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

Evaluation of Children With Urinary Incontinence

Evaluation of the child with urinary incontinence typically begins in the office setting (Figure 2). A thorough medical history will delineate the pattern of incontinence and can identify underlying neurologic or anatomic anomalies. The medical history should include information about the child's voiding habits, including straining, urinary frequency, urination posture, pain with urination, and associated constipation or infection. An obstetric history should be taken to reveal evidence of fetal distress, anoxia, birth trauma, prenatal hydronephrosis, or oligohydramnios. A history of developmental delay, impaired upper or lower motor skills, and associated encopresis raises the suspicion of a neurologic etiology for urinary incontinence. Finally, a family history and social history might be useful in the assessment of underlying medical conditions or stressors that might contribute to urinary incontinence.

If the patient's initial medical history, physical examination, or urine studies suggest an abnormality, a renal and/or bladder ultrasound, and urine flow rate with pelvic floor electromyogram should be obtained. Voiding cystourethrography is reserved for cases in which an anatomic or neuropathic etiology is considered, or when vesicoureteral reflux is suspected. Cystometrography rarely has a role in the evaluation of functional daytime incontinence. This investigation is reserved for severe cases of dysfunctional voiding, and when a neuropathic etiology is considered. Abbreviations: EMG, electromyography; VCUG, voiding cystourethrography.

A 3-day voiding and defecation diary is a useful tool to define the severity and frequency of incontinence episodes, as well as the presence or absence of constipation. The voiding diary should include an assessment of fluid intake.[6,8]

Physical examination should include an inspection of the abdomen, genitalia and spine, as well as a directed neurologic examination, which should include an assessment of lower extremity muscle tone and strength, gait, and symmetry of lower extremity reflexes. The abdomen should be palpated to determine the presence of suprapubic fullness suggestive of bladder distension. A palpable left lower quadrant mass can indicate fecal impaction. A genital examination might disclose the presence of labial adhesions, vulvovaginitis, ectopic ureter, or abnormal urethral position in girls and abnormalities of the urethral meatus in boys. The lower back is inspected for scoliosis as well as stigmata of occult spinal dysraphism, such as sacral dimple, hair tuft, hemangioma, or lipoma. The coccyx should also be examined for evidence of sacral agenesis. The lower extremities and gluteal folds should be evaluated for asymmetry, which might be evidence of tethered cord syndrome.[20]

Urinalysis is an important part of the initial evaluation of children with lower urinary tract dysfunction. Evidence of urinary tract infection, such as bacteriuria or pyuria, might require additional radiographic evaluation. Specific gravity of a first morning urine sample is useful in the evaluation of urine-concentrating ability, while urine glucose levels can identify diabetes mellitus. Presence of hematuria might also elicit additional radiographic or laboratory evaluation.

The need for additional imaging and functional studies is determined by findings from the patient's history and physical examination. Abdominal radiography is useful as an objective measure of constipation. In children with demonstrable neurologic or lumbosacral abnormalities on physical examination, an MRI is required in order to evaluate structural anomalies of the spinal cord.

Renal ultrasound is an excellent screening tool for patients with functional daytime incontinence. Ultrasonography is useful in the detection of structural abnormalities of the kidneys and bladder, such as hydronephrosis, ureterectasis, ureterocele, and bladder wall thickening (Figure 3). Children with recurrent or febrile urinary tract infections or bladder wall thickening, observed on ultrasound, should undergo voiding cystourethrography (VCUG). This procedure allows evaluation for vesicoureteral reflux, and structural abnormalities of the urethra in boys.

Ultrasound showing bladder-wall thickening in a 6-year-old female with recurrent urinary infections, vesicoureteral reflux, and daytime wetting. Normal bladder wall thickness should be less than 2 mm in normal children with a distended bladder; this child has a bladder-wall thickness of 5.2 mm.

VCUG should be used in children with suspected dysfunctional voiding. Children who fail to relax the urethral sphincter during voiding often have a 'spinning top' urethral configuration. This appearance is due to a failure to relax the external sphincter during voiding, causing dilation of the proximal urethra. In children with infrequent voiding, VCUG could reveal a large capacity, smooth-walled bladder with a significant PVR volume. Males with dysfunctional voiding should undergo a careful evaluation of the urethra during the voiding phase, to rule out obstructive abnormalities of the urethra.

A number of physiologic tests are available that evaluate bladder and sphincter function. The urine flow rate is an indirect measure of bladder and sphincter function, which is often used in conjunction with pelvic-floor electromyography, to evaluate pelvic-floor activity during voiding. Invasive urodynamic studies such as cystometrography and videourodynamics rarely add to the management of patients with milder forms of functional incontinence, and should be reserved for those patients with complex forms of functional urinary incontinence such as non-neurogenic neurogenic bladder syndrome.[6,21]

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