There is so much overlap when it comes to pediatric specialties. Sleep issues are rarely just about sleep, they also can be about other body systems intertwining. So when I thought about bringing in a guest to talk about bedwetting in children I wanted to bring in an expert who knows her stuff about the pelvic floor and how to best address one of the top causes of pediatric bedwetting: constipation. Dr. Kiley Gibbs checked all the boxes and it was an honor to have her be a guest speaker with me on instagram and for the blog below!
Q: Tell me about your background in physical therapy and what got you interested in
pediatric pelvic floor physical therapy?
A: I completed my Doctorate in physical therapy and did most of my clinical affiliations in pediatric settings. This solidified my interest in pediatrics and I began working at Mott Children’s Hospital in Ann Arbor, MI after graduating. Knowing that I could provide better care with advanced training, I continued on to complete a Pediatric Physical Therapy Residency program through the University of Michigan. This is where I was introduced to treatment of the pediatric pelvic floor and incontinence. It was a new program for us and it made such an incredible impact in the lives of the children and their families. I was immediately drawn to it for that reason, and the fact that so many children are in need of treatment but are often too embarrassed to discuss what is happening. We had great team collaboration between the psychologists, dietitians, surgeons, gastroenterologists, urologists, and therapy staff to treat these children from all angles of care. I received wonderful mentorship during that time, and was able to continue advancing those skills throughout my time at UofM. I eventually opened up my own private practice in 2018 after moving to Maryland.
Q: What are pelvic floor muscles and how are they developed in children?
A: Our pelvic floor muscles sit at the bottom of our pelvis and make up the bottom part of our “core”. They begin to develop and function most when we learn to sit (around 5-6 months old) because one of their main functions is to provide support to our organs.
Another main function is to seal off the sphincters of the urethra and anus (where pee and poop come out) in order to maintain continence. The pelvic floor contracts when we have increased pressure in the body such as when we cough, sneeze, laugh, and jump. Contractions of the pelvic floor result in relaxation of the bladder, which can give us enough time to get to the bathroom if needed, or to stop an overactive bladder that might not be full.
Q: Can you explain how constipation can cause incontinence (lack of voluntary control over pee or poop)?
A: Many people think that constipation means not having bowel movements, but actually, functional constipation just means that we aren’t able to get everything out each day. For example, if a child is able to have a daily bowel movement, or several bowel movements, but they are only getting rid of 70% of what their body needs to push out each day, then there’s 30% of the daily poop left to back up in the rectum. The rectum, where poop is stored before we push it out, sits just behind the bladder, where our pee is stored. If our body has a back up of poop, this can put pressure on the bladder and not allow it to fill up as much as it should. This can result in feeling a strong urge to pee during the day, with little time to make it to the bathroom, and incontinence over night because the bladder isn’t able to fill up and hold all of the urine (pee) that our body is making. Once we clear up any backup of poop that could be in the body, we decrease the pressure on the bladder and allow it to function better. This is why constipation is the primary cause for bedwetting after the age of 5, which is when we expect children to begin being dry at night (some literature says age 6).
Q: In terms of sleep and incontinence, once daytime accidents have resolved at what point should one consider night training?
A: Typically once daytime incontinence has resolved, it can take around 6 months for nighttime incontinence to clear up. Children may experience a gradual decrease in how much urine is voided at night (how full the pull up is), which is usually the first sign of nighttime progress and this can happen even before daytime accidents are resolved! Then we often see a few dry nights a month, then a few a week, and then dryness each night. It isn’t an all or nothing change (though I’ve seen that happen too!), but usually a gradual progression toward being dry. If a child was dry for a stretch of at least 6 months, and then bedwetting came back, they can be more likely to have a more abrupt/ sudden resolution of bedwetting instead of a gradual progression. Children who are still experiencing bedwetting after 6-12 months of daytime dryness can often benefit from a “dry nights” program, in which we investigate when the voiding (peeing) is happening during the night, and make a plan from there. Children who are voiding two or more times during the night are not ready to be dry yet. This indicates that there may be another underlying cause that needs to be addressed.
Q: Can you describe a common patient scenario that you help work on with pelvic floor PT?
A: Many families that I see are working through daytime incontinence of pee or poop either with or without night time wetting. One common scenario that I see is when a child is having urinary leakage/ accidents during the day and infrequent or difficult bowel movements. If the child isn’t having daily bowel movements, we look at diet and water intake to make sure they’re getting enough fiber to keep the poop moving through their system.
