Dr. Moses and Dr. Saunders discuss the pediatric population and pelvic floor muscle dysfunction. They clearly and concisely break the discussion up into sections on the topics of daytime wetting, nighttime wetting, constipation, psychological considerations, and treatment options.

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Pediatric Pelvic Floor Dysfunction

Dr. Moses and Dr. Saunders discuss the pediatric population and pelvic floor muscle dysfunction. They clearly and concisely break the discussion up into sections on the topics of daytime wetting, nighttime wetting, constipation, psychological considerations, and treatment options.

With Dr. Lindsay Moses, PT, DPT
and Dr. Lindsay Saunders, PT, DPT

Cindi Michaelson:

Hi Dr. Lindsay and Dr. Lindsay, it’s so nice to see you. Dr. Lindsey  Moses and Dr. Lindsey Saunders are with Grace Physical Therapy and Pelvic Health. Their entire practice is on the HER Health Collective expert panel and so we’re delighted to have them here today to talk to us more about pelvic health, and this time in children. I am just so excited to hear this, so I’m going to quickly turn it over to whichever doctor is starting first, and have you introduce yourself some more.


Dr. Lindsay Moses:

I’ll just say we’re together right now, in the office if you see me give a side glance to Dr. Saunders and vice versa.  We’re really excited to be part of the panel tonight, excited to talk about this topic.

A little intro about me, I’m Dr. Lindsay Moses. I have been a practicing PT since 2005. I graduated from Northwestern with my Doctorate. I’ve spent about ten years or so doing outpatient Orthopedic physical therapy.


Then I had my first child and things went south, literally, and I had to go and see a pelvic floor physical therapist, and that was sort of my introduction into the field. When we relocated here, about six years ago from Chicago, I was introduced to Dr. Erica Grace who had this practice and she mentored me. And ever since I’ve been working with men and women and for the past three years the pediatric population as well, with issues related to pelvic floor dysfunction. I will turn it over to Dr. Saunders for her intro.


Dr. Lindsay Saunders:

Hi, my name is Dr. Lindsay Saunders. I have been practicing in pelvic health ever since I finished PT school in 2018. I actually started training in adult and pediatric pelvic health when I was a student. So I’ve been doing this for a while now and I really, really love it.


When I started PT school, I started on a pediatric track, I didn’t know about pelvic health. So when I learned about the specialty I was really able to blend my two passions together, and I’ve really enjoyed working with our tiny human friends. And that’s a little bit about me.


Dr. Lindsay Moses:

Okay, so today we’re going to talk about the pediatric population and pelvic floor muscle dysfunction. We’re going to be talking about daytime wetting, nighttime wetting, constipation, psychological considerations, and treatment options. We’re going to break this up into some sections.


We typically treat children starting at the age of five. That is sort of our general cutoff, although some exceptions can be made if there is an issue that starts a bit younger. We do require a prescription from a medical provider, prior to treating patients in this population. The prescription can come from a Pediatrician, Urologist, GI specialist, but we do require some documentation, which is unlike our adult population which we don’t require that for.


So, as I typically do, I’m going to start with a little anatomy lesson, that hopefully doesn’t bore everyone. But it’s always a good place to start.


I have here, the model of the pelvis. So, here’s looking at you from the front. This is the pubic symphysis, which some mamas may be familiar with from pregnancy. We got your two hip bones.  And then if we flip it around we’re looking at the bottom of the lumbar spine and the sacrum or the tailbone and the little coccyx bone is down here. Right between the hip bones and at the base of the pelvis, all of these red and white things are the muscles that comprise the pelvic floor.


So when we talk about the pelvic floor again were referring to a group of muscles with four primary functions:


1:  These muscles support all of the pelvic organs resting on top. I like to think of it like a bowl or a hammock, supporting the bladder. In females, it supports the cervix, the uterus, the ovaries, and the rectum. In men, it supports the prostate, the bladder, and the rectum.


2:  These muscles are responsible for keeping us continent, but also for relaxing when we want to urinate or defecate.


3:   These muscles play a role in sexual function based on location.


4:   These muscles help to support the core. They are considered to be part of the core. They offer strength and stabilization to both the spine and the pelvis.


So for a group of muscles that we don’t talk a whole lot about, these are really integral roles in this area of the body.

Pediatric Population

So, let’s start by talking about what’s normal when it comes to the pediatric population. From the age of twelve on, when it comes to urination, when it comes to voiding, children should be urinating about four to six times a day.


That varies very differently from the first year of life when infants are voiding on average about twenty times a day. That decreases to about eleven times a day for children between the ages of one and three. And, again by the time kids are twelve they are voiding at the same frequency as an adult, which is that four to six times a day range.


