Paediatric Urinary Control – Daytime Urinary Incontinence and Nocturnal Enuresis

Original Editors - Laura Ritchie posting on behalf of Demetria Correia, MPT Class of 2022 at Western University, project for PT9584.

Lead Editors - Laura Ritchie  

Introduction[edit | edit source]

Bed wetting and daytime leakage can occur in children and adults. These can both be categorized under the umbrella term, urinary incontinence. For children, urinary incontinence is the most common urinary symptom and can be expected during the potty-training years. After the fifth year of life, the causes of incontinence are no longer considered physiological. Although varied with age and between genders, bladder control often stabilizes within the 3rd to 6th year of life.[1][2][3]

Urinary incontinence is any involuntary or uncontrollable leakage of urine. This can occur during the day, known as daytime urinary incontinence. Urinary incontinence can also occur at night. It is known as nocturnal enuresis or enuresis nocturna when one is unable to wake up to urinate. When one is able to wake up from sleep in order to urinate, it is known as nocturia.[4] A child can also have a mix of nocturnal enuresis and daytime urinary incontinence, known as a dual diagnosis.[2] Within the paediatric population, any of these can occur. Urinary incontinence can be divided into further subcategories, which are classified below:

  • Primary = children who have never achieved 6 consecutive months of continuously dry nights[2]
  • Secondary = children who have previously achieved 6 consecutive months of continuously dry nights, but no longer do[2]
  • Monosymptomatic = only symptom is nocturnal enuresis[5]
  • Non-monosymptomatic = enuresis is associated daytime or other lower urinary tract symptoms, such as daytime incontinence, urgency, frequency, dysuria/ stranguria, or others[6]

Pathophysiology[edit | edit source]

While pediatric urinary incontinence can come from both structural and functional causes, nocturnal enuresis and daytime urinary incontinence primarily derive from functional causes.

One common functional cause of nocturnal enuresis and daytime urinary incontinence is urinary tract infections (UTI) due to the impact on inflammation and irritation leading to incontinence. Incontinence can also be influenced by mood disorder. These can include attention deficit hyperactivity disorder, anxiety, and when a child is placed in a stressful life event.[2]

Paediatric monosymptomatic enuresis nocturna is mainly caused by the inability to wake up from a full bladder due to altered perception of bladder fullness or no perception of it at all, and an imbalance in bladder capacity and urine production. Majority of these children produce high volumes of urine due to a lack of circadian rhythm of vasopressin, which goes beyond the bladder capacity. The result is bed wedding. This process is known as nocturnal polyuria. Another cause of this could be detrusor overactivity and lack of relaxation resulting in a lower functional bladder capacity.[4] Finally, high arousal threshold can be a contributing factor.[6]

The main cause of paediatric non-monosymptomatic urinary incontinence is often due to bladder dysfunction. This can be due to nocturnal detrusor hyperactivity, which is seen as lowered bladder capacities or abnormal urodynamics.[7] Constipation can create bladder distortion from a full rectum resulting in a decrease in bladder capacity.[8]

Associated Risk Factors[edit | edit source]

There are a number of risk factors associated with pediatric urinary incontinence. Some of these include:[1] [4][9]

  • Increased stress
  • Neglect
  • Trauma
  • Parental history of daytime wetting or nocturnal enuresis
  • History of daytime wetting in male sibling
  • Obesity
  • Constipation
  • Vesico-uretic reflex
  • History of urinary tract infections
  • Diabetes Mellitus Type I

Assessment[edit | edit source]

History Taking[edit | edit source]

Finding out key information from the child and caregiver.

  • Questions related to the symptoms include: the daytime pattern, urgency, frequency, caffeine intake, nighttime fluid intake, age of onset, if it is primary or secondary enuresis, posture while voiding, amount of urine expelled at night, presence of polydipsia, presence of dysuria, both daytime and nighttime symptoms, abnormalities in urinary stream, presence of constipation, excessive stool retention[6] [7]
  • Other important questions include family history of enuresis, history of UTI’s, sleep disorders, hours of sleep, snoring or sleep-disordered breathing, use of chronic medications, psychological or behavioural disorders, and a developmental history[6]
  • Rule out anatomical or physiological urologic condition symptoms that may lead to nocturnal enuresis[4]

Bladder Diary[edit | edit source]

A two-to-three-day diary from day to night.

  • Fluid intake, voiding, voiding volume, and incontinence episodes

Questionnaires[edit | edit source]

  • Pediatric Incontinence Questionnaire (PIN-Q)
  • Incontinence Symptom Index-Pediatric (ISIP)
  • International Consultation on Incontinence Questionnaire Paediatric Lower Urinary Tract Symptoms (ICIQ-CLUTS)

Physical Exam[edit | edit source]

For children, there is an emphasis on external examination, unless an internal exam is deemed necessary.

