Treating pediatric pelvic floor dysfunction: constipation, incontinence and pain, oh my!

00:00:00 Music 00:00:03 Host: Hello, and welcome to this edition of Doc Talk. Today we're talking with the pediatric pelvic floor therapy team at Cook Children's Healthcare System. It's very busy in the Child Life Zone today so you may hear a little background noise. Before we get started, our guests. Caitlin Smith, who is an occupational therapist, and Kathy Manthuruthil, who is a physical therapist. This is such an interesting topic and truly life changing program for kids with pelvic floor conditions. And I can't wait to dive into this. But first, can you give an overview of your program and your team? 00:35 Kathy Manthuruthil: Sure, thank you. Our team is made up of both physical and occupational therapists like Caitlin and myself, we specialize in both neurodevelopmental and pediatric sports physical therapy, so we have a wide range of background. And we also have both male and female trained therapists. So if a patient has a comfort level with someone of their own gender, then we're able to provide that as well. We have therapists at each of our three outpatient clinics. 00:01:00 Host: So your team specializes in pediatric pelvic floor therapy, how does being pediatric only help the patients you see versus being more of an adult care provider who also sees kids? What are the benefits to your patients and their families? 00:01:15 Caitlin Smith: I think the biggest benefit is that we know how to engage with kids well, and this is a really sensitive area of therapy and being able to connect with kids and make them comfortable, and help them be able to understand the very complicated nature of what's going on is a huge, huge benefit to coming specifically to a pediatric pelvic floor site. 00:01:37 Host: So there's a pretty long list of issues related to pelvic floor issues bedwetting, wetting during the day, especially after the age of four. Urine leakage with laughing sports or activity, frequent urination and infrequent and urination, urinary retention, pain in pelvic or abdominal area, accidental bowel movements, pain with bowel movements, straining to complete bowel movements and constipation, like I said, a long list. So are these the most common conditions you see? And why are they so common? And is it easy for them to be overlooked? 00:02:12 Kathy Manthuruthil: Yes, those are definitely the most common we see, I would say number one and two are constipation and urinary leakage or incontinence, which in a lot of cases are tied with each other. And so those are definitely also the areas in which I think we see the biggest success with our patients, because it's such a high volume of what we see. Honestly, I don't know why it can be overlooked. And not necessarily misdiagnosed, but not necessarily managed more aggressively at a younger age. I think part of it is pelvic floor therapy is a new specialty area of practice in physical and occupational therapy. So a lot of doctors may not even know it's an option for their patients. And historically, it hasn't been available in this area until we started our program four or five years ago. And so I think it's great for us to kind of get the word out to physicians that we can help their patients so that they know that they can send them as early as four or five, six years old to work on these incontinence issues, and that those things aren't necessarily normal, and they're not necessarily things they're going to outgrow. 00:03:10 Caitlin Smith: And I also think parents may not know that these specific things are abnormal at that point. A lot of times parents will think it's still pretty typical for their kids to be leaking during the day or at night, when they are under the age of 10 even if it's not. And also a lot of times people can be constipated and not even know it. And that can be causing a lot of the other issues. So it's really helpful to send kids to us for constipation so that we can kind of help them resolve that and then hopefully resolve those other issues too. 00:03:43 Host: I was very surprised to learn about the relationship between constipation and bedwetting, I can't help but wonder how many kids and parents have struggled with this issue when it might actually be more easily resolved than most current treatment, is this the case? 00:03:58 Caitlin Smith: Yes, I think a lot of times, well most of the families that we see, don't really have the knowledge that constipation is related to bedwetting, and a lot of times when a kid is wetting the bed for so so long. People may think that it's going to take so much more to resolve it than it really does. And a lot of the kids that we see, once the constipation is resolved the bedwetting immediately resolves. And so giving parents that hope and being able to educate them on that and educate them on constipation management, and especially to work with the doctors to manage that constipation has been really helpful and honestly has given kids and their families a lot of hope in that because it's a pretty easy solution, if you think about it. There's not much more that you have to do. Other than that. Sometimes it can be caused by other things as well. But I feel like for the bulk of the kids we see constipation is the major cause of that bedwetting 00:04:55 Host: And can that include children like not just like as a short term but kids who have a long term issue with bedwetting? 