Urinary incontinence is defined as involuntary voiding of urine ≥ 2 times/month during the day or night; the incontinence may be intermittent or continuous. Revised terminology for the time of incontinence has been suggested (1, 2—see also the International Continence Society web site):
For urinary incontinence during the day: Diurnal incontinence (or diurnal wetting)
For urinary incontinence at night: Enuresis (or bed-wetting)
Diurnal (daytime) incontinence is usually not diagnosed until age 5 or 6. Nocturnal (nighttime) incontinence (that is, enuresis) is usually not diagnosed until age 7. Before this time, enuresis is typically referred to as nighttime wetting (3). These age limits are based on children who are developing typically and so may not be applicable to children with developmental delay. Both nocturnal and diurnal incontinence are symptoms—not diagnoses—and necessitate consideration of an underlying cause.
The age at which children attain urinary continence varies, but > 90% are continent during the day by age 5. Nighttime continence takes longer to achieve. Enuresis affects about 30% of children at age 4, 10% at age 7, 3% at age 12, and 1% at age 18. About 0.5% of adults continue to have nocturnal wetting episodes. Enuresis is more common among boys and when there is a family history of it (4).
Incontinence is classified as
Primary incontinence: Children have never achieved urinary continence for ≥ 6 months.
Secondary incontinence: Children developed incontinence after a period of at least 6 months of urinary control.
An organic cause is more likely in secondary incontinence. Even when there is no organic cause, appropriate treatment and parental education are essential because of the physical and psychologic impact of urine accidents (5).
(See also Urinary Incontinence in Adults.)
General references
1. Hashim H, Blanker M, Drake M, et al: International Continence Society (ICS) report on the terminology for nocturia and nocturnal lower urinary tract function. Neurourol Urodyn 38:499–508, 2019. doi: 10.1002/nau.23917
2. Austin PF, Bauer SB, Bower W, et al: The standardization of terminology of lower urinary tract function in children and adolescents: Updated report from the standardization committee of the International Children's Continence Society. Neurourol Urodyn 35(4):471–481, 2016. doi: 10.1002/nau.22751
3. Wright, AJ: The epidemiology of childhood incontinence. In Pediatric Incontinence, Evaluation and Clinical Management, edited by Franco I, Austin P, Bauer S, von Gontard A, Homsy I. Chichester, John Wiley & Sons Ltd., 2015, pp. 37–60.
4. Horowitz M: Diurnal and nocturnal enuresis. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 853–872.
5. Austin PF, Vricella GJ: Functional disorders of the lower urinary tract in children. In Campbell-Walsh Urology, ed. 11, edited by Wein A, Kavoussi L, Partin A, Peters C. Philadelphia, Elsevier, 2016, pp. 3297–3316.
Pathophysiology of Urinary Incontinence In Children
Bladder function has a storage phase and a voiding phase. Abnormalities in either phase can cause primary or secondary incontinence (1).
In the storage phase, the bladder acts as a reservoir for urine. Storage capacity is affected by bladder size and compliance. Storage capacity increases as children grow. Compliance can be decreased by repeated infections or by outlet obstruction, with resulting bladder muscle hypertrophy. External compression of the bladder from the colon and/or rectum may also decrease urine storage.
In the voiding phase, bladder contraction synchronizes with the opening of the bladder neck and the external urinary sphincter. If there is dysfunction in the coordination or sequence of voiding, incontinence can occur. There are multiple reasons for dysfunction. One example is bladder irritation, which can lead to irregular contractions of the bladder and asynchrony of the voiding sequence, resulting in incontinence. Bladder irritation can result from a urinary tract infection (UTI) or from anything that presses on the bladder (eg, a dilated rectum caused by constipation) (2).
The maturation of the voiding pattern from infant to adult involves changing from the infant's reflex pattern of urination, in which bladder contractions occur unopposed by increased outlet resistance, to the adult pattern, in which bladder contractions are suppressed by the pontine micturition center. During maturation there is a transition phase in which detrusor contractions are opposed by external sphincter contraction (3). The external sphincter is under voluntary muscle control in the neurotypical patient. Development of control occurs during toilet training.
