Daytime Incontinence in Children Dr Steven McTaggart Queensland Child & Adolescent Renal Service...

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(http://childrenshospital.org/clinicalservices/Site2852/Documents/voidind_diary.pdf)

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)

Diagnosis – Functional Voiding Disorders

Voiding

postponement /

“holding”

Underactive bladder

Urge syndrome

Stress Incontinence

Dysfunctional voiding

Extreme Daytime

Frequency

General Principles of Treatment

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™)

Bladder Retraining

“Bad” bladder behaviour

Imbalance in “inhibiting” and “initiating” voiding

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

Outcomes

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

Long Term Outcome

Kuh et al, 1999.› 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