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Urinary Incontinence in Children Urinary Incontinence in Children National Kidney and Urologic Diseases Information Clearinghouse What is urinary incontinence (UI) in children? Enuresis Urinary incontinence is the loss of bladder Urinary incontinence is also called enuresis. Types of enuresis include the U.S. Department control, which results in the accidental loss of of Health and urine. A child with UI may not stay dry dur- following: Human Services ing the day or night. Some UI is caused by a • Primary enuresis is wetting in a health problem such as NATIONAL child who has never been consis- INSTITUTES tently dry. OF HEALTH • a urinary tract infection (UTI) • diabetes, a condition where blood glu- • Secondary enuresis is wetting that cose, also called blood sugar, is too high begins after at least 6 months of dryness. • kidney problems • Nocturnal enuresis is wetting that • nerve problems usually occurs during sleep, also • constipation, a condition in which a called nighttime UI. child has fewer than two bowel move- • Diurnal enuresis is wetting when ments a week and stools can be hard, awake, also called daytime UI. dry, small, and difficult to pass • obstructive sleep apnea (OSA), a condi- tion in which breathing is interrupted during sleep, often because of inflamed occasional UI, and treatment is available for or enlarged tonsils most children who have a hard time con- trolling their bladder. Thus, caregivers of • a structural problem in the urinary tract children who wet the bed or have accidents Most of the time, the exact cause of UI is not during the day should approach this problem known, but it is often the result of more than with understanding and patience. one factor. The age at which children achieve dryness Although UI affects many children, it usually varies. Wetting in younger children is com- disappears naturally over time. UI after age mon and not considered UI, so daytime UI 3—the age when most children achieve day- is not usually diagnosed until age 5 or 6, and time dryness—may cause great distress and nighttime UI is not usually diagnosed until embarrassment. Many children experience age 7. How does the urinary tract the two kidneys process about 200 quarts of blood to produce about 1 to 2 quarts of work? urine, composed of wastes and extra water. The urinary tract is the body’s drainage Children produce less urine than adults. The system for removing wastes and extra water. amount produced depends on their age. The The urinary tract includes two kidneys, two urine flows from the kidneys to the bladder ureters, a bladder, and a urethra. The kid- through tubes called ureters. The bladder neys are two bean-shaped organs, each about stores urine until releasing it through urina- the size of a fist. They are located near the tion. When the bladder empties, urine flows middle of the back, just below the rib cage, out of the body through a tube called the one on each side of the spine. Every day, urethra at the bottom of the bladder. Kidney Ureter Bladder Urethra Kidneys Vagina Side view of the female urinary tract Kidney Ureter Ureters Bladder Bladder Urethra Urethra Front view of the urinary tract Side view of the male urinary tract 2 Urinary Incontinence in Children Circular muscles called sphincters help keep What causes nighttime UI? urine from leaking out of the bladder. The The exact cause of most cases of nighttime sphincters close tightly like rubber bands UI is not known. Though a few cases are around the urethra. As the bladder fills with caused by structural problems in the urinary urine, the need to urinate becomes stronger tract, most cases probably result from a mix and stronger, until the bladder reaches its of factors including slower physical develop- limit. Urination is the process of emptying ment, an overproduction of urine at night, the bladder. To urinate, the brain signals and the inability to recognize bladder filling the bladder muscles to tighten, squeezing when asleep. Nighttime UI has also been urine out of the bladder. At the same time, associated with attention deficit hyperactiv- the brain signals the sphincters to relax. As ity disorder (ADHD), OSA, and anxiety. the sphincters relax, urine exits the bladder Children also may inherit genes from one or through the urethra. When all the signals both parents that make them more likely to occur in the correct order, normal urination have nighttime UI. occurs. Babies’ bladders fill to a set point, then auto- Slower Physical Development matically contract and empty. As children Between the ages of 5 and 10, bedwetting get older, their nervous system matures. The may be the result of a small bladder capacity, brain begins to get messages from the filling long sleeping periods, and underdevelop- bladder and begins to send messages to the ment of the body’s alarms that signal a full bladder to keep it from automatically emp- or emptying bladder. This form of UI fades tying until children