Constipation may be an overlooked driver of urinary symptoms in children

Constipation and toileting behaviors can play a significant role in urinary symptoms among children and should be considered early in the evaluation, according to Carmen Tong, DO, a pediatric urologist at Children's of Alabama and associate professor at the University of Alabama at Birmingham.

Tong discussed practical approaches to evaluating and managing pediatric bladder and bowel dysfunction during the American Academy of Pediatrics (AAP) 2026 National Conference & Exhibition.

"First thing I always kind of think about when I ask any child with urinary symptoms is bladder-bowel dysfunction things relating to constipation," Tong said. "You really want to make sure that you cover those bases because we know that constipation can affect pelvic floor dysfunction, which can then lead to bladder dysfunction."

What should pediatricians look for when evaluating urinary symptoms?

After considering constipation, Tong said pediatricians should look for signs that could suggest an underlying neurologic or renal issue and potentially require additional evaluation.

A physical examination can include evaluating the child's back and spine and observing gait for signs such as lower extremity weakness. When renal function or anatomy is a concern, Tong considers factors including the duration of incontinence and family history and may obtain a urinalysis or renal bladder ultrasound.

Constipation, however, may be less obvious than families realize. A child having a bowel movement every day does not necessarily rule it out.

"Constipation is super important to ask, and I'm very specific and explicit in how I ask about constipation because oftentimes parents will tell you that their child is not constipated and they poop every day," Tong said.

Tong recommended asking specifically about stool frequency and appearance rather than relying solely on whether the child has daily bowel movements. The Bristol Stool Scale can help families describe stool consistency and shape. Occasionally, Tong said she obtains an X-ray when the history does not provide enough information, although imaging is not routinely necessary to determine whether constipation is present.

Why does behavioral management come before medication?

For children presenting with bladder or bowel dysfunction, Tong said her initial visit focuses primarily on counseling rather than medication.

"The first session is just all counseling. We really don't start medications during the first session because it's all about urine therapy," Tong said.

Education and demystifying incontinence are central to that approach. Tong encourages families to maintain a voiding diary documenting how often the child urinates, episodes of leakage, whether symptoms occur during the day or night, and fluid intake, including how much the child drinks before bedtime.

Management also includes addressing constipation through diet, fiber, toileting schedules, and other strategies when appropriate.

How can toileting habits contribute to urinary symptoms?

Proper positioning on the toilet can be particularly important for younger children, Tong said.

Young girls whose feet do not reach the floor may dangle their legs and clench them together while urinating. This can trap urine, resulting in dribbling after they stand that may be interpreted as incontinence. Tong recommended ensuring children are positioned appropriately and, for girls, keeping the legs apart while voiding.

She also advises avoiding potential bladder irritants such as caffeine, acidic or spicy foods, and certain beverages and foods containing red or yellow dye.

Timed and double voiding are additional components of her approach.

"Making sure they go to the bathroom every 2 to 3 hours to empty that bladder," Tong said.

To encourage double voiding, Tong tells children to urinate, stand up and briefly move around, then try to urinate again to promote more complete bladder emptying.

When should pediatricians refer to a urologist?

Tong emphasized that pediatricians should not hesitate to refer when families need additional support, even if initial evaluation does not reveal an obvious underlying disorder.

Referral may also be appropriate when behavioral strategies have been tried without improvement or when incontinence remains persistent enough to raise concern for an anatomic cause.

"If you feel like you've tried all the therapies and they're just not responding to it or they're just not getting it, that's also a good indication to go ahead and send them over," Tong said.

When persistent symptoms suggest a possible anatomic abnormality, pediatricians can consider obtaining a renal bladder ultrasound before referral. An abnormal result, Tong said, represents a clear point at which to involve pediatric urology.

References

Tong C. Enuresis: Not a Dry Subject. Presented at: American Academy of Pediatrics 2026 National Conference & Exhibition; October 2, 2026; San Diego, CA.