6 Urinary Incontinence in Children | NBM PHN - nbmphn.com.au

Urinary Incontinence in children

Dr Ritu Datta

VMO Paediatrician Blue Mountains Hospital

Background

Bowel and bladder dysfunction in children is common

Childhood incontinence is a medical problem

Untreated it can progress to adulthood causing significant problems

Potential for long term damage to the upper urinary tracts & GI tract if not properly assessed

Incontinence that begins in childhood is different to incontinence that develops in adulthood

Different aetiology, physiology and treatment

Prevalence

Not all children grow out of it

10% of healthy schoolchildren age 10-14yrs report incontinence

Daytime wetting varies between 30% at age 4 to 1.8% 15-17yrs

0.5-2% of enuretics carry it to adulthood

OAB in childhood 16-17%

Overall constipation prevalence of approx. 9%

Approx. 30% of children with constipation carry it to adulthood

Some facts….

Higher rates of incontinence in children with co-morbidities eg ADHD, developmental delay, neuro psychiatric disorders

More difficult to treat, more likely to relapse

Less compliant, poorer outcomes

Need to treat co-morbid behavioural problems separately to incontinence

Short Screening Instrument for Psychological Problems in Enuresis: (SSIPPE)- validated questionnaire

Facts

Incontinence impacts health, quality of life and health costs

Many children have low self esteem, anxiety and other psychological problems

resolve once child becomes dry

5 years

Urge incontinence (overactive bladder)• Urge• Frequency more than 7 times per day• Small volume voided

Voiding postponement • Infrequent micturition (< 5 times per day)• Postponement

Dysfunctional voiding • Straining to initiate and during micturition• Interrupted stream of urine

Stress incontinence • Wetting during coughing, sneezing• Small volumes

Giggle incontinence• Wetting during laughing• Large volumes with apparently completeEmptying

Detrusor under activity • Interrupted stream• Emptying of bladder possible only by straining

Developmental milestones

1-2 years develop conscious sensation of bladder filling

2-3 years develop ability to void or inhibit voiding voluntarily

Social consciousness

4+ years most have adult pattern of urinary control and are dry day & night

Normal bladder function

Bladder filling begins

Low detrusor pressure during storage phase

Detrusor distension activates stretch receptors

Perception of fullness via neural interplay

Cortical ‘motivation’ of desire to void

Voluntary initiation of micturition by −Detrusor muscle contraction

+ relaxation of pelvic floor & ext urethral sphincter

strong continuous urine flow & bladder emptying

General medical history including comorbidities

Family history of urinary incontinence

Urinary symptoms

Bowel history

Fluid intake and diet, caffeine

Toileting patterns

Sleep history

General health

Home, school and family situation

Assessment contd….

Physical examination (abdominal, neurological, genitalia)

Investigations (UA, uroflow/post void scan, pre- & post void Renal US)

Bladder/bowel diary

Behavioural assessment

• Incontinence episodes

• Urgency

• UTIs

• Normalise bladder storage and emptying (PVR)

• Pelvic floor relaxation during void pattern (uroflow)

• Normalise PFM capabilities

• Normalise bowel function

• Grade VUR; bladder wall changes

• QoL /psychological effects

Outcomes: resolution of symptoms and signs

Continuous urine leakage

Psychosocial well being at risk

Refractory incontinence (treatment failure after 6 months)

History of recurrent UTIs

Severe daytime symptoms (voiding symptoms, genital or LUT pain)

Known or suspected physical or neurological problems

Comorbid conditions eg FI or diabetes

Significant attention, developmental, behavioural or emotional problems

Family problems or vulnerabilities

What’s normal?

