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

Treatment Options for Pediatric Patients

Treatment should be chosen according to the cause of the incontinence. The different treatment options and their efficacies are summarized in Table 1 . As with nocturnal enuresis, many children outgrow daytime incontinence. Saedi and associates, in their study of 90 patients with daytime wetting, found that 91% had spontaneous resolution of their incontinence with a median time of 2.9 years. Maturation was thought to be the most important factor in improvement of voiding habits.[22] As a result, close monitoring and support of patients with functional incontinence is a cornerstone of treatment for children with uncomplicated daytime wetting.

Behavioral modification has remained the mainstay of treatment for daytime wetting. These measures focus on relearning and training the normal responses from the bladder and urethra. Bladder irritants such as caffeine should be eliminated from the diet. In children with underactive bladder, urge incontinence, and dysfunctional voiding, voiding at predetermined times aids in retraining the child to exercise voluntary bladder control. The child voids on waking, and subsequently at least every 2 h, during waking hours. As urgency improves, the interval between voids can be extended. In children with infrequent voiding, in whom an elevated PVR volume is encountered, double voiding will both increase functional bladder capacity and decrease the risk of infection.

Timed voiding alone has been successful in 30-50% of patients with dysfunctional voiding.[23] Wiener and colleagues showed that a combination of timed voiding, modification of fluid intake, pelvic-floor exercises, and voiding diaries improved daytime urinary control in 60% of patients.[24]

In children with poor bladder emptying, clean intermittent catheterization (CIC) is the treatment of last resort, used to decrease the frequency of recurrent infections and regain urinary continence. Pohl and associates treated 23 children who were neurologically and anatomically normal with CIC. Of the 23 patients, 16 successfully started CIC within 2 weeks of initial instruction, and remained on CIC for a mean of 4 months. All children who remained on CIC were dry, with three girls voiding normally and with normal PVR volumes within 6 months of treatment.[25]

Medical therapy can also be used in conjunction with bladder retraining, although medication should not be used as a replacement for behavioral therapy.[26]

Anticholinergic Agents. Anticholinergic treatment focuses on mediation of involuntary detrusor contraction. Medical treatment with anticholinergic agents has been shown to significantly improve or resolve urge incontinence in children, and most patients who have a continued durable response to these agents can stop medical therapy within 6 months of initiation.[19] In a study by Curran and colleagues, 26 of 30 patients treated with oxybutynin, hyoscyamine, or imipramine had significant improvement or resolution of their daytime incontinence; however, 38% of patients continued to be dependent on medication to stay dry at a mean follow-up period of 4.7 years.[27] Anticholinergic treatment seems to be most effective in patients who have 50-90% of the bladder capacity expected for their age.[28]

Oxybutynin chloride has been the most-studied anticholinergic agent in the pediatric population. Oxybutynin has antispasmodic effects and is often used in children with detrusor overactivity. Adverse effects associated with this treatment include dry eye, dry mouth, dysphagia, blurred vision, constipation, headache, transient urinary retention, and drowsiness. Oxybutynin crosses the blood-brain barrier and, therefore, children could also experience nightmares or personality changes. Adverse effects occur more frequently in children than in adults,[29] although the incidence of significant adverse events in children is less than 5%.[30] In a study by Hjalmas and associates, 70% of children with functional daytime incontinence improved significantly.[30] Randomized, controlled studies, however, have not shown a significant improvement in functional daytime wetting in children treated with oxybutynin.[31]

Alpha-adrenergic Antagonists. Alpha-adrenergic antagonist therapy has been studied as a treatment for children with pelvic-floor overactivity. Therapy aims to reduce bladder-outlet resistance, although studies suggest that alpha-adrenergic antagonists might also increase functional bladder capacity.[32] Austin et al. studied the use of doxazosin in 17 children, 12 of whom had evidence of non-neurogenic dysfunctional voiding. Of the children treated, 82% showed a significant improvement in symptoms, and 71% had a reduction in their PVR urine volume. All patients with uninhibited detrusor contractions experienced resolution of their symptoms, and symptoms in patients with evidence of detrusor-sphincter dyssynergia improved with therapy. All three children who failed to respond to treatment had evidence of non-neurogenic neurogenic bladder syndrome. Adverse events were minimal; only one child experienced mild postural hypotension, which resolved with dose reduction.[33] Although alpha-adrenergic antagonist therapy has not been studied extensively, it seems to be safe in children, and effective in treating children with dysfunctional voiding.

Tricyclic Antidepressants. Imipramine has been shown to have anticholinergic and antispasmodic effects,[34] and can improve awareness of bladder fullness.[26] Tricyclic antidepressants are, however, associated with significant adverse effects, including anxiety, nausea, insomnia, and personality changes. An overdose of tricyclic antidepressants can cause cardiac arrhythmia, hypotension, and convulsions, and in some cases can lead to death.[35] Furthermore, controlled studies of imipramine have failed to show a significant benefit over placebo in the treatment of urge incontinence or voiding dysfunction.[36] Although tricyclic antidepressants have been used extensively in children with nocturnal enuresis, they have a limited role in the treatment of daytime wetting in children.

Pelvic-floor biofeedback training has been used successfully in patients with pelvic-floor dysfunction. Children are taught to relax while voiding by sitting with the thighs spread apart and bending forward slightly. A bench or stool can be placed under the feet of smaller children to aid in relaxation. For a biofeedback program to be successful, however, the patient's participation and interest are required.[37,38] Porena and colleagues showed that biofeedback therapy was successful in treating children with functional detrusor-sphincter dyssynergia. Children who completed therapy had shorter voiding times, decreased PVR volumes, and quiescent pelvic-floor musculature during voiding, when compared to baseline.[39] Similarly, Chin-Peuckert and colleagues reported that 61% of their patients treated with biofeedback for detrusor-sphincter dyssynergia demonstrated durable improvement in symptoms at a mean follow up of 9 months.[40]

Interactive video games have been developed to aid in biofeedback training. Golf, basketball, and spaceship games, among others, have been developed that link the game scores to the patient's ability to contract and relax the pelvic-floor musculature. Use of these games resulted in a symptomatic improvement of up to 89% and cure rates of 61% in patients with daytime incontinence.[38] Factors associated with poor results include a small bladder capacity and patient noncompliance.[41]

Treatment of underlying constipation should be used in conjunction with primary treatment for daytime wetting. Loening-Baucke found that treatment of constipation alone led to resolution of urinary incontinence in 89% of children with functional incontinence.[12] The goal of treatment for constipation is to cleanse the bowel of impacted stool, and promote a soft, daily bowel movement. Enemas or laxatives are often used for initial bowel evacuation, followed by a maintenance program with either oral fiber supplementation or polyethylene glycol. Fiber supplements promote retention of water in the stool, which facilitates intestinal transit and defecation. Polyethylene glycol acts as a simple osmotic laxative.

A study of 55 patients with dysfunctional elimination treated with polyethylene glycol showed that 45 patients had resolution of their constipation and 44 had resolution or significant improvement of their urinary incontinence.[42] Although constipation should initially be treated medically, long-term control should include bowel training and a high-fiber diet. Bowel training requires maintenance of a defecation routine and parental support and encouragement. Use of these measures allows the majority of patients to remain free from both constipation and urinary incontinence symptoms.[43]

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