The Management of Urinary Incontinence in Children

Samih Al-Hayek and Paul Abrams

Bristol Urological Institute, Southmead Hospital, Bristol, UK

Introduction
The childhood period is characterized by marked development changes. Acquisition of
toileting skills is part of normal development. However, achievement of urinary control is
complex and yet to be fully understood.
In newborns micturition occurs at frequent intervals and voiding may have an intermittent
pattern, although bladder emptying efficiency is usually good. In over 80 percent of voids
the bladder empties completely (1).
Between the age of 1 and 2, conscious sensation of bladder filling develops. During the
second and third year of life, there is progressive development towards a socially conscious
continence and a more voluntary type of micturition control develops. Through an active
learning process, the child acquires the ability to voluntarily inhibit and delay voiding until
a socially convenient time, then actively initiate urination. This all depends on an intact
nervous system. By age of 4, most children will be able to keep dry both day and night. That
is influenced by family, social and environmental factors (2).
Urinary incontinence in children affects the whole family. To properly manage it, a full
appreciation of the problem, and thorough assessment of the child and the social
circumstances is needed.

Definition
The standardization of terminology committee of the International Continence Society (ICS)
has set the terms and definitions to be used when describing any lower urinary tract
dysfunction (LUTD) (3) and these can be used to describe LUTD in children, with few
exceptions. Indeed, it is important that the same terminology is used in children and adults
in order not to confuse patients, their families and their nursing and medical caregivers.
Urinary incontinence is defined as the complaint of any involuntary leakage of urine. It is
clear that this definition does not apply to infants and small children, and when reporting
incontinence in children further explanation is needed.
Urinary incontinence in children could be classified into two main categories:
Nocturnal enuresis: can be primary or secondary
Day and night incontinence: on the basis of urodynamics this could be
subcategorized into:
1. Detrusor overactivity (during filling)
2. Dysfunctional voiding (where there is urethral overactivity during voiding in the
absence of a neurological cause)
3. Detrusor underactivity

Nocturnal Enuresis (NE)
Definition and classification
Nocturnal enuresis (NE) can be defined as an involuntary voiding of urine during
sleep, with a severity of at least three times a week, in children over 5 years of age in
the absence of congenital or acquired defects of the central nervous system (4).
It has been agreed that 5 years is appropriate, as it is around this time that a child
normally has complete bladder control and has developed cognitive control over
voiding.
Nocturnal enuresis could be classified as primary or secondary:
Primary or persistent nocturnal enuresis describes children who have never achieved a period
of up to 6 months free of bedwetting.
Secondary or onset nocturnal enuresis is the reemergence of loss of control (wetting) after a
period of being dry. Secondary nocturnal enuresis appears to be associated with a higher
incidence of stressful events, particularly parental separation, disharmony between parents,
birth of a sibling, early separation of the child from parents and psychiatric disturbance in a
parent (5-7).
Both Jarvelin and Fergusson et al. argue that primary and secondary enuresis are aspects of
the same problem (6, 8). They claim the two classifications share a common etiological basis.

Nocturnal enuresis can also be classified according to the presenting symptoms as mono- or
non-monosymptomatic.
Monosymptomatic nocturnal enuresis refers to those children who report no bladder or
voiding problems associated with their wetting.
Non-monosymptomatic nocturnal enuresis refers to bedwetting, which is associated with
other symptoms such as urgency and frequency during the day, with or without daytime
wetting (9).
This classification helps in directing the treatment appropriately.
Prevalence of NE
The extent of bedwetting is widespread. But as expected, the frequency decreases with age
(10). It has been argued that nocturnal enuresis is the most prevalent of all childhood
problems.
In the United Kingdom, estimates suggest around three quarters of a million children and
young people over 7 years will regularly wet the bed. In the United States recent evaluations
of prevalence suggest some 5 to 7 million children regularly experience primary nocturnal
enuresis (11).
In the literature, there is a wide variation in the reported prevalence. This may be due to the
definition used for nocturnal enuresis related to the frequency of wet nights. Table I gives the
percentage of children with any episodes of nocturnal enuresis based on surveys undertaken
in Great Britain, Holland, New Zealand and Ireland (12-14).


