Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Continuous incontinence refers to constant urine leaking during both the day and at night. Revised terminology for the timing of intermittent incontinence has been suggested (1, 2):
For urinary incontinence during the day: Daytime incontinence (previously diurnal wetting)
For urinary incontinence at night: Enuresis (or nighttime or nocturnal [during sleep only] wetting or bed-wetting)
Daytime incontinence is usually not diagnosed until age 5 or 6. Enuresis is usually not diagnosed until age 7 and is more common among girls. Before this time, enuresis is typically referred to as nighttime wetting (3). These age limits are based on children who are developing typically and so may not be applicable to children with developmental delay. Both enuresis and daytime incontinence are symptoms and are not diagnoses; thus, they necessitate consideration of an underlying cause.
The age at which children attain urinary continence varies, but approximately 90% are continent during the day by age 5 (4, 5). Nighttime continence takes longer to achieve. Enuresis affects approximately 20% of children at age 5 and 10% at age 10; there is a spontaneous remission rate of 14% per year (6). Approximately 0.5 to 3% of adults continue to have enuresis episodes. Enuresis is more common among boys and when there is a family history of it (7).
Incontinence is classified as:
Primary incontinence: Children have never achieved urinary continence for ≥ 6 months.
Secondary incontinence: Children developed incontinence after a period of at least 6 months of urinary control.
An organic cause is more likely in secondary incontinence. Even when there is no organic cause, appropriate treatment and parental education are essential because of the physical and psychological impact of urine accidents (8).
(See also Urinary Incontinence in Adults.)
General references
1. Hashim H, Blanker M, Drake M, et al. International Continence Society (ICS) report on the terminology for nocturia and nocturnal lower urinary tract function. Neurourol Urodyn. 2019, 38:499–508. doi:10.1002/nau.23917
2. Austin PF, Bauer SB, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: Updated report from the standardization committee of the International Children's Continence Society. Neurourol Urodyn. 2016, 35(4):471–481. doi:10.1002/nau.22751
3. Wright, AJ: The epidemiology of childhood incontinence. In Pediatric Incontinence, Evaluation and Clinical Management, edited by Franco I, Austin P, Bauer S, von Gontard A, Homsy I. Chichester, John Wiley & Sons Ltd., 2015, pp. 37–60.
4. Nieuwhof-Leppink AJ, Schroeder RPJ, van de Putte EM, de Jong TPVM, Schappin R. Daytime urinary incontinence in children and adolescents. Lancet Child Adolesc Health. 2019;3(7):492-501. doi:10.1016/S2352-4642(19)30113-0
5. Nasir R, Schonwald A: Urinary function and enuresis. In Developmental and Behavioral Pediatrics, ed. 1, edited by Voight RG, Macias MM, Myers SM. American Academy of Pediatrics, 2010, pp. 602–609.
6. Caldwell PH, Edgar D, Hodson E, Craig JC. 4. Bedwetting and toileting problems in children. Med J Aust. 2005;182(4):190-195. doi:10.5694/j.1326-5377.2005.tb06653.x
7. Jacobs‐Perkins A: Enuresis. In Pediatric Clinical Advisor (Second Edition), edited by Garfunkel LC, Kaczorowski JM, Christy C. Philadelphia, Mosby, 2007, pp. 189–190.
8. Austin PF, Vricella GJ: Functional disorders of the lower urinary tract in children. In Campbell-Walsh Urology, ed. 11, edited by Wein A, Kavoussi L, Partin A, Peters C. Philadelphia, Elsevier, 2016, pp. 3297–3316.
Pathophysiology of Urinary Incontinence In Children
Physiologically, bladder function consists of a storage phase and a voiding phase. Abnormalities in either phase can cause primary or secondary incontinence (1).
