Urinary incontinence in children: Difference between revisions

Jump to navigation Jump to search
No edit summary
 
(52 intermediate revisions by one other user not shown)
Line 84: Line 84:
{{CMG}} {{AE}}{{Ifeoma Anaya}}
{{CMG}} {{AE}}{{Ifeoma Anaya}}


{{SK}} [[Urinary incontinence]] in kids; [[bedwetting]]; [[enuresis]]; [[nocturnal enuresis]]; [[enuresis]] nocturna; monosymptomatic [[enuresis]] nocturnal (MEN); non-monosymtomatic [[enuresis]] nocturnal (non-MEN)  
{{SK}} [[Urinary incontinence]] in [[Children|kids]]; [[Bedwetting]]; [[Enuresis]]; [[Nocturnal enuresis]]; [[Enuresis]] nocturna; Monosymptomatic [[enuresis]] nocturnal (MEN); Non-monosymtomatic [[enuresis]] nocturnal (non-MEN)  


==Overview==
==Overview==
[[Urinary incontinence]] in [[children]] is a very familiar finding and complaint amongst [[patients]] and their caregivers. The earliest documentation of [[urinary incontinence]] dates back to 1550 BC in the [[Ebers papyrus]]. It is broadly classified into [[physiological]] and [[pathological]] with its various subdivisions and [[nocturnal enuresis]] can be categorized into primary and [[secondary]]. The [[pathophysiology]] of [[urinary incontinence]] in [[children]], particularly [[enuresis]] can be described under increased [[urine]] production at night, reduced [[Urinary bladder|bladder]] capacity at night, and awakening [[disorder]]. The [[causes]] of [[urinary incontinence]] in [[children]] are identified based on the subclassification of [[pathological]] [[Urinary incontinence|incontinence]]. Differentials include [[diabetes mellitus]], [[diabetes insipidus]] and, [[Urinary tract infections|urinary tract infection]]. [[Children]] achieve the ability to [[control]] their [[Urinary bladder|bladder]] between the ages of 3 and 6 years.
[[Urinary incontinence]] in [[children]] is a very familiar finding and complaint amongst [[patients]] and their caregivers. The earliest documentation of [[urinary incontinence]] dates back to 1550 BC in the [[Ebers papyrus]]. It is broadly classified into [[physiological]] and [[pathological]] with its various subdivisions, and [[nocturnal enuresis]] can be categorized into primary and [[secondary]]. The [[pathophysiology]] of [[urinary incontinence]] in [[children]], particularly [[enuresis]], can be described as increased [[urine]] production at night, reduced [[Urinary bladder|bladder]] capacity at night, and awakening [[disorder]]. The [[causes]] of [[urinary incontinence]] in [[children]] are identified based on the sub-classification of [[pathological]] [[Urinary incontinence|incontinence]]. Differentials include [[diabetes mellitus]], [[diabetes insipidus]], and [[Urinary tract infections|urinary tract infection]]. [[Children]] achieve the ability to [[control]] their [[Urinary bladder|bladder]] between the ages of 3 and 6 [[Year|years]]. This begins initially during the daytime and nighttime control is achieved much later. [[Nocturnal enuresis]] is seen more frequently in boys. There is no documented [[racial]] predisposition for [[enuresis]]. Some [[risk factors]] include, [[age]] less than 5 [[Year|years]], positive [[family history]], [[family]] size, and [[birth]] order. Certain [[complications]] are poor [[self-esteem]] and inability to socialize with [[Peer support|peers]]. [[Prognosis]] is generally good due to the high chances of spontaneous [[resolution]] at the [[rate]] of 15% per [[year]]. The focus is to eliminate any [[potential]] organic [[Causes|cause]] of [[Urinary incontinence|incontinence]] and to classify and identify the type of functional [[Urinary incontinence|incontinence]] using detailed [[History and Physical examination|history]] and [[Non-invasive (medical)|non-invasive]] [[Procedure|procedures]]. Identify any [[comorbidities]] which are mostly [[psychological]] occurring alongside [[Urinary incontinence|incontinence]]. Fundamental [[diagnosis]] includes taking a detailed [[History and Physical examination|history]] using a standardized [[questionnaire]]. The primary aim of a [[physical examination]] is to look for possible organic [[causes]] of [[Urinary incontinence|incontinence]] and [[comorbidities]]. [[Urinalysis]] is essential to rule out [[urinary tract infections]]. [[Ultrasonography]] is a useful tool when further [[diagnostics]] is required especially in situations of a likely organic [[Causes|cause]] or a [[lack of response]] to [[therapy]]. Uroflowmetry and [[Urodynamics|urodynamic]] studies are additional [[diagnostic]] studies that can be employed. Urotherapy encompasses all non-[[pharmacological]] and non-[[surgical]] [[treatment]] methods employed in the [[treatment]] of [[urinary incontinence]] in [[children]]. [[Desmopressin]] and [[oxybutynin]] are common [[drugs]] used for the [[pharmacological]] management of [[urinary incontinence]] in [[children]]. [[Surgery]] is not routinely employed as a form of [[treatment]] but it might be of importance in correcting some organic [[causes]] of [[urinary incontinence]] in [[children]]. There are no documented primary [[Preventive care|preventive]] measures available for [[urinary incontinence]] in [[children]].
This begins initially during the daytime and nighttime control is achieved a lot later. [[Nocturnal enuresis]] is seen more frequently in boys. There is no documented [[racial]] predilection for [[enuresis]]. Some [[risk factors]] are age before 5 years, positive [[family history]], [[family]] size, and [[birth]] order. Certain [[complications]] are poor [[self-esteem]] and inability to socialize with peers. [[Prognosis]] is generally good due to the high chances of spontaneous [[resolution]] at the rate of 15% per year. The focus is to eliminate any potential organic cause of [[Urinary incontinence|incontinence]] and to classify and identify the type of functional [[Urinary incontinence|incontinence]] using detailed [[History and Physical examination|history]] and [[Non-invasive (medical)|non-invasive]] procedures. Identify any [[comorbidities]] which are mostly [[psychological]] occurring alongside [[Urinary incontinence|incontinence]]. Fundamental [[diagnosis]] includes taking a detailed [[History and Physical examination|history]] using a standardized [[questionnaire]]. The primary aim of a [[physical examination]] is to look for possible organic [[causes]] of [[Urinary incontinence|incontinence]] and [[comorbidities]]. [[Urinalysis]] is essential to rule out [[urinary tract infections]]. [[Ultrasonography]] is a useful tool when further [[diagnostics]] is required especially in situations of a likely organic [[Causes|cause]] or a lack of response to [[therapy]]. Uroflowmetry and [[Urodynamics|urodynamic]] studies are additional [[diagnostic]] studies that can be employed. Urotherapy encompasses all non-[[pharmacological]] and non-[[surgical]] [[treatment]] methods employed in the [[treatment]] of [[urinary incontinence]] in [[children]]. [[Desmopressin]] and [[Oxybutynin]] are common [[drugs]] used for the [[pharmacological]] management of [[urinary incontinence]] in [[children]]. [[Surgery]] is not routinely employed as a form of [[treatment]]. Might be of importance in correcting some organic [[causes]] of [[urinary incontinence]] in [[children]] and there are no documented primary [[Preventive care|preventive]] measures available for [[urinary incontinence]] in [[children]].


==Historical Perspective==
==Historical Perspective==
*Earliest documentation of [[urinary incontinence]] dates back to 1550 BC in the [[Ebers papyrus]].
 
