Pediatric nurse practitioner Bethany Cichon, a specialist in bladder and bowel dysfunction, knows well that parents need education on everything from penile hygiene to circumcision decisions to nightly bed-wetting. In this talk for primary care providers, she describes foreskin issues and solutions; offers a simple way to distinguish retractile testicles from undescended (spoiler: it's not ultrasound); presents a list of conditions that should preclude circumcision; and takes a deep dive into the age-old yet sensitive issue of urinary incontinence, clarifying what works – and what does not.
Today, we are going to cover um foreskin. We're gonna briefly touch on hypospadia, cordi smegma and physis. We're gonna talk a little bit about testicles, retractile and undescended. And then we're gonna close by talking about incontinence. And I'm gonna kind of share the way I present a lot of these things to the patient. So it might be a little bit different. I'm not gonna focus so much on like pathophysiology and science in this presentation. I'm just gonna give you the language I use with my patients and hopefully that is useful in your everyday practice the foreskin. This is exactly what I say to patients who are referred for concerns with foreskin. Almost before I take a history is, well, let's talk a little bit about what the foreskin is. So if you imagine this is a penis and this is the foreskin around it, every boy is born with a penis, foreskin and a thematic ring. Now, some boys are circumcised. They're f that's essentially taking off the thematic ring so that the p the penis sticks out like that other boys have really short foreskin. And so when they get little baby erections, the penis sticks through the thematic ring naturally. Now, on other kids, and I'm guessing you, because you were referred to urology, you have a slightly longer foreskin. So when the kid, your child gets a little, you know, little baby erection, it's not pushing all the way through the thematic ring. Ok. That's how I set up the, the visit. And I share that because it actually gives us a lot of um understanding on care of the uncircumcised penis, on physiologic physis and on pathologic physis. So care of the uncircumcised penis. People don't know, parents don't know what to do here. They were told everything from never touch it don't even look at it to, oh you should be pulling that back all the time. You haven't been doing that. Oh my goodness. And so um the way I describe it is like healthy skin stretches and we want that the hole, the urethra, the hole that kids pee out of to be able to be cleaned. We want that when pee comes out, it's not getting caught up in skin and kinda irritating the skin causing inflammation, allowing bacteria to grow. So we wanna gently teach that skin how to go back. We don't want to force anything, especially on babies and on kids that aren't having any issues because if the skin is dry, like dry knuckles, it'll just crack and then you have to deal with fissures and painful peeing and um all that, that brings. So we wanna keep a watchful eye, we wanna make sure the skin slowly over time starts to go back. Um So that when they're in the bath, you can see the hole they pee out of, you can splash water in there and it can kind of get rinsed out on the inside. This is a picture of physiologic phimosis. This is one of our most common referrals. Um And it's something that gets really confusing for families. Uh Let's talk about physiologic physis. So this is physis that you can see that thematic ring is tight, you can see it all the way around, it's so tight, that kind of inner skin is sticking out past it. And if you were to push back the glands in the urethra wouldn't come through. This is a problem because you can't clean the penis. But if you go back to my little example earlier is, you know, it's kind of just a problem of like almost stature, the penis, the foreskin is longer on these kids. And so we need to teach that skin how to gently go back. Oftentimes patients are prescribed steroid cream, which is what we use to make the skin more elastic and to make the skin healthy and to use the side effect of steroid cream, which is that it thins out the skin, but without actually opening up that hole, they don't see any results. Um and it kind of hurts the first time, which is scary and often a huge barrier for anyone to do it. So kind of setting those expectations and telling parents like this can hurt a little bit. Um It's, you know, something the body should be doing but hasn't been doing on its own. So we have to teach it how to do that. Pathologic fimosis is um tight for skin that is scarred because the skin is no longer healthy. There is uh inflammation in the area, bleeding, irritation, and then oftentimes the scarring of the skin leads to when a child pees, the foreskin kind of expands like a balloon. Um you know, it can lead to painful erections. It can lead to urine infections, infections of the penis, paraphimosis, which I have some