Urinary incontinence in children

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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

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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 under 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 subclassification 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 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 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. Might be of importance in correcting some organic causes of urinary incontinence in children and 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
  • It is expected and seen as a norm in the early years.
  • Requires a minimum age of 5 years, at least one event in a month, and a minimum period of 3 months.
  • 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.
  • Clinical evaluation of these kids remains normal.[3]
Pathological Organic:
  • Usually uncommon.
  • In-depth investigations needed to be identified more so in cases that have not responded to conventional treatment.[3]
Functional or psychosomatic:
  • Includes all forms of pathological urinary incontinence without anatomic or neurologic defects.
  • Manifestations of which have been subdivided into two:
Monosymtomatic enuresis(MEN):
  • 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.[4]
Non-monosymptomatic enuresis Nocturna(Non-MEN):
  • Diurnal presentation with an urge, frequency, and enuresis.[5]

Pathophysiology

Causes

Differentiating urinary incontinence from other Diseases

Epidemiology and Demographics

Age

Gender

Race

Risk Factors

Natural History, Complications and Prognosis

  • Complications are:
  • Prognosis is generally good due to 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.[14]

Diagnosis

Symptoms

  • Fundamental diagnosis includes taking a detailed history using a standardized questionnaire. Some of the important questions to ask include:
  • A symptom or bladder diary is completed over a period of 14 days.

Physical Examination

Laboratory Findings

Electrocardiogram

There are no ECG findings associated with this condition.

X-ray

There are no x-ray findings associated with urinary incontinence in children.

Echocardiography or Ultrasound

CT scan

MRI

Other Imaging Findings

There are no other imaging findings associated with urinary incontinence in children.

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Prevention

References

  1. 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.
  2. 2.0 2.1 2.2 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.
  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. 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.
  8. 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.
  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.