Urinary Incontinence

Cynthia D’Alessandri-Silva, MD
Some people feel the rain. Others just get wet.
―Bob Dylan
Learning Objectives:
1. Delineate the classification of urinary incontinence
2. Understand the importance of history in identification of the cause of daytime wetting
3. Become familiar with different etiologies of daytime urinary incontinence and enuresis
4. Develop counseling techniques for families whose children have enuresis
5. Become familiar with pharmacologic and non-pharmacologic interventions for enuresis

Primary References:
1. Roth EB, Austin PF. Evaluation and treatment of nonmonosymptomatic enuresis. Pediatrics in
Review. 2014;35(10): 430-436.
http://pedsinreview.aappublications.org/content/35/10/430.full.pdf+html
2. Bayne AP, Skoog SJ. Nocturnal enuresis: An approach to assessment and treatment. Pediatrics in
Review. 2014;35(8): 327-334.
http://pedsinreview.aappublications.org/content/35/8/327.full.pdf+html
3. Table 2 in: von Gontard A. The impact of DSM-5 and guidelines for assessment and treatment of
elimination disorders. Eur Child Adolesc Psychiatry. 2013;22(S1): S61-S67.
http://link.springer.com/content/pdf/10.1007%2Fs00787-012-0363-9.pdf

CASE ONE:
Sally P. Freely is a 6-year-old girl whose mother is concerned about her wetting problem
for the past month. Mrs. Freely reports that Sally frequently wets her pants at school.
Sally’s teacher has told Mrs. Freely that she catches Sally squatting and holding her crotch
intermittently during the day. Sally was previously toilet-trained and had no wetting for
more than 6 months before the problem started. Mrs. Freely has stopped having Sally go
over to friend’s houses for play-dates, and has taken her off of the soccer team due to fear
of embarrassment. As you elicit this history you notice Sally constantly pulling on her
mother’s shirt for attention and climbing on the chair and jumping off. When you question
Mrs. Freely on Sally’s behavior, she admits that Sally has always been a “busy child with
the energy of 100 children.” Mrs. Freely is almost to tears and asks, “Is there a medication
to give Sally so she can just be like other kids her age?”

1. What does urinary continence depend upon neurologically?

Continence is dependent on a complex interplay of the central, peripheral, autonomic, and somatic
nervous systems in order to ensure coordinated muscular activity in a socially appropriate setting. In
order for urine to be held in the bladder, the detrusor muscle must relax while the sphincters contract.
During micturition, the detrusor muscle contracts to empty the bladder, the internal sphincter
involuntarily relaxes, and the external sphincter voluntarily relaxes to allow urine flow through the
urethra.
2. What is urinary incontinence, and how are the different subtypes defined? Which type does
Sally exhibit?
There are two major classification systems for urinary incontinence: the DSM-5, which defines only
enuresis, and the International Children’s Continence Society (ICCS). The DSM-5 defines enuresis as
voiding into the bed or clothes at least twice per week for at least three successive months in a child
who is at least 5 years old. In contrast the ICCS guidelines provide a more descriptive definition
classifying the different subtypes of urinary incontinence clinically, and are more widely accepted by

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pediatric nephrologists and pediatric urologists. Therefore, the ensuing discussion focuses on the ICCS
guidelines.
The ICCS defines urinary incontinence as leakage of urine in an uncontrollable manner. The two broad
categories are enuresis and daytime urinary incontinence. Enuresis is synonymous with nocturnal
enuresis and is defined as any intermittent incontinence that occurs while sleeping (whether at night or
during daytime naps). The broad term “enuresis” is then further modified by the terms “primary” vs.
“secondary” and “monosymptomatic” vs. “non-monosymptomatic.” These are defined as follows:
• primary - a child has never achieved continence or has achieved continence for less than 6
months
• secondary - a relapse after a period of dryness of greater than 6 months
• monosymptomatic – no daytime bladder symptoms such as frequency, urgency, or holding
maneuvers
• non-monosymptomatic – daytime symptoms are present such as increased frequency, daytime
incontinence, urgency, genital or lower urinary tract pain.
Isolated daytime urinary incontinence is classified separately from enuresis because it is typically
functional, and is far less common than isolated nocturnal symptoms or symptoms that occur both
during day and night. Moderators should review the ICCS classification system in Table 2 of the von
Gontard article. Based on the ICCS definitions, Sally exhibits daytime urinary incontinence.
By 3 years of age, 98% of American children are toilet trained. However, at 3 years of age 30% of
children still experience daytime wetness at least once every 2 weeks. Therefore, regardless of the
classification system used, daytime wetting is generally not considered to be a problem necessitating
medical intervention until age 5 unless the child had previously achieved regular bladder control for
many months.

