Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / Stopping Bedwetting: Urology Insights from Dr. Tim Baumgardner

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Stopping Bedwetting: Urology Insights from Dr. Tim Baumgardner · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wehmins, and this is Pediatrics Now, brought to you by the Department
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of Pediatrics at UT Health San Antonio and University Health's new Women's and Children's Hospital.
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Today, I'm bringing you this talk by Dr. Tim Baumgardner, pediatric urologist.
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Thank you, everybody, for being out here tonight. So, I just want to give you
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a brief overview of UTP urology here first, a little bit about myself because
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I'm new to the practice within the past year.
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So our division is myself. I joined the practice in 2024. God forgets,
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she's our division chief. She's been on board since 2018.
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Actually, I just retired from the military last summer and I had a training
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affiliation agreement with UT.
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So I've actually been working on and off with UT since 2018.
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With military agreement, now that I retired last summer, I am full-time over at UT.
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And so the two of us have partnered really well together and have really started to grow our practice.
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And so just a little bit more about myself, just so you know,
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I've had a varied career. So I always like to tell my residents I graduated
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college last century and they just kind of give me this strange boob of luck.
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But I was a graduate of the Air Force Academy, did a few things in the military
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before going off to medical school up in Chicago in 2007.
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I did an internship in the military, having to go be a flight surgeon for three
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years out in Virginia, which was a great experience.
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Came back to San Antonio with the military program. So I rotated some with UT.
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So I know how important it is training residents within San Antonio.
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And I spent two years at Johns Hopkins doing a Pete's fellowship.
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Then came back to Wilford Hall, Brook Army Medical Center in 2017.
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So again, just a brief overview of my work experience. Post-fellowship at BMC,
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I finished my career as the last two years as the chief of surgery over at Brook Army Medical Center.
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So we're one of only two level one trauma centers within South Texas and the
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only one within Department of Defense.
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So I'm very excited to put all the admin stuff aside and actually just being
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full-time taking care of patients again.
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And so it's been really rewarding the first year.
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I highlight this last thing in 2024.
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The thing I'm most proud about this award here is the fact that the AUA considered me to be young.
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So usually when you're 47 years old and you get recognized for something else
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with the word young as an adjective in front of it.
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And so I'm most proud of the fact that AUA called me young when I was 47 years
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old. So a very varied career.
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One other thing that's very important to me is taking care of our underserved
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population, not only just here in San Antonio.
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I know it's a huge need here in South Texas.
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I think Bear County does a great job with CareLink and getting all of our children
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plugged in so they can get the care that they need. Humanitarian work's been a big part of my career.
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So through the military up through 2023, I've led mission trips down to Honduras.
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And then I've kept in touch with their pediatric surgeon at their training facility in.
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To go up to their capital. And so I've continued to go do mission work down there.
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Honduras just got their first pediatric urologist this year.
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So up until that time, the children within Honduras were really waiting on mission
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trips to come down and take care of severe issues such as severe hyposphalias,
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cloacal anomalies, all those kind of things. So it's been very, very rewarding.
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The other nice thing about it is we work very closely with their pediatric surgeons
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and their pediatric surgery residents to the point where we're teaching them skills.
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And so, for example, there's one resident I've worked with for a number of years.
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He's actually interested in doing some pediatric urology work,
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but he's taking on more advanced hypospadias and we text back and forth throughout
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the year and collaborate.
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And so it's been a nice training agreement. So I'm hoping that with UT support,
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I'll be making at least one, if not two trips annually from Honduras.
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And so that's That's a big part of my focus.
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So what do we do here in San Antonio? Everything.
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Really, if you have a urologic concern, question, whatever,
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as we all know, taking care of pediatric patients, it's not just the pediatric
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patients, it's the family members, the guardians, the parents taking care of,
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answering their questions, making sure that they feel confident and comfortable.
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And so any questions, please don't hesitate, whether it's a referral for us
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to see the patient in person.
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It's just a quick message. hey, I've seen this person, any advice,
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whatever, Dr. Gass and I are here to help you out.
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You know, this is a community that we're taking care of. And so really anything
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and everything we're willing to help out with.
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Within my fellowship, we took care of a lot of patients and so folks to mind
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the transition urology.
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So, you know, your spina bifida patients, your extra patients that transition
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to adulthood, but the adult urologists aren't quite comfortable taking care of them.
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And so another thing UH has done, which is nice, is they've set up a multidisciplinary
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spine abitidic clinic, which is really, really growing in popularity.