Interestingly, the capacity of the bladder actually increases by 400% during those first four or five years of life. There is just a huge period of growth that occurs, not only up here, but down below as well, during those first few years. So it’s a really important, integral time to develop good habits, during that growth period.

Constipation is one of the most common contributing factors to things like bedwetting and other forms of urinary leakage. So it’s often something that we explore as an underlying factor when parents bring their kids in with concerns about bedwetting or accidents at school.

Potty Training

A big question that I think we both get asked, is when should I start potty training my child? And that is a really good question. There are a few factors that we really like to emphasize.


Number one, and I think is probably the most important, but what is the child’s cognitive ability to train? Are they aware that they need to go? Do they have that cognition? Do they know they have to void? Are they mature enough to handle the process of toileting?


We also need to make sure that these children have the motor skills necessary to toilet. They need the ability to obviously undress and dress themselves. This typically happens on average, by age four, although as many of know, that may happen much sooner and for some children there is a delay period and their train is closer to five or six years old. So the age four obviously is just an average.


Typically, readiness to potty train is indicated when children are dry during the day for at least two hours. When they feel uncomfortable and voice their concern that they’re uncomfortable when they feel wet. And when they indicate the need to void, “Mommy, mommy, I have to go.”


Daytime dryness typically proceeds nighttime dryness, on average, by about ten months.


So, we’re going to shift gears a little bit. I’m going to pass it over to Dr. Saunders, next.


Dr. Lindsay Saunders:

So, we’ll talk about everyone’s favorite topic, which is food. Everyone loves to talk about food.


Constipation is one of the most common things that we see in the pediatric population. Whether the kiddo presents with that as the primary concern or whether its an underlying factor to some additional concerns like bedwetting or things of that nature. The research varies in the frequency that it says that this occurs in the pediatric population, but there are articles that will say as many as 80% of kiddos, between the age of 5 and 12 experience constipation at some point.


Kiddo’s constipation can look a little bit different than it does for our adult population. We typically think about being constipated as either not having very frequent bowel movements or it’s really hard to go. And we often see that in the pediatric population as well. So when we look at frequencies, we’re looking at constipation as defined as two or fewer bowel movements per week, or stool that’s really hard and difficult to pass, or the passage of larger stools, larger than what we would typically expect for someone at a given age range.


Constipation is one of the most common contributing factors to things like bedwetting and other forms of urinary leakage. So it’s often something that we explore as an underlying factor when parents bring their kids in with concerns about bedwetting or accidents at school.


There are two different types of constipation, there is Slow-Transit Constipation, which is where it takes the body a longer than expected period of time to allow flow to pass through the intestine.


There is also Outlet Dysfunction Constipation, which is where stool reaches the rectum in a reasonable amount of time, but it’s hard to get it out. Whether that’s part of the stool, or sometimes kids have underlying sensory processing concerns. A lot of Outlet Dysfunction Constipation has to do with those pelvic floor muscles. So part of our job is to help figure out, what exactly is going on? Sometimes it’s an issue of both Slow-Transit Constipation and some Outlet Dysfunction, sometimes it’s one versus the other. Treatment can just look a little bit different depending on what’s happening.


In our younger friends, it can be challenging to figure out when they’re actually constipated. Especially in the school-age population, parents aren’t with their kids all day, so they’re not exactly privy to everything that’s happened in those six hours when they’re away.


Some common things that might indicate your kid is constipated, you want to look at:


     *Do they have a loss of appetite?

     *Are they having abdominal pain or abdominal bloating?

     *Sometimes body odor can actually be an indicator that that’s happening.

     *Are they experiencing urinary or fecal leakage?


These are all things you want to consider. One of the things that we look at first when a kiddo comes in with suspected constipation, is diet. That is one of the major underlying categories that we focus on. Kiddos love constipating foods, the bland diet is very popular across age groups.


Things like dairy products can be extremely constipating, soda, things with additives. Kiddos who eat a lot of bananas, that’s another big one that I see a lot of. Bananas and dairy tend to be the two biggest ones. So a lot of what we try to do is look at diet and see, is there anything that shouldn’t be there. There are some kids who just don’t like to drink water. So looking at their water and fiber intake, and how can we better balance that for them. 


Another big thing that we see in the pediatric population is avoidance. Either they don’t want to go to the bathroom, because they had a previous episode of constipation that was scary or painful or they’re just too busy. They’ve got other things that they want to do, they don’t want to stop playing so they don’t like to go to the bathroom and that can throw voiding schedules or voiding habits into a little bit of chaos.


Changing routine is the final big category of things that we’re looking at, in terms of the psycho-social approach to what is happening. Kiddos who are starting school or changing schools, kids who have had the birth of a sibling or have experienced loss or have moved houses, that can all impact what the bowel does, and can contribute to constipation.