*Pliny the elder, in 77 AD wrote on how [[Urinary incontinence|incontinence]] of [[urine]] in [[children]] is treated by giving boiled mice in their [[food]].
*The earliest documentation of [[urinary incontinence]] dates back to 1550 BC in the [[Ebers papyrus]].
*Paulus Bagellardus of Padua wrote on the [[distress]] experienced by parents due to [[bedwetting]] when [[infants]] after the age of 3 years 'continue to pass water in the bed' which can sometimes last beyond the period of [[puberty]].
*Pliny the Elder, in 77 AD, wrote about how [[Urinary incontinence|urinary incontinence]] in [[children]] is treated by giving boiled mice in their [[food]].
*Jacobi placed a [[suppository]] into the [[rectum]] several times daily for the [[reinforcement]] of a supposedly weak [[Urinary bladder|bladder]] in order to [[Treatment|treat]] [[enuresis]] in the year 1891. The [[suppository]] was a mixture of old sheep fat and [[strychnine]].<ref name="Salmon2016">{{cite journal|last1=Salmon|first1=Michael A|title=An Historical Account of Nocturnal Enuresis and its Treatment|journal=Proceedings of the Royal Society of Medicine|volume=68|issue=7|year=2016|pages=443–445|issn=0035-9157|doi=10.1177/003591577506800726}}</ref>
*Paulus Bagellardus of Padua wrote about the [[distress]] experienced by parents due to [[bedwetting]] when [[infants]] after the age of 3 years 'continue to pass water in the bed' which can sometimes last beyond the period of [[puberty]].
*Rhazes, the Persian [[clinician]], identified some [[causes]] of [[enuresis]] in [[children]] to be:
*In 1790, the term '[[enuresis]]' was founded, which means 'to [[urinate]] within' and '[[nocturnal]]' which means 'nighttime occurrence'.<ref name="pmid24578827">{{cite journal| author=Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM| title=Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history. | journal=Iran Red Crescent Med J | year= 2013 | volume= 15 | issue= 8 | pages= 633-8 | pmid=24578827 | doi=10.5812/ircmj.5017 | pmc=3918184 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24578827  }} </ref>
**[[Urinary bladder|Bladder]] [[outlet]] [[muscle]] [[relaxation]].
*In 1891, Jacobi placed a [[suppository]] into the [[rectum]] several times daily for the [[reinforcement]] of a supposedly weak [[Urinary bladder|bladder]] in order to [[Treatment|treat]] [[enuresis]]. The [[suppository]] was a mixture of old sheep [[fat]] and [[strychnine]].<ref name="Salmon2016">{{cite journal|last1=Salmon|first1=Michael A|title=An Historical Account of Nocturnal Enuresis and its Treatment|journal=Proceedings of the Royal Society of Medicine|volume=68|issue=7|year=2016|pages=443–445|issn=0035-9157|doi=10.1177/003591577506800726}}</ref>
**Deep [[sleep]].
*Rhazes, the Persian [[clinician]], identified some [[causes]] of [[enuresis]] in [[children]] such as:
**Unrestricted [[fluid intake]] prior to [[bedtime]], etc.<ref name="pmid24578827">{{cite journal| author=Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM| title=Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history. | journal=Iran Red Crescent Med J | year= 2013 | volume= 15 | issue= 8 | pages= 633-8 | pmid=24578827 | doi=10.5812/ircmj.5017 | pmc=3918184 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24578827  }} </ref>
**[[Urinary bladder|Bladder]] [[outlet]] [[muscle]] [[relaxation]]
**Deep [[sleep]]
**Unrestricted [[fluid intake]] prior to [[bedtime]]<ref name="pmid24578827">{{cite journal| author=Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM| title=Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history. | journal=Iran Red Crescent Med J | year= 2013 | volume= 15 | issue= 8 | pages= 633-8 | pmid=24578827 | doi=10.5812/ircmj.5017 | pmc=3918184 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24578827  }} </ref>
*Some of his [[treatment]] [[protocols]] included:
*Some of his [[treatment]] [[protocols]] included:
**Minimizing [[fluid intake]] before [[bedtime]].
**Minimizing [[fluid intake]] before [[bedtime]]
**Intake of substances producing [[fluid retention]] and [[body fluid]] losses.
**Intake of [[Substance|substances]] producing [[fluid retention]] and [[body fluid]] losses
**Use of both [[oral]] and injectable [[medications]] to the [[bladder]] through the [[urethra]].<ref name="pmid24578827">{{cite journal| author=Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM| title=Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history. | journal=Iran Red Crescent Med J | year= 2013 | volume= 15 | issue= 8 | pages= 633-8 | pmid=24578827 | doi=10.5812/ircmj.5017 | pmc=3918184 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24578827  }} </ref>
**Use of both [[oral]] and [[Injection|injectable]] [[medications]] to the [[bladder]] through the [[urethra]]<ref name="pmid24578827">{{cite journal| author=Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM| title=Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history. | journal=Iran Red Crescent Med J | year= 2013 | volume= 15 | issue= 8 | pages= 633-8 | pmid=24578827 | doi=10.5812/ircmj.5017 | pmc=3918184 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24578827  }} </ref>
*The term '[[enuresis]]' was formed in 1790 which means 'to [[urinate]] within' and '[[nocturnal]]' which means 'nighttime occurrence'. <ref name="pmid24578827">{{cite journal| author=Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM| title=Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history. | journal=Iran Red Crescent Med J | year= 2013 | volume= 15 | issue= 8 | pages= 633-8 | pmid=24578827 | doi=10.5812/ircmj.5017 | pmc=3918184 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24578827  }} </ref>


==Classification==
==Classification==
*[[Urinary incontinence]], also known as '[[bedwetting]]' or '[[enuresis]]' can be classified as follows:
*[[Urinary incontinence]], also known as '[[bedwetting]]' or '[[enuresis]]' can be classified as follows:


Line 111: Line 112:
|+Classification of Urinary Incontinence in Children
|+Classification of Urinary Incontinence in Children
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Types of urinary incontinence
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Types of urinary incontinence
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Details
! colspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Details
|-
|-
| style="background:#DCDCDC;" + |'''[[Physiological]]'''
| style="background:#DCDCDC;" + |'''[[Physiological]]<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>'''
|
| colspan="2" |
*It is expected and seen as a norm in the early years.
*It is expected and seen as a norm in the early [[Year|years]].
*Requires a minimum age of 5 years, at least one event in a month, and a minimum period of 3 months.
*Requires a minimum [[age]] of 5 [[Year|years]], at least one [[Event study|event]] in a month, and a minimum [[period]] of 3 months.
*Persisting beyond the age of 5 years is termed [[pathological]].
*Persisting beyond the [[age]] of 5 years is termed [[pathological]].
*However, there are the 'late developers' who continue to experience [[physiologic]] [[urinary incontinence]] beyond the age of 5 years.
*However, there are the 'late developers' who continue to experience [[physiologic]] [[urinary incontinence]] beyond the [[age]] of 5 [[Year|years]].
*[[Clinical]] evaluation of these kids remains normal.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
*[[Clinical]] evaluation of these [[Children|kids]] remains [[normal]].
|-
|-
| rowspan="4" style="background:#DCDCDC;" + |'''[[Pathological]]'''
| rowspan="3" style="background:#DCDCDC;" + |'''[[Pathological]]<ref name="pmid21977217" /><ref name="pmid31844104">{{cite journal| author=Zhu W, Che Y, Wang Y, Jia Z, Wan T, Wen J | display-authors=etal| title=Study on neuropathological mechanisms of primary monosymptomatic nocturnal enuresis in children using cerebral resting-state functional magnetic resonance imaging. | journal=Sci Rep | year= 2019 | volume= 9 | issue= 1 | pages= 19141 | pmid=31844104 | doi=10.1038/s41598-019-55541-9 | pmc=6915704 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31844104  }} </ref><ref name="pmid27703953">{{cite journal| author=Arda E, Cakiroglu B, Thomas DT| title=Primary Nocturnal Enuresis: A Review. | journal=Nephrourol Mon | year= 2016 | volume= 8 | issue= 4 | pages= e35809 | pmid=27703953 | doi=10.5812/numonthly.35809 | pmc=5039962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27703953  }} </ref>'''
|'''Organic''':  
| colspan="2" |'''Organic''':  


*Usually uncommon.
*Usually uncommon.
*In-depth investigations needed to be identified more so in cases that have not responded to conventional [[treatment]].<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
*In-depth investigations needed to be identified more so in cases that have not responded to conventional [[treatment]].
|-
|-
|'''Functional or [[psychosomatic]]''':  
| rowspan="2" |'''Functional or [[psychosomatic]]''':  


*Includes all forms of [[pathological]] [[urinary incontinence]] without [[anatomic]] or [[neurologic]] defects.
*Includes all forms of [[pathological]] [[urinary incontinence]] without [[anatomic]] or [[neurologic]] [[Defect|defects]].
*Manifestations of which have been subdivided into two:
*Manifestations of which have been subdivided into two:
|'''''Monosymtomatic [[enuresis]] (MEN)'':'''
*These children have never had a dry period of >6 months and in the absence of any [[bladder]] [[dysfunction]] or [[symptoms]] suggestive of lower [[urinary tract]] issues.
|-
|-
|''Monosymtomatic [[enuresis]](MEN)'':
|'''''Non-monosymptomatic [[enuresis]] Nocturna (Non-MEN)'':'''
 
