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Urinary Incontinence In Children

By

Teodoro Ernesto Figueroa

, MD, Nemours/A.I. duPont Nemours Hospital for Children

Last full review/revision Oct 2019| Content last modified Oct 2019
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Topic Resources

Urinary incontinence is defined as involuntary voiding of urine 2 times/month during the day or night. Revised terminology for the time of incontinence has been suggested (see the International Incontinence Society web site):

  • For urinary incontinence during the day: Diurnal incontinence (or diurnal wetting)

  • For urinary incontinence at night: Enuresis (or bed-wetting)

Diurnal (daytime) incontinence is usually not diagnosed until age 5 or 6. Nocturnal (nighttime) incontinence (that is, enuresis) is usually not diagnosed until age 7. Before this time, enuresis is typically referred to as nighttime wetting (1). These age limits are based on children who are developing typically and so may not be applicable to children with developmental delay. Both nocturnal and diurnal incontinence are symptoms—not diagnoses—and necessitate consideration of an underlying cause.

The age at which children attain urinary continence varies, but > 90% are continent during the day by age 5. Nighttime continence takes longer to achieve. Enuresis affects about 30% of children at age 4, 10% at age 7, 3% at age 12, and 1% at age 18. About 0.5% of adults continue to have nocturnal wetting episodes. Enuresis is more common among boys and when there is a family history (2).

In primary incontinence, children have never achieved urinary continence for 6 months. In secondary incontinence, children have developed incontinence after a period of at least 6 months of urinary control. An organic cause is more likely in secondary incontinence. Even when there is no organic cause, appropriate treatment and parental education are essential because of the physical and psychologic impact of urine accidents (3).

General references

  • 1. Wright, AJ: The epidemiology of childhood incontinence. In Pediatric Incontinence, Evaluation and Clinical Management, edited by Franco I, Austin P, Bauer S, von Gontard A, Homsy I. Chichester, John Wiley & Sons Ltd., 2015, pp. 37–60.

  • 2. Horowitz M: Diurnal and nocturnal enuresis. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 853–872.

  • 3. Austin PF, Vricella GJ: Functional disorders of the lower urinary tract in children. In Campbell-Walsh Urology, ed. 11, edited by Wein A, Kavoussi L, Partin A, Peters C. Philadelphia, Elsevier, 2016, pp. 3297–3316.

Pathophysiology

Bladder function has a storage phase and a voiding phase. Abnormalities in either phase can cause primary or secondary incontinence (1).

In the storage phase, the bladder acts as a reservoir for urine. Storage capacity is affected by bladder size and compliance. Storage capacity increases as children grow. Compliance can be decreased by repeated infections or by outlet obstruction, with resulting bladder muscle hypertrophy.

In the voiding phase, bladder contraction synchronizes with the opening of the bladder neck and the external urinary sphincter. If there is dysfunction in the coordination or sequence of voiding, incontinence can occur. There are multiple reasons for dysfunction. One example is bladder irritation, which can lead to irregular contractions of the bladder and asynchrony of the voiding sequence, resulting in incontinence. Bladder irritation can result from a urinary tract infection (UTI) or from anything that presses on the bladder (eg, a dilated rectum caused by constipation; 2).

Pathophysiology references

  • 1. Wan J, Kraft K: Neurological control of storage and voiding. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 803–819.

  • 2. Bush N, Shah A, Pritzker J, et al: Constipation and lower urinary tract symptoms. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 873–883.

Etiology

Urinary incontinence in children has different causes and treatments than urinary incontinence in adults. Although some abnormalities cause both nocturnal and diurnal incontinence, etiology typically varies depending on whether incontinence is nocturnal or diurnal, as well as primary or secondary. Most primary incontinence is nocturnal (ie, enuresis) and not due to an organic disorder. Enuresis can be divided into monosymptomatic (occurring only during sleep) and complex (other abnormalities are present, such as diurnal incontinence and/or urinary symptoms).

Nocturnal incontinence (enuresis)

Organic disorders account for about 30% of cases and are more common in complex compared to monosymptomatic enuresis.

