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. | ||