The things that I’ve just named are pretty significant changes but it can also be something minor, like the introduction of a new food, or a new bedtime routine. Things that we might not think about as impacting our GI system but it can have a really significant impact on tiny bodies.


Lastly, we want to look at medications. ADHD is something that we see a lot of and ADHD medications tend to be very constipating. Kids who are on things like antidepressants or mood  stabilizers tend to be another big category. So all of these things can influence what the bowel does and the bowel is so closely related to the bladder that we often see an overlap in those two areas. It’s not uncommon for kids to present the clinic with something like bedwetting, but when we do a little bit more exploration, we find that actually what’s contributing to their bedwetting is not what their bladder is doing, but how their bladder is being compressed by their GI system. There is often a lot of interplay there.


I’ll talk a little more about treatment options later on, specific to constipation. I think the most important thing is to recognize that for kiddos, it may seem different than what we would expect for adults, they might portray it differently, so one of the most important things to do if you’re concerned about one of your kiddos having some constipation issues is paying really close attention to what they eat and what they drink and when they eat and when they drink. Because even little changes can have a really significant impact in a positive direction when it comes to what our bowels are doing.


The other Lindsay is going to take over and talk about some other things we often see in the clinic.


Dr. Lindsay Moses:

Alright, so that was very helpful and that kind of leads me into the next topic. We’re going to be talking about something called Enuresis, which is also known as bedwetting. Bedwetting is an involuntary urination and it’s really important when we talk about our kids or our patients’ bedwetting, that we don’t ever say something to the effect of “you had an accident!” We always want to put the blame on the bladder. We don’t want to make this child feel guilty about having an issue like this. So, we always say “Your bladder leaked” or “your bladder was too full” and “the bladder had an accident”. Again, taking away the blame from the child is really important when we are working with this population.


Enuresis is something that affects between 5 and 7 million children a year. We see it about 22% of the time in boys and 15% of the time in girls. And again, it is not an illness, it is often driven by physiological and behavioral issues, that we can easily work on adjusting.


There are two different types of Enuresis. There is Primary Enuresis, which refers to those kiddos that have never been dry overnight, they have been bedwetting since day one. Some of the reasons why we see Primary Enuresis could be because pelvic floor muscles that I described before are a little bit overactive or Hypotonic as we refer to it.


If the pelvic floor is really tight and sort of wound up and overactive it can impede our ability to fully empty the bladder. So, as I said earlier, when we urinate we have to fully relax our pelvic floor muscles and the sphincters need to open and relax to do that. If someone has a really tight or overactive pelvic floor those sphincters can kind of close prematurely and therefore were not fully emptying out our bladder. So a few minutes or a few hours later a little more can kind of trickle out because we just didn’t empty appropriately the first time. So again, muscle overactivity can be one of the causes.


Like Dr. Saunders just talked about, constipation is a huge driver when it comes to bedwetting. And it is probably the number one thing that we would look for if a patient came in with this issue. Diet, as Dr. Saunders talked about a minute ago, plays a huge factor here as well. There are lots of things that we eat and drink that are considered bladder irritants. And unfortunately, it’s all the good stuff in life. It’s milk, it’s chocolate, it’s anything with caffeine, it’s anything with carbonation, it’s tea, it’s acidic foods, it’s spicy foods, not pertaining to this population, but it’s alcohol. So, all the good stuff, unfortunately, can also be really irritating to the bladder, can make it contract a little bit more, and ultimately make kiddos a little bit leakier.


ADHD and the medications that kids can be on can also contribute to this kind of bedwetting. Another common reason why kids bedwet is because there is some upper airway obstruction. In this population we ask the parents, “are they breathing really loudly at night”, “are they snoring”, “are they asthmatic”, “has the pediatrician ever commented on any breathing difficulty or lung issue”. Because, follow me for a second, but when we breathe in, the diaphragm muscle moves down, and that puts pressure on the bladder and the pelvic floor. If we have to take a really big extra deep breath and because there is some sort of airway obstruction the diaphragm really has to push down quite a bit more on the bladder, which again can make it leaky. So, that’s Primary Enuresis, and just to recap that’s bedwetting that’s happened from day one.


Secondary Enuresis is bedwetting that has occurred after a child has been dry for a period of time. So, maybe from age 4 to 6 they were dry, then all of a sudden there are some bedwetting episodes that start to happen. Some of the causes of that can be a child becoming diabetic, there could be some urinary tract abnormalities that are starting to develop. There could be some psychological factors, which is often the case like Dr. Saunders said, it can be a new baby in the house, there could be some negative attention, some trauma occurring at home or at school that is contributing to this sudden change in urinary habits.