During the storage phase, the bladder serves as a reservoir for urine. Storage capacity is affected by bladder volume and the change in detrusor pressure (ie, bladder compliance, which refers to how easily the bladder stretches upon filling). Storage capacity tends to increase as children grow. Bladder compliance can be decreased by repeated infections or by outlet obstruction, with resulting bladder muscle hypertrophy. External compression of the bladder from the colon and/or rectum (eg, in children with constipation) may also decrease storage capacity.
During the voiding phase, bladder contractions synchronize with the opening of the bladder neck and the external urinary sphincter. If there is dysfunction in the coordination or sequence of voiding, incontinence can occur. There are multiple reasons for such dysfunction. One example is bladder irritation, which can lead to irregular contractions of the bladder and asynchrony of the voiding sequence, resulting in incontinence. Bladder irritation can result from a urinary tract infection (UTI) or from anything that presses on the bladder (eg, a dilated rectum caused by constipation) (2).
The maturation of the voiding pattern from infancy to adulthood involves changing from the infant's reflex pattern of urination (in which bladder contractions occur unopposed by increased outlet resistance) to the adult pattern (in which bladder contractions are suppressed by the pontine micturition center). During maturation there is a transition phase in which detrusor contractions are opposed by external sphincter contraction (3). The external sphincter is under voluntary muscle control in patients who are neurotypical. The development of voluntary sphincter control occurs during toilet training.
Pathophysiology references
1. Wan J, Kraft K: Neurological control of storage and voiding. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 803–819.
2. Bush N, Shah A, Pritzker J, et al: Constipation and lower urinary tract symptoms. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 873–883.
3. Horowitz, M: Diurnal and nocturnal enuresis. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 853–872.
Etiology of Urinary Incontinence In Children
Urinary incontinence in children has different causes compared to urinary incontinence in adults.
Although some abnormalities cause both nighttime and daytime incontinence, the etiology typically varies depending on whether incontinence is during nighttime or daytime, as well as primary or secondary. Most primary incontinence occurs at night (ie, enuresis) and not secondary to an organic disorder.
Enuresis can be divided into monosymptomatic (occurring only during sleep) and complex (other abnormalities are present, such as daytime incontinence and/or urinary symptoms).
Enuresis
Comorbid disorders (eg, urinary tract infection, constipation, acute renal failure) can contribute to up to 30% of cases and are more common in complex compared to monosymptomatic enuresis (1).
The remaining majority of cases are of unclear etiology (also called primary nocturnal enuresis) but are thought to be due to a combination of factors, including the following:
Maturational or developmental delay
Toilet training that has not been completed
Functionally small bladder capacity (the bladder is not actually small but contracts before it is completely full)
Increased nighttime urine volume
Difficulties in arousal from sleep
Family history
If one parent had enuresis, there is a 44% chance offspring will have it (2). The chance increases to 77% if both parents had it.
About 14% per year resolve with no intervention (3).
The factors contributing to organic causes of enuresis (also called secondary nocturnal enuresis) include the following:
Conditions that increase urine volume (eg, diabetes mellitus, arginine vasopressin deficiency [central diabetes insipidus], arginine vasopressin resistance, chronic renal failure, excessive water intake, sickle cell disease, sometimes sickle trait [hyposthenuria])
Conditions that increase bladder irritability (eg, UTI, pressure on the bladder by the rectum and sigmoid colon [caused by constipation])
Structural abnormalities (eg, ectopic ureter, which can cause both nighttime and daytime incontinence)
Abnormal sphincter weakness (eg, spina bifida, which can cause both nighttime and daytime incontinence)
Obstructive sleep apnea (which can disrupt sleep patterns, increase atrial natriuretic peptide, and disrupt release of arginine vasopressin, promoting enuresis)
Daytime incontinence
Common organic causes of daytime incontinence include:
Bladder irritability
Relative weakness of the detrusor muscle (making it difficult to inhibit incontinence)
Urethrovaginal reflux, or vaginal voiding: Girls who adopt an improper voiding position (eg, with legs close together) or have redundant skinfolds may have reflux of urine into the vagina, leading to leakage upon standing after urination
Structural abnormalities (eg, ectopic ureter)
Abnormal sphincter weakness due to neurogenic bladder (eg, spina bifida, tethered cord)
See table Some Risk Factors for and Organic Causes of Daytime Incontinence and Enuresis in Children.
