Enuresis and Daytime Incontinence in Children: Diagnosis and Treatment

Background

During 2016 I attended various Paediatric Continence Seminars in the UK and New Zealand which included presentations from expert nurse practitioners and physicians who deal with Enuresis (bedwetting) and Daytime Incontinence in children.

Analysing the causes of Enuresis and/or Daytime Incontinence is often not a straightforward process as a child may present with multiple symptoms which are indicative of the same or different causes. Successfully treating the causes is also challenging, depending on the child and family’s circumstances and commitment.

However, every school-age child has the right to be dry and should be afforded the opportunity to achieve continence and avoid the negative self-esteem issues that can hamper social interaction and development.

Diagnostic Tools and Resources

Developing a context for a child’s continence issues is achieved with an understanding of his or her developmental, medical and urological history.

A physical examination may reveal anatomical issues.

A (Bladder and Bowel) Voiding Diary provides evidence of frequency and volumes and can identify possible bladder capacity and constipation issues. (See Evelina London Children’s Hospital leaflet Bladder and Bowel Diary).

Urinalysis may provide information about Urinary Tract Infection (UTI), diabetes and kidney damage or disease causing proteinuria. Or, infection may be the result of dysfunctional voiding particularly if the bladder is not emptied completely or regularly.

Uroflowmetry, pelvic floor electromyography and pre-and post-void bladder scans are particularly useful for children suffering from Daytime Incontinence or Non-Monosymptomatic Enuresis (Enuresis with daytime symptoms such as urgency, frequency or voiding postponement). These techniques can assist in identifying dysfunctional voiding, neurogenic and underactive bladder and possible bladder outlet obstructions.

The NICE algorithm and top ten tips is an instructive approach to dealing with children who present with Enuresis. It stresses the early recognition and assessment of bedwetting and its underlying causes to improve treatment regimens and outcomes for patients. The Clinical Management Tool referred to in the NICE© algorithm suggests treatment pathways associated with diagnoses and how to manage treatment failures.

The article Diagnostic Evaluation of Children with Daytime Incontinence by Hoebeke, Bower, Combs et al provides an algorithm for the non-invasive assessment of children with daytime Lower Urinary Tract Dysfunction (LUTD).

Annex 1 outlines a diagrammatic algorithm for the treatment of Enuresis and Daytime Incontinence. The generally accepted treatment hierarchy is as follows:

  1. UTI symptoms
  2. Constipation or faecal incontinence
  3. Daytime Wetting (Incontinence)
  4. LUTD symptoms in the case of non-monosymptomatic enuresis
  5. Bedwetting (Enuresis)

Co-Morbidities such as psychological and behavioural problems should be treated alongside the treatment for enuresis and daytime incontinence.

Daytime Incontinence

Uroflowmetry is an excellent way to reveal voiding disorders in children. Used in conjunction with pelvic floor electromyography, and pre- and post-void bladder scans a uroflowmeter helps identify appropriate treatment pathways. It can also be used to follow-up on the effectiveness of bladder training and biofeedback training (in the case of dysfunctional voiding).

A Uroflowmeter calculates the amount of urine passed, the flow rate in seconds and the length of time it takes to empty the bladder completely and records this information on a chart.

During normal urination, the urine stream begins slowly, speeds up and then finally slows down again. This is recorded as a bell-shaped curve.

Abnormal flows plot different curves:

  1. A tower-shaped curve suggests an overactive or neurogenic bladder produced by an explosive voiding contraction.
  2. A staccato-shaped curve shows an irregular and fluctuating pattern which never reaches zero during urination. This suggests uncoordinated bladder/sphincter activity with intermittent sphincter overactivity. This is commonly known as dysfunctional voiding.
  3. An interrupted curve will display spikes and troughs where there is zero flow between the peaks. This pattern generally suggests an underactive bladder with the peaks resulting from the abdominal strain used by the child to evacuate the bowel.
  4. A plateau-shaped curve of long and low amplitude may indicate a bladder outlet obstruction (BOO). This type of curve may also be seen with an underactive bladder during long, continuous abdominal strain.

