Childhood urinary incontinence

Urinary incontinence in children occurs when they have involuntary urine leakage during the day. This may be due to multiple anatomical or neurological abnormalities. In the absence of these abnormalities, daytime urinary incontinence is referred to as functional bladder dysfunction to refer to bladder storage-emptying disorders that lead to urinary incontinence in children.

Under normal conditions, the bladder and urinary sphincter work as a coordinated unit that allows the storage of urine at low pressure and its voluntary and complete emptying. This control over the timing of urination is usually obtained at around 2-3 years of age.

Symptoms and causes of urinary incontinence in children

Urinary incontinence significantly affects the quality of life of children who suffer from it and their families, both at school and in their personal relationships.

Filling dysfunction: during the filling phase of the bladder, the bladder must relax to contain the urine without pressure and, on the contrary, it must contract to prevent urine leakage. If during this phase, the bladder shows uninhibited contractions, the patient will feel the urgent need to urinate and urine leakage will occur. This is called bladder hyperactivity and is manifested by the need to urinate very frequently and with low volume. It usually occurs between 6-7 years of age and is very common.

Weakness of the urinary sphincter may also be responsible for urine leakage during bladder filling, coinciding with laughter or physical exertion.

Voiding dysfunction: during the bladder emptying phase, the child often postpones the moment of urination by means of voluntary contraction of the bladder sphincter and retention maneuvers (crossing the legs, bending over, etc.). This situation, maintained over time, leads to the rupture of the normal micturition cycle between the bladder and the sphincter. This dysfunction is known as uncoordinated micturition and leads to incomplete bladder emptying, repeated urinary tract infections and urine leakage. This disorder is often associated with constipation-encopresis and requires joint assessment for pelvic floor rehabilitation.

Diagnosis of urinary incontinence in children

For the diagnosis of urinary incontinence in children, it is important to know when urine leakage occurs in order to identify the type of incontinence and its possible causes. It is also necessary to individualize the study protocol for each patient, minimizing unnecessary examinations and ensuring a correct diagnosis.

• Clinical examination: it is important to carry out an exhaustive clinical examination by means of questioning in order to know the situations in which the leaks occur and the patient's routines.

• Voiding diary: keeping a voiding diary helps the patient and his family to be aware of voiding habits and habitual fluid intake and to be able to make modifications, together with the specialist, to help him acquire continence.

• Urinalysis: since urinary incontinence is often associated with urinary tract infections, we will perform a urinalysis with urine culture in those patients in whom there is reasonable diagnostic doubt or need to rule out infection.

• Flowmetry with electromyogram and residual urine measurement: flowmetry is a non-invasive and painless test that we perform in the pediatric urology office in comfortable conditions so that the child is relaxed and in a favorable environment. After the test, we will perform an ultrasound to see if there is any urine left in the bladder and quantify it.

• Ultrasound: in specific cases, an ultrasound is performed to rule out anatomical abnormalities and to assess the situation of the upper urinary tract.

• Voiding cystography: in some patients, uncoordinated urination may lead to the appearance of vesico-ureteral reflux (occurs when urine from the bladder backs up and ascends into the ureters, instead of exiting through the urethra) and the need for this test.

• Urodynamic studies: although also available, they are not routinely performed in all cases of incontinence.

Treatment of childhood urinary incontinence

After having made a good diagnosis of urinary incontinence in the child and knowing his routines, the pediatric urologist will adapt new habits to his life, making him participate in the achievements and explaining the reasons.

Conservative treatment: this is the first step in the treatment recommended for all patients, regardless of the type of incontinence they have. Conservative treatment includes a combination of hygienic-dietary and voiding reeducation measures that involve the patient and family and follow-up by the specialist physician.

Likewise, there are many therapeutic options to help the patient in the management of urinary incontinence, among which the following stand out:

Biofeedback: is a technique based on a system of sensors that allows the patient to be aware, in real time, of several physiological parameters that describe the functioning of his body. In a comfortable and relaxed environment, the child will learn, through a computer program and without any pain, to contract and relax the pelvic floor, thus helping him/her to recover the normal micturition rhythm, avoiding infections and regaining self-confidence. These exercises should then be repeated at home to strengthen the pelvic floor and achieve the desired results.

Posterior tibial stimulation is a painless, in-office treatment to help restore normal voiding cycle and improve urinary incontinence.

Surgery: when these treatments are insufficient, surgical treatment may also be indicated in certain patients, including cystoscopic application of botulinum toxin in the urinary sphincter for the treatment of sphincter hypertonia or, in the bladder, for the treatment of uninhibited contractions that do not respond to conservative treatment.

In patients with congenital or acquired urological pathologies, there are multiple surgical treatment options to improve urinary continence, being essential to individualize the treatment according to the situation and needs of each patient.