3. What is the most-likely etiology of Sally’s incontinence? What are some other possibilities?
What other information would you obtain regarding her symptoms to help flesh out the cause?
The differential diagnosis for daytime urinary incontinence is broad, and includes voiding
postponement (holding urine until the last minute); urinary tract infection (UTI); labial fusion; urge
incontinence; giggle incontinence; stress incontinence; postvoid dribble syndrome; diabetes mellitus;
diabetes insipidus; constipation; vaginal reflux of urine; and traumatic, neurologic, or infectious
bladder obstruction. Further history and physical exam, including full review of the neurologic and
genitourinary systems, are necessary to evaluate for these causes.
Many young children with secondary non-monosymptomatic enuresis have voiding postponement, often
because they neglect the urge to urinate while involved in other activities. Scheduled toileting is a
simple solution to this problem. UTI, another common cause, usually presents with other signs and
symptoms of infection, but can be easily ruled out with a clean-catch urine culture.
Constipation may also be a contributing factor as it is associated with a reduced functional bladder
capacity. Parents are often unaware of constipation in a self-toileting child. The provider should
directly question school-age children about this problem and they should be instructed not to flush the
toilet. The parent should record the time, frequency, and character of bowel movements, and the
presence of soiling.
Postvoid dribble syndrome is characterized by the sensation of wetting after voiding, usually in 4 to 6
year old females. The sensation may be due to small detrusor contractions after voiding. Having the
child void completely and then immediately try voiding again, or “double voiding,” may be effective in
this scenario.
Neurogenic bladder is a result of a lesion at any level in the nervous system. Children with
myelomeningocele usually have daytime wetting. Diabetes mellitus is associated with polyuria as well
as with abnormalities in the afferent nerves from the bladder, which may develop many years after
diagnosis.
Sally’s story is classic for urge incontinence, or unstable bladder, due to unwanted detrusor
contractions. Affected children are typically of school age. Urge incontinence is more common among

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children with ADHD, and up to 7% of children with ADHD have a daytime wetting problem (from urge
incontinence or other etiologies). The squatting behavior noted by Sally’s teacher is a typical symptom
of urge incontinence, as it functions to suppress unwanted detrusor contractions. The diagnosis is
clinical, but, if performed, urodynamic studies will confirm the presence of unstable detrusor
contractions during bladder filling.

4. How would you treat secondary non-monosymptomatic enuresis? What about Sally’s type of
enuresis?
Treatment for secondary non-monosymptomatic enuresis would be geared towards any other causes or
contributing factors identified by history and physical (e.g., scheduled toileting for micturition
deferral, antibiotics for UTI, a bowel regimen to relieve constipation).
Treatment for urge incontinence is physiotherapy aimed at strengthening the pelvic floor muscles. By
strengthening these muscles children will learn to relax the pelvic floor muscles thereby relaxing the
detrusor. Children who require relaxation techniques need referral to an experienced physiotherapist.
If the symptoms are severe, further investigations are necessary (i.e., urodynamics and ultrasound of
the bladder and kidneys) which are best performed at a center experienced in conducting these studies
in children. Anticholinergics such as oxybutynin and hyoscyamine sulfate serve to decrease detrusor
hyperactivity and enlarge the functional capacity of the bladder. These agents may be helpful in some
cases. Children younger than 5 years of age should not be treated for urge incontinence as some
degree of irregular detrusor activity can be normal in this age group.

CASE TWO:
Peon Smith is a 12-year-old boy who presents for his annual physical. His mother reveals
that Peon is wetting his bed at night. She feels he is too old for “this type of embarrassing
behavior” and has been punishing him. You discover that she too used to wet the bed at
night and was punished by her parents. She is frustrated with his bed wetting and is
angered that she finds it difficult to wake him once she encounters his accidents. Peon
denies all urinary symptoms and has no urinary problems while awake. He has no other
medical problems. On physical exam his vital signs are stable and his BMI is >95th
percentile. The rest of his physical exam is benign.