*[[Diurnal]] presentation with an [[urge]], frequency, and [[enuresis]].
*These kids have never had a dry period of >6 months and in the absence of any [[bladder]] [[dysfunction]] or [[symptoms]] suggestive of lower [[urinary tract]] issues.<ref name="pmid31844104">{{cite journal| author=Zhu W, Che Y, Wang Y, Jia Z, Wan T, Wen J | display-authors=etal| title=Study on neuropathological mechanisms of primary monosymptomatic nocturnal enuresis in children using cerebral resting-state functional magnetic resonance imaging. | journal=Sci Rep | year= 2019 | volume= 9 | issue= 1 | pages= 19141 | pmid=31844104 | doi=10.1038/s41598-019-55541-9 | pmc=6915704 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31844104  }} </ref>
|-
|''Non-monosymptomatic [[enuresis]] Nocturna(Non-MEN)'':  
 
*[[Diurnal]] presentation with an [[urge]], frequency, and [[enuresis]].<ref name="pmid27703953">{{cite journal| author=Arda E, Cakiroglu B, Thomas DT| title=Primary Nocturnal Enuresis: A Review. | journal=Nephrourol Mon | year= 2016 | volume= 8 | issue= 4 | pages= e35809 | pmid=27703953 | doi=10.5812/numonthly.35809 | pmc=5039962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27703953  }} </ref>
|}
|}


*Another form of [[classification]] is based on the [[Course (medicine)|course]] of [[nocturnal]] [[enuresis]] is:
*Another form of [[classification]] based on the [[Course (medicine)|course]] of [[nocturnal]] [[enuresis]] is:
**'''Primary [[nocturnal enuresis]]''': 6 consecutive months without ever achieving [[bladder]] control at night. Most common form.
**'''Primary [[nocturnal enuresis]]''': 6 consecutive months without ever achieving [[bladder]] control at night. Most common form.
**'''Secondary [[nocturnal enuresis]]''': 6 consecutive months of [[Urinary bladder|bladder]] control attained before a recurrence of [[Urinary incontinence|incontinence]]. Could be related to an organic or [[psychological]] [[Causes|cause]].<ref name="pmid27703953">{{cite journal| author=Arda E, Cakiroglu B, Thomas DT| title=Primary Nocturnal Enuresis: A Review. | journal=Nephrourol Mon | year= 2016 | volume= 8 | issue= 4 | pages= e35809 | pmid=27703953 | doi=10.5812/numonthly.35809 | pmc=5039962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27703953  }} </ref>
**'''Secondary [[nocturnal enuresis]]''': 6 consecutive months of [[Urinary bladder|bladder]] control attained before a recurrence of [[Urinary incontinence|incontinence]]. Could be related to an organic or [[psychological]] [[Causes|cause]].<ref name="pmid27703953">{{cite journal| author=Arda E, Cakiroglu B, Thomas DT| title=Primary Nocturnal Enuresis: A Review. | journal=Nephrourol Mon | year= 2016 | volume= 8 | issue= 4 | pages= e35809 | pmid=27703953 | doi=10.5812/numonthly.35809 | pmc=5039962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27703953  }} </ref>


==Pathophysiology==
==Pathophysiology==
*The [[pathophysiology]] of [[urinary incontinence]] in [[children]], particularly [[enuresis]] can be described under 3 broad [[categories]]:
 
*The [[pathophysiology]] of [[urinary incontinence]] in [[children]], particularly [[enuresis]] can be described under three broad [[categories]]:
*'''Increased [[urine]] production at night'''
*'''Increased [[urine]] production at night'''
**The [[Urinary bladder|bladder]] is able to fill up at night as a result of an [[imbalance]] between the production of [[urine]] at night and the capacity of the [[Urinary bladder|bladder]]. This often leads to frequent awakenings to pass [[urine]] for children or [[Urinary incontinence|incontinence]] for those with difficulties in waking up.<ref name="pmid11196246">{{cite journal| author=Nevéus T, Läckgren G, Tuvemo T, Hetta J, Hjälmås K, Stenberg A| title=Enuresis--background and treatment. | journal=Scand J Urol Nephrol Suppl | year= 2000 | volume=  | issue= 206 | pages= 1-44 | pmid=11196246 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11196246  }} </ref>
**The [[Urinary bladder|bladder]] is able to fill up at night as a [[result]] of an [[imbalance]] between the [[urine]] production at night and the [[Urinary bladder|bladder]] capacity. This often leads to frequent awakenings to pass [[urine]] for [[children]] or [[Urinary incontinence|incontinence]] for those with difficulties in waking up.<ref name="pmid11196246">{{cite journal| author=Nevéus T, Läckgren G, Tuvemo T, Hetta J, Hjälmås K, Stenberg A| title=Enuresis--background and treatment. | journal=Scand J Urol Nephrol Suppl | year= 2000 | volume=  | issue= 206 | pages= 1-44 | pmid=11196246 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11196246  }} </ref>
**[[Nocturnal]] production of the [[Antidiuretic hormone]], [[ADH]] is higher when compared to daytime values.<ref name="pmid24955178">{{cite journal| author=Tas T, Cakiroglu B, Hazar AI, Balci MB, Sinanoglu O, Nas Y | display-authors=etal| title=Monosymptomatic nocturnal enuresis caused by seasonal temperature changes. | journal=Int J Clin Exp Med | year= 2014 | volume= 7 | issue= 4 | pages= 1035-9 | pmid=24955178 | doi= | pmc=4057857 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24955178 }} </ref> Thus, the insufficient production of [[ADH]] in these [[children]] has been identified with a subsequent rise in [[urine]] production, frequency of which is 2 out of 3 children.<ref name="pmid2705537">{{cite journal| author=Rittig S, Knudsen UB, Nørgaard JP, Pedersen EB, Djurhuus JC| title=Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis. | journal=Am J Physiol | year= 1989 | volume= 256 | issue= 4 Pt 2 | pages= F664-71 | pmid=2705537 | doi=10.1152/ajprenal.1989.256.4.F664 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2705537 }} </ref>
**[[Nocturnal]] production of the [[antidiuretic hormone]], [[ADH]] is higher when compared to daytime values. Thus, the insufficient production of [[ADH]] in these [[children]] has been identified with a subsequent rise in [[urine]] production, frequency of which is 2 out of 3 children.<ref name="pmid2705537">{{cite journal| author=Rittig S, Knudsen UB, Nørgaard JP, Pedersen EB, Djurhuus JC| title=Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis. | journal=Am J Physiol | year= 1989 | volume= 256 | issue= 4 Pt 2 | pages= F664-71 | pmid=2705537 | doi=10.1152/ajprenal.1989.256.4.F664 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2705537 }} </ref><ref name="pmid24955178">{{cite journal| author=Tas T, Cakiroglu B, Hazar AI, Balci MB, Sinanoglu O, Nas Y | display-authors=etal| title=Monosymptomatic nocturnal enuresis caused by seasonal temperature changes. | journal=Int J Clin Exp Med | year= 2014 | volume= 7 | issue= 4 | pages= 1035-9 | pmid=24955178 | doi= | pmc=4057857 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24955178 }} </ref>
*'''Reduced [[Urinary bladder|bladder]] capacity at night/Increased [[contractions]] of the [[detrusor muscle]]'''
*'''Reduced [[Urinary bladder|bladder]] capacity at night/Increased [[contractions]] of the [[detrusor muscle]]'''
**Studies have proposed a reduced [[Urinary bladder|bladder]] wall capacity to 70% of the expected values with an increase in the [[Urinary bladder|bladder]] wall thickness on [[ultrasound]] in [[children]] with majorly [[nocturnal enuresis]]. <ref name="pmid15118426">{{cite journal| author=Yeung CK, Sreedhar B, Leung VT, Metreweli C| title=Ultrasound bladder measurements in patients with primary nocturnal enuresis: a urodynamic and treatment outcome correlation. | journal=J Urol | year= 2004 | volume= 171 | issue= 6 Pt 2 | pages= 2589-94 | pmid=15118426 | doi=10.1097/01.ju.0000112978.54300.03 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15118426  }} </ref>
**Studies have proposed a reduced [[Urinary bladder|bladder]] wall capacity to 70% of the expected values with an increase in the [[Urinary bladder|bladder]] wall thickness on [[ultrasound]] in [[children]] with majorly [[nocturnal enuresis]].<ref name="pmid15118426">{{cite journal| author=Yeung CK, Sreedhar B, Leung VT, Metreweli C| title=Ultrasound bladder measurements in patients with primary nocturnal enuresis: a urodynamic and treatment outcome correlation. | journal=J Urol | year= 2004 | volume= 171 | issue= 6 Pt 2 | pages= 2589-94 | pmid=15118426 | doi=10.1097/01.ju.0000112978.54300.03 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15118426  }} </ref>
**In addition to this, there is [[disinhibition]] in [[contractions]] of the [[Urinary bladder|bladder]] wall in about 30% of kids with [[enuresis]].<ref name="pmid8719568">{{cite journal| author=Watanabe H| title=Sleep patterns in children with nocturnal enuresis. | journal=Scand J Urol Nephrol Suppl | year= 1995 | volume= 173 | issue=  | pages= 55-6; discussion 56-7 | pmid=8719568 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8719568  }} </ref>
**In addition to this, there is [[disinhibition]] in [[contractions]] of the [[Urinary bladder|bladder]] wall in about 30% of kids with [[enuresis]].<ref name="pmid8719568">{{cite journal| author=Watanabe H| title=Sleep patterns in children with nocturnal enuresis. | journal=Scand J Urol Nephrol Suppl | year= 1995 | volume= 173 | issue=  | pages= 55-6; discussion 56-7 | pmid=8719568 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8719568  }} </ref>
*'''Awakening [[Disorder]]'''
*'''Awakening [[Disorder]]'''
**The sudden [[Urinary urgency|urge]] to pass [[urine]] does not occur adequately in kids that are enuretic.
**The sudden [[Urinary urgency|urge]] to pass [[urine]] does not occur adequately in [[Children|kids]] that are enuretic.
**[[Chronic]] over-stimulation causing a [[down-regulation]] of the voiding center has been surmised by researchers.<ref name="pmid18509134">{{cite journal| author=Yeung CK, Diao M, Sreedhar B| title=Cortical arousal in children with severe enuresis. | journal=N Engl J Med | year= 2008 | volume= 358 | issue= 22 | pages= 2414-5 | pmid=18509134 | doi=10.1056/NEJMc0706528 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18509134  }} </ref>
**[[Chronic]] over-stimulation [[Causality|causing]] a [[down-regulation]] of the voiding center has been surmised by [[Research|researchers]].<ref name="pmid18509134">{{cite journal| author=Yeung CK, Diao M, Sreedhar B| title=Cortical arousal in children with severe enuresis. | journal=N Engl J Med | year= 2008 | volume= 358 | issue= 22 | pages= 2414-5 | pmid=18509134 | doi=10.1056/NEJMc0706528 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18509134  }} </ref>


