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Urinary Incontinence in Children

By

Teodoro Ernesto Figueroa

, MD, Nemours/A.I. duPont Nemours Hospital for Children

Last full review/revision Apr 2021| Content last modified Apr 2021
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Topic Resources
  • For urinary incontinence during the day: Diurnal incontinence (or diurnal wetting)

  • For urinary incontinence at night: Enuresis (or bed-wetting)

Diurnal (daytime) incontinence is usually not diagnosed until age 5 or 6. Nocturnal (nighttime) incontinence (that is, enuresis) is usually not diagnosed until age 7. Before this time, enuresis is typically referred to as nighttime wetting (3 General references Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more ). These age limits are based on children who are developing typically and so may not be applicable to children with developmental delay. Both nocturnal and diurnal incontinence are symptoms—not diagnoses—and necessitate consideration of an underlying cause.

The age at which children attain urinary continence varies, but > 90% are continent during the day by age 5. Nighttime continence takes longer to achieve. Enuresis 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 nocturnal wetting episodes. Enuresis is more common among boys and when there is a family history (4 General references Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more ).

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 psychologic impact of urine accidents (5 General references Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more ).

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 38:499–508, 2019. 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 35(4):471–481, 2016. 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. 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.

  • 5. 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

In the storage phase, the bladder acts as a reservoir for urine. Storage capacity is affected by bladder size and compliance. Storage capacity increases as children grow. Compliance can be decreased by repeated infections or by outlet obstruction, with resulting bladder muscle hypertrophy.

In the voiding phase, bladder contraction synchronizes 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 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 Urinary Tract Infection (UTI) in Children Urinary tract infection (UTI) is defined by ≥ 5 × 104 colonies/mL in a catheterized urine specimen or, in older children, by repeated voided specimens with ≥ 105 colonies/mL. In younger children... read more (UTI) or from anything that presses on the bladder (eg, a dilated rectum caused by constipation Constipation in Children Constipation is responsible for up to 5% of pediatric office visits. It is defined as delay or difficulty in defecation. Normal frequency and consistency of stool varies with children's age... read more ; 2 Pathophysiology references Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more ).

The maturation of the voiding pattern from infant to adult 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 Pathophysiology references Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more ).

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 and treatments than urinary incontinence in adults Urinary Incontinence in Adults Urinary incontinence is involuntary loss of urine; some experts consider it present only when a patient thinks it is a problem. The disorder is greatly underrecognized and underreported. Many... read more . Although some abnormalities cause both nocturnal and diurnal incontinence, etiology typically varies depending on whether incontinence is nocturnal or diurnal, as well as primary or secondary. Most primary incontinence is nocturnal (ie, enuresis) and not due to an organic disorder. Enuresis can be divided into monosymptomatic (occurring only during sleep) and complex (other abnormalities are present, such as diurnal incontinence and/or urinary symptoms).

Nocturnal incontinence (enuresis)

Organic disorders account for about 30% of cases and are more common in complex compared to monosymptomatic enuresis.

The remaining majority of cases are of unclear etiology but are thought to be due to a combination of factors, including

  • Maturational delay

  • Uncompleted toilet training

  • 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 nocturnal enuresis, there is a 30% chance offspring will have it, increasing to 70% if both parents were affected)

The factors contributing to organic causes of nocturnal incontinence include

Table
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Diurnal incontinence

Common causes of diurnal incontinence include

Table
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Evaluation of Urinary Incontinence In Children

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, no diagnostic tool can replace the sympathetic and discriminating ear of the physician (1 Evaluation references Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more ).

History of present illness inquires about 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 dribbling) or intermittent. 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 steam 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 UTIs. Similar to the voiding diary, a stooling diary can help identify constipation.

Review of systems should seek symptoms suggesting a cause, including frequency and consistency of stools (constipation); fever, abdominal pain, dysuria, and hematuria (UTI); perianal itching and vaginitis (pinworm infection); polyuria and polydipsia (diabetes insipidus or diabetes mellitus); and snoring or breathing pauses during sleep (sleep apnea). Children should be screened for the possibility of sexual abuse, which, although an uncommon cause, is too important to miss.

Past medical history should identify known possible causes, including perinatal insults or birth defects (eg, spina bifida), neurologic disorders, renal disorders, and history of UTIs. Any current or previous treatments for incontinence and how they were actually instituted should be noted, as well as a list of current drugs.

Developmental history should note developmental delay or other developmental 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 near the onset of symptoms, including difficulties at school, with friends, or at home; although incontinence is not a psychologic disorder, a brief period of wetting may occur during stress.

Clinicians also should ask about the impact of incontinence on the child because it also affects treatment decisions.

Physical examination

Examination begins with review of vital signs for fever (UTI), signs of weight loss (diabetes), and hypertension (renal disorder). Examination of the head and neck should note enlarged tonsils, mouth breathing, or poor growth (sleep apnea). Abdominal examination should note any masses consistent with stool or a full bladder.