Some Risk Factors for and Organic Causes of Daytime Incontinence and Enuresis in Children
Risk Factor/Cause | Suggestive Findings | Diagnostic Approach |
|---|---|---|
Infrequent, hard-pebble, or very large stools Sometimes encopresis, abdominal discomfort or distention History of a constipating diet (eg, excessive milk and dairy, few fruits and vegetables) | Usually history and physical examination alone (including stooling diary) Sometimes abdominal radiographs | |
Dysfunctional voiding secondary to lack of coordination of the detrusor muscle and urethral sphincter, not related to a neurologic cause | Often encopresis, vesicoureteral reflux (VUR), and UTI Possibly nighttime and daytime incontinence | Urodynamic studies to show dyssynergy of bladder musculature Uroflow testing Sometimes voiding cystourethrogram |
Giggle incontinence | Voiding during laughing, more common among girls At other times, completely normal voiding | History alone |
Increased urine output due to any cause (eg, diabetes mellitus, argininevasopressin deficiency [central diabetes insipidus], arginine vasopressin resistance, excessive water intake, sickle cell disease or trait)* | Vary by disorder | For diabetes mellitus, serum glucose For arginine vasopressin resistance, serum and blood osmolality and possibly urine sample For sickle cell, sickle cell screen |
Maturational or developmental delay* | No daytime incontinence More common among boys and heavy sleepers Possible family history of bed-wetting | History and physical examination alone |
Micturition deferral with overflow incontinence | In children, waiting until the last minute to void Common among preschool children when absorbed in playing | Consistent history Voiding diary |
Neurogenic bladder secondary to spinal dysraphism (eg, spina bifida, tethered cord, occult defects) or nervous system defect | Conspicuous vertebral defects, protruding meningeal sac, deep lumbosacral dimple or hair tuft, lower-extremity weakness, decreased sensation in lower extremities | Lumbosacral radiographs For occult conditions, spinal MRI Ultrasound of the kidneys and bladder Urodynamic studies |
History of snoring with pauses in breathing that last 15 seconds or longer followed by loud snorts Excessive daytime sleepiness Enlarged tonsils/adenoids Growth and weight faltering (formerly called failure to thrive) | Polysomnography (also called a sleep study) | |
Overactive bladder | Urinary urgency (essential for diagnosis); frequency and nocturia also common Sometimes use of holding maneuvers or body posturing (eg, squatting or Vincent curtsy sign) | History consistent with symptoms of overactive bladder Sometimes consideration of voiding diary, urodynamic studies, uroflow testing |
Sleep problems, school difficulties (eg, delinquency, poor grades) Inappropriate and sexualized behavior, depression, unusual interest in or avoidance of all things sexual, inappropriate knowledge of sexual things for age | Evaluation by sexual abuse experts | |
Stress*† | School difficulties, social isolation or difficulties, family stress (eg, divorce, separation) | History alone |
Structural abnormality (eg, ectopic ureter, posterior urethral valves) | In children, full daytime continence never achieved Nighttime and daytime incontinence in girls, history of normal voiding but with continually wet underwear, vaginal discharge Possible history of UTIs, history of other urinary tract abnormalities | Ultrasound of the kidneys Nuclear renal flow scan or IV urogram CT of abdomen and pelvis or MRI urogram |
UTI* | Dysuria, hematuria, frequency, urgency Fever Abdominal pain | Urinalysis Urine culture For patients with pyelonephritis, ultrasonography and voiding cystourethrogram |
Vaginal reflux (urethrovaginal reflux, or vaginal voiding) due to any cause (including labial adhesions) | Minor leakage when standing after urination | History and physical examination alone‡ |
* Both a risk factor for and a cause of enuresis as well. | ||
† Stress is a cause primarily when incontinence is acute. | ||
‡ Physician should note improvement with instruction on proper method of voiding to prevent retention of urine in vagina (eg, sitting backward on toilet bowl or sitting forward with knees wide apart). | ||
UTI = urinary tract infection. | ||
Etiology references
