Urinary incontinence is defined as the involuntary release of urine occurring 2 or more times per month after toilet training has been completed. Incontinence can be continuous (constant throughout the day) or may come and go (intermittent).
Intermittent incontinence may be present:
During the day (daytime incontinence [previously called diurnal incontinence])
At night (nighttime incontinence, enuresis, or bed-wetting (if incontinence occurs only during sleep, it is called nocturnal enuresis)
The duration of the process of toilet training, or the age at which children achieve urinary continence, varies greatly. However, about 90% of children achieve daytime urinary continence by age 5. Nighttime continence may take longer to achieve.
Bed-wetting or nighttime incontinence affects about 20% of children at age 5 and about 10% at age 10. About 0.5 to 3% of adults continue to have episodes of nighttime incontinence. Doctors take these timelines into account when diagnosing urinary incontinence. Because the duration of the process of toilet training varies, young children are usually not considered to have daytime incontinence if they are under age 5 or 6 or nighttime incontinence if they are under age 7. Urinary incontinence is a symptom of a problem and is not diagnosis, which is why doctors look for an underlying cause of it.
Daytime incontinence is more common among girls. Bed-wetting is more common among boys and among children who have a family history of it.
A person's urination (voiding) pattern matures and transitions from the one that occurs during infancy to the one that occurs during adulthood. In the infant pattern, bladder contractions occur by reflex, and the urine is not stopped by contractions of the urinary sphincter (muscles involved in expelling urine from the bladder). In the adult pattern, bladder contractions are suppressed by signals from the brain. People learn to control the urinary sphincter during toilet training.
Causes of Urinary Incontinence in Children
The pattern of incontinence helps the doctor determine the likely cause. If the child has never had a consistent dry period during the day, the doctor may consider the possibility of a birth defect, an anatomic abnormality, or certain behaviors that can lead to incontinence.
Several uncommon but potentially serious disorders affect the normal anatomy or function of the bladder, which can lead to urinary incontinence. For example, a spinal cord defect such as spina bifida can cause abnormal nerve function to the bladder and can lead to incontinence. Some infants have a birth defect that prevents the bladder or urethra from developing completely, leading to nearly constant urine loss (total incontinence). Another type of birth defect causes the tubes that connect the kidneys to the bladder (ureters) to end in an abnormal location in the bladder or even outside the bladder (such as in the vagina or urethra or on the surface of the body), causing incontinence (see Misplaced ureters). Some children have an overactive bladder that easily spasms or contracts, causing incontinence, whereas others may have difficulty emptying their bladder.
Certain behaviors can lead to daytime incontinence, especially in girls. Such behaviors include urinating infrequently and urinating using an incorrect position (for example, sitting on the toilet bowl with the legs too close together). In this position, urine can accumulate in the vagina during urination, then dribble out after standing. Some girls have bladder spasms when laughing, resulting in what doctors call giggle incontinence.
If the child has been dry for a long time and the incontinence is new, the doctor considers conditions that can cause loss of continence. These include constipation, infections, diet, emotional stress, and sexual abuse. Some medical conditions that the child develops can cause new urinary incontinence.
Constipation, which is defined as difficult or infrequent passing of stool, is the most common cause of sudden changes in urinary continence in children. Stools are harder and sometimes larger than usual and may be painful to pass.
Bacterial urinary tract infections (UTIs) and viral infections causing bladder irritation (bacterial or viral cystitis) are common infectious causes.
To prevent urine from leaking, many children with incontinence learn to cross their legs or use other positions (holding maneuvers), such as squatting (sometimes with their hand or heel pressed between their legs). These holding maneuvers may increase the chance of developing a urinary tract infection.
Sexually active adolescents can have urinary difficulties caused by certain sexually transmitted infections.
Dietary causes include caffeine and acidic juices, such as orange and tomato juice, which can irritate the bladder and lead to leakage of urine.
Stressful events such as divorce or separation of the parents, moving, or loss of a family member can cause a child to develop urinary incontinence (usually temporarily).
Children who are sexually abused may develop urinary incontinence.
Children with diabetes mellitus, arginine vasopressin deficiency (central diabetes insipidus), arginine vasopressin resistance, or sickle cell disease (and sometimes sickle cell trait) can develop incontinence because these disorders produce excessive amounts of urine.
Other disorders, such asattention-deficit/hyperactivity disorder, can increase the risk of incontinence.
Children with obstructive sleep apnea (OSA) may have incontinence, especially during sleep, because the disrupted sleep patterns and hormonal changes caused by OSA can lead to bed-wetting.
Common causes of urinary incontinence
Causes of urinary incontinence vary depending on whether incontinence occurs in the daytime or mainly at night.
