Overview
Toilet training is an important milestone for all children. Children in our society develop bladder control between the ages of 2 and 3 years of age and are continent of urine in the daytime by the age of 5. Bowel training usually precedes bladder training because stooling occurs less frequently and with more predictability. Developmentally, a child must be able to sit, follow directions and be able to stay dry for at least two hours to be ready to attempt toilet training.

Children with spina bifida usually have damage to the nerves that control the bowel and bladder. These nerves exit the spinal cord between the sacral levels 2 and 3. There can be “sparing” of the nerves that allow some children to attain a certain degree of bladder and bowel control. However, complete bladder and bowel continence without the use of intermittent catheterizations and/or medications is seen in less than 15% of individuals with spina bifida.

Getting Started
If it is not medically necessary to begin a catheterization or bowel program, families can safely wait to see what abilities a child may demonstrate. For a child with spina bifida, the age of toilet training is expected to be somewhat delayed. It is generally recommended that a continence program be started before the child enters the school system.

Preparation for toilet training of the bowel begins early. It is most important to prevent constipation in infants and young children to preserve the bowel tone and function. Fruit, fruit juices, water and additives (such as fiber supplements) can be used to regulate bowel movements in the very young child. Rectal stimulants can also be used to prompt evacuation and reduce constipation. Avoiding constipation in the young child gives the best chance for successful bowel management in later years. It is helpful for young children to be allowed to go into the bathroom. Understanding that adults go into the bathroom to toilet and that toileting is a private matter, helps the child learn appropriate behavior.

Because bowel control usually precedes urinary control, it is often helpful to begin toilet training by focusing on bowel patterns. Keeping a record of bowel movements for about three weeks can be helpful in determining if there is a natural pattern for bowel emptying. A good beginning is to place the child on the toilet 15-20 minutes after eating, make sure that the feet are supported, and teach the child to “grunt” or “bear down.” Praise the child for cooperating with the program. Rewards can be given initially for cooperation, then advance to rewards for having a bowel movement in the toilet, and finally for “accident free” days. Regular toileting times are the key to this method of bowel management.

If this “Habit Training” approach does not result in social continence, a cleanliness program is indicated. Methods used for a cleanliness program may include digital stimulation, suppositories, small and large volume enemas, or surgical stomas for administration of antegrade enemas. Doing any program on a regular schedule increases its success. SBA has publications and names of clinics available that can offer assistance in selecting and implementing an appropriate bowel program.

Special Considerations
Although a child does not attain bladder continence until later, there are some signs that may help determine potential for bladder control. Children who produce a good urinary stream, have periods of dryness between voiding and indicate some sensation of an urge to void have a greater potential to have bladder control. If a child with spina bifida leaks urine constantly, never produces a good urinary stream, or does not indicate any recognition of an urge to void, the prognosis for bladder control is poor. There is no harm in attempting toilet training as long as the parents remain positive and expectations are realistic.

Toilet training for the bladder does not differ from “normal” potty training with the exception of intensity and age. Putting the child on the toilet immediately after awakening in the morning and then at intervals of about every two hours during the day may result in some increase in dryness. Practicing all the steps of “pottying” is helpful. Steps should include removing clothes, sitting on the toilet, replacing clothes, flushing the toilet, and washing hands. Again, rewards can be helpful for cooperation, voiding in the toilet, and finally “accident free” days.

Clean Intermittent Catheterization (CIC)
If timed toileting does not result in dryness, advancing to a program utilizing medications and/or clean intermittent catheterization (CIC) is indicated. CIC is the insertion of a small plastic tube into the bladder at intervals to drain the urine. It is usually don e every three to four hours during the day. If the child is not dry between the catheterizations, often medication to relax the bladder can result in dryness. It is important to note that neither CIC nor medications lessen a child's given ability for bladder control. CIC simply empties the bladder completely at intervals and medications relax the bladder and/or increase the tightness of the sphincter during the time taken. If using CIC with medication does not result in social continence, surgical intervention may be needed.

Conclusion
Toilet training is an important part of development in our culture and has physical, emotional, and social implications. Determining abilities in this area and then appropriately addressing bowel and bladder control is critical for the health and well-being of children with spina bifida. The most important thing to remember is that no one with spina bifida should expect to live with uncontrolled bowel and bladder incontinence. Good medical care and individualized programs can successfully address incontinence.

This information does not constitute medical advice for any individual. As specific cases may vary from the general information presented here, SBA advises readers to consult a qualified medical or other professional on an individual basis.