00:05:01 Kathy Manthuruthil: Yes, I can actually speak to that from both the provider and parent perspective. This is actually why I got into pelvic floor therapy is because my oldest son struggled with this until he was 17 years old. And we manage the constipation, and we were very consistent about it. And finally, after 17 years, he has been totally dry for a year. I can tell you, I tried all of the alarms, I tried all of the waking him up a million times at night, I tried every single thing in the whole wide world. And was it easy to get him to take his Miralax every day and not eat gluten and dairy that were irritating him and his bowel? No, but it was way easier than waking up at 2 a.m. I love that I can kind of connect with parents on that as well, when we're talking through that and walking through that. It does typically take a lot longer to resolve the bedwetting than it does just the daytime leakage or the constipation. Unfortunately, it tends to be a long process, it took about two years for me and my son. But it improved significantly pretty quickly once we started working on treatment things. 00:05:59 Caitlin Smith: And it's such a sustainable solution. Compared to all of the other things that just require more effort from you. Even though constipation management does require effort. Once you get to the point where you can manage it pretty consistently and easily, it's so much easier to integrate into your daily routine than a lot of those other kind of high frequency things like waking up in the night and using an alarm. 00:06:23 Host: So what about more complex conditions that are some of the rarest and or most difficult to treat, 00:06:30 Kathy Manthuruthil: We do see some more rare conditions. For example, kiddos who have a history of Hirschsprung's, who have had like their pull through surgery or things along those lines, or we have seen some patients who have incontinence as well as a diagnosis of maybe autism, or some of those things that together make it a little bit more complicated to treat. I will say as far as our practice, we are not necessarily experts in the treatment of Hirschsprung's, because none of us have significant experience with that. But it's also definitely something we are willing to work through and learn and try with our patients. And something that's kind of important to mention, we do not do any kind of internal work or internal manual therapy or use any kind of balloon training, which is some of the training indicated in children with Hirschsprungs. But in our practice, and in our healthcare system, we do not do any internal work with these kids at all. And so that's part of the reason that for some of our kiddos who have the decreased sensation, we struggle a little bit just with that limitation that we have. So those are kind of the more complex things that we treat. Even though they aren't necessarily complex diagnoses, most of our kids that come to us have been dealing with these things like the constipation and the incontinence throughout their entire life. And so, even though they're not complex conditions, for them there's definitely a huge complexity to what is causing this issue. And we're typically able to get them down to the root cause of it most of the time. 00:07:59 Host: So working with kids, as health professionals, or as parents, can sometimes present unique challenges. What are some of the biggest challenges to pelvic floor therapy in kids? 00:08:10 Caitlin Smith: I think one of the biggest challenges is overcoming that awareness to what's going on and then being able to understand and be comfortable with what we're doing and what they're doing. I think also, another big thing is just that mental health aspect of it and the confidence and feeling like an outcast, for having leaks, feeling really embarrassed. Those psychological risk factors that the longer that they struggle with these things and have accidents in public, have things that happen around their friends, that can affect them mentally, and socially as they grow up and everything like that. And so walking along side kids in this is really tricky and kind of supporting them in that. And we also see a lot of kids that have been through trauma. So approaching this very sensitive area with them, pelvic floor, after they've gone through traumatic things, you have to be really careful about how you engage with them in it and make sure to build rapport with them, and really educate them on why you're doing what you're doing. And so I would say those probably are the biggest challenges to being in the pediatric setting. In this. 00:09:22 Kathy Manthuruthil: I would add to that, that also sometimes helping the parent and the child relate to each other as it relates to these accidents and or bedwetting, or any kind of incontinence that this child has been having, it can be a really big point of frustration between the parent and the child. And so helping the parent understand that this is not generally something the child is doing purposefully, and helping them start to rebuild their relationship and not have as much conflict about this, it can be really hard to get parents on board because so many of them come in and they say, "Nope, they're lazy and they're not going to the restroom." And that's generally not the case, sometimes the parent is right. But there are some. But for the most part, there's a major physiological issue happening with this kiddo. And we can help with that. But it's sometimes really difficult to get that parent buy-in, especially if the parent is who's really on board with bringing the child and the child could care less that they're having any leaks or accidents. 