Daytime Urinary Incontinence in Children

Daytime urinary incontinence in children is involuntary leakage of urine while awake in a child old enough to have bladder control (usually 5 years or older), and it ranges from functional bladder problems to anatomical and neurological causes.

• It affects about 3 to 8 percent of school-age children and is commoner in girls.
• Commonest causes are overactive bladder (urge incontinence), dysfunctional voiding, voiding postponement and giggle incontinence.
• Constipation, urinary tract infection, behavioural problems, attention deficit hyperactivity disorder and developmental delay are associated.
• Organic causes include ectopic ureter, neurogenic bladder, spina bifida, posterior urethral valves and urethral abnormalities.
• Continuous wetting from birth in a girl with otherwise normal voiding suggests ectopic ureter.

The pattern of wetting points to the cause.

• Overactive bladder: urgency, frequent small voids, holding manoeuvres (squatting, crossing legs, heel under the perineum), and leakage before reaching the toilet.
• Voiding postponement: wets when absorbed in play, after long delays.
• Giggle incontinence: complete emptying of the bladder with laughing.
• Stress incontinence: leakage on coughing or exertion (uncommon in children).
• Dysfunctional voiding: staccato or interrupted stream, straining, incomplete emptying.
• Constipation, soiling, urinary tract infection, or nocturnal enuresis may coexist.
• Continuous dribbling with a normal void suggests ectopic ureter.
• Differential diagnosis: neurogenic bladder, ectopic ureter, urinary tract infection, vaginal reflux, labial adhesions, diabetes mellitus, diabetes insipidus, posterior urethral valves, anorectal malformation and sexual abuse.
• Complications: urinary tract infection, vesicoureteric reflux, social embarrassment, low self-esteem, bullying and perineal skin irritation.

History, bladder diary and examination form the basis.

• History: voiding pattern, fluid intake, bowel habit, urinary infections, onset, behaviour and developmental history.
• Bladder and bowel diary for 2 days.
• Examination: abdomen (faecal loading, palpable bladder), genitalia (labial adhesions, urethral meatus, wet perineum), spine and lower limb neurology (sacral dimple, tuft of hair, gait, reflexes).
• Urinalysis and urine culture; blood glucose if polyuria.
• Uroflowmetry and post-void residual by ultrasound.
• Renal and bladder ultrasound. Video-urodynamics or MRI of the spine in suspected neurological or anatomical disease.

Behavioural therapy (urotherapy) is first-line.

• Supportive: education and reassurance, timed voiding every 2 to 3 hours while awake, relaxed posture on the toilet (feet supported, leaning forward), adequate fluid intake (about 1.5 litres daily, mostly earlier in the day), avoiding bladder irritants (caffeinated and carbonated drinks), and treating constipation.
• Treat constipation and urinary tract infection first.
• Pharmacological, for persistent urge symptoms after urotherapy: oxybutynin 0.1 to 0.2 mg/kg two to three times daily (maximum 5 mg per dose; ages 5 and above), or tolterodine 1 to 2 mg twice daily. Review for constipation, dry mouth and residual urine.
• Antibiotic prophylaxis: trimethoprim 2 mg/kg at night, or nitrofurantoin 1 to 2 mg/kg at night, for children with recurrent urinary infection.
• Biofeedback and pelvic floor retraining for dysfunctional voiding.
• Procedures: surgical correction for ectopic ureter, posterior urethral valves and anatomical defects. Intermittent catheterisation for neurogenic bladder.
• Special groups: children with neurological disease need specialist urology care. Suspicion of abuse needs safeguarding assessment.
• Red flags: continuous dribbling, weak stream, abnormal spine or neurology, recurrent febrile urinary infection, renal impairment and onset after trauma or sudden change in behaviour.
• Follow-up: review at 4 to 6 weeks with diary. Refer to paediatric urology or nephrology if failing to improve in 3 months.