Urinary incontinence resident survival guide (pediatrics)

Resident Survival Guide

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)

Urinary incontinence resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Urinary incontinence in children is a very familiar finding and complaint amongst patients and their caregivers. It is broadly classified into physiological and pathological with its various subdivisions. The causes of urinary incontinence in children are identified based on the sub-classification of pathological incontinence. 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, it might be of importance in correcting some organic causes of urinary incontinence in children.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated are not common. However, there are possible causes that could result in disability if left untreated and are considered red flags. These include:

• Sexual abuse
• Neurological impairment especially of the lower extremities suggesting possible spinal dysraphisms
• Diabetes mellitus
• Diabetes insipidus
• Urinary tract infection

These are considered to be of particular concern when encountered in practice.

Common Causes

These causes are based on the classification of urinary incontinence in children.

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 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.

FIRE: Focused Initial Rapid Evaluation

• The focus is to eliminate any potential organic cause of incontinence and to classify and identify the type of functional incontinence using detailed history, physical examination and non-invasive procedures.
• Identify any comorbidities which are mostly psychological occurring alongside incontinence.
• Features of importance include:
  • Weight loss
  • Hypertension (kidney disease)
  • Enlarged tonsils
  • Slow growth
  • Breathing through the mouth
  • Spinal malformations in the lumbosacral region such as sacral dimple, hair tufts.
  • Mass on palpation of the abdomen suggesting fecal impaction
  • Genital region abnormalities such as labial synechiae, anal soilage and/or excoriations
  • Asymmetric reflexes of the lower extremities.
  • Urinalysis:essential to rule out urinary tract infection; changes in urine specific gravity suggesting diabetes insipidus and glucosuria for diabetes mellitus

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of urinary incontinence in children according to the International Children's Continence Society guidelines.

•Detailed history: • Questionnaires for defecation and soiling, voiding, wetting should be used

•Establish bedwetting at night time only

• Preclude day symptoms (urgency, frequency) • Urinary tract infections • Other disease pathologies

•Establish nighttime urine output: first morning void and diapers • Fluid intake • Wetting at night

•Bladder diary: • Kept for at least 3 complete days and nights, fluid intake, urine output and volumes, incontinence and defecation should be documented

•Preclude incontinence during the day, frequency, constipation/soiling

•Physical examination

•Establish typical anatomy • Normal psychomotor development

•Preclude atypical anatomy(back and genital regions, reflexes to rule out neurological anomalies)

•Additional investigations required with high index of suspicion of other pathologies

Treatment

Shown below is an algorithm summarizing the treatment of urinary incontinence in children according the International Children's Continence Society guidelines. .

•Nocturnal wet episodes only from history and bladder diary?

No

Consider a different diagnosis

Yes

•Normal physical examination?

No

Consider a different diagnosis

Yes

•Difficulty waking up at night?

•Treatment options: • Patient education, regular fluid intake and urination, optimistic attitude • Plus behavior modification like alarm • Desmopressin alone or with alarm • Contemplate antimuscarinics alone or in combination

•Increased nocturnal urine output

•Multiple nightly wet episodes

Do's

• Encourage both patient and caregiver to undergo therapy and educate extensively about the causes and course of illness so as to ensure adherence to treatment modalities.
• 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.

Don'ts

• Never forget to rule out sexual abuse as a potential cause of urinary incontinence especially in secondary presentations. Failure to identify this is a catastrophic medical mistake as it is too important to neglect.