1. Franco I, von Gontard A, De Gennaro M; International Childrens's Continence Society. Evaluation and treatment of nonmonosymptomatic nocturnal enuresis: a standardization document from the International Children's Continence Society. J Pediatr Urol. 2013;9(2):234-243. doi:10.1016/j.jpurol.2012.10.026
2. Fritz G, Rockney R, Bernet W, et al. Practice parameter for the assessment and treatment of children and adolescents with enuresis. J Am Acad Child Adolesc Psychiatry. 2004;43(12):1540-1550. doi:10.1097/01.chi.0000142196.41215.cc
3. Caldwell PH, Edgar D, Hodson E, Craig JC. 4. Bedwetting and toileting problems in children. Med J Aust. 2005;182(4):190-195. doi:10.5694/j.1326-5377.2005.tb06653.x
Evaluation of Urinary Incontinence In Children
Evaluation should always include an assessment for constipation (which can be a contributing factor to both nighttime and daytime incontinence).
History
History is the most important diagnostic tool in the evaluation of a child with urinary incontinence. Although there are many technological advances that can support the evaluation, a clinical evaluation is still considered the primary diagnostic tool (1).
History of present illness inquires about the onset of symptoms (ie, primary vs secondary), timing of symptoms (eg, at night, during the day, only after voiding), and whether symptoms are continuous (ie, constant minor leakage) or intermittent. Noting the age at initial toilet training and whether complete dryness has been achieved since toilet training was completed is important. Recording a voiding schedule (voiding diary), including timing, frequency, and volume of voids, can be helpful. Important associated symptoms include polydipsia, dysuria, urgency, frequency, dribbling, and straining. Position during voiding and strength of urine stream should be noted. To prevent leakage, children with incontinence may use holding maneuvers, such as crossing their legs or squatting (sometimes with their hand or heel pushed against their perineum). In some children, holding maneuvers can increase their risk of UTI. Similar to the voiding diary, a stooling diary can help identify constipation.
Review of systems should seek symptoms suggesting a cause, including the frequency, size, and consistency of stools (constipation); fever, abdominal pain, dysuria, and hematuria (UTI); perianal itching and vaginitis (pinworm infection); polyuria and polydipsia (arginine vasopressin resistance or diabetes mellitus); and snoring or breathing pauses during sleep (sleep apnea). The possibility of sexual abuse should be considered, which, although an uncommon cause, is too important to be overlooked.
Past medical history should focus on identifying known possible causes, including perinatal insults or congenital defects (eg, spina bifida), neurologic disorders, gastrointestinal disorders, renal disorders, and a history of UTIs. Any current or previous treatments for incontinence and how they were actually implemented should be noted as should a list of current medications.
Developmental history should note maturational or developmental delay and other disorders related to voiding dysfunction (eg, attention-deficit/hyperactivity disorder, which increases the likelihood of incontinence).
Family history should note the presence of enuresis and any urologic disorders.
Social history should note any stressors occurring around the onset of symptoms, including difficulties at school, with friends, or at home; although incontinence is not a psychological disorder, a brief period of wetting may occur during stress.
Clinicians should also ask about the impact of incontinence on the child because it can impact treatment decisions.
Physical examination
Examination begins with review of vital signs for fever (UTI), signs of weight loss (diabetes mellitus), and hypertension (renal disorder). Examination of the head and neck should note enlarged tonsils, mouth breathing, or poor growth (obstructive sleep apnea). Abdominal examination should note any masses consistent with stool or a full bladder.
In girls, genital examination should note any significant erythema, labial adhesions, scarring, or findings suggesting sexual abuse (although the latter is rare). An ectopic ureteral orifice is often difficult to see but should be sought.
In boys, examination should note meatal irritation or any lesions on the glans or around the anus or rectum.