So, those are the two types. What does this do to kids? It has a lot of psychological impacts, and self-esteem is often severely affected. These kids often become angry, they become shameful. There is guilt, there is humiliation associated with this. These are the kids that don’t want to go to overnight camp. They are afraid to have sleepovers with friends for fear of bedwetting and the embarrassment that would come with that.


Interestingly enough, we see the same kind of effects on the parent. Parents often feel shame that their child should be potty trained at night for example and isn’t. And parents are embarrassed to talk about it for example.


So, what do we do about this? Number one we talk about changing behaviors. There are some medications that pediatricians and other providers can prescribe to kids that can be helpful. I think Dr. Saunders would agree that we try to avoid having to go that route. Because it’s really just sort of being a bandaid often over the actual problem. So one of the things we do is talk about settling the system during the day. A lot of kids have poor bladder habits in general. We want to establish good daytime habits because that usually carries over to the nighttime. That may be setting a timer on their phone, on their watch. Or getting teachers involved, encouraging the kids to go to the bathroom at a scheduled time or frequency during the day.


We talk about managing bowels like Dr. Saunders said she’ll get a little more into the treatment options for that. But, again constipation is a huge driver for urinary incontinence during the day or night. So managing the bowels is crucial, making some dietary changes, getting the bowels moving better, eliminating some of those bladder irritants can be really helpful.


I see some kids that parents will say their kid has a big cup of milk right before bed. Or they’re at sports practice and they’re getting home from practice at 8:00, they’re eating dinner and they’re in bed by 8:45 or 9:00. Well, we’re not setting that kid up for success, if they are having bedwetting issues. Again, thinking about cutting foods off completely two hours before bed. Restructuring dinner time, making sure that that meal is really well balanced and not irritating can make a big difference.


A lot of parents also asked about bedwetting alarms. They do exist if anyone’s not familiar with it, but it’s basically a pad with a sensor that kids would sleep on top of, and if it starts to get wet an alarm will sound. The point of that is that kids are supposed to become conditioned. So when that alarm goes off it’s supposed to encourage them to contract or engage their pelvic floor and then hopefully wake up and go to the bathroom. On average I think they say it takes about 3 months to see some improvement with that, and it’s encouraged that you would have a child use that until they’re dry for about 4 consecutive weeks.  So it’s definitely a commitment on behalf of the kids and the parents.


There’s also a program that both of us learned at one of the courses that we went to, it’s called the ‘Dry Days, Dry Nights’ program. And I think we’ve probably had the most success with this program, of all the things that we do. But, kids typically, when they bed wet, they bed wet within the first two hours of sleep. So, what this program advocates for is having the caregivers come into the room every night and determine at what time this child is bedwetting. So, let’s just say on average, it’s at midnight every night. Then the goal is going to be to come into the room before the time that the bedwetting incident occurs. Gently wake up or stimulate that child enough to walk them to the bathroom and give them that opportunity to go. Again, that can be a tough sell sometimes to parents because it’s sort of like sleep training all over again and we have a lot of exhausted, frustrated parents. But when it works, it can be really life-changing.


Lastly, positive reinforcement and praise go a really long way with this population, whether it comes to bowel or bladder dysfunction. We talk a lot about rewarding these children. Some parents are reluctant to do that, but kids work well when they have that positive reinforcement. It could be a reward chart, it could be every time you wake up to go to the bathroom in the middle of the night you’ll get 2 M&Ms first thing in the morning. Whatever it takes, but kids really thrive off of that reinforcement and we should not be reluctant to dole it out.


I’m going to pass it over to Dr. Saunders, she’s going to talk about some treatment options that are available.

Treatment Options

Dr. Lindsay Saunders:

Like Dr. Moses mentioned, one of the first things that we do, with really anyone who comes through the door, but specifically for our pediatric population is a pretty significant focus on education. So educating parents and caregivers but also educating these kiddos. It’s really important that they understand how they’re body works and that they understand what’s going on so that they can understand that they are not doing anything wrong. Right, that something that they don’t want to happen is happening within their body, but they’re not making a mistake. They’re not a bad kid. To try to reframe how they think about themselves. It is super common for these kiddos to come in feeling these feelings of shame and embarrassment.


So, one of the first things we want to do, and one of the first things we generally encourage parents to do is start working on taking those feelings of shame and embarrassment away. To use language like, “your bladder leaks”, or “your intestine is just being a little silly right now”. Taking it away from them as a human being and putting it on the actual organ or structure that is giving them some trouble. And then education about things like diet and water intake.


