Bladder and bowel continence in bilateral cerebral palsy: A population study

Summary

Introduction

The attainment of continence is an important milestone in all children, including those with disability.

Objective

To describe the age of bladder and bowel continence in children with bilateral cerebral palsy (BCP), and the association with intellectual impairment (II) and severity of motor disability.

Patients and methods

The parents of 346 children with BCP were interviewed as part of a population-based prospective study of the children at 3, 7, and 17 years of age. The age of bladder and bowel continence by day and night was ascertained and compared with controls from the Avon Longitudinal Study of Parents and Children (ALSPAC).

Results

The median age for daytime bladder and bowel continence in BCP children was 5.4 years compared with 2.4 years in the controls. At 13.8 years of age, 59.4% of BCP children and 99% of controls were continent by day. In BCP children, there was no difference between the attainment of daytime bladder and bowel control. Night-time bladder and bowel control was slower and less completely attained, with 50% of BCP children continent by the age of 11.8 years compared with 3 years in control children. At 13.8 years of age, 51.9% of BCP children compared with 99.4% of controls were continent for bowel and bladder at night. Gross Motor Functional Classification Score (GMFCS) and intellectual ability (IA) (II) were strongly associated with continence attainment (P < 0.0001), but gender was not.

Discussion

Delayed and less complete continence attainment was noted in other clinic series of children with cerebral palsy (including hemiplegics) and children with II. Severity of motor disability (GMFCS), and II impacted on other aspects of toilet training, such as: motivation, understanding, communication, and independence skills. The presence of neurogenic bladder and bowel dysfunction can occur in all levels of GMFCS. Thus, there are many reasons that can prevent continence attainment.

Conclusions

Children with BCP achieved day and night-time bladder and bowel continence more slowly and less completely than controls, with 60.8% being continent by day and 54.6% by night at the age of 17 years. The majority of BCP children who were continent by day had achieved this by the age of 5.5 years (86%). At least 88% of BCP children with GMFCS I/II and normal, specific or mild learning impairment were continent for bladder and bowel by day and night. Expectations should be shared with parents, and failure to attain expected continence should be actively investigated.

Introduction

Attainment of bladder and bowel control is an important developmental milestone in children. Epidemiological studies have shown that daytime control is achieved before night-time, with the majority of children achieving daytime continence at 3–4 years of age and night-time between 3.5 and 5 years of age [1], [2], [3], [4]. Mature bladder and bowel eliminatory behaviour requires close integration of the autonomic and somatic nervous systems, which depend on a complex neural control system located in the brain and spinal cord. Gender appears to be the single most important factor affecting control, with several studies showing that girls are continent earlier than boys [4], [5], [6], [7]. Developmental delay and intellectual impairment adversely affect attainment of continence [8], [9], [10], [11].

Limited information is available about the age of continence attainment in children with cerebral palsy (CP). A single, large cross-sectional Dutch study (n = 459) reported an overall prevalence of primary urinary incontinence of 23.5% with negatively associated factors of tetraplegia and low intellectual ability; bowel continence was not reported [12].

In order to diminish the considerable long-term physical, psychosocial and financial burden of incontinence, healthcare professionals and parents need information regarding the attainment of bladder and bowel control in children with cerebral palsy. The present study aimed to describe the age of attainment of bladder and bowel control in children with bilateral cerebral palsy (BCP), using a prospective, longitudinal population study including associated factors of gender, intellectual impairment and severity of functional motor disability, as measured by the Gross Motor Functional Classification Score (GMFCS). The patients were part of an original study that set out to chart the natural history of hip dysplasia in CP; it included five X-rays by 5 years of age. As hip dysplasia is uncommon in hemiplegic CP, it was not ethically justifiable to include them, leaving bilateral CP patients only (www.icps.org.uk). The continence data that were collected in this study formed the basis for the present paper.