Daytime wetting in children

Kiwi Enuresis Encopresis Association

Bedwetting is common and strategies for dealing with the problem are fairly clear in most health workers minds. However daytime wetting is much less well understood and interventions are at times inappropriate and counter productive. This can be frustrating for the parent and health professionals alike. Wetting pants in class is severely distressing for children. Children list it as the third most stressful event after losing a parent and going blind!

Daytime wetting is not uncommon. Approximately 3% of healthy children present with troublesome daytime wetting. 2/3 of these have combined day and nighttime wetting. It is difficult to address the nighttime wetting without the daytime wetting being sorted out first. The problem is more common in girls and late school entrants.

It is important that children with daytime wetting are seen by a doctor experienced with children's problems. Although still rare, there is a higher chance of structural problems with daytime wetting than with bed-wetting alone. Symptoms that should make one suspect structural problems include; pain on passing urine, a poor urinary stream or continuous dribbling of urine. The most important part of the assessment is a very good history, including voiding history and examination. Usually wetting is just a small patch through the layers of clothes rather than a full void.

Children characteristically feel the urge at the last minute and may suddenly demonstrate holding postures and may "curtsey" using their heel to stop the flow of urine. A diary of time and volume of urine output and fluid intake is very helpful. Fifty percent of girls who wet during the day will have occasional bacteria in their urine. All children with urinary tract infections should be asked if there are problems with daytime wetting.

A urine test is usually the only investigation most children will need. More invasive studies are not usually needed, but may show unstable bladders and incoordination between the bladder contraction and the expected relaxation of the valve. This can lead to increased bladder pressures, which may cause reflux of urine up the tubes to the kidneys. Occasionally a child may need cystoscopy, where a tube is used to look for any abnormalities in the bladder outlet.

It is thought that children with this problem get the message from the bladder late and there is a sudden over response and a desperate attempt to keep dry. Children may try to drink less to reduce the amount of urine but the slow bladder filling makes it harder to feel the bladder filling up and makes the problem worse.Ten to fifteen percent of children with daytime wetting become dry each year but it is a distressing problem and once established continues unless habits are broken. Daytime wetting can be brought under control with retraining, and occasionally suitable medication. The best approach is to encourage the child to pass urine on a timed basis before he/she feels the urge. This needs to be individually tailored for the child and family, especially one who is going to school. The child should also try to relax and empty the bladder without straining. Double voiding is a technique where they count to 10 or 20 and try to empty their bladder again. This reduces residual urine in the bladder. Sympathetic and energetic management putting the child in control, offering reminder alarms and sticker chart strategies are often helpful especially as the programme needs to be continued for at least 6 months.

There is some suggestion that pelvic floor exercises and teaching control with relaxation of sphincter muscles can be helpful, but exercises that encourage holding on to urine can make things worse.

Chronic constipation and even soiling are commonly associated. Addressing this is important in reducing residual urine in the bladder and obstruction of the outflow. Increasing water intake and avoiding caffeinated drinks is important.

Some drugs can be useful. Antibiotics control urinary tract infections and can reduce bladder instability. Antispasmodic drugs such as "Ditropan" do not result in long-term benefits by themselves, but may help short term in assisting with bladder retraining.

Surgery has met with little success and sometimes may worsen the problem. They can lead to true sphincter failure with stress incontinence. Patience and support are needed to correct this problem but a positive approach is usually rewarded by success.

Dr Bobby Tsang, Paediatrician, Northland Health

- reproduced with permission from K.E.E.A.

K.E.E.A. is the national organisation that supports families in New Zealand who have children with wetting and soiling problems. KEEA stands for Kiwi Enuresis Encopresis Association.  Enuresis is the medical term for bedwetting and encopresis the medical term for soiling. For more information, visit their website.