In girls, genital examination should note any labial adhesions, scarring, or lesions suspicious of sexual abuse. An ectopic ureteral orifice is often difficult to see but should be sought. In boys, examination should check for meatal irritation or any lesions on the glans or around the 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 complete neurologic evaluation is essential and should specifically target lower-extremity strength, sensation and deep tendon reflexes, sacral reflexes (eg, anal wink), and, in boys, cremasteric reflex 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 diurnal incontinence (beyond age 6 years)

  • Any neurologic signs, especially in the lower extremities

  • Physical signs of neurologic impairment

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 suggest possible causes (see Table: Some Factors Contributing to Nocturnal Incontinence Some Factors Contributing to Nocturnal Incontinence Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more ).

For children who are being evaluated for enuresis, it is important to determine whether diurnal 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 diurnal 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 Urinary Tract Infection (UTI) in Children Urinary tract infection (UTI) is defined by ≥ 5 × 104 colonies/mL in a catheterized urine specimen or, in older children, by repeated voided specimens with ≥ 105 colonies/mL. In younger children... read more 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 Constipation in Children Constipation is responsible for up to 5% of pediatric office visits. It is defined as delay or difficulty in defecation. Normal frequency and consistency of stool varies with children's age... read more should be considered in the absence of other findings in children who have hard stools and difficulty with elimination (and sometimes palpable stool on examination).

Testing

Diagnosis of incontinence is often apparent after history and physical examination. Urinalysis and urine culture are appropriate for both sexes (see How To Catheterize the Bladder in a Female Child How To Catheterize the Bladder in a Female Child Urethral catheterization is insertion of a flexible catheter through the urethra into the urinary bladder. Several types of catheters are available. If a catheter cannot be inserted, suprapubic... read more and see How To Catheterize the Bladder in a Male Child How To Catheterize the Bladder in a Male Child Urethral catheterization is insertion of a flexible catheter through the urethra into the urinary bladder. Several types of catheters are available. If a catheter cannot be inserted, suprapubic... read more ). Further testing is useful mainly when history, physical examination, or both suggest an organic cause (see Table: Some Factors Contributing to Nocturnal Incontinence Some Factors Contributing to Nocturnal Incontinence Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more and see Table: Some Organic Causes of Diurnal Incontinence Some Organic Causes of Diurnal Incontinence Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more ). Ultrasonography of the kidneys and bladder is often done to verify urinary tract anatomy is normal (2 Evaluation references Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more ). 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 part of treatment is family education about the cause and clinical course of incontinence. Education helps decrease the negative psychologic impact of urine accidents and results in increased adherence with treatment.

Treatment of urinary incontinence should be targeted toward any cause that is identified; however, frequently no cause is found. In such cases, the following treatments may be useful.

Nocturnal 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 enuresis, and the family is able to adhere. It can take up to 4 months of nightly use for complete resolution of symptoms. 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 prior to an enuretic event. These alarms are readily available online without prescription. An alarm should not be used by children with complex enuresis or children with reduced bladder capacity (as evidenced by voiding diary). These children should be treated the same as children with diurnal incontinence. It is essential to avoid punitive approaches because these undermine treatment and lead only to poor self-esteem.

Drugs such as desmopressin (DDAVP) and imipramine (see Table: Oral Drugs Used for Incontinence in Children* Oral Drugs Used for Incontinence in Children* Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more ) 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 potential of sudden death with imipramine use.

Diurnal incontinence

It is important to treat any underlying constipation Treatment Constipation is responsible for up to 5% of pediatric office visits. It is defined as delay or difficulty in defecation. Normal frequency and consistency of stool varies with children's age... read more . 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

For labial adhesions, a conjugated estrogen or triamcinolone 0.5% cream may also be used.

Drug treatment (see Table: Oral Drugs Used for Incontinence in Children* Oral Drugs Used for Incontinence in Children* Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more ) is sometimes helpful but is not typically first-line therapy. Anticholinergic drugs (oxybutynin and tolterodine) may benefit patients with diurnal incontinence due to voiding dysfunction when behavioral therapy or physiotherapy is unsuccessful. Drugs for enuresis may be useful in decreasing nighttime wetting episodes and are sometimes useful to encourage dryness during overnight events such as sleepovers.

Anticholinergics (eg, solifenacin and darifenacin) that are prescribed for the treatment of overactive bladder in adults 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 (2 Treatment references Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time... read more ).

Table
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Treatment references

  • 1. 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.

  • 2. 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 nocturnal incontinence (enuresis).

  • Constipation should be considered as a contributing source.

  • Most nocturnal incontinence abates with maturation (15%/year resolve with no intervention), but at least 0.5% of adults have nighttime wetting episodes.

  • Organic causes of incontinence are infrequent but should be considered.

  • Alarms are the most effective treatment for enuresis.

  • Other treatments include behavioral interventions and sometimes drugs.

  • Parental education is essential to the child’s outcome and well-being.

More Information

The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

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