In nighttime incontinence (enuresis, or bed-wetting), most cases do not involve a medical disorder but result from a combination of factors, including:
Developmental delay
Toilet training that has not been completed
A bladder that contracts before it is completely full
Drinking too much before bedtime
Problems waking up from sleep (for example, being a very deep sleeper)
Family history
If one parent had nighttime incontinence, there is a 44% chance their children will have it. The chance increases to 77% if both parents had it.
Up to 30% of cases are caused by an underlying medical issue (for example, a urinary tract infection, constipation, or kidney failure).
For daytime incontinence, common causes include:
A bladder that is irritated because of a urinary tract infection or because something is pressing on it (such as a full rectum caused by constipation)
Constipation
Urethrovaginal reflux (also called vaginal voiding), which can occur in girls who urinate in an incorrect position or who have extra skinfolds in the labia, and can cause urine to back up into the vagina and then leak out when they stand up
Weakness of the muscles involved in expelling urine from the bladder (the urinary sphincter and the bladder muscle)
A bladder that does not empty completely (neurogenic bladder) because of a spinal cord or nervous system defect
Evaluation of Urinary Incontinence in Children
Doctors first try to determine whether incontinence is simply a developmental issue or whether a disorder is involved.
Warning signs
In children with urinary incontinence, certain signs and characteristics are cause for concern. They include:
Signs or concerns of sexual abuse
Excessive thirst, excessive volume of urine, and weight loss
Incontinence during the day in children 6 years of age or older
Any signs of nerve damage, especially in the legs
Signs of an abnormality of the spine
Newly developed incontinence in children who have been dry for over 1 year
Signs of nerve damage in the legs include weakness in, or difficulty moving, one or both legs and complaints from the child that their legs "feel funny."
Signs of an abnormality of the spine may include a deep dimple or an unusual patch of hair in the lower back.
When to see a doctor
Children who have any warning sign should immediately be brought to a doctor with experience in treating children unless the only warning sign is daytime incontinence in children who are 6 years of age or older. Children in this age group should see a doctor at some point, but a delay of a week or so is not harmful.
What the doctor does
Doctors first ask questions about the child's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the incontinence and the tests that may need to be done (see table ).
In the medical history, doctors ask about when symptoms began, timing of symptoms, and whether symptoms are continuous (that is, constant leaking) or come and go. Parents can record the timing, frequency, and volume of urine in a voiding diary and the frequency, size, and consistency of stool in a stooling diary to help keep track of their child's symptoms. Position while urinating and strength of urine stream are discussed.
Some symptoms that suggest a cause include:
Decreased frequency of stools and/or hard or unusually large stools (constipation)
Fever, abdominal pain, pain while urinating, and increased urgency to pass urine (urinary tract infection)
Itching around the anus, rectum, or vagina especially at night (pinworm infection)
Urinating frequently during the day or night and producing a large volume of urine (argininevasopressin deficiency [central diabetes insipidus], arginine vasopressin resistance, or diabetes mellitus)
Snoring or breathing pauses during sleep and being excessively sleepy during the day (obstructive sleep apnea)
Doctors also ask about any history of birth injuries or birth defects (such as spina bifida), nerve disorders, kidney disorders, and urinary tract infections.
Doctors screen the child for the possibility of sexual abuse, which, although a rare cause, is too important to be overlooked.
Parents should tell doctors about any family history of bed-wetting or urinary tract disorders. Doctors also ask questions about any stressors occurring near the start of symptoms, including difficulties at school, with friends, or at home (including questions about the parents' relationship). Although incontinence is not a psychological disorder, a brief period of wetting may occur during times of psychological stress.
Doctors ask whether children feel weakness of the legs when running or standing.
