Primer: diagnosis and management of uncomplicated daytime wetting in children
Vijaya M Vemulakonda and Eric A Jones* About the author
Correspondence *Texas Children's Hospital, 6701 Fannin, Suite 660, Houston, TX 77030, USA
Email eajones@texaschildrenshospital.org
Summary
Functional daytime wetting is a common source of pediatric urologic complaints. Evaluation typically begins in the office setting. In contrast to the adult population, where an inability to maintain voiding control is virtually always considered pathologic, the evaluation of urinary incontinence in children must occur within the context of the child's developmental age. Functional incontinence refers to cases of urinary incontinence in which no structural or neurologic abnormality can be identified. The underlying etiologic mechanisms are heterogeneous, and include disorders of both the storage and voiding phases of the bladder cycle. Optimal treatment of functional daytime wetting depends on an accurate determination of the underlying etiology. Therapeutic options include behavior modification, medication, and aggressive treatment of comorbid conditions such as urinary infection and constipation.
Review criteria
PubMed was searched for abstracts of papers published between January 1980 and June 2005. Papers relevant to the topic of functional daytime incontinence were obtained and reviewed, and cited in this article at the authors' discretion.
Keywords:
Introduction
Daytime wetting is one of the most common urologic complaints in children. Wetting is often considered a minor annoyance, which is generally outgrown as the child matures. Parents often do not recognize daytime wetting as a problem until it has developed into a clinically significant pattern, and treatment of these patients is often difficult. One reason why daytime wetting is difficult to treat is that it can result from a wide spectrum of bladder storage and voiding disorders. As a result, physicians must understand the range of voiding disorders, as well as be familiar with the available diagnostic and management tools, if they are to address the problem of daytime wetting adequately. This article discusses the common etiologies of functional daytime wetting, outlines a simple diagnostic algorithm, and covers the available treatment options.
Etiology of daytime wetting in children
Unlike in the adult population, where the inability to maintain urinary voiding control is almost always pathologic, urinary incontinence in children must be evaluated within the context of the child's developmental age. The impact of voiding control on social interaction and function evolves as a child progresses through their first years of life and is influenced by social, cultural, and environmental factors.
In the infant (less than 1 year old), micturition occurs via a reflex mechanism mediated by the spinal cord. During bladder filling, the bladder reaches an intrinsic volume threshold, which triggers a spontaneous bladder contraction. This vesicovesical reflex coordinates relaxation of the bladder neck and external urethral sphincter. Voiding is complete, occurs at low pressures, and is autonomous. Owing to the low volume threshold for urination, an infant voids approximately 20 times per day.1
As the young child develops (generally between the ages of 1 and 2 years), neural pathways in the spinal cord mature, and the vesicovesical reflex is suppressed. A more complex voiding reflex develops, with the coordination of voiding control mediated by the pons and midbrain. During this transitional phase, functional bladder capacity increases, and urination becomes less frequent. By the age of 2 years, most children void 10 to 12 times per day, are aware of bladder fullness, and can announce their need to urinate.2 Between 2 and 3 years of age, children can volitionally postpone voiding, and can initiate voiding at bladder volumes below capacity. During this period, the child develops a stable, quiescent bladder, and an adult pattern of daytime urinary control emerges.
As with other developmental milestones, the time course for attaining urinary continence varies. The majority of children have volitional urinary control by the age of 5, before they enter school. Beyond this age, incontinence becomes of increasing social concern. Brazelton and colleagues found that 26% of children achieved daytime continence by the age of 24 months, 52.5% by 27 months, 85% by 30 months, and 98% by 3 years of age.3 Bloom and colleagues, in their study of 1,186 healthy children, found that toilet training occurred between 0.75–5.25 years of age, with a mean age of 2.4 years at the completion of toilet training. In their study, they found that toilet training occurred slightly earlier in girls than in boys.4 Hellstrom and associates, however, found that the incidence of diurnal incontinence was higher in 7-year-old girls (6%) than in similar-aged boys (3.8%).5
Classification of pediatric urinary incontinence
Classification of pediatric urinary incontinence has been complicated by the lack of standardized definitions. In 1997, the International Children's Continence Society addressed this problem by the publication of a report that aimed to standardize and define lower urinary tract dysfunction in children. In this consensus report, urinary incontinence was defined as "the involuntary loss of urine, objectively demonstrable, and constituting a social or hygienic problem".6 The International Children's Continence Society has recently released an updated report on the standardized terminology for lower urinary tract function in children and adolescents.7 The remainder of this article adheres to these updated guidelines.