Table I: Percent of children with enuresis in four surveys.

AGE (YEARS) BOYS % GIRLS %
5 13-19 9-16
7 15-22 7-15
9 9-13 5-10
16 1-2 1-2

Girls are more likely to experience secondary enuresis and associated daytime incontinence
compared to boys, but less likely to have a family history or genetic predisposition to
bedwetting (15-18). A recent survey of twin pairs in England and Wales found a significant
difference between boys and girls in the development of nocturnal bladder control with
54.5% of girls and 44.2% of boys being dry at night (18, 19)
As mentioned before, primary NE usually remits with age (14). The risk of remaining
enuretic during adult life if not treated actively during childhood is about 3% (20).

Treatment of NE
As it is not a life-threatening condition, most parents tend to delay consulting doctors
regarding their children. In England and Scotland only about 50% of children with NE
consult their doctors (21).
It is usually the frequency of bed wetting and how much the family is bothered by the
condition which drives the consultation. Fifteen percent (15%) of children with nocturnal
enuresis wet every night, and most children wet more than once a week (12, 22).
There may be a lack of awareness of the local health care providers (mainly general
practitioners) about the available options in managing NE. A French survey of school
children, most mothers of those children with NE had a rather tolerant attitude, but if the
child had moderate to severe NE then two thirds of the mothers had consulted the doctor,
mainly the general practitioner. However, most doctors suggested no solution or a wait-and-
see approach (23).
The management of nocturnal enuresis depends on the childs motivation to participate in
treatment; confounding psychosocial factors should be addressed, and any intervention
should be regularly reviewed.
It is still not clear whether active treatment of nocturnal enuresis in childhood is able to
reduce the number of adult enuretics.

A- General Measures
The approach in treating primary and secondary NE is the same. Nevertheless, co-morbid
psychiatric disorders in secondary NE should be taken into account.
It is essential to explain the problem to the child and their parents. Education about the
problem and a realistic discussion of the prognosis will help in achieving confidence in the
treatment offered and will improve both compliance and the outcome (24). Asking the child
and parents to keep a record of the wet and dry nights may play a role in engaging them in
treatment.
The family should be counseled to ensure that the child receives the optimal duration of
sleep (24). General advice such as to eat, drink and void regularly during the day, abstain
from drinking too much during the late afternoon and evening, and asking the child to void
before bedtime (25). School teachers should also be informed about these therapeutic rules.
A low calcium and sodium dietary content of the afternoon and evening meals may also be
useful (26, 27).
Regular family and child encouragement with positive attitude towards the child should be
utilized with the explanation that bed-wetting does have a high chance of resolving
spontaneously with up to 19% of children becoming dry within the next 8 weeks without
any further treatment (28-30).
B- Nonpharmacological
Therapy treatment modalities such as fluid restriction, dry-bed training, retention control
training, psychotherapy, acupuncture and hypnosis all have been used but there is still not
enough evidence that they are effective (31-38).
A randomized, controlled trial on laser acupuncture was compared to desmopressin
treatment. The authors concluded that this treatment should be considered as an alternative,
noninvasive, painless, cost-effective and short-term therapy for children with primary
nocturnal enuresis in case of a normal bladder function and high nighttime urine production.
Success rates (about 65%) indicated no statistically significant differences between the well-
established desmopressin therapy and the alternative laser acupuncture (37). However, this
is the only randomized, controlled trial available and included only 40 children.
Comparison of treatment outcome and cure rates for different treatment modalities is
difficult because of the inconsistent use of definitions, the inclusion of children with daytime
symptoms and the variable follow-up periods in most studies.
It is accepted that use of multiple treatment modalities achieves a significant reduction in the
number of wet episodes and possible cure to start with. This will give the parent and the
child confidence that the problem is treatable.



