How to Deal with Incontinence and Enuresis in your Child
The age at which children acquire bladder control is variable. Most children are dry during the day by the age of 3, and dry at night by 4, but some 10% of 5-year-olds wet the bed, as do 5% of 10-year-olds.
Any child seen with a continence problem should be given a physical examination and full history should be taken. Further investigation may then be necessary.
History: important aspects include familial and social factors, developmental history and details of micturition.
Examination: palpation of the abdomen may reveal abnormalities of the kidneys or bladder or may give evidence of constipation. The lower spine should be examined for evidence of spina bifida occulta, diastematomyelia and presence of a normal coccyx. The neurological examination should check reflexes, gait and saddle sensation. Any wasting or inequality of the feet or lower limbs should be noted.
Urinalysis : enuresis may be a result of infection and 10% of children with a continence problem will have a urinary tract infection (UTI). Treatment of UTI stops wetting in 50% of cases. The urine should be tested for glycosuria.
Radiography: a spinal radiograph may be indicated by the physical findings. Intravenous urography (IVU) and micturating cystourethrography is required if there is UTI or if a major anatomical fault is suspected. Following clinical assessment it should be possible to distinguish between enuresis and incontinence:
· Enuresis is voiding of urine inappropriately in the absence of neurological or urinary tract disease, at an age when most children have bladder control.
· Incontinence is the voiding of urine inappropriately as a result of neurological or urinary tract disease.
Enuresis
Most children with a continence problem are enuretic rather than incontinent. Nocturnal enuresis is more common than diurnal enuresis, and can occur in any sleep phase except rapid eye movement sleep.
Enuresis can be described as primary when the child has never been dry at night, but is usually dry during the day. Secondary enuresis is less common and occurs after a period of nocturnal continence. It is much more likely to be associated with stress factors.
Most children with enuresis are psychiatrically normal, but in severe long-standing cases there may be emotional problems in both the parents and the child. Stress is more likely to influence enuresis in three- and four-year olds and emotional or behavioural disturbance is more common in girls and in children with diurnal enuresis. There is a familial association in nocturnal enuresis: if a parent was enuretic there is a 40% chance of the child being enuretic, and if a sibling is enuretic, the child has a 25% chance of having the same problem. Enuresis is seen more often in social classes IV and V. Decreased functional, rather than structural, bladder capacity is associated with enuresis, and when the child becomes continent this is associated with an increase in functional capacity.
Treatment of nocturnal enuresis
School age children: the doctor should work with the child – not the parents – and should interview the child and parents separately whenever possible. He should explain the problem to the parents, stressing the normality of the child. Parent support is very important and a positive, rather than a punitive attitude should be encouraged. Reward systems, such as star charts are sometimes helpful. Practical measures include cutting down evening fluids and lifting the child and taking him to the toilet when the parents go to bed, but these should be avoided if they cause the child stress.
One third of children will become dry with these simple measures, either dramatically or gradually. The problem should be reviewed at least monthly; if there is no improvement in 3 months then a bell alarm or drug treatment can be tried. Any possibility of improving the social situation should be considered.
Bell-alarm – if used properly this cures 80% of children in 1 week to 6 months. At first the only improvement may be a decrease in the amount of wetting rather than total dryness. One third of children relapse, but dryness is achieved faster with retreatment than when the alarm is first used.
Success is much more likely if:
· The child has his own bed
· The alarm is carefully explained to him
· The child gets up and goes to the toilet even after wetting
· The child is encouraged to change his own sheets
· The alarm is used until there is a run of 21 dry nights.
Drugs – the only drugs found to be more useful than a placebo are the tricyclic antidepressants, and imipramine (Berkomine Tofranil) is the drug of choice. Improvement is usually temporary or partial, but is more likely in secondary enuresis – this group does better on imipramine than with the bell alarm. The dose is increased in 25 mg increments at intervals of 1 or 2 weks. Any benefit is usually noticeable after the first week of treatment and the drug should be stopped if there is no improvement after 6 weeks. Whenever this drug is prescribed, one should never forget the dangers of poisoning in the child or his siblings.
