It is important to recognize that the cause of daytime urinary incontinence in young children is rarely due to serious emotional problems, wilful manipulation, or laziness.
Daytime urinary incontinence (DUI) is the involuntary loss of bladder control with resultant uncontrolled urination that persists after four to five years of age.
DUI is most often caused by several distinct abnormalities of the bladder filling and release phrases.
Constipation or fecal soiling and urinary tract infections are often a problem in children with DUI. The general consensus is that these problems should be controlled or eliminated before beginning specific DUI treatment.
Urotherapy uses various forms of cognitive and biofeedback techniques and is generally considered the initial therapy for all forms of DUI.
When urotherapy is incompletely effective, particularly in children with overactive bladders, drug treatment and/or transcutaneous electrical nerve stimulation can successfully treat the problem.
My child’s pants are often wet or even soaked
Most children develop control of daytime urination by around five years of age, although some poor bladder control may persist beyond that age. Around 5 to 10% of seven-year-old children and 0.5 to 1% of adolescents have problems controlling urination.
The wetting ranges from damp underwear to soaking the clothing. Wetting can be a source of stress, embarrassment, and humiliation for the child, particularly when among peers or other adults. It also creates stress and frustration for the family.
Why is my child unable to control urination during the day?
The involuntary loss of bladder control during the day is called daytime urinary incontinence (DUI). In order to understand why your child has daytime wetting, it is helpful to have some familiarity with how urine is stored in the bladder and then released.
- The bladder wall has muscle tissue (the detrusor muscles) that remain at rest as the bladder fills, storing an average amount of urine.
- During this time, several muscles circling the urethra (two bladder sphincters) remain contracted, thus keeping urine from leaking.
- When we sense bladder fullness, the brain sends nerve signals for the bladder (detrusor muscles) to contract. At the same time, separate signals are sent to one of the urethral sphincter muscles that then relax. The other part of the urethral sphincter is controlled voluntarily.
- When you voluntarily relax the sphincter, urine flows out and the bladder empties.
- Normal urine voiding behavior requires coordination between the detrusor and sphincter muscles.
Common types of DUI in children
Several conditions underlie the vast majority of incontinence problems in children. These are “functional” disturbances, meaning that leakage of urine is due to problems during the bladder filling or emptying phases.
It is important to determine the cause since their treatments may be somewhat different:
- Habits such as holding urine in the bladder for too long, or limited access to the bathroom.
- An overactive bladder (urge incontinence) is the most common form of daytime wetting in children. This occurs when the bladder muscles begin to contract without warning causing a sudden strong urge to urinate. Often, the child will suddenly squirm, cross his or her legs, or squat while pressing in with their heel in an attempt to stop the leakage.
- An underactive bladder results in infrequent voiding during the day, often accompanied by a minimal or absent urge to urinate. Urine leakage may occur when the bladder is overdistended.
- Dysfunctional elimination results from poor bladder detrusor and urethral sphincter muscle coordination. Urine flow is interrupted when the bladder has not yet emptied. The remaining urine, plus the increased pressure in the bladder as it contracts but does not empty, can result in significant injury to the bladder and, possibly, the upper urinary tract.
Several conditions commonly contribute to DUI:
- Urinary tract infections can both cause or result from any of the above functional disturbances. Thus, successful treatment of urinary tract infection does not guarantee that the incontinence will resolve.
- Constipation or stool soiling (fecal incontinence) is present in up to 50% of children with DUI. The overfilled bowel can limit the amount of urine that the bladder can hold and stimulate unexpected bladder contractions.
- Neurodevelopmental disorders such as autism spectrum and untreated attention deficit disorders have an increased risk of DUI.
Evaluation of DUI
Otherwise healthy children with DUI do not usually require an extensive evaluation. When an examination is required, it may involve:
- Complete medical and family histories and a physical examination can provide a great deal of diagnostic information.
- Complete a one to two week home record of the frequency and volumes of voided urine, the characteristics of the urine stream, and observed behaviors just before and during urination. The volume and times of drinking should be noted along with bowel habits noting the frequency and any difficulty with elimination and the presence or absence of soiled underwear.
The evaluation also may require some noninvasive testing:
- A urinalysis and, if indicated, a urine culture, particularly for girls with incontinence.
- A uroflowmetry procedure provides information about the urine flow rate, volume, and the nature of the urine stream. This test can identify characteristics associated with different types of functional DUI.
- Electromyography also may be done at the time of uroflowmetry testing. This test uses electrodes on several adhesive pads placed on the skin. It can determine whether muscle activity during voiding is normal and coordinated, or abnormal.
- An ultrasound examination of the bladder and, if indicated, the upper urinary tract. This test can determine whether a significant amount of urine remains in the bladder after voiding, the size of the bladder and structural abnormalities often seen in several forms of DUI.
- An abdominal x-ray to evaluate constipation.
- Additional testing may be necessary on a case-by-case basis.
Management of DUI
In children with DUI and constipation or fecal soiling, the bowel problems should be treated first after which the DUI can be reevaluated. In some children, this is the only treatment necessary to achieve dryness.
Urotherapy is the generally accepted first line treatment for DUI. It employs cognitive behavioral methods to retrain bladder filling and emptying signals. These treatments require patience and consistency, and most studies show a significant degree of success. Compared to an annual spontaneous remission rate of 15% per year, around 50% or more can become dry when urotherapy is part of the treatment program.
Many children with overactive bladders will require additional therapy. Several drugs can modify the frequency and severity of unexpected bladder detrusor contractions. Among these, oxybutynin and propiverine are most often used.
Transcutaneous electrical nerve stimulation (TENS) has been used for children with overactive bladders as an alternative or supplement to medications. TENS is a noninvasive procedure that involves stimulation of the area containing the nerves for bladder contraction using patches applied to the skin. Although not yet widely used, studies have shown significant improvements in children with overactive bladders/urge incontinence.