The remaining majority of cases are of unclear etiology but are thought to be due to a combination of factors, including

  • Maturational delay

  • Uncompleted toilet training

  • Functionally small bladder capacity (the bladder is not actually small but contracts before it is completely full)

  • Increased nighttime urine volume

  • Difficulties in arousal from sleep

  • Family history (if one parent had nocturnal enuresis, there is a 30% chance offspring will have it, increasing to 70% if both parents were affected)

The factors contributing to organic causes of nocturnal incontinence include

Table
icon

Some Factors Contributing to Nocturnal Incontinence

Cause

Suggestive Findings

Diagnostic Approach

Infrequent, hard-pebble stools

Encopresis

Abdominal discomfort

History of a constipating diet (eg, excessive milk and dairy, few fruits and vegetables)

Clinical evaluation (including stooling diary)

Sometimes abdominal x-ray

Increased urine output due to any cause (eg, diabetes mellitus, diabetes insipidus, excessive water intake, sickle cell disease or trait)

Vary by disorder

For diabetes mellitus, serum glucose

For diabetes insipidus, serum and blood osmolality

For sickle cell, sickle cell screen

Maturational delay

No diurnal incontinence

More common among boys and heavy sleepers

Possible family history of bed-wetting

Clinical evaluation

History of snoring with sounds of breathing pauses followed by loud snorts

Excessive daytime sleepiness

Enlarged tonsils

Polysomnography

Spinal dysraphism (eg, spina bifida, tethered cord, occult defects), leading to urinary retention

Obvious vertebral defects, protruding meningeal sac, lumbosacral dimple or hair tuft, lower-extremity weakness, decreased sensation in lower extremities

Absence of ankle jerk reflex, cremasteric reflex, and anal wink

Lumbosacral x-rays

For occult conditions, spinal MRI

Stress

School difficulties, social isolation or difficulties, family stress (eg, divorce, separation)

Clinical evaluation (including voiding diary)

Dysuria, hematuria, frequency, urgency

Fever

Abdominal pain

Urinalysis

Urine culture

For patients with pyelonephritis, ultrasonography and voiding cystourethrogram

Diurnal incontinence

Common causes of diurnal incontinence include

  • Bladder irritability

  • Relative weakness of the detrusor muscle (making it difficult to inhibit incontinence)

  • Urethrovaginal reflux, or vaginal voiding: girls who use an incorrect position during voiding (eg, with legs close together) or have redundant skinfolds may have reflux of urine into the vagina, which subsequently leaks out on standing

  • Structural abnormalities (eg, ectopic ureter)

  • Abnormal sphincter weakness (eg, spina bifida, tethered cord)

Table
icon

Some Organic Causes of Diurnal Incontinence

Cause

Suggestive Findings

Diagnostic Approach

Infrequent, hard-pebble stools

Sometimes encopresis, abdominal discomfort

History of a constipating diet (eg, excessive milk and dairy, few fruits and vegetables)

Clinical evaluation (including stooling diary)

Sometimes abdominal x-ray

Dysfunctional voiding secondary to lack of coordination of the detrusor muscle and urethral sphincter and not related to a neurologic cause

Often encopresis, VUR, and UTI

Possibly nocturnal and diurnal incontinence

Urodynamic studies to show dyssynergy of bladder musculature

Uroflow testing

Sometimes VCUG

Giggle incontinence

Voiding during laughing, almost exclusively in girls

At other times, completely normal voiding

Clinical evaluation

Increased urine output due to any cause (eg, diabetes mellitus, diabetes insipidus, excessive water intake, sickle cell disease or trait)

Vary by disorder

For diabetes mellitus, serum glucose

For diabetes insipidus, serum and blood osmolality

For sickle cell, sickle cell screen

Micturition deferral with overflow incontinence

In children, waiting to the last minute to void

Common among preschool children when absorbed in playing

Consistent history

Voiding diary

Neurogenic bladder secondary to spinal dysraphism (eg, spina bifida, tethered cord, occult defects) or nervous system defect

Obvious vertebral defects, protruding meningeal sac, lumbosacral dimple or hair tuft, lower-extremity weakness, decreased sensation in lower extremities

Lumbosacral x-rays

For occult conditions, spinal MRI

Ultrasonography of the kidneys and bladder

Urodynamic studies

Overactive bladder

Urinary urgency (essential for diagnosis); frequency and nocturia also common

Sometimes use of holding maneuvers or body posturing (eg, squatting or Vincent curtsy sign)

