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Schooling First-Grade Teachers on Children's Bladder Health

By Steve Hodges, M.D.

schools restrict bathroom access

Should students get to use school restrooms whenever they want?

Not according to a team of first-grade teachers in Las Vegas, who last week told parents in a letter: “Students are wasting valuable learning time on bathroom breaks.”

The teachers asserted that “healthy first graders urinate one or two times during the school day” and pleaded with parents them to help their children “increase bladder endurance." They recommended parents have kids “wait 10-15 minutes from their first urge and increase the wait time by 5 minutes per day” until the child can go 2 hours without peeing.

After the letter went viral, the principal did a quick and admirable job of calming outraged parents. She assured them students can, in fact, use the restroom whenever they request, “as it is a basic human right and need.”

Good for her. Plenty of other schools actually enforce restroom restrictions in the name of “maximizing instructional time” and preventing wayward students from “roaming the hallways.” They limit bathroom passes, require students to “earn” passes with good behavior, and reward students with trinkets and pizza parties for ignoring their bodies’ urges.

As a pediatric urologist, I spend a lot of time writing letters to these schools on behalf of my patients, who are harmed by these retrograde and misguided policies.

But the Las Vegas principal must do more.

She needs to correct the erroneous information sent out by her teachers about children’s bladder health. I also urge her to educate her staff and herself about the real reasons children have accidents, the various ways teachers can help, and the consequences of overriding the body’s signals — topics unfamiliar to most educators.

In a University of California study, 82% of teachers said they’d had no training on appropriate bathroom regulations for children, and only 24% of elementary teachers met criteria for promoting their students’ lower urinary tract health. Though 81% of teachers allow children unlimited access to water, 88% encourage students to hold urine!

The Las Vegas principal would be ahead of the game if, instead of ending the conversation, she capitalized on this teachable moment.

In her follow-up letter to parents, the principal assured parents that first-graders’ bladders were not bursting left and right.

“I checked nurse records for pee accidents,” she wrote. “The numbers were very low.”

But these numbers mean virtually nothing.

Accidents in class, while not totally uncommon, represent the extreme end on the spectrum of kids’ bladder and bowel problems. I guarantee that plenty of students at this school have less noticeable conditions that are exacerbated by withholding both pee and poop. These two bodily functions affect each other in ways teachers may not recognize.

Let’s start with chronic constipation, epidemic among our kids and driven by our highly processed diets, physical inactivity, and preschool toilet-training deadlines (and influenced by a child’s genetic make-up). Probably one-third of kids sitting in our classrooms regularly delay pooping, causing stool to pile up in the rectum.

Over time, this poop pile-up can stretch the rectum, sometimes to two or three times its normal diameter. The super-sized rectum presses against the nearby bladder and aggravates the nerves that control bladder emptying, erroneously signaling to the child that the bladder is full. The upshot: urinary frequency (the constant need to pee ) and/or urinary urgency (the desperate need to pee).

Teachers frequently mistake these conditions for unruly behavior. In one online advice column, a schoolteacher wrote: “I have a student who will literally ask to use the bathroom 48 times in 4 hours. (I kept a tally.) This child does not have a medical condition. This child is not bored. This child just wants attention.”

Just as I’m not qualified to diagnose learning disorders, I don’t think teachers are qualified to diagnose medical conditions!

At any rate, urinary urgency and frequency are signs of constipation teachers should be aware of, and they represent the early stages of more significant and distressing bladder conditions I treat every day. (Incessant peeing also can be a symptom of a few rare medical conditions that should be ruled out by a physician.)

In their letter, the Las Vegas first-grade teachers assured parents that they allow restroom access in case of an “emergency” and posited that “most emergencies stem from children not using the bathroom during the appointed times.”

In reality, emergencies typically stem from chronic constipation and the resulting overactive bladder. Using the toilet during lunch recess, while always a good idea, won't prevent these emergencies.

Eventually, left untreated, urinary frequency and urgency can develop into enuresis (bedwetting or daytime accidents). At this point, the enlarged rectum wreaks such havoc that the bladder has frequent, spontaneous contractions, like hiccups, and empties without warning.

While the number of daytime accidents at the Las Vegas school may be low, as the principal reports, I’m certain the rate of bedwetting is not. Probably 13% percent of those first-graders wet the bed — not because they are “deep sleepers” or have underdeveloped bladders or anxiety (false explanations for bedwetting) but because they are severely constipated.

But most teachers have no idea whether a given student wets the bed at night. They may also not know which of their students have chronic urinary tract infections. Each year more than 1 million girls develop these infections, which are directly caused by withholding both pee and poop. I treat first-grade patients who have infections almost every month.