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So usually those patients would have to see the neurosurgeon,
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the orthopedic surgeon, urologist
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all separately. We now have them all together and we can then say...
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About all the patients. And so it's been really rewarding. That's really,
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really starting to grow.
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If you have further questions about that, ask me right now. The clinic's once a month at UH.
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And so really anything and everything, we're here to help you take care of the peace population.
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Clinic location. So it's kind of unique being a UT employee.
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We contract our UH, I guess you'd say, contracts with us to work in UH facilities as well.
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And so our UT office is up on Floyd Curl Drive the Medical Arts and Research Center.
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And then we also serve our UH office is at the Robert V. Green campus downtown.
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It's pretty easy to flip those consults back and forth. Obviously,
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you consider travel distance and those things for families.
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It's fairly easy just to flip the consult.
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Hey, it's more convenient to be seen down. Great, we'll just push the consult over and everything.
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Because bottom line, it's still Dr. Guest and myself seeing the patient.
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It's just the building. And we're going to get that family taken.
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Again, those are our clinic locations. So it's just a brief overview of us.
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And I'm just going to give a quick little talk about something that I know is
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a big part of our practices, which is nocturnal enuresis.
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And this is just a quick overview.
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So nocturnal enuresis, soft boiding dysfunction, that's a big part of everybody's
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practice within the world.
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Except for those that live in an issue and the near-the-quality good end.
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And a lot of that, but sometimes I don't know if you do a lot of places that
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visit, you can't even have a certain there's a lot of patient visits every year.
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You know, it's frustrating for the parents, whether it's robbery things like
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that, for the children you know, social embarrassment, things like that avoiding
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this one assembly, the urinary conducts, frequency during the day,
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focusing more specifically on nocturnal and your recess, and so again,
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you have really divided into monosymptomatic or post-symptomatic,
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monosymptomatic is they're not having the constipation issues.
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They're not having the daytime issues.
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It's solely, hey, we're wetting the bed at nighttime versus your polysymptomatic nocturnal enuresis.
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Hey, we got other things going on. The child's constipated. The child is having
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urinary frequency issues during the day and everything.
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And so really, our approach to that is work on the daytime first,
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and then we work on the nighttime. So really kind of falls in that order.
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And so then there's primary and secondary in your recess as well.
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And so primary, those that have never been dry, secondary, those that have been dry.
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And then for whatever reason, they've started having accidents again.
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As a military urologist, you know, we would see that, you know,
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not in frequently in the military.
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One thing that precipitates in kids are stressful events.
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Military families move a lot. And so, you know, the PCS cycle and things like that.
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PCS, permanent change, sorry for the military acronym, when they move to a new duty station.
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And so you got to think of those stressful events. Has there been a divorce
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in the family? You know, has there been a severe illness?
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All those kind of things. And so second thing, you got to really expand that
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realm as their psychological.
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Oh, I'm sorry, I just did have blocked you. So a big thing that I work with
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the children is, and as you know, it's really important to make the child feel
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as though they are not the only one that has this problem and everything.
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And so when it comes to nocturnal linear recess, you can tell some of them are
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shy, embarrassed to talk about it.
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You've got to make them feel like, hey, you're not the only one in the second
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grade that has this. You're not the only one in third grade that has it.
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Make them feel like they are not alone. That's the big part.
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One of my big strategies with treating nocturnal linear recess.
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One is make them realize, I get it. no one's
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talking about it on the playground no one raises their hand and says hey i
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wet the bed last night you don't talk about those things at school but what
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they need to know is that they're not the only one in the third grade that's
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having access at night time the only one in the third grade not having access
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at night time as you can see here the 10 that's kind of on the low end 15 of
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of six-year-olds so really five and under we don't even really kind of start
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thinking about if we happen to see someone for avoidance function we'll just
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kind of give the recommendations but really, we look at that.
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It thins out to time to get to 10-year-olds, much more common in boys than in girls.
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Genetics, as you know, medicine's evolving. We're finding genetic leaps for
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a lot of things. Family history is a big one.
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That's the big thing I ask. Hey, anyone in your family having had nocturnal
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aneuryses, delayed dryness at nighttime, you can see it falls in.
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Hey, if both parents were wet till their early teens, probably the child's going
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to have a little bit the difficulties too.
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So, more to come with the genetics as we research it.
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Pap-physiologic roles, nocturnal polyuria, really look at your bladder capacity.
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Essentially looking at your basal pressing and releasing between the day and the night time.
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What's interesting, EEG recordings are similar between bedwetters and non-bedwetters
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when they look at it. Distention, strong arousal symptoms.