Pathophysiology references
1. Wan J, Kraft K: Neurological control of storage and voiding. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 803–819.
2. Bush N, Shah A, Pritzker J, et al: Constipation and lower urinary tract symptoms. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 873–883.
3. Horowitz, M: Diurnal and nocturnal enuresis. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 853–872.
Etiology of Urinary Incontinence In Children
Urinary incontinence in children has different causes and treatments than urinary incontinence in adults. Although some abnormalities cause both nocturnal and diurnal incontinence, etiology typically varies depending on whether incontinence is nocturnal or diurnal, as well as primary or secondary. Most primary incontinence is nocturnal (ie, enuresis) and not due to an organic disorder. Enuresis can be divided into monosymptomatic (occurring only during sleep) and complex (other abnormalities are present, such as diurnal incontinence and/or urinary symptoms).
Enuresis
Organic disorders account for about 30% of cases and are more common in complex compared to monosymptomatic enuresis.
The remaining majority of cases are of unclear etiology but are thought to be due to a combination of factors, including
Maturational delay
Uncompleted toilet training
Functionally small bladder capacity (the bladder is not actually small but contracts before it is completely full)
Increased nighttime urine volume
Difficulties in arousal from sleep
Family history (if one parent had nocturnal enuresis, there is a 30% chance offspring will have it, increasing to 70% if both parents were affected)
About 15% per year resolve with no intervention.
The factors contributing to organic causes of enuresis include
Conditions that increase urine volume (eg, diabetes mellitus, argininevasopressin deficiency [central diabetes insipidus], nephrogenic diabetes insipidus, chronic renal failure, excessive water intake, sickle cell disease, sometimes sickle trait [hyposthenuria])
Conditions that increase bladder irritability (eg, UTI, pressure on the bladder by the rectum and sigmoid colon [caused by constipation])
Structural abnormalities (eg, ectopic ureter, which can cause both nocturnal and diurnal incontinence)
Abnormal sphincter weakness (eg, spina bifida, which can cause both nocturnal and diurnal incontinence)
Some Factors Contributing to Enuresis
Cause | Suggestive Findings | Diagnostic Approach |
|---|---|---|
Infrequent, hard-pebble, or very large stools Encopresis Abdominal discomfort History of a constipating diet (eg, excessive milk and dairy, few fruits and vegetables) | Usually clinical evaluation alone (including stooling diary) Sometimes abdominal x-ray | |
Increased urine output due to any cause (eg, diabetes mellitus, argininevasopressin deficiency [central diabetes insipidus], nephrogenic diabetes insipidus, excessive water intake, sickle cell disease or trait) | Vary by disorder | For diabetes mellitus, serum glucose For diabetes insipidus, serum and blood osmolality and possibly urine sample For sickle cell, sickle cell testing |
Maturational delay | No diurnal incontinence More common among boys and heavy sleepers Possible family history of bed-wetting | Clinical evaluation alone |
History of snoring with pauses in breathing that last 15 seconds or longer followed by loud snorts Excessive daytime sleepiness Enlarged tonsils/adenoids | Polysomnography | |
Spinal dysraphism (eg, spina bifida, tethered cord, occult defects), leading to urinary retention | Obvious vertebral defects, protruding meningeal sac, lumbosacral dimple or hair tuft, lower-extremity weakness, decreased sensation in lower extremities Absence of ankle jerk reflex, cremasteric reflex, and anal wink | Lumbosacral x-rays For occult conditions, spinal MRI |
Stress | School difficulties, social isolation or difficulties, family stress (eg, divorce, separation) | Clinical evaluation alone (including voiding diary) |
Dysuria, hematuria, frequency, urgency Fever Abdominal pain | Urinalysis Urine culture For patients with pyelonephritis, ultrasonography and voiding cystourethrogram |
Diurnal incontinence
Common causes of diurnal incontinence include
Bladder irritability