==Causes==
==Causes==
*The [[causes]] of [[urinary incontinence]] in [[children]] are identified based on the subclassification of [[pathological]] [[Urinary incontinence|incontinence]].
 
*[[Causes]] of MEN are not fully elucidated but are assumed to be a result of an interplay between the delayed maturation of the [[neurological]] [[Urinary bladder|bladder]] and how the production of [[urine]] is regulated.
*The [[causes]] of [[urinary incontinence]] in [[children]] are identified based on the sub-classification of [[pathological]] [[Urinary incontinence|incontinence]].
*[[Causes]] of MEN are not fully elucidated but are assumed to be as a [[result]] of an interplay between the delayed [[maturation]] of the [[neurological]] [[Urinary bladder|bladder]] and how the [[urine]] production is regulated.
*Non-MEN is subcategorized based on its [[symptoms]] which is predominantly day-time. These [[symptoms]] include:
*Non-MEN is subcategorized based on its [[symptoms]] which is predominantly day-time. These [[symptoms]] include:
**[[Overactive bladder]]
**[[Overactive bladder]]
**Discoordinated [[micturition]]
**Dis-coordinated [[micturition]]
**Infrequent voiding
**Infrequent voiding
*[[Causes]] of organic [[Urinary incontinence|incontinence]] which is usually rare include the following;
*[[Causes]] of organic [[Urinary incontinence|incontinence]] (which is usually [[rare]]) include the following;
**Structural [[renal]] problems such as:
**[[Structural biology|Structural]] [[renal]] problems such as:
***[[Ectopic ureter]]
***[[Ectopic ureter]]
***Malformed [[urethra]]
***[[Malformation|Malformed]] [[urethra]]
***Duplex [[kidney]]
***Duplex [[kidney]]
**[[Anatomic]] [[neural]] [[disorders]] like:
**[[Anatomic]] [[neural]] [[disorders]] such as:
***[[Spina bifida]]
***[[Spina bifida]]
***[[Neoplasms]] of the [[nervous system]]
***[[Neoplasms]] of the [[nervous system]]
***[[Tethered cord syndrome]]
***[[Tethered cord syndrome]]
***[[Sacral agenesis]]. <ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
***[[Sacral agenesis]].<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
**[[Obstructive sleep apnea]] (OSA)
**[[Obstructive sleep apnea]] ([[Obstructive sleep apnea|OSA]])
**Sexual [[abuse]]
**[[Sexual]] [[abuse]]
**[[Pinworm]] infestation
**[[Pinworm infection|Pinworm infestation]]
 
==Differentiating urinary incontinence from other diseases==


==Differentiating urinary incontinence from other Diseases==
*It must be differentiated from the following:
*[[Diabetes mellitus]]
**[[Diabetes mellitus]]
*[[Diabetes insipidus]]
**[[Diabetes insipidus]]
*[[Urinary tract infections|Urinary tract infection]]
**[[Urinary tract infections|Urinary tract infection]]
*[[Anxiety disorders|Anxiety disorder]]
**[[Anxiety disorders|Anxiety disorder]]
*[[Spinal cord]] [[neoplasms]]
**[[Spinal cord]] [[neoplasms]]
*[[Spinal cord]] [[trauma]]
**[[Spinal cord]] [[trauma]]
*Small [[Urinary bladder|bladder]]
**Small [[Urinary bladder|bladder]]


==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Age===
===Age===
*[[Children]] achieve the ability to control their [[Urinary bladder|bladder]] between the ages of 3 and 6 years.
 
*[[Children]] usually achieve the ability to [[control]] their [[Urinary bladder|bladder]] function between the [[Age|ages]] of 3 and 6 [[Year|years]].
*This begins initially during the daytime and nighttime control is achieved a lot later.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
*This begins initially during the daytime and nighttime control is achieved a lot later.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
*[[Nocturnal enuresis]] is still seen in 15%-20% of kids at 5 years old with a spontaneous [[recovery]] rate of 14% yearly.<ref name="ArdaCakiroglu2016">{{cite journal|last1=Arda|first1=Ersan|last2=Cakiroglu|first2=Basri|last3=Thomas|first3=David T.|title=Primary Nocturnal Enuresis: A Review|journal=Nephro-Urology Monthly|volume=8|issue=4|year=2016|issn=2251-7006|doi=10.5812/numonthly.35809}}</ref>
*[[Nocturnal enuresis]] is still seen in 15%-20% of five [[Year|year]] old [[Children|kids]] with a spontaneous [[recovery]] [[rate]] of 14% yearly.<ref name="ArdaCakiroglu2016">{{cite journal|last1=Arda|first1=Ersan|last2=Cakiroglu|first2=Basri|last3=Thomas|first3=David T.|title=Primary Nocturnal Enuresis: A Review|journal=Nephro-Urology Monthly|volume=8|issue=4|year=2016|issn=2251-7006|doi=10.5812/numonthly.35809}}</ref>
*10% of [[children]] still have [[nocturnal enuresis]] at the age of 7 years with daytime [[symptoms]] seen in 2%-9%.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
*10% of [[children]] still have [[nocturnal enuresis]] at the [[age]] of 7 [[Year|years]] with daytime [[symptoms]] seen in 2%-9%.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>


===Gender===
===Gender===
*[[Nocturnal enuresis]] is seen more frequently in boys.<ref name="pmid9202545">{{cite journal| author=Nørgaard JP, Djurhuus JC, Watanabe H, Stenberg A, Lettgen B| title=Experience and current status of research into the pathophysiology of nocturnal enuresis. | journal=Br J Urol | year= 1997 | volume= 79 | issue= 6 | pages= 825-35 | pmid=9202545 | doi=10.1046/j.1464-410x.1997.00207.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9202545  }} </ref>
*[[Nocturnal enuresis]] is seen more frequently in boys.<ref name="pmid9202545">{{cite journal| author=Nørgaard JP, Djurhuus JC, Watanabe H, Stenberg A, Lettgen B| title=Experience and current status of research into the pathophysiology of nocturnal enuresis. | journal=Br J Urol | year= 1997 | volume= 79 | issue= 6 | pages= 825-35 | pmid=9202545 | doi=10.1046/j.1464-410x.1997.00207.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9202545  }} </ref>


===Race===
===Race===
*There is no documented [[racial]] predilection for [[enuresis]].
 
