Urinary incontinence (enuresis) is defined as the involuntary release of urine occurring two or more times per month after toilet training. Incontinence may be present during the day (daytime incontinence), at night (nighttime incontinence or nocturnal enuresis), or both (combined incontinence). The duration of the process of toilet training, or the age at which children achieve urinary continence, varies greatly. However, more than 90% of children achieve daytime urinary continence by age 5. Nighttime continence may take longer to achieve. Bed-wetting or nighttime incontinence affects about 30% of children at age 4, 10% at age 7, 3% at age 12, and 1% at age 18. About 0.5% of adults continue to have nighttime incontinence. Doctors take these time lines into account when diagnosing urinary incontinence. Because the duration of the process of toilet training varies, young children are usually not considered to have daytime incontinence if they are under age 5 or 6 or nighttime incontinence if they are under age 7.

Daytime incontinence is more common among girls. Bed-wetting is more common among boys, and also when there is a family history of nighttime incontinence. Both daytime and nighttime incontinence are symptoms—not diagnoses—and doctors look for an underlying cause.

Causes

The pattern of incontinence helps the doctor determine the likely cause. If the child has never had a consistent dry period during the day, the doctor considers the possibility of a birth defect, an anatomic abnormality, or certain behaviors that can lead to incontinence.

Several uncommon but important disorders affect the normal anatomy or function of the bladder, which can lead to urinary incontinence. For example, a spinal cord defect such as spina bifida can cause abnormal nerve function to the bladder and lead to incontinence. Some infants have a birth defect that prevents the bladder or urethra from developing completely, leading to nearly constant urine loss (total incontinence). Another type of birth defect causes the tubes that connect the kidneys to the bladder (ureters) to end in an abnormal location in the bladder or even outside the bladder (such as in the vagina or urethra or on the surface of the body), causing incontinence. Some children have an overactive bladder that easily spasms or contracts, causing incontinence, whereas others may have difficulty emptying their bladder.

Certain behaviors can lead to daytime incontinence, especially in girls. Such behaviors include urinating infrequently and urinating using an incorrect position (with legs too close together). With such positions, urine can accumulate in the vagina during urination, then dribble out after standing. Some girls experience bladder spasm when laughing, resulting in “giggle incontinence.”

If the child has been dry for a long time and the incontinence is new, the doctor considers conditions that can cause loss of continence. These include constipation, infections, diet, emotional stress, and sexual abuse. Some medical conditions that the child develops can cause new urinary incontinence. Constipation, which is defined as difficult, hard, or infrequent stooling, is the most common cause of sudden changes in urinary continence in children. Bacterial urinary tract infections and viral infections causing bladder irritation (bacterial or viral cystitis) are common infectious causes.

To prevent urine from leaking, many children with incontinence learn to cross their legs or use other positions (holding maneuvers), such as squatting (sometimes with their hand or heel pressed between their legs). These holding maneuvers may increase the chance of developing a urinary tract infection. Sexually active adolescents can have urinary difficulties caused by certain sexually transmitted diseases. Dietary causes include caffeine and acidic juices, such as orange and tomato juice, which can irritate the bladder and lead to leakage of urine. Stressful events such as divorce or separation of the parents, moving, or loss of a family member can cause a child to develop urinary incontinence. Similarly, children who are sexually abused may develop urinary incontinence. Children with diabetes mellitus or diabetes insipidus can develop incontinence because these disorders produce excessive amounts of urine.

Common causes: Causes vary depending on whether incontinence occurs in the daytime or mainly at night.