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Nocturnal polyurea, it's really where you have that exaggerated nocturnal urine production.
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As it links to ADH, we're not really sure at this point everything.
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But you can see it's half-life 16 to 24 minutes and increases the free water absorption of tubules.
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You're not making as much urine that gets into our DD-ADP or desmopressin treatments
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for nocturnal in the recess.
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Evaluation, like everything with our patients, it's history,
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history, history. Figure things out. Figure out what's going on. you know, half me up.
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If you looked in the medical literature, you can self-select articles that say,
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hey, sleep apnea has a direct link to nocturnal enuresis.
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You know, they go get their tonsillectomy, their adenoidectomy,
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and you solve the sleep apnea, the nocturnal enuresis goes away.
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You got to find a subset of papers as well that says, hey, no difference.
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And so really, that's where it just gets individualized with the patients as
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well and setting the expectations.
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Secondary, again, you got to start considering these things.
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Sadly, I've seen pretty much all those things from abuse to divorce,
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the PCS, especially if they've had a long latency period of being dry.
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What has gone on? You know, what has gone on? Oh, I'm, you know,
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from one group home to another group home and things like that.
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It's really that social support network as well. And so secondary,
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you really, really got to get to that history and figure out what's going on.
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I mean, it could just be, you know, just physiologic, but you really got to
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start cluing into those things. We already talked about family history.
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Voiding diaries, I don't know how often you all ask for those.
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I ask for those quite frequently, and rarely do they come back with that voiding diary.
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Ideally, you get a three-day voiding diary.
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You ask for it, you explain it, but really, it's rare it comes back.
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The reason I did those, when you look at behavior strategies,
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is reducing that evening fluid consumption.
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It helps a lot to get it down on a piece of paper and everything.
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When I was in the military, I still saw adults and everything.
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Adults with nocturia, you'd be having to do the avoiding diet.
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Like, hey, I usually pee four times a night on Mondays. Well,
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I have a six o'clock of beer when I watch Monday Night Football.
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Yeah, figure out. I don't pee on Tuesday night because Wednesday I have X and
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so I'm not up drinking beer.
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Get it on paper. And it really helps the family see like, oh,
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my child gets home and drinks all this fluid.
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Yeah, they're wetting the bed, you know? And so that's really to kind of help
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you help them see where things are.
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So again, physical exam, it helps in some practices where you room your own patient.
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If I know I'm seeing someone for boy dysfunction, I'll watch that child walk down the hallway.
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Oh, I noticed that your child walks on their toes. So they always,
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you know, things like that. Look for that gank and everything.
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And so, you know, you got your abdominal exam. Rarely are you going to palpate,
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you know, that big fecal mass or whatever because they're severely constipated,
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but you can't on occasion.
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Genital exam. Every once in a while, you'll pick up some metal stenosis.
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Metal stenosis, you know, young boys, last thing they want to do is spend a
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long time in the bathroom.
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If they got metal stenosis, they aren't emptying quite as quickly, and so they'll.
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Empty enough to take the urge away, exit the bathroom, they're emptying their
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bladder completely. You can set them up for having accidents later on.
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Urinalysis, urine culture, really the urinalysis. Family history is a family history of diabetes.
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Rarely this can be a presentation of diabetes. You look for glucosuria. Urine culture, rarely.
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Renal bladder ultrasound, I put on here a KUB as well. If you're concerned for
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clinical constipation, get that KUB.
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Show them the picture. Hey, you're full of stool. Get them on a mirror, wax, bowel, clean out.
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Renal bladder ultrasound, I tend to say that for my older children.
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Make sure we get the PBRs and things like that.
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Uroflow, we don't do it that often for the children.
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Treatment, so the bristle stool chart usually gets a good giggle out of your
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patients. We ask them to describe their stool to you.
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Is it rocks? Is it corn cobs? Is it sausages?
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Have them tell you, does it hurt when they have a bowel movement that really
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clears, keys you in? You have to push really hard. They say,
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yes, it hurts. Yes, I got to push.
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Looks like rocks. Hey, we got constipation column. Let's solve that.
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A lot of your urinary urgency and frequency, you boil it down to that.
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A lot of them, you get them pooped and better. A lot of those symptoms tend to go away.
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Really, so I always say those three arms, treatment, behavioral,
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alarm, therapy, and medication.
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So again, you're setting expectations. This isn't a quick fix.
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When they come to see us as the pediatric urologist, they see us as the expert.
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We're going to solve things right away. No, we're not solving things right away.