00:10:23 Caitlin Smith: Well, and that's also why we call them leaks and not accidents. Because we put the blame on the body and physiological things. And we really tried to educate the kids on that, that it isn't your fault. And try to change that verbiage around what parents are calling it, what kids are calling it, so that we can put it more on what's going on with them physiologically versus their voluntary control. 00:10:49 Host: So it sounds like you really have to build a trust factor. And then also build relationships, not only between the child and the parent, but also with both the parent and the child and your team, 00:11:00 Caitlin Smith: For sure. And that's why our evaluations are so long, they're about an hour and a half. Because we really try to work on building that relationship with the patient and their parent, and also being able to educate them on the pelvic floor and on all of these things to really get them comfortable and increase their knowledge on that as well. 00:11:19 Host: Beyond the challenges, what are the biggest obstacles to your child's success? 00:11:24 Kathy Manthuruthil: I think it really varies a lot. The number one obstacle to any child's success is not following through with the recommendations that we're making for them. So I've had to have really tough conversations with kids. And I love it. The nurse practitioners that refer to us a lot, they have started telling their patients that we make 100% of their patients better, and I really appreciate their vote of confidence. But I then have to look at their patients and say, "Okay, I make 100% of my patients better, that do their homework." So sometimes I feel like I am a dietitian, a physical therapist and a behavior modification therapist all in one room, when I'm doing pelvic floor therapy, because so much of it is getting the kiddos to buy in to what we're doing. So we do sticker charts, we have rewards, we have prizes, and some of the parents will work on kind of reward systems at home with them, depending on the kiddos level of motivation, to be able to get the kiddo to really buy in to what we're doing, because that's the biggest limiting factor. The kiddos that we struggle to really see progress with, even if they are doing their home exercises, are kiddos who have undergone significant trauma really recently and have a lot of mental health issues. Sometimes, the pelvic floor therapy just really needs to take a backseat. And with some of those, we'll just say you know what we've we've given this a good try for a little bit but I think some other things need to take priority. And you know, let's come back in six months or a year and try again, because sometimes they just need to work through those mental health things first, when they have major depression, or OCD or some of those kinds of things. We have started to see several more kiddos who are on the autism spectrum. But we also should be really specific and saying we are not working on toilet training patients who are on the autism spectrum. So it is a kind of a tricky balance for us to say like where we can be helpful and where we cannot. And so that's another sort of challenge. When they have another diagnosis that's co-occurring with what's going on with the pelvic floor, incontinence, constipation, etc., sometimes it can be kind of difficult for us to see the same progress that we see with our patients who are normally developing, just having incontinence. 00:13:40 Host: So in those instances, when you have kids like with autism, or specific conditions like that, do you have to coordinate with the physicians to make sure that they understand one, that you're not helping with the toilet training and, two, do they have to let you know about special things to help improve that care? 00:13:57 Kathy Manthuruthil: We have had to have some conversations with families and the families have always been receptive. And I think the physicians that have referred to us have been very receptive and welcoming of the information as well, that we're going to work through these things. And let's see how much progress we can make. And some of it also depends on the willingness and the motivation of the family to work on the things we're talking about. But you know, sometimes we may see a kiddo and, and we'll have that conversation with a family after an evaluation. And then of course, we'll, we'll communicate that back to the physician in our reports as well. 