Basics
Description
- Daytime wetting in a child ≥5 years of age warrants evaluation.
- Causes of functional incontinence include an array of bladder storage and voiding disorders.
- Voiding dysfunction is abnormal behavior of the lower urinary tract without a recognized organic cause, generally in the form of pelvic floor hyperactivity or bladder-sphincter discoordination.
- Dysfunctional elimination syndrome describes the association between abnormal bladder and bowel behavior.
Prevalence
- Studies in children 6-7 years of age have shown that 3.1% of girls and 2.1% of boys had an episode of wetting at least once per week.
- Spontaneous cure rate of 14% per year without treatment
- Of all children who wet, 10% have only daytime wetting, 75% wet only at night, and 15% wet during the day and at night.
Risk Factors
- Constipation
- Recurrent urinary tract infections (UTIs)
- Diabetes mellitus/diabetes insipidus
- Attention-deficit disorder/attention-deficit/hyperactivity disorder (ADD/ADHD)
- Developmental delay
Genetics
- Only anecdotal relationships have been seen in functional daytime incontinence, unlike studies showing genetic tendencies in nocturnal enuresis.
- Increased rates of daytime wetting have been reported in urofacial (Ochoa) syndrome, an autosomal recessive condition, and Williams syndrome, which is the result of a deletion involving the elastin gene in chromosome 7.
Etiology
- Neurogenic bladder (e.g., myelomeningocele)
- Anatomic anomalies (e.g., ectopic ureter)
- Obstructive uropathy (e.g., posterior urethral valves)
- Bladder irritability caused by UTI
- Constipation
- Increased urinary output-polyuria
- Infrequent or deferred voiding
- Overactive bladder
- Low functional bladder capacity, with detrusor instability during filling
- Vaginal reflux
- Giggle incontinence
- Temperamental factors (e.g., short attention span, inattentiveness to body signals) in children who ignore the urge to void
- Developmental differences in age at which toilet training is achieved
Commonly Associated Conditions
- Constipation (common)
- Nocturnal enuresis (common)
- UTIs (common)
- Vesicoureteral reflux is more common in children with voiding dysfunction due to elevated detrusor pressures that overcome a marginal vesicoureteral junction.
Diagnosis
Signs and Symptoms
- Urgency
- Posturing, Vincent curtsy
- Frequent urination
- Deferred voiding
- Weak or intermittent stream
- Large, hard, or infrequently passed bowel movements
- Recurrent UTIs
History
- Onset (primary vs. secondary)
- Frequency of voiding
- Frequency and degree of wetting
- Presence or absence of any dry interval
- Signs of urgency, use of hold maneuvers, waiting until the last minute to void
- Description of stream (i.e., strong/weak, continuous/interrupted)
- Straining or pushing during voiding
- Frequency and description of bowel movements
- Presence or history of fecal soiling
- Quality and quantity of fluid intake
- History of UTIs, vesicoureteral reflux
- ADD/ADHD, learning disabilities, or developmental delays
- Level of concern on part of child/family
- Medications
Physical Exam
- Abdomen: signs of constipation, distended bladder
- Rectal: if constipation is suspected
- Spine: sacral abnormalities
- Genitalia: labial adhesions, labial erythema, phimosis, urethral stenosis, evidence of leakage
- Neurologic: sensation, reflexes, and gait
Diagnostic Tests & Interpretation
Lab
- 1st morning urinalysis to check concentrating ability, rule out occult renal disease
- Urine culture to rule out infection
Imaging
- Renal and bladder ultrasound in children who wet with a history of UTIs and in children with persistent wetting despite regular voiding
- Kidneys, ureter, and bladder (KUB) x-ray to assess for constipation
- MRI of lumbosacral spine if sacral abnormality or refractory to treatment
Diagnostic Procedures/Other
- Uroflowmetry and assessment of postvoid residual urine
- Invasive urodynamic testing is not indicated in neurologically normal children unless refractory to treatment.
Differential Diagnosis
- UTI
- Constipation
- Developmental variations in toilet training
- Neurogenic bladder
- Spinal cord abnormality
- Giggle incontinence
- Stress incontinence
- Genitourinary tract abnormality (posterior urethral valve, ectopic ureter)
- Vaginal reflux
- Benign increased urinary frequency (pollakiuria)
- Sexual abuse
Treatment
General Measures
- Aggressive management of bowels so that child is passing at least 1 soft bowel movement daily (see "Constipation")
- Elimination schedule, with voids every 2-3 hours and time to defecate at least once a day. A reminder watch may be helpful.