Enuresis alarm
In a recent Cochrane review, C.M. Glazener et al. found that the enuresis alarm is the most
effective means of facilitating arousal from sleep and remains the most effective way to
treat monosymptomatic nocturnal enuresis (39). They reviewed the results of 53 trials,
involving 2862 children and found that most alarms used audio methods. Compared to no
treatment, about two thirds of children became dry during alarm use. Nearly half who
persisted with alarm use remained dry after treatment finished, compared to almost none
after no treatment. There was insufficient evidence to draw conclusions about different types
of alarm, or about how alarms compare to other behavioral interventions. Similarly, body-
worn alarms were as effective as bedside ones. Relapse rates were lower when overlearning
was added to alarm treatment usually done by giving extra fluids at bedtime after
successfully becoming dry for a considerable period of about 14 consecutive nights to
strengthen the bladder control. Alarms using electric shocks were unacceptable to children
or their parents. Although desmopressin may have a more immediate effect, alarms appear
more effective by the end of a course of treatment (39).
Forsythe and Buttler have summarized the history and progress of the enuretic alarm over a
period of 50 years and came to the same conclusion (40).
The systematic review by Mellon and McGrath reported 78% dry children which was
significantly better than no treatment (41).
Alarm therapy has been shown in a meta-analysis to have a 43 percent lasting cure rate (42,
43) which means that is more effective than other forms of treatment (44).Interestingly, the
use of alarm has been found to increase the functional bladder capacity, without any change
in nocturnal urine production or vasopressin secretion, which may explain why children
after successful treatment are often able to sleep without nocturia (45, 46).

Alarms are usually suitable for children aged over 7 years who wants to be dry and can take
responsibility for the alarm with the familys help. The key to success is not the stimulus
intensity of the alarm triggering but the childs preparedness to awake and respond to the
signal.

Relapse may develop but this often responds to further alarm therapy. Failure does not
preclude future successful treatment in an older more motivated child.

Several factors may affect the efficacy of alarm use (Box 1) with potential difficulties (Box 2).


Box I: Factors which might affect the alarm use.

Factors which improve the efficacy of the alarm(2):
Optimal motivation of the child and family,
A higher frequency of wet nights and longer duration of use.
In a successfully treated child, alarm therapy should be continued
for at least a month after sustained dryness.

Reduced efficacy is associated with(2):
Lack of concern shown by the child,
Lack of supervision, inconsistent use
Family stress
Abnormal scores on behavioral check lists
Psychiatric disorder in the child, failure to awaken in response to the
alarm, unsatisfactory housing conditions, and more than one
wetting episode per night.

Box II: Some difficulties when using the alarm.
Common problems with using the alarm (47):
Alarm treatment is slow in the beginning so it should be continued
at least 6 to 8 weeks before it is judged.
Compliance remains a problem. Dropout rates are rarely disclosed
in reported studies. Family members may find this method too
disruptive. Lots of encouragement is needed.
The child may consider it as a punishment. Further explanation to
the child may help.
The alarm may fail to go off or go off for no reason which may cause
disturbance to the child and family.
The child may not wake up to the alarm. Then a family member
should then take the responsibility to do so. It is not necessary for
the child to be fully awakened.
Proper guidance and instructions would resolve many of the above difficulties.
Arousal training
Van Londen et al. first described this procedure with a group of 41 children. He concluded
that arousal training is a fast, simple and effective form of bibliotherapy for nocturnal
enuresis with nonclinical children between 6 and 12 years of age (48).
They reported a response rate of 100%, 98% (14 consecutive dry nights) compared to 73%
with alarm monotherapy, which is an unusually high rate.
Arousal training entails reinforcing appropriate behavior (waking and toileting) in response
to alarm triggering. The parents act as therapists. They reward the operant behavior-pattern
following the urine alarm. The instructions involve (2):
setting up the alarm before sleep
when the alarm is triggered the child must respond by turning it off within 3 minutes
the child completes voiding in the toilet, returns to bed and resets the alarm
when the child reacts in this fashion he is rewarded with 2 stickers
when the child fails to respond in this way the child pays back one sticker
Reward and positive reinforcement
Although star charts for dry beds has been traditionally used by many parents and health
professionals, they tend to be largely unsuccessful. That could be due to the way they are
introduced to the child with a reward for positive outcome, but the child has little or no
control on the outcome (dry night). It was even reported that rewards for actions the child
wishes to engage in will decrease and undermine intrinsic motivation, by decreasing the
childs sense of self-determination and competence (49). For most children the dry night is a
reward in itself.
A better way of using this method is to start rewarding what is controllable. For example,
rewarding regular daytime voiding, waking up to go to the toilet, voiding before sleep and
waking quickly to an alarm triggering.
Cognitive restructuring
Butler suggested three cognitive processes: auto-suggestion, restructuring beliefs and
visualization. Few studies have, however, investigated cognitive change directly.
Normalized voiding
Normalized voiding involves increasing daytime fluid intake, increasing the frequency of
micturitions during the day with voiding regularly at predetermined times (every 2-3 hours)
with avoidance of postponing urination.
This is usually used in combination with other treatment modalities. It is an attempt to
normalize voiding, because many of the children postpone voiding. Although it seems
appealing, this approach has not been examined on its own.

