pediatrics
Urinary Incontinence in Children
Evaluation of Urinary Incontinence In Children
Evaluation should always include Evaluation (which can be a contributing factor to both nocturnal and diurnal incontinence). 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 ( Evaluation references ). 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. should seek symptoms suggesting a cause, including frequency, size, and consistency of stools ( Constipation in Children ); fever, abdominal pain, dysuria, and hematuria ( 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 (ADD, ADHD) , 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. 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. 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 Usually, primaryenuresisoccurs 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). 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. Indiurnal 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 Urinary Tract Infection (UTI) in Children 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 in Children 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). Obstructive Sleep Apnea (OSA) in Children 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 Pinworm Infestation . Excessive thirst, diurnal incontinence and enuresis, and weight loss suggest a possible organic cause (eg, Diabetes Mellitus in Children and Adolescents ). 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. 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 ). Ultrasonography of the kidneys and bladder is often done to verify that the renal and urinary tract anatomy is normal ( Evaluation references ). 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. 1. Wintner A, Figueroa TE: History and physical examination of the child. InThe 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. InThe 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. 