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Potty Accidents- Urine leakage- 3 year old

Where can I turn?!  I'm struggling with helping our three-year-old be successful in using the potty.  Our DD began toilet learning in Mid-May. At first, she was very motivated to use the potty.  We went straight to underwear, and she got stickers frequently throughout the day for keeping her panties dry.  She did very well at the start, but would often have 1 or 2 accidents a day.

And so that pattern has continued.  For SEVEN months.  DD's accidents do not include her emptying her bladder; just "leaking" a bit.  Her accidents are more frequent toward the end of the day -- between naptime & dinnertime is the "danger zone."  She can *very easily* have an accident 20 mins after she uses the toilet. 

DD attends school 5 mornings a week, but her accidents there are much more infrequent; she will only have 1 accident there about every 10 days.  Her track record is much worse at home.  1-2 accidents a day is typical, 3-4 is not unheard of.

She will poop in the potty, but only when she goes w/ me.  (I work 32 hours a week).  If I am not available, she will hold her poop until a sleep period when she has a diaper on.

I have tried to be casual & not pressure her.  I've tried stickers as as a reward for being dry; also prizes she selected from the dollar store.  I do not want to use food as a reward.  I read that using panties is best, so that the child has the feeling of being wet.  However, we do use a pull-up at night (she still sleeps in her crib) and we use a diaper or pull-up for naptime as well.  Both are usually quite wet after sleep time is over, even though her nap is only 1.5 hours at most.

Since things are worse in the afternoon, I thought getting rid of the diaper at naptime might help.  I tried that last month.  It took her a couple of days, but then she was able to stay dry during her nap.  She got a prize from the dollar store that she picked when she was successful.  However, when we were travelling over Thanksgiving, she went back to having difficulty.  Since she was completely emptying her bladder AND often having a b.m. during nap -- without a diaper/pull-up, in my sister-in-law's home, I retreated.

I have questioned that there may be something biologic wrong, but when I discussed this w/ her pediatrician at her three-month check up, the MD told us that this is a "process" & that some children take longer.  I have avoided talking about "big girls" using the potty, or "babies using diapers."  I try oh so hard to be calm & nonchalant when there is an accident.

I will confess, however, that I am getting increasingly frustrated & annoyed.  In the past week, I have had two conversations that have involved much more "shaming" than I've used in the past.  This, of course, has backfired & the accidents seem to have increased in the last few days.  She has been wet at school the past three days & yesterday she had FOUR accidents total!  The babysitter tells me she peed on her upholstered rocking chair this afternoon for the first time!!

What can I do?  How can I help my daughter be successful ... and keep from loosing my mind?  I'm especially frustrated because her pediatrician & preschool teachers don't seem concerned, but her peers seem to have caught on much faster than she.  I'm told that she won't be walking down the aisle in a pull-up, but I'm starting to wonder if this is true!!  Please  help!! Thank you!

What a frustrating situation!  The first thing to remember is that your daughter wants to be successful in using the potty.  If she is not being successful, it is not because she is a bad child, or because she doesn't want to.  As you say, in the beginning she was very motivated by the panties and stickers. She was also successful before Thanksgiving in keeping her diaper dry during naps, which certainly took great effort.   But something is getting in the way of her being successful at this big new change in her life.  Your job as the mom is to figure out what's getting in her way, and to help her solve that.  As I know you know, shaming her and getting angry at her will only make it harder for her to be successful.

I first want to share with you that a small percentage of girls do suffer from leakage about 15 minutes after they pee, presumably because they have not fully emptied their bladders.  When taught how to properly pee, this issue clears up.  The rest of us for some reason just learn to pee well enough without these instructions, so maybe there is something about the kids' bodies that just needs a little extra help.  Here are the instructions used to successfully teach these girls to pee, that in some cases do clear up the leakage issue:

  1. Sit steadily on the toilet brim, legs fully supported.
  2. Keep the legs well apart.
  3. Lean the trunk forward (as much as you can) making the pelvic tilt forward and the urinary stream more vertical.
  4. Separate the labia before voiding. At end of voiding, use toilet paper to press and lift the perineum forward/upward (from the base of the vagina and away from the rectum) to empty urine fully.