In nighttime incontinence (nocturnal enuresis), most cases do not involve a medical disorder but result from a combination of factors, including

• Developmental delay
• Uncompleted toilet training
• A bladder that contracts before it is completely full
• Drinking too much before bedtime
• Problems waking up from sleep (for example, being a very deep sleeper)
• Family history (if one parent had nighttime incontinence, there is a 30% chance offspring will have it, increasing to 70% if both parents had it)

For daytime incontinence (diurnal enuresis), common causes include

• A bladder that is irritated because of a urinary tract infection or because something is pressing on it (such as a full rectum caused by constipation)
• An overactive bladder
• Urethrovaginal reflux (also called vaginal voiding), which can occur in girls who urinate in an incorrect position or who have extra skin folds, and can cause urine to back up into the vagina and then leak out when they stand up
• Anatomic abnormalities (for example, a misplaced ureter in girls or a congenital urinary tract obstruction)
• Weakness of the urinary sphincter, which controls the flow of urine out of the bladder (for example, because of a spinal cord abnormality)

In both types of incontinence, stress, attention-deficit/hyperactivity, or urinary tract infection can increase the risk of incontinence.

Less common causes: For nighttime incontinence, an underlying medical disorder accounts for about 30% of cases. Contributing factors include some of the disorders that cause daytime incontinence along with disorders that increase the amount of urine. Such disorders include diabetes mellitus, diabetes insipidus, sickle cell disease (and sometimes sickle cell trait).

Evaluation

Doctors first try to determine whether incontinence is simply a developmental issue or whether a disorder is involved.

Warning signs: In children with urinary incontinence, certain signs and characteristics are cause for concern. They include

• Signs or concerns of sexual abuse
• Excessive thirst, excessive volume of urine, and/or weight loss
• Incontinence during the day in children continuing beyond age 6
• Any signs of nerve damage, especially in the legs
• Signs of an abnormality of the spine

When to see a doctor: Children who have any warning sign should immediately be brought to a doctor with experience in treating children unless the only warning sign is daytime incontinence continuing past age 6. Such children should see a doctor at some point, but a delay of a week or so is not harmful.

What the doctor does: Doctors first ask questions about the child's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the incontinence and the tests that may need to be done (see Incontinence in Children: Some Causes and Features of Nighttime Incontinenceand see Incontinence in Children: Some Causes and Features of Daytime Incontinence).

In the medical history, doctors ask about onset of symptoms, timing of symptoms, and whether symptoms are continuous (that is, constant dribbling) or intermittent. Having the parents record the timing, frequency, and volume of urine (a voiding diary) or stool (a stooling diary) in a journal can be helpful. Position while urinating and strength of urine steam are discussed.

Symptoms that suggest a cause include

• Decreased frequency of stools and/or hard stools (constipation)
• Fever, abdominal pain, pain while urinating, and increased urgency to pass urine (urinary tract infection)
• Itching around the anus and vagina (pinworm infection)
• Urinating frequently and producing a large volume of urine (diabetes insipidus or diabetes mellitus)
• Snoring or breathing pauses during sleep and being excessively sleepy during the day (sleep apnea)

Doctors also ask about any history of birth injuries or birth defects (such as spina bifida), nerve disorders, kidney disorders, and urinary tract infections. Doctors screen the child for the possibility of sexual abuse, which, although an uncommon cause, is too important to miss.

If there is a family history of bed-wetting or any urologic disorders, these should be brought to the doctors' attention. Doctors also ask questions about any stressors occurring near the start of symptoms, including difficulties at school, with friends, or at home (including questions about parents' marital difficulties). Although incontinence is not a psychologic disorder, a brief period of wetting may occur during times of psychologic stress.

Doctors then do a physical examination. Examination begins with the following:

• A review of vital signs for fever (urinary tract infection), signs of weight loss (diabetes), and hypertension (a kidney disorder)
• Examination of the head and neck for enlarged tonsils, mouth breathing, or poor growth (sleep apnea)
• Examination of the abdomen for any masses that suggest stool is being retained or for a full bladder
• Examination of the genitals in girls for any adhesions, scarring, or signs suggesting sexual abuse and in boys for any irritation or lesions on the penis or around the rectum
• Examination of the spine for any defects (for example, a tuft of hair or a dimple at the base of the spine)
• A neurologic examination to evaluate leg strength, sensation, deep tendon reflexes, and other reflexes (such as lightly touching the anus to see whether it constricts—called the anal wink—and, in boys, lightly stroking the inner thigh to see whether the testis is pulled up—called the cremasteric reflex)
• A rectal examination may be done during the physical examination to detect constipation or decreased rectal tone