Many of my patients with enuresis and/or urinary tract infections also have poop accidents, known as encopresis.

In these cases, the rectum becomes so stretched that it loses its tone and can’t pump stool out the door with enough oomph. The floppy rectum loses sensation, too, so the child no longer feels the urge to poop and just drops out of the child’s bottom, often without the child noticing.

Schools routinely mistake encopresis for a behavioral or psychological condition and refer these kids to therapists, even though no amount of counseling will prompt a stretched rectum to shrink back to size. (It takes enemas and laxatives, ideally in combination, for that to happen.)

Schools can be particularly cruel to kids with encopresis. Administrators in Gustine, Texas, ordered fifth-graders to pull down their pants for a “poop inspection” after stool was repeatedly found on the gym floor.

I’ve just described several conditions caused by withholding poop. Now I’ll explain how overriding the urge to pee makes these conditions worse.

In their letter, the Las Vegas teachers recommended kids increase “bladder endurance” by delaying a trip to the bathroom by 10 to 15 minutes after their first urge.

Burt these folks have it backward. Do you know what actually increases bladder endurance? Peeing right when the urge strikes!

We all have the power, at least temporarily, to override this urge by squeezing the external urethral sphincter, a band of muscle that controls urine flow. The problem is, each time you squeeze this sphincter, you create resistance that makes the bladder wall thicker and stronger.

Holding pee on occasion, like when you’re in a car or at the movies, doesn’t lead to any appreciable change in the bladder muscle. But when a child delays peeing multiple times a day over months and years, the bladder wall becomes thicker and more muscular. Eventually, bladder capacity decreases, and the sensation mechanism of a thick-walled bladder goes awry.

It is false, as the Vegas teachers wrote, that “healthy first graders pee once or twice during the school day.” Children should pee about every 2 hours. Kids with any of the medical conditions I’ve described may need to pee far more often, and they need all the encouragement they can get to heed their signals to both pee and poop. Only with frequent peeing will a thickened bladder return to normal, and only with complete evacuation every day will a stool-stretched rectum bounce back to size.

The Las Vegas teachers would love my patients, many of whom never, ever use the school restroom. These kids will withhold pee from 8 a.m. to 4 p.m., no matter what I say. Sure, they get plenty of “valuable learning time,” but they are also compromising their recovery.

It’s hard to get my patients to use the school bathrooms. The older ones are afraid of being laughed at or bullied. Some are grossed out by dirty bathrooms. Many are stopped by restrictive school policies or discouraged by their teachers. Others are just in the bad habit of overriding their urges.

I have numerous patients in middle and upper grades — sixth-graders who have accidents during soccer practice, middle schoolers too embarrassed to attend birthday sleepovers and school overnights, bedwetting 18-year-olds who’ve had to delay college because they don’t want to bring extra-large pull-ups to their dorm. You know what these kids were doing back in first grade?

Holding their pee and poop.

Unfortunately for these kids, their conditions were dismissed or undertreated by their physicians and misunderstood by their schools.

All toileting problems can be resolved, as long as kids receive appropriate medical treatment and support. Most kids don’t. I run a private Facebook support group for parents of children with enuresis and encopresis, and clashes with schools are a frequent topic of discussion. Students run up against restroom restrictions and other obstacles so often that I created a free download titled “4 Tips to Help Your Child Manage Toileting Troubles at School.”

Children spend nearly half their waking hours at school, and the toileting habits they practice there can affect them throughout childhood and beyond.

Schools promote Child Passenger Safety Week, No Name-Calling Week, and Sleep Awareness Week, My dream is for school nurses to launch Toileting Awareness Week, but I’d settle for teachers devoting 20 minutes to healthy pooping and peeing.

To make it easy, I’ve created a free download titled “The K-12 Teacher’s Packet on Student Toileting Troubles.” It’s full of useful facts, graphics, and games that teachers can use introduce to these topics, including what healthy poop looks like (mushy blobs, thin snakes, or frozen yogurt — not logs or rabbit pellets!) and why it’s important to pee and poop right when the urge strikes.

As a father of three, I know teachers want the best for their students and that educators face many stresses. But they shouldn't prioritize academic development over student health. If a child has to sacrifice 10 minutes of daily learning in order to avoid a lifetime of bladder problems, that sounds like a fine trade-off to me.

In their letter to parents, the Las Vegas teachers wrote to parents, “The first grade teachers need your help!”

When it comes to bathroom issues, I would argue that it is the students who need help.

Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine and coauthor of Bedwetting and Accidents Aren't Your Fault, Jane and the Giant Poop, and The M.O.P. Book: Anthology Edition — A Guide to the Only Proven Way to STOP Bedwetting and Accidents.

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