5. What type of enuresis does Peon have? What, if any, further evaluation is necessary?
Peon has monosymptomatic enuresis (commonly referred to as nocturnal enuresis) since he has
symptoms occurring exclusively during sleep. His enuresis is primary since he has never achieved
continence.
His mother’s history of enuresis is telling. Children with nocturnal enuresis are thought to have
maturational delay in recognizing bladder fullness while asleep. When it is the solitary cause,
maturational delay typically results in primary monosymptomatic enuresis. Those with one parent who
was enuretic in childhood have 44% incidence of enuresis and those with both parents affected have
77% incidence, as compared to the 15% incidence in children whose parents did not have enuresis.
Had Peon previously achieved a period of continence (secondary monosymptomatic enuresis), then an
alternative or additional cause would be likely. In secondary monosymptomatic enuresis, clinicians
must consider other contributing etiologies such as UTI, constipation, sleep disordered breathing,
emotional stress, or anatomic, neurologic, or endocrine abnormalities. Additional history and physical
exam should target these etiologies, and must include evaluation of the nervous system and urinary
tract.
Based on Peon’s history, maturational delay is the likely explanation, though obstructive sleep apnea
may be a contributing etiology. Additional questions regarding daytime or nighttime signs and
symptoms of sleep apnea (e.g., snoring, daytime sleepiness) are indicated. Sleep apnea and upper
airway obstruction have been linked to enuresis due to difficulty arousing from sleep.

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For primary and secondary monosymptomatic enuresis, a targeted work-up should be directed by
history and examination, though urinalysis is typically obtained regardless of other findings. In primary
monosymptomatic enuresis, additional work-up is rarely required unless findings on history or physical
raise suspicions.

6. What non-pharmacologic treatments would you suggest for Peon’s enuresis? Would you advise
his mother to continue punishing him?
Spontaneous resolution of primary nocturnal enuresis is quite common (15% per year), lending support
to the theory of maturational delay of sensing bladder fullness. Nevertheless, all children with
enuresis can benefit from non-pharmacologic therapy, especially those children greater than 8 years of
age and those in which the behavior is a cause of family distress. In patients with secondary
monosymptomatic enuresis or concomitant daytime symptoms (i.e., non-monosymptomatic enuresis),
underlying etiologies should also be addressed as a first step in treatment.
It is important to incorporate family education and use of motivational techniques as part of any
treatment regimen for enuresis. Families must learn that enuresis is not grounds for punishment.
Punishing the child for enuresis may be counterproductive to solving the problem, and may affect the
child’s already fragile self-esteem. The parents should discourage ridicule from siblings as well.
There are a variety of effective motivational strategies available. Positive reinforcement is effective,
and can be delivered through setting up a reward system for each night the child remains dry. In
addition, the child should be kept involved in the resolution process, which will help him (and the
family) to view enuresis as an accepted problem that he is working to solve. Embarrassment should be
minimized. The child should participate in the morning clean-up and be encouraged to keep a journal
or dry bed chart.
In addition, Peon should refrain from large amounts of fluid for at least two hours before bedtime to
decrease urine production at night-time. He should empty his bladder just before bedtime, and should
also be awoken by a parent at the parent’s presumably later bedtime to do so again.
If these motivational and behavioral strategies discussed are not successful after a few months, or in
older children in whom nocturnal enuresis can be more distressing, more advanced behavioral therapy
should be implemented. A Cochrane review revealed that conditioning through use of an enuresis
alarm has the highest overall cure rate (70%), especially when used in conjunction with positive
reinforcement and charting. These devices are small and worn in the patients’ underwear. When the
device is exposed to urine, a circuit is completed and the alarm sounds. Cost can range from $15 to
$85 and is not usually covered by state insurance. The alarm can be discontinued in children who
remain dry for 3 consecutive weeks. If bedwetting recurs, the alarm can be used again successfully.
Conditioning through “dry bed training” has been successful in treating nocturnal enuresis. The
process involves waking the child nightly at decreasing intervals over several nights. The child should
change pajamas if wet and go to the toilet. The eventual goal is having the child awaken alone to
void. Although the cure rate is high, this process is labor intensive and hard for many families to
perform.

7. What medications are available to treat enuresis? At what point would you initiate
pharmacotherapy?
Desmopressin (DDAVP) is an analog of ADH which acts on the distal tubules of the kidney to increase
water reabsorption, thereby producing less urine. Desmopressin is available in both nasal spray and
oral form, but the nasal spray has greater bioavailability. Effects can be evident within a few days of
use. Children treated with desmopressin, as compared to those receiving placebo, have an average of
1.3 fewer wet nights per week. The initial dose is 10 mcg, one puff in each nostril 2 hours before
bedtime; the dose can be increased by increments of 10 mcg weekly to a dose of 40 mcg. Patients can
remain on this therapy for 3 to 6 months while behavioral methods are being applied, and the dose
should then be tapered if the enuresis is improving. If there is no resolution in a child’s enuresis after
6 months then combination therapy should be considered after revisiting possible underlying etiologies.

