However, it is more often a learned problem-as in the case where a child continually holds urine in all day--that is difficult to unlearn. Children get into this routine for different reasons. Some may be routinely too busy to break for the bathroom. Others may have experienced a urinary tract infection that caused bad pain and as a result are fearful of urinating. Sometimes the problem is related to potty training. A child may have taken on abnormal urinating habits from the beginning.

Whatever the reason, a child gets into a pattern of failing to relax the external urethral sphincter. The bladder can tolerate this for months and in some cases years, depending on how hard the child works to avoid urinating. Eventually the bladder muscle, which has to continually work against this voluntary blockage, will become so strong that it will overcome the blockage and periodically empty on its own, whether the child is sitting in a classroom or out on the ball field.

Further evaluation of the urinary tract is tailored to each individual patient and is dictated by the severity and character of the presenting symptoms. Those children with a history of one or more febrile urinary tract infections (pyelonephritis) require a specialized x-ray called a voiding cystourethrogram (VCUG) to evaluate for possible vesicoureteral reflux (backward flow of urine from the bladder to the ureter and/or kidney). In some children, mostly girls who are toilet trained, a radionuclide cystogram is preformed instead. It too detects the backward flow or urine from the bladder to the kidneys(with less radiation, but somewhat less resolution). Vesicoureteral reflux may facilitate delivery of infected urine from the bladder to the upper tracts, resulting in pyelonephritis (an inflammation of part of the kidney), renal scarring, and/or focal areas of kidney damage secondary to high pressure reflux of uninfected urine (sterile reflux). The renal scan (DMSA) is the most sensitive test available for quantifying relative renal function and identifying areas of kidney damage.

Long-term evaluation of patients with voiding dysfunction is mandatory. Considerations include prevention of urinary tract infection, and appropriate management of associated vesicoureteral reflux, bladder dysfunction and/or renal functional impairment, as needed. Baseline and periodic (as needed) urodynamic study are important for patients with severe manifestations of voiding dysfunction. When appropriate, this may be performed simultaneously with reevaluation of vesicoureteral reflux via radionuclide cystogram (RNC).

If present initially, vesicoureteral reflux may resolve following correction of the abnormal voiding pattern. Vesicoureteral reflux that persists, especially when associated with recurrent pyelonephritis, may require ureteral reimplantation. In some children, additional therapy such as prophylactic antibiotic to decrease the risk of urinary tract infection, anticholinergic medication (to decrease bladder hyperactivity) and/or clean intermittent catheterization (to empty a noncontracting or severely dyssynergic bladder) is required long-term. Rarely, extensive reconstructive surgery such as bladder augmentation (adding a piece of the intestine or stomach to the bladder to increase bladder capacity) may be necessary.

Comprehensive initial and prospective evaluation, coupled with appropriate, directed treatment and aggressive follow up is important for optimal outcome in patients with voiding dysfunction. The goal is to identify the dysfunctional voiding early, treat it proactively, and evaluate systematically the response to specific therapy for upper and/or lower urinary tract abnormalities due to voiding dysfunction, and therefore, potentially limit the deleterious effects on bladder and kidney function.