Positive practice
The aim of positive practice is to develop an alternative response to bedwetting. Following a
wet bed, the child is encouraged to practice the following, both immediately and prior to
bedtime the next night (2):
the child is encouraged to lie in bed with the lights off,
count to 50,
go to the toilet and attempt to urinate, and
repeat this few times.
Bollard and Nettelbeck have reported success rate of 83% (50).
It may be clear that this can only be attempted in motivated children and good parental
support.
Retention control training
This is to help the child increase his bladder capacity and the ability to retain urine. The child
will be asked to have a drink, when he or she indicates the need to void, they will be asked
to hold and will be praised if they do. Using a enuresis alarm will increase the methods
effect.
Scheduled waking
The aim is to encourage arousability from sleep. As originally described, there are two
aspects: hourly waking on the first night and scheduled waking thereafter (51).
With the hourly waking on one night only, the child is:
woken each hour with a minimal prompt,
asked to void in the toilet, and
praised for having kept the sheets dry.
On subsequent nights, scheduled waking involved waking the child 3 hours after sleep and
encouraging him or her to void. For every dry night the waking time is brought forward by
a half hour until it is timed to occur one hour after going to sleep.
Bollard & Nettelbeck found this procedure was 100% effective when combined with the
alarm in 12 children (50).


Dry bed training
This was first described by Azrin et al. in 1974 (51) with high success rate. Adjustments have
been made to make the procedure easier, but it is still considered a complex, time-consuming
and demanding procedure (52-54).
The procedure incorporates (2):
the enuresis alarm
positive practice (practice of waking)
cleanliness training (encouraging the child to take responsibility for removing of wet
night clothes and sheets, re-making the bed and resetting the alarm)
waking schedules - to improve arousability from sleep as described above and
involving:
For the first night, waking the child each hour, praising a dry bed, encouraging the child to
decide at the toilet door whether he or she needed to void, and on returning to bed the child
is encouraged to have a further drink. On the second night, the child is woken and taken to
the toilet 3 hours after going to sleep. For each dry night the waking time is brought forward
by 30 minutes. If wet on any night the waking time stays at the time of the previous evening.
The waking schedule was discontinued when the waking time reached 30 minutes following
the child going to sleep. The waking schedule is resumed if the child begins wetting twice or
more in any week, stating again 3 hours after sleep.
social reinforcement and
increased fluid intake.
Final message for nonpharmacological treatment
In a recent Cochrane review, 13 trials were assessed, involving 702 children of whom 387
received a simple behavioral intervention. In single small trials, reward systems (e.g., star
charts), lifting and waking were each associated with significantly fewer wet nights, higher
cure rates and lower relapse rates compared to controls. There was not enough evidence to
evaluate retention control training (bladder training). Cognitive therapy may have lower
failure and relapse rates than star charts, but this finding was based on one small trial only.
This makes the evidence behind using these methods shaky. However, simple methods could
be tried as first-line therapy before considering alarms or drugs, because these alternative
treatments may be more demanding and may have adverse effects (52).
The same group have reviewed 16 trials involving 1,081 children which included a complex
or educational intervention for nocturnal enuresis. A complex intervention, such as dry bed
training (DBT) or full-spectrum home training (FSHT) including an alarm, was better than
no-treatment control groups, but there was not enough evidence about the effects of complex
interventions alone if an alarm was not used. An alarm on its own was also better than DBT
on its own, but there was some evidence that combining an alarm with DBT was better than
an alarm on its own, suggesting that DBT may augment the effect of an alarm. There was
also some evidence that direct contact with a therapist might enhance the effects of an
intervention (53).
C- Pharmacotherapy
Pharmacological treatment for nocturnal enuresis can have either a full, partial or no
response. A full response has been defined as a reduction in wet nights of at least 90%, to
allow for the occasional accidental wetting, partial response is defined as a reduction in wet
nights of 50-90%; less than 50% reduction in wet nights is considered to be nonresponse (55,
56).
A lasting cure is defined as a full response, still present 6 months or longer after
discontinuation of pharmacotherapy.
With a follow-up of at least 6 months, response can become a lasting cure (>90% reduction)
or a lasting improvement (50-90% reduction).
