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overactive bladder ( oab ) is a common and vexing problem in children , and despite great advancement in therapies , a certain percentage of patients remains resistant to treatment .
we believe that children whose symptoms do not resolve with timed voiding , laxatives , anticholinergic medications , and biofeedback physical therapy do so because of an undiagnosed and inadequately treated megarectum and that therapy directed specifically at the dilated rectum will resolve oab symptoms most efficaciously . in this study , we evaluated the efficacy of daily enemas for the treatment of oab in children .
exclusion criteria included neurogenic cause of bladder dysfunction , urinary tract infection , prior lower - urinary - tract surgery , and any diagnosed anatomical abnormalities of the urinary tract that could influence voiding function , such as posterior urethral valves .
oab was defined as uncontrolled daytime urge incontinence , and bladder function was measured using the pediatric voiding dysfunction symptom score ( dvss ) .
the 40 control patients were treated with traditional therapies , including timed voiding , osmotic laxative peg3350 ( regardless of bowel history to maintain daily , soft bowel movements ) , and in select cases , anticholinergic medications and/or biofeedback therapy .
the 20 remaining patients were prescribed only a daily enema ( liquid glycerin suppository for ages 2 to 5 , pediatric fleet enema for ages 6 to 11 ) and enough osmotic laxative to maintain soft spontaneous bowel movements , with no other therapy or voiding schedule . if the voiding symptoms resolved while on the daily enemas , patients were instructed to taper off the daily enemas over a 2-month time period ( an enema every other day for a month , and then an enema twice weekly for a month ) .
all patients were evaluated on each visit with complete history and physical , urinalysis , bristol stool scale ( bss ) , rome iii criteria , kub x - ray , and pediatric voiding dysfunction questionnaire .
data analysis was performed using spss statistics version 23 ( ibm corp , armonk , ny ) . for the nonparametric variables  dvsss , bss scores , and rome iii scores  comparisons were made using mann - whitney u tests .
for the continuous variable  maximum rectal diameter on kub  a student t test was used .
comparisons were made both within groups for the pretreatment and posttreatment phases as well as between groups .
a total of 60 children ( 20 experimental and 40 controls ) were included in this study .
table 1 demonstrates the mean dvss , bss , rome iii , and rectal diameters prior to treatment .
there was no significant difference on any of these measurements between the control and treatment groups .
table 2 demonstrates the mean posttreatment measures and the mean change in each metric after the treatment period .
patients who underwent enema had significantly more improvement in dvsss and significantly greater change in maximum rectal diameters than control patients ( figures 1 and 2 ) .
of note , both control and treatment groups demonstrated significant improvement in all measured variables after the treatment period .
abbreviations : dvss , pediatric voiding dysfunction symptom score ; bss , bristol stool scale .
there were no variables that were significantly different between the control and treatment groups prior to enema .
abbreviations : dvss , pediatric voiding dysfunction symptom score ; bss , bristol stool scale . participants who underwent enemas had a significantly greater improvement in dvsss and maximum rectal diameters .
pretreatment and posttreatment pediatric voiding dysfunction symptom score ( dvsss ) : the treatment group showed a significantly greater improvement in dvss when compared with the control group .
pretreatment and posttreatment maximum rectal diameters : the treatment group also showed a significantly greater improvement in maximum rectal diameter on kub when compared with the control group .
the historical teaching regarding oab of childhood was that a congenital obstruction interrupted urine flow and led to the development of detrusor hypertrophy and hyperactivity , and the accepted therapy was serial and repeated dilation of this obstruction .
as time progressed , this anatomical obstruction was found to be the result of a willful dyssynergic contraction of the pelvic floor during voiding , and the treatment was changed to biofeedback physical therapy .
this nonphsyiological contraction of the urethral sphincter was no medical curiosity but a disease process so severe that it could influence the natural history of many childhood disorders , such as vesicoureteral reflux and nocturnal enuresis , and in extreme cases induce renal failure .
there is some debate among scientists as to whether this dyssynergic sphincter contraction is a learned or inborn condition .
it is the author s opinion that in children with an intact nervous system , uninhibited voiding dominates the infantile period of voiding prior to toilet training .
this is most clearly represented by the progressive bladder growth in pre  toilet - trained children , with increasing compliance .
this is mirrored in children with cerebral palsy , who demonstrate progressive bladder growth when they maintain an uninhibited , infantile voiding pattern .
the teaching of bladder overactivity as the natural progression of an obstructed voiding pattern evolved from pathological models of voiding dysfunction such as posterior urethral valves and the neurogenic bladder , which develops in myelodysplastic patients with discoordinated sphincters .
