Daytime Incontinence in Children Dr Steven McTaggart Queensland Child & Adolescent Renal Service Royal Children’s and Mater Children’s Hospitals Brisbane. Paediatric Society of Queensland Meeting Friday 12 October, 2012

Children rated wetting themselves at school as the third most catastrophic event behind losing a parent and going blind. Ollendick et al, Behav Res Therapy, 1989.

?A Mental Illness Enuresis – DSM V Repeated voiding of urine into bed or clothes (whether involuntary or intentional). The behaviour is clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. Chronological age is at least 5 years (or equivalent developmental level). The behaviour is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic or an antipsychotic medication) or another medical condition (e.g., diabetes, spina bifida, a seizure disorder).

Outcomes Vemulakonda VM and Jones EA (2006) Nat Clin Pract Urol 3: 551–559

International Childrens Continence Society Classification (2006)

Case Study 10 year old girl - Referred from GE Clinic ›Long-standing patient of regional paediatrician ›Chronic constipation ­multiple investigations and treatment incl 4 previous admissions for washout ›Daytime incontinence and nocturnal enuresis

Evaluation - History Age and pattern of toilet training ›longest dry periods - primary vs secondary ­Toilet trained 2 years age ­Dry during day for 2 months - never been dry since then ­Wets daily – never dry at night Current symptoms and signs ›voiding pattern - stream/volume/frequency/post-void dribbling ­Wears pad during the day – always damp but rarely soaks through to clothes ­Frequent voiding – up to 8x/day at school – ?small vols ­No post-void dribbling ­Not continuously wet → Consider Voiding Diary

Voiding Diary (

Voiding Diary App

Ectopic Ureter

Evaluation - History ›urgency / holding manoeuvres ›perineal hygiene - vulvovaginitis/balanitis ›dysuria / frequency / UTI’s ­Previously recurrent UTI – none for 3 years

Evaluation - History ›CONSTIPATION ­Constipation with soiling since 2 years age ­Multiple unsuccessful treatments ­Does not use school toilets ­‘withholding’ behaviour Family history of urological problems ­Nil Developmental / behavioural issues Social history - think about CSA

Evaluation - Physical Exam Exclude structural lesions ›Abdominal examination ›Genital examination ­labial adhesions/meatal stenosis ­bifid clitoris Exclude occult neurological disorders ›examine back for signs of occult spina bifida ›DTR’s lower limbs ›gait ›?anal wink

Evaluation - Investigations Urinalysis - dipstick, M/C/S, (urine osmolality) Ultrasound ›estimate functional bladder capacity & residual IVP/CT urogram if suspect ectopic ureter MCU ›if abnormal USS esp trabeculation/thickened bladder wall Spinal imaging – not routine Urodynamics – not routine

Evaluation - Role of Spinal Imaging Wraige E & Borzyskowski M, Arch Dis Child, 2002 ­retrospective study - 48 children with voiding dysfunction ­closed spina bifida present in 5 patients - only 1 had no cutaneous, neuro-orthopaedic or lumbosacral spine abnormalities. Nejat et al, Pediatr 2008 ­176 children with encoporesis/enuresis - 88 with SBO and 88 control ­17 (38%) bony spina bifida occulta ­10/48 underwent MRI - 1 had lipoma requiring resection

Recommendations for Spinal Imaging neurological /neuro-orthopaedic abnormality secondary enuresis or deterioration in primary enuresis significant associated bowel abnormality urodynamic study suggesting neurogenic bladder

Evaluation - Urodynamic Studies Not required for majority of children Indicated if; ›evidence of/at risk of upper tract deterioration ­hydroureteronephrosis ­high grade VUR ­recurrent episodes of pyelonephritis ›suspicion or evidence of neurological abnormality ›?significant daytime enuresis that fails to respond to conventional treatment ›(unexplained secondary enuresis - cystoscopy is preferable)

General Principles of Treatment Explanation of condition and natural history Treat constipation / UTI Ensure adequate fluid intake Bladder retraining ›Timed voiding schedule ›Double voiding if large post-void residual ›Physiotherapy - pelvic floor retraining ›Biofeedback Medications ›Antibiotic prophylaxis if UTI ›Anticholinergics

Diagnosis – Functional Voiding Disorders Voiding postponement / “holding” Voiding postponement / “holding” Underactive bladder Urge syndrome Stress Incontinence Dysfunctional voiding Extreme Daytime Frequency

General Principles of Treatment Voiding Pattern Constipation UTI Urotherapy Pharmacological

Management Urotherapy ›Timed voiding, posture, avoiding holding ›Lifestyle – fluid intake ›Biofeedback / physiotherapy Pharmacological ›Anticholinergics ­oxybutinin tabs / patches (Ditropan™) ­tolteridine (Detrusitol™) ­solenifacin (Vesicare™) ›(Tricyclic antidepressants) ›? prazosin / ? ddAVP (Minirin™)

Pathogenesis of Bladder Dysfunction Neonate - bladder emptying via sacral spinal cord reflex ~ 2 yr age develop conscious sensation of bladder fullness  spinal reflex gradually modified and inhibited by pontine micturition centre in brain stem Between 2-4 years child develops ability to control voiding - conscious voiding requires relaxation of the external sphincter just prior to detrusor contraction Balance between “inhibiting voiding” and “initiating voiding” not fully mastered until ~ 4yrs age Note that ethnic,cultural,economic and individual family differences exist in relation to toilet training and the perception that daytime incontinence is abnormal

Bladder Retraining “Bad” bladder behaviour Imbalance in “inhibiting” and “initiating” voiding

Urodynamics Urge Syndrome

Pharmacological Management

Management Urotherapy ›Timed voiding, posture, avoiding holding ›Lifestyle – fluid intake ›Biofeedback / physiotherapy Pharmacological ›Anticholinergics ­oxybutinin tabs / patches (Ditropan™) ­tolteridine (Detrusitol™) ­solenifacin (Vesicare™) ›(Tricyclic antidepressants) ›? prazosin / ? ddAVP (Minirin™) ? combination therapy

Urge Syndrome Most common voiding dysfunction Peak ages 5-7 years Characterised by; ›urgency, frequency ›holding manoeuvres eg squatting ›usually normal bladder emptying UTI’s and constipation common Mx - Treat constipation - Increase fluid intake - Timed voiding - Anticholinergics

Underactive Bladder Characterised by; ›Large capacity, hypotonic bladder ›Infrequent voiding ›Poor urinary stream ›Abdominal straining to void Incontinence between voiding due to overflow Decreased sensation of bladder fullness Incomplete emptying predisposes to UTI Mx - Timed voiding / Double voiding - Treat constipation if present - Antibiotics for UTI - Physio / Biofeedback

Voiding Disorders - Summary

Outcomes Vemulakonda VM and Jones EA (2006) Nat Clin Pract Urol 3: 551–559

Long Term Outcome Kuh et al, ›Longitudinal study of 1333 women with urinary incontinence (mean age 48 years) ›50% reported stress incontinence ›22% reported urge incontinence ›8% had severe symptoms ›Women who had daytime wetting as a child were more likely to have severe symptoms

The End