Dysfunctional Voiding and Overactive Bladder with no post void residue

Where a child exhibits the symptoms of urge incontinence and uroflowmetry indicates an overactive bladder or dysfunctional voiding with no post-voiding residues, then Urotherapy would be an appropriate treatment regime. In fact, most experts believe that Urotherapy should be an integral part of the management of enuresis, as well.

Urotherapy teaches a child to recognise and employ conscious control over their lower urinary tract. It includes advice regarding voiding postures, comfortable buttock support and hip abduction, as well as foot rest. Elevating a child’s legs on a small stool during toileting may help achieve these outcomes. Urotherapy also includes programmed regular toilet visits (every 2-3 hours, or 4-7 times/day), and optimising fluid intake.

If the symptoms persist then, in the case of an overactive bladder, consideration could be given to the use of slow release anti-cholinergics, and, in the case of dysfunctional voiding, referral to acute urology services for biofeedback should be considered. This is also an option for the treatment of overactive bladder where other treatments have failed.

Biofeedback is a technique that gives information about functions that are usually regulated automatically by the body. It indicates when a child’s bladder and urethral muscles contract, to help them gain awareness and control of the urinary tract muscles.

A therapist then teaches the child how to use this information to control the 'involuntary' activities. In the case of urinary incontinence, it can help to re-educate and strengthen the pelvic floor muscles, particularly if they are weak and the child does not know how to produce contractions.

Dysfunctional Voiding and Overactive Bladder with post void residue

Treatment for dysfunctional voiding in this case is with biofeedback referral and this is also the case after for an overactive bladder if Urotherapy does not result in complete voiding.

Where an underactive bladder or bladder obstruction is indicated referral to a Urologist is recommended.

Daytime Incontinence in the absence of LUTD

Where there is no indication of UTI, behavioural intervention is recommended including addressing the need for toilet training with the family. If the child is at school, there will need to be a care plan put in place and consideration should be given for a referral to a paediatrician for a developmental assessment.

Enuresis (monosymptomatic)

Up to 75% of bedwetters are monosymptomatic i.e. they do not experience Daytime Incontinence or Lower Urinary Tract Dysfunction (LUTD).

However, the incidence of Enuresis tends to be higher in children who exhibit symptoms of constipation, attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and upper airway obstruction (including sleep apnoea). Dealing with these issues first (in the case of constipation and sleep apnoea) or alongside (behavioural disorders) may improve the outcomes for Enuresis. Also, where the child presents with symptoms of (Recurrent) Urinary Tract Infection (UTI) this should be dealt with immediately with the appropriate medical management or referrals.

The main causes of Enuresis are usually due to developmental factors:

  • defective arousal responses during sleep with high arousal thresholds preventing the child from waking fully in response to urges to void;
  • nocturnal polyuria which can be a function of low levels of anti-diuretic hormone (ADH) or a small bladder capacity for age, or both;
  • lack of inhibition of the bladder voiding reflex.

Standard Urotherapy treatment is used to ensure that the child’s daily fluid intake (6-8 drinks/day taken earlier) and voiding habits (4-7 times/day) are optimised. This helps stretch the bladder and improve its capacity.

Alarm treatment can be very successful in cases of defective arousal responses and where the bladder voiding reflex is absent.

In the case of nocturnal polyuria, pharmacological treatments such as desmopressin can also produce improvements where low levels of ADH are indicated and the child is unresponsive to alarm treatment or bladder training.

Where small bladder capacity is implicated together with an overactive bladder then anticholinergics may provide improvement in the child’s bedwetting when standard therapies fail.

Enuresis (non-monosymptomatic)

Up to 25% of bedwetters evidence signs of LUTD without daytime wetting. It is recommended that the underlying LUTD symptoms are treated first as effective management of an overactive bladder, voiding postponement or dysfunctional voiding can lead to the cessation of enuresis. The various treatment alternatives for LUTD have been discussed above under Daytime Incontinence.

Treatment of Enuresis Flowchart

 

 

 

 

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Lydia and her girls

My daughter loves the alarm. She’s told me to ‘sell my pull-ups on eBay mommy’. She just loves that she doesn’t have to wear pull-ups…

- Lydia Du Buisson