pictures of um skin issues. Yo, here's a picture of more scar tissue and you can see in that white, thickened tissue that's never gonna stretch open. So it, there's no other option besides the circumcision. And this is a case where the patient would be recommended. A circumcision right away with physiologic physis. We actually typically try and avoid circumcision. Um Most men around the world are not circumcised and most men around the world are don't have issues with their foreskin. You don't and you know, you don't have to be circumcised if you're born with foreskin. Um Here's another picture of scarring to the tip of the penis. So um here's a quick reminder of everything I just said is you do need to teach families how to retract the foreskin. We're always happy to teach them. We I love these visits. Parents are so excited to have a solution. Um Physis typically doesn't require a circumcision. Um unless there's like thickened scar tissue, urine infections or other issues. And you know, in the latest numbers, I read these numbers are a little bit out of date, so I should update that. But 68% of boys in California were no longer circumcised. It's become the norm. Um When not to do some circumcision, brief overview, if you do newborn circumcisions, um blood disorders concern of hypos spades. Uh If the penis is really buried because when the penis is buried in a fat pad, you kinda get skin from down here, stuck to the glands and then they either need a revision or a lysis of those bridged skins. Um scrotal webbing, if the scrotum attaches to the penis, uh you should do a circumcision or if the penis is bent. Um for newborn circumcisions, these are all the kind of considerations. Um in the discussion with parents, I will say I'm very, it's very often that I hear parents didn't know that they needed to ask for a newborn circumcision. Um and uh it always breaks my heart because a newborn circumcision. Yes, a medical intervention, a big deal. But a lot simpler than a circumcision outside of the newborn period, which is done at least after six months, ideally after eight months because it is under general anesthesia. Um It is a surgical procedure where they cut off the extra skin and put stitches in that just dissolve. Um Pain is managed with Tylenol and Motrin afterwards. There's no special bandage on the wound. Um but there can be a little bit of bleeding into the diaper, especially as kids start to walk and are a little bit more active. Um So I encourage families to have the the conversation um before, before a boy is born on whether they want a circumcision to kind of set up some appointments and try and arrange that. Uh There are cultural issues with this different cultures circumcised at different ages, some circumcised at age two, others at age seven. and unfortunately, it we're coming into just the place where the US health care system is, doesn't work very well. Um The newborn circumcision is expensive, usually about $500 a circumcision outside of the newborn period, if not covered by insurance is $15,000 whether it's covered by insurance is really a mystery to me, month to month. We try and do what we can and sometimes it is and sometimes it isn't and I can't figure out what insurance is, why, why this one, why not that one. But we are, it is a thing that we are working on because we do want families to have what they want. Um we did go through a period where we had in our department a huge backlog of emergency and medically necessary surgeries. Um And so we had a sixish month of saying we can't perform circumcisions uh anymore. I think we are catching up on, on that back backlog. And so that's not how we're approaching the problem anymore. I do want to clarify in case you did get those notes um from us that was back in the spring. Here are some pictures, some reasons not to circumcise. Here's hypos spades. You can see that the who the meatus is not at the tip of the penis. Um Reason not to circumcise is because the foreskin can be used in the revision for the hypos spades for all of these following cordi. Again, another reason not to circumcise, you might need to extend the urethra. This is what a buried penis looks like. Um buried penises themselves are not pathologic. Um We do wanna teach kids how to care for their bodies and how to clean their penis with this. But you can imagine if you cut off the foreskin, how um any scarring to that area could c could cause the penis to get stuck on the inside and it causes kind of this series of revisions that might be needed. So typically, with these patients, we discuss and kind of encourage them not to circumcise smegma. Um is often a really, really big concern. It's often considered concerned it's often sent to me as like a cyst on the penis. You can kind of see this like white, smooth bump. Sometimes it moves around and what this tells me is that there is tight for skin and also the patient isn't able to pull the skin back far enough to clean underneath. Um Smegma itself is just a