History consistent with symptoms or overactive bladder

Consideration of voiding diary, urodynamic studies, uroflow testing

Sleep problems, school difficulties (eg, delinquency, poor grades)

Seductive behavior, depression, unusual interest in or avoidance of all things sexual, inappropriate knowledge of sexual things for age

Evaluation by sexual abuse experts

Stress*

School difficulties, social isolation or difficulties, family stress (eg, divorce, separation)

Clinical evaluation

Structural abnormality (eg, ectopic ureter, posterior urethral valves)

In children, full diurnal continence never achieved

Nocturnal and diurnal incontinence in girls, history of normal voiding but with continually wet underwear, vaginal discharge

Possible history of UTIs, history of other urinary tract abnormalities

Ultrasonography of the kidneys

Nuclear renal flow scan or IV urography

CT of abdomen and pelvis or MRI urography

UTI

Dysuria, hematuria, frequency, urgency

Fever

Abdominal pain

Urinalysis

Urine culture

For patients with pyelonephritis, ultrasonography and VCUG

Vaginal reflux (urethrovaginal reflux, or vaginal voiding) due to any cause (including labial adhesions)

Dribbling when standing after urination

Clinical evaluation, including improvement with instruction on proper method of voiding to discourage retention of urine in vagina (eg, sitting backward on toilet or with knees wide apart)

* Stress is a cause primarily when incontinence is acute.

UTI = urinary tract infection; VCUG = voiding cystourethrogram; VUR = vesicoureteral reflux.

Evaluation

Evaluation should always include assessment for constipation (which can be a contributing factor to both nocturnal and diurnal incontinence).

History

History of present illness inquires about onset of symptoms (ie, primary vs secondary), timing of symptoms (eg, at night, during the day, only after voiding), and whether symptoms are continuous (ie, constant dribbling) or intermittent. Recording a voiding schedule (voiding diary), including timing, frequency, and volume of voids, can be helpful. Important associated symptoms include polydipsia, dysuria, urgency, frequency, dribbling, and straining. Position during voiding and strength of urine steam should be noted. To prevent leakage, children with incontinence may use holding maneuvers, such as crossing their legs or squatting (sometimes with their hand or heel pushed against their perineum). In some children, holding maneuvers can increase their risk of UTIs. Similar to the voiding diary, a stooling diary can help identify constipation.

Review of systems should seek symptoms suggesting a cause, including frequency and consistency of stools (constipation); fever, abdominal pain, dysuria, and hematuria (UTI); perianal itching and vaginitis (pinworm infection); polyuria and polydipsia (diabetes insipidus or diabetes mellitus); and snoring or breathing pauses during sleep (sleep apnea). Children should be screened for the possibility of sexual abuse, which, although an uncommon cause, is too important to miss.

Past medical history should identify known possible causes, including perinatal insults or birth defects (eg, spina bifida), neurologic disorders, renal disorders, and history of UTIs. Any current or previous treatments for incontinence and how they were actually instituted should be noted, as well as a list of current drugs.

Developmental history should note developmental delay or other developmental disorders related to voiding dysfunction (eg, attention-deficit/hyperactivity disorder, which increases the likelihood of incontinence).

Family history should note the presence of enuresis and any urologic disorders.

Social history should note any stressors occurring near the onset of symptoms, including difficulties at school, with friends, or at home; although incontinence is not a psychologic disorder, a brief period of wetting may occur during stress.

Clinicians also should ask about the impact of incontinence on the child because it also affects treatment decisions.

Physical examination

Examination begins with review of vital signs for fever (UTI), signs of weight loss (diabetes), and hypertension (renal disorder). Examination of the head and neck should note enlarged tonsils, mouth breathing, or poor growth (sleep apnea). Abdominal examination should note any masses consistent with stool or a full bladder.

In girls, genital examination should note any labial adhesions, scarring, or lesions suspicious of sexual abuse. An ectopic ureteral orifice is often difficult to see but should be sought. In boys, examination should check for meatal irritation or any lesions on the glans or around the rectum. In either sex, perianal excoriations can suggest pinworms.

The spine should be examined for any midline defects (eg, deep sacral dimple, sacral hair patch). A complete neurologic evaluation is essential and should specifically target lower-extremity strength, sensation and deep tendon reflexes, sacral reflexes (eg, anal wink), and, in boys, cremasteric reflex to identify possible spinal dysraphism. A rectal examination may be useful to detect constipation or decreased rectal tone.