This definition of full response means that a child could still be wet 2 or 3 times per month,
and many would not regard this as a full response!
Desmopressin (dDAVP)
Desmopressin (dDAVP) is an analogue of vasopressin created by deaminating the cysteine
residue at position 1 and substituting D-arginine for L-arginine at position 8. These changes
result in significantly increased antidiuretic activity but loss of the vasopressor activity. The
half-life of dDAVP is 1.5-3.5 hours.
The normal circadian variation in urine production, with a nocturnal rise in vasopressin, is
absent in a significant proportion of patients with monosymptomatic nocturnal enuresis
(MNE) (24).
When NE is a significant problem for the child and the child is older than 6 years, treatment
for enuresis should be offered. Initial treatment will usually be the enuresis alarm or
desmopressin. Desmopressin is easy to administer and the clinical effects appear
immediately. The usual dose is 0.2-0.4 mg orally or 20 -40 g intranasally at bedtime. A small
group of children who do not respond to desmopressin in ordinary dosage will become dry
when the dose is doubled (57).
Desmopressin can also be helpful in children who have failed to respond to, or who have
withdrawn from alarm therapy, or for whom alarm therapy is unacceptable. Also, it is useful
when the child would like to attend an overnight school trip or stay at a friends house (28).
Placebo-controlled studies have shown that the antidiuretic drug dDAVP is significantly
more effective than placebo (58).
Patients on desmopressin were 4.6 times more likely to achieve 14 consecutive dry nights
compared with placebo (59). However, there was no difference after treatment was finished.
Kruse et al. found that the best results were obtained in older children who respond to 20 g.
dDAVP and who do not wet frequently (60).
A better response to desmopressin has been found in children with larger bladder capacities
(25).
Relapse after short-term treatment is rather the rule, whereas long-term treatment may yield
better cure rates (61). Intermittent therapy appears to decrease the number of relapses (62).
It has recently been shown that the chances of permanent cure may increase by adopting a
structured withdrawal program. This implies a gradual discontinuation of the drug (over an
8-week period) and positive reinforcement of dry nights without medication. At week 10
with complete cessation of medication, 75% of children remained dry (63).
Although several studies have shown that dDAVP is a well-tolerated and safe drug, even
during long-term usage, one has to be aware that dDAVP is a potent antidiuretic drug and
that there have been reports on severe water retention with hyponatremia and convulsions,
but these are infrequent (64-68).
Combined treatment with alarm and desmopressin
Combined treatment is superior to alarm alone especially for nonresponders of each
individual treatment. Both treatments are started at the same time: the rapid action of
dDAVP is believed to facilitate the childs adaptation to the alarm. Leebeek reported a
temporary, positive effect on enuresis using desmopressin combined with alarm therapy.
However, both treatment modalities had a low long-term success rate of 36-37% (69, 70).
Compared with either therapy alone, the combination has been found to be particularly
effective in children with high wetting frequencies and behavioral problems.
Combination with full-spectrum therapy may even yield higher success rates (71, 72).
Van Kampen et al. reported their results of full-spectrum therapy in 60 patients: they were
treated for 6 months with a combination of alarm, bladder training, motivational therapy and
pelvic floor muscle training: 52 patients became dry (71).
Antimuscarinic drugs
Antimuscarinic drugs are mainly used for patients with overactive bladder symptoms (OAB)
which might lead to daytime incontinence. They might therefore be of use for the subset of
enuretic patients who have restricted bladder capacity due to detrusor overactivity at night,
a pattern found at nocturnal cystometry in 30% or more of enuretic children (19). Because it
is difficult to perform a nighttime cystometry in children, antimuscarinic drugs may be used
in children who have more than 2 wetting episodes per night and who do not respond to
dDAVP. They could also be used in combination with alarm or dDAVP (73, 74).
Tricyclic antidepressants
The mechanism by which imipramine helps NE is not clear. The therapeutic effect does not
appear to be mediated via its antidepressant effect; a suggested mechanism of action is
reduced detrusor activity and increased bladder capacity due to anticholinergic and smooth
muscle relaxant effects and sympathomimetic or central noradrenergic mechanisms.
Due to major cardiotoxic side effects, even in therapeutic doses, and the possibility of death
with overdose, they cannot be generally recommended for treatment of this nonlethal
disorder (75).
Only in selected cases (like adolescent boys with attention deficit hyperactivity disorder and
persistent nocturnal enuresis) should it be considered (76).