*There is no documented [[racial]] predisposition for [[enuresis]].


==Risk Factors==
==Risk Factors==
*[[Age]], before 5 years
 
*Positive [[family history]]. Risk is highest when one parent had been a sufferer of [[enuresis]]
*Below is a list of [[risk factors]] associated with [[urinary incontinence]] in [[children]]:
*[[Family]] size
**[[Age]] less than five [[Year|years]]
*[[Birth]] order
**Positive [[family history]] (risk is highest when one parent had been a sufferer of [[enuresis]])
*[[Male]] gender
**[[Family]] size
*Low socioeconomic status
**[[Birth]] order
*[[Constipation]]
**[[Male]] gender
*History of [[Urinary tract infections|urinary tract infection]], [[diabetes]],
**Low socioeconomic status
*[[Psychological]]:
**[[Constipation]]
**[[Birth]] of a sibling <ref name="pmid9202545">{{cite journal| author=Nørgaard JP, Djurhuus JC, Watanabe H, Stenberg A, Lettgen B| title=Experience and current status of research into the pathophysiology of nocturnal enuresis. | journal=Br J Urol | year= 1997 | volume= 79 | issue= 6 | pages= 825-35 | pmid=9202545 | doi=10.1046/j.1464-410x.1997.00207.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9202545  }} </ref>
**History of [[Urinary tract infections|urinary tract infection]]
**[[ADHD]]
**History of [[diabetes]]
**[[Anxiety]]
**[[Psychological]]:
**Change of school
***[[Birth]] of a sibling <ref name="pmid9202545">{{cite journal| author=Nørgaard JP, Djurhuus JC, Watanabe H, Stenberg A, Lettgen B| title=Experience and current status of research into the pathophysiology of nocturnal enuresis. | journal=Br J Urol | year= 1997 | volume= 79 | issue= 6 | pages= 825-35 | pmid=9202545 | doi=10.1046/j.1464-410x.1997.00207.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9202545  }} </ref>
**New home
***[[ADHD]]
**Divorce of parents
***[[Anxiety]]
***Change of school
***[[New]] home
***[[Divorcee|Divorce]] of [[Parenting|parents]]


==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
*[[Complications]] are:
 
*[[Complications]] include:
**Poor [[self-esteem]]
**Poor [[self-esteem]]
**Inability to socialize with peers
**Inability to socialize with peers
Line 224: Line 233:
**[[Stress]]
**[[Stress]]
**General affectation of [[child]] and family's quality of life such as poor academic performance
**General affectation of [[child]] and family's quality of life such as poor academic performance
*[[Prognosis]] is generally good due to the high chances of spontaneous resolution at the rate of 15% per year.
*[[Prognosis]] is generally good due to the high chances of spontaneous resolution at the [[rate]] of 15% per [[year]].
**As a result of slow response to conventional [[treatment]] like alarm therapy and [[Desmopressin]], 20% will remain incontinent by adulthood.<ref name="pmid31424765">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=31424765 | doi= | pmc= | url= }} </ref>
**As a [[result]] of [[slow]] response to conventional [[treatment]] such as alarm therapy and [[desmopressin]], 20% will remain incontinent by adulthood.<ref name="pmid31424765">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=31424765 | doi= | pmc= | url= }} </ref>


==Diagnosis==
==Diagnosis==
*The focus is to eliminate any potential organic [[Causes|cause]] of [[Urinary incontinence|incontinence]] and to classify and identify the type of functional [[Urinary incontinence|incontinence]] using detailed history and non-invasive procedures.
 
*Identify any [[comorbidities]] which are mostly [[psychological]] occurring alongside [[Urinary incontinence|incontinence]]. <ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
*The focus is to eliminate any potential organic [[Causes|cause]] of [[Urinary incontinence|incontinence]] and to classify and identify the type of functional [[Urinary incontinence|incontinence]] using detailed history and [[non-invasive]] [[Procedure|procedures]].
*Identify any [[comorbidities]] which are mostly [[psychological]] occurring alongside [[Urinary incontinence|incontinence]].<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>


===Symptoms===
===Symptoms===
*Fundamental [[diagnosis]] includes taking a detailed history using a standardized [[questionnaire]]. Some of the important questions to ask include:
*Fundamental [[diagnosis]] includes taking a detailed history using a standardized [[questionnaire]]. Some of the important questions to ask include:
**Time of the day [[child]] wets self?
**Time of the day [[child]] wets self?
**[[Pattern]] of occurrence (every night or every other night)?
**[[Pattern]] of occurrence (every night or every other night)?
**Place of occurrence (at home)?
**Place of occurrence (at home)?
**Frequency of restroom visits during the day and any at night?
**[[Frequency]] of restroom visits during the [[Daytime wetting|day]] and any at night?
**How does the child pass [[urine]]?
**How does the [[child]] pass [[urine]]?
**Any colored stains on pants during the daytime?
**Any [[Color|colored]] [[Stain|stains]] on pants during the [[Daytime wetting|daytime]]?
**Any holding movements are seen?
**See any holding movements?
**Pattern of [[urine]] stream?
**[[Pattern]] of [[Urinary Stream (Decrease)|urine stream]]?
**Any straining?
**Any [[Strain|straining]]?
**Child's drinking habits especially in the evenings?
**[[Child|Child's]] [[drinking]] habits especially in the evenings?
**Previous/recurrent [[urinary tract infections]]?
**Previous/recurrent [[urinary tract infections]]?
**[[Constipation]]?
**[[Constipation]]?
Line 249: Line 260:
**[[Psychological]] issues?
**[[Psychological]] issues?
**Previous [[surgery]]?
**Previous [[surgery]]?
**Any stressful circumstances recently either at home or school?
**Any [[Stress|stressful]] circumstances recently either at home or school?
**Method of [[treatment]] of [[Urinary incontinence|incontinence]] in the past?
**Method of [[treatment]] of [[Urinary incontinence|incontinence]] in the past?
*A [[symptom]] or [[Urinary bladder|bladder]] diary is completed over a period of 14 days.
*A [[symptom]] or [[Urinary bladder|bladder]] diary is completed over a [[period]] of 14 days.


===Physical Examination===
===Physical Examination===


*Primary aim of a [[physical examination]] is to look for possible organic [[causes]] of [[Urinary incontinence|incontinence]] and [[comorbidities]].
*Primary aim of a [[physical examination]] is to look for possible organic [[causes]] of [[Urinary incontinence|incontinence]] and [[comorbidities]].
**Weight loss
**[[Weight loss]]
**Hypertension (kidney disease)
**[[Hypertension]] ([[kidney disease]])
**Enlarged tonsils
**Enlarged [[tonsils]]
**Slow growth
**[[Slow]] [[growth]]
**Breathing through the mouth
**[[Breathing]] through the [[mouth]]
**Spinal [[malformations]] in the lumbosacral region:
**Spinal [[malformations]] in the [[Lumbosacral trunk|lumbosacral]] [[Region of interest|region]]:
***[[Lipoma]]
***[[Lipoma]]
***Hair tufts
***[[Hair]] tufts
***Dimpled [[sacrum]]
***[[Dimple|Dimpled]] [[sacrum]]
***[[Gluteal]] folds that appear non-symmetric
***[[Gluteal fold|Gluteal folds]] that [[Appearance|appear]] non-[[Symmetric function|symmetric]]
***[[Hemangiomas]]
***[[Hemangiomas]]
**Mass on [[palpation]] of the [[abdomen]] suggesting [[fecal impaction]]
**[[Mass]] on [[palpation]] of the [[abdomen]] suggesting [[fecal impaction]]
**[[Genital]] region:
**[[Genital area|Genital region]]:
***[[Phimosis]]
***[[Phimosis]]
***[[Urine]] leak
***[[Urine]] leak
***[[Labial]] synechiae
***[[Labial]] synechiae
***[[Vulva|Vulval]] [[inflammation]]
***[[Vulva|Vulval]] [[inflammation]]
***[[Labial]] scars
***[[Labial]] [[scars]]
***[[Cremasteric reflex]]
***[[Cremasteric reflex]]
**[[Anal]] area:
**[[Anal]] [[area]]:
***Soilage
***[[Soiling|Soilage]]
***Scratch marks/excoriations
***[[Scratch]] marks/[[Excoriation|excoriations]]
**[[Lower extremities]]:
**[[Lower extremities]]:
***Asymmetric [[reflexes]]
***Asymmetric [[reflexes]]
***[[Atrophic]] [[muscles]]
***[[Atrophic]] [[muscles]]
***[[Deformities]] on the [[foot]]
***[[Deformities]] on the [[foot]]
**Assess [[developmental]] milestones attained
**Assess [[developmental milestones]] attained
**Assess child's [[behavior]] and [[Screening (medicine)|screen]] for any [[behavioral]] [[abnormalities]] using appropriate [[questionnaires]].
**Assess [[Child|child's]] [[behavior]] and [[Screening (medicine)|screen]] for any [[behavioral]] [[abnormalities]] using [[Appropriate Use Criteria|appropriate]] [[questionnaires]].