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Some Causes and Features of Nighttime Incontinence Cause Common Features* Tests Constipation Infrequent, hard, pebblelike stools Sometimes abdominal discomfort In people who consume a constipating diet (for example, excessive milk and dairy products and few fruits and vegetables) A doctor's examination Sometimes an x-ray of the abdomen Stooling diary Increased urine output, which can have many causes, such as Diabetes mellitus Diabetes insipidus Excessive water intake Sickle cell disease or trait Vary by the disorder For diabetes mellitus, urine tests for glucose (sugar) and ketones, and/or a blood test For diabetes insipidus or sickle cell disease, blood tests Developmental delay No daytime incontinence More common among boys and heavy sleepers Possibly family members who had wet the bed A doctor's examination Sleep apnea Sometimes in children who snore and have pauses in breathing during sleep followed by loud snorts Excessive daytime sleepiness Enlarged tonsils A sleep study test Spinal defects (for example, spina bifida), leading to difficulty emptying the bladder (urinary retention) Obvious spinal defects, a dimple or hair tuft in the lower back, and weakness or decreased sensation in the legs and feet X-rays of the lower back Sometimes MRI of the spine Stress School problems, social isolation or problems, and family stress (such as divorce or separation of the parents) A doctor's examination Voiding diary Urinary tract infection Pain while urinating, blood in the urine, the need to urinate frequently, and a sense of needing to urinate urgently Fever Abdominal pain Urine analysis and urine culture *Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. MRI = magnetic resonance imaging.

