When we think of pelvic floor physical therapy, if you do at all, you probably think of cis-gender adult women. You might be surprised to find out that many potty and pelvic conditions that affect kiddos can be caused by pelvic floor dysfunction and can be treated with pelvic floor physical therapy. Pelvic floor physical therapy for kiddos is a noninvasive way to get your child to feel a whole lot better. When you are dealing with potty issues in kiddos, it can be absolutely maddening. Hopefully, by the time you are finished reading this blog, you will feel more confident in helping your kiddo tackle their pelvic issues and you will have many practical options to help your kiddo feel a whole lot better.
What are Conditions in Kiddos that are Associated with the Pelvic Floor?
- Urinary Incontinence
- Pelvic Pain
Constipation is an extremely common condition in both adults and kiddos. Approximately 9.5% of people suffer from functional constipation. We often see constipation occurring with a history of withholding behavior.
Withholding happens when a child deliberately tries not to have a bowel movement because it is unpleasant, (usually painful or frightening). Continued withholding can affect the pelvic floor’s ability to properly relax to evacuate and can impair the rectum’s ability to sense when stool is filling it, putting the child at risk for encopresis (fecal incontinence), which we will discuss later on in this blog. Basically, this means when a kiddo holds in their stool for too long, the pelvic floor muscles (the ones responsible for relaxing and getting out of the way) get really tight, making it harder and more painful to poop. As you can see, this can become a vicious cycle. Getting ahead of this cycle as soon as you notice it, is really important.
Sometimes your kiddo can lack proper coordination to have a full and complete bowel movement. For someone, kiddo or adult alike, to be an A+ pooper, they must be able to generate enough abdominal muscle tone to keep downward pressure on the pelvic floor with pooping. In addition, their pelvic floor muscles must be able to relax and stretch to get out of the way of the incoming stool. Sometimes the pelvic floor can be tight and rigid, preventing good relaxation. Other times, the pelvic floor may squeeze shut when it’s meant to open, making it really difficult to poop. If pelvic floor and or abdominal coordination is not up to par, one may experience constipation and difficulty pooping.
Bowel frequency alone is not enough to diagnose constipation, in fact, very constipated kids may have frequent but incomplete bowel movements. If your child has two of the following symptoms, they may be experiencing functional constipation:
- 2 or fewer bowel movements in the toilet a week in an individual over 4 years old
- At least one episode of fecal incontinence
- History of retentive posturing or excessive stool holding
- History of hard or painful bowel movements
- Presence of large stool in the rectum
- History of large diameter stools that can obstruct the toilet
Chronic constipation can be painful and sometimes persist into adulthood. It is really important to catch it early and treat it appropriately so poo worries are not an issue that follows them into adulthood.
Skid marks or smears on the underwear are the telltale signs of encopresis. Encopresis is defined as the involuntary leakage of stool in a person who is 4 years or older. Encopresis occurs when liquid stool sneaks its way around harder stool in the digestive tract. When this happens it can seep out onto underwear usually without the kiddo being aware that it has even happened. Oftentimes, when a kiddo is experiencing encopresis, their caregiver may mistakenly assume the child is not wiping properly or not listening to their signals that it is time to go to the bathroom and attempt a bowel movement. Sometimes these behaviors are co-occurring, but they are not the proximate cause of encopresis.
Encopresis usually occurs as a consequence of constipation. With longstanding constipation, the rectum can get overly stretched by hard, dry stool. An overstretched rectum is not good at relaying the information that it is time to poop to the brain, resulting in further constipation. When the rectum becomes stuffed with stool, liquid stool can sneak around the hard stool and seep out. Because the rectum, at this point, is not consistently telling the brain that stool is there, most of the time fecal smearing is not felt by the kiddo and they are unaware that it has occurred until they or their caregiver notices stains on their underwear.
Lower Urinary Tract Dysfunction
Lower urinary tract dysfunction can include, urinary incontinence, frequency, and urgency.
Incontinence problems can fall into many different categories. Some of the most common we see in kiddos are stress urinary incontinence, urge incontinence, and nocturnal enuresis (aka bedwetting).
Stress urinary incontinence and urge incontinence are both categorized as daytime urinary incontinence. 7-10% of people aged 5-13 years old experience daytime incontinence.
Stress incontinence occurs when pressure from the abdomen, (usually coughing, jumping, sneezing, or laughing) is too much for the pelvic floor to counteract. Treatment can look like improving pelvic floor coordination through non-invasive techniques like biofeedback and or improving pressure management by improving the strength and recruitment of the core stabilizers.
Kiddos may also experience urge incontinence. This type of incontinence occurs when a kiddo suddenly has an urge to pee that they can not hold back. Oftentimes, this urge can come out of nowhere leaving them with very little warning. Kiddos who habitually delay peeing due to engaging in more fun activity (video games, I am looking at you) or avoiding the bathroom due to fear of using a public toilet can be at higher risk for urge incontinence. Bladder training in physical therapy to help your kiddo feel when their bladder is approaching full can be tremendously helpful in improving urge incontinence.