00:14:25 Caitlin Smith: And sometimes when the physicians make the initial referral, they tell the families, "Hey, they may not pick you up for therapy. But when you go in for the evaluation, they'll be able to look at everything and give you recommendations, maybe train you in some things to do." And so a lot of the families do have clear expectations coming into the evaluation that we're not going to be toilet training their child, but that we can help give them maybe some modifications to implement in their daily routine to help with whatever's going on with them. 00:14:55 Host: And I want to backtrack just a minute. Each of you mentioned trauma earlier. Are there specific types of trauma that you're referring to. 00:15:02 Kathy Manthuruthil: I'm referring primarily to child abuse of any sort, I mean, physical, emotional, sexual, all of the above. But I wouldn't say that there's one that specifically is more prominent than another. But there is definitely a correlation between continued bedwetting and or daytime incontinence and trauma. And so there is a, I think a higher number of my patients that I see for pelvic floor versus in my regular therapies that I'm providing that have that history and that background of trauma. 00:15:30 Caitlin Smith: This may not relate directly to trauma, but I have seen a few patients recently that have anxiety pretty severely. And that's been related to their urinary or fecal issues as well. 00:15:44 Host: So a lot of times when the average person thinks about leakage, especially urinary leaks, we think about girls, but boys have issues too. So what are they? And is there a difference in the care provided to boys versus girls? 00:15:59 Caitlin Smith: Well, honestly, our treatment approach depends on the child. So it could be a little bit different from kid to kid no matter if they are a boy or a girl. But some specific things that we do that is a little bit different for boys than girls are training the boys in how to relax when they're standing up versus sitting because boys urinate standing and girls urinate sitting. So we have to work a little bit differently on stuff like that. But most of the things that we do, are pretty consistent between genders. 00:16:32 Host: So for both boys and girls involved in sports, leakage can also be a problem and can be either an existing issue, maybe even one that's only triggered by activity, but also injury related. So what are the causes? And is there a difference in how those are treated? 00:16:47 Kathy Manthuruthil: Definitely not as far as boys versus girls, there's really not a difference, especially for any of the like stress incontinence or incontinence with sports and activity, we see several of these patients. One of the nice things is that our pediatric sports therapists are also trained in some pelvic floor training as well. So sometimes if they're having leakage only with sports activities, like I've had one girl who only leaked when she went to spike the volleyball. And so I was able to transition her over to our physical therapist on the sports team, who was able to kind of take her the rest of the way through the strengthening and the control that she needed to be able to participate fully in her support without any leakage. And so it's nice because we kind of have a team of experts that can help us progress as patients, you know, want to do more high level activities as far as that goes. 00:17:35 Host: So while we're on the subject of sports, is there a different role for occupational therapists, physical therapists and sports therapists in treating kids based on the cause, 00:17:44 Kathy Manthuruthil: Typically no. The training that we have, and the care that we provide looks very similar. One of the benefits of us having both physical and occupational therapists available is that, say a child is receiving occupational therapy due to difficulty with handwriting or feeding or different things along those lines, then they can come see me as a physical therapist without having to stop their occupational therapy that they're already doing. Same thing for PT. If they're seeing PT for an ankle sprain, they can come and see Caitlin for OT pelvic floor therapy. But the care we're both using biofeedback, we're both using exercise, strengthening, stretching, all of those sorts of things in order to help improve their pelvic floor function. Our sports therapists do tend to help when it is that more sports specific exercise, that's usually when we tag them in. 00:18:35 Host: Obviously, therapy doesn't end with the office visit, what role do parents play in their child's therapy, 00:18:41 Caitlin Smith: In any therapy at our outpatient clinics, parents play a huge role, because one of the biggest parts of our model is the parents come back with the kids every single session, they see everything that we're doing, and we're able to touch base with them, talk with them each session, to make sure that they know exactly what we're doing and exactly why we're doing it. That helps so much just with carryover and with implementation of the home exercise program, and everything at home. And parents have been a huge tool for us, especially in pelvic floor therapy, because the home exercise program is probably the most important thing of our therapy program. Because if the kids aren't doing it, like Kathy said earlier, we're not going to see any progress. And when the parent buys in and is super committed and motivated to see progress, and they help their child keep up with the home exercise program at home. That's when we see the most progress. When a parent is not as bought-in and is not as consistent with keeping up with that home exercise program we don't see as great a progress or as much as progress or even progress at all. So the parent involvement is extremely important. 