Daytime Urinary Incontinence Turkey
Daytime Urinary Incontinence Turkey

This content created by Halil Tuğtepe, Prof. Dr. with attribution to scientific articles.

Daytime Urinary Incontinence Turkey

What Is Daytime Urinary Incontinence?

Daytime urinary incontinence is urine leakage that the child cannot control while awake. These urine leaks can drop by drop, or they can be enough to wet the place. This is changing from child to child.

It is normal for 5 years and older children to urinate at most 7 times a day, but 8 or more urination is unusual. Frequent urination and sudden urgency symptoms are admitted as symptoms of the lower urinary system, even in the absence of incontinence, and urinary incontinence treatment is given.

How Common Is Daytime Urinary Incontinence?

Day wetting is more common in girls than boys. Approximately 8-10% of children between the ages 4 and 12 suffer from daytime wetting. It is most common among school-age children.

What Causes Daytime Urinary Incontinence?

Daytime urinary incontinence can occur due to many reasons. Pelvic floor muscle dysfunction is the main reason for this.

  • Overactive bladder: Overactive bladder is, the frequent spasm of the bladder muscles during the filling phase. In children with an overactive bladder, the urge of urinating comes suddenly. Generally, they may exhibit behaviours such as squeezing the penis with their hands, crossing their feet, sitting on the heel in sudden squeezing. If there is no toilet nearby, they may pee one's pants at the last minute. At the same time, they feel an immediate need to urinate, and they pee little. They often go to the toilet.
     
  • Dysfunctional urination: It is the unusual spasm of the sphincter (muscles around the anus) muscles during urination, often with an overactive bladder. While the child is urinating, intermittent urination occurs with the pelvic floor muscles spasm (normally it should relax).

Therefore, residual urine in the bladder, frequency of urinary tract infections, constipation and urine leakage to the kidney are more common in this group. It is more painful and dangerous than an overactive bladder. It is more painful and dangerous than an overactive bladder. If untreated, it can cause severe functional deterioration of the arteries and kidney failure.

  • Less active bladder: This is because by insufficient bladder muscles spasm required for urination in children. Generally, they try to urinate by squeezing their abdominal muscles, or by pressing the bladder with their hands. Bladder capacities are 150% more than they should be. Usually, these children go to toilet less than 3 times a day. After the urination, much urine remains in the bladder. This can lead to urinary tract infection.
     
  • Urination delaying: Some children fall into the game, play with the tablet, become lazy, and may delay going to the toilet. The children, who delay urination, put more load on the pelvic floor muscles and the muscles become dysfunction. This situation is going with problems such as urine retention in the bladder and urinary tract infection.
     
  • Constipation: Intestines filled with faeces can compress the bladder and cause frequent urination.
     
  • Urinary Tract Infections
     
  • Incontinence while laughing (Giggle incontinence): It is a particular and rare situation. The child releases almost all of his urine while laughing. Usually, these children have weak pelvic floor muscles.
     
  • Anatomical anomalies: Continuous urinary incontinence complaint occurs when the urinary tract, called the ureter, opens not to the bladder, but the vagina or external genital area (in girls). Therefore, it is crucial to know that girls with urinary incontinence can stay dry at certain hours. If urinary incontinence is continuous, this disease should be kept in mind.

What Examinations And Evaluations Should Be Done For Daytime Urinary Incontinence?

For understand the reason the wetting, firstly taken a detailed history, and physical examination to the child with daytime wetting.

The doctor will ask questions about urinary incontinence like "when?" and "how often?" to the family and the child. One of the most important problems that families are not aware or overlook is constipation. Constipation and incontinence or frequent urination are like an inseparable duo. It is crucial to pay attention to whether the child has constipation.

As part of the physical examination, the child's abdomen, rectum, spine, and genital area are checked-up. The EMG-uroflowmeter is performed and the urination quality is checked-up. Depending on the results of the physical exam, other tests may be ordered, such as:

  • If there is a possibility of bladder or kidney infection: urinalysis, urine culture and sensitivity test.
  • If there is a possibility of birth defects in the urinary system: ultrasound, cystoscopy, intravenous pyelogram or urination cystourethrogram. (Daytime wetting may be related to problems in the development of the urinary system.)
  • If there is a possibility of a lack of nervous system control of the bladder: urodynamic study.
  • All examinations may be normal. At the same time, pelvic floor physiotherapists should evaluate the function of the pelvic floor muscles. The function of the pelvic floor muscles cannot be understood by the tests above. For this, EMG performed manually or with electrodes on the muscles in the pelvic floor should be evaluated.

Physical evaluation: In enuresis, weight, blood pressure measurement and head-neck-abdomen examination are crucial besides the general physical examination. A detailed neurological examination, especially a hair growth, swelling or dimples (spina bifida) that appear in the midline in the waist may indicate an underlying neurological disease.

The child's ability to walk and tendon reflexes are also crucial in clinical findings. The child's hyperactivity or attention deficit can be also noticed by the doctor during history taking or physical examination.

