Urinary Incontinence / Enuresis (Pediatric)

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What is urinary incontinence (enuresis)?

Urinary incontinence (enuresis) is a medical name for bedwetting or accidental daytime urination by children who should be developmentally able to control their bladders. Females usually have bladder control before males do. Diagnosis of enuresis is for females over age 5 and males over age 6 who still have urinary control problems. Different types of urinary incontinence are:

diurnal enuresis or wetting during the day
nocturnal enuresis or wetting during the night
primary enuresis, when the child has never fully mastered toilet-training
secondary enuresis, when the child had a period of dryness and later returned to periods of incontinence

Primary enuresis is the most common type, as it is bedwetting at night.

Nocturnal enuresis affects 5 to 7 million children in the United States and occurs three times more frequently in males than in females.

Up to 20 percent of all five-year-old children wet their bed at least once a month, but this number declines to 4 to 5 percent by age 12.

Only slightly more than one-third of children with enuresis seek the advice of a doctor. This low number may be due to their parents' embarrassment or to the situation resolving itself in most children. Slightly more males than females experience enuresis. There may also be a genetic factor for enuresis; children with a family history of bedwetting are more likely to experience this condition.

What causes enuresis?

Most of our patients have wetting problems without neurological or serious anatomical causes. For example, children do not always want to stop an activity to go to the bathroom. They may urinate only two or three times a day because they do not take the time to go and then cannot make it to a toilet fast enough. Other explanations are:

Uncontrolled bladder contractions make them feel like they need to go to the bathroom "right now!"
When going to the bathroom, they don't completely empty their bladder, which also puts them at risk for a urinary tract infection.

Contrary to popular beliefs, major causes of wetting are usually not laziness, emotional problems, inappropriate toilet training, and family problems. Many parents, and even some pediatricians, are surprised to learn the problem's root is physical, not psychological. Identifying the physical source takes time, as children with nearly identical symptoms may have different underlying disorders, each with its own treatment. Our team thoroughly evaluates children to identify the cause of their symptoms and uses this information to customize a plan for their care.

How is enuresis diagnosed?

Our experts begin with a thorough history and physical examination of your child. In addition, we want to know your child’s drinking habits, the frequency of your child's bathroom visits and wetting accidents, and whether there is a pattern of urinary tract infections. Our pediatric urologists will also conduct a physical examination of the abdomen, spine, and genitals, and may perform "urodynamic" tests to assess urinary function. We have performed more than 1,400 such studies each year. Tests may include:

X-ray of the abdomen helps us determine if your child is constipated. Incontinence and constipation often occur together.
Uroflow study measures the urine flow rate and the time needed to empty the bladder. Your child will be asked to urinate into a special uroflow chair. We check for any urine left in the bladder by using an ultrasound.
Ultrasound of the kidneys and bladder shows the size and shape of the kidneys and helps to identify bladder abnormalities.
Video urodynamics examination is a comprehensive bladder study necessary for children with spina bifida, posterior urethral valves or cerebral palsy, or sometimes for those who have wetting problems associated with vesicoureteral reflux (when urine backs up toward the kidney). The study involves placement of a special catheter into your child's bladder to measure pressure as the bladder fills with fluid. Once the bladder is full, your child urinates. Our doctors evaluate the bladder pressures and urine flow parameters.
Voiding cystourethrogram (VCUG) may be recommended if your child has had a urinary tract infection with fever. A catheter is inserted into the bladder, which is filled with fluid and viewed under an X-ray.

How is enuresis treated?

Based on the results of your child's evaluation, our urodynamics team recommends treatments, such as:

Changing urination or bowel-emptying habits. We commonly recommend your child start taking stool softeners to treat any underlying constipation. We will also help you to structure your child's schedule to include time to go to the bathroom at regular intervals throughout the day.
Increasing fluid intake to control the wetting. Children are often not drinking fluids during school and daytime activities. Frequently, we find that children are not drinking enough water throughout the day. We teach your child why water drinking is important and recommend how much water to drink during the day. We also limit other fluids, such as juice and soda, that can irritate the bladder.
Using biofeedback to teach your child to relax pelvic floor muscles and fully empty the bladder. Our urodynamic nursing team show children how to control and coordinate their muscles during urination using biofeedback techniques, as demonstrated by computerized games. Voiding problems are often corrected in as few as three one-hour biofeedback sessions.
Prescribing medication may be a component of treatment for some children. We may recommend medications to treat frequent urinary tract infections, overactive bladder, and night-time wetting.