In either sex, perianal excoriations can suggest pinworms.
The spine should be examined for any midline defects (eg, deep sacral dimple, sacral hair patch). A basic neurologic evaluation targeting lower-extremity strength, sensation, and sacral reflexes (eg, anal wink) and, in boys, the cremasteric reflex should be performed to identify possible spinal dysraphism. A rectal examination may be useful to detect constipation or decreased rectal tone.
Red flags
Findings of particular concern are:
Signs or concerns of sexual abuse
Excessive thirst, polyuria, and weight loss
Prolonged primary daytime incontinence (beyond age 6 years)
Any neurologic signs, especially in the lower extremities
Physical signs of neurologic impairment
New-onset incontinence after dryness for > 1 year
Interpretation of findings
Usually, primary enuresis occurs in children with an otherwise unremarkable history and examination and probably represents maturational delay. A small percentage of children have a treatable medical disorder; sometimes findings can suggest possible causes (see table Some Risk Factors for and Organic Causes of Daytime Incontinence and Enuresis in Children).
For children who are being evaluated for enuresis, it is important for clinicians to determine whether daytime symptoms of urgency, frequency, body posturing or holding maneuvers, and incontinence are present. Children with these symptoms have complex enuresis, and management should be directed primarily toward controlling the daytime symptoms.
In diurnal incontinence, dysfunctional voiding is suggested by intermittent incontinence preceded by a sense of urgency, a history of being distracted by play, or a combination. Incontinence after urination (due to lack of total bladder emptying) can also be part of the history.
Incontinence caused by a UTI is likely a discrete episode rather than a chronic, intermittent problem and may be accompanied by typical symptoms (eg, urgency, frequency, pain on urination); however, other causes of incontinence can result in secondary UTI.
Constipation should be considered in the absence of other findings in children who have hard or unusually large stools and difficulty with elimination (and sometimes palpable stool on examination).
Sleep apnea should be considered with a history of excessive daytime sleepiness and disrupted sleep; parents may provide a history of snoring or respiratory pauses.
Anal or rectal itching (especially at night), vaginitis, urethritis, or a combination can be an indication of pinworms.
Excessive thirst, daytime incontinence and enuresis, and weight loss suggest a possible organic cause (eg, diabetes mellitus).
Stress, including sexual abuse, can be difficult to ascertain but should be considered. Sexual abuse is a rare cause but is too important to be overlooked.
Testing
Determining the etiology of incontinence is often apparent after history and physical examination.
Urinalysis and urine culture are often done for both sexes (see How To Catheterize the Bladder in a Female Child and see How To Catheterize the Bladder in a Male Child).
Further testing is useful mainly when history, physical examination, or both suggest an organic cause (see table Some Risk Factors for and Organic Causes of Daytime Incontinence and Enuresis in Children). Ultrasound of the kidneys and bladder is often done to verify that the renal and urinary tract anatomy is normal (2). Ultrasound also can be used to assess rectal diameter, and, if constipation is suspected, an abdominal radiograph may be done to confirm a large stool burden. Uroflow testing can show a staccato voiding pattern in patients with dysfunctional voiding.
Evaluation references
1. Wintner A, Figueroa TE: History and physical examination of the child. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 3–27.
2. Coplen DE: Radiologic assessment of bladder disorders. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 780–787.
Treatment of Urinary Incontinence In Children
The most important component of treatment is family education about the cause and clinical course of incontinence (1). Appropriate education helps decrease the negative psychological impact of urine accidents and results in increased adherence with treatment.
Successful treatment of urinary incontinence also depends on voluntary participation of both the parents and the child in the treatment plan. If the child is developmentally delayed for age, not bothered by the incontinence, or unwilling to participate in the treatment plan, the plan should be postponed until the child is ready to participate.
The treatment of urinary incontinence should be directed toward any underlying cause that is identified; however, frequently no cause is found. In such cases, the following treatments may be useful.
