Urinary incontinence in children

Urinary incontinence in children Microchapters
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differential Diagnosis
Epidemiology and Demographics
Risk factors
Natural History, Complications and Prognosis
Diagnosis
Treatment
Prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ifeoma Anaya, M.D.[2]

Synonyms and keywords: Urinary incontinence in kids; bedwetting; enuresis; nocturnal enuresis; enuresis nocturna; monosymptomatic enuresis nocturnal (MEN); non-monosymtomatic enuresis nocturnal (non-MEN)

Overview

Urinary incontinence in children is a very familiar finding and complaint amongst patients and their caregivers. The earliest documentation of urinary incontinence dates back to 1550 BC in the Ebers papyrus. It is broadly classified into physiological and pathological with its various subdivisions and nocturnal enuresis can be categorized into primary and secondary. The pathophysiology of urinary incontinence in children, particularly enuresis can be described under increased urine production at night, reduced bladder capacity at night, and awakening disorder. The causes of urinary incontinence in children are identified based on the subclassification of pathological incontinence. Differentials include diabetes mellitus, diabetes insipidus and, urinary tract infection. Children achieve the ability to control their bladder between the ages of 3 and 6 years. This begins initially during the daytime and nighttime control is achieved a lot later. Nocturnal enuresis is seen more frequently in boys. There is no documented racial predilection for enuresis. Some risk factors are age before 5 years, positive family history, family size, and birth order. Certain complications are poor self-esteem and inability to socialize with peers. Prognosis is generally good due to the high chances of spontaneous resolution at the rate of 15% per year. The focus is to eliminate any potential organic cause of incontinence and to classify and identify the type of functional incontinence using detailed history and non-invasive procedures. Identify any comorbidities which are mostly psychological occurring alongside incontinence. Fundamental diagnosis includes taking a detailed history using a standardized questionnaire. The primary aim of a physical examination is to look for possible organic causes of incontinence and comorbidities. Urinalysis is essential to rule out urinary tract infections. Ultrasonography is a useful tool when further diagnostics is required especially in situations of a likely organic cause or a lack of response to therapy. Uroflowmetry and urodynamic studies are additional diagnostic studies that can be employed. Urotherapy encompasses all non-pharmacological and non-surgical treatment methods employed in the treatment of urinary incontinence in children. Desmopressin and Oxybutynin are common drugs used for the pharmacological management of urinary incontinence in children. Surgery is not routinely employed as a form of treatment. Might be of importance in correcting some organic causes of urinary incontinence in children and there are no documented primary preventive measures available for urinary incontinence in children.

Historical Perspective

• Earliest documentation of urinary incontinence dates back to 1550 BC in the Ebers papyrus.
• Pliny the elder, in 77 AD wrote on how incontinence of urine in children is treated by giving boiled mice in their food.
• Paulus Bagellardus of Padua wrote on the distress experienced by parents due to bedwetting when infants after the age of 3 years 'continue to pass water in the bed' which can sometimes last beyond the period of puberty.
• Jacobi placed a suppository into the rectum several times daily for the reinforcement of a supposedly weak bladder in order to treat enuresis in the year 1891. The suppository was a mixture of old sheep fat and strychnine.
• Rhazes, the Persian clinician, identified some causes of enuresis in children to be:
  • Bladder outlet muscle relaxation.
  • Deep sleep.
  • Unrestricted fluid intake prior to bedtime, etc.
• Some of his treatment protocols included:
  • Minimizing fluid intake before bedtime.
  • Intake of substances producing fluid retention and body fluid losses.
  • Use of both oral and injectable medications to the bladder through the urethra.
• The term 'enuresis' was formed in 1790 which means 'to urinate within' and 'nocturnal' which means 'nighttime occurrence'.

Classification

• Urinary incontinence, also known as 'bedwetting' or 'enuresis' can be classified as follows:

Classification of Urinary Incontinence in Children

Types of urinary incontinence	Details
Physiological	It is expected and seen as a norm in the early years. Requires a minimum age of 5 years, at least one event in a month, and a minimum period of 3 months. Persisting beyond the age of 5 years is termed pathological. However, there are the 'late developers' who continue to experience physiologic urinary incontinence beyond the age of 5 years. Clinical evaluation of these kids remains normal.
Pathological	Organic: Usually uncommon. In-depth investigations needed to be identified more so in cases that have not responded to conventional treatment.
	Functional or psychosomatic: Includes all forms of pathological urinary incontinence without anatomic or neurologic defects. Manifestations of which have been subdivided into two:
	Monosymtomatic enuresis(MEN): These kids have never had a dry period of >6 months and in the absence of any bladder dysfunction or symptoms suggestive of lower urinary tract issues.
	Non-monosymptomatic enuresis Nocturna(Non-MEN): Diurnal presentation with an urge, frequency, and enuresis.

