Urinary incontinence in children
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
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.
- In 1891, Jacobi inserted a suppository into the rectum multiple times a day for reinforcement of a supposedly weak bladder to treat enuresis. The suppository was a mixture of old sheep fat and strychnine.[1]
- 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.[2]
- 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.[2]
- The term 'enuresis' was formed in 1790 which means 'to urinate within' and 'nocturnal' which means 'nighttime occurrence'. [2]
Classification
- Urinary incontinence, also known as 'bedwetting' or 'enuresis' can be classified as follows:
- Physiological urinary incontinence: 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.[3]
- Pathological urinary incontinence: This is further classified into two broad categories;
- Functional or psychosomatic urinary incontinence: includes all forms of pathological urinary incontinence without anatomic or neurologic defects. Manifestations of which have been subdivided into:
- 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.[4]
- Non-monosymptomatic enuresis nocturna(Non-MEN): diurnal presentation with an urge, frequency, and enuresis.[5] Further sub-categorized based on diurnal symptoms into:
- Overactive bladder
- Discoordinated micturition and
- Infrequent voiding.
- Organic urinary incontinence: usually uncommon. In-depth investigations needed to be identified more so in cases that have not responded to conventional treatment.[3]
- Functional or psychosomatic urinary incontinence: includes all forms of pathological urinary incontinence without anatomic or neurologic defects. Manifestations of which have been subdivided into:
- 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.[5]
Pathophysiology
- The pathophysiology of urinary incontinence in children, particularly enuresis can be described under 3 broad categories:
- Increased urine production at night
- The bladder can fill up easily 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.[6]
- Nocturnal production of the Antidiuretic hormone, ADH is higher when compared to daytime values.[7] 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.[8]
- 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. [9]
- In addition to this, there is disinhibition in contractions of the bladder wall in about 30% of kids with enuresis.[10]
- 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.[11]
Causes
Differentiating [disease name] from other Diseases
For further information about the differential diagnosis, click here.
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.[3]
- Nocturnal enuresis is still seen in 15%-20% of kids at 5 years old with a spontaneous recovery rate of 14% yearly.[12]
- 10% of children still have nocturnal enuresis at the age of 7 years with daytime symptoms seen in 2%-9%.[3]
Gender
- Nocturnal enuresis is seen more frequently in boys.[13]
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 e.g. birth of a sibling, ADHD, anxiety. [13]
Natural History, Complications and Prognosis
- The majority of patients with [disease name] remain asymptomatic for [duration/years].
- Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
- If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
- Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
- Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
Diagnosis
Diagnostic Criteria
- The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
- [criterion 1]
- [criterion 2]
- [criterion 3]
- [criterion 4]
Symptoms
- [Disease name] is usually asymptomatic.
- Symptoms of [disease name] may include the following:
- [symptom 1]
- [symptom 2]
- [symptom 3]
- [symptom 4]
- [symptom 5]
- [symptom 6]
Physical Examination
- Patients with [disease name] usually appear [general appearance].
- Physical examination may be remarkable for:
- [finding 1]
- [finding 2]
- [finding 3]
- [finding 4]
- [finding 5]
- [finding 6]
Laboratory Findings
- There are no specific laboratory findings associated with [disease name].
- A [positive/negative] [test name] is diagnostic of [disease name].
- An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
- Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
Electrocardiogram
There are no ECG findings associated with [disease name].
OR
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
X-ray
There are no x-ray findings associated with [disease name].
OR
An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
Echocardiography or Ultrasound
There are no echocardiography/ultrasound findings associated with [disease name].
OR
Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
CT scan
There are no CT scan findings associated with [disease name].
OR
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
MRI
There are no MRI findings associated with [disease name].
OR
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
Other Imaging Findings
There are no other imaging findings associated with [disease name].
OR
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
Other Diagnostic Studies
- [Disease name] may also be diagnosed using [diagnostic study name].
- Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].
Treatment
Medical Therapy
- There is no treatment for [disease name]; the mainstay of therapy is supportive care.
