Beyond Basic Potty Training: Pediatric Pelvic Floor Rehabilitation

Northwestern Medicine
Pediatrics June 15, 2021
As a mother of triplets, Deborah Perez is used to juggling the various wants and needs of her children. Although they’re all the same age, they’ve reached their developmental milestones at different times.

For six-year-old Ezekiel (Zeke), potty training was a constant struggle between the ages of three and five. Although the process is bound to have some “oops!” moments as children learn to tell when they need to use the bathroom, Deborah knew her son needed some additional help.

At age three he was referred to Beth Kohler-Rausch, an occupational therapist at Northwestern Medicine Central DuPage Hospital, for fine motor delay. Kohler-Rausch discovered there were sensory processing issues as well as toilet training and pelvic health concerns.

“Pelvic floor dysfunction is usually caused by a combination of factors, including overly weak or overly tight muscles in the pelvic floor, constipation, diet and fluid intake,” Kohler-Rausch said. “There can also be sensory issues preventing a child from understanding how and when they need to use the bathroom.”

Since Kohler-Rausch has to assess many different factors, there can be a lot of trial and error throughout the process as she helps children like Zeke improve their pelvic floor function and understand what is happening inside their body.

“I talk with the kids about their internal awareness, and a lot of that is addressing their sensory needs,” she said. “We talk about things like awareness of hunger, of thirst, what it feels like when you have to go to the bathroom – we really work on helping them understand the cues from their body.”

One tool that can help children understand the physical response in their body is biofeedback. Biofeedback is a non-invasive treatment that attaches external sensors to the child’s bottom and then displays the tightening or relaxing of their pelvic floor muscles in the form of a flower or alternate graphic on the computer screen. Although biofeedback wasn’t used with Zeke, it is an important and useful tool for many patients.

“When they relax their muscles, the flower will open, and the visual helps kids better understand how their body is feeling when they use those muscles,” she said.

Kohler-Rausch sees frequent core and lower body weakness in her patients, which can contribute to a weak pelvic floor. Since the pelvic floor muscles can’t be isolated, Kohler-Rausch will often work with children on their lower extremity strength and posture. To help the lower body and diaphragm better work together, she’ll also focus on breathing strategies.

Before meeting with Kohler-Rausch, Deborah could sense Zeke’s frustration about potty training and felt frustrated herself.

“It wasn’t like he wasn’t trying,” she said. “He would tell me constantly that he needed to go to the bathroom and we’d try to go and he just couldn’t. It made it really frustrating to go anywhere, like the museum or a store, when he’s saying he needs to go to the bathroom every 10 minutes.”

Before connecting with Northwestern Medicine, each of the triplets received therapy services offered by other organizations. Though some services were helpful with other issues, Deborah felt she’d hit a wall when it came to finding help for Zeke’s potty training troubles.

“A lot of times we were just told, ‘This is what we do for everyone,’ and it was like he never qualified to be offered additional help, but I knew something else was wrong,” she said. “When we connected with (Kohler-Rausch), she could actually see what I was saying and as a parent, it was so important for someone to actually validate what I was describing.”

Kohler-Rausch uses different approaches to help make toilet time less intimidating or scary to kids. Deborah remembers that in the beginning, Zeke worked on a coloring page with the outline of a super hero.

“He was really into super heroes and so they drew a potty superhero,” she said. “To this day he has it taped on the wall above his bed. It was empowering for him.”

Finding the right solution is different for every child, and some cases are more complicated than others. The one consistency is Kohler-Rausch’s passion for helping both kids and their parents get past the frustration their experiencing.

“I am so glad that I can work with this population because of how impactful it can be to help a child not have accidents during the day or night,” she said. “This not only improves their overall health and body functioning, but their social well-being. By helping them gain the motor skills, adjusting lifestyle factors, and establishing new routines, they can achieve control of their bladder and bowel across their lifespan.”

Deborah wants to share her and Zeke’s experience to help other parents and children struggling with similar issues.

“It was emotional for me, because with triplets, they start to compare themselves to their siblings and start to think, ‘There’s something wrong with me,” she said. “If we can raise awareness so someone else gets the help we got, that means everything.”

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