Urinary Incontinence in children

Dr Ritu Datta

VMO Paediatrician Blue Mountains Hospital Background

 Bowel and bladder dysfunction in children is common

 Childhood incontinence is a medical problem

 Untreated it can progress to adulthood causing significant problems

 Potential for long term damage to the upper urinary tracts & GI tract if not properly assessed

 Incontinence that begins in childhood is different to incontinence that develops in adulthood

 Different aetiology, physiology and treatment Prevalence

 Not all children grow out of it

 10% of healthy schoolchildren age 10-14yrs report incontinence

 Daytime wetting varies between 30% at age 4 to 1.8% 15-17yrs

 0.5-2% of enuretics carry it to adulthood

 OAB in childhood 16-17%

 Overall constipation prevalence of approx. 9%

 Approx. 30% of children with constipation carry it to adulthood Some facts….

 Higher rates of incontinence in children with co-morbidities eg ADHD, developmental delay, neuro psychiatric disorders

 More difficult to treat, more likely to relapse

 Less compliant, poorer outcomes

 Need to treat co-morbid behavioural problems separately to incontinence

 Short Screening Instrument for Psychological Problems in Enuresis: (SSIPPE)- validated questionnaire Facts

 Incontinence impacts health, quality of life and health costs

 Many children have low self esteem, anxiety and other psychological problems  resolve once child becomes dry

5 years Urge incontinence (overactive bladder) • Urge • Frequency more than 7 times per day • Small volume voided

Voiding postponement • Infrequent micturition (< 5 times per day) • Postponement

Dysfunctional voiding • Straining to initiate and during micturition • Interrupted stream of urine Stress incontinence • Wetting during coughing, sneezing • Small volumes

Giggle incontinence • Wetting during laughing • Large volumes with apparently complete Emptying

Detrusor under activity • Interrupted stream • Emptying of bladder possible only by straining Developmental milestones

 1-2 years develop conscious sensation of bladder filling

 2-3 years develop ability to void or inhibit voiding voluntarily

 Social consciousness

 4+ years most have adult pattern of urinary control and are dry day & night Normal bladder function

 Bladder filling begins

 Low detrusor pressure during storage phase

 Detrusor distension activates stretch receptors

 Perception of fullness via neural interplay

 Cortical ‘motivation’ of desire to void

 Voluntary initiation of micturition by −Detrusor muscle contraction + relaxation of pelvic floor & ext urethral sphincter  strong continuous urine flow & bladder emptying  General medical history including comorbidities

 Family history of urinary incontinence

 Urinary symptoms

 Bowel history

 Fluid intake and diet, caffeine

 Toileting patterns

 Sleep history

 General health

 Home, school and family situation Assessment contd….

 Physical examination (abdominal, neurological, genitalia)

 Investigations (UA, uroflow/post void scan, pre- & post void Renal US)

 Bladder/bowel diary

 Behavioural assessment Outcomes: resolution of symptoms and signs

• Incontinence episodes • Urgency • UTIs • Normalise bladder storage and emptying (PVR) • Pelvic floor relaxation during void pattern (uroflow) • Normalise PFM capabilities • Normalise bowel function • Grade VUR; bladder wall changes • QoL /psychological effects  Continuous urine leakage

 Psychosocial well being at risk

 Refractory incontinence (treatment failure after 6 months)

 History of recurrent UTIs

 Severe daytime symptoms (voiding symptoms, genital or LUT pain)

 Known or suspected physical or neurological problems

 Comorbid conditions eg FI or diabetes

 Significant attention, developmental, behavioural or emotional problems

 Family problems or vulnerabilities What’s normal?