Punitive approaches should be avoided because they undermine treatment and lead only to poor self-esteem.
Enuresis
Behavioral modifications should be first-line recommendations for patients with enuresis. Modifications include the following:
Regular fluid intake during the day and minimization of fluid and solute (eg, dinner) intake 1 to 2 hours before sleep (2)
Double voiding (voiding twice consecutively) before sleep
Managing constipation appropriately
The most effective long-term strategy, when no organic causes are present, is a bed-wetting alarm. Evidence indicates that children are approximately 7 times more likely to achieve a complete response (ie, 14 consecutive dry nights) and are approximately 9 times more likely to sustain it long-term when using a bed-wetting alarm compared to a control (ie, regular) alarm or no alarm (3). Children may need to use a bed-wetting alarm nightly for up to 4 months before symptoms completely resolve.
The alarm triggers when wetting occurs. Although children initially continue to have wetting episodes, over time, they learn to associate the sensation of a full bladder with the alarm and then wake up to void before an enuretic event. These alarms are readily available without a prescription.
A bed-wetting alarm should not be used by children with complex enuresis or by children with reduced bladder capacity (as evidenced by voiding diary). These children should be treated the same as children with daytime incontinence.
Medications such as oral desmopressin (DDAVP, Medications such as oral desmopressin (DDAVP,arginine vasopressin) and imipramine (see table ) and imipramine (see tableSome Oral Medications Used for Urinary Incontinence in Children) can decrease nighttime wetting episodes. However, results are not sustained in most patients when the treatment is stopped; parents and children should be forewarned of this to help limit disappointment. DDAVP is preferable to imipramine because of the rare possibility of sudden death with imipramine use.
Daytime incontinence
It is important that clinicians treat any underlying constipation. Information from the voiding diary can help identify children with reduced functional bladder capacity, frequency and urgency of urination, and urinary infrequency, all of whom may present with urinary incontinence.
General measures may include:
Urgency containment exercises: Children are directed to go to the bathroom as soon as they feel the urge to urinate. They then hold the urine as long as they can and, when they can hold it no longer, start to urinate and then stop and start the urine stream. This exercise strengthens the sphincter and gives children confidence that they can make it to the bathroom before they have an accident.
Gradual lengthening of voiding intervals (if detrusor instability or dysfunctional voiding is suspected)
Changes in behaviors (eg, delayed urination) through positive reinforcement and scheduled urination (time voiding): Children are reminded to urinate by a clock that vibrates or sounds an alarm (preferable to having a parent in the reminder role).
Use of correct voiding methods to discourage retention of urine in the vagina: In girls with vaginal pooling of urine, treatment is to encourage sitting facing backward on the toilet bowl or sitting facing forward with the knees wide apart, which will spread the introitus and allow direct flow of urine into the toilet bowl.
Biofeedback: This nonsurgical therapy is used to treat bladder dysfunction, urinary incontinence, fecal incontinence, urgency, and pelvic pain; to re-educate the pelvic floor muscles; and to restore and maintain health. Children are taught how to properly isolate and activate specific pelvic floor and abdominal muscles while minimizing the involvement of surrounding muscles, which serves to promote coordinated and synergistic voiding (4).
For labial adhesions, a conjugated estrogen or triamcinolone 0.5% cream may also be used.For labial adhesions, a conjugated estrogen or triamcinolone 0.5% cream may also be used.
Medication (see table Some Oral Medications Used for Urinary Incontinence in Children) is not typically first-line therapy but is sometimes helpful. Anticholinergics (oxybutynin and tolterodine) may benefit patients with daytime incontinence due to voiding dysfunction. These medications are typically prescribed when behavioral therapy or physiotherapy is deemed unsuccessful. Medications for daytime incontinence may sometimes be useful in treating enuresis as well.) is not typically first-line therapy but is sometimes helpful. Anticholinergics (oxybutynin and tolterodine) may benefit patients with daytime incontinence due to voiding dysfunction. These medications are typically prescribed when behavioral therapy or physiotherapy is deemed unsuccessful. Medications for daytime incontinence may sometimes be useful in treating enuresis as well.
