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Prof. Dr. Ali Avanoğlu
Vesicoureteral Reflux (VUR) • Bladder and bowel

Urotherapy: Timed Voiding, Fluids, and Toilet Habits

Urotherapy is a drug-free, non-invasive education program that teaches the child to empty the bladder at the right time, in the right way, and completely. It is the first step of treatment in a child with vesicoureteral reflux (VUR) who also has voiding dysfunction or constipation, and it begins to show its effect within weeks.

Who this is forFamilies of children for whom urotherapy has been recommended because of voiding dysfunction, bladder-bowel dysfunction, or vesicoureteral reflux
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ByProf. Dr. Ali AvanoğluUpdated
This page is part of vesicoureteral reflux.Read the full treatment overview on the hub page
CONSTIPATION: a full bowel presses on the bladderBLADDERBOWEL (RECTUM)REGULAR EMPTYING: the bladder fills and empties easilyBLADDERBOWEL (RECTUM)
CONSTIPATION: a full bowel presses on the bladderBLADDERBOWEL (RECTUM)REGULAR EMPTYING: the bladder fills and empties easilyBLADDERBOWEL (RECTUM)
a full bowel presses on the bladder; with regular emptying the bladder fills easily
01 · What is urotherapy, and who is it used for?02 · Components of standard urotherapy03 · When does it take effect, and how is success measured?04 · If it is not enough: specific urotherapy and medication
In brief4 madde
  • What is urotherapy, and who is it used for?: Urotherapy is the collective name for all non-drug approaches aimed at correcting lower urinary tract function.
  • Components of standard urotherapy: Standard urotherapy is not a 'list of advice' but a holistic program made up of five to six components applied together.
  • When does it take effect, and how is success measured?: Urotherapy is a habit change; unlike medication, it shows its effect over weeks, not days.
  • If it is not enough: specific urotherapy and medication: If staccato voiding, a high residual urine volume, or urgency persist despite 2–3 months of regular application of the standard program, the next step is specific…
01

What is urotherapy, and who is it used for?

Urotherapy is the collective name for all non-drug approaches aimed at correcting lower urinary tract function. The International Children's Continence Society (ICCS) divides it into two: 'standard' and 'specific' — standard urotherapy is the basic program applied to every child, while specific urotherapy consists of additional methods such as biofeedback, alarm therapy, or neurostimulation.

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  • Every toilet-trained child with daytime incontinence, urgency, holding maneuvers, staccato voiding, residual urine, or recurrent urinary tract infection together with constipation is a candidate. In a child with vesicoureteral reflux, once BBD (bladder-bowel dysfunction) is identified, the first step is urotherapy; the decision for endoscopic injection or surgery is not made until this program has been completed.
  • The child is at the center of the program. From about five or six years of age, most children can understand how their bladder works through simple drawings and can keep their own chart; the family and school take on a supporting role. In children with a neurological condition, the program is adapted according to bladder pressure.
02

Components of standard urotherapy

Standard urotherapy is not a 'list of advice' but a holistic program made up of five to six components applied together. Applying only one of the components is usually not enough.

  • Education: how the bladder works, what is going wrong
  • Timed voiding: every 2–3 hours, 5–7 times a day
  • Correct posture: foot support, relaxation, no straining
  • Fluids: water spread through the day, no evening loading
  • Bowel: constipation treatment and post-meal toilet sitting
  • Record-keeping: feedback through the voiding diary and chart
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  • Education and explanation: The child and family are taught the bladder's filling-and-emptying cycle, why holding it in and straining are harmful, and that incontinence is a functional problem, not 'laziness.' This component removes guilt and builds cooperation. Timed voiding: The child goes to the toilet by the clock, every 2–3 hours, without waiting for the urge; the goal is generally 5–7 voids a day — on waking, before school, at midday, after school, in the evening, and before bed. A vibrating watch or phone reminder works well at school.
  • Posture and relaxation: On the toilet, the trunk is tilted slightly forward, the knees are a little higher than the hips, and the feet are flat on the floor or on a step; the child voids without straining or rushing and waits a few seconds to make sure the bladder has finished; in girls, sitting with the legs apart prevents urine from pooling in the vagina. Fluid schedule: Age-appropriate water intake, spread throughout the day, is the goal; not drinking water at school and drinking a large amount all at once in the evening are common mistakes. Carbonated and caffeinated drinks are limited. Bowel management: If constipation is present, it is treated at the same time; sitting on the toilet with foot support after meals is part of the program.
03

When does it take effect, and how is success measured?

Urotherapy is a habit change; unlike medication, it shows its effect over weeks, not days. In the first 4–8 weeks, a reduction in urgency and daytime incontinence, a more regular number of voids, and a drop in residual urine are expected; full improvement takes several months in most children.