00:19:54 Kathy Manthuruthil: And I think all the caregivers like so many of our kiddos you know they may be with mom and dad in the evenings but grandma takes care of them before school. So grandma needs to know that this kiddo has discovered that dairy hurts their belly and causes them to be constipated. So they should not have milk in their cereal for breakfast. I have written letters to grandparents stating, please stop buying ice cream for your, for your grandchild every day, because they're trying to avoid dairy this week and see if it helps their pelvic floor. So it's huge. And it's huge for the family to get everybody that's in contact with the child on board. Because some of the things that we do is we do ask the kids to make some dietary changes sometimes to see if that can kind of help relieve their symptoms. And most of the time I suggest that the whole family try it because the kids going to feel very singled out if they're the only one who's not having ice cream, those kinds of things. And so the parent and family and caregiver, their whole circle really needs to kind of buy in to help with these things. 00:20:55 Caitlin Smith: Oh, yeah. And even leading off of that, the involvement of the school as well, because when kids are at school, they're not with their families, but they still need to be going to the bathroom regularly. They still need to be drinking water regularly throughout the day. And a lot of times, Kathy and I and the other therapists will have to send a letter to the school asking them to make sure they let our patient go to the bathroom whenever they need to. Or keep a water bottle on their desk so that they can drink it throughout the day as well. So it really spans their whole entire day versus just when they're at home. And our plans of care end up usually being one time a week. So that's why it's so important for the caregivers and the patients to implement the home exercise program, because we're only with them one hour a week. But they're spending the rest of their time at home out in the community, with their parents. And so it's so important that what we do in therapy carries over to the rest of the time, because that's how we're actually going to see progress is if they're implementing things every day, instead of just one day a week. 00:22:00 Host: What educational information do you provide families to ensure a good outcome? 00:22:04 Kathy Manthuruthil: That's one of the things we talk about with our patients at really every evaluation is asking them what their preferences. So, because we talked so much about how it's so important that they're doing these things at home, typically, we try to do whatever they share with us as their preferred learning method. But we're always showing them. I'm always having families come in, I'll do an exercise with a kiddo once and then make them do it next so that they understand what they need to do, how it feels. The kiddo will give them feedback and say, yep, no, no, that feels different than when that therapist lady did it, I need you to push harder on my belly mom. And so they are able to replicate what we're doing in therapy at home. Since you know, we're only seeing them once a week. And some of our patients drive really far. And they're not able to come once a week. So sometimes we're only seeing them every other week, or once a month, depending on their abilities to come. And so we always give them written information as well, in order for them to reference that when they get home. 00:23:00 Caitlin Smith: And there are lots of different areas that we educate on as well. Especially when they come to the evaluation. We obviously educate on what the pelvic floor is, what it does, and what it means when it's not working well and why. And then just as we talked about in answering so many of these questions, there's so many different areas that we can educate families on to empower them to be able to change what's going on with their child. So food changes, dietary changes, different modifications to their routine, different schedules to have, drinking water intake. Literally every time one of my patients comes in that's one of the first questions I ask them. So how much water have you had this week? And if they drink the right amount, I cheer so loudly because it's so rare. I mean, none of us drink the right amount of water either, I would say. There's so many areas that you can educate on families and that are so easy to talk about and are so simple, but just making those really simple changes makes the biggest difference. We also will teach families in different manual techniques, like different massages they can do to help with constipation. We'll educate on exercises to do at home. And I mean lots of different things, the opportunities, possibilities, possibilities, that's what it is. I've been having word finding issues recently. The possibilities are endless. 