Cure of enuresis/bowel dysfunction in children may provide insights for adult dysfunctions

Dear Sir

A recently published randomized controlled trial of day/night enuretic children gave high cure rates for co-occurring day/night enuresis, (86%), constipation and fecal incontinence by a squatting-based regime [1] (https://www.researchgate.net/publication/343206998_A_four_month_squatting-based_pelvic_exercise_regime_cures_daynight_enuresis_and_bowel_dysfunction_in_children_7-11_years).

The enuresis study comprised 48 children, 7.6 ± 2.5 years, 34 females, 14 males applying a modification of Patricia Skilling’s pioneering squatting-based pelvic floor exercises (PFE) [2]. The programme was strictly supervised and recorded, 10 squats, 10 bridge, twice daily, fitball exercises involving proprioception exercises with surface perineal electromyogram (EMG) once a week. Eligibility criteria: daytime urine leakage plus night-time bedwetting. Assessment was by intention to treat. Criterion for cure was complete dryness.

At first review (4 weeks), 12/24 in the treatment group reported total cure of wetting; 41/48 children (86%) were cured of both daytime/night-time enuresis (p < 0.001) at 4 months. There were no adverse events. Secondary outcomes were  > 80% cure rates for constipation, fecal incontinence, urinary retention.

The enuresis and bowel problems were explained by laxity/immaturity of the muscle/ligament complex preventing normal function of the common feedback control mechanism which is binary and cortically directed [3]. With reference to Fig. 1, the cortex directs reflex binary control of the bladder and bowel by a peripheral feedback system: muscles reflexly contract against ligaments to close the urethral/anal emptying tubes to effect closure for continence; open them for evacuation; stretch the organs bilaterally to support the stretch receptors whose afferent impulses activate the evacuation reflexes, micturition and defecation. In this context, the weak point in the system is the ligaments, specifically, collagen, the main structural component of the ligaments.

Fig. 1
figure1

Binary control of bladder and bowel. Schematic 3D sagittal view. System in normal closed mode. Control of bladder and bowel is binary, via a feedback system [3]. It has two components, central (cortical) which directly suppresses or facilitates (large white arrows) and peripheral, activated by three reflex forces forward/backward/downward. The organs are stretched and balanced, much like a trampoline, by three opposite muscle forces (red arrows), forwards PCM (m.pubococcygeus) contracting against PUL (pubourethral ligaments) backwards ‘LP’ (levator plate) and downwards ‘LMA’ (longitudinal muscle of the anus) contracting against USL (uterosacral ligaments). Afferent impulses (small green arrows) originating from stretch receptors ‘N’ travel to the cortex. They are routinely reflexly suppressed cortically (white arrows). When required, the cortex activates the defecation and micturition reflexes for evacuation: the forward muscles relax, pubococcygeus for urethra (broken circle), puborectalis or anus (not shown); this allows the posterior muscles (arrows) to unrestrictedly open out the posterior wall of anus and urethra (broken white lines) just prior to bladder/rectal evacuation by smooth muscles contraction. If PUL or USL are loose, the muscles contracting against them (red arrows) weaken. Urethra/anus cannot be closed (incontinence), opened (emptying problems) or organs stretched to support ‘N’, (‘urge incontinence). CX = cervix; CL = cardinal ligament; ATFP = arcus tendineus fascia pelvis

The day/night enuresis cure was attributed to collagenopoiesis from muscle-activated exercise which strengthened the muscle/ligament complex [4].

These results may provide some insights into pathogenesis for adults in both the urology and colorectal disciplines. Our thesis is that because collagen changes with age, it can largely explain the very different results noted at different ages with pelvic floor exercises. We know from histology studies that collagen is the key structural component in ligaments, and from video X-ray studies that squatting strengthens the three reflex muscle muscles, pubococcygeus (PCM), levator plate (LP), conloint longitudinal muscle of the anus (LMA) which control the micturition and defecation reflexes and the ligaments they contract against, pubourethral (PUL) and uterosacral (USL) ligaments (Fig. 1).

At one end of the scale where children are in collagen creation mode for bones and ligaments, exercises created new collagen to hasten ligament maturation; bladder and bowel dysfunctions were both cured in 86% of the children [1]. In a group of premenopausal women (mean age 52), Skilling found 50% improvement but no cure [2]. She found the results were poor for post-menopausal women. This was attributed to known breakdown and excretion of collagen in post-menopausal women. It is highly unlikely that either exercises or “native tissue” repairs can restore ligament integrity in the elderly if there is a lack of collagen. In contrast, an implanted tape which can create new collagen can repair weak ligaments and gives high cure rates at 5 years [5]. This methodology, formed part of the 1990 Integral Theory and is the basis for the mid-urethral and other ligament repair slings.

References

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Both authors contributed to the conceptualization and writing of the paper. AGF oversaw and conducted the RCT.

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Correspondence to P. E. Petros.

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Petros, P.E., Garcia-Fernandez, A. Cure of enuresis/bowel dysfunction in children may provide insights for adult dysfunctions. Tech Coloproctol (2021). https://doi.org/10.1007/s10151-021-02410-1

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