this led to the development of the modern model of dysfunctional elimination , an acquired condition where children paradoxically fail to relax their pelvic floor during elimination , resulting in bowel and bladder pathology .
this study sought to investigate an alternative theory regarding the origins of dysfunctional elimination , with a therapy directed toward that cause to examine its benefits .
this was first noticed in the 1960s , largely because of the presence of urinary symptoms in children with hirschsprung s disease . in his seminal work
, shopfner noted that the distention of the colon , especially the rectum , could have profound effects on bladder function .
oregan furthered this work with several groundbreaking studies linking rectal distention to bladder overactivity , with excellent success in treating nocturnal enuresis , urinary tract infections , and vesicoureteral reflux simply by alleviating this rectal distention .
what has unfortunately hampered the development of this work has been the lack of a uniform definition of constipation .
oregan defined constipation not as functional constipation , but mainly as the presence of fecal soiling , incomplete rectal emptying , and/or grossly decreased level of perception to balloon insufflation on anorectal manometry . the interesting discovery that oregan made was that often children with oab symptoms presented with no functional signs of constipation , yet had markedly abnormal anorectal manometry studies . in other words ,
they often volitionally delayed defecation until the rectum distended to fill the anatomical pelvis and then would reach a new , abnormal homeostasis where stools would evacuate at regular intervals and with surprisingly normal appearance ; yet the rectal tone would be so diminished as to have abnormal manometry studies . put another way , these children were changing the rectum from a sensing organ ( which in normal circumstances provides cues on the need to defecate ) , to a storage organ , with decreased sensation , and often resultant fecal soiling , but more often than not  normal stooling patterns .
oregan early on discovered what we have also demonstrated in this study that parental reporting of their children s bowel habits by bss or rome iii criteria is often inaccurate , and even when accurate , often not helpful in diagnosing rectal distention in children with oabs .
not only that , but in children with completely normal bowel habits , rectal distention can be the main or sole cause of urinary symptoms , leading to compression of the bladder , uninhibited contractions , and often urethral obstruction , all of which has been proved years ago .
the ability of rectal stool to induce uninhibited bladder contractions is well understood and was described as early as the 1980s ; this work has been supported by numerous studies , although the exact mechanisms have yet to be defined . the uncanny ability of children to be cured of nocturnal enuresis by simply restoring normal rectal tone is a great testament to this relationship .
what oregan proposed was that  in chronically constipated children ; the rectum is never empty , necessitating the repetition or maintenance of rectal sphincter complex contraction to maintain fecal continence .
in other words , the pelvic floor contractions during voiding are not a willful process that can be unlearned , but a physiological response to stool withholding . and
this could be reversed by directing therapy specifically at rectal dilation , in other words daily enemas , with excellent results .
so what if the modern theory of dysfunctional elimination and the resultant oab is wrong ?
we have proved that simply emptying the rectum repeatedly with the goal of restoring normal rectal tone resolves oab in children more efficaciously than the standard of care .
in fact , if the current model of voiding dysfunction were accurate , it should be impossible for our treatment to have been beneficial at all because we made no effort to influence pelvic floor function .
some would argue that our therapy would make pelvic floor contractions worse . yet , in almost all children , the bladder symptoms resolved . and in children whose symptoms
a daily enema regimen specifically targeted at restoring normal rectal tone is more effective than the standard of care for the treatment of oab in children .
sjh contributed to the conception and design ; contributed to the acquisition , analysis , and interpretation of data ; drafted the manuscript ; gave final approval ; and agrees to be accountable for all aspects of work ensuring integrity and accuracy .
our objective was to evaluate the efficacy of daily enemas for the treatment of overactive bladder ( oab ) in children . 
 this study was a prospective , controlled trial of 60 children with nonneurogenic oab . 
 the control patients ( 40 ) were treated with standard therapies , including timed voiding , constipation treatment with osmotic laxatives , anticholinergics , and biofeedback physical therapy , whereas the treatment patients ( 20 ) received only daily enemas and osmotic laxatives . on assessment of improvement of oab symptoms , only 30% of the traditionally treated patients parents reported resolution of symptoms at 3 months , whereas 85% of enema patients did . at the onset of the study , the average pediatric voiding dysfunction score of all patients was 14 , 
 whereas on follow - up , the average scores for traditionally treated patients and enema - treated patients were 12 and 4 , respectively . 
 this study demonstrated that daily enema therapy is superior to traditional methods for the treatment of oab .