• Another form of classification is based on the course of nocturnal enuresis is:
  • Primary nocturnal enuresis: 6 consecutive months without ever achieving bladder control at night. Most common form.
  • Secondary nocturnal enuresis: 6 consecutive months of bladder control attained before a recurrence of incontinence. Could be related to an organic or psychological cause.

Pathophysiology

• The pathophysiology of urinary incontinence in children, particularly enuresis can be described under 3 broad categories:
• Increased urine production at night
  • The bladder is able to fill up at night as a result of an imbalance between the production of urine at night and the capacity of the bladder. This often leads to frequent awakenings to pass urine for children or incontinence for those with difficulties in waking up.
  • Nocturnal production of the Antidiuretic hormone, ADH is higher when compared to daytime values. Thus, the insufficient production of ADH in these children has been identified with a subsequent rise in urine production, frequency of which is 2 out of 3 children.
• Reduced bladder capacity at night/Increased contractions of the detrusor muscle
  • Studies have proposed a reduced bladder wall capacity to 70% of the expected values with an increase in the bladder wall thickness on ultrasound in children with majorly nocturnal enuresis.
  • In addition to this, there is disinhibition in contractions of the bladder wall in about 30% of kids with enuresis.
• Awakening Disorder
  • The sudden urge to pass urine does not occur adequately in kids that are enuretic.
  • Chronic over-stimulation causing a down-regulation of the voiding center has been surmised by researchers.

Causes

• The causes of urinary incontinence in children are identified based on the subclassification of pathological incontinence.
• Causes of MEN are not fully elucidated but are assumed to be a result of an interplay between the delayed maturation of the neurological bladder and how the production of urine is regulated.
• Non-MEN is subcategorized based on its symptoms which is predominantly day-time. These symptoms include:
  • Overactive bladder
  • Discoordinated micturition
  • Infrequent voiding
• Causes of organic incontinence which is usually rare include the following;
  • Structural renal problems such as:
    • Ectopic ureter
    • Malformed urethra
    • Duplex kidney
  • Anatomic neural disorders like:
    • Spina bifida
    • Neoplasms of the nervous system
    • Tethered cord syndrome
    • Sacral agenesis.
  • Obstructive sleep apnea (OSA)
  • Sexual abuse
  • Pinworm infestation

Differentiating urinary incontinence from other Diseases

• Diabetes mellitus.
• Diabetes insipidus.
• Urinary tract infection.
• Anxiety disorder.
• Spinal cord neoplasms.
• Spinal cord trauma.
• Small bladder.

Epidemiology and Demographics

Age

• Children achieve the ability to control their bladder between the ages of 3 and 6 years.
• This begins initially during the daytime and nighttime control is achieved a lot later.
• Nocturnal enuresis is still seen in 15%-20% of kids at 5 years old with a spontaneous recovery rate of 14% yearly.
• 10% of children still have nocturnal enuresis at the age of 7 years with daytime symptoms seen in 2%-9%.

Gender

• Nocturnal enuresis is seen more frequently in boys.

Race

• There is no documented racial predilection for enuresis.

Risk Factors

• Age, before 5 years
• Positive family history. Risk is highest when one parent had been a sufferer of enuresis
• Family size
• Birth order
• Male gender
• Low socioeconomic status
• Constipation
• History of urinary tract infection, diabetes,
• Psychological:
  • Birth of a sibling
  • ADHD
  • Anxiety
  • Change of school
  • New home
  • Divorce of parents

Natural History, Complications and Prognosis

• Complications are:
  • Poor self-esteem
  • Inability to socialize with peers
  • Mood disorders
  • Stress
  • General affectation of child and family's quality of life such as poor academic performance
• Prognosis is generally good due to high chances of spontaneous resolution at the rate of 15% per year.
  • As a result of slow response to conventional treatment like alarm therapy and Desmopressin, 20% will remain incontinent by adulthood.

Diagnosis

• The focus is to eliminate any potential organic cause of incontinence and to classify and identify the type of functional incontinence using detailed history and non-invasive procedures.
• Identify any comorbidities which are mostly psychological occurring alongside incontinence.

Symptoms

• Fundamental diagnosis includes taking a detailed history using a standardized questionnaire. Some of the important questions to ask include:
  • Time of the day child wets self?
  • Pattern of occurrence (every night or every other night)?
  • Place of occurrence (at home)?
  • Frequency of restroom visits during the day and any at night?
  • How does the child pass urine?
  • Any colored stains on pants during the daytime?
  • Any holding movements seen?
  • Pattern of urine stream?
  • Any straining?
  • Child's drinking habits especially in the evenings?
  • Previous/recurrent urinary tract infections?
  • Constipation?
  • Encopresis?
  • Developmental delays?
  • Psychological issues?
  • Previous surgery?
  • Any stressful circumstances recently either at home or school?
  • Method of treatment of incontinence in the past?
• A symptom or bladder diary is completed over a period of 14 days.