Children are dry at night when they have no more than one wet bed a month and can be discharged when they have been dry for 6 months.
Pre-school children: the problem should be explained to parents and simple measures used at first, with a review of progress every 6 months.
Treatment of diurnal enuresis
This is usually associated with nocturnal enuresis but is much less common and more difficult to treat than nocturnal enuresis alone. The functional bladder capacity is even smaller than in children with nocturnal enuresis alone, and frequency and urgency are common associated findings. Many of these children are found to have unstable bladders with uninhibited detrusor contractions when investigated urodynamically. Circumstantial evidence suggests that in this group of children the symptoms persist longer, eventually moderating to nocturia and frequency. This may, in the long term, settle down to normality. Treatment is the same as for nocturnal diuresis with more emphasis on interval bladder training. Drug therapy may be very useful, particularly the use of anticholinergic drugs such as propantheline (Pro-Banthine), which may decrease the number of unstable contractions and increase bladder capacity.
Giggle micturition is an uncommon condition precipitated by giggling. It continues until the bladder empties even though giggling has ceased. Because children do not giggle until they are 5 or 6, it is not seen in younger children and it tends to resolve at the time of puberty. It can be worsened by stress but discussion of the problem can reduce its frequency and alleviate distress. Interval training and practicing arresting the flow of urine during micturition may be helpful. In severe unresolving cases, a urodynamic study should be performed to exclude bladder instability and urethral abnormality.
Incontinence
The main causes of incontinence in childhood are anatomical abnormality, mental subnormality and neuropathic bladder.
Anatomical abnormality
It is important to diagnose and surgically correct abnormalities of the urinary tract, such as posterior urethral valves, ectopic ureters and meatal stenosis. Details of micturition should sugest such an abnormality, and indicate radiological investigation.
Mental subnormality
The pattern of bladder activity is appropriate to the child’s mental age and this should be explained to the parents.
Neuropathic bladder
This is a rare condition, but because of the serious implications the diagnosis must be made early, and not missed. The commonest cause in childhood is spina bifida, and more of these children are surviving through improved management. Other causes include spinal dysraphism, sacral agenesis, spinal cord tumour, traumatic paraplegia and myelitis, and there is a small group of patients in whom the aetiology is unknown. The main problems are incontinence, recurrent urinary tract infections, and progressive renal damage. The classification of the types of neuropathic bladder is difficult in children, as the classical distinction between upper and lower motor neurone bladder is inappropriate because a mixed picture is usually seen. The small, trabeculated, unstable bladder which may or may not contract against a closed sphincter is a common finding. The large hypotonic bladder is seen infrequently, and usually some unihibited contractions occur against anopen or closed sphincter. Many of these children have absent or greatly diminished bladder sensation. Reflux may also be seen.
Because of many long-term problems and degree of specialist care and surveillance necessary, all these children should be managed jointly by the hospital and general practitioner. Renal and bladder function should be assessed either after diagnosis or immediately after treatment of the causative lesion.
Assessment of renal function includes measurement of plasma urea and creatinine, glomerular filtration rate and urinalysis of midstream urine (MSU). Radiological investigations include IVU and, if renal function is impaired, a DNSA scan which provides information about the functional contribution of each kidney.
Assessment of bladder function: urodynamic assessment consists of a micturating cystourethrogram combined with a bladder pressure study. This will provide information on bladder tone, pressure, capacity, sensation, detrusor activity, bladder outline, reflux, the urethra, urinary flow and residual urine. A urethral pressure profile may also be useful.
This information is necessary in order to plan management which aims at preserving renal function and achieving continence. It is important to treat UTI and constipation and to help the child to lead as normal a life as possible.
Management of incontinence
Renal function: the timing of regular assessment of renal function has to be assessed individually, but there should be monthly urinalysis of a midstream or catheter specimen of urine. Prophylactic antibiotic therapy with co-trimoxazole (Bactrim, Septrin), to give a dose of sulphamethoxazole 10mg/kg/day plus trimethoprim 2 mg/kg/day, or alternatively with nitrofurantoin (Berkfurin, Furadantin) 1-2 mg/kg/day, reduces the risk of infection, but UTI must be treated actively.
