A Quick Guide to Paediatric Urinary Incontinence

Though paediatric urinary incontinence may be concerning for the child and parent(s) involved, it is quite common – it’s very likely that you will frequently encounter this issue in your work.

Typically, a child will have achieved daytime bladder control by the age of four. When this doesn’t occur, and a child is still prone to wetting at inappropriate times or during the night, intervention is required.

Urinary incontinence can have a significant negative impact on a child’s psychosocial wellbeing and affect their day-to-day life. Fortunately, there are many treatment options available.

This article will discuss the presentation and treatment of paediatric urinary incontinence.

How Common is Paediatric Urinary Incontinence?

Children usually attain continence during the day by age four or five. Nighttime continence usually takes longer to achieve.

• Recent statistics show that around 17 to 20% of children experience urinary incontinence during the day, and a further 6.6% of children will also have problems at night.
• This steadily decreases as children move toward adolescence; rounding to 1% by age 18.
• It is estimated that roughly 0.5% of adults continue to experience wetting at night.
• Nighttime wetting is more common among boys and when there is a known family history.

(Nankivell & Caldwell 2014; Figueroa 2018)

Physiology of Paediatric Urinary Incontinence

To be considered as presenting with paediatric urinary incontinence: the child will involuntarily void urine at least once per month for up to three months (The Royal Children’s Hospital Melbourne 2018).

As is understood, the bladder has a dual function: to store and eliminate urine. Paediatric urinary incontinence occurs when the child is unable to carry out the following actions:

• Throughout the day, responding to the sensation of fullness in their bladder the child will contract their detrusor muscle as they relax their urinary sphincters and pelvic floor muscles – this permits the stream of urine until the bladder is emptied.
• At night, the child should be able to sleep without needing to urinate, but still possess the ability to wake up and void when they sense bladder fullness.

Types of Paediatric Urinary Incontinence

Paediatric urinary incontinence is separated into two distinct categories:

1. Diurnal incontinence (day wetting)

Diurnal incontinence (or day wetting) is urinary incontinence during the day, which is not diagnosed until the age of 5 or 6; and

2. Enuresis (bed-wetting)

Enuresis (or bed-wetting) is urinary incontinence at night. The child can be diagnosed as having nocturnal (nighttime) incontinence by the age of 7.

(Nankivell & Caldwell 2014)

These age indicators may not be applicable to children with developmental delay, and are therefore based on children who are developing typically (Figueroa 2018).

How Does Paediatric Urinary Incontinence Present?

Common problems that are to be observed are:

• Leakage: this occurs when the child is prone to avoiding going to the toilet and wets when the bladder overfills.
• Overactive bladder: the child’s bladder is struggling to store urine. The child may express urgency, they may urinate while trying to get to the toilet and will need to void up to or more than eight times a day.
• Underactive bladder: the child goes to the toilet infrequently, less than four times a day, and sometimes urine escapes. Urinary tract infection is common in this case.
• Partial emptying of the bladder: the child has not grasped how to completely empty their bladder.

(Continence Foundation of Australia 2019)

Urinary Tract Infections (UTIs)

Urinary tract infections, constipation and stress should be considered as possible factors of urinary incontinence (Raising Children Network 2017).

Often children will present other lower urinary tract (LUT) symptoms such as:

• A weak stream;
• Urgency presenting in the sudden and unpredictable need to void;
• Urge incontinence, an inability to suppress voiding with urgency;
• Heightened or lessened voiding frequency;
• Straining; and
• Holding manoeuvres including crossing their legs, standing on tip-toes, or squatting.

(Nankivell & Caldwell 2014)

Treatment and Management Options

There are many options available for the treatment and management of paediatric urinary incontinence.

Urotherapy

The first-line of therapy for children with this condition is urotherapy. Urotherapy is a nonpharmacological and nonsurgical intervention frequently used to treat lower urinal tract and bowel dysfunction.

In terms of assessment, a general practitioner (GP) will undertake a physical examination of the child’s stomach, lower back and genitals; the GP might also test the child’s urine (Raising Children Australia 2017.)

Urotherapy involves:

• Education on normal lower urinary tract function;
• Regular voiding habits and voiding posture;
• Lifestyle advice regarding fluid intake and constipation prevention; and
• Bladder diaries and/or frequency-volume charts.

It also encompasses:

• Pelvic floor muscle training; and
• Behavioural modification, neuromodulation and catheterisation.

(Figueroa 2018; Horowitz & Misseri 2007; Maternik et al. 2015; Nankivell & Caldwell 2014; Raising Children Network 2017)

If urotherapy alone is deemed to be insufficient, a combination of alarm training and prescribed medications may be recommended.

Family education about the cause and clinical course of incontinence is important to reduce stigma and assist with treatment.

Prevention of Paediatric Urinary Incontinence

Incontinence can, in most cases, be prevented by learning and practising particular healthy habits.

To prevent any form of incontinence it is important to encourage patients to be physically active, learn and practice good toilet habits, drink plenty of fluids, and overall endeavour to make and maintain a healthy lifestyle.

When to Refer

Patients should be referred on to a specialist in the following cases, or when treatment is not successful after roughly six months (Nankivell & Caldwell 2014):

• If the child shows severe daytime symptoms;
• If the child frequently contracts urinary tract infections; and
• If the child experiences physical or neurological problems and psychosocial or other co-occurring conditions that require further management.

Conclusion

Paediatric diurnal incontinence and enuresis are frequently encountered in general practice, as they are common issues in school-aged children.

Effective treatment is enormously beneficial for the child in their wellbeing and self-esteem. The stigma surrounding urinary incontinence should not be underestimated.

To determine the most effective treatment and to reach an accurate diagnosis, a detailed assessment of family history and examination are crucial.

Additional Resources

• 

  Continence Foundation of Australia

  Caring for someone with incontinence: A page and video resources dedicated to carers who are looking after someone with incontinence.

  Webinar library: Several video resources on incontinence.

References

• Figueroa, TE 2018, ‘Urinary Incontinence In Children’, MSD Manual . Viewed 10 June 2019, https://www.msdmanuals.com/en-au/professional/pediatrics/incontinence-in-children/urinary-incontinence-in-children#v26433797.
• Horowitz, M, & Misseri R 2007, ‘Diurnal and Nocturnal Enuresis’, Clinical Pediatric Urology, ed. 5, edited by Docimo S, Canning D, Khoury A. London, Martin Dunitz Ltd., pp. 819–840.
• Maternik, M, Krzeminska, K, & Zurowska, A 2015, ‘The Management of Childhood Urinary Incontinence’, Pediatric Nephrology (Berlin, Germany), issue 30, pp. 41–50.
• Nankivell, G & Caldwell P HY 2014, ‘Paediatric Urinary Incontinence', Australian Prescriber, issue 37, pp.192–5. Viewed 8 June, https://www.nps.org.au/australian-prescriber/articles/paediatric-urinary-incontinence.
• Raising Children Network 2017, Urinary Incontinence, Sydney, viewed 8 June 2019, https://raisingchildren.net.au/guides/a-z-health-reference/urinary-incontinence.
• The Royal Children’s Hospital Melbourne 2018, 'Urinary Incontinence - Daytime Wetting', RCH, Melbourne. Viewed 18 June 2019, https://www.rch.org.au/clinicalguide/guideline_index/Urinary_Incontinence_-_Daytime_wetting/.
• Continence Foundation of Australia 2019, 'Day Wetting', Surrey Hills (VIC), viewed 8 June 2019, https://www.continence.org.au/pages/day-wetting.html.

(Answers: c, c, d.)