Doctors then do a physical examination. Examination begins with the following:
A review of vital signs for fever (may indicate a urinary tract infection), weight loss and excessive thirst (may indicate diabetes), and high blood pressure (may indicate a kidney disorder)
Examination of the head and neck for enlarged tonsils, mouth breathing, or poor growth (may indicate obstructive sleep apnea)
Examination of the abdomen for any masses that suggest stool is being retained or for a full bladder
Examination of the genitals in girls for any redness, adhesions (when the lips of the vagina stick together), scarring, or signs suggesting sexual abuse
Examination of the genitals in boys for any irritation or sores on the penis or around the anus or rectum (may indicate sexual abuse)
Examination of the spine for any defects (for example, a tuft of hair or a deep dimple in the lower back)
A neurologic examination to evaluate leg strength, sensation, and certain reflexes (such as lightly touching the anus to see whether it constricts—called the anal wink—and, in boys, lightly stroking the inner thigh to see whether the testis on that same side is pulled up—called the cremasteric reflex)
A rectal examination may be done during the physical examination to detect constipation, weakened muscles around the anal sphincter (decreased rectal tone), or pinworms
Some Risk Factors for and Causes and Features of Urinary Incontinence in Children
Risk Factor/Cause | Common Features* | Diagnostic Approach |
|---|---|---|
A bladder that does not empty completely (neurogenic bladder) because of a spinal cord or nervous system defect | Abnormalities of the spine that can be seen, a deep dimple or hair tuft in the lower back, and weakness and decreased sensation in the legs and feet | X-rays of the lower back Sometimes MRI of the spine Ultrasound of the kidneys and bladder Studies of urine flow and pressure in the bladder (urodynamic studies) |
Anatomic abnormality (for example, a misplaced ureter in girls or posterior urethral valves in boys) | Complete daytime continence never achieved In girls, daytime and nighttime incontinence, a history of normal voiding but with continually wet underwear, and a discharge from the vagina Possibly a history of urinary tract infections and of other urinary tract abnormalities | Imaging studies of the kidneys and ureters, including ultrasound of the kidneys CT of the abdomen and pelvis or MRI of the urinary tract Often a voiding cystourethrogram (x-rays taken before, during, and after urination) Kidney flow scan (to detect urinary flow) or an intravenous urogram with a contrast agent (to identify anatomical abnormalities) |
An overfull bladder | Waiting until the last minute to urinate Common among preschool children when they are absorbed in playing | Questions about when incontinence occurs Recording the timing, frequency, and volume of urine in a voiding diary |
Back up of urine into the vagina (urethrovaginal reflux, or vaginal voiding) | Leaking when standing after urination | A doctor's examination alone |
Infrequent, hard, pebblelike, or very large stools Sometimes abdominal discomfort or bloating Often in children who consume a constipating diet (for example, excessive milk and dairy products and few fruits and vegetables) | Usually a doctor's examination alone Sometimes an x-ray of the abdomen Recording the timing, frequency, and volume of stool in a stooling diary | |
Developmental delay† | No daytime incontinence More common among boys and heavy sleepers Possibly family members who had wet the bed | A doctor's examination alone |
Dysfunctional urinating because the muscles involved in expelling urine from the bladder (the bladder muscle and urinary sphincter) are not coordinated | Often stool incontinence, backward flow of urine, and urinary tract infections Possibly daytime and nighttime incontinence | Studies of urine flow Sometimes a voiding cystourethrogram (x-rays taken before, during, and after urination) Ultrasound of the kidneys and bladder |
Giggle incontinence | Urinating while laughing, more common among girls At other times, completely normal urination | A doctor's examination alone |
Increased urine output, which can have many causes, such as:†
| Vary by disorder | For diabetes mellitus, blood tests for glucose (sugar)‡ For arginine vasopressin resistance, blood tests and possibly a urine test For sickle cell disease, blood tests |
Sometimes in children who snore and have pauses in breathing that last 15 seconds or more during sleep followed by loud snorts Excessive daytime sleepiness Enlarged tonsils, adenoids, or both Growth and weight faltering (formerly called failure to thrive) | A sleep study test | |
Overactive bladder | A need to urinate urgently Commonly a frequent need to urinate during the day and night Sometimes use of holding maneuvers or body posturing (for example, children may squat) | A doctor's examination Sometimes studies of urine flow, urodynamic studies, or a voiding diary |
Sleep problems or school problems (such as delinquency or poor grades) Inappropriate and sexualized behavior, depression, an unusual interest in or avoidance of all things sexual, and inappropriate knowledge of sexual things for age | Evaluation by sexual abuse experts | |
Stress†§ | School problems, social isolation or problems, and family stress (for example, divorce or separation of the parents) | A doctor's examination alone |
Pain while urinating, blood in the urine, a need to urinate frequently, and a sense of needing to urinate urgently Sometimes fever, abdominal pain, and/or back pain | Urine culture and urinalysis If urine culture and urinalysis results are positive and especially if there is also a kidney infection, ultrasounds of the kidneys and bladder and voiding cystourethrogram (x-rays taken before, during, and after urination) | |
* Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. | ||
† This disorder is also a risk factor for and a cause of nighttime incontinence. | ||
‡ Diabetes does not typically cause incontinence until blood sugar (glucose) levels are high enough to cause glucose to enter the urine. | ||
¶ Stress is a cause primarily when incontinence is sudden. | ||
CT = computed tomography; MRI = magnetic resonance imaging. | ||
Testing
Often doctors can diagnose the cause by the history and a physical examination. Doctors may do other tests depending on what they find during their evaluation (see table ). For example, to help diagnose diabetes mellitus and arginine vasopressin resistance, doctors do blood and urine tests to check glucose (sugar) and electrolyte levels. To diagnose urinary tract infection, doctors do a urinalysis and urine culture.
If a birth defect is suspected, an ultrasound of the kidneys and bladder and x-rays of the spine may be necessary. Ultrasound also can be used to determine the size of the rectum. An x-ray of the abdomen may done to confirm the presence of a large amount of stool.