Expected bladder capacity:(Age in yrs+ 1) x 30 (up to 390mls)

VV:65-159% of EBC

Frequency: 4-7x/p day

Nocturnal urine output: <130% EBC

Bladder diary…

crucial for assessment of LUT function in children

Baseline info 24hr over 3 normal days at home(ICCS) (doesn’t need to be consecutive)

Assess frequency, MVV, urgency, wetting, overnight urine production & fluids

Helps with establishing provisional diagnosis

Repeat to assess response to Rx

Uroflow

Normal

Staccato void Infrequent voider

Impact of constipation Constipation can affect bladder function (mechanical and neurological mechanism)

-Change neural stimuli of the bladder and PFM causes progressive decreased urge to evacuate, chronic bladder spasms, incomplete emptying Santos 2017, Chung 2014

-Cause DUI (29%) NE (34%) and recurrent UTI (11%) which resolve with treatment of constipation

→Bowel program successful in 52% ,89% resolution of DUI, 63% NE, no further UTI Loening-

Baucke 1997

Assessing for constipation: Rome IV• 2 of following (weekly for last month)

• -</= 2 defaecations in toilet per week

• -Faecal incontinence

• -Retentive posturing/volitional stool retention

• Painful or hard stools

• Large faecal mass in rectum

• Large diameter stools

Bowel History and assessment Toileting pattern

Frequency of stool

Pain or straining

Stool consistency

Faecal incontinence?

History of constipation

Use of foot support

Diet and fluids

Ultrasound for Rectal Faecal Mass

Joensson I’M et al. J Urol 2008; 179: 1997-2002

Constipation > 3cm Normal <3cm(most<2cm)

Treatment for constipation

Adequate drinking (50ml/kg/day)

Laxative- stimulants and softeners

Assess toilet height/posture/defecation dynamics

Regular toilet sit (gastro colic reflex)

Diet (fibre intake)

Disimpaction and maintenance

Multi modal treatment• Multidisciplinary approach for investigation and intervention

• Urotherapy (education, fluids, regular voiding, bowel program) Austin et al ICCS 2014

• Plus teaching relaxed voiding and optimal toilet posture

→most children respond well Hoebeke 1996,2006; Bachmann 2000; Hagstroem 2008; Bower 2006; Mulders2009

• Typical physical, cognitive, behavioural development & comorbidities

• Consider environmental factors

• Individualised to reflect child and family’s preferences, learning style and cultural beliefs

Multi modal treatment: Adjunctive

Pharmacotherapy: antimuscarinic/alpha blocker

Pelvic floor muscle rehabilitation

Neuromodulation

Clean intermittent catherization

Cognitive behavioural therapy

Overnight drainage if child is polyuric

Surgery

Stable & relaxed toilet posture Wennergren et al 1991

Buttock & foot support

Neutral spine & relaxed

Knees/hips apart/position

Relaxed abdominals→relax PFM

Boys: free penis from clothes

Defecation: Lean forward, squat, knees higher than hips

Minimal effort: peristalsis

26

CFA Victoria

27

Tens

OAB/ Dysfunctional voiding (storage disorders)

Overactive bladder- urgency, frequency, urge countered by posturing or PF contraction; frequent low volume voids;+/- DUI

Dysfunctional voiding: ↑outlet resistance during voiding: bladder neck, urethral sphincter or pelvic floor muscles –change in motor programming → change in motor performance

-staccato or interrupted uroflow (voiding with raised IAP); often PVR and UTI; infrequent voiding Chase

2010 ICCS

OAB/dysfunctional voiding can coexist

Urinary incontinence soon after void in (usually) pre pubertal toilet trained girls or deconditioned girls

Caused by vaginal entrapment of urine

Fusion/adhesion of labia, posterior pelvic tilt

Treatment: Hip adduction with pelvic tilt to allow labia majora separation, careful wiping,(reverse sit),stomp

Giggle Incontinence

Unknown etiology (central disinhibition)

Partial or complete bladder emptying during or immediately after laughing

Bladder function normal without laughter

Misdiagnosis: Children more commonly have leakage with laughter due to OAB, void postponement

Giggle Incontinence

Usually improves with age

Treatment (difficult to treat):

Methylphenidate

Urotherapy especially timed voiding

PFMT with lumbo- pelvic postural correction

Mindfulness

Enuresis

Prevalence

20% 5 yrs 10% 10 yrs3% 15 yrs (Bower et al BrJ Urol 1996)

Spontaneous remission 14% per year (until adolescence)

0.5-2% adults (Hirasing Scand J Urol Nephrol 1997; Yeung BJU Int 2004)