Childhood urinary incontinence can be caused by an underlying disease process (organic incontinence), or can have no underlying associated abnormality (functional incontinence) (Figure 1). In patients with organic urinary incontinence, an underlying anatomic or neurogenic abnormality is present. Structural urinary incontinence refers to developmental, iatrogenic, and traumatic anatomic abnormalities of the lower urinary tract that interfere with the urinary system's ability to store or evacuate urine. Included in this classification are etiologic factors such as the exstrophy–epispadias complex, ectopic ureter, and posterior urethral valves. Neuropathic urinary incontinence refers to abnormalities of bladder or urinary sphincter innervation, and can also be congenital or acquired. Common neuropathic causes of urinary incontinence include neurospinal dysraphism, sacral agenesis, spinal-cord injury, cerebral palsy, and tethered spinal cord.
Figure 1 Classification of childhood incontinence.
The diagram shows the International Children's Continence Society classification for childhood urinary incontinence, and includes the most common causes of functional daytime incontinence. Abbreviation: OAB, overactive bladder.
Full figure and legend (16K)Figures & Tables indexDownload Power Point slide (220K)In contrast to organic urinary incontinence, functional urinary incontinence refers to cases of urinary incontinence in which no structural or neurologic abnormality can be identified. This classification covers a heterogeneous group of disorders, including urge syndrome, dysfunctional voiding, enuresis, and vaginal voiding. The majority of cases of urinary incontinence in children are included in this category.
Urge incontinence
Detrusor overactivity (or the inability to maintain detrusor quiescence) is common during the transition from infantile voiding to an adult pattern of urinary control. Urge incontinence results from a recurrence or persistence of this transitional phase. Clinically, patients present with urinary frequency, the sudden imperative to void, and holding maneuvers such as flexing the pelvic-floor muscles, crossing the legs, and squatting on the heel (Vincent's curtsy). This symptom complex is caused by overactivity of the detrusor muscle, which results in sudden bladder contractions at volumes below the capacity that is expected for a particular age. Incontinence occurs in children who are unable to volitionally suppress these bladder contractions.8
Dysfunctional voiding
Dysfunctional voiding includes several patterns of voiding with a common underlying feature: overactivity of the pelvic-floor musculature during micturition. Urge incontinence and dysfunctional voiding are thought to represent different time points during the natural history of a single disease process. Children with urgency symptoms learn to suppress detrusor contractions by volitionally contracting the external urethral sphincter and pelvic-floor muscles. Two forms of dysfunctional voiding have been described. Staccato voiding is characterized by bursts of pelvic floor activity during voiding, which leads to a rhythmic voiding pattern with incomplete bladder emptying and prolonged urinary flow. Fractionated voiding is characterized by small voided volumes with incomplete bladder emptying and an underactive detrusor muscle. Often, the detrusor contraction can be augmented by performing the Valsalva maneuver to increase urine flow rate and completeness of bladder emptying.6 Long-term consequences of pelvic-floor overactivity include high-pressure voiding, urinary-tract infection, vesicoureteral reflux and, ultimately, decompensation of the detrusor muscle. Urinary incontinence can occur at any point along this spectrum and might be the result of detrusor instability, urinary-tract infection, or overflow incontinence.8
Underactive bladder
Previously termed 'lazy bladder syndrome', underactive bladder is characterized by infrequent voiding. Patients typically void only once or twice daily, and often do not void on waking. They are typically dry at night-time. Children have an increased bladder capacity and diminished sensation of bladder fullness. The syndrome is more common in girls than boys.9
Non-neurogenic neurogenic bladder syndrome
The most severe form of dysfunctional voiding is non-neurogenic neurogenic bladder syndrome (Hinman–Allen syndrome). In this condition, children present with features of severe obstructive uropathy, including elevated postvoid residual (PVR) urine volume, a thickened, trabeculated bladder wall, recurrent urinary-tract infections, and acquired vesicoureteral reflux and hydronephrosis. Despite the severity of their symptoms, no underlying anatomic or neurologic etiology can be found in these children. This syndrome is thought to result from learned discordance between detrusor contraction and external urethral sphincter relaxation.10
Enuresis
Unlike other forms of functional incontinence, enuresis is characterized by a physiologically coordinated void that occurs at a socially unacceptable time. It typically occurs while asleep (nocturnal enuresis). This disorder is extremely common in young children, with a reported incidence of 15–20% in five-year-olds. It is characterized by spontaneous resolution, which occurs in 15% of affected children each year after the age of 5. Approximately 2% of 15-year-old children will continue to have nocturnal enuresis.11
Giggle incontinence
A rare type of incontinence, giggle incontinence occurs during intense laughter. It is characterized by an abrupt, uncontrollable bladder contracture and is generally associated with complete bladder emptying. Affected individuals often modify their social interactions to avoid situations likely to induce laughter.