Other medications
Carbamazepine is chemically related to imipramine. It can reduce prostaglandin E2-like
activity in inflammation. It has been recently tried in NE with 30-day treatment periods of
either placebo or carbamazepine (200 mg) tablets, in a randomized, double-blind, crossover
design. There was 1 week washout period between medications. The patients or their parents
received a calendar sheet to record wet and dry nights and offered subjective opinions
concerning changes in sleep patterns, occurrence of nocturia and appearance of side effects.
The difference in response to placebo and carbamazepine was statistically significant.
Indomethacin had also been investigated (77-79). However, these are still pilot studies with a
small number of patients preventing their use from being recommended at present.
D- Refractory NE
About one third of children do not respond to treatment with alarm and/or dDAVP.
There is a role for anticholinergics especially if the child voids more frequently than his/her
peers or has urgency and daytime incontinence. Treatment success is usually noted between
1-2 months. Treatment should be continued for 6-12 months, but good clinical evidence is
lacking for efficacy.
On the other hand, some of these children may have functional incontinence. They should be
given a strict voiding regimen and a combination of dDAVP with the alarm (80).
If all the above do not work, then absorptive nocturnal hypercalciuria may be responsible for
the nocturnal enuresis in some of these patients. With an appropriate (low-calcium) diet
these patients became desmopressin responders (81).

Day and Night Incontinence
If the development process of bladder control is not completed, the child may have urinary
incontinence. This can be with no obvious cause (functional) but occasionally is secondary to
causes such as congenital or neurological.
Urinary incontinence in children may be due to disturbances of the filling phase, the voiding
phase or a combination of both.
Those who have incontinence they usually have other symptoms such as frequency, urgency
and infection. The use of urodynamics investigations (82, 83) helped to classify those children
into different categories:
Detrusor overactivity (during filling)
Dysfunctional voiding (where there is urethral overactivity during voiding in the
absence of a neurological cause)
Detrusor underactivity