Relative weakness of the detrusor muscle (making it difficult to inhibit incontinence)
Urethrovaginal reflux, or vaginal voiding: girls who use an incorrect position during voiding (eg, with legs close together) or have redundant skinfolds may have reflux of urine into the vagina, which subsequently leaks out on standing
Structural abnormalities (eg, ectopic ureter)
Abnormal sphincter weakness (eg, spina bifida, tethered cord)
Some Organic Causes of Diurnal Incontinence
Cause | Suggestive Findings | Diagnostic Approach |
|---|---|---|
Infrequent, hard-pebble, or very large stools Sometimes encopresis, abdominal discomfort History of a constipating diet (eg, excessive milk and dairy, few fruits and vegetables) | Usually clinical evaluation alone (including stooling diary) Sometimes abdominal x-ray | |
Dysfunctional voiding secondary to lack of coordination of the detrusor muscle and urethral sphincter, not related to a neurologic cause | Often encopresis, VUR, and UTI Possibly nocturnal and diurnal incontinence | Urodynamic studies to show dyssynergy of bladder musculature Uroflow testing Sometimes VCUG |
Giggle incontinence | Voiding during laughing, almost exclusively in girls At other times, completely normal voiding | Clinical evaluation alone |
Increased urine output due to any cause (eg, diabetes mellitus, argininevasopressin deficiency [central diabetes insipidus], nephrogenic diabetes insipidus, excessive water intake, sickle cell disease or trait) | Vary by disorder | For diabetes mellitus, serum glucose For diabetes insipidus, serum and blood osmolality and possibly urine sample For sickle cell, sickle cell screen |
Micturition deferral with overflow incontinence | In children, waiting to the last minute to void Common among preschool children when absorbed in playing | Consistent history Voiding diary |
Neurogenic bladder secondary to spinal dysraphism (eg, spina bifida, tethered cord, occult defects) or nervous system defect | Obvious vertebral defects, protruding meningeal sac, lumbosacral dimple or hair tuft, lower-extremity weakness, decreased sensation in lower extremities | Lumbosacral x-rays For occult conditions, spinal MRI Ultrasonography of the kidneys and bladder Urodynamic studies |
Overactive bladder | Urinary urgency (essential for diagnosis); frequency and nocturia also common Sometimes use of holding maneuvers or body posturing (eg, squatting or Vincent curtsy sign) | History consistent with symptoms or overactive bladder Sometimes consideration of voiding diary, urodynamic studies, uroflow testing |
Sleep problems, school difficulties (eg, delinquency, poor grades) Inappropriate and sexualized behavior, depression, unusual interest in or avoidance of all things sexual, inappropriate knowledge of sexual things for age | Evaluation by sexual abuse experts | |
Stress* | School difficulties, social isolation or difficulties, family stress (eg, divorce, separation) | Clinical evaluation alone |
Structural abnormality (eg, ectopic ureter, posterior urethral valves) | In children, full diurnal continence never achieved Nocturnal and diurnal incontinence in girls, history of normal voiding but with continually wet underwear, vaginal discharge Possible history of UTIs, history of other urinary tract abnormalities | Ultrasonography of the kidneys Nuclear renal flow scan or IV urography CT of abdomen and pelvis or MRI urography |
Dysuria, hematuria, frequency, urgency Fever Abdominal pain | Urinalysis Urine culture For patients with pyelonephritis, ultrasonography and VCUG | |
Vaginal reflux (urethrovaginal reflux, or vaginal voiding) due to any cause (including labial adhesions) | Dribbling when standing after urination | Clinical evaluation alone† |
* Stress is a cause primarily when incontinence is acute. | ||
† Physician should note improvement with instruction on proper method of voiding to discourage retention of urine in vagina (eg, sitting backward on toilet or with knees wide apart). | ||
UTI = urinary tract infection; VCUG = voiding cystourethrogram; VUR = vesicoureteral reflux. | ||
Evaluation of Urinary Incontinence In Children
Evaluation should always include assessment for constipation (which can be a contributing factor to both nocturnal and diurnal incontinence).