- The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
- [Medical therapy 1] acts by [mechanism of action 1].
- Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
Surgery
- Surgery is the mainstay of therapy for [disease name].
- [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
- [Surgical procedure] can only be performed for patients with [disease stage] [disease name].
Prevention
- There are no primary preventive measures available for [disease name].
- Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
- Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].
References
- ↑ Salmon, Michael A (2016). "An Historical Account of Nocturnal Enuresis and its Treatment". Proceedings of the Royal Society of Medicine. 68 (7): 443–445. doi:10.1177/003591577506800726. ISSN 0035-9157.
- ↑ 2.0 2.1 2.2 Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM (2013). "Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history". Iran Red Crescent Med J. 15 (8): 633–8. doi:10.5812/ircmj.5017. PMC 3918184. PMID 24578827.
- ↑ 3.0 3.1 3.2 3.3 Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H (2011). "Urinary incontinence in children". Dtsch Arztebl Int. 108 (37): 613–20. doi:10.3238/arztebl.2011.0613. PMC 3187617. PMID 21977217.
- ↑ Zhu W, Che Y, Wang Y, Jia Z, Wan T, Wen J; et al. (2019). "Study on neuropathological mechanisms of primary monosymptomatic nocturnal enuresis in children using cerebral resting-state functional magnetic resonance imaging". Sci Rep. 9 (1): 19141. doi:10.1038/s41598-019-55541-9. PMC 6915704 Check
|pmc=value (help). PMID 31844104. - ↑ 5.0 5.1 Arda E, Cakiroglu B, Thomas DT (2016). "Primary Nocturnal Enuresis: A Review". Nephrourol Mon. 8 (4): e35809. doi:10.5812/numonthly.35809. PMC 5039962. PMID 27703953.
- ↑ Nevéus T, Läckgren G, Tuvemo T, Hetta J, Hjälmås K, Stenberg A (2000). "Enuresis--background and treatment". Scand J Urol Nephrol Suppl (206): 1–44. PMID 11196246.
- ↑ Tas T, Cakiroglu B, Hazar AI, Balci MB, Sinanoglu O, Nas Y; et al. (2014). "Monosymptomatic nocturnal enuresis caused by seasonal temperature changes". Int J Clin Exp Med. 7 (4): 1035–9. PMC 4057857. PMID 24955178.
- ↑ Rittig S, Knudsen UB, Nørgaard JP, Pedersen EB, Djurhuus JC (1989). "Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis". Am J Physiol. 256 (4 Pt 2): F664–71. doi:10.1152/ajprenal.1989.256.4.F664. PMID 2705537.
- ↑ Yeung CK, Sreedhar B, Leung VT, Metreweli C (2004). "Ultrasound bladder measurements in patients with primary nocturnal enuresis: a urodynamic and treatment outcome correlation". J Urol. 171 (6 Pt 2): 2589–94. doi:10.1097/01.ju.0000112978.54300.03. PMID 15118426.
- ↑ Watanabe H (1995). "Sleep patterns in children with nocturnal enuresis". Scand J Urol Nephrol Suppl. 173: 55–6, discussion 56-7. PMID 8719568.
- ↑ Yeung CK, Diao M, Sreedhar B (2008). "Cortical arousal in children with severe enuresis". N Engl J Med. 358 (22): 2414–5. doi:10.1056/NEJMc0706528. PMID 18509134.
- ↑ Arda, Ersan; Cakiroglu, Basri; Thomas, David T. (2016). "Primary Nocturnal Enuresis: A Review". Nephro-Urology Monthly. 8 (4). doi:10.5812/numonthly.35809. ISSN 2251-7006.
- ↑ 13.0 13.1 Nørgaard JP, Djurhuus JC, Watanabe H, Stenberg A, Lettgen B (1997). "Experience and current status of research into the pathophysiology of nocturnal enuresis". Br J Urol. 79 (6): 825–35. doi:10.1046/j.1464-410x.1997.00207.x. PMID 9202545.