Vaginal reflux
Functional urinary incontinence can also result from extraurethral causes. A common example is vaginal reflux. Vaginal reflux is a specific form of incontinence characterized by post-void dribbling. This condition is seen primarily in overweight girls who cannot adequately separate the labia during urination. Occasionally, vaginal reflux occurs in slender girls who adopt a hairpin posture while sitting on an adult toilet. Vaginal voiding is generally treated by modification of the voiding posture to prevent pooling of urine in the vagina during voiding. Overweight girls will respond to reverse toilet voiding. Slender girls should be encouraged to void with a pediatric toilet insert.
Conditions associated with urinary tract dysfunction
Constipation
Constipation has been implicated as an etiology for urinary tract dysfunction in children. In a study of 234 children with chronic constipation and urinary incontinence, Loening-Baucke found that, after their constipation was treated, 89% of children had resolution of their daytime wetting and all children with chronic urinary tract infections and anatomically normal urinary tracts had resolution of their infections.12 The mechanism by which constipation affects urinary continence and urinary tract infection is not clear. Physical displacement of the bladder by stool accumulated in the rectum can directly affect bladder capacity, and could promote bladder instability.13, 14 Parasympathetic efferent nerve fibers from the distended colon might affect bladder sensation and contractility by a mechanism that is yet to be determined.15
Urinary tract infections
The association between urinary tract infection and daytime incontinence has been studied extensively, although the reason for the link remains elusive. The incidence of recurrent urinary tract infection is between 50% and 90% in children with functional incontinence, with girls affected more often than boys.16, 17 Incomplete bladder emptying might facilitate the transition from bacterial colonization to development of urinary tract infection.18 The presence of urinary tract infection exacerbates the urgency and frequency symptoms that are associated with daytime incontinence, by causing inflammation of the bladder wall.19 There is an association between urinary tract infection and detrusor–sphincter dyssynergia and, therefore, children with recurrent urinary tract infections and incontinence should be evaluated for dysfunctional voiding. Likewise, it is important to evaluate all children with incontinence for urinary tract infections.
Evaluation of children with urinary incontinence
Medical history
Evaluation of the child with urinary incontinence typically begins in the office setting (Figure 2). A thorough medical history will delineate the pattern of incontinence and can identify underlying neurologic or anatomic anomalies. The medical history should include information about the child's voiding habits, including straining, urinary frequency, urination posture, pain with urination, and associated constipation or infection. An obstetric history should be taken to reveal evidence of fetal distress, anoxia, birth trauma, prenatal hydronephrosis, or oligohydramnios. A history of developmental delay, impaired upper or lower motor skills, and associated encopresis raises the suspicion of a neurologic etiology for urinary incontinence. Finally, a family history and social history might be useful in the assessment of underlying medical conditions or stressors that might contribute to urinary incontinence.
Figure 2 Evaluation of childhood wetting.
If the patient's initial medical history, physical examination, or urine studies suggest an abnormality, a renal and/or bladder ultrasound, and urine flow rate with pelvic floor electromyogram should be obtained. Voiding cystourethrography is reserved for cases in which an anatomic or neuropathic etiology is considered, or when vesicoureteral reflux is suspected. Cystometrography rarely has a role in the evaluation of functional daytime incontinence. This investigation is reserved for severe cases of dysfunctional voiding, and when a neuropathic etiology is considered. Abbreviations: EMG, electromyography; VCUG, voiding cystourethrography.