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Desmopressin is a relatively safe medication with rare side effects, which include abdominal pain,
headache, nausea, and epistaxis. There have been reports of dilutional hyponatremia in children
leading to seizures. It is recommended to trial desmopressin at home prior to longer-term initiation of
therapy at overnight events (e.g., sleep away camps). This trial should occur 4-6 weeks prior to the
overnight event with close laboratory monitoring of serum sodium (e.g., weekly for 2 weeks, then
monthly until stability ensured). Dilutional hyponatremia with desmopressin typically occurs with
disproportionate fluid intake in the evening hours. To prevent this, fluid intake should be limited to
eight ounces (240 mL) from one hour before to eight hours after administration of desmopressin.
Treatment should be held during acute illnesses that interfere with water or food consumption such as
vomiting or diarrhea as these can alter electrolyte levels.
Imipramine is a tricyclic antidepressant that has been available for use in nocturnal enuresis for
decades. It is an inexpensive alternative to DDAVP thought to reduce enuresis by increasing bladder
capacity through weakly anticholinergic effects. Success rates range from 15-50%, with a high rate of
relapse upon discontinuation. In general, side effects are minimal, and include dry mouth, decreased
appetite, and headaches. The concern with this medication is related to its misuse and overdose as
tricyclic antidepressants can cause arrhythmias, seizures, coma, and death. Therefore imipramine
should only be used after careful patient and family education, and if the physician feels comfortable
that there is no psychiatric illness in the patient or family members. Given the concerns surrounding
life-threatening side effects of imipramine, many providers reserve its use for nocturnal enuresis that
is refractory to other treatments.
Oxybutynin, an antispasmodic anticholinergic medication, is more useful for children who have non-
monosymptomatic enuresis. It prevents detrusor contractions, thus increasing bladder capacity while
the child sleeps. It is not approved by the FDA for treatment in children younger than 5 years of age.
The decision about when to initiate pharmacologic therapy must be individualized. The patient’s age
is a primary consideration. In general, for children less than 8 years of age, education, motivation and
behavioral modification are recommended. For children 8 through 11 years, more success is found in
combining these modalities with the use of enuresis alarms. Desmopressin can be useful sporadically
for sleepovers or trips in this age group. Children 12 years and older should be treated more
aggressively due to the emotional impact of bed wetting in the adolescent years. Enuresis alarms are
helpful, but if not successful within a short period of time, the addition of medication is justified.
Once two months of dryness has been achieved, the medication can be tapered with ongoing use of the
alarm. In no circumstances should medications be used without simultaneous motivational or
behavioral therapy. Ongoing support and education of the patient and family is crucial.

Additional References:
1. Fritz G, et al. AACAP practice parameter for the assessment and treatment of children and
adolescents with enuresis. Journal of the American Academy of Child & Adolescent Psychiatry.
2004;43(12):1540-50.
2. Glazener CM, et al. Simple behavioural and physical interventions for nocturnal enuresis in
children. Cochrane Database of Systematic Reviews. 2004;1: CD004668.
3. Glazener CM, Evans JH, Peto R. Alarm interventions for nocturnal enuresis in children. Cochrane
Database Systematic Reviews. 2005;2: CD002911.
4. Glazener CM, Evans JH. Desmopressin for nocturnal enuresis in children. Cochrane Database
Systematic Reviews. 2009;CD002112.
5. Lawless MR, McElderry DH. Nocturnal enuresis: current concepts. Pediatrics in Review. 2001;22(12):
399-406.
6. Makari J, Rushton HG. Nocturnal enuresis. American Family Physician. 2006;73(9):1611-3
7. McGrath KH, Caldwell PHY, Jones MP. The frequency of constipation in children with nocturnal
enuresis: a comparison of parental reporting. J Paediatr Child Health. 2008;44: 19-27.
8. Neveus T, et al. The standardization of terminology of lower urinary tract function in children and
adolescents: report from the Standardization Committee of the International Children’s Continence
Society (ICCS). Journal of Urology. 2014;176: 314-324.
9. Robson WL. Etiology, evaluation, and treatment for enuresis. New England Journal of Medicine.
2009;360: 1429.

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10. Robson WL, et al. Enuresis in children with attention-deficit hyperactivity disorder. Southern
Medical Journal. 1997;90:503-5.

Resource:
1. Information for patients and families from National Kidney Foundation.
http://www.kidney.org/patients/bw/BWKidsTeens.cfm

Acknowledgment:
The current author would like to thank Dr. Karen Dorsey for her work on a previous version of this
chapter.

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