Primer: Diagnosis and Management of Uncomplicated Daytime Wetting in Children

Vijaya M Vemulakonda; Eric A Jones

Disclosures

Nat Clin Pract Urol. 2006;3(10):551-559. 

In This Article

Etiology of Daytime Wetting in Children

Unlike in the adult population, where the inability to maintain urinary voiding control is almost always pathologic, urinary incontinence in children must be evaluated within the context of the child's developmental age. The impact of voiding control on social interaction and function evolves as a child progresses through their first years of life and is influenced by social, cultural, and environmental factors.

In the infant (less than 1 year old), micturition occurs via a reflex mechanism mediated by the spinal cord. During bladder filling, the bladder reaches an intrinsic volume threshold, which triggers a spontaneous bladder contraction. This vesicovesical reflex coordinates relaxation of the bladder neck and external urethral sphincter. Voiding is complete, occurs at low pressures, and is autonomous. Owing to the low volume threshold for urination, an infant voids approximately 20 times per day.[1]

As the young child develops (generally between the ages of 1 and 2 years), neural pathways in the spinal cord mature, and the vesicovesical reflex is suppressed. A more complex voiding reflex develops, with the coordination of voiding control mediated by the pons and midbrain. During this transitional phase, functional bladder capacity increases, and urination becomes less frequent. By the age of 2 years, most children void 10 to 12 times per day, are aware of bladder fullness, and can announce their need to urinate.[2] Between 2 and 3 years of age, children can volitionally postpone voiding, and can initiate voiding at bladder volumes below capacity. During this period, the child develops a stable, quiescent bladder, and an adult pattern of daytime urinary control emerges.

As with other developmental milestones, the time course for attaining urinary continence varies. The majority of children have volitional urinary control by the age of 5, before they enter school. Beyond this age, incontinence becomes of increasing social concern. Brazelton and colleagues found that 26% of children achieved daytime continence by the age of 24 months, 52.5% by 27 months, 85% by 30 months, and 98% by 3 years of age.[3] Bloom and colleagues, in their study of 1,186 healthy children, found that toilet training occurred between 0.75-5.25 years of age, with a mean age of 2.4 years at the completion of toilet training. In their study, they found that toilet training occurred slightly earlier in girls than in boys.[4] Hellstrom and associates, however, found that the incidence of diurnal incontinence was higher in 7-year-old girls (6%) than in similar-aged boys (3.8%).[5]

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