Full figure and legend (24K)Figures & Tables indexDownload Power Point slide (228K)A 3-day voiding and defecation diary is a useful tool to define the severity and frequency of incontinence episodes, as well as the presence or absence of constipation. The voiding diary should include an assessment of fluid intake.6, 8
Physical examination
Physical examination should include an inspection of the abdomen, genitalia and spine, as well as a directed neurologic examination, which should include an assessment of lower extremity muscle tone and strength, gait, and symmetry of lower extremity reflexes. The abdomen should be palpated to determine the presence of suprapubic fullness suggestive of bladder distension. A palpable left lower quadrant mass can indicate fecal impaction. A genital examination might disclose the presence of labial adhesions, vulvovaginitis, ectopic ureter, or abnormal urethral position in girls and abnormalities of the urethral meatus in boys. The lower back is inspected for scoliosis as well as stigmata of occult spinal dysraphism, such as sacral dimple, hair tuft, hemangioma, or lipoma. The coccyx should also be examined for evidence of sacral agenesis. The lower extremities and gluteal folds should be evaluated for asymmetry, which might be evidence of tethered cord syndrome.20
Analysis of urine
Urinalysis is an important part of the initial evaluation of children with lower urinary tract dysfunction. Evidence of urinary tract infection, such as bacteriuria or pyuria, might require additional radiographic evaluation. Specific gravity of a first morning urine sample is useful in the evaluation of urine-concentrating ability, while urine glucose levels can identify diabetes mellitus. Presence of hematuria might also elicit additional radiographic or laboratory evaluation.
Imaging and urodynamic studies
The need for additional imaging and functional studies is determined by findings from the patient's history and physical examination. Abdominal radiography is useful as an objective measure of constipation. In children with demonstrable neurologic or lumbosacral abnormalities on physical examination, an MRI is required in order to evaluate structural anomalies of the spinal cord.
Renal ultrasound is an excellent screening tool for patients with functional daytime incontinence. Ultrasonography is useful in the detection of structural abnormalities of the kidneys and bladder, such as hydronephrosis, ureterectasis, ureterocele, and bladder wall thickening (Figure 3). Children with recurrent or febrile urinary tract infections or bladder wall thickening, observed on ultrasound, should undergo voiding cystourethrography (VCUG). This procedure allows evaluation for vesicoureteral reflux, and structural abnormalities of the urethra in boys.
Figure 3 Ultrasound showing bladder-wall thickening in a 6-year-old female with recurrent urinary infections, vesicoureteral reflux, and daytime wetting.
Normal bladder wall thickness should be less than 2 mm in normal children with a distended bladder; this child has a bladder-wall thickness of 5.2 mm.
Full figure and legend (8K)Figures & Tables indexDownload Power Point slide (212K)VCUG should be used in children with suspected dysfunctional voiding. Children who fail to relax the urethral sphincter during voiding often have a 'spinning top' urethral configuration. This appearance is due to a failure to relax the external sphincter during voiding, causing dilation of the proximal urethra. In children with infrequent voiding, VCUG could reveal a large capacity, smooth-walled bladder with a significant PVR volume. Males with dysfunctional voiding should undergo a careful evaluation of the urethra during the voiding phase, to rule out obstructive abnormalities of the urethra.
A number of physiologic tests are available that evaluate bladder and sphincter function. The urine flow rate is an indirect measure of bladder and sphincter function, which is often used in conjunction with pelvic-floor electromyography, to evaluate pelvic-floor activity during voiding. Invasive urodynamic studies such as cystometrography and videourodynamics rarely add to the management of patients with milder forms of functional incontinence, and should be reserved for those patients with complex forms of functional urinary incontinence such as non-neurogenic neurogenic bladder syndrome.6, 21
Treatment options for pediatric patients
Treatment should be chosen according to the cause of the incontinence. The different treatment options and their efficacies are summarized in Table 1. As with nocturnal enuresis, many children outgrow daytime incontinence. Saedi and associates, in their study of 90 patients with daytime wetting, found that 91% had spontaneous resolution of their incontinence with a median time of 2.9 years. Maturation was thought to be the most important factor in improvement of voiding habits.22 As a result, close monitoring and support of patients with functional incontinence is a cornerstone of treatment for children with uncomplicated daytime wetting.