During genital examination, noticing a constantly leaking urine -especially in girls, may indicate a ureter (urethra) opening into the genital area or urethra (urinary tract). At the same time, rectal evaluation is important in understanding the circumstance of constipation and the function of the pelvic floor muscles (rectal muscles).

Tests requested for diagnosis:

  • Urinalysis and urine culture: Urinalysis is a test that should be done in all pediatric urology patients. The appearance of bacteria, leukocytes (the white blood cell responsible for defence) or blood in the urine indicates a urinary tract infection.
     
  • Kidney and bladder ultrasonography: Ultrasonography is a simple but informative imaging method. It gives information about whether there is an enlargement (hydronephrosis) in the kidneys, the presence of a cystic structure in the kidneys, whether there is an enlargement in the ureters and the condition of the bladder.

Also, ultrasonography is consumable to measure bladder wall thickness, bladder volume, urine remaining in the bladder after the urination and the diameter of the rectum (the last part of the large intestine).

  • Blood analysis: It may be requested by your doctor when necessary for the examination of kidney and liver functions.
     
  • 2-day urination schedule: It is one of the indispensable tests in the evaluation of children with urinary incontinence. If it is complete correctly, it gives information about the number of the urinate times, how many ccs of urine he urinates, whether there is incontinence during the day and the type and amount of fluid he drinks.
     
  • EMG uroflowmetry test (urine flow test): It is a very simple and fast test that is used in clinical decision making. After drinking water, two EMG electrodes are attached to the area where the pelvic floor muscles (muscles around the anus) are located, and they are asked to urinate in a urine container connected to a computer.

With this test, important information is obtained about the type of urination, the amount of urine, the rate of urination, the duration of urination, whether the pelvic floor muscles contract during urination, and whether or not there is urine in the bladder after urination. The test is practical and gives the test result instantly. During the procedure, there is no pain that will disturb and worry children.

  • EMG pelvic floor muscle measurement test: For evaluate the tension and functionality of the pelvic floor muscles, EMG measurements are made with electrodes. All these examinations may be normal.

Also, pelvic floor physiotherapists need to evaluate the function of the pelvic floor muscles. The function of the pelvic floor muscles cannot be understood from the above tests. For this, EMG applied to the pelvic floor muscles with manual or superficial electrodes should be evaluated.

  • Urodynamics: This test is desirable for children who we think are resistant to treatment or have a neurogenic problem. This test is required in only 5-10% of the children who comes with daily urinary incontinence problems.

What Are The Commonly Used Treatment Options For Daytime Urinary Incontinence?

Healthy Bladder and Bowel Training

Children with bladder problems like urinary incontinence, urination dysfunction, overactive bladder, and underactive bladder should be provided with toilet training. For this, should be spent time with the child, but shouldn't be pressure exerted on the child. Family and children; should be informed about pelvic floor muscles, urination physiology and anatomy, bladder-bowel recommendations and should follow all the rules. The school teacher should be involved in the treatment process, be informed, and the importance of permitting the child whenever he asks to go to the toilet. Also, families should motivate and sometimes reward their children.

For bladder-bowel problems, this training is a crucial part of treatment. Thanks to this training, the child's bladder and intestine are retrained with the habit changes made in his daily life. Therefore, it is beneficial that this training is given by an experienced pediatric urologist and pelvic floor physiotherapist who are constantly monitored.

Biofeedback

Biofeedback has been used for the first time in urology in patients with overactive bladder diseases. Today, it can be used in all bladder problems like dysfunctional urination, bladder wall muscle - bladder neck muscle incompatibility disorders, overactive bladder, underactive bladder.

The aim is to ensure the correct and effective use of the pelvic floor muscles, which significant in urination control. The tension, fatigue and endurance of the pelvic floor muscles should be examined before and after the treatment, and the treatment process should determine accordingly.

Biofeedback is an animated education on the computer used particularly in children. It is applied entertainingly. EMG electrodes (such as stickers) are placed around the patient's anus and told the patient to relax and contract the pelvic floor muscles.

When it contracts, fish, birds, etc. in computer animation, the animal moves up, and when it relaxes, it moves down. It is made to understand this with commands such as hold your pee or do it. There are different times in the literature regarding the duration of treatment. The duration of treatment depends on the patient. Studies have shown that animated biofeedback therapy cures faster than non-animated ones.

Biofeedback therapy is not enough to train the pelvic floor muscles alone. For an effective pelvic floor rehabilitation, in addition to biofeedback therapy; Different physical therapy modalities like different exercises, manual therapy, breathing and posture training, relaxation training should be added to the treatment. This rehabilitation should be done by a pelvic floor physiotherapist under the control of a pediatric urologist.

Neuromodulation (Electrical Stimulation with Electrodes)

Although the mechanism of nerve stimulation is still not fully understood, it admitted that stimulation of the sacral nerve roots provides modulation of the reflex pathways between the pelvic floor, bladder and bladder outlet.