I, and I think Dr. Moses as well, use a lot of tracking logs. So, having parents and kiddos when they can, track what they eat and when they eat, what their bathroom habits are so that we can get a really good sense of what’s going on. Then taking those findings and working within their own individual lives and schedules to come up with a program that really works for them and targets their specific concerns. Little changes to diet and things of that nature like scheduling can have a really significant impact. So that’s usually one of the first things that we like to focus on.


My favorite thing to work with these kiddos on is toileting posture. I think that toileting posture is one of the most important aspects of bladder and bowel help, across the board. I’m willing to bet that a lot of my adult patients get tired of hearing me talk about how important toileting posture is. But when we go to the bathroom most of us aren’t in an optimal position to do it. So if we’re having to work harder to empty our bladder or to have a bowel movement that can kind of come back on to the pelvic floor and reiterate tension and reiterate pain and discomfort which then plays into the feelings of avoidance or fear that kids might be having. So, I like to take a lot of time to really focus on ‘let’s look at how you sit when you sit on a potty, let’s see what changes we can make there’.


Breathing is another really important aspect of bladder and bowel help. Dr. Moses mentioned that your respiratory diaphragm and your pelvic floor work together, they go hand in hand. Right about the time you notice, if you have really little babies, like infants, infants who aren’t sitting up yet, if you watch them breathe and then you compare that to how they breathe once they start sitting up, standing, and walking you’ll notice that their breathing pattern changes. And that’s because, even though the human body is really, really cool, it’s really lazy. It’s definitely a work smart not hard type of thing, and we stop using our diaphragm. So teaching these kids how to pull their diaphragm back into the picture and how to really use that to help them empty their bladder, to help their pelvic floor muscles relax so they can have a bowel movement and reduce that downward pressure on those organs, can be really, really beneficial. It’s really fun to work with them on breathing patterns. Everything that we do, especially with our younger kiddos is all about making it fun. Finding ways to make breath work fun, employing yoga and things like that, that family units can do together or siblings can do together, tends to be very helpful.  But getting them in good toileting posture and making sure they can breathe well is kind of the first step to making sure that they get to where they want to be.


We also work with the pelvic floor muscle, we do this in a little bit of a less direct way than we do with our adult population. With our pediatric patients, we use something called biofeedback. Biofeedback essentially picks up the signaling from the pelvic floor muscle through these little sticky sensors and transmits it to a computer. With that computer program, kids can actually play games that can teach them how to engage, or how to relax their pelvic floor muscles. We can do it in different positions and under different circumstances. To say okay like, look at what your pelvic floor muscles do when you are laying down.  Now let’s see what they do when you’re sitting on the potty. Let’s mock up a potty in the clinic and let’s see how it changes. And see if you can beat your high score or get a lower score, depending on what you’re working on.


Biofeedback can be a really great way to teach these kids how to tap into that muscle group. So that they can really, for lack of a better term, harness their power and it’s just kind of fun. They really seem to enjoy it. And sometimes, especially with our older kiddos, we’ll do a lot of external work through the abdomen, making sure the abdomen moves well and that the diaphragm moves well. That the bones are aligning well and things of that nature, just so they can be set up for the best success. Toileting schedules and things of that nature to really make sure that kids not only start to associate like okay if I wait for this amount of time to go to the bathroom I might have some leakage so I should probably go before then. Or I am not shy about communicating with teachers (parent permission provided) to make sure that school-age kiddos have what they need in their school day to allow them to be successful and not have to worry about what their bladder and bowel is doing.


And just like any PT we do a lot of strengthening stuff and stretching. We have to make sure these kids have good core strength and core activation in order to really successfully have optimal bladder and bowel habits. So, we turn lots of things into games to make it fun. But making sure that they work those muscles the right way and that they understand how they work in an age-appropriate way. And every kid is different so no plan of care looks the same for two kids. They really can present with the same concerns and the treatment approach is totally different. It depends on what their interests are, what motivates them, and where they are developmentally.  We want to pay attention to, are there possible underlying developmental concerns that could be contributing. That’s usually when I make an exception to the 5-year-old rule. I’ve seen kids younger than 5 who have underlying developmental things that we need to work with, in order to make them successful.  Really, it’s just about teaching kids how their body works and how to harness its power and then giving them the tools and strategies that they need to be successful.


Dr. Lindsay Moses:

I’m just going to wrap up by saying that bedwetters are unfortunately often punished by parents and by caretakers. And what studies have shown is that the kids that are punished for doing this involuntary act, often have high levels of depression and very decreased qualities of life. And what studies have pointed to is that in households where there is a high level of internal stress and emotional tension that does very often tend to be the driver for some of these bowel and bladder dysfunction issues.


