Daytime Incontinence in Children

1. Daytime Incontinence in Children Dr Steven McTaggart Queensland Child & Adolescent Renal Service Royal Children’s and Mater Children’s Hospitals Brisbane. Paediatric Society of Queensland Meeting Friday 12 October, 2012

2. Children rated wetting themselves at school as the third most catastrophic event behind losing a parent and going blind. Ollendick et al, Behav Res Therapy, 1989.

3. ?A Mental Illness Enuresis – DSM V Repeated voiding of urine into bed or clothes (whether involuntaryor intentional). The behaviour is clinically significant as manifested by either afrequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairmentin social, academic (occupational), or other important areas offunctioning. Chronological age is at least 5 years (or equivalent developmentallevel). The behaviour is not due exclusively to the direct physiologicaleffect of a substance (e.g., a diuretic or an antipsychotic medication) or another medicalcondition (e.g., diabetes, spina bifida, a seizure disorder).

4. Outcomes Vemulakonda VM and Jones EA (2006) Nat Clin Pract Urol3:551–559

5. International Childrens Continence Society Classification (2006)

6. Case Study • 10 year old girl - Referred from GE Clinic • Long-standing patient of regional paediatrician • Chronic constipation • multiple investigations and treatment incl 4 previous admissions for washout • Daytime incontinence and nocturnal enuresis

7. Evaluation - History Age and pattern of toilet training longest dry periods - primary vs secondary Toilet trained 2 years age Dry during day for 2 months - never been dry since then Wets daily – never dry at night Current symptoms and signs voiding pattern - stream/volume/frequency/post-void dribbling Wears pad during the day – always damp but rarely soaks through to clothes Frequent voiding – up to 8x/day at school – ?small vols No post-void dribbling Not continuously wet → Consider Voiding Diary

8. Voiding Diary (http://childrenshospital.org/clinicalservices/Site2852/Documents/voidind_diary.pdf)

9. Voiding Diary App

10. Ectopic Ureter

11. Evaluation - History urgency / holding manoeuvres perineal hygiene - vulvovaginitis/balanitis dysuria / frequency / UTI’s Previously recurrent UTI – none for 3 years

12. Evaluation - History • CONSTIPATION • Constipation with soiling since 2 years age • Multiple unsuccessful treatments • Does not use school toilets • ‘withholding’ behaviour • Family history of urological problems • Nil • Developmental / behavioural issues • Social history - think about CSA

13. Evaluation - Physical Exam • Exclude structural lesions • Abdominal examination • Genital examination • labial adhesions/meatal stenosis • bifid clitoris • Exclude occult neurological disorders • examine back for signs of occult spina bifida • DTR’s lower limbs • gait • ?anal wink

14. Evaluation - Investigations • Urinalysis - dipstick, M/C/S, (urine osmolality) • Ultrasound • estimate functional bladder capacity & residual • IVP/CT urogram if suspect ectopic ureter • MCU • if abnormal USS esptrabeculation/thickened bladder wall • Spinal imaging – not routine • Urodynamics – not routine

15. Evaluation - Role of Spinal Imaging • Wraige E & Borzyskowski M, Arch Dis Child, 2002 • retrospective study - 48 children with voiding dysfunction • closed spina bifida present in 5 patients - only 1 had no cutaneous, neuro-orthopaedic or lumbosacral spine abnormalities. • Nejat et al, Pediatr 2008 • 176 children with encoporesis/enuresis - 88 with SBO and 88 control • 17 (38%) bony spina bifida occulta • 10/48 underwent MRI - 1 had lipoma requiring resection

16. Recommendations for Spinal Imaging • neurological /neuro-orthopaedic abnormality • secondary enuresis or deterioration in primary enuresis • significant associated bowel abnormality • urodynamic study suggesting neurogenic bladder

17. Evaluation - Urodynamic Studies • Not required for majority of children • Indicated if; • evidence of/at risk of upper tract deterioration • hydroureteronephrosis • high grade VUR • recurrent episodes of pyelonephritis • suspicion or evidence of neurological abnormality • ?significant daytime enuresis that fails to respond to conventional treatment • (unexplained secondary enuresis - cystoscopy is preferable)

18. Diagnosis – Functional Voiding Disorders Stress Incontinence Underactive bladder Voiding postponement / “holding” Extreme Daytime Frequency Dysfunctional voiding Urge syndrome

19. General Principles of Treatment Urotherapy Pharmacological

20. Management • Urotherapy • Timed voiding, posture, avoiding holding • Lifestyle – fluid intake • Biofeedback / physiotherapy • Pharmacological • Anticholinergics • oxybutinin tabs / patches (Ditropan™) • tolteridine (Detrusitol™) • solenifacin (Vesicare™) • (Tricyclic antidepressants) • ? prazosin / ? ddAVP (Minirin™)

21. Bladder Retraining “Bad” bladder behaviour Imbalance in “inhibiting” and “initiating” voiding

22. Pharmacological Management

23. Management • Urotherapy • Timed voiding, posture, avoiding holding • Lifestyle – fluid intake • Biofeedback / physiotherapy • Pharmacological • Anticholinergics • oxybutinin tabs / patches (Ditropan™) • tolteridine (Detrusitol™) • solenifacin (Vesicare™) • (Tricyclic antidepressants) • ? prazosin / ? ddAVP (Minirin™) ? combination therapy

24. Outcomes Vemulakonda VM and Jones EA (2006) Nat Clin Pract Urol3:551–559

25. Long Term Outcome • Kuh et al, 1999. • Longitudinal study of 1333 women with urinary incontinence (mean age 48 years) • 50% reported stress incontinence • 22% reported urge incontinence • 8% had severe symptoms • Women who had daytime wetting as a child were more likely to have severe symptoms

26. The End