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Some Causes and Features of Daytime Incontinence Cause Common Features* Tests Constipation Infrequent, hard, pebblelike stools Sometimes abdominal discomfort Often in people who consume a constipating diet (for example, excessive milk and dairy products and few fruits and vegetables) A doctor's examination Sometimes an x-ray of the abdomen Stooling diary Dysfunctional voiding because the muscles involved in expelling urine from the bladder (the bladder muscle and urinary sphincter) are not coordinated Sometimes stool incontinence and frequent urinary tract infections Possibly daytime and nighttime incontinence Studies of urine flow Sometimes a voiding cystourethrogram (x-rays taken before, during, and after urination―see Incontinence in Children: Testing) Ultrasonography of the kidneys and bladder Giggle incontinence Urinating while laughing, almost exclusively in girls At other times, completely normal urination A doctor's examination Increased urine output, which can have many causes, such as Diabetes mellitus Diabetes insipidus Excessive water intake Sickle cell disease or trait Vary by disorder For diabetes mellitus, urine tests for glucose (sugar) and ketones and/or a blood test† For diabetes insipidus or sickle cell disease, blood tests An overfull bladder Waiting to the last minute to urinate Common among preschool children when they are absorbed in playing Questions about when incontinence occurs Recording the timing, frequency, and volume of urine in a journal (voiding diary) A bladder that does not empty completely (neurogenic bladder) because of a spinal cord or nervous system defect Obvious abnormalities in the spine, a dimple or hair tuft in the lower back, and weakness and decreased sensation in the legs and feet X-rays of the lower back Sometimes MRI of the spine Ultrasonography of the kidneys and bladder Studies of urine flow and pressure in the bladder (urodynamic studies) Overactive bladder A need to urinate urgently (essential for diagnosis) Commonly a frequent need to urinate during the day and night Sometimes use of holding maneuvers or body posturing (for example, children may squat) A doctor's examination Sometimes studies of urine flow, voiding diary Sexual abuse Sleep problems or school problems (such as delinquency or poor grades) Seductive behavior, depression, an unusual interest in or avoidance of all things sexual, and inappropriate knowledge of sexual things for age Evaluation by sexual abuse experts Stress‡ School problems, social isolation or problems, and family stress (for example, divorce or separation of the parents) A doctor's examination Anatomic abnormality (for example, a misplaced ureter in girls) Complete daytime continence never achieved In girls, daytime and nighttime incontinence, a history of normal voiding but with continually wet underwear, and a discharge from the vagina Possible a history of urinary tract infections and of other urinary tract abnormalities Imaging studies of the kidneys and ureters, including sometimes CT of the abdomen and pelvis or MRI of the urinary tract Urinary tract infection Pain while urinating, blood in the urine, a need to urinate frequently, and a sense of needing to urinate urgently Sometimes fever, abdominal pain, and/or back pain Urine culture and tests If results are positive, further evaluation Back up of urine into the vagina (urethrovaginal reflux, or vaginal voiding) Dribbling when standing after urination A doctor's examination *Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. †Diabetes does not typically cause incontinence until blood sugar (glucose) levels are high enough to cause glucose to enter the urine. ‡Stress is a cause primarily when incontinence is sudden. CT = computed tomography; MRI = magnetic resonance imaging. Some Causes and Features of Daytime Incontinence Cause Common Features* Tests Constipation Infrequent, hard, pebblelike stools Sometimes abdominal discomfort Often in people who consume a constipating diet (for example, excessive milk and dairy products and few fruits and vegetables) A doctor's examination Sometimes an x-ray of the abdomen Stooling diary Dysfunctional voiding because the muscles involved in expelling urine from the bladder (the bladder muscle and urinary sphincter) are not coordinated Sometimes stool incontinence and frequent urinary tract infections Possibly daytime and nighttime incontinence Studies of urine flow Sometimes a voiding cystourethrogram (x-rays taken before, during, and after urination―see Incontinence in Children: Testing) Ultrasonography of the kidneys and bladder Giggle incontinence Urinating while laughing, almost exclusively in girls At other times, completely normal urination A doctor's examination Increased urine output, which can have many causes, such as Diabetes mellitus Diabetes insipidus Excessive water intake Sickle cell disease or trait Vary by disorder For diabetes mellitus, urine tests for glucose (sugar) and ketones and/or a blood test† For diabetes insipidus or sickle cell disease, blood tests An overfull bladder Waiting to the last minute to urinate Common among preschool children when they are absorbed in playing Questions about when incontinence occurs Recording the timing, frequency, and volume of urine in a journal (voiding diary) A bladder that does not empty completely (neurogenic bladder) because of a spinal cord or nervous system defect Obvious abnormalities in the spine, a dimple or hair tuft in the lower back, and weakness and decreased sensation in the legs and feet X-rays of the lower back Sometimes MRI of the spine Ultrasonography of the kidneys and bladder Studies of urine flow and pressure in the bladder (urodynamic studies) Overactive bladder A need to urinate urgently (essential for diagnosis) Commonly a frequent need to urinate during the day and night Sometimes use of holding maneuvers or body posturing (for example, children may squat) A doctor's examination Sometimes studies of urine flow, voiding diary Sexual abuse Sleep problems or school problems (such as delinquency or poor grades) Seductive behavior, depression, an unusual interest in or avoidance of all things sexual, and inappropriate knowledge of sexual things for age Evaluation by sexual abuse experts Stress‡ School problems, social isolation or problems, and family stress (for example, divorce or separation of the parents) A doctor's examination Anatomic abnormality (for example, a misplaced ureter in girls) Complete daytime continence never achieved In girls, daytime and nighttime incontinence, a history of normal voiding but with continually wet underwear, and a discharge from the vagina Possible a history of urinary tract infections and of other urinary tract abnormalities Imaging studies of the kidneys and ureters, including sometimes CT of the abdomen and pelvis or MRI of the urinary tract Urinary tract infection Pain while urinating, blood in the urine, a need to urinate frequently, and a sense of needing to urinate urgently Sometimes fever, abdominal pain, and/or back pain Urine culture and tests If results are positive, further evaluation Back up of urine into the vagina (urethrovaginal reflux, or vaginal voiding) Dribbling when standing after urination A doctor's examination *Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. †Diabetes does not typically cause incontinence until blood sugar (glucose) levels are high enough to cause glucose to enter the urine. ‡Stress is a cause primarily when incontinence is sudden. CT = computed tomography; MRI = magnetic resonance imaging.

