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Urinary Incontinence in Children

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Urinary Incontinence in Children 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) • -</= 2 defaecations in toilet per week • -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
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