See also

Constipation
Nocturnal Enuresis
Urinary Tract Infection

Key points

1. Daytime urinary incontinence in school aged children is distressing and requires timely assessment and management
2. The goal of evaluation of daytime incontinence is to distinguish neurological and anatomical causes from functional causes of bladder dysfunction
3. A thorough history of voiding symptoms and a Bladder diary are essential components to assessment, directing targeted investigation and treatment 
4. The most common treatment for urinary incontinence is behaviour modification 

Background

Urinary incontinence is defined as day wetting in a child over 5 years of age that occurs more than once per month for ≥3 months 

• Daytime urinary continence is usually achieved by 4 years of age. Day wetting occurs in around 10 percent of 5-6 year olds, decreasing with age 
• Normal bladder capacity can be estimated prior to adolescence by the formula (age + 2) x 30 = capacity in mL 

Functional causes of incontinence in children include:

• Over active bladder (OAB)- urgency being the most important feature 
• Voiding postponement- habitually delayed urination, with overfilling and leakage 
• Underactive bladder- infrequent urination and overfilling leading to overflow incontinence. A large post-void residual is common 
• Dysfunctional voiding (non-neurogenic) - an inability to relax the urethral sphincter and/or pelvic floor musculature during voiding, resulting in an interrupted urinary flow and prolonged voiding time 

Assessment

Red flags feature in Red

History:

Previously ever been dry during the day? If there has never been a period of dryness noted, or child has continuous incontinence/dribbling (not intermittent) strongly consider anatomical abnormalities 

Symptoms: voiding frequency, incontinence, urgency, nocturia, polyuria, holding manoeuvres (eg standing on tiptoes, crossing of the legs, or squatting with the heel pressed into the perineum), straining, weak stream, intermittency, dysuria 

Completed Bladder Diary

Other:

• Post micturition dribble
  • Girls; consider urethral-vaginal reflux with leakage of urine from the vagina after voiding (when they stand up) 
  • Boys; consider incomplete emptying or dysfunctional voiding 
• Urinary retention
• Spraying of the urinary stream 

Look for comorbidities and treat as appropriate (see Initial Management):

• Constipation
• Urinary tract infection (UTI)
• Night-time wetting (enuresis)
• Excessive tiredness or loss of weight; consider an underlying chronic illness or renal impairment
• Polydipsia or polyuria; Consider possible causes (diabetes mellitus, diabetes insipidus, renal tubular disease, psychogenic)

Examination:

A focused physical examination will assist in identifying underlying conditions/causes of incontinence.

• Height, weight, BP – growth faltering / loss of weight / hypertension 
• Abdomen – distended bladder, renal mass, faecal mass
• Inspection of perineum and external genitalia (and perianal area if constipation also present) 
  • Exclude epispadias; opening on the dorsal surface of the penis in boys or a patulous urethra in girls may suggest a female epispadias 
• Lower Back/Spine – exclude occult spinal dysraphism/tethered cord 
• Neurology - assessment of lower limbs, observation of gait 

Management

Investigations

Routine investigations:

• Urinalysis and culture; repeat urinalysis if previous UTIs or concern about possible renal/metabolic disease 

Secondary Investigations:
Renal tract ultrasound (with pre and post void residual)

• Indicated when failing initial behavioural management, or if there are red flags present (e.g. continuous incontinence, recurrent UTIs)
• Consider in children with established daytime incontinence, review and repeat ultrasound if it is not adequate or recent

Initial (standard) management

Behavioural modification

• Behavioural modification is standard initial management including:
• Educating children/parents about LUT anatomy and function, demystification of pathophysiology and therapeutic approaches
• Micturition behaviour; timed voiding, avoidance of holding manoeuvers, optimal voiding posture
• Use the bladder diary as the reference source and documentation of progress 
• Fluid intake/diet
• Suggest a drink with each meal and snack, spread over the day
• Follow routine nutritional guidelines 
• Re-education
• Address any adherence issues and re-educate if required
• Active management for 3 months. This will allow for approximately 2 cycles of re-education. If unsuccessful, refer to a local paediatrician 

Treat Comorbidities

• Treat constipation and/or soiling simultaneously 
• Treat UTI simultaneously, if recurrent UTIs refer on to local paediatrician
• Enuresis; treat daytime symptoms first for children with combined day-night wetting 

Pharmacological management for Overactive Bladder (OAB)

Pharmacological management is second line treatment. It should be commenced by local paediatric team or continence service. Behavioural modification should continue throughout treatment

Oxybutynin:
Oral. First-line option.
Ditropan^TM 5 mg Tablets*

• 5–12 years, oral, initially 2.5 mg twice daily; if needed, gradually increase to 5 mg 2 or 3 times daily
• 12–18 years, oral, initially 5 mg 2 or 3 times daily; if needed, increase up to a maximum of 5 mg 3 times daily 

Transdermal route (Oxytrol^TM patch- off label <12 yo) can be used if patient can’t swallow or can’t tolerate oral oxybutynin. Do not cut or divide patches as drug release characteristics may be affected 

Practice Points

• Monitor for adverse effects (eg constipation, dry mouth, flushing) and consider laxatives for constipation which may cause or worsen incontinence
• Clinical effect should appear within 2 months  
• Treatment will need to be continued for 3 to 6 months and weaned gradually reassessing regularly
• Monitor for features of incomplete bladder emptying and urinary retention, if anticholinergic therapy is ongoing

AMH Children’s Dosing Companion (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2017 July. Available in  AMH website

Consider consultation with the local paediatric team or continence service when

If red flags for other disorders are present, refer as appropriate.

• Refer to Urology if anatomical abnormality suspected on history (eg continuous wetting) or identified on imaging
• Refer to Nephrologist/ Paediatrician if:
  • Significant haematuria and/or proteinuria
  • Polyuria / Polydipsia (once diabetes mellitus excluded)
• Concurrently refer to mental health services if significant behaviour concerns or psychological comorbidities

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650

Parent information

Day time wetting and Bladder retraining
Bladder Diary
Urinary Incontinence (Raising Children Network)
Day wetting (Continence Foundation of Australia)

Last revised July 2018