So, a big part of what we also do is helping to direct families to the appropriate resources. Not only do the children need intervention but sometimes the family unit needs intervention as well. It can be a very frustrating and stressful experience and it’s just helpful to have some really good resources available for parents to learn like we talked about, the right words to use and the right ways to approach their children when they’re in this situation to make it nothing but a positively reinforced experience. And those are the kids that we end up seeing the most success with.


Again, just to summarize, we work with the adult population, but Lindsay and I both really enjoy working with this population as well. A lot of people don’t know but pelvic floor PT, as far as insurance reimbursement goes, is no different than if you went to rehab for your knee or for your shoulder. It is reimbursed if you have any sort of therapeutic benefits. We are in-network work with most insurance companies  and we do offer very reasonable rates for patients that are out of network and cash pay. We typically see these patients once a week, on average and our goal is never to see them indefinitely. It’s to get them to the point where symptoms are improving and both the child and the families feel empowered to manage the symptoms independently at that point. That can really vary, like Dr. Saunders said, based on some underlying factors, but typically within a few weeks to a few months we see some significant gains in this population. It’s very dependent on family compliance, which is an issue that unfortunately we struggle quite a bit with. But, when the parents come in and the caregivers come in and they are very motivated to work on this, again we have a very high success rate.


So I will turn it over to the audience. Are there any questions, we are happy to field them?


Cindi Michaelson:

I do actually, I’ll start us all off with a question. How about for older kids? Is there any difference in older children for their inability to hold their urine throughout the entire night? And I have a second part of that question. I’ll have to ask it, but if you could tell me about that first part, that would be wonderful.


Dr. Lindsay Moses:

From the age of 12 on kids have the same bladder capacity as an adult. If we see a kid that is older, maybe I would say 14, 15 or 16, the only difference perhaps is that we might consider doing an internal pelvic floor assessment to kind of get our hands on those muscles to see what they are doing and how they are responding. From a behavioral approach we’ll go at it a little bit differently, But, a lot of the treatment strategies Dr. Saunders talked about, we use with our adult population too. I have given my adult patients the bladder box chart before. We’re having them track their fluid intake and looking at their diet. So, again the basic principles whether we’re dealing with a 5-year-old or 50-year-olds again we just have to approach it differently in both scenarios.


Cindi Michaelson:

Okay, that helped because you lead me into another question that I had. When a child is potty training and they’re not able to hold their bladder at night, when does the parent know when to seek out pelvic floor rehab or physical therapy? I know for myself, with our children, it was ‘oh well, it’s just not developing, they’re still maturing’ and you wait and wait and wait. And there still might be a problem.


Dr. Lindsay Saunders:

So, the short answer to that is that in part it can be hard to tell. What we use as a marker is what is the kiddo telling us?  Or what kind of signs is the child showing that this is distressing to them? Have they expressed concerns about it? Do they seem frustrated by what’s happening? Really, truly we don’t expect maturing bladder and bowel habits until about age 4 to 4 ½. So there can be benefits to waiting and seeing what the body does. Sometimes what we have found is that kids respond really well to some cognitive peer pressure, either from preschool classmates or siblings or other family members that are of the same age. And when they start to notice other kiddos that they relate to being dry or not needing diapers or what have you, that is the fuel for the fire for them.


It’s not uncommon for kiddos to experience bedwetting especially as they are potty training. Typically daytime habits will be in place well before nighttime habits, as Dr. Moses mentioned. But, one of the things we look for, that we ask parents about and even kids, depending on how old they are, is how it’s making them feel. What kinds of signs are they showing of distress, or being upset about it? Unfortunately, a lot of the answers in PT are “it depends”. So, I think taking it on an individual basis is the most important thing and kind of assessing the whole situation. Does that make sense?


Cindi Michaelson:

Yes, it did.


Dr. Lindsay Moses:

So, one of the best pieces of advice our personal pediatrician ever gave to us, was when my son was starting to potty train and this was before I got into the pediatric realm of PT, but he was so frustrated and I was getting angry and annoyed and I think he could sense that, and the doctor just said STOP.   He said, forget about it. He’s just not ready! Take a few months off and come back to us. And the two or three months that we took off was what made the change. Cause when we took the time off and sort of reset and went about it with a more positive attitude and more patience and I sensed that my son was ready to do it, it was almost instantaneous. I think in two or three days it was textbook and we were done. So, I think like Lindsay said, just acknowledging how the kid is responding to it, if it seems like there is too much pressure or frustration surrounding the situation, just know that there is nothing wrong with taking a step back sometimes.


Cindi Michaelson:

Does any other participant have a question?



