What Is Bladder-Bowel Dysfunction (BBD), and How Does It Affect Reflux?

The International Children's Continence Society (ICCS) defines bladder-bowel dysfunction (BBD) as the coexistence of lower urinary tract symptoms and bowel problems (constipation and/or fecal incontinence) in a toilet-trained child with no neurological disease.

In vesicoureteral reflux, what is actually feared is not the reflux itself but infected urine reaching the kidney. BBD feeds this chain at two points, increasing both the likelihood of infection and the persistence of reflux.

BBD often persists without the family noticing; the child is seen as a child who 'holds it in,' 'forgets to go to the toilet,' or is 'a bit constipated.' For this reason, assessment relies on questions, and the information does not come to light unless the physician specifically asks.

• Wetness in the daytime underwear or daytime urinary incontinence
• Holding maneuvers such as crossing the legs, squatting, or sitting on the heel
• Fewer than 3 or more than 8 voids per day
• Fewer than 3 bowel movements per week, hard or painful defecation; fecal soiling of the underwear
• Staccato or straining voiding, post-void dribbling

The sequence is clear: BBD first, then the reflux-specific decision. Constipation treatment and standard urotherapy (timed voiding, correct sitting posture, fluid schedule) are started; because the risk of febrile infection is high during this period, antibiotic prophylaxis (CAP) accompanies treatment in most children.

• Once BBD is brought under control, reflux resolves on its own in some children, or infections stop and the need for intervention disappears. If intervention is still needed, endoscopic injection or ureteral reimplantation gives a far more reliable result once performed on a bladder that has been corrected. In our practice, this evaluation is carried out by the same two pediatric urologists who perform the reflux treatment, so that bladder treatment and the reflux decision are never disconnected from each other.