Daytime Incontinence

Daytime Incontinence: Excerpt from The 5-Minute Pediatric Consult

Amanda K. Berry, BSN, MSN, CPNPSeth L. Schulman, MD

Daytime Incontinence - BASICS

Daytime Incontinence - description

• Daytime wetting in a child ≥5 years of age warrants evaluation.
• Causes of functional incontinence include an array of bladder storage and voiding disorders
• Voiding dysfunction is abnormal behavior of the lower urinary tract without a recognized organic cause, generally in the form of pelvic floor hyperactivity or bladder–sphincter discoordination
• Dysfunctional elimination syndrome describes the association between abnormal bladder and bowel behavior

• Failure to recognize and manage constipation before attempting to manage wetting
• Failure of anticholinergic medication in children with significant postvoid residuals or with constipation
• Use of anticholinergic medications in children with benign frequency of childhood is generally ineffective.
• Increased risk of urinary tract infections when child is placed on anticholinergic medication, due to infrequent voiding/incomplete emptying

Daytime Incontinence - prevalence

• Studies in children 6–7 years of age have shown that 3.1% of girls and 2.1% of boys had an episode of wetting at least once per week.
• Spontaneous cure rate of 14% per year without treatment
• Of all children who wet, 10% have only daytime wetting, 75% wet only at night, and 15% wet during the day and at night.

Daytime Incontinence - risk factors

• Constipation
• Recurrent UTIs
• Diabetes mellitus/diabetes insipidus
• ADD/ADHD
• Developmental delay

Daytime Incontinence - genetics

• Only anecdotal relationships have been seen in functional daytime incontinence, unlike studies showing genetic tendencies in nocturnal enuresis.
• Increased rates of daytime wetting have been reported in urofacial (Ochoa) syndrome, an autosomal-recessive condition, and Williams syndrome which is the result of a deletion involving the elastin gene in chromosome #7.

Daytime Incontinence - etiology

• Neurogenic bladder (e.g., myelomeningocele)
• Anatomic anomalies (e.g., ectopic ureter)
• Obstructive uropathy (e.g., posterior urethral valves)
• Bladder irritability caused by urinary tract infection
• Constipation
• Increased urinary output—polyuria
• Infrequent or deferred voiding
• Overactive bladder
• Low functional bladder capacity, with detrusor instability during filling
• Temperamental factors (e.g., short attention span, inattentiveness to body signals) in children who ignore the urge to void
• Developmental differences in age at which toilet training is achieved
• Vaginal reflux with subsequent leakage of urine

Daytime Incontinence - associated conditions

• Constipation
• Nocturnal enuresis
• UTIs
• Vesicoureteral reflux is more common in children with voiding dysfunction, due to elevated detrusor pressures that overcome a marginal vesicoureteral junction

Daytime Incontinence - DIAGNOSIS

Daytime Incontinence - signs & symptoms

• Urgency:
  • Posturing; Vincent’s curtsy
• Frequent urination
• Deferred voiding
• Weak or intermittent stream
• Large, hard or infrequently passed bowel movements
• Recurrent UTIs

Daytime Incontinence - history

• Onset (primary versus secondary)
• Frequency of voiding
• Frequency and degree of wetting
• Presence or absence of any dry interval
• Signs of urgency; use of hold maneuvers; waiting until the last minute to void
• Description of stream (i.e., strong/weak, continuous/interrupted)
• Straining or pushing during voiding
• Frequency and description of bowel movements
• History of soiling
• History of UTIs, vesicoureteral reflux
• Attention deficit disorder/attention deficit hyperactivity disorder, learning disabilities, or developmental delays
• Level of concern on part of child/family
• Medications
• Quality and quantity of fluid intake

Daytime Incontinence - physical exam

• Abdomen: Signs of constipation; distended bladder
• Rectal: If constipation is suspected
• Spine: Sacral abnormalities
• Genitalia: Labial adhesions, labial erythema, phimosis, urethral stenosis
• Neurologic: Sensation, reflexes, and gait

Daytime Incontinence - tests

Daytime Incontinence - lab

• 1st morning urinalysis to check concentrating ability, rule out occult renal disease
• Urine culture to rule out infection

Daytime Incontinence - imaging

• Renal and bladder ultrasound in children who wet with a history of urinary tract infections and in children with persistent wetting despite regular voiding
• Kidneys, ureter, and bladder (KUB) x-ray to assess for constipation

Daytime Incontinence - diag proced-surgery

Invasive urodynamic testing is not indicated in neurologically normal children unless refractory to treatment.