Bladder Functions: management of bladder emptying is aimed at continence – 10% of children with myelomeningocoele develop a useful degree of bladder control between the ages of 5 and 10 years. Each child must be reassessed regularly and if management is unsatisfactory then other methods should be employed singly or in combination – for example intermittent catheterization with drugs or bladder-neck surgery with expression.
Expression works well in a few cases but it may be difficult and unrewarding, particularly in the presence of a tight sphincter, and many children hate the procedure. Renal damage in children with reflux is a possibility, although not proven.
Appliances – penile appliances, which collect urine and are regularly emptied, are useful in boys. To date, no really effective implantable bladder stimulator or sphincteric appliance has been produced.
Continuous catheterization is only a short-term measure, long-term it is cumbersome. There is a risk of resistant infection, and a possibility of bladder wall metaplasia.
Intermittent catheterization is a clean, non-sterile procedure performed 2-3 hourly. It is used extensively in the USA and increasingly in the UK. A bladder capacity of 50 ml or more is required it continence is to be achieved.
Surgery is of three types.
1- Bladder-neck, internal or external sphincter resection is undertaken where obstruction has been shown but may cause total incontinence in females.
2- Reimplantation of ureters in gross reflux.
3- Ileal, or, more recently, colonic conduit diversion is not without risk of upper renal tract dilatation, infection, calculi and hypertension and has all the problems of stoma care. Formerly it was used electively on girls at school age to attain continence; it should now be reserved for those children in whom all else has failed when renal impairment leaves no other option open.
Drugs are divided into four main groups, and can be used in conjuction with any of the other methods of treatment.
1- Parasympathomimetics produce a more forceful detrusor contraction and facilitate bladder emptying, for example myotonine chloride (Bethanecol chloride) 0.6 mg/kg/day in 3 does.
2- Anticholinergics decrease unstable contractions and increase bladder capacity, for example propantheline (Pro-Banthine) 1 month – 12 years 1 mg/kg/day in 3 doses, over 12 years 15 mg 8-hourly.
3- Alpha-adrenergic blockers decrease internal sphincter tone, for example phenoxybenzamine (Dibenyline) 1 month – 12 years 0.3 – 0.5 mg/kg/day in 2 doses, over 12 years 0.5-1 mg/kg/day in 2 doses.
4- Alpha-adrenergic stimulants increase bladder-neck tone, for example ephedrine, 1 month – 12 years, 2.5 mg/kg/day in 3 doses, over 12 years 90 mg/day in 3 doses.
Constipation can be very difficult to manage. Dietary advice should always be given, and laxatives such as senna and dioctyl sodium sulphosuccinate (Diocty-Medo) are very useful.
Finally, one must never forget the degree of disruption that may occur in a family with an incontinent child. A great deal of help and support is often necessary, and the provision of a washing machine can make a tremendous difference. The management has to be acceptable to the whole family if it is carried out properly and this may require much explanation. Most parents are so desperate they will try any method which might diminish the amount of wetting in their child, and are most grateful if this occurs.
Treatment of nocturnal enuresis
School age children: the doctor should work with the child – not the parents – and should interview the child and parents separately whenever possible. He should explain the problem to the parents, stressing the normality of the child. Parent support is very important and a positive, rather than a punitive attitude should be encouraged. Reward systems, such as star charts are sometimes helpful. Practical measures include cutting down evening fluids and lifting the child and taking him to the toilet when the parents go to bed, but these should be avoided if they cause the child stress.
One third of children will become dry with these simple measures, either dramatically or gradually. The problem should be reviewed at least monthly; if there is no improvement in 3 months then a bell alarm or drug treatment can be tried. Any possibility of improving the social situation should be considered.
Bell-alarm – if used properly this cures 80% of children in 1 week to 6 months. At first the only improvement may be a decrease in the amount of wetting rather than total dryness. One third of children relapse, but dryness is achieved faster with retreatment than when the alarm is first used.