Red flags

Findings of particular concern are

  • Signs or concerns of sexual abuse

  • Excessive thirst, polyuria, and weight loss

  • Prolonged primary diurnal incontinence (beyond age 6 years)

  • Any neurologic signs, especially in the lower extremities

  • Physical signs of neurologic impairment

Interpretation of findings

Usually, primary enuresis occurs in children with an otherwise unremarkable history and examination and probably represents maturational delay. A small percentage of children have a treatable medical disorder; sometimes findings suggest possible causes (see Table: Some Factors Contributing to Nocturnal Incontinence).

For children who are being evaluated for enuresis, it is important to determine whether diurnal symptoms of urgency, frequency, body posturing or holding maneuvers, and incontinence are present. Children with these symptoms have complex enuresis, and management should be directed primarily toward controlling the diurnal symptoms.

In diurnal incontinence, dysfunctional voiding is suggested by intermittent incontinence preceded by a sense of urgency, a history of being distracted by play, or a combination. Incontinence after urination (due to lack of total bladder emptying) can also be part of the history.

Incontinence caused by a UTI is likely a discrete episode rather than a chronic, intermittent problem and may be accompanied by typical symptoms (eg, urgency, frequency, pain on urination); however, other causes of incontinence can result in secondary UTI.

Constipation should be considered in the absence of other findings in children who have hard stools and difficulty with elimination (and sometimes palpable stool on examination).

Sleep apnea should be considered with a history of excessive daytime sleepiness and disrupted sleep; parents may provide a history of snoring or respiratory pauses.

Rectal itching (especially at night), vaginitis, urethritis, or a combination can be an indication of pinworms.

Excessive thirst, diurnal and nocturnal incontinence, and weight loss suggest a possible organic cause (eg, diabetes mellitus).

Stress or sexual abuse can be difficult to ascertain but should be considered. Sexual abuse is an uncommon cause, but is too important to miss.

Testing

Diagnosis of incontinence is often apparent after history and physical examination. Urinalysis and urine culture are appropriate for both sexes. Further testing is useful mainly when history, physical examination, or both suggest an organic cause (see Table: Some Factors Contributing to Nocturnal Incontinence and see Table: Some Organic Causes of Diurnal Incontinence). Ultrasonography of the kidneys and bladder is often done to verify urinary tract anatomy is normal. Uroflow testing can show a staccato voiding pattern in patients with dysfunctional voiding.

Treatment

The most important part of treatment is family education about the cause and clinical course of incontinence. Education helps decrease the negative psychologic impact of urine accidents and results in increased adherence with treatment.

Treatment of urinary incontinence should be targeted toward any cause that is identified; however, frequently no cause is found. In such cases, the following treatments may be useful.

Nocturnal incontinence

The most effective long-term strategy is a bed-wetting alarm. Although labor intensive, the success rate can be as high as 70% when children are motivated to end the enuresis, and the family is able to adhere. It can take up to 4 months of nightly use for complete resolution of symptoms. The alarm triggers when wetting occurs. Although children initially continue to have wetting episodes, over time, they learn to associate the sensation of a full bladder with the alarm and then wake up to void prior to an enuretic event. These alarms are readily available online without prescription. An alarm should not be used by children with complex enuresis or children with reduced bladder capacity (as evidenced by voiding diary). These children should be treated the same as children with diurnal incontinence. It is essential to avoid punitive approaches because these undermine treatment and lead only to poor self-esteem.

Drugs such as desmopressin (DDAVP) and imipramine (see Table: Oral Drugs Used for Incontinence in Children*) can decrease nighttime wetting episodes. However, results are not sustained in most patients when the treatment is stopped; parents and children should be forewarned of this to help limit disappointment. DDAVP is preferable to imipramine because of the rare potential of sudden death with imipramine use.

Diurnal incontinence

It is important to treat any underlying constipation. Information from the voiding diary can help identify children with reduced functional bladder capacity, frequency and urgency of urination, and urinary infrequency, all of whom may present with urinary incontinence.

General measures may include

  • Urgency containment exercises: Children are directed to go to the bathroom as soon as they feel the urge to urinate. They then hold the urine as long as they can and, when they can hold it no longer, start to urinate and then stop and start the urine stream. This exercise strengthens the sphincter and gives children confidence that they can make it to the bathroom before they have an accident.