History
History is the most important diagnostic tool in the evaluation of a child with urinary incontinence. Although there are many technological advances that can support the evaluation, no diagnostic tool can replace the sympathetic and discriminating ear of the physician (1).
History of present illness inquires about onset of symptoms (ie, primary vs secondary), timing of symptoms (eg, at night, during the day, only after voiding), and whether symptoms are continuous (ie, constant dribbling) or intermittent. Noting the age at initial toilet training and whether complete dryness has been achieved since toilet training was completed is important. Recording a voiding schedule (voiding diary), including timing, frequency, and volume of voids, can be helpful. Important associated symptoms include polydipsia, dysuria, urgency, frequency, dribbling, and straining. Position during voiding and strength of urine stream should be noted. To prevent leakage, children with incontinence may use holding maneuvers, such as crossing their legs or squatting (sometimes with their hand or heel pushed against their perineum). In some children, holding maneuvers can increase their risk of UTIs. Similar to the voiding diary, a stooling diary can help identify constipation.
Review of systems should seek symptoms suggesting a cause, including frequency, size, and consistency of stools (constipation); fever, abdominal pain, dysuria, and hematuria (UTI); perianal itching and vaginitis (pinworm infection); polyuria and polydipsia (diabetes insipidus or diabetes mellitus); and snoring or breathing pauses during sleep (sleep apnea). Children should be screened for the possibility of sexual abuse, which, although an uncommon cause, is too important to miss.
Past medical history should identify known possible causes, including perinatal insults or birth defects (eg, spina bifida), neurologic disorders, renal disorders, and history of UTIs. Any current or previous treatments for incontinence and how they were actually instituted should be noted, as well as a list of current medications.
Developmental history should note developmental delay or other developmental disorders related to voiding dysfunction (eg, attention-deficit/hyperactivity disorder, which increases the likelihood of incontinence).
Family history should note the presence of enuresis and any urologic disorders.
Social history should note any stressors occurring near the onset of symptoms, including difficulties at school, with friends, or at home; although incontinence is not a psychologic disorder, a brief period of wetting may occur during stress.
Clinicians also should ask about the impact of incontinence on the child because it also affects treatment decisions.
Physical examination
Examination begins with review of vital signs for fever (UTI), signs of weight loss (diabetes), and hypertension (renal disorder). Examination of the head and neck should note enlarged tonsils, mouth breathing, or poor growth (sleep apnea). Abdominal examination should note any masses consistent with stool or a full bladder.
In girls, genital examination should note any labial adhesions, scarring, or findings suggesting sexual abuse. An ectopic ureteral orifice is often difficult to see but should be sought. In boys, examination should check for meatal irritation or any lesions on the glans or around the anus or rectum. In either sex, perianal excoriations can suggest pinworms.
The spine should be examined for any midline defects (eg, deep sacral dimple, sacral hair patch). A complete neurologic evaluation is essential and should specifically target lower-extremity strength, sensation and deep tendon reflexes, sacral reflexes (eg, anal wink), and, in boys, cremasteric reflex to identify possible spinal dysraphism. A rectal examination may be useful to detect constipation or decreased rectal tone.
Red flags
Findings of particular concern are
Signs or concerns of sexual abuse
Excessive thirst, polyuria, and weight loss
Prolonged primary diurnal incontinence (beyond age 6 years)
Any neurologic signs, especially in the lower extremities
Physical signs of neurologic impairment
New-onset incontinence after dryness for > 1 year
Interpretation of findings
Usually, primary enuresis occurs in children with an otherwise unremarkable history and examination and probably represents maturational delay. A small percentage of children have a treatable medical disorder; sometimes findings suggest possible causes (see table Some Factors Contributing to Enuresis).
