Daytime Incontinence

Basics

Description

  • Daytime wetting in a child ≥5 years of age warrants evaluation.
  • Causes of functional incontinence include an array of bladder storage and voiding disorders.
  • Voiding dysfunction is abnormal behavior of the lower urinary tract without a recognized organic cause, generally in the form of pelvic floor hyperactivity or bladder–sphincter discoordination.
  • Bowel bladder dysfunction (BBD) describes the association between abnormal bladder and bowel behavior.

Epidemiology

Prevalence

  • Studies in children 6 to 7 years of age have shown that 3.1% of girls and 2.1% of boys had an episode of wetting at least once per week.
  • Daytime incontinence is 2 to 5 times more common in girls than boys from age 7 years to adolescence.
  • Spontaneous cure rate of 14% per year without treatment
  • Of all children who wet, 10% have only daytime wetting, 75% wet only at night, and 15% wet during the day and at night.

Risk Factors

  • Constipation
  • Recurrent urinary tract infections (UTIs)
  • Diabetes mellitus/diabetes insipidus
  • Attention deficit disorder (ADD)/attention deficit hyperactivity disorder (ADHD)
  • Neurodevelopmental conditions
  • Developmental delay
  • Obesity
  • History of abuse

Genetics

  • Only anecdotal relationships have been seen in functional daytime incontinence, unlike studies showing genetic tendencies in nocturnal enuresis.
  • Increased rates of daytime wetting have been reported in:
    • Urofacial (Ochoa) syndrome, an autosomal recessive condition
    • Williams syndrome, which is the result of a deletion involving the elastin gene in chromosome 7

Pathophysiology

  • Detrusor instability or over active bladder (OAB), which results from involuntary and uninhibited detrusor contractions during bladder filling
  • Dysfunctional voiding, or detrusor sphincter discoordination, caused by incomplete relaxation of the pelvic floor muscles during urination and often resulting in incomplete bladder emptying
  • Detrusor underactivity characterized by a large capacity, hypotonic bladder. This condition may be the result of longstanding dysfunctional voiding or voiding postponement.
  • Neurogenic bladder

Etiology

  • Bladder irritability caused by UTI
  • Constipation
  • Increased urinary output—polyuria
  • Infrequent or deferred voiding
  • Overactive bladder
  • Low functional bladder capacity, with detrusor instability during filling
  • Vaginal reflux
  • Giggle incontinence
  • Temperamental factors (e.g., short attention span, inattentiveness to body signals) in children who ignore the urge to void
  • Developmental differences in age at which toilet training is achieved
  • Obstructive uropathy (e.g., posterior urethral valves)
  • Neurogenic bladder (e.g., myelomeningocele)
  • Anatomic anomalies (e.g., ectopic ureter)

Commonly Associated Conditions

  • Constipation (common)
  • Nocturnal enuresis (common)
  • UTIs (common)
  • Vesicoureteral reflux is more common in children with voiding dysfunction due to elevated detrusor pressures that overcome a marginal vesicoureteral junction.

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