EXPERT ADVICE: Day time wetting in children
Day time wetting (sometimes also called diurnal enuresis ) is a fairly frequent problem in children with approximately 2-4% of 5-7 year olds wet at least once per week during the day.
Up to half of these children may also be wet at night (bed wetting or nocturnal enuresis).
Day time wetting can have a significant impact on the child's day to day activities, family dynamics and integration with peers. This article will concentrate on day time wetting, the different causes and ways in which this can be managed. This should hopefully allow families and children to understand this condition better. The article is not intended to give advice on any specific condition and parents are urged to see their GP if they have any concerns regarding the well being of their child.
What is the normal structure of the urinary tract?
The urinary tract consists of two bean shaped kidneys which are located at the back of the tummy. These produce urine which is collected in a little sac- the pelvis. From here the urine runs through a hollow tube called the ureter into the bladder.
The bladder is a hollow muscular organ situated low down in the pelvis that stores the urine. In normal circumstances there is a one way flow from the kidneys to the bladder and not the other way around.
From the bladder the urine passes to the outside through another tube called the urethra. At the outlet of the bladder is a muscle by which we can avoid leakage of urine- the sphincter. The working of the bladder and sphincter is dependent on nerves to and from the bladder and sphincter to the spinal column and up to the brain.
How do we develop control of our bladder (continence)?
The bladder is an organ that can stretch to accommodate urine. The amount of urine the bladder can hold increases with age. The bladder should be able to hold urine at a low pressure. Hence as urine comes down from the kidneys, the bladder muscle stretches allowing more filling of the bladder.
When the capacity of the bladder is reached, the muscle of the bladder squeezes as a single unit. At the same time the sphincter (the tap) relaxes allowing urine to be passed and the bladder to empty completely.
Once empty, the bladder muscle relaxes completely allowing the cycle to repeat. During the process of bladder filling, the muscle remains calm and relaxed.
At birth and in the first few years of life, children do not have control over this cycle which occurs as an involuntary reflex. During the time of potty training, the nerve pathways from the bladder to and from the spinal column and the brain mature and children develop increased awareness of filling of the bladder and voluntary control over the sphincter. Hence if it is socially convenient, the children can voluntarily relax the sphincter to allow the bladder to empty when they need to pass urine. This repetitive cycle (bladder cycling) stimulates the bladder to increase its capacity with age.
What can lead to day time wetting?
Day time wetting may occur as a result of problems during the bladder filling phase of the cycle or the bladder emptying phase. The bladder muscle itself may behave normally or abnormally as can the sphincter. The various types of day time wetting are:
A. Those children in which the bladder itself behaves normally
1. Delayed control due to immaturity of the nerve pathways results in bladder control not being achieved until later than average. These children have normal bladders that behaves as it would in the first few years of life. The children either do not have awareness of when their bladder is full or the control over their sphincter to prevent passing urine. This does not require any treatment as with time full control will be achieved.
2. Holders on- are children with normal bladders who do not go to the toilet when necessary and hold on for as long as possible and as a result have accidents.
3. Wetting can be caused as a result of irritation of the sensitive lining of the bladder muscle due to a urine infection and this usually resolves with treatment of the infection.
4. Some children may lose bladder control at times of illness or stress. This is usually temporary.
5.Some children may develop giggle incontinence. In this a normally dry child can experience accidents with laughing or giggling. These children have a normal bladder control and sphincter control. It is thought that the act of laughing or giggling stimulates the bladder muscle to suddenly squeeze causing accidents.
B. Those children in whom the bladder/sphincter behaves abnormally ( functional incontinence)
1. Bladder muscle overactivity: Normally the muscle of the bladder remains relaxed till the bladder is full and then it squeezes with a single strong squeeze. Sometimes, the muscle may be twitchy and squeeze while the bladder is filling in between cycles. This makes the child feel the need to pass urine desperately there and then ( when they need to go, they need to go!). This is called an unstable bladder. Some children may get urine infections. With an unstable bladder, children pass small amounts of urine quite frequently, sometimes every hour and can be dry in between. Sometimes this may be caused due to problems with the nerves to and from the bladder.
2. There may be problems with sensation of bladder filling and stretching of the bladder to allow urine storage. There can also be a problem of the sphincter which does not remain closed and allows leakage of urine.
3. Bladder muscle underactivity: During the emptying phase the bladder may not squeeze with sufficient strength or may not squeeze at all. Urine is retained in the bladder and may leak as a result of overflow.
