Urinary Incontinence in Children

Question 1

At what age can we start diagnosing children with daytime urinary incontinence?

Answer 1

≥5 years of age

At least twice per week for at least 3 consecutive months

Question 2

Which gender is usually potty-trained first? Which gender is affected by daytime incontinence more?

Answer 2

Girls are earlier than boys

Girls are affected twice as much as boys

Question 3

What is daytime incontinence?

Answer 3

Repeated daytime voiding in urine into clothes

Question 4

What are two types of causes of daytime incontinence?

Answer 4

Function or organic

Question 5

What are examples of functional causes of daytime incontinence?

Answer 5

UTI
Stress
Urge syndrome
Deferral of voiding (holding)
Functional constipation

Question 6

What are organic causes of daytime incontinence?

Answer 6

Neurogenic bladder
Partial urethral obstruction
Ectopic ureter

Question 7

What is enuresis?

Answer 7

Bedwetting during sleep (inclusive of nap time)

Question 8

At what age can you start diagnosing children with enuresis?

Answer 8

5+ years for girls
6+ years for boys

More than twice weekly

Question 9

What is the difference between primary enuresis and secondary enuresis?

Answer 9

Primary- bladder control has never been achieved
Secondary- loss of bladder control after at least 6 months without bedwetting

Question 10

Which of the two types of primary enuresis is more common in boys?

Answer 10

Primary enuresis

Question 11

What are two types of primary enuresis?

Answer 11

Volume-dependent enuresis
Detrusor dependent enuresis

Question 12

Which of the two types of enuresis is associated with nocturnal incontinence?
What’s the mechanism of action?

Answer 12

Volume-dependent enuresis

A normal nocturnal rise in antidiuretic hormone (ADH) does not occur

Question 13

Which of the two types of enuresis is associated with daytime incontinence?

Answer 13

Detrusor-dependent enuresis

Question 14

The two subtypes of enuresis are old classification methods. What is the new classification method for enuresis?

Answer 14

Monosymptomatic and non-monosymptomatic (daytime and nighttime incontinence)

Question 15

What are non-pharm choices for incontinence in children?

Answer 15

• Encourage child to avoid deferral
• Advise caregivers to avoid punishing behaviour
• Avoid excessive intake of fluids within 2 hours of bedtime
• Enuresis alarms

Question 16

Is there any evidence for complementary therapies such as hypnosis, chiropractic, or homeopathy?

Answer 16

No

Question 17

What age can we start pharmacologic therapy for children?

Answer 17

≥5 years of age

Question 18

What are the two classes of medications that can be used as pharmacologic choices?

Answer 18

Antidiuretic hormone analogues
Anticholinergic smooth muscle relaxants

Question 19

Which drug is under the antidiuretic hormone analogue drug class?

Answer 19

Desmopressin

Question 20

What’s the mechanism of action with desmopressin?

Answer 20

Analogue of human antidiuretic hormone (ADH).
Decreases urine production when given at bedtime

Question 21

When does desmopressin come into play?

Answer 21

When a rapid response is required

Question 22

How do we monitor desmopressin once we’ve started the therapy?

Answer 22

If therapy is effective, consider a 1 week interruption every 3 months to see if treatment is no longer needed

Question 23

________ children with ____ urine output and ______ bladder capacity would benefit the most from desmopressin.

Answer 23

Older
Large
Normal

Question 24

Patients with ____ urine output and _________ bladder capacity would require combo treatment with desmopressin and smooth muscle relaxant.

Answer 24

Large
Reduced

Question 25

What is a serious adverse effect associated with desmopressin use?

Answer 25

Overhydration and hyponatremia Can lead to seizures and death

Question 26

How doe we avoid the risk of hyponatremia?

Answer 26

Limiting fluid intake 1 hour before and 8 hours after taking desmopressin Hold dose during illness that can cause electrolyte imbalance (Ex: fever, vomiting, diarrhea)

Question 27

What are signs of hyponatremia that would warrant discontinuation and need to referral for medical attention?

Answer 27

Headache, nausea, vomiting

Question 28

Is nasal desmopressin indicated for treatment of nocturnal enuresis?

Answer 28

No, higher incidence of hyponatremia

Question 29

Which drugs are in the anticholinergic smooth muscle relaxant drug class?

Answer 29

Oxybutynin Tolterodine Solifenacin Propiverine

Question 30

Which of the four medications is good for reducing bladder contraction in those with detrusor overactivity?

Answer 30

Oxybutynin

Question 31

What's the most common side effect with oxybutynin?

Answer 31

Constipation, dry mouth, and flushing

Question 32

Of the four smooth muscle relaxants, which are selective agents?

Answer 32

Tolterodine Solifenacin

Question 33

If they're selective and have fewer systemic side effects, why is its use limited?

Answer 33

Not indicated for use in children in Canada

Question 34

What is its use limited to?

Answer 34

Reserved for cases in which oxybutynin is not tolerated

Question 35

Oxybutynin and tolteridone is both available in immediate and extended release form. What is the benefit with extended release form?

Answer 35

Better efficacy in urinary incontinence

Question 36

What makes propiverine an uncommon choice?

Answer 36

Weight based dosing

Question 37

When do we consider combo therapy of desmopressin and anticholinergic?

Answer 37

Refractory cases

Question 38

Which drugs are most commonly used for combo therapy?

Answer 38

Desmopressin and tolterodine

Question 39

When combining the two drugs, what do we have to adjust for the dose?

Answer 39

Lower dose of desmopressin - 200mcg tablets or 120mcg melts

Question 40

If child has failed all other therapies, what other drug can they try?

Answer 40

Tricyclic antidepressant - Amitriptyline - Desipramine - Imipramine

Question 41

Why are TCAs last line?

Answer 41

Low quality evidence Adverse effects include dizziness, GI discomfort, headache, mood changes

Question 42

What is considered treatment of relapse?

Answer 42

>1 symptom recurrence per month No response to desmopressin (at maximum dosages), alarm therapy, or combo of alarm therapy and desmopressin. If relapse occurs following desmopressin therapy, consider combo therapy

Question 43

Summary: What drug class do we use for enuresis?

Answer 43

Desmopressin

Question 44

Summary: What drug class do we use for daytime incontinence?

Answer 44

Anticholinergic (muscle relaxant)