Urinary Incontinence
Urinary Incontinence: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics
Urinaryincontinence or enuresis refers to the involuntary passage of urine.Most children have achieved urine continenceduring the day by 4 yrs of age, and during the night by 6 yrs ofage.Primary incontinence exists when achild has never gained bladder control, whereas secondary incontinenceexists when a child who has gained control begins to wet again. Principal Causes of Urinary Incontinence
- Maturationaldelay
- Stress-related causes
- Urinary tract disorders
- Urinarytract infection
- Dysfunctional voiding disorders
- Lower urinary tract obstruction
- Ectopic ureter in girls
- Neurologic disorders
- Mentalretardation
- Neurogenic bladder
- Abdominal or pelvic mass
- Polyuria
- Primary psychologic disturbance
Clinical Features and Diagnosis
Maturational Delay
Most commoncause of primary urinary incontinence is lag in maturation of normal inhibitingmechanism of urine control. There is often family history of incontinence.Many children may achieve daytime controlbut still experience incontinence during sleep.This is a diagnosis of exclusion inan otherwise normal child who has no evidence of organic disease,no history of stress-related or psychologic disturbance, and normalUA and urine culture.At 5–10 yrs of age, spontaneouscure rate of nocturnal enuresis is about 15%/yr. Stress-Related Causes
Stress is frequent cause of secondary incontinence.Examples of stress-related factors are illness, separation, birthof sibling, attending new school, death of family member, divorcein family, and other personal and family problems. Once problemis recognized, proper support and counseling usually help with itsresolution.
Urinary Tract Disorders
Urinary Tract Infection
May causenighttime and daytime incontinence.Other common findings include fever,dysuria, urinary frequency, abdominal or flank pain, and vomiting.Positive urine culture confirms diagnosis(see Chap. 15, Dysuria). Dysfunctional Voiding Disorders
Voidingdysfunction occurs in many children who do not have known organiccause (e.g., neurologic disorder, injury, or malformation).Although some children have small-capacitybladder and experience urgency and often incontinence, others havehyperreflexic bladder with uninhibited detrusor contractions duringfilling. Still others have large hypotonic bladder that does notempty completely with voiding.Failure to empty bladder results inchronically distended bladder that is prone to urinary tract infectionand overflow incontinence.Urinary urodynamic testing is helpfulin determining abnormality in each case. Lower Urinary Tract Obstruction
Can producebladder distension and overflow incontinence. Poor urinary streamwith dribbling and excessive straining with urination are prominentfeatures.Specific causes include posterior urethralvalves, urethral duplication, or urethral cyst.Combination of tests including renalU/S, intravenous urography, and voiding cystourethrographyusually can confirm diagnosis. Retrograde urethrography is generallyrequired for adequate evaluation of urethral duplication. Ectopic Ureter in Girls
Ectopicureter may empty into bladder neck, urethra, vagina, or, rarely,uterus with continuous leakage of small amount of urine. Child hasnormal voiding habits but is frequently wet.Because of frequent occurrence of completeureteral duplication and associated renal parenchymal dysplasiain segment drained by ectopic ureter, renal U/S, intravenousurography, and voiding cystourethrography are useful in evaluation.If diagnosis remains uncertain afterthese studies, but ectopic ureter is still suspected, magnetic resonanceurography may be diagnostic. Cystoscopy can help identify ureteralorifice if it is in urethra, whereas vaginoscopy may be needed ifureter empties into vagina. Neurologic Disorders
Mental Retardation
Although children with mild mental retardationmay have voluntary control of urination, they may have incontinencefor behavioral reasons, while those with severe retardation usuallylack voluntary control of urination.
Neurogenic Bladder
Lower extremityweakness, gait disturbance, fecal incontinence, decreased or absent perianalsensation, and lack of normal anal sphincter tone are common findingsin children with neurogenic bladder.Bladder size can be small, normal,or large, but usually it is small with thick wall.Evaluation of urinary tract may includerenal U/S, voiding cystourethrography, and urodynamic testing.Spinal dysraphism, a common cause ofneurogenic bladder in children, includes myelomeningocele, congenitaldermal sinus, diastematomyelia, and tethered cord syndrome.Myelomeningoceleand dermal sinus tract are visible on physical exam.Diastematomyelia is the splitting ofspinal cord at 1 or more vertebral levels, usually by bony or fibrousspur in spinal canal. The bone spicule may be detectable on spineradiography, but MRI is definitive imaging procedure.Tethering of spinal cord maintainsabnormally low position of cord and prevents its normal ascent.Lipoma, dermoid cyst, or dermal sinus tract are associated lesions,and MRI is diagnostic. Other causes of neurogenic bladderare sacral agenesis, spinal cord injury, and spinal cord tumors.Failure to palpate sacrum and coccyxsuggest sacral agenesis. Radiography of lumbosacral spine showsabsence of sacral segments.History of trauma exists with spinalcord injury.Tumors affecting spinal cord are discussedin Chap. 5, Back Pain. Abdominal or Pelvic Mass
Abdominal or pelvic mass (fecal impaction,mesenteric cyst, presacral teratoma) that impinges on bladder cancause urinary incontinence during running, laughing, coughing, orlifting. Abdominal or pelvic U/S is most useful screeningtest.
Polyuria
Childrenwith diabetes mellitus may have incontinence, especially at night,if they have persistent hyperglycemia that is difficult to control.Other causes of polyuria are diabetes insipidus and psychogenicpolydipsia.Diabetes insipidus is associated withdefect in urine-concentrating ability. Random sample of urine withspecific gravity of >1.028 rules out concentration defect.Even specific gravity of >1.020 on random or early-morningurine sample is evidence of good concentrating ability and againstconcentrating defect.Children with persistent polyuria mayhave structural and functional changes in bladder, which contributeto voiding dysfunction.See Chap.47, Polyuria and Polydipsia. Primary Psychologic Disturbance
Urine incontinence occurs in some childrenwith primary psychologic problems (e.g., depression, a severe personalityor behavioral disorder, or psychosis). History, physical exam, clinicalobservation, and psychologic testing are diagnostic.
Diagnostic Approach
Thoughtfullistening to parents and child usually reveals maturational, stress-related, orother psychologic factors that contribute to urinary incontinence.History, physical exam, UA (includingmeasurement of specific gravity), and urine culture screen for organicdisorders and are helpful in pinpointing the cause of urinary incontinence.Physical exam should include observation of any gait disturbance,exam of sacrum, and testing of perianal sensation, anal sphinctertone, and lower extremity strength, sensation, and reflexes.Abdominal U/S is useful forsuspected lower urinary tract obstruction, ectopic ureter, and abdominalor pelvic mass. Urinary urodynamic testing helps distinguish varioustypes of dysfunctional voiding disorders. CT and MRI are usefulin diagnosis of lesions that cause neurogenic bladder. References
- Ball WS Jr, ed. Pediatric neuroradiology.Philadelphia: Lippincott-Raven, 1997.
- Baskin LS, et al., eds. Handbook of pediatric urology.Philadelphia: Lippincott-Raven, 1997.
- Bauer SB, et al. The unstable bladder of childhood.Urol Clin North Am 1980;7:321–336.
- Rowe MI, et al. Essentials of pediatric surgery. St.Louis: Mosby-Year Book, 1995.
- Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
- Schmitt BD. Daytime wetting (diurnal enuresis). PediatrClin North Am 1982;29:9–19.
- Wojcik LJ, Kaplan GW. The wet child. Urol Clin NorthAm 1998;25:735–744.
Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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