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The management of urinary incontinence

Wetting presents in two forms, enuresis and incontinence. Enuresis is defined as wetting when no underlying anatomical or functional abnormality of the urinary tract can be detected. A diagnosis of incontinence implies the presence of an underlying anomaly that requires investigation and treatment. However, the diagnosis of incontinence in children is not simple. When an adult presents with wetting the diagnosis of incontinence is automatic, but most wetting children will be enuretic and in the majority spontaneous improvement is to be expected. Many children are labelled as enuretic and incontinence is missed. The art of paediatrics is to recognise the incontinent patient. This can be done in the majority of patients with a proper history, examination, and knowledge of the conditions that cause incontinence (table 1). Urinary and faecal dysfunction commonly coexist and both systems should be assessed and treated simultaneously.1

View this table:

Table 1 
Causes of isolated urinary incontinence



Before discussing the management of incontinence it is important to identify the clinical features that should alert us to the diagnosis.

A detailed micturition history is essential. Frequency, urgency, and urge incontinence are suggestive of dysfunctional voiding, as occurs with idiopathic detrusor instability or the urge syndrome.2 A history of a weak or intermittent stream raises the possibility of bladder outflow obstruction. A patient who has never been reliably dry in the upright position has an ectopic ureter or sphincter weakness till proved otherwise. An accurate assessment of fluid intake is also important. It is now clear that drinks containing blackcurrant and caffeine can provoke detrusor instability in susceptible patients. Emotional or behavioural problems may coexist, but it can be difficult to distinguish between those causing wetting and those that are secondary to it. A detailed bowel history is also required.

The abdomen is palpated for a full bladder and faecal masses. …