I’ll ask a question. Thank you guys so much for doing this, this was awesome. I’m interested to hear a little bit more about your transition, both of you, into this realm. I know Dr. Saunders you sort of started in pediatrics and moved to pelvic, and then Dr. Moses it sounds like you started with adults and then moved towards pelvic then incorporated pediatric. And from where I’m coming from, I’m ortho and pelvic PT for adults now and the idea of treating kids in pelvic health is super intimidating. So I’d just like to know how you guys did that. Your thoughts on it.


Dr. Lindsay Moses:

Well, Dr. Saunders is all about pediatrics, that’s her bread and butter. It wasn’t mine. I think I got a referral one day from a pediatrician and I panicked, and Chevon who is on this call right now, she is my only pediatric PT friend and I called her in a panic saying what on earth do I do with this kid?  And it prompted me ultimately to take some continuing education courses out in Texas. I went to that course and it was really sort of groundbreaking for me. When I realized how much help these kids needed and how little help was available, it was extremely motivating, empowering to me. That course that I took really changed the game and I came back and felt like, I can do this. And it’s hard. It’s hard to readjust the way that you talk to kids. When I take my pelvic model out for them, I’m like wait a second this isn’t how to go about this. We show them the Poo and U video on YOUtube, so it is hard at least for me at the beginning to sort of restructure how I do things, but it’s very rewarding to work with this population. So if you have a chance to do it, I would say give it a shot.


Dr. Lindsay Saunders:

And so for me, I had done my pelvic health rotation when I was in school. It was an adult based population, for the most part. But that rotation was followed by a school system rotation. In that school system rotation, I was working with kiddos who had a myriad of developmental or physical impairments. I was working with these kids on things like core strength, functional movement, and then one day I stepped back and was like, no one is teaching these kids how to control their bowel and bladder. Which for me, from my perspective is so fundamental to our emotional development and to our sense of control and our sense of belonging, because I think sometimes we’re not always aware of how much kids pick up on.


So, for me it was really telling, that when I was in this school system and were teaching these kids all these wonderful things that are super important, but at the end of the day no one was teaching them about their bowel and bladder and how to access it and how to control them. I can see especially as I transitioned from my elementary school kiddos up to my high school kids, what an impact that had on self-esteem and things like that. Really, it made me kind of angry, because this is such an underserved population, why aren’t people up in arms about this? So when I got into clinical practice, I hit the ground running with these because I knew that that would be a transition that I would struggle with. If I started solely with adults then had to transition to pediatrics pelvic health, so I wanted to kind of soften the blow for myself. So, you know what, as soon as I get out there I’m going to just start and that’s just what I do. So for me it was kind of the opposite of a transition from Dr. Moses.



That’s so true. Thank you so much.


Cindi Michaelson:

What does a typical appointment look like, when you bring in your child, based on their age of course? If you have an older child that is between the age of say 9-12 and they haven’t yet reached maturity of their bladder, like an adult bladder? Do you do internal exams?


Dr. Lindsay Moses:

No, not typically at that age. I’m not really comfortable doing internal work on anyone much younger, 14 is the youngest I’ve considered it. And there had to be very clear parental consent, and then child’s consent and understanding of what we were about to do, for obvious reasons.


A typical appointment involves getting a really thorough history, which we try to get as much of ahead of time. We reach out to the referral source and try to get any medical records that are available, so we have a really clear picture of what’s been going on. We talk a lot about what the diet looks like, what is this kid drinking, what is this kid eating, what are the current bowel habits, are they urinating every 4 or 5 hours during the day, are they urinating before they go to school and then once when they get home from school and maybe right before bed. How often are they bedwetting, what is the volume like, is it just a few little drips or are we talking about enough volume that we are changing all the bedding in the middle of the night. Were evaluating behavioral issues that may be present. Some strength testing is of course involved.  And we do examine the pelvic floor even in the very youngest of kids. But we do it from an external perspective, again after there is a very clear understanding by the parent and child, what we’re doing. But we do have the child undress and we are looking externally at the muscles, we’ll say can you go ahead and squeeze your pee or poop muscles, can you hold in a fart, they all get that real quick. Holding in a fart, and what we’re looking for is that contraction, that activation of the pelvic floor. Okay, now relax, pretend you’re going to pee, do we see some differentiation. Is there some sensation when we touch with a q-tip around that area? Are there some neurological concerns that we need to be thinking about. Are the reflexes intact?


So, doing a muscular-skeletal and neurological evaluation and then again just trying to get as much information as we can from the child and from parents about what a typical day looks like. Is the urge present, do they get the urge to urinate, do they get the urge to have a bowel movement, but they’re busy playing a video game and just rather not stop or they’re outside running around and rather not come in, so they ignore that. One thing we didn’t really get into, but I think it’s important to note, that there are some little sensors if you will right at the bottom of the rectum and when poop comes down through the passageways, kind of sits on that little sensor and it sort of “ding” and say hey ‘it’s time to go.”