Success is much more likely if:
· The child has his own bed
· The alarm is carefully explained to him
· The child gets up and goes to the toilet even after wetting
· The child is encouraged to change his own sheets
· The alarm is used until there is a run of 21 dry nights.
Drugs – the only drugs found to be more useful than a placebo are the tricyclic antidepressants, and imipramine (Berkomine Tofranil) is the drug of choice. Improvement is usually temporary or partial, but is more likely in secondary enuresis – this group does better on imipramine than with the bell alarm. The dose is increased in 25 mg increments at intervals of 1 or 2 weks. Any benefit is usually noticeable after the first week of treatment and the drug should be stopped if there is no improvement after 6 weeks. Whenever this drug is prescribed, one should never forget the dangers of poisoning in the child or his siblings.
Children are dry at night when they have no more than one wet bed a month and can be discharged when they have been dry for 6 months.
Pre-school children: the problem should be explained to parents and simple measures used at first, with a review of progress every 6 months.
Treatment of diurnal enuresis
This is usually associated with nocturnal enuresis but is much less common and more difficult to treat than nocturnal enuresis alone. The functional bladder capacity is even smaller than in children with nocturnal enuresis alone, and frequency and urgency are common associated findings. Many of these children are found to have unstable bladders with uninhibited detrusor contractions when investigated urodynamically. Circumstantial evidence suggests that in this group of children the symptoms persist longer, eventually moderating to nocturia and frequency. This may, in the long term, settle down to normality. Treatment is the same as for nocturnal diuresis with more emphasis on interval bladder training. Drug therapy may be very useful, particularly the use of anticholinergic drugs such as propantheline (Pro-Banthine), which may decrease the number of unstable contractions and increase bladder capacity.
Giggle micturition is an uncommon condition precipitated by giggling. It continues until the bladder empties even though giggling has ceased. Because children do not giggle until they are 5 or 6, it is not seen in younger children and it tends to resolve at the time of puberty. It can be worsened by stress but discussion of the problem can reduce its frequency and alleviate distress. Interval training and practicing arresting the flow of urine during micturition may be helpful. In severe unresolving cases, a urodynamic study should be performed to exclude bladder instability and urethral abnormality.
Incontinence
The main causes of incontinence in childhood are anatomical abnormality, mental subnormality and neuropathic bladder.
Anatomical abnormality
It is important to diagnose and surgically correct abnormalities of the urinary tract, such as posterior urethral valves, ectopic ureters and meatal stenosis. Details of micturition should sugest such an abnormality, and indicate radiological investigation.
Mental subnormality
The pattern of bladder activity is appropriate to the child’s mental age and this should be explained to the parents.
Neuropathic bladder
This is a rare condition, but because of the serious implications the diagnosis must be made early, and not missed. The commonest cause in childhood is spina bifida, and more of these children are surviving through improved management. Other causes include spinal dysraphism, sacral agenesis, spinal cord tumour, traumatic paraplegia and myelitis, and there is a small group of patients in whom the aetiology is unknown. The main problems are incontinence, recurrent urinary tract infections, and progressive renal damage. The classification of the types of neuropathic bladder is difficult in children, as the classical distinction between upper and lower motor neurone bladder is inappropriate because a mixed picture is usually seen. The small, trabeculated, unstable bladder which may or may not contract against a closed sphincter is a common finding. The large hypotonic bladder is seen infrequently, and usually some unihibited contractions occur against anopen or closed sphincter. Many of these children have absent or greatly diminished bladder sensation. Reflux may also be seen.
Because of many long-term problems and degree of specialist care and surveillance necessary, all these children should be managed jointly by the hospital and general practitioner. Renal and bladder function should be assessed either after diagnosis or immediately after treatment of the causative lesion.
Assessment of renal function includes measurement of plasma urea and creatinine, glomerular filtration rate and urinalysis of midstream urine (MSU). Radiological investigations include IVU and, if renal function is impaired, a DNSA scan which provides information about the functional contribution of each kidney.
