Urinary Incontinence (Daytime Wetting)

Question 1

At which age is daytime wetting abnormal?

Answer 1

After 4yo

Question 2

Aetiology of daytime wetting (and which is most common)

Answer 2

• Constipation
• Voiding post-ponement 
	○ Behavioural problem
• OAB - *most common*
	○ Filling problem
• Dysfunctional voiding
	○ Emptying problem
• Urethrovaginal reflux 
	○ Common in girls 
	○ Posture problem 
• Psychological

Question 3

What is essentially the pathophys of overactive bladder?

Answer 3

• Bladder spasms causing urgency with a bladder which is not full

Question 4

What is the major complication of OAB, and how might this happen?

Answer 4

• UTI risk is increased due to:
○ ‘milk back’ phenomenon
○ increased residual volume

Question 5

What essentially occurs in dysfunctional voiding?

Answer 5

• Lack of co-ordination (dyssynergia) between detrusor muscle and sphincter

Question 6

What essentially occurs in urethrovaginal reflux?

Answer 6

• Common in girls

* Posture problem e.g. rush -> don’t sit properly -> urine pools in vagina -> stand up and urine trickles

Question 7

What advice can we give to girls/their parents to help manage urethrovaginal reflux?

Answer 7

• Trial of sitting backwards on toilet
○ Sit steadily on the toilet brim, legs fully supported
○ Keep the legs well apart.
○ Lean the trunk forward (as much as you can) making the pelvis tilt forward and the urinary stream more vertical
○ Separate the labia before voiding.

• At end of voiding, use toilet paper to press and lift the perineum forward/upward (from the base of the vagina and away from the rectum) to empty urine from the vagina.

Question 8

What are some psychological causes of daytime wetting?

Answer 8

• Child abuse
• Childhood trauma
• Low awareness bladder sensation
• Poor attention/concentration

Question 9

What is a high PVR volume in paeds?

Answer 9

○ PVR > 20ml in paeds (inc risk of infection)

Question 10

Describe different graphs from urodynamic studies and which pathologies they might indicate.

Answer 10

○ Bell = normal
○ Tower = OAB
○ Staccato = voiding dysfunction

Question 11

What are some general behavioural and urotherapy mx points for daytime wetting?

Answer 11

Behaviour
• Regular toileting and fluids
• 7 wees a day and drink with each meal and snack

Urotherapy
○ Regular voiding
○ Pelvic floor relaxation (anal probe)
○ Posture
○ Check bowels

Question 12

Rx for daytime wetting: what, side effects and indication for cessation

Answer 12

• Treat with oxybutynin (anticholinergic) 5mg tab bd
○ Most important side effects include dry mouth and constipation
○ May cause mood changes (irritability) - indication for cessation