Bedwetting or nocturnal enuresis, as it is also known, can be particularly frustrating for both child and caretaker. Bedwetting can affect a child’s ability to participate in sleepovers and sleepaway camps and create a whole heap of dirty laundry to deal with. Bedwetting is not terribly uncommon, it affects 15% of kiddos with female anatomy and 22% of kiddos with male anatomy. After age 6, we still see approximately 10% of kiddos experiencing. 1.5% of these kiddos will spontaneously kick bedwetting each year thereafter, but 1-3 % of 18 year olds will still continue to wet the bed.
There appears to be some degree of heritability between parents with a history of bedwetting and their children, with 72% of children who bed wet having 1 or both parents with a history of bedwetting as children. Bedwetting can be caused by many different medical conditions including urinary tract infection (UTI), and diabetes among others so it is really important to ensure that your kiddo sees a doctor if they are experiencing new-onset bedwetting, prior to starting physical therapy.
With all bladder issues, it is important to treat constipation first. This is because the rectum lives directly behind the bladder. If the rectum is full of stool, it leaves very little room for the bladder to expand and adequately store urine. Making sure you and your physical therapist treat constipation first can go a long way to ensuring that your kiddo gets the most out of pelvic floor physical therapy.
Unfortunately, pelvic pain is something that is seen in kiddos. We see pelvic pain in all genders. Pelvic pain in kiddos is what we call a red flag. This means if your kiddo or a kiddo you are close with is complaining of pelvic pain they should see a doctor ASAP. As in the bladder section, pelvic pain in kiddos can have a variety of medical causes including infection, endometriosis, a fall resulting in fracture of the coccyx, severe constipation, and others. For these medical causes we may also see pelvic floor dysfunction as a result of these conditions, but when a medical condition is a primary driver, it is important that it is treated first.
Pelvic pain can persist after these medical conditions are treated or in the absence of a diagnosable medical condition altogether. Typically when this happens we look to the pelvic floor as a cause. With pain, the pelvic floor is usually tight or hypertonic. This tightness can feel achy, burning, or stabbing and can be tremendously distressing. People can develop pelvic floor tightness for myriad reasons. Typically, we see poor core strength leading to pelvic floor overwork or stress causing excessive holding in the pelvic floor. We also can see pelvic floor pain and tightness occurring in folks of all ages who have recently undergone a big life change or stressor.
Though the thought of pelvic floor pain in kids is terribly sad, the good news is there is a lot we can do to help kiddos feel better, from relaxation exercises, biofeedback, and strengthening, there is a lot we can do to help your kiddos feel better.
As mentioned previously, endometriosis (endo for short) is a cause of pelvic pain. Endo occurs in folks with female anatomy. Endometrium lines the inside of the uterus and it sloughs off during menstruation. With endo, we find endometrial-like cells outside of the uterus. The classical symptom of endometriosis is painful periods. Though typically this is a hallmark of the condition, there are other symptoms that oftentimes go overlooked.
This is where I get on my soapbox. Healthcare professionals and childcare providers must keep a keen eye on our children with female anatomy to detect endo early. The road to diagnosis with Endo is often long. On average folks will wait up to 7 years for diagnosis. In that time, they may spend countless days in unnecessary pain and missing important events due to pain.
Symptoms of Endometriosis in Adolescents
- Chronic pelvic pain
- Pain below the belly button lasting at least 3-6 months
- One 3rd of kiddos with chronic pelvic pain are estimated to have endo
- Difficulty defecating (dyschezia)
- Pain with penetration (use of tampons/gyn exam)
- Pain or difficulty with urination
Endometriosis can have a significant effect on the quality of life of those experiencing it. There is a lot we can do to help lessen the effects of endo on a kiddo. Normalizing period pain leads to delays in diagnosis. If your kiddo is missing school due to their period pain or NSAIDs ( ibuprofen, naproxen, etc.,). Just don’t cut it, it may be time to visit an endo specialist.
What Does Pelvic Floor Physical Therapy Look Like with Kiddos
For the most part, pelvic floor treatment is driven by the kiddo. It is so important that at a young age, we instill a sense of autonomy and agency in our youngest pelvic floor patients, which will hopefully allow them to advocate for their own needs as they progress through life.
As pelvic floor physical therapists, we have a lot of tools to approach kiddos with pelvic floor dysfunction and we can select the tools and techniques that are the very best fit for your kiddo. We will assess strength, posture, and habits that may be contributing to your child’s symptoms. If your kiddo is comfortable with it, we can do an external assessment of the pelvic floor, where we assess by looking at how well your child’s pelvic floor muscles are functioning. We are also trained in myofascial release and visceral release which can be helpful for folks with constipation or endo. Kiddos with pelvic floor dysfunction also respond well to exercises that strengthen the core, and improve breath mechanics, and posture. All we have to do is sprinkle a little physical therapy magic on it, and we can make pelvic floor physical therapy feel a whole lot like recess! Who doesn’t love a little extra recess?
Once we have a good handle on what is going on by hanging out with and examining your kiddo, we explain to both parent and child (using language that is accessible to little ears) what is happening, and how we as a team can work together to feel better.
If you feel your child could benefit from pelvic floor physical therapy, call or book an appointment today
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- Soe S, Barnes E Caldwell P. Urinary incontinence during laughter in children: is it giggle incontinence. J Paediatr Child Health. 2021 Dec; 57(12): 1971- 75
- Van Mill, Koppen J, Benninga M et al. Controversies in the management of function constipation in children. Current Gastroenterology Reports. 2019. 21:23
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