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INCONTINENCE

BACKGROUND

As a result of maturation, children usually become continent during the day-time by the second year and at night by the fourth year. In cases of persistent wetting, a distinction has to be made between enuresis and urinary incontinence. Particular attention should be paid to:

• Anatomic defects of sphincteric muscle and bladder (e.g. complete epispadias, bladder exstrophy,
urogenital sinus, ectopic ureter)

• Impaired innervation of bladder and sphincteric muscle (e.g. myelomeningocele)

• Functional disturbances of the bladder and sphincteric muscle.

CLASSIFICATION

Enuresis

This is defined as a normal void occurring at an inappropriate or socially unacceptable time or place. Children with nocturnal enuresis void in bed while asleep and are generally not aroused by the wetting. The condition is mono-symptomatic and has a clear familial tendency.

Primary nocturnal enuresis

Involuntary bed wetting from the time of birth without an uninterrupted period of at least 6 months.

Secondary (onset) nocturnal enuresis

Involuntary bed wetting after a dry period of at least 6 months.

Nocturnal polyuria enuresis

This describes nocturnal enuresis in children who have urine production in excess of their functional bladder

capacity, as shown by voiding charts.

Diurnal enuresis

Wetting in attention-deficit disorders; voiding is complete; bladder and urethral function are normal.

Urinary incontinence

This is defined as the involuntary loss of urine, objectively demonstrable and constituting a social or hygienic problem. It denotes a symptom (patient's recognition of involuntary urine loss), a sign (the objective demonstration of urine loss) and a condition (the urodynamic demonstration of urine loss). Day-time, night-time or both day- and night-time incontinence may be encountered. Urinary incontinence is classified according to aetiology:

Incontinence associated with anatomic abnormalities of the urinary tract

Ectopic ureter, ureterocele, prune-belly syndrome, bladder exstrophy, epispadias, posterior urethral valves and

cloacal abnormalities.

Incontinence associated with neurogenic disorder

Spinal dysraphism, caudal regression condition and other central nervous system (CNS) disorders.

Functional incontinence in non-neuropathic bladder sphincter dysfunction (urge syndrome and dysfunctional

voiding)

Often associated with recurrent UTIs and occur predominantly in girls.

DIAGNOSIS

The basic diagnostic evaluation includes:

• History (including family and social history)

• Physical, urological and gross neurological examination (urinalysis and culture, specific gravity)

• Sonography (residual urine, bladder wall thickness, upper tracts)

• Frequency-volume chart (after treatment of infection)

If the basic evaluation does not reveal any pathology, an enuresis (uncomplicated, mono-symptomatic) can be assumed and no further examinations are required.

Further evaluation is required if any pathology is revealed in the basic evaluation and includes:

• Uroflow (if pathological, repeated uroflow and uroflow-electromyography (EMG) study)

• VCUG in case of thickened bladder wall and/or residual urine, in case of pathological, but co-ordinated
micturition

• (Video) urodynamics on suspicion of functional voiding disturbances

• Intravenous urogram (optional if sonography is normal)

• Examination under anaesthesia (urethrocystoscopy, urethral calibration, mainly for UTIs)

• Extended neurological, radiological and psychiatric examinations (including MRI of the spinal cord)

• Radionuclide renal study to assess renal function

TREATMENT

4.4.1 Nocturnal enuresis (mono-symptomatic)

Therapy is started when the condition becomes distressing and the child becomes motivated to be dry, usually after the age of 5-6 years. Behavioural therapy including motivation, counselling about regular voiding and drinking habits, classical conditioning with an alarm-clock, and appropriate handling of constipation, is the first option. Complete dryness in 70% and considerable improvement in 12% of cases can be achieved by treatment with 10-40 mg DDAVP (Desmopressin) nasal spray over a maximum period of 6 months. However, relapse occurs in almost all cases after discontinuation of the medication. Oxybutynin can be helpful in some cases with wetting at the beginning of the night (uninhibited contractions of the bladder).