Report from the workshop Bladder training

Failing Bladder Training: What to do now?
Marianne Vijverberg, Leontien Berntssen, Aart Klijn; The Netherlands
Cathrine Renson; Belgium

Introduction
Imagining, a nine year old girl with daytime incontinence, UTI, DV, constipation and treated by the pediatric urologist with medication and advices about toilet position and fluid intake. The complaints didn’t disappear and the patient was referred to the urotherapist. The urotherapist has first given an out patient training during 3 month without improvement. Finally she followed an in patient trainingprogramme with a follow up period of a half year. After the treatment the complaints were improved, but the girl still had wet incidents 4 of the 7 days weekly. So she could stay dry but not all days. The effort and support were sufficient.
What is the best way to do? How long should we continue the training? Do we need other approach? I hope we will answer together these questions in this workshop. And hopefully we will find solutions for the hardcore group of patients, so we can help them to be continent. At the same time we have to be careful that children had treated too long with a less of success.
We would like to start with three short presentations and in addition a few cases. First of all I am delighted to introduce the first presentation by Leontien Berntssen, urotherapist of the UMC Utrecht. She will present in short the causes of treatment failure.

Do you all recognize this feeling when the training is not successful? Well, we do.
To find solutions to these problems, we have to know first what the possible causes of failing could be.
By way of explanation we have split up the causes of failure during training in medical causes and psychological causes.
The main factors of medical causes are the urinary tract infections, constipation, obstructions and insufficient sphincter.
Dr. Klijn will tell you more about these factors later on.
First, I would like to explain the psychological causes.

Psychological causes:
In our opinion there are 7 main points
The first point is the difficulty to maintain.

1. Fore some children it’s difficult to maintain the training instructions. They can only be continent with a very high concentration and continuous effort. Especially for children with an overactive bladder. They have to be alert to urge signals all the time. This is something they cannot maintain in social life.
    
2. Age is an important factor to understand the training instructions and to hold on. If the child is too young, its character is playful and cognitive skills are under-developed. Still, there are different reasons to start a training, despite of this knowledge:
    
   For example
   • There is a big medical pressure so that you will start training, despite your doubt.
      
   And an other reason can be
   • Psychosocial pressure is high and the child is suffering.
      
3. The next point, the child is still ignoring the problem as a solution. Ignoring is a human mechanism of survival for not to be bothered by things you don’t like. Part of the training is to break through this kind of behavior. Causes of not succeeding are:
   • Fear of failure
   • Perfectionism
   • Uncertainty
   • Negative attitude from the parents
      
4. What do we have more: Lack of dedication. This problem is very common in children with high intelligence. These children have no learning problems and will be able to reproduce all the training instructions faultless. They know what their own bladder problem is. But to carry out the trainingprogramme and to dedicate them will be much harder to do. Because, never before, they had to work so hard to achieve something. With a bladder problem dedication is necessary to break through inveterate patterns. You can compare the dedication with top-sport. These children are not used to this. They are not used to fail, so they quit before the training has ended.
    
5. Further more, the behavior problems. These are problems as ADHD, autistic problems, mental retardation etc. Despite of extensive preparation and an adjusted training programme, it can appear that the training structure is too difficult for these children to handle.
    
6. It would not surprise you that an other cause of failure is a lack of parental support or struggle between the parents and the child. Parental support is a very important factor for succeeding the training. Some parents are incapable to support their child despite of the coaching of them by the urotherapist. The different causes of this can be:
   • Long lasting struggle in the past
   • Having no confidence in a good result
   • The incapacity to coach
      
7. Other psychological problems such as school problems, fears, lack of confidence etc. And problems activated by the situation, like divorce, birth and decease of a family member. Before a child starts a bladder training, it must be in a calm environment where it feels o.k. This enlarges the chance of succeeding. Children with these problems could be referring to a psychologist, before starting a training.
   These problems can occur during the training. This is most often not foreseen and has its influence on the training result.