 Expected bladder capacity:(Age in yrs+ 1) x 30 (up to 390mls)

 VV:65-159% of EBC

 Frequency: 4-7x/p day

 Nocturnal urine output: <130% EBC Bladder diary…

 crucial for assessment of LUT function in children

 Baseline info 24hr over 3 normal days at home(ICCS) (doesn’t need to be consecutive)

 Assess frequency, MVV, urgency, wetting, overnight urine production & fluids

 Helps with establishing provisional diagnosis

 Repeat to assess response to Rx Uroflow

Normal

Staccato void Infrequent voider Impact of constipation

 Constipation can affect bladder function (mechanical and neurological mechanism)

-Change neural stimuli of the bladder and PFM causes progressive decreased urge to evacuate, chronic bladder spasms, incomplete emptying Santos 2017, Chung 2014

-Cause DUI (29%) NE (34%) and recurrent UTI (11%) which resolve with treatment of constipation

→Bowel program successful in 52% ,89% resolution of DUI, 63% NE, no further UTI Loening- Baucke 1997 Assessing for constipation: Rome IV

• 2 of following (weekly for last month)

• -

• -Faecal incontinence

• -Retentive posturing/volitional stool retention

• Painful or hard stools

• Large faecal mass in rectum

• Large diameter stools Bowel History and assessment

 Toileting pattern

 Frequency of stool

 Pain or straining

 Stool consistency

 Faecal incontinence?

 History of constipation

 Use of foot support

 Diet and fluids Ultrasound for Rectal Faecal Mass

Constipation > 3cm Normal <3cm(most<2cm)

Joensson I’M et al. J Urol 2008; 179: 1997-2002 Treatment for constipation

 Adequate drinking (50ml/kg/day)

 Laxative- stimulants and softeners

 Assess toilet height/posture/defecation dynamics

 Regular toilet sit (gastro colic reflex)

 Diet (fibre intake)

 Disimpaction and maintenance Multi modal treatment • Multidisciplinary approach for investigation and intervention

• Urotherapy (education, fluids, regular voiding, bowel program) Austin et al ICCS 2014

• Plus teaching relaxed voiding and optimal toilet posture

 →most children respond well Hoebeke 1996,2006; Bachmann 2000; Hagstroem 2008; Bower 2006; Mulders 2009

• Typical physical, cognitive, behavioural development & comorbidities

• Consider environmental factors

• Individualised to reflect child and family’s preferences, learning style and cultural beliefs Multi modal treatment: Adjunctive

 Pharmacotherapy: antimuscarinic/alpha blocker

 Pelvic floor muscle rehabilitation

 Neuromodulation

 Clean intermittent catherization

 Cognitive behavioural therapy

 Overnight drainage if child is polyuric

 Surgery 26

Stable & relaxed toilet posture Wennergren et al 1991

 Buttock & foot support

 Neutral spine & relaxed

 Knees/hips apart/position

 Relaxed abdominals→relax PFM

 Boys: free penis from clothes

 Defecation: Lean forward, squat, knees higher than hips

 Minimal effort: peristalsis CFA Victoria 27 Tens OAB/ Dysfunctional voiding (storage disorders)

 Overactive bladder- urgency, frequency, urge countered by posturing or PF contraction; frequent low volume voids;+/- DUI

 Dysfunctional voiding: ↑outlet resistance during voiding: bladder neck, urethral sphincter or pelvic floor muscles –change in motor programming → change in motor performance

-staccato or interrupted uroflow (voiding with raised IAP); often PVR and UTI; infrequent voiding Chase 2010 ICCS

 OAB/dysfunctional voiding can coexist  Urinary incontinence soon after void in (usually) pre pubertal toilet trained girls or deconditioned girls

 Caused by vaginal entrapment of urine

 Fusion/adhesion of labia, posterior pelvic tilt

 Treatment: Hip adduction with pelvic tilt to allow labia majora separation, careful wiping,(reverse sit),stomp Giggle Incontinence

 Unknown etiology (central disinhibition)

 Partial or complete bladder emptying during or immediately after laughing

 Bladder function normal without laughter

 Misdiagnosis: Children more commonly have leakage with laughter due to OAB, void postponement Giggle Incontinence

 Usually improves with age

 Treatment (difficult to treat):  Methylphenidate  Urotherapy especially timed voiding

 PFMT with lumbo- pelvic postural correction

 Mindfulness Enuresis Prevalence

 20% 5 yrs 10% 10 yrs 3% 15 yrs (Bower et al BrJ Urol 1996)  Spontaneous remission 14% per year (until adolescence)  0.5-2% adults (Hirasing Scand J Urol Nephrol 1997; Yeung BJU Int 2004)

 2.4% wet nightly (Sureshkumar et al J Urol 2009)

 4% have day and night wetting (Bower et al Brit J Urol 1996)

 NE more common in boys (60%) (Bower et al Brit J Urol 1996) Enuresis is more common in children with:

 Daytime lower urinary tract symptoms  Positive family history  Sleep disordered breathing  Obesity  Constipation/faecal incontinence  UTI  Diabetes mellitus/insipidus  Developmental delay, physical/learning disability  Attention difficulties: ASD/ADHD  Sleep arousal difficulties  a reduced ability to wake to noise or to bladder contractions.

