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- What Symptoms
Are Associated With VoidingProblems in Children?
- Loss of Urinary Control (Enuresis)
- Frequent Urination
- Urinary Urgency
- Squarring/Squeezing to Prevent Urination
- Recurrent Urinary Tract Infections
- Tendency Towards Constipation
How Common are these problems?
About 15 percent of all 5 year old
children, 5 percent of all 10 year old children, and 1
percent of all 15 year old children occasionally wet themselves.
Therefore, this represents a common childhood problem.
Not every child is ready for complete urinary control
by 5 years of age, and it is difficult to predict their
ability to gain this control. It would seem to be a continuous
developmental situation with most problems resolving as
the child grows older. Often, it seems to be a family
trait with a parent, brother or sister late in developing
complete urinary control.
How can your initial physician evaluation
help?
The office evaluation should include
a complete history and physical examination, with a urine
specimen obtained for urinalysis and urine culture. This
allows identification of 3 subgroups of incontinent children:
1. Children who wet only at night,
without evidence of abnormalities on physical exam, a
urinary tract infection, or daytime voiding symptoms.
2. Children with daytime urinary symptoms
such as frequency, urgency, damp underwear, and squatting
or squeezing to avoid wetting. They may have a tendency
towards constipation, urinary tract infections and night
bedwetting, too.
3. Children with obvious abnormalities
(such as spina bifida) on physical exam, or continuous
day and night wetting despite an otherwise normal voiding
pattern (suggests an ectopic ureter). Fortunately, only
a very small minority of children fall into this subgroup.
What is the cause of incontinence?
The majority of children with this
problem (in subgroups 1 and 2) have a degree of maturational
delay in their ability to store and empty urine from their
bladder. Recent studies have demonstrated bedwetting children
(in subgroup 1) may produce more urine at night than other
children. A truly serious problem that causes urinary
incontinence is unusual and exists in only a small minority
of these children (in subgroup 3).
Many children feel frustrated and embarrassed
by this problem and this can certainly be emotionally
stressful. However, in an otherwise emotionally healthy
child this does not represent an underlying psychological
problem (they don't need a psychiatrist!).
Whar tests are necessary?
1. Urinalysis and urine culture.
2. X-rays are not always indicated,
unless an abnormality is noted on the initial physicians
evaluation or there is a history of urinary tract infection.
3. A sonogram is a safe, non-invasive
test to screen children with persistent problems for significant
urinary tract abnormalities. This often proves reassuring
for the parents and child.
4. Cystoscopic examination under anesthesia
is very rarely indicated and urethral dilation (stretching)
is not helpful.
What treatment may be helpful?
1. For children who wet only at night
and void normally during the daytime (subgroup 1) patience
and understanding are most important. A common sense approach
includes: voiding just before bed- time, limiting fluid
intake about 2 hours before going to sleep, and encouraging
success with a positive reinforcement (reward) program.
The use of punishment for wetting should always be avoided.
The older (usually >8) more mature child may find therapy
helpful. Treatment options that have proven to be effective
include: the enuretic alarm system and DDAVP Nasal Spray,
(we can provide additional information on these therapeutic
options).
2. Children with wetting and daytime
urinary symptoms (subgroup 2) often respond to medication,
bladder anti-spasmodics. Many have a tendency towards
constipation and this should be treated vigorously with
high fiber diets, stool softeners, laxatives, suppositories
and even enemas if necessary. Encourage regular bladder
emptying. voiding by the clock every 3-4 hours during
the day. For recurring urinary tract infections, antibiotic
therapy is essential. Occasionally, for severe problems,
bladder emptying may be improved by intermittent catheterizations
or behavior modification therapy.
3. Children with anatomic abnormalities
of their urinary tract (subgroup 3) may require surgery
for correction. Those children with neurologic dysfunction
of their lower urinary tract (spina bifida, spinal cord
trauma) often need a combination of medications, intermittent
catheterization SS and surgery. |