===Laboratory Findings===
===Laboratory Findings===


*[[Urinalysis]]
*[[Urinalysis]]:
**Essential to rule out [[Urinary tract infections|urinary tract infection]].
**Essential to rule out [[Urinary tract infections|urinary tract infection]]
**Changes in [[urine]] [[specific gravity]] suggesting [[Diabetes insipidus]]
**Changes in [[urine]] [[specific gravity]] [[Suggestion|suggesting]] [[diabetes insipidus]]
**[[Glucosuria]] for [[Diabetes mellitus]]
**[[Glucosuria]] for [[diabetes mellitus]]
*Lack of response to [[therapy]]/[[interventions]] and a [[diagnosis]] of Non-MEN will warrant further work-up.
*[[Lack of response]] to [[therapy]]/[[interventions]] and a [[diagnosis]] of Non-MEN will warrant further work-up


===Echocardiography or Ultrasound===
===Ultrasound===


*[[Ultrasonography]] is a useful tool when further [[diagnostics]] is required especially in situations of a likely organic [[Causes|cause]] or a lack of response to [[therapy]]. It can detect anomalies in the [[renal system]] such as:
*[[Ultrasonography]] is a useful tool when further [[diagnostics]] is required, especially in situations of a likely organic [[Causes|cause]] or a [[lack of response]] to [[therapy]].
*It can [[Anomaly detection|detect anomalies]] in the [[renal system]] such as:
**Increase in thickness of the [[Urinary bladder|bladder]] wall
**Increase in thickness of the [[Urinary bladder|bladder]] wall
**Dilated [[ureters]]
**Dilated [[ureters]]
Line 301: Line 313:
**[[Ureterocele]]
**[[Ureterocele]]
**Duplex [[kidney]]
**Duplex [[kidney]]
**Distended [[rectum]]. <ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
**[[Distended abdomen|Distended]] [[rectum]]<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>


===CT scan===
===CT scan===


*There are no [[CT scan]] findings associated with [[urinary incontinence]] in [[children]]. However, a [[CT scan]] may be helpful in the [[diagnosis]] of organic [[causes]] where a more detailed [[observation]] of [[anatomical]] [[abnormalities]] is required.
*There are no [[CT scan]] findings [[Association (statistics)|associated]] with [[urinary incontinence]] in [[children]]. However, a [[CT scan]] may be helpful in the [[diagnosis]] of organic [[causes]] whenever a more detailed [[observation]] of [[anatomical]] [[abnormalities]] is required.


===MRI===
===MRI===


*There are no [[MRI]] findings associated with [[urinary incontinence]] in [[children]]. However, an [[Magnetic resonance imaging|MRI]] may be helpful in the [[diagnosis]] of organic [[causes]] where a more detailed [[observation]] of [[anatomical]] [[abnormalities]] is required.
*There are no [[MRI]] findings [[Association (statistics)|associated]] with [[urinary incontinence]] in [[children]]. However, an [[Magnetic resonance imaging|MRI]] may be helpful in the [[diagnosis]] of organic [[causes]] whenever a more detailed [[observation]] of [[anatomical]] [[abnormalities]] is required.


===Other Diagnostic Studies===
===Other Diagnostic Studies===


*Uroflowmetry: This shows the [[Urinary bladder|bladder]]'s pattern of voiding. If this [[test]] comes out suspicious, further testing like the uroflow-[[electromyography]] is required to observe [[pelvic floor]] details.<ref name="pmid16753432">{{cite journal| author=Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W | display-authors=etal| title=The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. | journal=J Urol | year= 2006 | volume= 176 | issue= 1 | pages= 314-24 | pmid=16753432 | doi=10.1016/S0022-5347(06)00305-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16753432  }} </ref>
*'''Uroflowmetry:''' This shows the [[Urinary bladder|bladder's]] [[pattern]] of voiding. If this [[test]] comes out suspicious, further [[testing]] like the uroflow-[[electromyography]] is required to [[Observation|observe]] [[pelvic floor]] details.<ref name="pmid16753432">{{cite journal| author=Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W | display-authors=etal| title=The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. | journal=J Urol | year= 2006 | volume= 176 | issue= 1 | pages= 314-24 | pmid=16753432 | doi=10.1016/S0022-5347(06)00305-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16753432  }} </ref>
*Urodynamic studies: reveals problems associated with the capacity of the [[Urinary bladder|bladder]], [[compliance]] (detrusor muscles).
*'''[[Urodynamics|Urodynamic studies]]:''' Reveal problems [[Association (statistics)|associated]] with the [[Urinary bladder|bladder]] capacity, and [[compliance]] ([[Detrusor muscle|detrusor muscles]]).
**Valuable for illustrating [[neurogenic]] [[Urinary bladder|bladder]] or issues related to [[obstruction]] of the [[Urinary bladder|bladder]] outlet. <ref name="pmid15118427">{{cite journal| author=Yeung CK, Sihoe JD, Sit FK, Diao M, Yew SY| title=Urodynamic findings in adults with primary nocturnal enuresis. | journal=J Urol | year= 2004 | volume= 171 | issue= 6 Pt 2 | pages= 2595-8 | pmid=15118427 | doi=10.1097/01.ju.0000112790.72612.0a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15118427  }} </ref>
**Valuable for illustrating [[neurogenic]] [[Urinary bladder|bladder]] or issues related to the [[bladder outlet obstruction]].<ref name="pmid15118427">{{cite journal| author=Yeung CK, Sihoe JD, Sit FK, Diao M, Yew SY| title=Urodynamic findings in adults with primary nocturnal enuresis. | journal=J Urol | year= 2004 | volume= 171 | issue= 6 Pt 2 | pages= 2595-8 | pmid=15118427 | doi=10.1097/01.ju.0000112790.72612.0a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15118427  }} </ref>


==Treatment==
==Treatment==


*[[Treatment]] [[modality]] is based on the following fundamental principles:
*[[Treatment]] [[modality]] is based on the following [[Fundamental science|fundamental]] [[Principle (chemistry)|principles]]:
**Encourage both [[patient]] and caregiver to undergo [[therapy]].
**Encourage both [[patient]] and caregiver to undergo [[therapy]].
**[[Treatment|Treat]] day-time [[symptoms]] prior to night-time in non-MEN.
**[[Treatment|Treat]] [[Daytime wetting|day-time]] [[symptoms]] prior to night-time in non-MEN.
**[[Fecal]] [[Urinary incontinence|incontinence]] where present should be treated first.
**[[Fecal]] [[Urinary incontinence|incontinence]] where present should be [[Treatment|treated]] first.
**[[Psychiatric]] [[comorbidities]] should be treated concurrently.
**[[Psychiatric]] [[comorbidities]] should be [[Treatment|treated]] [[Concurrent overlap|concurrently]].
**Higher success rates documented with combined [[treatment]] modalities.
**Higher success [[rates]] documented with combined [[treatment]] [[Modality|modalities]].
**Continuous monitoring of [[treatment]] is highly essential.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
**Continuous [[Monitoring competence|monitoring]] of [[treatment]] is highly essential.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>


