Fecal incontinence (Encopresis) It is the fecal incontinence condition observed in children with chronic constipation over 1-2 years.

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1 WHAT IS DYSFUNCTIONAL URINATION (URINATION FUNCTION DISORDER)? It stands for the urination phase disorders, which appear due to wrongly acquired urination habits during the toilet training of some neurologically normal children. It is a problem which is observed as urinating at intervals, and not being able to completely empty the bladder, caused by the impairment of the bladder dynamics. The reason for this impairment is that during the urinary bladder emptying phase, the child contracts his sphincter (closing the urinary tract), which keeps urine at bladder bottom, and pelvic floor muscles. There is an increase of activity in the pelvic floor muscles and sphincter which need to be relaxed during urination. To come over this resistance, the child uses his/her abdominal front wall muscles and empties the bladder, therefore urine flow speed increases, and the bladder is not emptied completely. SYMPTOMS OBSERVED IN URINATION FUNCTION DISORDER Constipation It is hard defecating in solid consistence. It is a condition where a person defecates less than 3 times a week. Fecal incontinence (Encopresis) It is the fecal incontinence condition observed in children with chronic constipation over 1-2 years.

2 Polyurea (Frequency) It is the condition of going too often to the toilet, in a number exceeding the normal amount. Usually the normal amount is between 3 and 8, and if it 9 more times, it is defined as polyurea. Sparse urination (Infrequency) It is defined as going to the toilet less than 4 times a day. Sudden Urge to Urinate (Urgency) It is being defined as the sudden urge to urinate and trying to keep the urine by crossing the legs. Urinary incontinence (Enuresis) It is a normal kind of urination, which inappropriately happens in a time and place which is not socially acceptable. FINDINGS OBSERVED IN URINATION FUNCTION DISORDERS REPETITIVE SIDE URINARY TRACT INFECTION It is being defined as the condition of observing two or more urinary tract infection within a period of six months. PEG TOP SHAPED URETHRA It is particularly observed in girls with an urination function disorder. It is observed through radiological examination. Peg top shaped urethra VESICOURETERAL REFLUX It is being defined as a condition where urine goes back from the bladder to the urethra and kidney during urination.

3 URODYNAMIC FINDINGS - Increased Residual Urine Amount= Residual urine is defined as the urine left in the bladder after urination. - Bladder Capacity Changes= In children with urination function disorder, bladder capacity is decreased, while in a small number of children it has increased (Those who are lazy to urinate have an increased bladder capacity). - Urinating with short pauses= It is characterized by the periodic activation of the pelvic floor, which causes an increase in the detrusor pressure (detrusor muscle is the muscle at the bladder wall), following the decrease in urine flow. - Horizontal urinating= It is the insufficient and incomplete plato urination, which has more than one urination phase. - Increased urination time= Normally urination time is 30 seconds, but urination time increases in urination function disorders. Normal urination curve Extended urination curve Paused urination - Increased urination pressure = Children who contract pelvic floor muscles while urination, may display increase in urination pressure. SYNDROMES ACCOMPANYING URINATION FUNCTION DISORDER * Lazy Bladder Syndrome It is a term used to describe children who seldom urinate. These children urinate 3 or less times per 24 hours. They do not go to toilet when they wake up in the morning, do not feel any urgency. Urine incontinence is in the style of overflowing. Urination is done by the contraction of abdominal

4 muscles. They have a larger urinary bladder than expected. They frequently display urinary infection and constipation. * Laughing Incontinence It is the urinary incontinence which involuntarily happens during laughing. The child is absolutely dry in the other times. * HINMAN-ALLEN Syndrome It is the most severe form of urination disorder. Even though there are no neurological findings, there are neurological bladder findings. *OCHOA Syndrome In addition to urinary incontinence, urinary tract infection, upper urinary system disorders and constipation findings, it has a special facial expression. When these kids are smiling, one gets the impression that they are crying. * Daytime Frequent Urine Syndrome It is particularly observed in preschool children who were given toilet training. It is characterized with the sudden urge to urinate in 5-10 minute intervals. *Asymptomatic Day Urine Incontinence Some children between the ages of 3 and 5 incline to hold their urine, due to high concentration to play and television. Because of this, they may have a wet underwear form time to time. This condition will go away by itself, without the need of any intervention. * Irritable Bladder of Childhood Era It is seen as day wetting in preschool girls. These patients have hyper activity and attention deficit disorder. They display bed and day wetting, frequent and urgent urination urges. Vesicoureteral reflux and urinary infection, constipation may be observed. * Vaginal Urination It is seen during urination in obese girls, due to the reflux of the urine to the vagina. HOW TO MAKE A DIAGNOSIS? The physical, psychological, social and environmental factors effecting the urination problem must be comprehensively diagnosed in a multidisciplinary manner. Tests to be Performed for Diagnosis:

5 * History of the Child - how do the child and the parents perceive the problem - the effect of the problem on quality of life - mental situation of the child - functional abilities - when the problem start - how often is the child experiencing problems - the existence of accompanying urinary system infection * History of Urination Urination frequency, whether or not using holding back manoeuvres, the existence of urgent need to urinate, existence of pain during urination, type of urine flow (continuous/with intervals, strong/weak) * Questionnaire Form to Specifically Question the Urination Problems * Intestine Habit of the Child Constipation, abdominal pain, pain in defecation * Rectal Examination Measuring the rectum diameter * Physical Examination * Ultrasonographic Evaluation of Kidney, Urinary Bladder and Urinary Tract Upper urinary system, bladder wall thickness, post urination residue are evaluated.

6 * Urinary Tests * Abdominal x-ray * Urination Test (uroflowmetry) A non-invasive test to measure urine flow, shape and quality. * Uroflowmetry-EMG test Urine canal closing (external sphincter muscle) muscle activity is measured during urination. *Urodynamic evaluation HOW IS IT TREATED? 1- Pelvic floor rehabilitation and bladder training under the scope of urination development program 2-Anticholinergic drug treatment Note: If there is an accompanying constipation problem, it must be treated with priority. We have been treating urinary incontinence problem for over 15 years, under the scope of urination development programme.