collection of white dead skin cells. Um And mucus, it's not dangerous, it's not yeast, it's not an infection, it's a normal natural lubricant. Um, but it does need to get cleaned off. It's itchy. Um And non hygienic. I reviewed this. But when we recommend circumcisions, you're the kind of some of the cases that we would recommend a circumcision, paraphimosis. I wouldn't be doing my job if I talked about the foreskin and I did not talk about paraphimosis, but phimosis is when the skin gets stuck in behind the glands. So a patient has pulled the skin back. Maybe they're treating physis, the skin isn't elastic yet and they don't return it forward right away. This is a medical emergency. Um What happens with the skin being tight is it can cut off blood flow to the glands if it's left alone. So, um this is send them to the emergency room right away manually, try and pull it back. It might be one of the things that we do. We could also do a dorsal slit where we open it up and then do a surgery later to fix the problem, um, permanently the dorsal slit would fix the problem immediately but it just looks um incomplete. I briefly reviewed if a patient does get a circumcision, what do we tell them? Um, what's the, what's the proper care? Um Usually Tylenol Motrin work actually, really well for this pain. I always tell patients it's not like a deep surgery, it's just skin, it shouldn't affect his ability to pee. Um, There's no bandages on the wound, no special wound care, applying Vaseline, keeping the area nice and moist. We love moist environments for healing. Um No bathing until post op day two and then don't rub it with a washcloth, just let it soak in soapy water and try and avoid straddle toys, balls, swimming, monkey bars, things that could hit you in that area. Um But most of the time parents come back and they're like, I tried to control them but they're one years old. So they just discovered walking and no one can slow them down. Um And parents are usually happy with the uh post op experience. It's not usually super painful, different for teenagers. It can be, it can be painful for teenagers and sometimes use stronger medication. Um The peanuts can look ugly after circumcision, it can look black and blue and can slowly get more black and blue for the first couple of days and then stay that way for the first couple of weeks. Um There can be some post-operative swelling for up to six months. We have seen that. Um We do know that when kids start to move around a lot, it rub like the diaper will rub on the cuts. And we notice a little bit of blood in the diaper that's not worrisome to us. But what is worrisome is if obviously if there's active bleeding coming from the penis, um they might need a pressure dressing in the emergency room. Ok. So if you have questions, please put them in the chat, I do wanna answer all the questions. I'm gonna move on to talk a little bit about testicles, um undescended testicles or testicles that don't occupy the scrotum. They are common, more common in, in premature infants. Uh 10% of premature infants and 3% of full term babies. Um uh oftentimes retractile testicles are referred to are referred as undescended testicles. And this is because testicles are so light and they have really, really active cremasteric muscles. So the light testicle kind of just floats up and down really, really quickly. Um And so differentiating between the two is what our goal is to discuss today. Um When feeling for testicles, um we want to kind of gently rub our thumb down the groin, hold the testicle and the scrotum for a second. And then do we call it like one Mississippi or one California? Um See if it stays there for about a second on both sides if it does, even if it goes back up after that, that would be what we call retractile testicles, the testicles down, they stay down, um, for a second and then they go back up. This is because testicles naturally move up in response to colds and stress. And what is a doctor's office? It is a usually very cold place where you get lots of shots. Your mom's a little nervous, everyone's stressed and then you're in a diaper, your diapers, open strangers kind of poking around there. So it's not a surprise to us that testicles don't really wanna be hanging out in the scrotum all the time. So we just wanna kind of swipe down, see if we can feel them. Um If you can't find them or if they don't stay down, we would love, we would need to see that patient ultrasounds are not helpful when it comes to determining undescended or retractile testicles. The first thing you do in an ultrasound is you take open the diaper and you squirt cold jelly right on the testicles, which sends even the descended testicles shooting right up into the, into the groin. So we actually don't recommend ultrasounds for these patients. Um Diagnosis is based on exam. Uh The cause of undefended testicles has to do with during development. The um migration of the testicles from the abdomen to the groin area is interrupted either