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  • The literature reports marked improvement in daytime incontinence and voiding symptoms with standard urotherapy in a significant proportion of children (varying by center, roughly more than half); results are better when constipation is treated at the same time. In a child with vesicoureteral reflux, the real goal is for infection recurrence to stop and for the reflux decision to be made on a bladder that has been 'cleaned up.'
  • Success is monitored objectively with the voiding diary, DVSS score, uroflowmetry curve, and ultrasound measurement of residual urine. Follow-up visits are generally scheduled every 4–6 weeks; because the program can be tiring for the family, these visits serve not only for measurement but also for motivation.
04

If it is not enough: specific urotherapy and medication

If staccato voiding, a high residual urine volume, or urgency persist despite 2–3 months of regular application of the standard program, the next step is specific urotherapy. Biofeedback, which teaches relaxation of the pelvic floor muscles, is the most commonly used method in this group.

  • For an overactive bladder, options such as anticholinergic medication, or an alpha blocker in selected cases, can be used together with urotherapy; medication does not replace urotherapy, it complements it. In our practice, these steps and reflux treatment proceed under the follow-up of the same two pediatric urologists; which child urotherapy is sufficient for, and which child will need injection or surgery, is decided together at the end of this follow-up.
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Frequently asked questions
My child doesn't want to go to the toilet at school; how is timed voiding applied there?
School is the most difficult link in urotherapy. A short note to the teacher from the physician, allowing free toilet permission, a vibrating reminder watch, and making the school toilet feel clean and safe resolve most problems. The goal is to go to the toilet during breaks even without feeling urgency.
Does timed voiding shrink the bladder?
No. The goal is to teach the bladder to empty before it becomes overstretched and before high pressure builds up. Voiding too frequently (such as every hour) is not recommended; the 2–3 hour interval is chosen to prevent both overfilling and incontinence. Bladder capacity is monitored with the voiding diary.
How long does urotherapy take?
The first results come within a few weeks, and lasting improvement is achieved in 3–6 months in most children. Constipation treatment can take longer. Consciously maintaining the habits for a while even after symptoms have improved reduces the chance of relapse.
Is urotherapy needed while taking antibiotic prophylaxis?
Yes, it is especially necessary. Antibiotic prophylaxis suppresses bacteria, while urotherapy removes the underlying conditions for infection (residual urine, high pressure, constipation). Once the bladder improves, the need for antibiotics usually decreases as well.
Prof. Dr. Ali Avanoğlu and Doç. Dr. Yaşar Issı's publications on this topic · 2
  1. Issi Y, Biçakci U (2021). Does desmopressin withdrawal strategy affect relapse rates in monosymptomatic enuresis treatment? European journal of pediatrics. PubMed ↗
  2. Sözübir S, Ergun G, Celik A, et al. (2006). The influence of urine osmolality and other easily detected parameters on the response to desmopressin in the management of monosymptomatic nocturnal enuresis in children. Minerva urologica e nefrologica. PubMed ↗
←Previous • Bladder and bowelDoes Constipation Cause Urinary Tract Infection and Reflux?Next • Bladder and bowelVoiding Dysfunction, Urgency, Urinary Incontinence, and VUR→
Related pagesFull index →
Bladder and bowelWhat Is Bladder-Bowel Dysfunction (BBD), and How Does It Affect Reflux?Bladder-bowel dysfunction (BBD) is a condition in toilet-trained children in which voiding problems are intertwined with constipation. In children with vesicoureteral reflux (VUR), BBD both increases the recurrence of urinary tract infections and delays the resolution of reflux; for this reason, it is screened for and treated before deciding on reflux treatment.Bladder and bowelDoes Constipation Cause Urinary Tract Infection and Reflux?Constipation is one of the most commonly overlooked causes of urinary tract infection in children, and in a child with vesicoureteral reflux (VUR), it increases infection recurrence and delays the resolution of reflux. This page explains how constipation is recognized, how it affects the bladder, and how it is treated.Bladder and bowelVoiding Dysfunction, Urgency, Urinary Incontinence, and VURDaytime urinary incontinence, sudden urgency, and holding maneuvers are the most visible signs of voiding dysfunction in children. In a child with vesicoureteral reflux (VUR), these symptoms are not merely a social problem: high pressure and residual urine in the bladder feed infection and the persistence of reflux. This page explains the difference between 'urinary incontinence' and 'urine backflow (reflux)', and the treatment approach.Bladder and bowelVoiding Diary, Uroflowmetry, and BiofeedbackThe voiding diary, uroflowmetry (urine flow measurement), and residual urine measurement are simple, painless, radiation-free tools that show how the bladder is working. They are used in a child with vesicoureteral reflux (VUR) to reveal voiding dysfunction and to monitor response to treatment; biofeedback, in turn, is the specific way of correcting the problem found.
Vesicoureteral Reflux (VUR) topic clustersMain treatment page →
Basics 6Diagnosis and evaluation 6By age and special situations 5Bladder and bowel 5Treatment pathways 10Kidney health and infection 5After treatment and follow-up 6
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