A lot of kids initially get that dinging but they ignore it for one reason or another. They’re in school, they don’t want to poop or pee there.  They’re on the playground, they’re with friends. They’re in the middle of sports or something. Well after a while if we keep ignoring that ding then eventually the bowel or bladder just says ‘screw you’. I’m not going to tell you anymore. And that’s often when we get some leakage. So that little sensor just kind of deadens, it goes numb. We see that in the adult population, too.


So, again we are trying to figure out with these kids initially, are getting that little ding, and are they ignoring that ding? Or are they just not getting it at all and then again we’re starting to think, could there be neurological issues? Is this something that requires further medical evaluation? Is this appropriate for us from a physical therapy standpoint? It can get a lot more complex, we’re just skimming the surface. But we definitely need to do a very thorough evaluation of these patients, sometimes even more so than with our adult population.


Cindi Michaelson:

Great and Dr. Saunders would you be able to touch on what proper toilet posture is? Does that involve a “Squatty Potty” or what are you referring to there?


Dr. Lindsay Saunders:

Yes! So, I love the Squatty Potty for my adult patients and older kiddos. The Squatty Oppomous is the child’s version. It’s super cute, they have a hippy and a dog. They have fancy ones too, that are made out of wood and they’re stained if you are really passionate about the appearance of your bathroom. But, what we’re looking for is for the kiddo to have their knees just a little bit above their hips, with their feet supported. And I really encourage a nice forward lean with their forearms resting kind of on their thighs, so that they can relax. So that’s like the positioning portion of it, but we put in an extra piece which is how they’re breathing when they go to the bathroom.


So think about in your life, if you’ve ever been constipated, when you go to have a bowel movement that is challenging, you tend to strain, so that strain causes your pelvic floor muscle to tighten up. So teaching kiddos to either hum while they’re sitting on the toilet trying to pee or poop or blowing bubbles helps them to keep the pelvic floor muscles relaxed so they effectively void their bladder or their bowel whatever they’re trying to do. Some kiddos too, right it’s the size mismatch, between the size of their little body and the size of the toilet, so we always consider the addition of a specialized seat for our smaller friends. To give them a little more support so they feel a little bit safer and able to go to the potty.


Cindi Michaelson:

Will let our participants know where they will be able to reach you and how to go about setting up an appointment with you, etc.?


Dr. Lindsay Saunders:

You can access our website and we are happy to do a free 15-minute phone consultation with anybody who may be interested in bringing their kiddos in. We do have three offices, but right now we’re only operating out of two of them just for safety and health concerns for all involved parties. But, it’s pretty easy to get a consult with us, and then we can talk through things and any concerns and help determine if PT is kind of the right next step for that individual child and any additional information that we might need prior to getting that appointment scheduled or at least prior to that child coming into the office to see us.


Cindi Michaelson:

Do you encourage, for the 15-minute consultation if you do have an older child that they are on that call with you?


Dr. Lindsay Saunders:

I generally don’t do phone consults with older kids, I typically do them with the parents. In that 15 minutes what we are really trying to figure out if a PT assessment would be beneficial, is that the next best step or is more appropriate for further medical investigation warranted. Are there other pieces of information that we would need to have before seeing a child in the clinic. So generally I just have them with parents, I think Dr. Moses is the same.  Sometimes kids will unknowingly join their parents on the calls but generally, I have them with just the parents.


Cindi Michaelson:

We are very grateful for both your times today. It was such a really enlightening conversation and we were just so grateful for all the work you’re doing for the pediatric population, and as moms, to know that you are helping us. So, thank you.


Dr. Lindsay Saunders:

Thank you for having us.

Dr. Lindsay Moses received her Doctorate of Physical Therapy from Northwestern University and holds a Bachelor’s degree in Kinesiology/Exercise Science from Indiana University. She has extensive experience working with a variety of orthopedic problems, including neck and back pain as well as shoulder, knee, hip, foot, and ankle issues. Dr. Moses works with children and their families to address bladder and bowel concerns.
Dr. Saunders received her Doctorate in Physical Therapy from The University of North Carolina at Chapel Hill and holds a Bachelor of Science degree in Health and Exercise Science from Wake Forest University. She also has experience working with patients with a variety of orthopedic and post-surgical concerns. Dr. Saunders has worked with children in a variety of settings and is also passionate about offering patient-centered and LGBTQIA+ inclusive care.
Both Dr. Moses and Dr. Saunders have pursued advanced training pelvic health through the Herman and Wallace Pelvic Health Rehabilitation Institute, including in pediatric bladder and bowel dysfunction. They are physical therapists at Grace Physical Therapy and Pelvic Health.

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