by short um muscles or some other path. Again, we don't need an ultrasound, uh, treatment for under understanded testicles is surgery usually done around a year of age. Um, the reason it's a year of age is actually cause testicles can keep moving down over that first year of age. So, um, we, if we can find them and they're close to the scrotum but not there, we'll say come back, you know, depending on how old they are in a couple of months and see if they've maybe move down further. And if they have, we can avoid the surgery and the patient is not at any risk. Um, if you know the testicle is stuck up in the groin or doesn't move down at all, then we need to do surgery. Um, testicles often come with hernias and those would be repaired at the same time. All right, incontinence in Children, we're gonna learn through a case. So again, I'm gonna speak to you the way I explain things to my patients. Here's our patient. She's an eight year old female with nighttime incontinence. She had one lower tract ut I three months ago. She was treated with antibiotics. She also has some urinary urgency and frequency which was evident on a recent road trip. She went to bed every night with a large amount of urine. She has always wet the bed. Since potty training, she has a daily bowel movement. She does complain of frequent stomachaches. She drinks about one, maybe two bottles of water a day. She also has a cup of milk at breakfast. No imaging has been done yet. She had a U A at the time of referral which had no significant findings. All right. Step one. I say I know how hard it is to get an appointment with me. I know how frustrating this is. And I want to tell you and your child, you're not, the only one is literally my whole career. This is all I do. I've probably even seen kids in your class. Now, I won't tell you who because I also won't tell them that I saw you. But this is a really, really common problem and it often feels like a deep dark secret and you can't figure out because you've tried to do everything. OK? Um It's actually a pretty common um problem. So I love this pie chart because it breaks down things by age. Um And so 75% of 3 to 10 year olds are discussing incontinence at some point um during their outpatient visits, that's a lot. No, I keep in mind ages 3 to 10 is a really wide age. But even so, um you know, in the future, I hope they were to break this down even more. So we could see the difference between 3 to 5 and 5 to 10, but it is very, very common. Um I love this slide. It talks OK, the historic treatments of incontinence, we have bound medical scrolls back to 1550 BC discussing incontinence, the first century, the 17 hundreds, you know, 19 seventies in Nigeria. All of these things very interesting. But what does that tell us that tells us that this is not a COVID problem. This is not a screen problem. This is not a modern day issue. This is not XYZ. This is part of the human condition. Some bodies wet the bed incontinence. We're talking mostly about functional. I'm not gonna go into neurogenic or um structural kind of incontinence. Today, we're gonna talk about kids that um can tell the parents when they need to pee don't have any spinal anomalies and um have had some success with potty training. We can also talk uh if in the Q and A session, if you want to about behavioral interventions, which I know can happen, we could meet with patients who might have autism or um oftentimes A DH D are big questions. All right. So back to our patient. So we figured out she's not the only one. In fact, this has happened throughout history. Now, I'm gonna ask her about her everyday life. Do you use the bathroom at school? That is that question tells us so much. And it's so sad. I wish I had another life where I could go into uh schools and figure out systems so that kids can safely use clean bathrooms. Because oftentimes kids not only do they not want to go to the bathroom because recess is more fun. But they get points removed if they go more than three times a semester or the bathroom, kids are playing in the bathroom so they don't feel safe but the lock on the door is broken. Um, or they're dirty and so kids are really smart, they don't want to use those bathrooms. So I was like, are you using the bathroom at school? Are you drinking your water at school? Because oftentimes kids will bring a water bottle, but it's almost like a little vacation for the water bottle. It gets to go out of the house and then back in and out of the house and back in. So how do we know how much water you're drinking? Um And then we talk about peeing. So for then we'll explain. Do you know what a filter is? Yeah. Yeah, I know what a pool filter is or a coffee filter and a filter takes all the bad stuff out to leave all the good stuff in your kidneys are your filters for your blood. They absolutely, positively 100% must do their job. So what we have to do is we have to set our filters up with the things that they need so that they can do their job. Well, what