Physical Examination

• Primary aim of a physical examination is to look for possible organic causes of incontinence and comorbidities.
  • Weight loss
  • Hypertension (kidney disease)
  • Enlarged tonsils
  • Slow growth
  • Breathing through the mouth
  • Spinal malformations in the lumbosacral region:
    • Lipoma
    • Hair tufts
    • Dimpled sacrum
    • Gluteal folds that appear non-symmetric
    • Hemangiomas
  • Mass on palpation of the abdomen suggesting fecal impaction
  • Genital region:
    • Phimosis
    • Urine leak
    • Labial synechiae
    • Vulval inflammation
    • Labial scars
    • Cremasteric reflex
  • Anal area:
    • Soilage
    • Scratch marks/excoriations
  • Lower extremities:
    • Asymmetric reflexes
    • Atrophic muscles
    • Deformities on the foot
  • Assess developmental milestones attained
  • Assess child's behavior and screen for any behavioral abnormalities using appropriate questionnaires.

Laboratory Findings

• Urinalysis
  • Essential to rule out urinary tract infection.
  • Changes in urine specific gravity suggesting Diabetes insipidus
  • Glucosuria for Diabetes mellitus
• Lack of response to therapy/interventions and a diagnosis of Non-MEN will warrant further work-up.

Echocardiography or Ultrasound

• Ultrasonography is a useful tool when further diagnostics is required especially in situations of a likely organic cause or a lack of response to therapy. It can detect anomalies in the renal system such as:
  • Increase in thickness of the bladder wall
  • Dilated ureters
  • Hydronephrosis
  • Ureterocele
  • Duplex kidney
  • Distended rectum.

CT scan

• There are no CT scan findings associated with urinary incontinence in children. However, a CT scan may be helpful in the diagnosis of organic causes where a more detailed observation of anatomical abnormalities is required.

MRI

• There are no MRI findings associated with urinary incontinence in children. However, an MRI may be helpful in the diagnosis of organic causes where a more detailed observation of anatomical abnormalities is required.

Other Diagnostic Studies

• Uroflowmetry: This shows the bladder's pattern of voiding. If this test comes out suspicious, further testing like the uroflow-electromyography is required to observe pelvic floor details.
• Urodynamic studies: reveals problems associated with the capacity of the bladder, compliance (detrusor muscles).
  • Valuable for illustrating neurogenic bladder or issues related to obstruction of the bladder outlet.

Treatment

• Treatment modality is based on the following fundamental principles:
  • Encourage both patient and caregiver to undergo therapy.
  • Treat day-time symptoms prior to night-time in non-MEN.
  • Fecal incontinence where present should be treated first.
  • Psychiatric comorbidities should be treated concurrently.
  • Higher success rates documented with combined treatment modalities.
  • Continuous monitoring of treatment is highly essential.

Medical Therapy

• Urotherapy.
  • This encompasses all treatment methods employed in the treatment of urinary incontinence in children.
  • They are non-pharmacological and non-surgical and usually first-line approach.
  • It has been proven effective in the management of functional urinary incontinence and supplementary to treatment methods of organic urinary incontinence.
  • The components of urotherapy are divided into Standard urotherapy and specific interventions which may or may not be needed.
  • Standard urotherapy which is the primary treatment for the functional type of urinary incontinence involves the following;
    • Extensive family education regarding the disorder and its management.
    • Suggestions on voiding behavior such as schedules for urination.
    • Fluid intake restrictions and, nutrition in the setting of constipation.
    • Tracking of the progress of treatment.
  • Specific interventions that can be occasionally added to treatment are;
    • Alarm therapy: Most useful for disorders with awakening. It is intended to increase the capacity of the bladder at night. The child is groomed to awaken prior to bedwetting. The ideal treatment for children < 8 years with MEN and with good support from caregivers.
    • Neuromodulation: Transcutaneous parasacral neurostimulation for overactive bladder cases.
    • Biofeedback: using optical and auditory cues to help children to relax and empty their bladder in cases of micturition that are discoordinated.
    • Anti-stress program.
    • Pelvic floor exercise.
    • Self-catheterization.
    • Etc.

• Pharmacological treatment.
  • ADH analogs such as Desmopressin are helpful in the setting of high urine output at night. Effective in 70% of cases with complete remission seen in 25%. Relapse is however a concern but the coordinated stepwise withdrawal of therapy is promising.
  • Anticholinergics like Oxybutynin, Propiverine (preferred due to lower side-effects) are sometimes used in cases of overactive bladder with failure to achieve dryness from urotherapy. 65%-87% response rates are reported with chances of relapse also documented.
  • Botulinum toxin A: rarely indicated.
  • Alpha-blockers
  • Tricyclic antidepressants: has lethal heart side effects and not usually used.

Surgery

• Surgery is not routinely employed as a form of treatment. Might be of importance in correcting some organic causes of urinary incontinence in children.

Prevention

• There are no documented primary preventive measures available for urinary incontinence in children.