can reach a toilet. UI away as the bladder grows and the natural results when communication problems occur alarms become operational. between the brain and bladder; these prob- lems can range from simple to complex. Overproduction of Urine at Night How common is UI in The body produces antidiuretic hormone children? (ADH), a natural chemical that slows down the production of urine. More ADH is pro- By 5 years of age, more than 90 percent of duced at night so the need to urinate lessens. children can control urination during the If the body does not produce enough ADH day. Nighttime wetting is more common at night, the production of urine may not than daytime wetting in children, affecting slow down, leading to bladder overfilling. If 30 percent of 4-year-olds. The condition a child does not sense the bladder filling and resolves itself in about 15 percent of children awaken to urinate, wetting will occur. each year; about 10 percent of 7-year-olds, 3 percent of 12-year-olds, and 1 percent of 18-year-olds continue to experience night- time wetting.1 1Urinary Incontinence in Children (Enuresis). The Merck Manuals Online Medical Library. http:// www.merckmanuals.com/professional/pediatrics/ incontinence_in_children/urinary_incontinence_in_ children.html. Updated August 2009. Accessed April 13, 2012. 3 Urinary Incontinence in Children Structural Problems Anxiety A small number of UI cases are caused Anxiety-causing events that occur between by physical problems in the urinary tract. 2 and 4 years of age—before total bladder Rarely, a blocked bladder or urethra may control is achieved—might lead to primary cause the bladder to overfill and leak. Nerve enuresis. Anxiety experienced after age 4 damage associated with the birth defect spina might lead to secondary enuresis in children bifida can cause UI. In these cases, UI can who have been dry for at least 6 months. appear as a constant dribbling of urine. Events that cause anxiety in children include physical or sexual abuse; unfamiliar social Attention Deficit Hyperactivity situations, such as moving or starting at a Disorder new school; and major family events such as Children with ADHD are three times more the birth of a sibling, a death, or divorce. likely to have nighttime UI than children UI itself is an anxiety-causing event. Strong 2 without ADHD. The connection between bladder contractions resulting in daytime ADHD and bedwetting has not been leakage can cause embarrassment and anxi- explained, but some experts theorize that ety that lead to nighttime wetting. both conditions are related to delays in cen- tral nervous system development. Genetics Obstructive Sleep Apnea Certain genes have been found to contribute to UI. Children have a 30 percent chance Nighttime UI may be one sign of OSA. of having nighttime UI if one parent was Other symptoms of OSA include snoring, affected as a child. If both parents were mouth breathing, frequent ear and sinus affected, there is a 70 percent chance of infections, sore throat, choking, and daytime bedwetting.1 drowsiness. Experts believe that when the airway in people with OSA closes, a chemical may be released in the body that increases What causes daytime UI? water production and inhibits the systems Daytime UI can be caused by a UTI or struc- that regulate fluid volume. Successful treat- tural problems in the urinary tract. Daytime ment of OSA often resolves the associated UI that is not associated with UTI or struc- nighttime UI. tural problems is less common and tends to disappear much earlier than nighttime UI. Overactive bladder and infrequent or incom- plete voiding, or urination, are common causes of daytime UI. 2Shreeram S, He JP, Kalaydjian A, Brothers S, Merikangas KR. Prevalence of enuresis and its association with attention-deficit/hyperactivity disorder among U.S. children: results from a nationally representative study. Journal of the American Academy of Child and Adolescent Psychiatry. 2009 Jan;48(1):35–41. 4 Urinary Incontinence in Children Overactive Bladder How is UI in children Overactive bladder is a condition in which a treated? child experiences at least two of the follow- Most UI fades away naturally as a child ing conditions: grows and develops and does not require • urinary urgency—inability to delay treatment. When treatment is needed, urination options include bladder training and related strategies, moisture alarms, and medications. • urge urinary incontinence—urinary leakage when the bladder contracts Growth and Development unexpectedly As children mature • urinary frequency—urination eight or more times a day or more than twice at • bladder capacity increases night • natural body alarms become activated Infrequent or Incomplete • an overactive bladder settles down Voiding • production of ADH becomes normal Infrequent voiding is when children volun- • response to the body’s signal that it is tarily hold urine for prolonged periods of time to void improves time.
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