Assessment of bladder function: urodynamic assessment consists of a micturating cystourethrogram combined with a bladder pressure study. This will provide information on bladder tone, pressure, capacity, sensation, detrusor activity, bladder outline, reflux, the urethra, urinary flow and residual urine. A urethral pressure profile may also be useful.
This information is necessary in order to plan management which aims at preserving renal function and achieving continence. It is important to treat UTI and constipation and to help the child to lead as normal a life as possible.
Management of incontinence
Renal function: the timing of regular assessment of renal function has to be assessed individually, but there should be monthly urinalysis of a midstream or catheter specimen of urine. Prophylactic antibiotic therapy with co-trimoxazole (Bactrim, Septrin), to give a dose of sulphamethoxazole 10mg/kg/day plus trimethoprim 2 mg/kg/day, or alternatively with nitrofurantoin (Berkfurin, Furadantin) 1-2 mg/kg/day, reduces the risk of infection, but UTI must be treated actively.
Bladder Functions: management of bladder emptying is aimed at continence – 10% of children with myelomeningocoele develop a useful degree of bladder control between the ages of 5 and 10 years. Each child must be reassessed regularly and if management is unsatisfactory then other methods should be employed singly or in combination – for example intermittent catheterization with drugs or bladder-neck surgery with expression.
Expression works well in a few cases but it may be difficult and unrewarding, particularly in the presence of a tight sphincter, and many children hate the procedure. Renal damage in children with reflux is a possibility, although not proven.
Appliances – penile appliances, which collect urine and are regularly emptied, are useful in boys. To date, no really effective implantable bladder stimulator or sphincteric appliance has been produced.
Continuous catheterization is only a short-term measure, long-term it is cumbersome. There is a risk of resistant infection, and a possibility of bladder wall metaplasia.
Intermittent catheterization is a clean, non-sterile procedure performed 2-3 hourly. It is used extensively in the USA and increasingly in the UK. A bladder capacity of 50 ml or more is required it continence is to be achieved.
Surgery is of three types.
1- Bladder-neck, internal or external sphincter resection is undertaken where obstruction has been shown but may cause total incontinence in females.
2- Reimplantation of ureters in gross reflux.
3- Ileal, or, more recently, colonic conduit diversion is not without risk of upper renal tract dilatation, infection, calculi and hypertension and has all the problems of stoma care. Formerly it was used electively on girls at school age to attain continence; it should now be reserved for those children in whom all else has failed when renal impairment leaves no other option open.
Drugs are divided into four main groups, and can be used in conjuction with any of the other methods of treatment.
1- Parasympathomimetics produce a more forceful detrusor contraction and facilitate bladder emptying, for example myotonine chloride (Bethanecol chloride) 0.6 mg/kg/day in 3 does.
2- Anticholinergics decrease unstable contractions and increase bladder capacity, for example propantheline (Pro-Banthine) 1 month – 12 years 1 mg/kg/day in 3 doses, over 12 years 15 mg 8-hourly.
3- Alpha-adrenergic blockers decrease internal sphincter tone, for example phenoxybenzamine (Dibenyline) 1 month – 12 years 0.3 – 0.5 mg/kg/day in 2 doses, over 12 years 0.5-1 mg/kg/day in 2 doses.
4- Alpha-adrenergic stimulants increase bladder-neck tone, for example ephedrine, 1 month – 12 years, 2.5 mg/kg/day in 3 doses, over 12 years 90 mg/day in 3 doses.
Constipation can be very difficult to manage. Dietary advice should always be given, and laxatives such as senna and dioctyl sodium sulphosuccinate (Diocty-Medo) are very useful.
Finally, one must never forget the degree of disruption that may occur in a family with an incontinent child. A great deal of help and support is often necessary, and the provision of a washing machine can make a tremendous difference. The management has to be acceptable to the whole family if it is carried out properly and this may require much explanation. Most parents are so desperate they will try any method which might diminish the amount of wetting in their child, and are most grateful if this occurs.
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