do you think your kidneys might need? What do you need to pour into a filter that might help them? Well, water. Ok. Yes. Water. So we're gonna figure out how to start the day with a big glass of water because we want our kidneys working a lot during the daytime. So that the p by the time you go to sleep, they just rest, there's nothing left to do. We're setting the circadian rhythm for your kidneys. This explanation has been the best thing I found for patients to understand. So I want patients to drink a lot of water, especially in the early hours of the day. And then I want that water to be able to drain. So step one is gonna be drinking lots of water. Step two is keeping your bladder emptier than you're used to. So when you hold your pee, when the bladder gets really full and then it kind of stops taking more pee. There's only so much space it can take so it backs everything up like a clog. But if we keep emptying our bladder, constantly, things keep flowing through. Um And then the kidneys can keep their filtering going all day long so that when you go to sleep at night, you're, there's nothing left to filter. Mhm. Um I just at all this, but you can read the slide if you would like. So practically I want you to go pee more often. I want you to go pee before you feel the need to go pee. I want you to go pee every two hours and I pick two hours because normal peeing is every 3 to 4 hours. And I want you to go before you're full, but you're gonna be drinking so much water that you're gonna have to go. Parents often ask the, the biggest question is how much water should a kid be drinking? And I have my formula up on the screen. Um, basically by years of age you add eight ounces of water up until the adult dose of water, which is about 64 ounces. Now, there's all sorts of formulas of like your weights um in ounces. That's how much divided by two. That's how much water you should be drinking. Um Those are great if you wanna use those use that. Um This is simple and easy to remember and um easy to explain. So I tend to use this. Ok? At this point, I have talked a lot to the family about what the kid needs to be doing. Mostly at school. The kids at school all day. I do everything I can, I send them with a water bottle. I talked to the teacher. I just don't know if they're doing it. Ok. That's fine. I understand. We're gonna control the controllable. We can make sure your, your kid gets a drink of water before school. On the way to school. They can be sipping on a water bottle on the way home from school, they can be sipping on another water bottle. Now the water will go through your kid at some point will have to go pee. And so let's control what we can. Ok. Now, if the patient was also having daytime incontinence, we would need more support. We would need to figure out how to have her, him, her, her go to the bathroom every two hours. They make potty watches that vibrate every two hours, which are really, really exciting for patients for the first two or three days. But you know, who won't ignore a potty watch is the teacher. So sometimes I encourage families to buy a $5 potty watch on Amazon, whatever one that vibrates every two hours and ask the teacher to keep it on his or her desk because the teacher can then remind the kid to go to the bathroom. It's not a perfect system. I'm open to other creative ideas. Um, the other thing I think is important is I, I'm really a big fan of flavorings in water. I think it's ok to use a little bit of juice. Um, there's these new water bottles called Circle, which is spelled on the screen, um, which have flavor cartridges in them. They sell them at Target for my kids. My patients that, uh, don't drink water at all. They love these things and they start drinking, um, which is really important. All right, good poopers, make good peers. So, so far we've talked about filtering the blood, we've talked about giving the kidneys what they need to function and then we talked a little bit about a log about if you don't go pee at all, then, um, you, your kidneys kinda get it back backed up. Here's the other thing that can kind of back things up the stretched out rectum. Ok. So this is a little different than constipation and this is definitely different than like stool impaction. Um, but essentially what happens is Children, for whatever reason, get constipated. It can be as far away as months ago, years ago. But the rectum which is a really stretchy muscle designed to hold gets stretched out. And if the rectum is never really empty, it'll never shrink back down. So the rectum has gotten stretched out and stool is moving through. Patient is pooping every day. If you remember our history, the patient pooped every day, but this muscle is still kind of squishing the structures around it. So when we assign our big poop clean outs, we're actually not treating constipation in the sense of like, well, I didn't poop today or yesterday. I pooped today. I'm all good. We're treating this rectum muscle which is designed to