Urinary incontinence 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 or diurnal incontinence)
At night (nighttime incontinence, enuresis, or bed-wetting)
Both (combined incontinence)
The duration of the process of toilet training Toilet Training Most children can be taught to use the toilet when they are between 2 years and 3 years old. Using the toilet to defecate is usually accomplished first. Most children can be trained to control... read more , 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 among children who have a family history of nighttime incontinence. Both daytime and nighttime incontinence are symptoms—not diagnoses—and doctors should look for an underlying cause.
Urination (voiding) matures from infancy to adulthood. In infants, bladder contractions occur by reflex, and the urine is not stopped by contraction of the urinary sphincter (muscles around the tube that drains urine from the bladder). In adults, bladder contractions are suppressed by signals from the brain.
Causes of Urinary Incontinence in Children
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 may consider 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 Neural Tube Defects and Spina Bifida Neural tube defects are a certain type of birth defect of the brain, spine, and/or spinal cord. Neural tube defects can result in nerve damage, learning disabilities, paralysis, and death. The... read more 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 (see Misplaced ureters Misplaced ureters Ureters are the tubes that transport urine from the kidneys (the two organs that filter waste from the blood to make urine) to the bladder (the expandable, muscular sac that holds urine). People... read more ). 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 Constipation in Children Constipation refers to delay or difficulty in passing stool for a period of at least 1 month in infants and toddlers and a period of 2 months in older children (see also Constipation in adults)... read more , 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 Urinary Tract Infection (UTI) in Children A urinary tract infection is a bacterial infection of the urinary bladder ( cystitis), the kidneys ( pyelonephritis), or both. Urinary tract infections are caused by bacteria. Infants and younger... read more (UTIs) and viral infections causing bladder irritation (bacterial or viral cystitis Bladder Infection Cystitis is infection of the bladder. Usually, bacteria are the cause of cystitis. A frequent need to urinate and pain or burning while urinating are the most common symptoms. Doctors can often... read more ) 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 infections. 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 Divorce and Children Separation and divorce, and the events leading up to them, interrupt the stability and predictability that children need. Other than the death of an immediate family member, divorce is the most... read more or separation of the parents, moving, or loss of a family member Death of a Family Member or Loved One Many families have to deal with the difficulties surrounding an ill and dying child. Adults often have a difficult time dealing with death, and children may have a particularly difficult time... read more can cause a child to develop urinary incontinence. Similarly, children who are sexually abused Sexual abuse Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (for example, clergy, coach, or teacher)... read more may develop urinary incontinence. Children with diabetes mellitus or diabetes insipidus can develop incontinence because these disorders produce excessive amounts of urine.
Causes of urinary incontinence vary depending on whether incontinence occurs in the daytime or mainly at night.
In nighttime incontinence (enuresis), most cases do not involve a medical disorder but result from a combination of factors, including
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, 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 Misplaced ureters Ureters are the tubes that transport urine from the kidneys (the two organs that filter waste from the blood to make urine) to the bladder (the expandable, muscular sac that holds urine). People... read more 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)
A bladder that does not empty completely (neurogenic bladder Neurogenic Bladder Neurogenic bladder is lack of bladder control because of a nerve problem such as a stroke, spinal cord injury, or tumor. Uncontrollable loss of urine (urinary incontinence) is the primary symptom... read more ) because of a spinal cord or nervous system defect
In both types of incontinence, stress, attention-deficit/hyperactivity Attention-Deficit/Hyperactivity Disorder (ADHD) Attention-deficit/hyperactivity disorder (ADHD) is poor or short attention span and/or excessive activity and impulsiveness inappropriate for the child’s age that interferes with functioning... read more , or urinary tract infection Urinary Tract Infection (UTI) in Children A urinary tract infection is a bacterial infection of the urinary bladder ( cystitis), the kidneys ( pyelonephritis), or both. Urinary tract infections are caused by bacteria. Infants and younger... read more 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 Mellitus (DM) in Children and Adolescents Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin or fails to respond normally to the insulin produced... read more , diabetes insipidus Central Diabetes Insipidus Central diabetes insipidus is a lack of the hormone vasopressin (antidiuretic hormone) that causes excessive production of very dilute urine (polyuria). Central diabetes insipidus has several... read more , sickle cell disease Sickle Cell Disease Sickle cell disease is an inherited genetic abnormality of hemoglobin (the oxygen-carrying protein found in red blood cells) characterized by sickle (crescent)-shaped red blood cells and chronic... read more (and sometimes sickle cell trait).
Evaluation of Urinary Incontinence in Children
Doctors first try to determine whether incontinence is simply a developmental issue or whether a disorder is involved.
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
Signs of nerve damage in the legs include weakness in, or difficulty moving, one or both legs and complaints that the legs "feel funny." Signs of an abnormality of the spine include a deep pit or dimple or an unusual patch of hair in the middle of the lower back.
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 Table: Some Causes and Features of Nighttime Incontinence in Children Some Causes and Features of Nighttime Incontinence in Children and see Table: Some Causes and Features of Daytime Incontinence in Children Some Causes and Features of Daytime Incontinence in Children ).
In the medical history, doctors ask about when symptoms began, 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 stream are discussed.
Symptoms that suggest a cause include
Fever, abdominal pain, pain while urinating, and increased urgency to pass urine (urinary tract infection Urinary Tract Infection (UTI) in Children A urinary tract infection is a bacterial infection of the urinary bladder ( cystitis), the kidneys ( pyelonephritis), or both. Urinary tract infections are caused by bacteria. Infants and younger... read more )
Urinating frequently and producing a large volume of urine (diabetes insipidus Central Diabetes Insipidus Central diabetes insipidus is a lack of the hormone vasopressin (antidiuretic hormone) that causes excessive production of very dilute urine (polyuria). Central diabetes insipidus has several... read more or diabetes mellitus Diabetes Mellitus (DM) in Children and Adolescents Diabetes mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin or fails to respond normally to the insulin produced... read more )
Snoring or breathing pauses during sleep and being excessively sleepy during the day (sleep apnea Sleep Apnea Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide... read more )
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 ask whether children feel weakness of the legs when running or standing.
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 (when the lips of the vagina stick together), 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
Often 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 Table: Some Causes and Features of Nighttime Incontinence in Children Some Causes and Features of Nighttime Incontinence in Children and see Table: Some Causes and Features of Daytime Incontinence in Children Some Causes and Features of Daytime Incontinence in Children ). 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 Cystography and cystourethrography There are a variety of tests that can be used in the evaluation of a suspected kidney or urinary tract disorder. (See also Overview of the Urinary Tract.) X-rays are usually not helpful in evaluating... read more , may also be needed. 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 of Urinary Incontinence in Children
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 of incontinence 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 (enuresis)
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 given by mouth such as desmopressin (DDAVP) and imipramine can decrease the number of bed-wetting episodes. However, bed-wetting resumes in most children when the drugs are stopped. Parents and children should be warned of this likelihood so that the child does not become devastated if bed-wetting starts again. Imipramine is now rarely given because it may rarely cause sudden death.
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)
Teaching children how to exercise and control the pelvic floor muscles (the uterus, vagina, bladder, urethra, and rectum) and abdomen muscles to promote coordinated urination (biofeedback Biofeedback Biofeedback, a type of mind-body medicine, is a method of bringing unconscious biologic processes under conscious control. In biofeedback, electronic devices are used to measure and report information... read more )
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.
Girls who have adhesions are given a cream that contains estrogen.
The drugs oxybutynin and tolterodine can help if the problem is bladder spasm.
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 enuresis.
Most nighttime enuresis improves as the child matures (15%/year resolve with no intervention).