2.4% wet nightly (Sureshkumar et al J Urol 2009)

4% have day and night wetting (Bower et al Brit J Urol 1996)

NE more common in boys (60%) (Bower et al Brit J Urol 1996)

Enuresis is more common in children with:

Daytime lower urinary tract symptoms

Positive family history

Sleep disordered breathing

Obesity

Constipation/faecal incontinence

UTI

Diabetes mellitus/insipidus

Developmental delay, physical/learning disability

Attention difficulties: ASD/ADHD

Sleep arousal difficulties

a reduced ability to wake to noise or to bladder contractions.

Bladder dysfunction

reduced bladder capacity, bladder overactivity or lack of inhibition of bladder emptying during sleep

Nocturnal polyuria and vasopressin deficiency

production of larger than normal overnight urine (often>nocturnal bladder capacity).

Copyright 2018. The Children’s Hospital at Westmead and John Hunter Children’s Hospital

Treatment resistance: understand the reason Address sleep issues, sleep hygiene

Alarm training pitfalls, overlearning

Treat OSA – enuresis resolve in 30-50% Jeyakumar 2012

Improve sleep (melatonin or clonidine), improves the ability to wake to void (useful in combination with other therapy) Ohtomo 2017, Waters 2017

Newer treatments under investigation: newer antimuscarinics –(solifenacin); selective beta 3 agonists (mirabegron), Botulinum toxin A.

TENS

Combination therapies

Multidisciplinary approach

• Improve and normalise physiological function• Improve posture and body awareness for optimal voiding

and defaecation • Teach relaxed voiding • Retrain muscle patterns and coordination for bladder/bowel

emptying• Neuromodulation – TENS for overactive bladder and TENS

interferential for slow transit constipation

Motor control and the developing child Maturation of systems will affect performance in a child

Influencing function:

- Musculoskeletal development

- Posture and postural control and influence on pelvic floor

- Size and geometry of pelvis, thoracic, spine will affect biomechanics and postural control

- Sensory development and influence on motor functioning

- Cognitive and behavioural development

- Influence of predisposing factors and comorbidities to typical development

A tool to visually assess & measure outcomes in a non invasive way for children Bower et al 2006

→PFM function, bladder volume, PVR, rectal diameter

Visualise movement of PFMs-effective lift of bladder base during contraction Sherburn 2005

Good intra & inter-rater reliability in adults Thompson 2011

Education and engagement of child & parent

Snapshot in time

Potential for research

Neuromodulation Parasacral TENS: Favourable results in children with LUTS/OAB Bower 2001; Hoebeke 2001; Barroso 2011; De Gennaro 2011; de Oliveira 2013; Sillen

2014; Borsch 2017; Wright 2017

Cochrane 2016: TENS interferential current for STC Chase 2005; Clarke 2009; Ismail 2009; Clarke 2012; Leong 2011

RCT: TENS increases rectal activity in children with OAB Moeller 2015

Large RCTs needed to understand mechanisms of action, best modality for condition, optimal parameters and long term outcomes

Project developed with NSW Agency for Clinical Innovation

Aim: to improve management and health outcomes for children/young people in NSW with primary urinary incontinence

Outcomes:

Reduce variation in management

Reduce waiting times and improve access to specialists

Involve young people and families in their management

Further education to upskill

Nocturnal enuresis resource kit 2nd edition

Agency for Clinical Innovation: Young People with Urinary Incontinence

International Children’s Continence Society

Continence Foundation of Australia

- Online paediatric continence course

Some cases….

How to cure PNE with 3 visits

8 year old boy with primary enuresis

Wants to be dry for school camps

BG: Enlarged adenoids & snoring, sleep study normal.

FHx: Mother wet until the age of 10yrs

Toilet trained by 3 years

Continence History

Wears pull-ups at night

Wets every night, not waking

Occasional dry night

Never wakes to void

Day time Occasional urgency due to void postponement, prefers to play

No day time wetting

Fluids and Bowels Low daily fluid intake-most drinks after school

Frequently consumes caffeine

Bowels open every 2nd day, type 2-3 stool

Some straining and discomfort.

