Bethanechol can be transformative for carefully selected children with underactive bladder. These pearls emphasize safe initiation, coordination with pelvic floor therapy, and vigilant monitoring for cholinergic effects.
Obtain a bladder scan, uroflow/EMG, or catheterization to document detrusor underactivity before prescribing bethanechol.
Begin at 0.5 mg/kg/day divided q6h and increase every 5–7 days only if voiding diaries and residuals demonstrate improvement.
Bethanechol works best when scheduled voiding or clean intermittent catheterization reinforces bladder cycling and protects renal function.
Advise families to administer with food or milk and to report severe abdominal pain, diarrhea, or hypersalivation promptly.
Suspend bethanechol temporarily if the child develops wheezing, pneumonia, or needs frequent albuterol—resume only after pulmonary clearance.
If post-void residuals and UTI frequency do not improve by three months, taper bethanechol and escalate to alternative modalities (biofeedback, intravesical therapy).