For children who are being evaluated for enuresis, it is important to determine whether diurnal symptoms of urgency, frequency, body posturing or holding maneuvers, and incontinence are present. Children with these symptoms have complex enuresis, and management should be directed primarily toward controlling the diurnal symptoms.
In diurnal incontinence, dysfunctional voiding is suggested by intermittent incontinence preceded by a sense of urgency, a history of being distracted by play, or a combination. Incontinence after urination (due to lack of total bladder emptying) can also be part of the history.
Incontinence caused by a UTI is likely a discrete episode rather than a chronic, intermittent problem and may be accompanied by typical symptoms (eg, urgency, frequency, pain on urination); however, other causes of incontinence can result in secondary UTI.
Constipation should be considered in the absence of other findings in children who have hard or unusually large stools and difficulty with elimination (and sometimes palpable stool on examination).
Sleep apnea should be considered with a history of excessive daytime sleepiness and disrupted sleep; parents may provide a history of snoring or respiratory pauses.
Anal or rectal itching (especially at night), vaginitis, urethritis, or a combination can be an indication of pinworms.
Excessive thirst, diurnal incontinence and enuresis, and weight loss suggest a possible organic cause (eg, diabetes mellitus).
Stress or sexual abuse can be difficult to ascertain but should be considered. Sexual abuse is an uncommon cause but is too important to miss.
Testing
Diagnosis of incontinence is often apparent after history and physical examination.
Urinalysis and urine culture usually are done routinely for both sexes (see How To Catheterize the Bladder in a Female Child and see How To Catheterize the Bladder in a Male Child).
Further testing is useful mainly when history, physical examination, or both suggest an organic cause (see table Some Factors Contributing to Enuresis and table Some Organic Causes of Diurnal Incontinence). Ultrasonography of the kidneys and bladder is often done to verify that the renal and urinary tract anatomy is normal (2). Ultrasonography also can be used to assess rectal diameter, and, if constipation is suspected, an abdominal x-ray may be done to confirm a large stool burden. Uroflow testing can show a staccato voiding pattern in patients with dysfunctional voiding.
Evaluation references
1. Wintner A, Figueroa TE: History and physical examination of the child. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 3–27.
2. Coplen DE: Radiologic assessment of bladder disorders. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 780–787.
Treatment of Urinary Incontinence In Children
The most important part of treatment is family education about the cause and clinical course of incontinence. Education helps decrease the negative psychologic impact of urine accidents and results in increased adherence with treatment.
Successful treatment of urinary incontinence also depends on parent and child participation in the treatment plan. If the child is immature, not bothered by the incontinence, or unwilling to participate in the treatment plan, the plan should be postponed until the child is ready to participate.
Treatment of urinary incontinence should be targeted toward any cause that is identified; however, frequently no cause is found. In such cases, the following treatments may be useful.
Enuresis
Behavioral modifications should be first-line recommendations for patients with enuresis. Modifications include the following:
Shifting liquid intake toward earlier times of the day—80% of daily liquid intake should be ingested before 5 PM
Limiting liquids 2 hours before sleep
Double voiding (voiding twice consecutively) before sleep
Managing constipation appropriately
The most effective long-term strategy, when no organic causes are present, is a bed-wetting alarm. Although labor intensive, the success rate can be as high as 70% when children are motivated to end the enuresis, and the family is able to adhere. It can take up to 4 months of nightly use for complete resolution of symptoms. The alarm triggers when wetting occurs. Although children initially continue to have wetting episodes, over time, they learn to associate the sensation of a full bladder with the alarm and then wake up to void prior to an enuretic event. These alarms are readily available online without prescription. An alarm should not be used by children with complex enuresis or children with reduced bladder capacity (as evidenced by voiding diary). These children should be treated the same as children with diurnal incontinence. It is essential to avoid punitive approaches because these undermine treatment and lead only to poor self-esteem.