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This is a process. This is a process we're going to work through together.
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Review the voiding diary. Usually you don't get the voiding diary.
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You know, it helps with the reward system. You know, I have four boys.
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Two of them are wedding the bed when they're seven. I can get personal experience.
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Hey, we use the reward chart and everything.
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Motivation, positively important. And as you all know, negative reinforcement
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and parenting, those don't go together.
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Whether it's schoolwork, bedwetting, what have you, you've got to have that
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positive reinforcement.
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The child's not wet. We all know this. The child's not wetting the bed on purpose.
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You know, it's just what's happening. I get it. There's laundry. It's frustrating.
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But the child's not doing it. It's positive reinforcement.
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So again, just using that behavioral
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therapy. And we talked about the constipation as well. Alarm therapy.
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So I'll use personal experience for this. Again, two of my boys were waiting
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to bed at seven. We used alarm therapy.
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After a couple of months, we were done.
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So success rates approaching 80% with low relapse. You got to be persistent.
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I tell most of my patients that greater than 90% of my patients come back and tell me that it failed.
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And I ask, why did it fail? Well, my child didn't wake up to the alarm.
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Same thing in my house.
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Kids are deep sleepers. You go in, you flip the light on, you yell their name,
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they're sleeping right through it. They're not going to wake up to an alarm
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initially for the alarm therapy.
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Our house, we still had a baby monitor. We put that in there.
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That way my wife and I could hear it. We could go in and wake them up.
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It's a family, family event.
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The big difference is, here's like, oh, well, we've tried something similar
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to that. Before I go to bed, I wake my child up, take them into the bathroom, go to the bathroom.
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The difference is, is there's no feedback loop system to the brain.
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And so with the alarm therapy, whenever the child starts wetting the bed at
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one in the morning, alarm goes off, they wake up, they should constantly think,
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oh, I'm in bed, I shouldn't be wetting the bed right now.
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And they stop, go to the bathroom and finish. And it's that constant feedback learning.
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You know, the way I explain to the patients, like, you know,
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if you play sports, you know, you're going to go out to shoot free throws to
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that when in game and it matters that you have that rhythm down or you prepare for a test.
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This is this is training your brain but but
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just waking up someone coming in waking you up at 11 p.m
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saying let's go to the bathroom and you're not actively urinating does
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not achieve the same effect all it does is make everyone else tired so the alarm
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therapy but it's a family family event and i emphasize that to the parents over
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and over and over again it's if you leave it up to the child it's not gonna
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well for the majority of children it's not gonna work because they're not gonna wake,
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So it becomes a family event.
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DDAVP, medication, amiprimine, that's kind of old school, really focusing on
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DDAVP, antidiuretic hormone.
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I tend to reserve that for my older children.
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If you look at the data, you put people on DDAVP, generally you take them off.
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Two months later, you have a greater than 50% relapse of the nocturnal inuresis.
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I tend to use my practice mostly for kids, give a trial, hey,
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we want to have sleepovers. We want to go to summer camp, those kind of things and everything.
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It works in some, it doesn't work in others. You start at 0.2 and titrate up and everything.
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Again, the big thing with that works in the collecting system,
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side effects. The big one you always talk about is the hyponatremia.
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Oral form is the only one that's FDA approved in the United States.
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Nasal spray is over, I think it's in the European Union. The book, again, oral is ours.
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The big serious thing is the hyponatremia. just because that you are holding
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on to all that free water.
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So if your child is sneaking water in the middle of the night,
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all those kinds of things, it can lead to seizures, you know, it was a phrenia.
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Again, intranasal is not used. Hour before you go to that. And I tell the parents
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like, hey, if we're doing this, you've been doing all the behavioral stuff.
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So we shouldn't have to worry about the child drinking at nighttime because
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you've already eliminated that.
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Like we're not jumping straight to medicine without doing the behavioral stuff first.
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It's gotta be used in combinations, not a sole thing. If you're not fully on
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board, We're not using the medicine.
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So again, I usually, if I do start patients on it.
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Oh, yeah, we'll wrap up. I think I have one more slide. So again,
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I pause every three months, give them a holiday, see where they're at.
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And anti-coloners, there's really a pattern of overactive bladder in the daytime.
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You get that from your voiding diary, and that can help nocturnal in your recess.
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And that's it. So again, thank you again so much for having me out here to speak to you all.
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Again, we look forward as a practice, Dr. Guss and I, to serving the community.
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Anything that you all need, feel free to reach out to us. And sorry to rush you.
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Okay, Whitney, we're good. No, thank you.
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