00:24:26 Host: And so in addition to coordinating care with the families, do you work closely with the referring physician? 00:24:32 Kathy Manthuruthil: Yes. And really, we have developed really good relationships. I feel like with the physicians that primarily refer to us, which right now has mostly been our urology team, some of the nurse practitioners there as well as our GI nurse practitioners as well. And so, you know, whenever we're having concerns or issues with them, either I'm reaching out to them or I'm having the family reach out to them, because sometimes, you know, the families are coming in to see us every week and so what's great is that we can kind of establish a relationship and check in on some things. So we'll have families that come in and say, Well, okay, so we took that MiraLAX, everyday like the doctor told us to, but now he's having these like explosive accidents at school. And it's a really big problem. And so I can say, "You know what it is time to go. And let's talk with your doctor, because you could talk to them about seeing if they're okay with you backing off on that a little bit." And so I'm able to sort of facilitate that conversation for them in their ability to communicate with their doctors, because I think so often, they don't want to ask those questions, because they don't want to bother anyone. And so it's nice, because I can be like, no, no, they want you to bother them. Let's talk to them about that. And so and that's what's nice, too, is some of the other like lifestyle changes that Caitlin was talking about, you know, I know that their doctors are telling them these things, the same things that we're telling them. But they see us every week. And so if we say, "You know, these foods can irritate your bowel and your bladder, why don't you try cutting out these two that we saw that on your food blog, you're eating all the time?" Well, they come back to see us next week and they tell us if they did it or not. And we can talk about how much better they feel. Versus they're seeing their doctors every three to six months. If that. And their doctor has 10, 15 minutes with them, we have an hour. And so it's really nice, because we can really help coach them through some of those things as they're going. But we're always, you know, obviously, we don't change anything or recommend any changes to any of their regimens whatsoever other than exercise, but we have had some, you know, where we're concerned, like, we're not making the progress that we think we should. So, you know, maybe I'm concerned that we should look into a tethered cord, or you know, what, I wonder, is this kids really using the restroom a lot, do they maybe have diabetes, have we checked them, have we checked their glucose? Because we have those relationships, and sometimes the families, they start to open up to us a little bit more, because they see us so much, that it's nice, because we can communicate those concerns back to the physicians and and they're able to then refer them for whatever testing they think is indicated. 00:26:55 Caitlin Smith: And it's been awesome for us to get referrals from Cook physicians, because we can see all the imaging that they do. And especially before an eval, it's so nice to be able to look and be able to see, okay, they did a que UB, we can see exactly how constipated they are. Recently, we can see the renal ultrasound that they've done. And we know what their post void residual was, because they did that at their most recent urology visit. So that stuff is really nice for us to see because it can help inform the way that we approach our care with our patients as well. 00:27:27 Host: Some of the kids referred to your team have complex conditions like sensory dysfunction, movement disorders, etc. Where does pelvic floor therapy fit into their care? And how is it coordinated with other therapies that they may need or be receiving? 00:27:41 Caitlin Smith: So we do see a lot of kids with other diagnoses and conditions, I would say a lot of the kids that we do see do have sensory dysfunction. And what that looks like is us collaborating with their other therapists. So say, Kathy is a physical therapist, she's seeing somebody who's an OT, and they're working on sensory stuff. So then she can communicate with the OT and figure out, "Hey, these are the things that we do at the beginning of our sessions to help them increase their attention to task and tolerate these different things. So we're going to implement that in our pelvic floor therapy session to see if that can help get us where we want to go. Also, kids who are dealing with a lot of other conditions, we do see are seeing other therapists, like I have a lot of patients right now that are also in physical therapy. And we do a lot of core strengthening work and a lot of flexibility and stretching as