The present excellent review of “Functional Bladder Problems in Children” by Dr Franco has many metaphors in this story. It has been decades since Terry Allen’s landmark description of nonneurogenic bladder dysfunction. However, the medical community on this planet has largely relegated the critical attention this problem demands to specific dedicated practitioners and specialists. And if they were to strike, it could easily wipe out the health and welfare of the patient.

As the author indicates, if bladder dysfunction remains unidentified and uncorrected in childhood, it frequently manifests in life-long lower urinary tract problems in adulthood such as prostadynia/prostatitis or interstitial cystitis and urethral syndrome. Ask any adult urologist how impossibly common or unmanageable these conditions can be. Even more devastating is the notion that attendant kidney damage and loss of function are preventable consequences of failure to recognize and correct bladder dysfunction in childhood. There are reports of children progressing to total renal failure and kidney transplantation in the face of the most severe forms of elimination dysfunction.

In our institution, trainees are taught to think that virtually all children presenting to the pediatric urology service (indeed one could say all children) are suspect for some degree of constipation and/or bladder dysfunction until proven otherwise. Given its great prevalence, it is somewhat ironic, then, that the colony of practicing physicians perennially takes a cursory view of this problem or relegates it to superficial management strategies with little goal or conviction. And as with the volunteer in the story, there is often little sense of obligation or urgency for the importance of the role played by those few who do manage this problem effectively and thoroughly.

An appreciation of the protean manifestations and subtle diagnostic clues to bladder dysfunction, as outlined by the author, can be extremely useful in identifying patients at risk. When the primary inciting problem is addressed at the bladder level, the added and more obvious problems of urinary tract infection (UTI), or even ongoing vesicoureteral reflux then often become secondary management issues. Nevertheless, it is easy for recurrent UTI or reflux to become a distraction as these can be more objectively diagnosed. However, their resolution is most often inexorably tied to effectively treating bladder dysfunction; little progress will be made with the former without correcting the latter.

Of all the internal organs, only the colon and bladder can come under such rigid control of their owner. Moreover, the term dysfunctional elimination syndrome (DES), coined by Koff and colleagues is more apropos when one considers the intimate proximity of the anal and bladder outlet muscle sphincter complexes. It is difficult for the young child who is just beginning to appreciate their ability to voluntarily control these muscle groups, to contract or relax them independently of each other. Thus, when children experience the dysuria of UTI or pain from voiding through a meatal stenosis, they will engage in the most primitive of responses and stop the pain by stopping voiding (permanently, if they could). In contracting the bladder outlet complex, the anal sphincter also contracts, ostensibly unnecessarily. Thus begins the vicious cycle of secondary constipation brought on by the primary bladder problem. Conversely, an anal fissure, hard stool, or even repeated avoidance of undesirable or unfamiliar bathroom conditions can lead to anal sphincter contraction, bowel movement avoidance, and sympathetic (and here I refer not to autonomic function) contracting of the bladder outlet, with the same outcome. Despite the eventual resolution of the painful stimulus, during such a formative period, this bladder/bowel behavior becomes locked in and learned.

The learned sympathy of the 2 sphincters for each other leads to the brain and to behavior. In perhaps one of the more important considerations in this field to date, the author lays out what is undoubtedly the tip of the iceberg in the complex interplay between higher brain centers and lower urinary tract (and gastrointestinal tract) control. It comes as no surprise, therefore, that when outward psychosocial pressures perturb the intense developmental stages of functional brain development in the child, this creates the neurobiological potential to modulate lower urinary tract function.

One of the most profound and well-known examples of psychosocial stress in this context (but unfortunately not always inquired about because social moirés continue to inhibit even the health professional) is the ability of child abuse or sexual abuse to alter the voiding behavior of the victim. Therapy for such assaults on the psyche, even in adults, can have a positive and corrective effect on even longstanding bladder dysfunction. Recently, Zderic and Valentino and their research teams, using animal models of social stressing, have begun to show that social stress leads to acquired (and measurable) bladder dysfunction and tissue remodeling. Even more intriguing are the emerging associations between the ability of the brain and the bladder to affect each other, such that the dysfunctional bladder (or colon or other pelvic organs) can neuroanatomically project to specific neuronal regions in the brain to incite neurobehavioral consequences, and vice versa. It should come as no surprise then that corticotropin releasing factor, a stress hormone, has been identified as a principle neurotransmitter projecting to and emanating from the Barrington nucleus in the pons, the Grand Central Station for micturition. This raises the intriguing possibility of targeting cerebral centers in the management of distinct lower urinary tract pathology.

Presaging this association on a more clinical basis, although somewhat arbitrarily at the time, we specifically included additional scoring points for the presence of psychosocial pressures or events (positive or negative) when we established the first bladder dysfunction scoring system for children in 2000. Using this or one of the modified voiding scoring systems that followed can help to provide a somewhat more objective measure of bladder functional status before and after institution of bladder management programs and strategies such as those outlined by the author.

A functional bladder problem in the child is in many ways the pediatric urologist’s hypertension diagnosis. It is insidious. It is often ignored. It can be caused or aggravated by psychosocial stressors. It can lead to muscle hypertrophy, excessive intralumenal pressure, and bladder wall failure. Untreated, it can permanently damage other systems, and may even likely affect the brain. Unsupported by their family and health professional, the patient is often noncompliant with therapy. Like antihypertensive therapy, retraining bladder strategies and good bladder habits must be adhered to for life. The author treats many of these issues in depth and from familiar personal experience derived from many years of dedicated consideration of these problems. As Asimov suggests, we need to pay more attention to Igor and his family.