Table 1 Comparison of treatment modalities for uncomplicated day-time wetting.
Full tableFigures & Tables indexDownload Power Point slide (218K)
Behavioral therapy
Behavioral modification has remained the mainstay of treatment for daytime wetting. These measures focus on relearning and training the normal responses from the bladder and urethra. Bladder irritants such as caffeine should be eliminated from the diet. In children with underactive bladder, urge incontinence, and dysfunctional voiding, voiding at predetermined times aids in retraining the child to exercise voluntary bladder control. The child voids on waking, and subsequently at least every 2 h, during waking hours. As urgency improves, the interval between voids can be extended. In children with infrequent voiding, in whom an elevated PVR volume is encountered, double voiding will both increase functional bladder capacity and decrease the risk of infection.
Timed voiding alone has been successful in 30–50% of patients with dysfunctional voiding.23 Wiener and colleagues showed that a combination of timed voiding, modification of fluid intake, pelvic-floor exercises, and voiding diaries improved daytime urinary control in 60% of patients.24
Clean intermittent catheterization
In children with poor bladder emptying, clean intermittent catheterization (CIC) is the treatment of last resort, used to decrease the frequency of recurrent infections and regain urinary continence. Pohl and associates treated 23 children who were neurologically and anatomically normal with CIC. Of the 23 patients, 16 successfully started CIC within 2 weeks of initial instruction, and remained on CIC for a mean of 4 months. All children who remained on CIC were dry, with three girls voiding normally and with normal PVR volumes within 6 months of treatment.25
Medical treatments
Medical therapy can also be used in conjunction with bladder retraining, although medication should not be used as a replacement for behavioral therapy.26
Anticholinergic agents
Anticholinergic treatment focuses on mediation of involuntary detrusor contraction. Medical treatment with anticholinergic agents has been shown to significantly improve or resolve urge incontinence in children, and most patients who have a continued durable response to these agents can stop medical therapy within 6 months of initiation.19 In a study by Curran and colleagues, 26 of 30 patients treated with oxybutynin, hyoscyamine, or imipramine had significant improvement or resolution of their daytime incontinence; however, 38% of patients continued to be dependent on medication to stay dry at a mean follow-up period of 4.7 years.27 Anticholinergic treatment seems to be most effective in patients who have 50–90% of the bladder capacity expected for their age.28
Oxybutynin chloride has been the most-studied anticholinergic agent in the pediatric population. Oxybutynin has antispasmodic effects and is often used in children with detrusor overactivity. Adverse effects associated with this treatment include dry eye, dry mouth, dysphagia, blurred vision, constipation, headache, transient urinary retention, and drowsiness. Oxybutynin crosses the blood–brain barrier and, therefore, children could also experience nightmares or personality changes. Adverse effects occur more frequently in children than in adults,29 although the incidence of significant adverse events in children is less than 5%.30 In a study by Hjalmas and associates, 70% of children with functional daytime incontinence improved significantly.30 Randomized, controlled studies, however, have not shown a significant improvement in functional daytime wetting in children treated with oxybutynin.31
Alpha-adrenergic antagonists
Alpha-adrenergic antagonist therapy has been studied as a treatment for children with pelvic-floor overactivity. Therapy aims to reduce bladder-outlet resistance, although studies suggest that alpha-adrenergic antagonists might also increase functional bladder capacity.32 Austin et al. studied the use of doxazosin in 17 children, 12 of whom had evidence of non-neurogenic dysfunctional voiding. Of the children treated, 82% showed a significant improvement in symptoms, and 71% had a reduction in their PVR urine volume. All patients with uninhibited detrusor contractions experienced resolution of their symptoms, and symptoms in patients with evidence of detrusor–sphincter dyssynergia improved with therapy. All three children who failed to respond to treatment had evidence of non-neurogenic neurogenic bladder syndrome. Adverse events were minimal; only one child experienced mild postural hypotension, which resolved with dose reduction.33 Although alpha-adrenergic antagonist therapy has not been studied extensively, it seems to be safe in children, and effective in treating children with dysfunctional voiding.