Daytime Incontinence - pathological findings

• Posterior urethral valves
• Ectopic ureter
• Tethered spinal cord

Daytime Incontinence - differencial diagnosis

• UTI
• Constipation
• Developmental variations in toilet training
• Neurogenic bladder
• Spinal cord abnormality
• Giggle incontinence
• Genitourinary tract abnormality (posterior urethral valve, ectopic ureter)
• Vaginal reflux
• Benign increased urinary frequency (pollakiuria)
• Sexual abuse

Daytime Incontinence - TREATMENT

Daytime Incontinence - general measures

• Aggressive management of bowels so that child is passing at least 1 soft bowel movement daily (see: “Constipation”)
• Elimination schedule, with voids every 2–3 hours and time to defecate at least once a day. A reminder watch may be helpful.
• Voiding diary provides concrete data and focus for child
• Positive reinforcement for regular voiding
• Avoid acidic/diuretic beverages (caffeine, carbonation, chocolate, citrus)
• Adequate hydration
• Local management of perineal irritation/vulvovaginitis to ensure comfort during voiding
• Girls with postvoid dribbling due to vaginal reflux should void with their legs wide apart, sitting backward on the toilet when possible, to minimize backflow of urine into the vagina. Wipe after standing up.

Daytime Incontinence - medication

• A trial of an anticholinergic may be indicated if the child wets despite conservative medical/behavioral management.
• Extended-release formulations available
• Common side effects include dry mouth, decreased diaphoresis with flushing and constipation. Blurred vision and dizziness less common.

Daytime Incontinence - first line

• Oxybutynin (Ditropan/Ditropan XL): 5–15 mg/d
• Tolterodine (Detrol/Detrol LA): 2–4 mg/d
• Hyoscyamine (Levbid): 0.75–1.5 mg/d

Daytime Incontinence - FOLLOW UP

Daytime Incontinence - disposition

Daytime Incontinence - issues for referral

Referral to pediatric urologist:

• When wetting is refractory to behavioral management child may benefit from a noninvasive urodynamic evaluation to assess flow pattern, voiding mechanics and ability to empty the bladder.

Daytime Incontinence - prognosis

• Spontaneous cure rate of 14% per year without treatment.
• 72% of patients sustained improvement 1 year after simple behavioral therapy.

Daytime Incontinence - complications

• Local irritation and inflammation of the perineum
• Functional daytime incontinence is primarily a social problem that affects children’s self-esteem and interactions with peers.

Daytime Incontinence - bibliography

1. Herndon CDA, Joseph DB. Urinary incontinence. Ped Clin N Am. 2006;53:363–377.
2. Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics. 1997;100:228–231.
3. Saedi N, Schulman SL. Natural history of voiding dysfunction. Pediatr Nephrol. 2003;18:894–897.
4. Schulman SL. Voiding dysfunction in children. Urologic Clinic North Am. 2004;31:381–390.
5. Wiener JS, Scales MT, Hampton J, et al. Long-term efficacy of simple behavioral therapy for daytime wetting in children. J Urol. 2000;164:786–790.

Daytime Incontinence - CODES

Daytime Incontinence - icd9

788.30 Urinary incontinence, unspecified

Daytime Incontinence - FAQ

• Q: What findings can distinguish functional incontinence from an ectopic ureter?
• A: An ectopic ureter usually empties below the sphincter or elsewhere, such as in the vagina. Therefore, these girls wet all the time, with no dry period. They do not have symptoms such as urgency. Because in most cases the ureter draining the kidney is duplicated, an ultrasound or IV pyelogram (IVP) may provide more information.
• Q: What is a normal bladder capacity for a child?
• A: Normal bladder capacity can be estimated as the child’s age plus 2 ounces. A child’s bladder capacity can be determined by measuring voided volumes for 2 consecutive days when the child is well hydrated. The largest voided volume is considered the child’s maximum functional capacity.
• Q: When is an MRI of the spine indicated?
• A: Spinal cord imaging should be considered in children with refractory daytime wetting and signs and symptoms suggestive of neuropathic voiding dysfunction, including difficulty voiding, significant postvoid residual urine or impaired bladder sensation. It should also be considered when ultrasound reveals a thickened bladder wall and hydroureteronephrosis is present in the absence of an obstruction such as posterior urethral valves.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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