Prevalence of Day and Night Incontinence
Most have looked at childrens incontinence as either diurnal or nocturnal, and less often at
the subcategories of daytime incontinence. This makes it difficult to have a representative
picture of the prevalence of the different types.
Overall, the prevalence varies from 1% to 10%, but in general for 6- to 7-year-old children,
the prevalence is somewhere between 2% and 4%, and rapidly decreases during the
following years (10-16 yrs): it is more common in girls than in boys (82-84).
This prevalence obviously depends on the criteria used to define incontinence. Sureshkumar
et al. in a population based survey of over 2000 new entrant primary school children (age 4-6
years) in Sydney, Australia, noted an overall prevalence of daytime wetting of 19.2% when
considering at least one daytime wetting episode in the prior 6 months, with a further 16.5%
having experienced more than one wetting episode and only 0.7% experienced wetting on a
daily basis (85).
Children with daytime or mixed wetting were found to suffer from urgency in 50.7% of the
cases, with 79.1% wetting themselves at least once in 10 days (15). Urgency as a symptom
seems to peak at age 6-9 years and diminish towards puberty, with an assumed spontaneous
cure rate for daytime wetting of about 14% per year (86, 87).
Swithinbank et al. have found a prevalence of day wetting of 12.5% in children age 10-11
years, which decreases to 3.0% at age 15-16 years but this included "occasional" wetting (88).

Treatment of Day and Night Incontinence
Overactive bladder (OAB)
The treatment of OAB involves a multimodal approach. Behavioral modification is important
and in some children may be all that is necessary. Others will require the addition of
antimuscarinic medication. In some children, the addition of biofeedback is useful. It is
important to treat other underlying and potentially complicating conditions such as
constipation and UTIs (2).
Dysfunctional voiding
Treatment is aimed at optimizing bladder emptying and inducing full relaxation of the
urinary sphincter and pelvic floor, prior to and during voiding.
Strategies include pelvic floor muscle awareness and timing training, repeated sessions of
biofeedback, visualization of pelvic floor activity and relaxation, clean intermittent self-
catheterization for large post-void residual volumes of urine, and antimuscarinic drug
therapy if detrusor overactivity is present. If the bladder neck is implicated in increased
resistance to voiding, -blocker drugs may be introduced (89-91).
Recurrent urinary infections and constipation should be treated and prevented during the
treatment period.
A review of interventions for children with dysfunctional voiding revealed 17 studies; eight
evaluating biofeedback or pelvic floor muscle awareness training, five reporting -blockade
pharmacotherapy, two relating to electrical stimulation and one each describing clean
intermittent catheterization and the use of anticholinergic medication. Only one study was
randomized, none were controlled and five were retrospective.
As with overactive bladder, the natural history of untreated dysfunctional voiding is not well
delineated, and thus the optimum duration of therapy is not well described.
Detrusor underactivity (DUA)
Treatment is aimed at optimizing bladder emptying after each void. Clean intermittent (self-
) catheterization is the procedure of choice to promote complete bladder emptying, in
combination with treatment of infections and constipation (which may be extreme in these
patients). Intravesical electrostimulation has been described, but at this time it is not
recommended as a routine procedure for children.
Giggle incontinence
Since the etiology of giggle incontinence is not known it is difficult to determine the
appropriate form of treatment. Positive results have been reported with conditioning
training, methylphenidate and imipramine (75, 92-94). Others have tried antimuscarinic
agents and -sympathomimetics. There is no acceptable evidence that any form of treatment
is superior to no intervention.

Conclusion
Although some studies have been conducted on possible treatment for daytime incontinence,
most lack proper randomization, long-term follow-up or good number of participants. This
was confirmed by the Cochrane review for the period between 1996 and 2001: the authors
identified only five trials that compared two or more interventions using a randomized
controlled design (95). Of these five studies, four evaluated pharmacotherapy. Of the four
pharmacotherapy studies, two evaluated the use of terodiline, one evaluated the use of
imipramine and the remaining abstract the use of oxybutynin versus biofeedback (96-98).
The remaining study evaluated the use of alarm therapy for daytime incontinence (99).
Terodiline is no longer available due to its adverse effect profile, imipramine is not the first
choice for daytime incontinence due to its side effects, and alarm therapy is not felt to be a
useful therapy for daytime incontinence. Therefore only one study in over 30 years was felt
to be of high quality. This review highlights the need for properly designed studies to assess
the impact of the various forms of therapy on daytime incontinence.
The limited number of identified randomized controlled trials does not allow a reliable
assessment of the benefits and harms of different methods of management in children.
Further work is required in this difficult clinical area.


References
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