4. Lack of coordination between the bladder muscle and the sphincter: Normally when the bladder muscle squeezes, the sphincter ( tap) should relax to allow urine to pass. Sometimes this does not happen and the sphincter remains closed or can open and close repeatedly while the child is passing urine. This may give a stop start nature to the urinary stream. A result of this lack of coordination is that the bladder muscle squeezes against resistance and the pressure inside the bladder rise significantly. This can affect the kidneys and the squeezing capacity of the bladder. The bladder may not empty adequately and the child may get urine infections and wetting. After a long period of time, the bladder muscle may fail completely.
5. The bladder may not empty adequately due to a blockage at the outlet of the bladder that has been present before birth. Other structural abnormalities may also lead to children to be wet.
C. Constipation and fluid intake:
Constipation may cause accumulation of hard stool in the rectum. This presses on the bladder and prevents the bladder from emptying completely. It may also cause the bladder to become unstable. Poor fluid intake does not allow efficient cycling of the bladder and fluids containing fizzy drinks or caffeinated drinks cause irritation of the bladder lining described above.
What can I do for my child's day time wetting?
There is no single fixed age at which children become dry during the day. Some children may start wetting after having been dry day and night for a while and others will never have been dry.
Simple measures that can be carried out at home include regular toileting (getting the child to pass urine at regular intervals during the day), avoiding fizzy drinks, encouraging plenty of water based drinks and avoiding constipation. This may require a visit to your child's school to allow access to toilets and drinking water. However if you have any concerns, the wetting has not resolved during the day by 5 years of age or if your child is getting urine infections , you should see your GP/health visitor/school nurse for further advice. You may be referred to the local continence clinic for further guidance.
What investigations might my child need?
When first presenting, you may be asked a detailed history about the nature of the accidents, frequency of going to the toilet, fluid intake and nature, bowel habits, diet and general health and development. A physical examination will be carried out to rule out any obvious underlying problems. A routine urine test might be done to rule out a urine infection. You may be given advice as described in the section above. If there is no improvement in symptoms, you may be referred to see a specialist.
You may be asked to complete a voiding diary or frequency volume chart. This is usually done by completing a chart with varying amounts of information including volume of urine passed on each occasion during the day (this will need your child to pass urine into a jug to be measured), number of accidents, fluid intake etc. The volume of urine passed can give an idea about the bladder capacity. An ultrasound scan of the urinary tract may be requested as an outpatient to confirm structural normality. Your child will have to come with a full bladder for the scan and how well the bladder empties will be documented. An Xray of the spine may also be performed.
Your specialist may feel further tests are necessary to see how well the bladder is working. To see how well the bladder is filling and emptying, your child will have an ultrasound scan of the bladder following which he/she will pass urine in a special toilet attached to a computer. This gives an idea of the capacity of the bladder, emptying of the bladder, how quickly your child can pass urine ( flow rate ) and how much urine is left in the bladder. Further to this, your child may need tests to check the activity of the bladder. This is usually done by passing a small tube into the bladder through the urethra or through the tummy wall under an anaesthetic. The bladder is filled up by fluid that can be seen by Xrays an attempt to mimic what happens in real life. This tube is attached to the computer and the bladder activity is recorded.
Certain specialist investigations like an MRI scan or a cystoscopy (telescopic examination of the bladder and urethra) may be recommended in a small number of children.
What treatment might my child need?
Treatment for children is tailored according to their individual needs as per their response and any form of intervention does not guarantee a cure.
1. A programme of regular toileting, avoiding or treating constipation, increasing water based fluid intake, and avoiding fizzy drinks may be all that is necessary. This should be common to all treatments
2. If the bladder is not relaxing and is twitchy or unstable, medication may be prescribed to allow the bladder to relax and store more urine. Similarly medication may be prescribed to allow the bladder to empty better
3. If there is possibility of a blockage to the urine flow from the bladder a telescopic examination of the bladder and urethra with removal of the blockage if any might be performed. If there is any other structural abnormality, this will be addressed accordingly.
4. In the vast majority of children, symptoms improve with time or with the above mentioned interventions.
Mr Prasad Godbole is a Consultant Paediatric Urologist and Surgeon at the Sheffield Children's NHS Foundation Trust and the BMI Thornbury Hospital in Sheffield. His special interests include daytime voiding disorders in children, reconstructive urology, paediatric kidney stones and the management of antenatally diagnosed problems with the urinary tract.
The views and opinions expressed in this article are the sole responsibility of the author. The Sheffield Children's Foundation Trust does not accept any responsibility for the content of the above article or the accuracy thereof
This article is the first in a series on children's health. Read more about our new Children's Health column: Taking away the anxiety of children's health for parents
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