  • Gradual lengthening of voiding intervals (if detrusor instability or dysfunctional voiding is suspected)

  • Changes in behaviors (eg, delayed urination) through positive reinforcement and scheduled urination (time voiding): Children are reminded to urinate by a clock that vibrates or sounds an alarm (preferable to having a parent in the reminder role).

  • Use of correct voiding methods to discourage retention of urine in the vagina: In girls experiencing vaginal pooling of urine, treatment is to encourage sitting facing backward on the toilet or with the knees wide apart, which will spread the introitus and allow direct flow of urine into the toilet.

  • Biofeedback: This conservative, nonsurgical therapy is used to treat bladder dysfunction, urinary incontinence, fecal incontinence, urgency, and pelvic pain and to re-educate the pelvic floor muscles to restore and maintain health. With this therapy, children can be evaluated for and instructed in the proper isolation, exercise, and use of the pelvic floor muscles and abdomen muscles to promote synergistic coordinated voiding (1).

For labial adhesions, a conjugated estrogen or triamcinolone 0.5% cream may also be used.

Drug treatment (see Table: Oral Drugs Used for Incontinence in Children*) is sometimes helpful but is not typically first-line therapy. Anticholinergic drugs (oxybutynin and tolterodine) may benefit patients with diurnal incontinence due to voiding dysfunction when behavioral therapy or physiotherapy is unsuccessful. Drugs for enuresis may be useful in decreasing nighttime wetting episodes and are sometimes useful to encourage dryness during overnight events such as sleepovers.

Anticholinergics (eg, solifenacin and darifenacin) that are prescribed for the treatment of overactive bladder in adults have shown effectiveness in children. Similarly, the beta3-receptor agonist mirabegron has been used in children to treat symptoms of urinary incontinence due to detrusor muscle overactivity refractory to anticholinergics.

Table
icon

Oral Drugs Used for Incontinence in Children*

Drug

Dosage

Some Adverse Effects

Voiding dysfunction in diurnal incontinence (bladder overactivity)

Oxybutynin

For children > 5 years, 5 mg 2 times a day, may be increased to 5 mg 3 times a day

Extended-release: For children > 6 years, 5 mg once a day, increased as tolerated by 5 mg/day to a maximum of 15 mg/day

Confusion, dizziness, increased temperature, flushing, constipation, dry mouth

Tolterodine

For children > 5 years, 1 mg 2 times a day

Children who can swallow pills, extended-release capsules 2 mg to 4 mg once a day

Constipation, flushing, dry mouth

Nocturnal incontinence

Desmopressin (DDAVP)

For children 6 years, initially 0.2 mg once a day 1 hour before bedtime, increased as needed to a maximum of 0.6 mg once a day

Intranasal DDAVP is no longer recommended because of the risk of dilutional hyponatremia.

Imipramine

For children 6–8 years, 25 mg once a day at night

For children > 8 years, 50 mg once a day at night

Rarely, death†

Possible nervousness, personality change, disordered sleep, cardiac arrhythmias‡

* These drugs are mostly used as 2nd-line therapy. Treatment of the underlying disorder and behavioral therapy should be used first.

† Sudden death of unclear etiology has been reported. This drug is now rarely used.

‡ ECG should be done to identify prolongation of the QT interval and/or the corrected QT (QTc) interval, which contraindicate use of imipramine.

Treatment reference

  • 1. Rae A, Renson, C: Biofeedback in the treatment of functional voiding disorders. In Pediatric Incontinence, Evaluation and Clinical Management, edited by Franco I, Austin P, Bauer S, von Gontard A, Homsy I. Chichester, John Wiley & Sons Ltd., 2015, pp. 145–152.

Key Points

  • Primary urinary incontinence most frequently manifests as nocturnal incontinence (enuresis).

  • Constipation should be considered as a contributing source.

  • Most nocturnal incontinence abates with maturation (15%/year resolve with no intervention), but at least 0.5% of adults have nighttime wetting episodes.

  • Organic causes of incontinence are infrequent but should be considered.

  • Alarms are the most effective treatment for enuresis.

  • Other treatments include behavioral interventions and sometimes drugs.

  • Parental education is essential to the child’s outcome and well-being.

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