brain to receive messages from the bladder wall tension via the spine so the child senses that his bladder is becoming full. The child then learns how to relax the inhibition and allow himself to urinate at the right time and place.

Normal maturation of all the parts of the nervous system is required for a child to be able to control urination. The ability to control the bladder at night is usually achieved after the child learns to stay dry during the day. Incontinence happens when the control mechanism of the urinary system fails for some reason. These reasons range from the simple to the complex.

While you are working on the problem, it is helpful to use absorbent disposable underpants. Whether using them during the day or at night, when kids feel dry, it can help their self-esteem and prevent embarrassment caused by wet pants. An added bonus for parents is fewer loads of wet laundry.

Special Needs Kids and Incontinence

Any conditions affecting the brain or the spinal cord can cause urinary incontinence. For example, spina bifida basically scrambles the wiring at the spinal level. This may affect any part of the transmission or response system. Dr. Cisek explains that the disruption usually is in the reflex – either blocking it, un-regulating it or blocking transmission of bladder tension to the brain or the reception of inhibitory input.

Children with learning disorders such as attention deficit hyperactivity disorder (ADHD) have an increased incidence of bedwetting as well as daytime incontinence. Dr. Cisek says this may cause problems such as a failure to learn how to relax the inhibition or to attend to the filling signal. Children with Down syndrome have problems primarily due to their learning impairment. Children with autism have problems related to sensory issues.

Children with cerebral palsy tend to have a "spasticity," which can present as an overactive bladder, while children with cystic fibrosis have a high incidence of bedwetting for unknown reasons.

But no matter what your child's special need, Dr. Hellerstein urges parents and caregivers to remember that special needs kids deserve the same ongoing attention, support and management for incontinence as children who have no developmental delays.

*Names have been changed for privacy.

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