Urinary Incontinence in Children

1. 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. 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.

3. 3. 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.

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)

About 15% per year resolve with no intervention.

The factors contributing to organic causes of enuresis include

• Conditions that increase urine volume (eg, diabetes mellitus, argininevasopressin deficiency [central diabetes insipidus], nephrogenic diabetes insipidus, chronic renal failure, excessive water intake, sickle cell disease, sometimes sickle trait [hyposthenuria])

• Conditions that increase bladder irritability (eg, UTI, pressure on the bladder by the rectum and sigmoid colon [caused by constipation])

• Structural abnormalities (eg, ectopic ureter, which can cause both nocturnal and diurnal incontinence)

• Abnormal sphincter weakness (eg, spina bifida, which can cause both nocturnal and diurnal incontinence)

Common causes of diurnal incontinence include

• Bladder irritability

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

• Constipation

• 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)

History is the most important diagnostic tool in the evaluation of a child with urinary incontinence. Although there are many technological advances that can support the evaluation, no diagnostic tool can replace the sympathetic and discriminating ear of the physician (1).

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. Noting the age at initial toilet training and whether complete dryness has been achieved since toilet training was completed is important. 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 stream 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, size, 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 medications.

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.

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 findings suggesting 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 anus or 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.

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

• New-onset incontinence after dryness for > 1 year

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 Enuresis).

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 or unusually large 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.

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

Excessive thirst, diurnal incontinence and enuresis, 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.

Diagnosis of incontinence is often apparent after history and physical examination.

Urinalysis and urine culture usually are done routinely for both sexes (see How To Catheterize the Bladder in a Female Child and see How To Catheterize the Bladder in a Male Child).

Further testing is useful mainly when history, physical examination, or both suggest an organic cause (see table Some Factors Contributing to Enuresis and table Some Organic Causes of Diurnal Incontinence). Ultrasonography of the kidneys and bladder is often done to verify that the renal and urinary tract anatomy is normal (2). Ultrasonography also can be used to assess rectal diameter, and, if constipation is suspected, an abdominal x-ray may be done to confirm a large stool burden. Uroflow testing can show a staccato voiding pattern in patients with dysfunctional voiding.

1. 1. Wintner A, Figueroa TE: History and physical examination of the child. 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. 3–27.

2. 2. Coplen DE: Radiologic assessment of bladder disorders. 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. 780–787.

Behavioral modifications should be first-line recommendations for patients with enuresis. Modifications include the following:

• Shifting liquid intake toward earlier times of the day—80% of daily liquid intake should be ingested before 5 PM

• Limiting liquids 2 hours before sleep

• Double voiding (voiding twice consecutively) before sleep

• Managing constipation appropriately

The most effective long-term strategy, when no organic causes are present, 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.

Oral Medications 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.

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).

Medication (see table Oral Medications Used for Incontinence in Children

2).

1. 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.

2. 2. Johnson EK, Bauer SB: Neurogenic voiding dysfunction and functional voiding disorders: Evaluation and nonsurgical management. 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. 820–852.