Testing: Sometimes doctors can diagnose the cause by the history, physical examination, a urinalysis, and a urine culture. Doctors may do other tests depending on what they find during their evaluation (see Incontinence in Children: Some Causes and Features of Nighttime Incontinenceand see Incontinence in Children: Some Causes and Features of Daytime Incontinence). For example, to help diagnose diabetes mellitus and diabetes insipidus, doctors do blood and/or urine tests to check sugar and electrolyte levels.

If a birth defect is suspected, an ultrasound examination of the kidneys and bladder and x-rays of the spine may be necessary. A special x-ray of the bladder and kidneys, called a voiding cystourethrogram, may also be necessary. With this test, a dye is injected into the bladder using a catheter, which shows the anatomy of the urinary tract as well as the direction of urine flow.

Treatment

Learning about the cause and course of incontinence helps decrease the negative psychologic impact of urine accidents. Doctors ask how the child is being impacted by the incontinence because that could affect the treatment decision.

Treatment depends on the cause of the incontinence. For example, an infection is usually treated with antibiotics. Children with birth defects or anatomic abnormalities may need surgery. Nonspecific measures can be taken depending on whether incontinence is at night or during the day.

Nighttime incontinence: The most effective long-term strategy is a bed-wetting alarm. Although labor intensive, the success rate can be as high as 70% when children are motivated to end the bed-wetting, and the family is able to follow the plan. It can take up to 4 months of nightly use for symptoms to completely resolve. Punishing children for bed-wetting is not helpful. It serves only to undermine treatment and cause poor self-esteem.

Drugs such as desmopressinSome Trade Names
DDAVP STIMATE
(DDAVP) and imipramineSome Trade Names
TOFRANIL
can decrease the number of bed-wetting episodes. However, bed-wetting resumes in most children when the drug is stopped. Parents and children should be warned of this likelihood so that the child does not become devastated if bed-wetting starts again. Doctors prefer DDAVP to imipramineSome Trade Names
TOFRANIL
because of the rare potential of sudden death with imipramineSome Trade Names
TOFRANIL
use.

Daytime incontinence: General measures may include

• Trying urgency containment exercises (to strengthen the urinary sphincter)
• Gradually lengthening the time between visits to the bathroom (if the child is thought to have a weak bladder muscle or dysfunctional voiding)
• Changing behavior (for example, delaying urination) through positive reinforcement and scheduled urination
• Reminding children to urinate by a clock that vibrates or sounds an alarm (preferable to having a parent in the reminder role)
• Using methods that discourage retention of urine in the vagina (for example, sitting facing backward on the toilet or with the knees wide apart)

Urgency containment exercises involve telling children to go to the bathroom as soon as they feel the urge to urinate. But once in the bathroom, they are asked to hold the urine as long as they can. When they can hold it no longer they should start to urinate but then stop and start urinating every few seconds. This exercise strengthens the urinary sphincter and also gives children confidence that they can make it to the bathroom before they have an accident. This exercise should be taught after the child has been evaluated by a doctor.

The drugs oxybutyninSome Trade Names
DITROPAN
and tolterodineSome Trade Names
DETROL
can help if the problem is bladder spasm.

Key Points

• Understanding why the child is incontinent is essential to the child's outcome and well-being.
• Most often, incontinence is not caused by a medical disorder.
• Treatment includes behavioral changes, dietary changes, and sometimes drugs.
• Alarms are the most effective treatment for nighttime incontinence.
• Most nighttime incontinence improves as the child matures (15%/year resolve with no intervention).

Last full review/revision October 2012 by Teodoro Ernesto Figueroa, MD