Reasonable fibre intake

No faecal incontinence.

Toilet too high at home.

Examination

Wt. 22.54 kg, Ht. 125cm. BP 90/40.

Abdominal, neurological and perineal examination –all normal

Normal urine analysis

Treatment Plan

Increase and redistribute fluids to 1L/day

Regular voiding (Listen to your bladder messages)

Bowel program: Monitor, foot support

Bladder diary

Follow up in 1 month.

Fluids 1070mls

MVV = 300mls

Exp 270mls (age+1 x 30)…8yo boy

OUV = 225mls

Exp <350mls

1 month later

Compliant with urotherapy

Increased fluids.

Constipation has improved.

Now 2 dry nights/week, sleeping through

Commenced alarm training and chart progress

→overlearning once he has obtained 14 dry nights.

Case study (2)

14yr old girl, 2 yr h/o DUI with trampolining. Changes pads 2x during training. Voids before/after trampolining.

Normal milestones/exams, toilet trained 3 yrs, no UTIs

RUS: Normal Pre void : 594ml PVR: 4ml

Hgt: 170.3cm Wgt: 74.1kg

s/b urologist, commenced bladder training, voiding 5x day, trialled Vesicare 5mg when trampolining. Urologist requested PFM strengthening

Bowels: daily no pain or strain, type 4, soft abdo

Drinks approx 1.5L/day, likes caffeine drinks

DUI assoc with laughter and urgency

Needs to push to empty bladder

H/o void postponement

Night sleeps through dry

Uroflow: Staccato 687mls PVR 54mls.

DUI related to VP and jumping on trampoline. (?urge/stress)

Case study

Rx: Urotherpy- drinks, TV, PFM Xs, T&V, (+/- vesicare)

6 weeks later:

Only wets with trampolining and only on lift. Dry on Vesicare days.

T&V incomplete: Voids 4x ;Fluids 1250 L; MVV 315

Case study (3)

5 ½ year old boy with day and night wetting, frequency and urgency

Autism spectrum disorder

Toilet timing, drinking and bowel program with continence nurse

Mum concerned re awareness of need to void and not dry with toilet timing

-Oxytrol transdermal patch-Wobl watch-Fluid distributed-bowel programme

- Rewards for drinks- Listen to the watch

2months later-Dry daysSelf-voids

Anticholinergiccimproved void volumeTimed-voiddeveloped awareness & control

Cystic Fibrosis study

Aims:

1. Identify prevalence of daytime wetting in children with CF

2. Identify causes of daytime wetting

3. Assess relationship between daytime wetting and severity of lung disease, age and gender

4. Assess response to treatment

Method

Survey of all children attending CF annual review at a tertiary paediatric hospital

Treatment based on diagnosis:

Standard urotherapy

Pelvic floor muscle training

18% referral to continence service

Followed up every 3 months

Males (%)n = 63

Females (%)n = 79

Total (%) n = 142

Daytime Wetting 6 (10) 23 (29) 29 (20)

Stress urinary incontinence 0 21 21

Overactive Bladder Syndrome 2 0 2

Voiding postponement 1 9 10

Constipation 1 6 7

Other 2 0 2

Nocturnal Enuresis 6 (10) 0 6 (4)

Males (%)n = 63

Females (%)n = 79

Total (%) n = 142

Daytime Wetting 6 (10) 23 (29) 29 (20)

Damp 3 17

Outer clothing 2 5

Puddles 1 2

< 1 x per week 3 9

1 – 3 x per week 2 8

4+ x per week 1 5

Causes of stress incontinence: cough 100% laugh 76% exercise 65%

Results

At 3 months follow up (24 patients)

84% responded

At 6 months follow up (14 patients)

93% responded

No relationship between onset of UI, severity of lung disease and age

Conclusion

Stress incontinence is common in girls with cystic fibrosis

Impacts on cough, exercise and quality of life

Intervention in a clinic setting can be effective

Early intervention may have a positive impact on quality of life and continence as an adult

Acknowledgements:

Gail NankivellSenior Physiotherapist Children’s Hospital at Westmead