hold on to poop and we're trying to get that muscle to empty so that it'll shrink back down and kind of get away from the other structures there. Um I am a big fan of Miralax for these clean outs. I also am starting to use more exlax um because the research has kind of questioned this idea of, is there any dependence? Is there any evidence of dependency and looking there is there's not any evidence so far. Um But I like Miralax because it's an osmotic laxative, it's very, very safe. Um And it's really easy to control the amount kids are getting. However, Miralax as an osmotic laxative only works if you drink enough water. So if you take it every day, but the patients only drinking one water bottle a day, it doesn't work. Um So for kids about 45 pounds and under, I use about seven doses of Miralax, um one dose every hour for seven hours. And then I ask them to repeat it monthly because we're not treating constipation in the traditional sense, we are treating a stretched out muscle. So in the same way that if I wanted to grow a bicep, I can't go to the gym and lift one heavy barbell and then have a little Popeye bicep come up. If I wanna shrink a muscle, I can't empty it once and then have it shrink. I have to kind of do this consistently over time to teach the body to do something new. So we do clean outs once a month, daily, Miralax in between. And that's um usually one dose, sometimes half a dose for really smaller for smaller Children. Um I've gone up to two doses a day but not really that common. Not that often. I'd rather do more clean outs and one dose of Miralax a day than increase the daily dose of Miralax. Mm. I really do not think my child is constipated. She said she's pooping every day. I watched this. I know. Well, let's check, let's look at the Kub. Um, you know, I always tell families, the radiologist report for KUB will say that there's no acute injury, there's no impaction, uh, normal Kub. We have to look and see if, you know, is the rectum kind of distended. Is there poop throughout the whole colon? Is there tons of gas in there? Those are all the signs I would say like, look, this isn't emptying really well. I know that they are emptying regularly. This patient also said they have stomachaches and as you all know, much better than I stomachaches are often a cause of stool retention, often caused by stool retention. So, Miralax alternatives, magnesium citrate for a clean out. And then we would use lactulose or cena as a maintenance enemas are a great option. They take about 45 minutes. You do one a day in the first month, sometimes two a day. Um And then one every other day and then one every third day um to try and shrink down that muscle. Uh And like I said, Xbox starting to use Xbox a lot more um nocturnal enuresis, again, part of the human condition. But on the screen is how it's um the, the physiology of it. Uh vasopressin or anti diuretic hormone is not present in concentrating the urine. Some bodies release that later. What's really interesting is if the parents wet the bed, if one parent wet the bed, there's a 40% chance each child might wet the bed. If both parents wet the bed, there's a 70% chance the chi Children will. Um but without any intervention, kids typically stop at the exact same age their parent did, which I think is so cool because it does kind of lend to like this is just some genetic thing for some people. Um Sometimes families are really eagerly waiting for sleep studies for nocturnal ayes, this isn't indicated um solely for nocturnal auris. Now, if you're doing a sleep study for other concerns and they happen to have bed wetting, that's great. Um But kids being in their sleep typically isn't a sign of a sleep arousal issue and um the most common cause is bladder dysfunction. Uh We treat all of these the same, but here's some kind of different categories for daytime incontinence as well. Um So we talked with our case about nocturnal auris. The treatment is the same for daytime incontinence. The treatment is also the same for uh especially for lower urinary tract infections. Um, sometimes dysuria with negative urine cultures will treat it this way. Um My child does not feel these accidents happening. This is the biggest concern. I've asked them, they don't feel it. Sometimes they don't even feel the fact that their pants are wet like this doesn't make any sense. Um The first thing I say is I believe them. So when you look at this big old stretched out rectum, you can see the bladder is squished, but the spine is also right here. The signal to the brain is gonna come through the nerves in the spine. And my hypothesis is if the rectum is squishing that, then it might not be able to send as strong of a signal um to the brain. So the kid actually isn't feeling the urge at the same, at the same moment. Um, we also know the bladder sends signals based on stretch receptors. So if you imagine the bladder wall, if it stretches and closes and stretches, closes, the stretch receptors are really a tune, really