Urinary Incontinence Flashcards
Define urinary incontinence in children
Lack of bladder control during the day or night in a child old enough to be continent (over 3-5 years)
DSM 5: involuntary wetting during sleep, at least twice a week, in children older than 5 years of age with no congenital or acquired defects of the central nervous system
What is the difference between primary and secondary incontinence
Primary = the child has never achieved sustained continence at night
Secondary = bedwetting occurs after the child or young person has been previously dry at night for more than 6 months
What are the causes of daytime enuresis
Lack of attention to bladder sensation (normal)
Detrusor instability
Bladder neck weakness
Neuropathic bladder (enlarged and fails to empty properly)
UTI
Constipation
Ectopic ureter (constant dribbling and a child that is always damp)
What are the causes of nocturnal enuresis
Primary
- Sleep arousal difficulties - inability to wake to noise, sensation of a full bladder, bladder contractions
- Polyuria
- Bladder dysfunction (overactive or small capacity)
Secondary
- Emotional upset (most common)
* UTI
* Overactive bladder
* Osmotic diuresis in DM (polyuria)
* Ectopic ureter (constant dribbling and a child that is always damp)
* Constipation (faecal impaction severe enough to reduce bladder volume and cause bladder neck dysfunction)
* Renal concentration disorder e.g. sickle cell disease, CKD (polyuria)
* Diabetes insipidus (polyuria)
What are the risk factors for urinary incontinence in children
Male sex (2:1)
First degree relative with Hx of enuresis
Stress (emotional, physical)
Developmental delay (physical or intellectual)
Neurodevelopmental conditions e.g. spina bifida (neuropathic bladder)
Constipation, faecal incontinence, daytime urinary incontinence
Psychological or behavioural disorders e.g. ADHD, ASD, anxiety, depression, conduct disorders
Sleep apnoea and upper airway obstructive symptoms
What is the prevalence of urinary incontinence in children
5-10% in 7yo
1-2% adolescents
What are the important features to ask about in a history for urinary incontinence in chidlren
- How was toilet training
- Have they been dry at night without assistance for 6 months
- type of bedwetting
- Symptoms of urgency, frequency, day/night, straining, poor stream, dysuria
- Quantity of urine
- Do they avoid toilets e.g. at school
- Are they dry, but then wet on getting up (ectopic) - Fluid intake
What are the signs of urinary incontinence in children on examination
Abdominal exam: Neuropathic bladder (bladder distended)
Pelvic exam: Abnormal perianal sensation and anal tone
Neurological:
- Abnormal leg reflexes and gait
- Sensory loss (S2, S3, S4)
- Visible spinal lesion
What are the investigations for urinary incontinence in children
Bedside: urine dip, urine MC&S, urine osmolality
Other:
- US pelvis: incomplete bladder emptying, bladder wall thickening
- Urodynamic studies
- X-ray spine (vertebral anomaly)
- MRI (may show spinal defect)
What is the management for children <5yo with urinary incontinence
Bedwetting at this age is normal and does not require active management.
1. explain diagnosis and give advice:
- resolves without treatment
- the child shouldn’t feel blamed for it, stop any punitive procedures
- Fluid restriction 2h before bedtime (NOT during day)
- toilet advice: empty bladder fully and regularly, waterproof mattress and duvet cover, easy access to toilet
- Star chart: praise and a star for agreed behaviour (changing sheets, dry nights, using toilet before bed, adequate fluid intake)
What is the management for children >5yo with urinary incontinence
- Explain diagnosis and give advice (same as <5yo)+ star chart
First line: Enuresis alarm
Second line: desmopressin
+ follow up after 4 weeks
Third line: refer to enuresis clinic/secondary care (may prescribe oxybutynin)
What is the management for daytime enuresis
Rule out neurological cause → refer to enuresis clinic
Star charts
Bladder training
Pelvic floor exercises
Treat any constipation
Enuresis alarm
What is the prognosis for urinary incontinence
After 4 years old, enuresis resolves spontaneously in 5% of affected children
Most children will be continent by adolescence
7 in 100 children bedwetting at 7yo will continue to have nocturnal enuresis into adulthood
Describe the enuresis alarm
Sensory alarm placed in the pant’s or on the bed, makes a sound when wet
The child should then wake, get out of bed, pass urine, then return and remake the bed
May take several weeks, but is effective
The child and carers must be highly motivated
NOT NHS prescribed: borrow form an enuresis advisor or bought from ERIC
Describe desmopressin as treatment for enuresis
Oral/sublingual once a day
Used if alarm was unsuccessful, or for short term relief (take 1 week before desired effect)
Restrict fluid intake after use
