Urinary Incontinence - Paediatrics

Genito-Urinary

Urinary Incontinence

Daytime incontinence

·        History:

o   Previously continent? 

o   Frequency, volume, urgency, pain, colour, continuous dribble (are nappies never dry - nearly always pathological)?

o   Infection history:

§  Associated symptoms

§  Past infections, kidney complications 

§  Constipation (® urinary retention due to pressure ® infection).  Need to fix bowels first 

§  Family History

·        Exam:

o   Palpable/distended bladder

o   Kidneys: palpable, tender?

o   Boy: examine penis carefully: balanitis (inflamed foreskin), constricted urethra

o   Girl: effusion of the perineum, can labia be parted

o   Signs of occult spina bifida (eg skin or vascular lesions over sacrum)

o   Are legs neurologically normal

o   Blood pressure: whenever risk of kidney disease

o   Screen for infection

o   Not PR

·        Investigations:

o   Urine microscopy

o   Paediatric US referral

o   Further tests:

§  Bladder volume scanning

§  Paediatric MCU

§  Cystoscopy

§  Urodynamics

·        If repeat infection:

o  ?Genitourinary malformation: do US or MCU to check for reflux 

o  Infection leads to temporary scarring, which predisposes to infection. Break the cycle with prophylactic antibiotics

Bed Wetting/Enuresis

·        Very common: 12% at age 6, 4% at age 14

·        History:

o  Just at night time, or day as well (pathology more likely – must fix this first)

o  Is it primary or secondary: 

§  Primary: have never been dry, most common, usually no associated pathology. No daytime problems. Pass large volume without waking. Ask about proportion of dry nights, getting worse or better? 

§  Secondary: were dry, now wets (regression) ® pathology common. Detailed history of when it began, pattern since then (­ or ¯), symptoms of infection (dysuria, frequency), diabetes (weight loss, thirst), physical abuse. Can be induced by stress (eg starting boarding school, family disruption) 

o  How much wetting: big patch, small patch. How often in the night (if several times then will take longer to come right)

o  Urinary symptoms: polyuria, dysuria, frequency 

o  ?Constipation or soiling ® need to fix this first 

o  Family history (if one parent wet the bed, 40% of children will wet, if both parents then 80%). This is key information – normalises it for parents and child ® ¯anxiety 

o  Parents management style: punitive (unhelpful but common) or supportive (ignore wet pants, praise for waking to pass urine, not common but more helpful)

o  Previous treatment experiences

o  Expectations of parents and child

o  General developmental screen, including faecal continence, bladder training

o  Social history: how much extra support will the child or parent need to manage the treatment

·        Exam:

o  End of bed: note weight loss, hydration

o  Growth 

o  Lumbosacral area (midline defects ® ?spina bifida), perianal sensation and neurological exam of legs 

o  Abdominal palpation: kidneys, distended bladder, constipation

o  External genitalia

o  Blood pressure

·        Investigations:

o  If primary then tests usually reveal nothing

o  MSU: blood, protein, glucose, casts, bacteria, urine analysis

o  May be: blood sugar (diabetes) and electrolytes (renal failure)

·        Treatment: 

o  Reassurance: a nuisance, but normal and curable. Not silly or on purpose. Primary enuresis is NOT a psychological problem, a personality disorder or ADD, but one of delayed maturation. However, stress will make a tendency to bedwetting worse 

o  Parental intolerance will worsen it and ¯self-esteem

o  Avoid covert rewards (eg getting into parent‟s bed when their bed is wet)

o  No night nappy, leave lights on in toilet, normal fluids before bed

o  Convenient hygienic care of bed (eg waterproof under-blanket)

o  Keep a diary (good for any symptom):

§  Day, time of bed, hourly check till parents go to bed, size of wet patch

§  Helps keep accurate record and has therapeutic value (gives feedback, is something to do, etc) 

o  Don‟t treat until age 6 or 7 – but do treat then otherwise psychological sequalae as they head into teens

o  Four options:

o   Encouragement (rewards).  

o   Systematic Waking: wake half an hour before normal wetting time, and shift toileting time closer to bedtime/morning by half an hour a week 

o   Pad Alarms: Good ones best. Not funded. Parents need to be instructed on how to get maximum value from them. Explain and demonstrate to child. Hard work for parents as they must get up (take turns, may need extra support if solo parent). Must wake child properly (eg cold flannel on face). Relapse ® immediate resumption of pad and alarm. Relapse reduced by over-training (once consistently dry, push fluids at bedtime, will recommence wetting but overcome it quickly) 

o   Bladder training exercises

·        Which options:

o   Wets once or twice a week: Rewards for 4 weeks then pad and bell

o   Wets at the same time each night: systematic awakening

o   Wets many times through the night with small patches: bladder retraining and alarm

o   Wetting more than twice a week at unpredictable times: bell and pad

·        If not improvement after two lots of 4 weeks then ?anatomical problem

·        Not medication: Nasal ADH/vasopressin (specialist only) treats symptoms but doesn‟t change behaviour. Maybe useful for short term protection (eg school camps, etc)