Then we look at the pelvic floor muscles. One reason that it can be difficult to get the poop out each day is if the pelvic floor muscles can’t relax. There’s one muscle in particular: the puborectalis muscle. This muscle creates a sling around the rectum (where poop is stored) and can put a kink in it! If we aren’t positioned properly on the toilet, or if this muscle is too tight, then we aren’t going to be able to get all of the poop out each day. This muscle becomes tighter and tighter each time we squeeze to hold in poop or gas. So you can see that if a child isn’t listening to the signals of their body and going poop as soon as they feel the urge to go, then physically being able to get the poop out can become very difficult. This turns into functional constipation, then traditional constipation (infrequent or hard bowel movements), and incontinence of pee or poop. The longer the poop stays in the body, the harder it becomes, and the more difficult it is to push out!
Q: Before even starting night time potty training what are some things parents can do in order to prepare for the process?
A: Making sure that their child is drinking enough water can make a huge difference in potty training success! Water helps to keep the bladder healthy and flushed out, and helps to keep poop moving through the system and soft. If a child isn’t drinking enough water each day, the bowel movements can become difficult to get out, infrequent, or incomplete, which can result in putting pressure on the bladder. Increased pressure on the bladder makes it unable to fill completely, which can result in a strong urge to go pee suddenly (urge incontinence), and inability to hold all of the urine (overflow incontinence). We need to be drinking half of our body weight in ounces per day (Example: a 50lb child should be drinking 25 ounces of water each day).
After that, setting up the toilet to have ideal potty posture will allow for more success. Whether you are using a toddler potty or the regular toilet, the child’s body position should be the same to make sure the pelvic floor muscles (the puborectalis muscle in particular!) are able to relax. The optimal potty posture positions our knees above the level of our hips, around belly button level. To do this we may need a supportive footstool – I like the Squatty Potty brand for children and adults (yes, adults should be using a footstool to poop!). Children may also need a “ring reducer” or toilet seat support to make the seat larger for their tiny bottoms. If they feel at all like they might fall in, children will tense their muscles to hold themselves up, which can also include tightening of the pelvic floor muscles making it more difficult to pee and poop. There are many ring reducers online to choose from, but I like the “Jool Baby Folding Travel Potty Seat” because it is low profile, portable, and comes in many colors. I also like the built-in potty seats that look just like the regular toilet seat such as this one from MayFair.
Learn more about Dr. Gibbs here:
Dr. Gibbs received her Doctor of Physical Therapy degree from Nova Southeastern University. She completed advanced training guided by her passion for pediatrics, in the Pediatric Physical Therapy Residency Program through the University of Michigan. After completion of the residency, Dr. Gibbs earned certification as an ABPTS Board-Certified Clinical Specialist in Pediatric Physical Therapy. During her time with Michigan Medicine, Dr. Gibbs began treating children who were experiencing incontinence and pelvic floor dysfunction. After moving to Maryland, Dr. Gibbs opened a private practice specializing in the treatment of pelvic floor dysfunction, incontinence, and constipation for children 0-18 years old.
Dr. Gibbs has contributed to the advancement of pediatric physical therapy through being an Adjunct professor at Shenandoah University, and has presented at national conferences about her work in pediatric pelvic health. She has been published in national scientific journals including the Journal of Women’s Health Physical Therapy and the Journal of Pediatric Physical Therapy for her work as a pediatric clinical specialist and pediatric pelvic health provider. Currently, Dr. Gibbs is a member of the Pediatric Specialty Council. Outside of work, Dr. Gibbs enjoys gardening and hiking with her husband and daughter.
Contact info:
Phone (240) 377-6179
Website: https://www.kcgpediatricpt.com
Instagram: @theincontinentchild
References:
Reilly M, Homry Y. Treatment of a child with Daytime Urinary Incontinence. Pediatric Physical Therapy. 2008;20(2):185-193.
The Rome Foundation: Rome IV criteria. https://theromefoundation.org/rome-iv/rome-iv- criteria/
Gibbs K, Kenyon L. Biofeedback-Assisted Muscle Training for Pelvic Floor Dysfunction to Address Pediatric Incontinence: A Case Report. Journal of Women’s Health Physical Therapy. 2018;42(1):17-22