well. And it's been really helpful to be able to work hand in hand with their physical therapist to say, Oh, hey, okay, I'm working on this today, you're working on that, perfect, these go together really, really well. And now I can focus on this and implement what you guys are working on. And they can focus on their focus, but can also implement some aspects of our care as well. And so it's really nice, because it is a more holistic approach. And these things are able to be addressed in a lot of different ways. But with the sensory dysfunction, it's been really great because, especially having the OT background that I do have, educating families on what that means and how it can affect their kids continence and give them the strategies that they need to be able to implement throughout the day, like a sensory diet, and different sensory activities to help increase that in their kids as well. 00:29:36 Kathy Manthuruthil: And one of my favorite things that we've learned about and I feel like started to do with more with our kids in the last few years is you know, we don't always think about the sense of like interoception and so when you're talking about sensory dysfunction, like so many of these kids, they truly don't know what things feel like inside their body. And so, what's one of the things that I feel like I do with a lot of my patients is, I'll make them like talk about what food feels like in their mouth. Because if they don't know what it feels like when they need to go to the bathroom, they're not going to go to the bathroom. And so it's like we start at the opposite end of the tube. And let's start to talk about what these things feel like. And I feel like that's been really helpful. And it's really great to work with our OTs, like Caitlin, because PTs don't get quite as much experience in the sensory dysfunction world. And so it's been really nice to be able to collaborate and work together and get strategies from our OTs for some of those things as well. 00:30:25 Caitlin Smith: And one thing that also I feel like is very common that parents get extremely worried about when they come see us is, "Oh my gosh, my child cannot feel when they've had a leak, they can't feel that their underwear is wet, oh my gosh, I'm so worried." And that's been something that's really been helpful to educate families on is, "Hey, if your child has been leaking for years and years of their life, and they're used to that sensation of being wet, they're not going to be able to feel it anymore, because their body has completely adjusted to that." And so I feel like that's a big part of what we have to educate families on is, eventually, your child will be able to get back to feeling, hopefully, what it feels like to feel wet versus dry. But we have to get them being dry sometimes first for them to be able to feel the difference of being wet versus dry. And so that sensory aspect of it as well, I feel like we integrate a lot into our treatment 00:31:21 Host: For referring doctors, what are some symptoms that would suggest a trip to the pelvic floor program? And when should they consider it? In other words, is there a long list of causes they should rule out first, or should this care be considered early? 00:31:36 Kathy Manthuruthil: I think really anything on that list that we stated at the beginning, you know, any kind of urinary or fecal incontinence, constipation, frequency, painful urination, all of those things are things we can be helpful with. It is definitely helpful for us, because we can't order any imaging, to know do you have that information from the KUB and know is this patient constipated? Is that part of what they're struggling with? So do we need to help them manage that. It's helpful for us to have the information from urology about like a uro flow where sometimes gi doctors will do an A.R.M. study, and that information is helpful, but it's not always 100% necessary for us to have it, Something we're very happy to say, okay, you know, we've been working on this a little while and we're not getting there as fast as we hoped. Let's communicate back with that referring provider and say, what would you think about doing this study? What would you think about ordering a KUB to find out if this kiddo is still struggling with constipation, or if we've been able to help? Because like Caitlin mentioned earlier, so many kids are constipated and they have no idea. Because they don't feel it. They don't know. I can't tell you how many of my patients moms tell me, "I don't know, they say she's constipated but she never complains about her belly hurting." It can be helpful to us to have some background information and some imaging, but it's not something typically, unless you're concerned about something like a tethered cord, or a neurogenic. bowel and bladder, it's not something that typically there needs to be a ton of workup done for us to be able to be helpful. 