Bladder bowel dysfunction (BBD) is a combination of bladder and bowel disturbances in children who have no identifiable or recognizable neurologic abnormality. In BBD the entire pelvic floor is dysfunctional,  bladder and bowel are  just a part of it.
We here in describe that the muscular component (bulbospongiosus muscle [BSM]) of the pelvic floor may substantially contribute to the voiding disorder children.

Study includes all children presented to us with lower urinary tract (LUTS) and bowel symptoms (constipation / incontinence).   After ruling out of any other causes of symptoms like neurogenic or structural abnormality, bladder and bowel diaries with uroflowmetry and pelvic floor EMGs (Fig. 1) were assessed.   The children who continued to have persistent LUTS even after 3 months of Urotherapy were further subjected to pelvic floor functional MRI (FrMRI) (Fig. 2) and high-resolution anorectal manometry (HRAM) to study the anatomy and physiology of pelvic floor muscular components with special reference to bulbospongiosus muscle.
Dysfunctional voiding score system (DVSS) was obtained at start of the  treatment which was also used for the monitoring of symptoms.  
Management included Urotherapy along with EMG biofeedback and   bowel program.

Between January 2015 and December 2023, a total of 110 children with median age of 7.5 yrs (range 3.5-12) diagnosed with BBD were included in the study.  Of these 25 (22.7%) children who failed to show improvement after Urotherapy were counselled for Fr MRI and HRAM.   Fifteen   of them accepted.  The Fr MRI during voiding showed occlusive contraction of bulbospongiosus in these children (Fig. 2). HRAM also recorded high anal pressure while attempting for evacuation (Fig. 3). 
The 4 (33.3%) children responded to first line (Targeted Urotheray) and rest 8 (67.7%) needed second line of management (Botulinum toxin, Neuromodulation and Pharmacotherapy). The Median DVSS symptom score of was 15   and 6 before and after treatment (p value 0.31). The DVSS score and total QOL score were statistically correlated (r = 0.281, p = 0.05).

The Fr MRI during voiding showed occlusive contraction of bulbospongiosus in   children with BBD (Fig. 2). HRAM also recorded high anal pressure while attempting for evacuation (Fig. 3). The authors  hypothesize that    the muscular component (bulbospongiosus muscle [BSM]) of the pelvic floor may substantially contribute to the voiding disorder children.
Targeted Urotheray showed good response in 4 (33.3%) children   and rest 8 (67.7%) needed more aggressive second line of management (Botulinum toxin, Neuromodulation and Pharmacotherapy).

In lower urinary tract dysfunction (LUTD) in children one need to look beyond the bowel and bladder involvement. Other muscular component of the pelvic floor may substantially contribute to the similar voiding disorder. When suspected these children should undergo more elaborate work up to achieve the best therapeutic goals.

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