So definitely do that teaching with your daughter, in case that is all she needs to clear this up.  However, I am betting that it's a bigger issue.  Here are my thoughts.

My first concern in reading your letter is that your daughter still wakes up soaking after her nap.
  One of the readiness indicators that we use to determine whether a child is ready to toilet train is whether she wakes up dry, as you'll see on this list of toddler readiness indicators from my website:

Easy Potty Training

Now, your daughter was able to stay dry during naps for a special "prize" after a few days of trying.  It's not surprising, though, that this new learning was thrown off in a new environment while you were traveling at Thanksgiving.   You don't say how long she was successful at it, but the fact that she is presently waking up with soaked diapers makes me question whether she really is ready to toilet train.

I don't know how many months she is exactly, and I do know that many kids are exclusively using the toilet by her age.  BUT I also know that there are plenty of normal kids who master this skill towards the age of four and really, who cares?  They all get out of diapers sooner or later, and our goal is to make it as nontraumatic as possible for them and for us.  The last thing either of you needs is to make your daughter feel like a failure because you're expecting something of her that she is simply not ready to do.  So there's a big unresolved question -- maybe you started training too early?  I know that's hard to hear, and it's even harder to figure out what to do now, since you're been working on this for seven months.  We really do want to go forward and make her successful, now that she's trying so hard.

My next--even larger--concern in reading your letter is that your daughter's fairly constant accidents are NOT about emptying her bladder, but about "leaking."  In other words, she is not running behind the couch while you're out of the room and peeing on the rug (as many three year olds do, believe it or not).  When that happens it is most likely an expression of anxiety or anger. 

But your daughter is not really having full-fledged accidents, but accidents that consist of urine leaking out in small amounts.  This happens even when she has supposedly emptied her bladder as short a time as 20 minutes ago. That is a concern to me because it suggests a physiological issue. Is the bladder somehow not emptying fully?  Is something physically putting pressure on the bladder, so the urine then finds its way out in small amounts? 

I am a psychologist, not a physical doctor.  However, I do know that there are two frequent explanations for urine leakage in children. 

First is if the child is holding in her urine and has a full bladder.  Naturally, small amounts will leak out.  But there is nothing in your letter to suggest that your daughter is doing this.  She seems to pee at home, school and the babysitter.  The problem is that even when she does pee, more pee leaks out in small amounts throughout the afternoon.  (If my assumption about this is wrong, and you think she IS holding in pee, then no wonder she is leaking.  IF that is the case, skip the next section and go to the end of this letter where I talk about helping her get through her fears about using the toilet.) 

The second common explanation is if the child is holding in her poop.  The full colon puts pressure on the bladder so there's leakage.  You do not say your daughter is constipated, luckily.  However, a child who routinely holds in poop--as it sounds like your daughter does-- can get blocked up so that even when she does poop, more is left inside her.  The colon gets full.  One of the symptoms of that happening is urine leakage.

This would also explain why when she poops in her diaper at naptime she also ends up with a wet diaper. It even explains why she would pee in her sleep even if she does not poop, because if the colon is putting pressure on the bladder, she would have to exercise a great deal of control all day long so that she doesn't leak constantly.  So when she sleeps and lets her guard down, the urine comes flooding out.  (If this is the case, think how hard she is trying all day long, to keep the pee in.  But she would need to sit on the toilet constantly to be successful.)

A pediatric gastroenterologist could take an x-ray of your daughter's colon and tell you if this is happening.  If she is indeed backed up, the doctor might recommend a clean-out to get her colon emptied so it is no longer pressuring her bladder. Of course, after that you would need to make sure she was able to poop every day without holding.  This is important for the health of her colon as well.  When kids hold in their poop, the internal organs can get distended and lose tone, and the child sometimes stops feeling the signals that they need to go.  So I highly recommend you listen to the clues from your daughter's body and have an x-ray. If my hypothesis is correct, you will be so glad to correct this early.  If not, then you will be glad to have ruled it out.

