Overview
Definition:
Daytime urinary incontinence in children refers to the involuntary loss of urine during waking hours
It is distinct from nocturnal enuresis and can significantly impact a child's social and emotional well-being
Bladder training is a cornerstone behavioral therapy aimed at improving bladder control and reducing episodes of leakage.
Epidemiology:
The prevalence of daytime urinary incontinence varies with age, decreasing as children mature
Approximately 3-5% of children aged 5-12 years experience daytime wetting
It is more common in boys than girls, particularly in younger age groups
Underlying causes are diverse, ranging from functional voiding issues to anatomical or neurological deficits.
Clinical Significance:
Daytime urinary incontinence can lead to significant psychosocial distress, including bullying, social isolation, and decreased self-esteem
For medical professionals, understanding and effectively managing this condition is crucial for improving the quality of life for affected children and their families
Prompt diagnosis and appropriate intervention, like bladder training, can prevent long-term complications and emotional sequelae.
Clinical Presentation
Symptoms:
Sudden urge to urinate followed by leakage
Frequent urination (frequency)
Urgency without leakage
Holding maneuvers such as squatting or crossing legs (dysfunctional voiding posture)
Incomplete bladder emptying sensation
History of recurrent urinary tract infections
Leakage associated with physical activity or laughter (stress incontinence, less common in children).
Signs:
Normal abdominal and genitourinary examination in most cases
Palpable distended bladder in severe cases of retention
Evidence of constipation (abdominal distension, hard stools)
Signs of spinal dysraphism (hair patch, dimple on lower back).
Diagnostic Criteria:
Diagnosis is primarily clinical, based on a history of involuntary urine loss during the day in a toilet-trained child
Absence of a demonstrable organic cause (e.g., urinary tract infection, structural anomaly, neurological deficit) after appropriate evaluation is often implied
International Children's Continence Society (ICCS) criteria can be utilized for classification.
Diagnostic Approach
History Taking:
Detailed voiding history: frequency, urgency, wetting episodes (timing, triggers, amount)
Bowel habits: constipation is a common contributing factor
Fluid intake patterns: type and quantity of fluids
Previous urinary tract infections or renal issues
Family history of incontinence or voiding dysfunction
Daytime activities and school routine
Child's and parents' perception of the problem
Red flags: fever, flank pain, dysuria, hematuria, neurological deficits, constipation with overflow soiling.
Physical Examination:
General examination: assess for signs of dehydration or systemic illness
Abdominal examination: palpate for distended bladder or fecal impaction
Genitourinary examination: inspect external genitalia for abnormalities, assess for signs of vulvovaginitis or phimosis
Neurological examination: assess lower extremity motor function, sensation, and reflexes
Spinal examination: check for signs of spinal dysraphism.
Investigations:
Urinalysis and urine culture: to rule out urinary tract infection
Post-void residual urine measurement (ultrasound): to assess for incomplete bladder emptying
Renal and bladder ultrasound: to assess renal anatomy and bladder morphology, and rule out structural anomalies
Urodynamic studies: considered in complex cases or when conventional management fails, to assess bladder filling and emptying pressures
Voiding diary: a crucial tool to record fluid intake, voiding frequency, volume, and episodes of incontinence over 2-7 days.
Differential Diagnosis:
Urinary tract infection
Overactive bladder
Detrusor-sphincter dyssynergia (dysfunctional voiding)
Constipation with encopresis
Anatomical abnormalities (e.g., ectopic ureter, vesicovaginal fistula)
Neurological conditions (e.g., spina bifida occulta, spinal cord lesions)
Diabetes insipidus or mellitus (polyuria leading to frequent voiding and potential urgency).
Management
Initial Management:
Education for child and parents about the condition and treatment goals
Reassurance that the child is not at fault
Addressing any contributing factors identified, most importantly constipation.