able to send signals. I need to go pee, I don't need to go pee. But if it's constantly here and then kind of here and then here and here, those signals probably aren't coming until it's like, wow, we really, really need to, um, accidents right after voiding. So this is probably some issue with outlet. Um, for uncircumcised boys, I would see if they're pulling back. Their foreskin is urine getting caught in the foreskin and then dripping into the underwear, just postvoid dribbling for girls, girls who sit on the toilet pee really quickly with their knees kind of pushed together because they're afraid of falling in. Can have urine travel out the urethra and up and reflux up into the vagina. Now, this isn't dangerous. It's not really a problem. It can cause a little skin irritation, but they pop up. They pull up their underwear and urine goes into their underwear. Super easy fix. They just need to get a squatty potty, put their knees on something. So they don't feel like they're gonna fall in as much and they need to sit on the toilet with their knees wide open, kind of leaning forward. I joke, it's like peeing like a cowgirl. Like you're sitting on a horse and you're leaning over watching the pee come out. Um And that usually solves any type of vaginal voiding. Now you did all this, you did the bowel program, you did the time voiding, you've increased water intake and it's still happening. What next or review it. Um It's a really confusing program. It's a lot of habit change. If you've ever said a New Year's resolution like I have, then you've probably broken a New Year's resolution like I have. And so we wanna make sure that the family is actually able to remember all three of the steps and follow through on all these three of the steps. The way we do this is by repeating things. Voiding diaries are really, really helpful. Um And so you can do it with just how frequently the patient is voiding, write the, write it down on two non consecutive days or you can actually measure the collection and collect how much urine. Um with a hat, I would consider a renal bladder, ultrasound, a Kub and a referral to urology, the pathway of improvement. So nighttime incontinence does not improve before daytime, incontinence, daytime, incontinence does not improve until frequent UTIs or urinary, urgency and frequency have resolved things that should work, but don't waking kids up at random intervals. Logically, 100% this should work. If your kid is woken up at 11 pm or at 2 a.m. to go pee there is less pee in their body. Therefore, they should not pee in the bed. It just doesn't work. Sometimes they pee before you get there. Sometimes they don't pee well, sometimes they just, yeah, they pee in the toilet, then they pee again in the bed. Um It's not actually getting to the root cause or fixing the problem. So we don't recommend that. I actually say everyone in the household should sleep. Um I am a big fan of pull ups. I am a big fan of sheet protectors. I am also a big fan of having kids help with the laundry, not in a punishment but in a take responsibility way. Um You know, our patients, they didn't choose this. It's really hard. I wish I had a magic wand that could make it better for them, but it is their responsibility. It is part of it. So I do encourage kids to kind of learn that responsibility. Um and then fluid restriction. So again, logically, it should work. If my kid not drinking after 7 p.m. they will have less intake, therefore less output. That actually it just doesn't work, you know, hundreds and hundreds of families have tried this to come to my office and they're still needing care because it, it just doesn't work. What does work is actually focusing on the outlet. So rather than saying, stop taking in, why don't you go pee every hour when you're home in the evening? Why don't you go pee more, pee more, go on a walk, get your blood flowing, get everything going and then go pee again. Um that I've seen really good results with OK, we're gonna move on to question and answers, but I first want to talk about um our long wait times and what's happening. So we are working to hire more staff. Um They are coming, we had some staff out on maternity leave and some other um absences. So our wait times are really terrible. We apologize. We're, we're aware of it. We want it to be fixed. Um I don't like it also. Um And one of our creative solutions is actually we're gonna be starting a bowel and bladder dysfunction group visit. So we don't have our first date yet, but this will be a group patient visit where we talk about these things. We review full history order any necessary imaging medications testing and, um, review it with a nurse, do group teaching and then individual one on ones with a provider. Um, so the goal is that we'll have one of those groups every other week. Um, so your patients can always just kind of be rolled into that while they're waiting for their one on one visit. Um, and we'll get more information out to you as we have it.
