A Quick Guide to Paediatric Urinary Incontinence

Though paediatric urinary incontinence may be concerning for the child and parent(s) involved, it's quite common – and it’s very likely that you will frequently encounter this issue in your work.

Typically, a child will have achieved daytime bladder control by the age of four (Continence Foundation of Australia 2020). When this doesn’t occur, and a child is still prone to wetting at inappropriate times or during the night, intervention is required.

Urinary incontinence can have a significant negative impact on a child’s psychosocial wellbeing and affect their day-to-day life. Fortunately, there are many treatment options available.

This article will discuss the presentation and treatment of paediatric urinary incontinence.

What is Paediatric Urinary Incontinence?

Paediatric urinary incontinence refers to the inability of a child to control their bladder, which results in wetting (Continence Foundation of Australia 2020).

Children usually attain continence during the day by the age of four. Nighttime continence usually takes longer to achieve and generally occurs by the age of seven or eight (Continence Foundation of Australia 2020, 2022).

Note: These age indicators may not be applicable to children with developmental delay, and are therefore based on children who are developing typically (Figueroa 2018).

Paediatric urinary incontinence is separated into two distinct categories:

1. Diurnal incontinence (day wetting)

Diurnal incontinence (or day wetting) is urinary incontinence during the day, which is not diagnosed until after the age of five (RCHM 2018).

2. Nocturnal enuresis (bed-wetting)

Enuresis (or bed-wetting) is urinary incontinence at night (Continence Foundation of Australia 2022).

How Common is Paediatric Urinary Incontinence?

• Statistics show that around 17 to 20% of children experience urinary incontinence during the day, and a further 6.6% of children will also have problems at night.
• This steadily decreases as children move toward adolescence; rounding to 1% by the age of 18.
• It is estimated that roughly 0.5% of adults continue to experience bedwetting at night.
• Nighttime wetting is more common among boys and when there is a known family history.

(Nankivell & Caldwell 2014; Figueroa 2018)

Physiology of Paediatric Urinary Incontinence

Paediatric urinary incontinence is defined as the involuntarily voiding of urine at least once per month for at least three months in a child over the age of five (RCHM 2018).

As is understood, the bladder has a dual function: to store and eliminate urine. Paediatric urinary incontinence occurs when the child is unable to carry out the following actions:

• Throughout the day, responding to the sensation of fullness in their bladder, the child will contract their detrusor muscle as they relax their urinary sphincters and pelvic floor muscles – this permits the stream of urine until the bladder is emptied
• At night, the child should be able to sleep without needing to urinate, but still possess the ability to wake up and void when they sense bladder fullness.

How Does Paediatric Urinary Incontinence Present?

Common problems that are to be observed are:

• Leakage: This occurs when the child is prone to avoiding going to the toilet and wets when the bladder overfills.
• Overactive bladder: the child’s bladder is struggling to store urine. The child may express urgency, they may urinate while trying to get to the toilet and will need to void up to or more than eight times per day.
• Underactive bladder: the child goes to the toilet infrequently, less than four times a day, and sometimes urine escapes. Urinary tract infection is common in these cases.
• Partial emptying of the bladder: the child has not grasped how to completely empty their bladder.

(Continence Foundation of Australia 2020)

Urinary Tract Infections (UTIs)

Urinary tract infections, constipation and stress should be considered as possible contributing factors of urinary incontinence (Raising Children Network 2020).

Often, children will present with other lower urinary tract (LUT) symptoms such as:

• A weak stream
• Urgency presenting in the sudden and unpredictable need to void
• Urge incontinence, an inability to suppress voiding with urgency
• Heightened or lessened voiding frequency
• Straining
• Holding manoeuvres, including crossing their legs, standing on tip-toes or squatting.

(Nankivell & Caldwell 2014)

Treatment and Management Options

If urinary incontinence is suspected, the child should first be assessed by a general practitioner (GP). The GP will undertake a physical examination of the child’s abdomen, lower back and genitals and may also test the child’s urine (Raising Children Australia 2020).

There are several options available for the treatment and management of paediatric urinary incontinence.

The first-line treatment for children with this condition is usually urotherapy - a nonpharmacological and nonsurgical intervention that involves behaviour modification (Raising Children Australia 2020).

Urotherapy involves:

• Education on normal lower urinary tract function
• Advice on regular voiding habits and voiding posture
• Lifestyle advice regarding fluid intake and constipation prevention
• Bladder diaries and/or frequency-volume charts
• Constipation management.

(Nankivell & Caldwell 2014; Raising Children Network 2020)

Other potential interventions include alarm training (placing wetness sensors under the bedsheets or in the child's underpants to wake them up when they are wet) and prescribed medications such as desmopressin may also be recommended (Nankivell & Caldwell 2014).

Family education about the cause and clinical course of incontinence is important in order to reduce stigma and assist with treatment.

Prevention of Paediatric Urinary Incontinence

Incontinence can, in most cases, be prevented by learning and practising particular healthy habits.

To prevent any form of incontinence, it's important to encourage the child to be physically active, learn and practice good toilet habits, drink plenty of fluids, and overall endeavour to make and maintain a healthy lifestyle.

When to Refer

Children may need to be referred to a specialist if:

• They show severe daytime symptoms
• They frequently contract urinary tract infections
• They experience physical or neurological problems and psychosocial or other co-occurring conditions that require further management
• Initial treatment strategies have not been successful after roughly six months.

(Nankivell & Caldwell 2014)

Conclusion

Paediatric diurnal incontinence and enuresis are frequently encountered in general practice, as they are common issues in school-aged children.

Effective treatment is enormously beneficial for the child, their wellbeing and their self-esteem. The stigma surrounding urinary incontinence should not be underestimated.

To determine the most effective treatment and to reach an accurate diagnosis, a detailed assessment of family history and examination are crucial.