Bladder Training:
Bladder training is the cornerstone of behavioral therapy for daytime urinary incontinence
It involves a structured program to improve bladder capacity, reduce urgency, and establish regular voiding patterns
Key components include: Scheduled voiding: children are instructed to attempt to void at regular intervals, typically every 2-3 hours, regardless of the urge to urinate
Increased fluid intake: encouraging adequate fluid intake during the day, preferably with water
Avoiding bladder irritants: reducing intake of caffeine, carbonated beverages, and artificial sweeteners
Timed voiding: children are encouraged to void immediately upon waking up and before going to bed
Urge suppression techniques: teaching children to resist the urge to void by distraction or relaxation techniques
Positive reinforcement: praising and rewarding successful voiding and dry periods.
Medical Management:
Pharmacological treatment is usually reserved for cases where bladder training alone is insufficient or as an adjunct
Anticholinergic medications (e.g., oxybutynin, tolterodine) may be prescribed to reduce detrusor overactivity and increase bladder capacity
Dosing is age and weight-dependent
For example, oxybutynin can be initiated at 0.2-0.5 mg/kg/day divided into 2-3 doses
Tricyclic antidepressants (e.g., imipramine) may also be used off-label for their anticholinergic and alpha-adrenergic effects, particularly in conjunction with behavioral therapy
Dosing typically starts low and is titrated up, e.g., imipramine 10-25 mg at bedtime.
Surgical Management:
Surgical management is rarely indicated for primary daytime urinary incontinence due to functional voiding issues
It is reserved for cases with underlying structural abnormalities that cannot be corrected by conservative means, such as vesicovaginal fistulas or severe anatomical defects
Procedures may include ureteral reimplantation, creation of continent urinary diversions, or artificial urinary sphincters in extreme situations.
Supportive Care:
Regular follow-up with healthcare providers is essential to monitor progress, adjust treatment, and provide ongoing support
Addressing psychological and social impact through counseling or support groups
Managing constipation concurrently with appropriate laxatives and dietary advice.
Complications
Early Complications:
Frustration and discouragement for the child and parents due to slow progress
Social withdrawal and emotional distress
Increased risk of urinary tract infections in cases of persistent incomplete emptying.
Late Complications:
Chronic low self-esteem and psychological issues
Persistent social isolation
Potential for developing chronic bladder dysfunction if left untreated
Development of upper urinary tract damage in severe, untreated cases with recurrent UTIs and vesicoureteral reflux.
Prevention Strategies:
Early identification and management of constipation
Consistent application of bladder training techniques
Adequate hydration and avoidance of irritants
Regular follow-up and prompt intervention for any recurrent UTIs
Open communication and positive reinforcement for the child.
Prognosis
Factors Affecting Prognosis:
Adherence to bladder training program
Presence of underlying comorbidities (e.g., neurological deficits, severe constipation)
Age of the child at diagnosis
Parental support and engagement
Severity of the voiding dysfunction.
Outcomes:
With consistent and appropriate bladder training and management, most children achieve significant improvement or complete resolution of daytime urinary incontinence
The success rate is high, especially when constipation is addressed and behavioral strategies are diligently followed
Some children may require intermittent pharmacological support.
Follow Up:
Follow-up is typically guided by the child's response to treatment
Initial follow-up may be every 1-3 months
Once continence is achieved, routine annual check-ups may be sufficient, but it's important to remain vigilant for any recurrence
Long-term follow-up may be necessary for children with underlying chronic conditions.
Key Points
Exam Focus:
Bladder training components: scheduled voiding, urge suppression, timed voiding
Importance of addressing constipation in pediatric incontinence
Role of anticholinergics in refractory cases
Differential diagnoses to consider beyond simple functional incontinence.
Clinical Pearls:
Always rule out constipation
it is a major contributor to daytime wetting
Use a voiding diary as a crucial diagnostic and therapeutic tool
Empower the child and involve them in the treatment plan
Celebrate small victories to maintain motivation
Recognize that bladder training is a process that requires patience and consistency.
Common Mistakes:
Dismissing the problem as a behavioral issue without thorough evaluation
Neglecting to address constipation
Over-reliance on medication without implementing behavioral strategies
Inadequate parental education and support
Punitive approaches that cause shame and anxiety in the child.