  • Observation: improper gait, spinal deformity, foot abnormality indicating sacral neuropathy, occult spinal abnormalities, abdominal examination
  • Internal Examination: feacal impaction, poor perineal sensation, reduced anal sphincter tone, narrowing of urethral meatus for boys with observation of voiding, introitus for position of the urethra for girls, observation of wetting or irritation of labia or vagina indicating dribbling or incomplete emptying

Urinalysis[edit | edit source]

Usually unnecessary for monosymptomatic enuresis but can be indicated for non-monosymptomatic enuresis and a lack of therapy response. Identifies infection, renal damage, or diabetes[2]

Other[edit | edit source]

Additional workups indicated by non-monosymptomatic enuresis or a lack of therapy response:

  • Bladder ultrasound (post-void residual volume, measurement of urine flow rate, urodynamics studies, anorectal manometry)[6]

Treatment[edit | edit source]

Management is dependent on the results of the assessment in determining the root cause of the incontinence between functional, structural, or anatomical cause. The earlier treatment starts in life, the better. Because daytime urinary incontinence and nocturnal enuresis are due to functional causes, this is what we will focus on. For both daytime urinary incontinence and nocturnal enuresis, any issues with constipation should be targeted first. Furthermore, behavioural and psychological comorbidities should be addressed as well.[2] [6]

Daytime Urinary Incontinence[edit | edit source]

  • Education for children and parent/ caregiver:
    • Normal bladder function and sensation
  • Behavioural Therapy: Goal is to re-educate and restore normal bladder sensation and habits, while suppressing urges.
    • Timed voiding every 2-3h
    • Avoid caffeinated, carbonated, and highly acidic fluids
    • Voiding diary: amount voided, number of times voided, incontinence, fluid intake
  • Biofeedback Therapy: Visual and auditory feedback for children during bladder filling and emptying
    • Games and programs to respond to normal bladder urges and pelvic floor relaxation during voiding
  • Pharmacological therapy:
    • Oral anticholinergic therapy: for overactive bladder and urge incontinence

Nocturnal Enuresis[edit | edit source]

  • Education:
    • Voiding schedule: when arising, during day, and right before bed
    • Drinking most fluids in morning and afternoon, minimal at night
  • Alarm Therapy:[10]
    • Alarm senses moisture and arouses patient with auditory or vibrational stimulation. At this time, patient should wake up and use the bathroom.
  • Pharmacological Therapy:
    • Desmopressin Acetate
    • Anticholinergic agents
    • Tricyclic Antidepressant

Why It Matters[edit | edit source]

Pediatric urinary incontinence is impactful to both the child involved and their family. It requires extra planning, care, and preparation for day to day living from everyone involved. For the child, incontinence can have a lot of negative connotations and cause a decrease in quality of life. This could result in social isolation and low self-esteem. There is a high rate of comorbid emotional distress in children suffering from incontinence. The diagnostic criteria are met in 20 to 40% of children with daytime urinary incontinence and 20 to 30% of children with nocturnal enuresis meet the diagnostic criteria for psychiatric disorders.[11]

A lack of education on this topic leads parents down a path of the ‘wait and see’ approach. This is based on the assumption that the incontinence is normal and will resolve as the child gets older. Unfortunately, many children continue to suffer from continued symptoms into their adulthood with worsened symptoms. This can be prevented with access to the necessary education and resources about the abnormalities within paediatric urinary incontinence.

References[edit | edit source]

  1. 1.0 1.1 Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H. Urinary incontinence in children. Dtsch Arztebl Int [Internet]. 2011 Sept [cited 2022 Mar 20]; 108(37): 613–620. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3187617/
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Schaeffer AJ, Diamond DA. Pediatric urinary incontinence: Classification, evaluation, and management. Afr J Urol [Internet]. 2014 Mar [cited 2022 Mar 20]; 20(1): 1-13. Available from: https://doi.org/10.1016/j.afju.2013.10.001
  3. Maternik M, Krzeminska K, Zurowska A. The management of childhood urinary incontinence. Pediatr Nephrol [Internet]. 2014 Mar 11 [cited 2022 Mar 29]; 30(1): 41-50. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4240910/
  4. 4.0 4.1 4.2 4.3 Tekgul S, Nijman R, Hoebeke P, Canning D, Bower W, Von Gontard A. Diagnosis and Management of Urinary Incontinence in Childhood [Internet]. Nd [cited 2022 Mar 22]. Available from: https://www.ics.org/Publications/ICI_4/files-book/Comite-9.pdf
  5. Baird DC, Seehusen DA, Bode, DV. Enuresis in Children: A Case-Based Approach. Am Fam Physician [Internet]. 2014 Oct 15 [Cited 2022 Mar 23]; 90(8): 530-568. Available from: https://www.aafp.org/afp/2014/1015/p560.html
  6. 6.0 6.1 6.2 6.3 6.4 6.5 Rincon MG, Leslie SW, Lotfollahzadeh S. Nocturnal Enuresis. StatPearls [Internet]. 2022 Feb 14 [Cited 2022 Mar 25]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545181/
  7. 7.0 7.1 Graham KM, Levy JB. Enuresis. Pediatr Rev [Internet]. 2009 May [cited 2022 Mar 25]; 30(5):165-72. Available from: https://pubmed.ncbi.nlm.nih.gov/19411333/
  8. Nevéus T. Pathogenesis of enuresis: Towards a new understanding. Int J Urol [Internet]. 2017 Mar [cited 2022 Mar 28]; 24(3):174-182. Available from: https://pubmed.ncbi.nlm.nih.gov/28208214/
  9. Buckley BS, Sanders CD, Kwong JS, Kilpatrick KA, Anderson CA. Conservative treatment for functional daytime urinary incontinence in children. 2016 Sep [cited 2022 Mar 28]; 2016(9) CD012367. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457796/
  10. Kiddoo DA. Nocturnal enuresis. CMAJ [Internet]. 2012 May 15 [cited 2022 Mar 28]; 184(8), 908–911. Available from: https://doi.org/10.1503/cmaj.111652
  11. von Gontard A, Baeyens D, Van Hoecke E, Warzak WJ, Bachmann C. Psychological and psychiatric issues in urinary and fecal incontinence. Urol. J. [Internet]. 2011 Apr 1 [cited 2022 Mar 29]; 185(4), 1432–1436. Available from: https://doi.org/10.1016/j.juro.2010.11.051