A special x-ray of the bladder and kidneys, called a voiding cystourethrogram, may also be needed. With this test, a contrast agent is injected into the bladder using a catheter, which shows the anatomy of the urinary tract as well as the direction of urine flow.
Treatment of Urinary Incontinence in Children
Learning about the cause and course of incontinence helps decrease the negative psychological impact of urine accidents. Doctors ask how the child is being impacted by the incontinence because that could affect the treatment decisions.
Treatment of incontinence depends on the cause. For example, an infection is usually treated with antibiotics. Children with birth defects or anatomic abnormalities may need surgery.
Successful treatment of urinary incontinence also depends on parent and child participation in the treatment plan. If the child is developmentally delayed for age, not bothered by the wetting, or unwilling to participate in the treatment plan, the plan should be postponed until the child is ready to participate.
Parents should not punish children for urinary incontinence. No amount of discipline or punishment is going to help children stop wetting the bed. Punishments only increase their stress and anxiety levels and cause poor self-esteem.
Other measures can be taken depending on whether incontinence occurs at night or during the day.
Nighttime incontinence (enuresis, or bed-wetting)
Doctors typically tell parents to begin with behavioral modifications for their child. Modifications include the following:
Having the child drink regularly during the day and limiting fluids and food 1 to 2 hours before sleep
Urinating 2 times consecutively before sleep (called double-voiding)
Managing constipation appropriately
The most effective long-term strategy is a bed-wetting alarm. The alarm is triggered when it senses moisture (urine). It then emits a loud beep or tone or vibrates to wake the child. Although children initially continue to have bed-wetting episodes, over time, they are conditioned to associate the sensation of a full bladder with the alarm and then wake up to urinate before they wet the bed. These alarms are readily available without a prescription.
Children are about 7 times more likely to have 14 dry nights in a row and are about 9 times more likely to stay dry at night for an even longer time when they use a bed-wetting alarm compared to children who use a regular alarm or to those who do not use a bed-wetting alarm. Children may need to use a bed-wetting alarm every night for up to 4 months before they stop wetting the bed completely.
Each year, bed-wetting tends to resolve without treatment in about 14% of affected children as they grow.
Medications given by mouth such as desmopressin (DDAVP) and imipramine can decrease the number of bed-wetting episodes. However, bed-wetting resumes in most children when the medications are stopped. Parents and children should be warned of this likelihood so that children do not become devastated if bed-wetting starts again. More children are given DDAVP than Medications given by mouth such as desmopressin (DDAVP) and imipramine can decrease the number of bed-wetting episodes. However, bed-wetting resumes in most children when the medications are stopped. Parents and children should be warned of this likelihood so that children do not become devastated if bed-wetting starts again. More children are given DDAVP thanimipramine because imipramine may rarely cause sudden death.
Daytime incontinence
General measures may include:
Trying urgency containment exercises (to strengthen the urinary sphincter)
Gradually lengthening the time between visits to the bathroom (if the child is thought to have a weak bladder muscle or dysfunctional voiding)
Changing behavior (for example, delaying urination) through positive reinforcement and scheduled urination
Reminding children to urinate by a clock that vibrates or sounds an alarm (this is preferable to having a parent in the reminder role)
Using methods that prevent retention of urine in the vagina (for example, sitting facing backward on the toilet bowl or sitting facing forward with the knees wide apart)
Teaching children how to exercise and control the pelvic floor muscles (the uterus, vagina, bladder, urethra, and rectum) and abdomen muscles to promote coordinated urination (using biofeedback)
Urgency containment exercises involve telling children to go to the bathroom as soon as they feel the urge to urinate. But once in the bathroom, they are asked to hold the urine as long as they can. When they can hold it no longer they should start to urinate but then stop and start urinating every few seconds. This exercise strengthens the urinary sphincter and also gives children confidence that they can make it to the bathroom before they have an accident. This exercise should be taught after the child has been evaluated by a doctor.
Girls who have adhesions are given a cream that contains estrogen.
Certain medications given my mouth may help children who have daytime incontinence. Oxybutynin and tolterodine can help if the cause of incontinence is bladder spasm. Solifenacin, darifenacin, and mirabegron may help children who have an overactive bladder. Certain medications given my mouth may help children who have daytime incontinence. Oxybutynin and tolterodine can help if the cause of incontinence is bladder spasm. Solifenacin, darifenacin, and mirabegron may help children who have an overactive bladder.Medications that are used to treat nighttime incontinence may also help children who have daytime incontinence.
Key Points
Determining why a child is incontinent is essential to the child's outcome and well-being.
Most often, incontinence is not caused by a medical disorder.
Treatment includes behavioral changes and sometimes medications.
Alarms are the most effective treatment for bed-wetting.
Most nocturnal enuresis (bed-wetting) improves as the child matures.
