Some Risk Factors for and Organic Causes of Daytime Incontinence and Enuresis in Children

Constipation*

Infrequent, hard-pebble, or very large stools

Sometimes encopresis, abdominal discomfort or distention

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

Usually history and physical examination alone (including stooling diary)

Sometimes abdominal radiographs

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

Often encopresis, vesicoureteral reflux (VUR), and UTI

Possibly nighttime and daytime incontinence

Urodynamic studies to show dyssynergy of bladder musculature

Uroflow testing

Sometimes voiding cystourethrogram

Giggle incontinence

Voiding during laughing, more common among girls

At other times, completely normal voiding

History alone

Increased urine output due to any cause (eg, diabetes mellitus, argininevasopressin deficiency [central diabetes insipidus], arginine vasopressin resistance, excessive water intake, sickle cell disease or trait)*

Vary by disorder

For diabetes mellitus, serum glucose

For arginine vasopressin resistance, serum and blood osmolality and possibly urine sample

For sickle cell, sickle cell screen

Maturational or developmental delay*

No daytime incontinence

More common among boys and heavy sleepers

Possible family history of bed-wetting

History and physical examination alone

Micturition deferral with overflow incontinence

In children, waiting until 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

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

Lumbosacral radiographs

For occult conditions, spinal MRI

Ultrasound of the kidneys and bladder

Urodynamic studies

Obstructive sleep apnea*

History of snoring with pauses in breathing that last 15 seconds or longer followed by loud snorts

Excessive daytime sleepiness

Enlarged tonsils/adenoids

Growth and weight faltering (formerly called failure to thrive)

Polysomnography (also called a sleep study)

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 of overactive bladder

Sometimes consideration of voiding diary, urodynamic studies, uroflow testing

Sexual abuse

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

Inappropriate and sexualized 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)

History alone

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

In children, full daytime continence never achieved

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

Possible history of UTIs, history of other urinary tract abnormalities

Ultrasound of the kidneys

Nuclear renal flow scan or IV urogram

CT of abdomen and pelvis or MRI urogram

UTI*

Dysuria, hematuria, frequency, urgency

Fever

Abdominal pain

Urinalysis

Urine culture

For patients with pyelonephritis, ultrasonography and voiding cystourethrogram

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

Minor leakage when standing after urination

History and physical examination alone‡