Luckily your daughter is not constipated and is able to go with you on a regular basis, right?   If that is not the case, then I would have some specific recommendations, and here is the letter on my website that explains the Soiling Solutions protocol I would recommend:

http://www.ahaparenting.com/ask-the-doctor-1/fecal-retention-encopresis-in-5-year-old


You can also see from all the comments on that link why I would so strongly suggest that you rule this issue out before proceeding.  It is a big deal.

If your daughter is pooping every day, then you don't need the Soiling Solutions protocol but you still might still want to see a Pediatric GI for an Xray.  In other words, I suspect this is a physical issue and you were right to ask your pediatrician, even though most of them do not know much about this.

But regardless,  I suspect that step one in resolving your daughter's leakage issue will actually be helping her to poop in the potty when her body tells her she needs to go, every single day without waiting.  That will eliminate the pressure on the bladder that her symptoms (leakage) tell us is almost certainly happening.  I think the way to do that is to help her past her fears about pooping.  The best way I know to do that is the Hand-in-Hand method that Patty Wipfler describes here:

http://www.handinhandparenting.org/news/161/64/A-Toilet-Tale-Part-I

http://www.handinhandparenting.org/news/162/64/A-Toilet-Tale-Part-II

Of course, your daughter is not resisting either peeing or pooping in the toilet while you are there, so the Hand in Hand suggestions are not directly relevant. What IS happening is that she is resisting using the toilet to poop at school or with her babysitter, right? 

So I would recommend playing school with stuffed animals and then having one refuse to poop in the toilet and instead ask for a diaper for naptime.  But don't make this heavy.  Make it lighthearted and totally silly, exaggerate the little animal's fears and demands to make your daughter laugh.  Have the little animal almost fall in the toilet, or be afraid the poop will hurt or whatever makes your daughter laugh.  The more she can discharge her tension about pooping in the toilet at school and with the babysitter, the more likely she will actually be to do this.  Just keep playing about it; you'll know you're on the right track if she laughs.
 
If she doesn't spontaneously begin to poop at school or the babysitters, you can begin talking with her about doing so, and help her directly confront her fears about it.  You can even have her "pretend" to do so, by telling her that you want to play school or babysitter and then put her on the potty at home, pretending you are the teacher or babysitter, and ask her to poop.  Obviously, this will work better if she actually does have to poop at that moment.  If she resists or cries, follow the suggestions in the Hand in Hand articles.  Eventually she will cry out her fears and successfully poop in your pretend game and that will transfer to success at school.  If she doesn't express fears in your pretend game that is less good because you don't know if she is actually working through anything, but keep pretending that the pooping she is doing at home is happening at school or with the babysitter, and keep the game going (over time) until she successfully poops.  Eventually she will transfer this success to outside the home pottying. 

So, to recap:

1. Teach your daughter to void properly just in case that helps.

2. Stop worrying about your daughter's leakage.  She almost certainly cannot control it because it is a bigger physical issue, probably caused by fecal retention .  Address that first.  In the meantime, leave her in diapers or pullups at naptime and nighttime and as much as she will let you in the afternoons.

3. Take her to a pediatric GI for an exray of her colon to see if she is backed up and if so do a clean out.  Just tell them that her symptom is urine leakage, and that she won't poop unless you are there but you work so she has gotten used to holding.

4. Help her move past her fears of pooping with anyone but you by using play and pretend.

AFTER you do all this and your daughter begins listening to her body to poop in the toilet at school and the babysitter's, I am betting her urine leakage issue will resolve on its own. IF not, please do let me know and I will see what I can recommend at that point. 
Good luck!
warmly,
Dr. Laura

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