00:32:59 Caitlin Smith: And I would say one of the biggest things too, is that if a kid is coming to us, it is important that they are potty trained, because we don't potty train in pelvic floor therapy. We help kids gain continence, if they have the ability to be potty trained, and if they are potty trained. And so it's important that they know how to use the toilet and that they have the ability to use it in order to be seen for pelvic floor therapy, as well. And so that's why we say as a rule of thumb, that we see kids four and older, we can see kids that are a little bit younger than that. But we recommend that they be really, really good at following directions and understanding what's going on. 00:33:45 Host: So what are some other things you wish referring physicians knew that could contribute to better outcome for the child, 00:33:52 Kathy Manthuruthil: I would say the number one thing is just if the family is really motivated and really wants to work on this and address this issue, not to tell families to wait it out, and that they'll grow out of it. Because so many of these kids do not grow out of it. And I will tell you, my son did not grow out of it, we had to address it really hard for a really long time. And typically, we see almost complete resolution of the symptoms for kiddos within four months. I would say that's my average. Sometimes it's longer, but also sometimes it's a lot shorter. I've had kids who've come in for three visits and no longer had any issues with incontinence. And so we can make such a huge impact in a really short period of time for these families that have been struggling for so long. And so with all the other struggles that kids have in the world today, if we can help this one be better, let's do it now. Let's not wait until they're 8, 9, 10, 15, 18, etc. I would love to see them all when they're 5 and 6. 00:34:51 Host: At what age should a patient transition to an adult program? 00:34:55 Kathy Manthuruthil: We typically do not see patients after the age of 18 and really at that point an adult provider is appropriate for them. And there are several great adult pelvic floor therapy providers in the area. I have had a few patients referred to me with things such as pain with intercourse. I will tell you that is not something as a pediatric specific therapist that I have any experience in treating, and so she had some incontinence issues as well. And we were able to work through those. But once I discharged her, and we helped with the incontinence issues, I encouraged her to see an adult's pelvic floor provider for her other concerns. So there are some where we, you know, when they get into that 16 to 18 year old age range, depending on what their concerns are, and why they're coming to therapy, an adult provider who does do some internal work or has a little bit different experience and expertise could be a good option for them. But for the most part, if they're looking at incontinence, and or constipation only, then up until 18 is usually our age range. 00:35:54 Host: And considering some of the physical and emotional issues that kids deal with, what are the complications kids might face without therapy, like short and long term? 00:36:04 Caitlin Smith: Like we talked about earlier, it's mental health issues, anxiety, all of those things can be a huge, huge factor in experiencing the things that they've experienced with their incontinence. I think also, another short term complication that could also be a long term complication is UTIs. A lot of the kids that we see get frequent UTIs, because of all of these things they're experiencing, and a lot of them that I know have been on antibiotics for a really long time. So that's a long term and short term factor that could happen, because of all of these things if they don't get therapy and don't resolve their issues as well. 00:36:45 Host: Before we wrap up, is there anything else you'd like to add to this conversation? 00:36:50 Pelvic floor, pelvic floor therapy is awesome. I feel like I've seen such transformations in so many of my kids, it's amazing to see their confidence improve, and just to see the change from them, having leaks every single day to being dry for weeks and just see the big impact that that has on a child's life. And it's amazing as therapists to be able to see that improvement in a child. And to see it so many times over with so many of the kids that we see, it's, it's really awesome. 00:37:26 Kathy Manthuruthil: It's hugely impactful. And I always say that it's my favorite thing to treat, because it's the one thing I can almost always fix. We can't always fix all of our kids issues. But this one we usually have the answers for. And so it's really, really great to see them be able to just go on and live a normal life and do all the things they want to do and not have to be worried about this anymore. 00:37:47 Host: Thank you so much for joining us today and talking about this incredibly important topic and taking time out of your very busy schedules. 00:37:56 Caitlin Smith: Of course, thanks for talking to us. 00:37:57 Kathy Manthuruthil: Thank you so much. 00:37:58 Host: And thank you for listening. If you're interested in learning more about pelvic floor therapy or any program at Cook Children's, or you have a patient you think might be a good candidate, please visit Cook Children's dot org. Like what you heard, subscribe to our Doc Talk podcast on our site, or wherever you get your podcasts.