Tricyclic antidepressants
Imipramine has been shown to have anticholinergic and antispasmodic effects,34 and can improve awareness of bladder fullness.26 Tricyclic antidepressants are, however, associated with significant adverse effects, including anxiety, nausea, insomnia, and personality changes. An overdose of tricyclic antidepressants can cause cardiac arrhythmia, hypotension, and convulsions, and in some cases can lead to death.35 Furthermore, controlled studies of imipramine have failed to show a significant benefit over placebo in the treatment of urge incontinence or voiding dysfunction.36 Although tricyclic antidepressants have been used extensively in children with nocturnal enuresis, they have a limited role in the treatment of daytime wetting in children.
Biofeedback training
Pelvic-floor biofeedback training has been used successfully in patients with pelvic-floor dysfunction. Children are taught to relax while voiding by sitting with the thighs spread apart and bending forward slightly. A bench or stool can be placed under the feet of smaller children to aid in relaxation. For a biofeedback program to be successful, however, the patient's participation and interest are required.37, 38 Porena and colleagues showed that biofeedback therapy was successful in treating children with functional detrusor–sphincter dyssynergia. Children who completed therapy had shorter voiding times, decreased PVR volumes, and quiescent pelvic-floor musculature during voiding, when compared to baseline.39 Similarly, Chin-Peuckert and colleagues reported that 61% of their patients treated with biofeedback for detrusor–sphincter dyssynergia demonstrated durable improvement in symptoms at a mean follow up of 9 months.40
Interactive video games have been developed to aid in biofeedback training. Golf, basketball, and spaceship games, among others, have been developed that link the game scores to the patient's ability to contract and relax the pelvic-floor musculature. Use of these games resulted in a symptomatic improvement of up to 89% and cure rates of 61% in patients with daytime incontinence.38 Factors associated with poor results include a small bladder capacity and patient noncompliance.41
Treatment of constipation
Treatment of underlying constipation should be used in conjunction with primary treatment for daytime wetting. Loening-Baucke found that treatment of constipation alone led to resolution of urinary incontinence in 89% of children with functional incontinence.12 The goal of treatment for constipation is to cleanse the bowel of impacted stool, and promote a soft, daily bowel movement. Enemas or laxatives are often used for initial bowel evacuation, followed by a maintenance program with either oral fiber supplementation or polyethylene glycol. Fiber supplements promote retention of water in the stool, which facilitates intestinal transit and defecation. Polyethylene glycol acts as a simple osmotic laxative.
A study of 55 patients with dysfunctional elimination treated with polyethylene glycol showed that 45 patients had resolution of their constipation and 44 had resolution or significant improvement of their urinary incontinence.42 Although constipation should initially be treated medically, long-term control should include bowel training and a high-fiber diet. Bowel training requires maintenance of a defecation routine and parental support and encouragement. Use of these measures allows the majority of patients to remain free from both constipation and urinary incontinence symptoms.43
Conclusion
Uncomplicated daytime wetting represents a spectrum of voiding disorders in children. Although most cases are not related to any structural or neurologic abnormality, it is important to exclude an organic etiology in any child who presents with daytime wetting. As a result, a thorough medical history and physical examination is essential at the time of diagnosis. Additional laboratory, radiographic, and urodynamic investigations might be indicated in selected patients.
Once functional urinary incontinence has been diagnosed, a variety of behavioral modification and medical treatments are available. Use of a structured approach to the diagnosis and treatment of voiding dysfunction in children means that the physician can address the underlying voiding disorder effectively, while minimizing the effects of the condition on the child's social development and preventing the potentially harmful effects of infection, vesicoureteral reflux, and obstructive uropathy that are associated with untreated voiding dysfunction.
Key points
- Daytime wetting in the pediatric population must be evaluated in the context of the patient's developmental age
- Functional daytime wetting in children is caused by diverse abnormalities in urine storage and voiding
- It is important to identify and treat comorbid conditions such as urinary infection and constipation
- Invasive urodynamic studies rarely have a role in the evaluation of functional daytime wetting
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Competing interests
The authors declared no competing interests.
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Subject areas under which this article appears: Pediatric urology | Urinary incontinence, urodynamics and lower urinary tract dysfunction