Nerve stimulation therapy in the clinic, it applied to the sacral area and the area around the ankle where the nerves related to the bladder pass. It is made with the TENS device. This is not a surgical procedure. It can be applied very easily with electrodes in the form of stickers. It has no side effects.

In 2013, we are also applying our sacral nerve stimulation to patients with resistant to drug treatment in Turkey. 85% have achieved success. We have proven that we have achieved permanent success by following our successful patients for 2 years. This treatment method which is we use only in Turkey has started to become increasingly common.

Like Biofeedback, neuromodulation is not a stand-alone treatment method. It should be used in addition to other treatment modalities.

Medication Therapy

Your doctor should decide on medication. The amount and dosage of medication should be adjusted by the doctor. There is no requirement that every child with urinary incontinence will use medication. In our clinic, we try to treat our patients with as little or no medication as possible.

  • Drugs that relax the bladder wall muscle: All drugs in this class, prevent the bladder from contracting, causing the bladder to relax. They usually used in overactive bladder. Constipation, dry mouth and hot flushes can be discernible as side effects. There is a false belief among the public that these drugs cause infertility. However, these drugs have no such side effects.
     
  • Drugs that relax bladder neck muscles: The purpose of these drugs is to treat bladder emptying in patients with dysfunctional urination difficulties. Before these drugs, which used as blood pressure drugs, cardiology consultation is required.
     
  • Protective antibiotics: Prophylactic antibiotics used in cases where urination problems lead to recurrent urinary tract infections.
     
  • Botox application to the bladder wall muscle: The urological use of botulinum toxin A (Botox) has increased in the last decade. It causes relaxation of the muscles by preventing the release of some substances in the nerve terminals.

It can be used in children with resistant detrusor overactivity and neurogenic bladder diseases. Most studies report that the relaxing effect lasts 6-9 months. As side effects, it has been reported that the amount of urine remaining in the bladder after dose-dependent urination and the use of clean intermittent catheterization increased.

Clean Intermittent Catheterization (CIC)

Although it is primarily used for the treatment of the neurogenic bladder, also, it can be used in children with urine remaining in the bladder after urination. CIC can make children quite uncomfortable. The purpose of the treatments reducing the number of CIC in children by preventing urine remaining in the bladder.

Other methods

In patients who are not treated and have severe bladder structure; If worsening continues despite CIC, anticholinergic and/or Botox, bladder augmentation (bowel patch to the bladder) may be required. Even more rarely, these patients may require kidney transplantation.

How Do Treat Urinary Incontinence Problem as Tuğtepe Children's Bladder-Intestinal Disorders Center?

After evaluating the pelvic floor muscles, we plan the treatment program for each child. In our treatment, we consider the pelvic floor and all the muscles related to the pelvic floor. In our treatment program;

  • manual therapy,
  • diaphragm breathing,
  • exercises,
  • pelvic floor exercises,
  • There are many different processes like biofeedback. With the electrodes we attach around the anus, we use the child's muscle to play computer games and make the treatment more enjoyable.

For example; An aircraft is placed on the computer screen. The plane takes off when the child squeezes the pelvic floor muscles. It goes down when he relaxes. With games, we try to teach the activity of these muscles more quickly and funnily.

As a result of these treatments, we enable the regain the function of the pelvic floor muscles of the child. In this way, we teach correct urination and defecation. Thanks to the pelvic floor muscles that have regained their function, children also manage to stay dry day and night.

What Happens If Daytime Urinary Incontinence Is Not Treated?

Daytime incontinence can negatively affect the child's self-esteem and psychology. Therefore, children with daytime incontinence should be examined and treated as early as possible.

The problem of incontinence during the day is considerable, even in drops. It can lead to more critical issues in the future. Families with urinary incontinence "It passes after a while, it is a child" "His father also pee when he was little." and does not consider the possibility of treatment. Without improving the function of the pelvic floor muscles and giving bladder-bowel training, leaving this situation to time may cause urinary incontinence to continue increasing.

The child who has only urinary incontinence issues about time; With the addition of poo incontinence, urinary tract infection, psychological problems, it can become a complex health problem. After a while, urine starts to remain in the bladder of children whose treatment is delayed, the remaining urine starts to flow back to the kidneys and permanent damage to the kidneys may occur.

In cases such as dysfunctional urination or underactive bladder, the bladder may lose its function at older ages and the child may not be able to urinate. Bladder structure may be injured. Children with kidney disease, usually start with the complaint of urinary incontinence and urinary tract infection, which families see as innocent. Therefore, should be consulted to the pediatric urologist before the complaint of daytime incontinence is simplified.

Studies also conducted in recent years have shown that urinary incontinence problems that are not treated sufficiently in childhood cause serious bladder problems in adulthood, kidney problems during pregnancy, critical constipation and urinary tract infection problems.

Published: 08 Şubat 2021
Updated: 25 Şubat 2021

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