 Bladder dysfunction  reduced bladder capacity, bladder overactivity or lack of inhibition of bladder emptying during sleep

 Nocturnal polyuria and vasopressin deficiency  production of larger than normal overnight urine (often>nocturnal bladder capacity).

Copyright 2018. The Children’s Hospital at Westmead and John Hunter Children’s Hospital Treatment resistance: understand the reason

 Address sleep issues, sleep hygiene

 Alarm training pitfalls, overlearning

 Treat OSA – enuresis resolve in 30-50% Jeyakumar 2012

 Improve sleep (melatonin or clonidine), improves the ability to wake to void (useful in combination with other therapy) Ohtomo 2017, Waters 2017

 Newer treatments under investigation: newer antimuscarinics –(solifenacin); selective beta 3 agonists (mirabegron), Botulinum toxin A.

 TENS

 Combination therapies

 Multidisciplinary approach • Improve and normalise physiological function • Improve posture and body awareness for optimal voiding and defaecation • Teach relaxed voiding • Retrain muscle patterns and coordination for bladder/bowel emptying • Neuromodulation – TENS for overactive bladder and TENS interferential for slow transit constipation Motor control and the developing child

 Maturation of systems will affect performance in a child

 Influencing function:

- Musculoskeletal development

- Posture and postural control and influence on pelvic floor

- Size and geometry of pelvis, thoracic, spine will affect biomechanics and postural control

- Sensory development and influence on motor functioning

- Cognitive and behavioural development

- Influence of predisposing factors and comorbidities to typical development  A tool to visually assess & measure outcomes in a non invasive way for children Bower et al 2006 →PFM function, bladder volume, PVR, rectal diameter  Visualise movement of PFMs-effective lift of bladder base during contraction Sherburn 2005

 Good intra & inter-rater reliability in adults Thompson 2011  Education and engagement of child & parent  Snapshot in time  Potential for research Neuromodulation

 Parasacral TENS: Favourable results in children with LUTS/OAB Bower 2001; Hoebeke 2001; Barroso 2011; De Gennaro 2011; de Oliveira 2013; Sillen 2014; Borsch 2017; Wright 2017

 Cochrane 2016: TENS interferential current for STC Chase 2005; Clarke 2009; Ismail 2009; Clarke 2012; Leong 2011

 RCT: TENS increases rectal activity in children with OAB Moeller 2015

 Large RCTs needed to understand mechanisms of action, best modality for condition, optimal parameters and long term outcomes Project developed with NSW Agency for Clinical Innovation

 Aim: to improve management and health outcomes for children/young people in NSW with primary urinary incontinence

 Outcomes:  Reduce variation in management  Reduce waiting times and improve access to specialists  Involve young people and families in their management

Further education to upskill

 Nocturnal enuresis resource kit 2nd edition

 Agency for Clinical Innovation: Young People with Urinary Incontinence

 International Children’s Continence Society

 Continence Foundation of Australia

- Online paediatric continence course Some cases…. How to cure PNE with 3 visits

 8 year old boy with primary enuresis

 Wants to be dry for school camps

 BG: Enlarged adenoids & snoring, sleep study normal.

 FHx: Mother wet until the age of 10yrs

 Toilet trained by 3 years Continence History

 Wears pull-ups at night

 Wets every night, not waking

 Occasional dry night

 Never wakes to void

 Day time  Occasional urgency due to void postponement, prefers to play  No day time wetting Fluids and Bowels

 Low daily fluid intake-most drinks after school

 Frequently consumes caffeine

 Bowels open every 2nd day, type 2-3 stool

 Some straining and discomfort.