===Medical Therapy===
===Medical Therapy===


*Urotherapy.
*'''Urotherapy:'''
**This encompasses all [[treatment]] methods employed in the [[treatment]] of [[urinary incontinence]] in [[children]].
**This encompasses all the [[treatment]] methods employed in the [[treatment]] of [[urinary incontinence]] in [[children]].
**They are non-[[pharmacological]] and non-[[surgical]] and usually first-line approach.
**They are non-[[pharmacological]] and non-[[surgical]] and usually first-line approach.
**It has been proven effective in the management of functional [[urinary incontinence]] and supplementary to [[treatment]] methods of organic [[urinary incontinence]].
**It has been proven [[Effective method|effective]] in the management of functional [[urinary incontinence]] and supplementary to [[treatment]] methods of [[Organic Chemistry|organic]] [[urinary incontinence]].
**The components of urotherapy are divided into Standard urotherapy and specific [[interventions]] which may or may not be needed.
**The components of urotherapy are divided into [[standard]] urotherapy and specific [[interventions]] which may or may not be needed.
**Standard urotherapy which is the primary [[treatment]] for the functional type of [[urinary incontinence]] involves the following;
**'''[[Standard]] urotherapy''' which is the primary [[treatment]] for the functional type of [[urinary incontinence]] involves the following:
***Extensive [[family]] [[education]] regarding the [[disorder]] and its management.
***Extensive [[family]] [[education]] regarding the [[disorder]] and its management.
***Suggestions on voiding [[behavior]] such as schedules for [[urination]].
***[[Suggestions]] on voiding [[behavior]] such as schedules for [[urination]].
***[[Fluid intake]] restrictions and, [[nutrition]] in the setting of [[constipation]].
***[[Fluid intake]] [[Restriction|restrictions]] and [[nutrition]] in the setting of [[constipation]].
***Tracking of the progress of [[treatment]].
***[[Tracking changes|Tracking]] of the progress of [[treatment]].
**Specific [[interventions]] that can be occasionally added to [[treatment]] are;
**'''Specific [[interventions]]''' that can be occasionally added to [[treatment]] include:
***Alarm therapy: Most useful for [[disorders]] with awakening. It is intended to increase the capacity of the [[Urinary bladder|bladder]] at night. The [[child]] is groomed to awaken prior to [[bedwetting]]. The ideal [[treatment]] for [[children]] < 8 years with MEN and with good support from caregivers.<ref name="pmid7962877">{{cite journal| author=Houts AC, Berman JS, Abramson H| title=Effectiveness of psychological and pharmacological treatments for nocturnal enuresis. | journal=J Consult Clin Psychol | year= 1994 | volume= 62 | issue= 4 | pages= 737-45 | pmid=7962877 | doi=10.1037//0022-006x.62.4.737 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7962877  }} </ref>
***'''Alarm [[therapy]]:'''
***[[Neuromodulation]]: [[Transcutaneous electric nerve stimulation|Transcutaneous]] parasacral neurostimulation for [[overactive bladder]] cases.
****Most useful for [[disorders]] with awakening.
***[[Biofeedback]]: using [[optical]] and [[auditory]] cues to help [[children]] to relax and empty their [[Urinary bladder|bladder]] in cases of [[micturition]] that are discoordinated.
****It is intended to increase the [[Urinary bladder|bladder]] capacity at night.
***Anti-stress program.
****The [[child]] is groomed to awaken prior to [[bedwetting]].
***[[Pelvic floor]] exercise.
****The [[Ideal solution|ideal]] [[treatment]] for [[children]] < 8 [[Year|years]] with MEN and with good [[support]] from caregivers.<ref name="pmid7962877">{{cite journal| author=Houts AC, Berman JS, Abramson H| title=Effectiveness of psychological and pharmacological treatments for nocturnal enuresis. | journal=J Consult Clin Psychol | year= 1994 | volume= 62 | issue= 4 | pages= 737-45 | pmid=7962877 | doi=10.1037//0022-006x.62.4.737 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7962877  }} </ref>
***Self-[[catheterization]].
***'''[[Neuromodulation]]:''' [[Transcutaneous electric nerve stimulation|Transcutaneous]] parasacral neurostimulation for [[overactive bladder]] cases.
***Etc.<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
***'''[[Biofeedback]]:''' Using [[optical]] and [[auditory]] cues to help [[children]] to [[Relaxation|relax]] and empty their [[Urinary bladder|bladder]] in cases of [[micturition]] that are uncoordinated:<ref name="EbilogluErgin2016">{{cite journal|last1=Ebiloglu|first1=Turgay|last2=Ergin|first2=Giray|last3=Irkilata|first3=Hasan Cem|last4=Kibar|first4=Yusuf|title=The biofeedback treatment for non-monosymptomatic enuresis nocturna|journal=Neurourology and Urodynamics|volume=35|issue=1|year=2016|pages=58–61|issn=07332467|doi=10.1002/nau.22678}}</ref>
 
****Anti-[[stress]] program
*[[Pharmacological]] [[treatment]].
****[[Pelvic floor]] [[exercise]]
**[[ADH]] analogs such as [[Desmopressin]] are helpful in the setting of high [[urine output]] at night. Effective in 70% of cases with complete remission seen in 25%. [[Relapse]] is however a concern but the coordinated stepwise [[withdrawal]] of [[therapy]] is promising.
****Self-[[catheterization]]<ref name="pmid21977217">{{cite journal| author=Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H| title=Urinary incontinence in children. | journal=Dtsch Arztebl Int | year= 2011 | volume= 108 | issue= 37 | pages= 613-20 | pmid=21977217 | doi=10.3238/arztebl.2011.0613 | pmc=3187617 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21977217  }} </ref>
**[[Anticholinergics]] like [[Oxybutynin]], [[Propiverine]] (preferred due to lower side-effects) are sometimes used in cases of [[overactive bladder]] with [[failure]] to achieve dryness from urotherapy. 65%-87% response rates are reported with chances of [[relapse]] also documented.
**'''[[Pharmacological]] [[treatment]]:'''
**[[Botulinum toxin]] A: rarely indicated.
***'''[[ADH]] analogs''' such as [[desmopressin|'''desmopressin''']] are helpful in the setting of high [[urine output]] at night. Effective in 70% of cases with complete [[remission]] seen in 25%. [[Relapse]] is however a concern but the [[Coordination|coordinated]] stepwise [[withdrawal]] of [[therapy]] is promising.
**[[Alpha-blockers]]
***'''[[Anticholinergics]]''' such as '''[[oxybutynin]], and [[propiverine]]''' (preferred due to lower side-effects) are sometimes used in cases of [[overactive bladder]] with [[failure]] to achieve dryness from urotherapy. 65%-87% [[Response rate|response rates]] are [[Reporting results|reported]] with [[Chance|chances]] of [[relapse]] also documented.
**[[Tricyclic antidepressants]]: has [[lethal]] [[heart]] side effects and not usually used.<ref name="pmid27703953">{{cite journal| author=Arda E, Cakiroglu B, Thomas DT| title=Primary Nocturnal Enuresis: A Review. | journal=Nephrourol Mon | year= 2016 | volume= 8 | issue= 4 | pages= e35809 | pmid=27703953 | doi=10.5812/numonthly.35809 | pmc=5039962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27703953  }} </ref>
***'''[[Botulinum toxin]] A:''' [[Rare|rarely]] indicated.
***'''[[Alpha-blockers]]'''
***'''[[Tricyclic antidepressants]]:'''  Have [[lethal]] [[heart]] [[side effects]] and not usually used.<ref name="pmid27703953">{{cite journal| author=Arda E, Cakiroglu B, Thomas DT| title=Primary Nocturnal Enuresis: A Review. | journal=Nephrourol Mon | year= 2016 | volume= 8 | issue= 4 | pages= e35809 | pmid=27703953 | doi=10.5812/numonthly.35809 | pmc=5039962 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27703953  }} </ref>


===Surgery===
===Surgery===


*[[Surgery]] is not routinely employed as a form of [[treatment]]. Might be of importance in correcting some organic [[causes]] of [[urinary incontinence]] in [[children]].
*[[Surgery]] is not routinely employed as a form of [[treatment]]. Might be of importance in [[Corrective|correcting]] some organic [[causes]] of [[urinary incontinence]] in [[children]].