Anticholinergics (specifically, antimuscarinic anticholinergics) that are prescribed for the treatment of overactive bladder in adults (eg, solifenacin, darifenacin) have shown effectiveness in children. Similarly, the beta3-receptor agonist mirabegron has been used in children to treat symptoms of urinary incontinence due to detrusor muscle overactivity refractory to anticholinergics (Anticholinergics (specifically, antimuscarinic anticholinergics) that are prescribed for the treatment of overactive bladder in adults (eg, solifenacin, darifenacin) have shown effectiveness in children. Similarly, the beta3-receptor agonist mirabegron has been used in children to treat symptoms of urinary incontinence due to detrusor muscle overactivity refractory to anticholinergics (5).
Some Oral Medications Used for Urinary Incontinence in Children*
Medication | Some Adverse Effects |
|---|---|
Voiding dysfunction in daytime incontinence (bladder overactivity) | |
OxybutyninOxybutynin | Confusion, dizziness, increased temperature, flushing, constipation, dry mouth |
Tolterodine Tolterodine | Constipation, flushing, dry mouth |
SolifenacinSolifenacin | Constipation, dry mouth, gastrointestinal effects, blurred vision |
DarifenacinDarifenacin | Constipation, dry mouth, gastrointestinal effects, blurred vision |
MirabegronMirabegron | Headache, gastrointestinal effects, nasopharyngitis, hypertension |
Enuresis | |
Desmopressin (DDAVP, Desmopressin (DDAVP,arginine vasopressin) | Intranasal DDAVP is not recommended because of the risk of dilutional hyponatremia. |
ImipramineImipramine | Possible nervousness, personality change, disordered sleep, cardiac arrhythmias† Should be used only for therapy-resistant cases given risk–benefit profile Rarely, death‡ |
* These medications are mostly used as second-line therapy. Treatment of the underlying disorder and behavioral therapy should be used first. | |
† ECG should be done to identify prolongation of the QT interval and/or the corrected QT (QTc) interval, which contraindicate use of imipramine. | |
‡ Sudden death of unclear etiology has been reported. This medication is now rarely used. | |
Treatment references
1. Vande Walle J, Rittig S, Bauer S, et al. Practical consensus guidelines for the management of enuresis. Eur J Pediatr. 2012;171(6):971-983. doi:10.1007/s00431-012-1687-7
2. Maternik M, Krzeminska K, Zurowska A. The management of childhood urinary incontinence. Pediatr Nephrol. 2015;30(1):41-50. doi:10.1007/s00467-014-2791-x
3. Caldwell PH, Codarini M, Stewart F, Hahn D, Sureshkumar P. Alarm interventions for nocturnal enuresis in children. Cochrane Database Syst Rev. 2020;5(5):CD002911. Published 2020 May 4. doi:10.1002/14651858.CD002911.pub3
4. Rae A, Renson, C: Biofeedback in the treatment of functional voiding disorders. In Pediatric Incontinence, Evaluation and Clinical Management, edited by Franco I, Austin P, Bauer S, von Gontard A, Homsy I. Chichester, John Wiley & Sons Ltd., 2015, pp. 145–152.
5. Johnson EK, Bauer SB: Neurogenic voiding dysfunction and functional voiding disorders: Evaluation and nonsurgical management. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 820–852.
Key Points
Primary urinary incontinence most frequently manifests as incontinence at night (enuresis).
Constipation should be considered as a contributing factor.
Organic causes of incontinence (secondary incontinence) are infrequent but should be considered.
Most enuresis abates with maturation (14% per year), but 0.5 to 3% of adults may continue to have wetting episodes at night.
A bed-wetting alarm is the most effective treatment for enuresis related to maturational or developmental delay.
Other treatments include behavioral interventions and sometimes medications.
Parental education is essential to the child’s outcome and well-being.
Drugs Mentioned In This Article