 Reasonable fibre intake

 No faecal incontinence.

 Toilet too high at home. Examination

 Wt. 22.54 kg, Ht. 125cm. BP 90/40.

 Abdominal, neurological and perineal examination –all normal

 Normal urine analysis

Treatment Plan

 Increase and redistribute fluids to 1L/day

 Regular voiding (Listen to your bladder messages)

 Bowel program: Monitor, foot support

 Bladder diary

 Follow up in 1 month.  Fluids 1070mls 

 MVV = 300mls 

 Exp 270mls (age+1 x 30)…8yo boy

 OUV = 225mls 

 Exp <350mls 1 month later

 Compliant with urotherapy

 Increased fluids.

 Constipation has improved.

 Now 2 dry nights/week, sleeping through

 Commenced alarm training and chart progress →overlearning once he has obtained 14 dry nights. Case study (2)

 14yr old girl, 2 yr h/o DUI with trampolining. Changes pads 2x during training. Voids before/after trampolining.

 Normal milestones/exams, toilet trained 3 yrs, no UTIs

 RUS: Normal Pre void : 594ml PVR: 4ml

 Hgt: 170.3cm Wgt: 74.1kg

 s/b urologist, commenced bladder training, voiding 5x day, trialled Vesicare 5mg when trampolining. Urologist requested PFM strengthening  Bowels: daily no pain or strain, type 4, soft abdo

 Drinks approx 1.5L/day, likes caffeine drinks

 DUI assoc with laughter and urgency

 Needs to push to empty bladder

 H/o void postponement

 Night sleeps through dry

 Uroflow: Staccato 687mls PVR 54mls.

 DUI related to VP and jumping on trampoline. (?urge/stress) Case study

 Rx: Urotherpy- drinks, TV, PFM Xs, T&V, (+/- vesicare)

 6 weeks later:

 Only wets with trampolining and only on lift. Dry on Vesicare days.

 T&V incomplete: Voids 4x ;Fluids 1250 L; MVV 315 Case study (3)

 5 ½ year old boy with day and night wetting, frequency and urgency

 Autism spectrum disorder

 Toilet timing, drinking and bowel program with continence nurse

 Mum concerned re awareness of need to void and not dry with toilet timing

-Oxytrol transdermal patch -Wobl watch -Fluid distributed -bowel programme

- Rewards for drinks - Listen to the watch 2months later- Dry days Self-voids

Anticholinergiccimproved void volume Timed-voiddeveloped awareness & control Cystic Fibrosis study

Aims:

1. Identify prevalence of daytime wetting in children with CF

2. Identify causes of daytime wetting

3. Assess relationship between daytime wetting and severity of lung disease, age and gender

4. Assess response to treatment Method

 Survey of all children attending CF annual review at a tertiary paediatric hospital

 Treatment based on diagnosis:  Standard urotherapy  Pelvic floor muscle training  18% referral to continence service

 Followed up every 3 months Males (%) Females (%) Total (%) n = 63 n = 79 n = 142 Daytime Wetting 6 (10) 23 (29) 29 (20)

Stress urinary incontinence 0 21 21

Overactive Bladder Syndrome 2 0 2

Voiding postponement 1 9 10

Constipation 1 6 7

Other 2 0 2

Nocturnal Enuresis 6 (10) 0 6 (4) Males (%) Females (%) Total (%) n = 63 n = 79 n = 142 Daytime Wetting 6 (10) 23 (29) 29 (20)

Damp 3 17

Outer clothing 2 5

Puddles 1 2

< 1 x per week 3 9

1 – 3 x per week 2 8

4+ x per week 1 5

Causes of stress incontinence: cough 100% laugh 76% exercise 65% Results

 At 3 months follow up (24 patients)  84% responded

 At 6 months follow up (14 patients)  93% responded

 No relationship between onset of UI, severity of lung disease and age Conclusion

 Stress incontinence is common in girls with cystic fibrosis

 Impacts on cough, exercise and quality of life

 Intervention in a clinic setting can be effective

 Early intervention may have a positive impact on quality of life and continence as an adult Acknowledgements:

Gail Nankivell Senior Physiotherapist Children’s Hospital at Westmead