- Voiding diary provides concrete data and focus for child.
- Positive reinforcement for regular voiding
- Avoid acidic/diuretic beverages (caffeine, carbonation, chocolate, citrus).
- Adequate hydration
- Local management of perineal irritation/vulvovaginitis to ensure comfort during voiding
- Girls with postvoid dribbling due to vaginal reflux should void with their legs wide apart, sitting backward on the toilet when possible, to minimize backflow of urine into the vagina. Wipe after standing up.
Alert
- Failure to recognize and manage constipation before attempting to manage wetting
- Use of anticholinergic medications in children with benign frequency of childhood is generally ineffective.
- Increased risk of UTIs when child is placed on anticholinergic medication due to infrequent voiding/incomplete emptying
Medication
- A trial of an anticholinergic may be indicated if the child wets despite conservative medical/behavioral management.
- Extended-release formulations are available.
- Common side effects include dry mouth, decreased diaphoresis with flushing, and constipation. Blurred vision and dizziness are less common.
First Line (≥ 5 years old)
- Oxybutynin (Ditropan/Ditropan XL): 5-15 mg/24 h
- Tolterodine (Detrol/Detrol LA): 2-4 mg/24 h (adult dose; pediatric dose not established)
- Solifenacin (Vesicare): 5-10 mg/24 h (adult dose; pediatric dose not established)
Additional Treatment
Pelvic floor muscle retraining through biofeedback can help children learn to identify and relax the pelvic floor muscles to empty the bladder smoothly and completely.
Issues for Referral
Referral to pediatric urologist
- When wetting is accompanied by recurrent UTIs
- When wetting is refractory to behavioral management, child may benefit from a noninvasive urodynamic evaluation to assess flow pattern, voiding mechanics, and ability to empty the bladder.
Ongoing Care
Prognosis
- Spontaneous cure rate of 14% per year without treatment
- 72% of patients sustained improvement 1 year after simple behavioral therapy.
Complications
- Local irritation and inflammation of the perineum
- Functional daytime incontinence is primarily a social problem that affects children's self-esteem and interactions with peers.
Additional Reading
- Deshpande AV, Craig JC, Smith GH, et al. Management of daytime urinary incontinence and lower urinary tract symptoms in children. J Paediatr Child Health. 2012;48(2):E44-E52. [View Abstract]
- Herndon CDA, Joseph DB. Urinary incontinence. Pediatr Clin North Am. 2006;53(3):363-377. [View Abstract]
- Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics. 1997;100(2, Pt 1):228-232. [View Abstract]
- Thibodeau BA, Metcalfe P, Koop P, et al. Urinary incontinence and quality of life in children. J Pediatr Urol. 2013;9(1):78-83. [View Abstract]
- Wiener JS, Scales MT, Hampton J, et al. Long-term efficacy of simple behavioral therapy for daytime wetting in children. J Urol. 2000;164(3, Pt 1):786-790. [View Abstract]
Codes
ICD09
- 788.30 Urinary incontinence, unspecified
- 788.39 Other urinary incontinence
ICD10
- R32 Unspecified urinary incontinence
- N39.498 Other specified urinary incontinence
SNOMED
- 281862002 Daytime enuresis
- 165232002 urinary incontinence (finding)
- 8702009 diurnal only enuresis (finding)
- 111478000 Nocturnal AND diurnal enuresis (finding)
FAQ
- Q: What findings can distinguish functional incontinence from an ectopic ureter?
- A: An ectopic ureter in girls usually empties below the sphincter or elsewhere, such as in the vagina. Therefore, these girls wet all the time, with no dry period. They do not have symptoms such as urgency. Because in most cases the ureter draining the kidney is duplicated, an ultrasound may be obtained but is not always diagnostic. MR urography provides superior imaging of the urinary tract and is useful in diagnosing ectopic ureter.
- Q: What is a normal bladder capacity for a child?
- A: Normal bladder capacity (in ounces) can be estimated as the child's age plus 1 oz. A child's bladder capacity can be determined by measuring voided volumes for 2 consecutive days when the child is well hydrated. The largest voided volume (not including the first morning void) is considered the child's functional capacity.
- Q: How much water should a child drink each day to cycle the bladder well?
- Adequate water drinking is important to keep the urine more dilute and less irritating to the bladder and to help cycle the bladder. In addition to other fluids, children 5-7 years old should drink at least 20-28 oz of water/day, children 8-12 years old should drink 28-32 oz of water/day, and teens should drink 36-48 oz of water/day.