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August 13, 2019 Tuesday 04:09:43 PM IST

Tackle Urinary Problems of School-Going Children

Health Monitor

Paediatric urologists focus their work on conditions in children related to the kidneys, ureter, bladder, the urethra, the genitalia - their structure and control of urination.  Many of the congenital anomalies would have been picked up by diligent parents and paediatricians and reached the paediatric urologist by the toddler-stage.

However,parents do get worried about urinary symptomsthat become noticeableafter their children have started going to school.Here are some of them:

1.     My 6-year-old son keeps going to the toilet to pass urine very frequently. The paediatrician has checked his urine and there is no urinary infection.

‘Pollakiuria’ is the name given to the condition that affects almost exclusively young boys. The child wants to pass urine again and again. He is anxious to find out where the nearby toilet is. But if he is engrossed in something he likes, he can go without having to pass urine.  Unlike a urinary infection, there is no increase in frequency in the night, nor does he wet his bed at night.

‘Pollakiuria’ is not a kidney or bladder-related problem, but only an anxiety to pass urine. It does not respond to any bladder or kidney medications. There is some suggestion that at least in some children, it is due to a form of autoimmune response triggered by a streptococcal infection in the past.  It is important to tell parents to convey to the teachers that the children should not be told to hold the urine as this will only worsen their anxiety. The symptoms become less troublesome by the time the child reaches adolescence and they are more in control of themselves.

2.   After having been well all these years, why did my 7-year-old daughter develop a urinary infection? The ultrasound of her kidneys is normal.

After ruling out a neurological problem, the next important step for the paediatric urologist is to find out the bladder emptying habits in utmost detail. The urethra in girls is shorter and easier for bacteria to reach the bladder by moving up the urethra. Between boys and girls, girls tend to pass urine at greater intervals. At school, many girls,having a heightened sense of cleanliness,find it revolting to go to a wet and smelly toilet. They avoid passing urine while at school. Unlike in the past, children do not reach home to use the toilet at home.This period of stasis of urine is enough to allow an occasional bacterium to multiply and set up a urinary infection.

Unless this problem is recognised and remedied, the overdistension of the bladder may precipitate other maladies. The bladder may start overriding the conscious instructions and may start letting out urine resulting in wetting of the undergarments. The bladder can become overstretched and become unable to empty urine completely, making it easier for bacteria to linger on instead of getting washed out with every void. In some children the condition can become so bad that a valve mechanism that prevents urine in the bladder from going back to the kidneys fails. When that happens, the infection can affect the kidneys directly, and over time lead to kidney failure.

So, when urine infection happens for the first time in a school going child, the treatment should not stop with antibiotics, but should extend to regularising bladder emptying and ensuring a regular bowel habit. Parents can help by visiting the school, inspecting the toilets and securing a higher level of regular cleaning by means of interactions with the teachers or management, installation of exhaust fans, provision of staggered rest breaks so that the toilets are not crowded. The doctor can provide a letter expressing the medical need. Teachers may extend permission for the affected child to use the staff toilet and even insist that the child uses during every rest break.

3.   My child is embarrassed that he / she continues to wet the bed at night.

Children attain daytime control of micturition (passing urine by intention) by 3 years of age. As children grow, the night-time production of urine becomes less by two mechanisms. One is that they feed less at night-time; the other, the more important one, is the night-time surge of antidiuretic hormone by the pituitary gland as part of a normal maturation process. More and more nights become dry and by around 5 years,bedwetting becomes anexception than the rule.If a child takes longer than usual to become consistently dry at night, it is a social problem rather than disease.

The doctor will be worried if bedwetting reappears in a child who had previously stopped wetting the bed at night. If it is so, tests for urine infection and kidney function may be necessary.Daytime wetting also has to be taken seriously and brought to medical attention as early as it is found.

Most parents address bedwetting by waking up the child using an alarm to send him or her to the toilet to empty their bladder. A few sensible measures could include the following:

·        Encourage water intake during the day at school. This way the child is less thirsty and hence drinks less water in the evenings.

·        Ensure that meals are finished a good 2 hours before bedtime and the child empties the bladder just before turning in for the night.

·        Avoid bedtime drinks.

·        Follow a regular time every night to put off the light and go to sleep.

·        A small amount of salt such as in ‘kanji’ at night can fool the body into keeping the moisture in the food in the body for longer.

·        Bedwetting alarms are available online. Their effect is to wake up the child when they start wetting, not really preventing bedwetting.

Some are prepared to wait while practising the measures outlined above. For older children who wish to gain immediate relief, antidiuretic hormone in the form of a tablet before going to bed is available, but it should be used only under strict medical supervision as it can cause seizures from water retention.

4.   Every now and then, my child comes back from school and complains of pain while passing urine. The pain is not there every time.

The question here is, does the pain occur only when the urine is very concentrated. The first response should be to drink water. It is an occasional sportsman that suffers the most. Regular players are experienced to know that they have to drink a large amount of water whenever it is hot or they are sweaty. By drinking enough water, the crystals that form in concentrated urine dissolve or get washed away.

Besides urinary infection, there are other causes both within and outside the bladder that can cause pain while passing urine. So, if the pain continues inspite of drinking enough water and passing a dilute urine, it is important to see a doctor.

5.    My 10-year-old son complaints of sudden sharp pain and swelling in one of his testicles with abdominal pain and vomiting.

Testicular pain and swelling could be due to myriad of causes but should always be considered one of the few emergency situations in paediatric urology. This is because it may be due to torsion of testis. In such a case, the testis twists around the chord thereby hampering the blood flow to it. It happens due to incomplete attachment of testis inside the scrotum which enables it to move freely. It requires immediate surgery within 4-8 hours failure of which lead to loss of the testicle. Children are embarrassed to talk about their genitals, but it is important to educate your son about this entity and if he or his friends ever develop pain or swelling in testicle, to immediately inform you (or their parent) so that timely medical care can be given to save the testicle.

The above is a guide to some conditions that worry parents of schoolage children that do not appear very serious but at the same time keep coming back again and again. The condition 5 is one of those rare emergencies that both children and parents need to be aware of for prompt treatment to save the testicle.

Dr. Balagopal Nair & Dr. Reju J.Thomas

( Dr.Balagopal Nair is Consultant, Urology & Paediatric Urology; 

Dr.Reju J Thomas is Consultant Paediatric Surgery & Paediatric Urology, Rajagiri Hospital, Aluva.)

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