Oral Medications Used for Incontinence in Children) can decrease nighttime wetting episodes. However, results are not sustained in most patients when the treatment is stopped; parents and children should be forewarned of this to help limit disappointment. DDAVP is preferable to imipramine because of the rare potential of sudden death with imipramine use.
Diurnal incontinence
It is important to treat any underlying constipation. Information from the voiding diary can help identify children with reduced functional bladder capacity, frequency and urgency of urination, and urinary infrequency, all of whom may present with urinary incontinence.
General measures may include
Urgency containment exercises: Children are directed to go to the bathroom as soon as they feel the urge to urinate. They then hold the urine as long as they can and, when they can hold it no longer, start to urinate and then stop and start the urine stream. This exercise strengthens the sphincter and gives children confidence that they can make it to the bathroom before they have an accident.
Gradual lengthening of voiding intervals (if detrusor instability or dysfunctional voiding is suspected)
Changes in behaviors (eg, delayed urination) through positive reinforcement and scheduled urination (time voiding): Children are reminded to urinate by a clock that vibrates or sounds an alarm (preferable to having a parent in the reminder role).
Use of correct voiding methods to discourage retention of urine in the vagina: In girls experiencing vaginal pooling of urine, treatment is to encourage sitting facing backward on the toilet or with the knees wide apart, which will spread the introitus and allow direct flow of urine into the toilet.
Biofeedback: This conservative, nonsurgical therapy is used to treat bladder dysfunction, urinary incontinence, fecal incontinence, urgency, and pelvic pain and to re-educate the pelvic floor muscles to restore and maintain health. With this therapy, children can be evaluated for and instructed in the proper isolation, exercise, and use of the pelvic floor muscles and abdomen muscles to promote synergistic coordinated voiding (1).
Medication (see table Oral Medications Used for Incontinence in Children
2).
Oral Medications Used for Incontinence in Children*
Medication | Some Adverse Effects |
|---|---|
Voiding dysfunction in diurnal incontinence (bladder overactivity) | |
Confusion, dizziness, increased temperature, flushing, constipation, dry mouth | |
Constipation, flushing, dry mouth | |
Constipation, dry mouth, gastrointestinal effects, blurred vision | |
Constipation, dry mouth, gastrointestinal effects, blurred vision | |
Headache, gastrointestinal effects, nasopharyngitis, hypertension | |
Enuresis | |
Intranasal DDAVP is no longer recommended because of the risk of dilutional hyponatremia. | |
Rarely, death† Possible nervousness, personality change, disordered sleep, cardiac arrhythmias‡ Should be used only for therapy-resistant cases given risk–benefit profile | |
* These medications are mostly used as 2nd-line therapy. Treatment of the underlying disorder and behavioral therapy should be used first. | |
† Sudden death of unclear etiology has been reported. This medication is now rarely used. | |
Treatment references
1. Rae A, Renson, C: Biofeedback in the treatment of functional voiding disorders. In Pediatric Incontinence, Evaluation and Clinical Management, edited by Franco I, Austin P, Bauer S, von Gontard A, Homsy I. Chichester, John Wiley & Sons Ltd., 2015, pp. 145–152.
2. Johnson EK, Bauer SB: Neurogenic voiding dysfunction and functional voiding disorders: Evaluation and nonsurgical management. In The Kelalis-King-Belman Textbook of Clinical Pediatric Urology, ed. 6, edited by Docimo S, Canning D, Khoury A, Salle JLP. Boca Raton, CRC Press, 2019, pp. 820–852.
Key Points
Primary urinary incontinence most frequently manifests as nocturnal incontinence (enuresis).
Constipation should be considered as a contributing source.
Most enuresis abates with maturation (15%/year), but at least 0.5% of adults have nighttime wetting episodes.
Organic causes of incontinence are infrequent but should be considered.
Alarms are the most effective treatment for maturational-related enuresis.
Other treatments include behavioral interventions and sometimes medications.
Parental education is essential to the child’s outcome and well-being.
More Information
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
International Continence Society (ICS): Provides advocacy, education, and research programs and services