===Prevention===
===Prevention===


*There are no documented primary preventive measures available for [[urinary incontinence]] in [[children]].
*There are no documented [[Primary prevention|primary preventive]] [[Measure (mathematics)|measures]] available for [[urinary incontinence]] in [[children]].


==References==
==References==
Line 367: Line 381:
   
   
[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Primary care]]
[[Category:Up-To-Date]]

Latest revision as of 14:24, 9 April 2021

Urinary incontinence in children Microchapters

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differential Diagnosis

Epidemiology and Demographics

Risk factors

Natural History, Complications and Prognosis

Diagnosis

Treatment

Prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ifeoma Anaya, M.D.[2]

Synonyms and keywords: Urinary incontinence in kids; Bedwetting; Enuresis; Nocturnal enuresis; Enuresis nocturna; Monosymptomatic enuresis nocturnal (MEN); Non-monosymtomatic enuresis nocturnal (non-MEN)

Overview

Urinary incontinence in children is a very familiar finding and complaint amongst patients and their caregivers. The earliest documentation of urinary incontinence dates back to 1550 BC in the Ebers papyrus. It is broadly classified into physiological and pathological with its various subdivisions, and nocturnal enuresis can be categorized into primary and secondary. The pathophysiology of urinary incontinence in children, particularly enuresis, can be described as increased urine production at night, reduced bladder capacity at night, and awakening disorder. The causes of urinary incontinence in children are identified based on the sub-classification of pathological incontinence. Differentials include diabetes mellitus, diabetes insipidus, and urinary tract infection. Children achieve the ability to control their bladder between the ages of 3 and 6 years. This begins initially during the daytime and nighttime control is achieved much later. Nocturnal enuresis is seen more frequently in boys. There is no documented racial predisposition for enuresis. Some risk factors include, age less than 5 years, positive family history, family size, and birth order. Certain complications are poor self-esteem and inability to socialize with peers. Prognosis is generally good due to the high chances of spontaneous resolution at the rate of 15% per year. The focus is to eliminate any potential organic cause of incontinence and to classify and identify the type of functional incontinence using detailed history and non-invasive procedures. Identify any comorbidities which are mostly psychological occurring alongside incontinence. Fundamental diagnosis includes taking a detailed history using a standardized questionnaire. The primary aim of a physical examination is to look for possible organic causes of incontinence and comorbidities. Urinalysis is essential to rule out urinary tract infections. Ultrasonography is a useful tool when further diagnostics is required especially in situations of a likely organic cause or a lack of response to therapy. Uroflowmetry and urodynamic studies are additional diagnostic studies that can be employed. Urotherapy encompasses all non-pharmacological and non-surgical treatment methods employed in the treatment of urinary incontinence in children. Desmopressin and oxybutynin are common drugs used for the pharmacological management of urinary incontinence in children. Surgery is not routinely employed as a form of treatment but it might be of importance in correcting some organic causes of urinary incontinence in children. There are no documented primary preventive measures available for urinary incontinence in children.

Historical Perspective

Classification

Classification of Urinary Incontinence in Children
Types of urinary incontinence Details
Physiological[3]
Pathological[3][4][5] Organic:
  • Usually uncommon.
  • In-depth investigations needed to be identified more so in cases that have not responded to conventional treatment.
Functional or psychosomatic: Monosymtomatic enuresis (MEN):
Non-monosymptomatic enuresis Nocturna (Non-MEN):

Pathophysiology

Causes

Differentiating urinary incontinence from other diseases

Epidemiology and Demographics

Age

Gender

Race

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Symptoms

Physical Examination

Laboratory Findings

Ultrasound

CT scan

MRI

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Prevention

References

  1. 1.0 1.1 1.2 Changizi Ashtiyani S, Shamsi M, Cyrus A, Tabatabayei SM (2013). "Rhazes, a genius physician in the diagnosis and treatment of nocturnal enuresis in medical history". Iran Red Crescent Med J. 15 (8): 633–8. doi:10.5812/ircmj.5017. PMC 3918184. PMID 24578827.
  2. Salmon, Michael A (2016). "An Historical Account of Nocturnal Enuresis and its Treatment". Proceedings of the Royal Society of Medicine. 68 (7): 443–445. doi:10.1177/003591577506800726. ISSN 0035-9157.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Schultz-Lampel D, Steuber C, Hoyer PF, Bachmann CJ, Marschall-Kehrel D, Bachmann H (2011). "Urinary incontinence in children". Dtsch Arztebl Int. 108 (37): 613–20. doi:10.3238/arztebl.2011.0613. PMC 3187617. PMID 21977217.
  4. Zhu W, Che Y, Wang Y, Jia Z, Wan T, Wen J; et al. (2019). "Study on neuropathological mechanisms of primary monosymptomatic nocturnal enuresis in children using cerebral resting-state functional magnetic resonance imaging". Sci Rep. 9 (1): 19141. doi:10.1038/s41598-019-55541-9. PMC 6915704 Check |pmc= value (help). PMID 31844104.
  5. 5.0 5.1 5.2 Arda E, Cakiroglu B, Thomas DT (2016). "Primary Nocturnal Enuresis: A Review". Nephrourol Mon. 8 (4): e35809. doi:10.5812/numonthly.35809. PMC 5039962. PMID 27703953.
  6. Nevéus T, Läckgren G, Tuvemo T, Hetta J, Hjälmås K, Stenberg A (2000). "Enuresis--background and treatment". Scand J Urol Nephrol Suppl (206): 1–44. PMID 11196246.
  7. Rittig S, Knudsen UB, Nørgaard JP, Pedersen EB, Djurhuus JC (1989). "Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis". Am J Physiol. 256 (4 Pt 2): F664–71. doi:10.1152/ajprenal.1989.256.4.F664. PMID 2705537.
  8. Tas T, Cakiroglu B, Hazar AI, Balci MB, Sinanoglu O, Nas Y; et al. (2014). "Monosymptomatic nocturnal enuresis caused by seasonal temperature changes". Int J Clin Exp Med. 7 (4): 1035–9. PMC 4057857. PMID 24955178.
  9. Yeung CK, Sreedhar B, Leung VT, Metreweli C (2004). "Ultrasound bladder measurements in patients with primary nocturnal enuresis: a urodynamic and treatment outcome correlation". J Urol. 171 (6 Pt 2): 2589–94. doi:10.1097/01.ju.0000112978.54300.03. PMID 15118426.
  10. Watanabe H (1995). "Sleep patterns in children with nocturnal enuresis". Scand J Urol Nephrol Suppl. 173: 55–6, discussion 56-7. PMID 8719568.
  11. Yeung CK, Diao M, Sreedhar B (2008). "Cortical arousal in children with severe enuresis". N Engl J Med. 358 (22): 2414–5. doi:10.1056/NEJMc0706528. PMID 18509134.
  12. Arda, Ersan; Cakiroglu, Basri; Thomas, David T. (2016). "Primary Nocturnal Enuresis: A Review". Nephro-Urology Monthly. 8 (4). doi:10.5812/numonthly.35809. ISSN 2251-7006.
  13. 13.0 13.1 Nørgaard JP, Djurhuus JC, Watanabe H, Stenberg A, Lettgen B (1997). "Experience and current status of research into the pathophysiology of nocturnal enuresis". Br J Urol. 79 (6): 825–35. doi:10.1046/j.1464-410x.1997.00207.x. PMID 9202545.
  14. "StatPearls". 2020. PMID 31424765.
  15. Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W; et al. (2006). "The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society". J Urol. 176 (1): 314–24. doi:10.1016/S0022-5347(06)00305-3. PMID 16753432.
  16. Yeung CK, Sihoe JD, Sit FK, Diao M, Yew SY (2004). "Urodynamic findings in adults with primary nocturnal enuresis". J Urol. 171 (6 Pt 2): 2595–8. doi:10.1097/01.ju.0000112790.72612.0a. PMID 15118427.
  17. Houts AC, Berman JS, Abramson H (1994). "Effectiveness of psychological and pharmacological treatments for nocturnal enuresis". J Consult Clin Psychol. 62 (4): 737–45. doi:10.1037//0022-006x.62.4.737. PMID 7962877.
  18. Ebiloglu, Turgay; Ergin, Giray; Irkilata, Hasan Cem; Kibar, Yusuf (2016). "The biofeedback treatment for non-monosymptomatic enuresis nocturna". Neurourology and Urodynamics. 35 (1): 58–61. doi:10.1002/nau.22678. ISSN 0733-2467.