Pediatricians and clinical staff manage patients with urinary incontinence on a regular basis. In fact, an estimated 20 percent of boys and 17 percent of girls, ages 6 to 7 years old experience some form of daytime or nighttime wetting.
Because of the highly personal and private nature of the condition, many children and families are reluctant to talk about wetting with their pediatricians.
Notes discussed the condition with Carlos Estrada, Jr., MD, urologist and director of the Voiding Improvement Program (VIP) at Boston Children’s Hospital, along with Nursing Program Director Pamela Kelly, MS, RN, CPNP, and they offer the following insight on the overall diagnosis and treatment of daytime wetting in children.
What are common mistakes made when diagnosing daytime wetting?
A common mistake clinicians make is to consider all cases of daytime wetting the same. The condition, although manageable, requires putting all the diagnostic pieces together. There can be a wide variety of underlying pathologies for daytime incontinence and it is very important to be thorough and exclude all the possibilities.
When should a patient see a voiding specialist and what steps are taken to diagnose a voiding issue?
Once a complete medical history and physical exam have been completed, further evaluation is necessary to make sure a more serious underlying medical or surgical issue is not present.
We feel that just about every child with urinary incontinence can benefit from a visit in the Voiding Improvement Program. Given the breadth of our available resources, the Voiding Improvement team has the ability to perform a comprehensive evaluation and formulate an individualized treatment plan which may include:
- The evaluation process: Our VIP team — comprised primarily of nurse practitioners and nurses, along with an attending Urology physician, begins the evaluation process by investigating a child’s elimination habits and voiding patterns. We have detailed discussion with the parents and the child and review the child’s diary of daily toileting habits and wetting episodes. Our goal is to determine the following:
- Elimination hygiene or position when they void: Is the child evacuating all the urine from the genital area? Is the child wiping properly? Many kids develop poor elimination (withholding and/or not taking the time to completely empty their bladders or have a complete bowel movement) habits because they are distracted by daily activities (e.g., video game and electronics use). Improper elimination and/or distractions can be very impactful and cause incontinence and discomfort with toileting. Constipation is a key contributor to voiding issues and a majority of kids who come to the VIP with daytime incontinence have some measure of constipation.
- Is the child constipated? Constipation is a key contributor to voiding issues. Our nursing team reviews the child’s diet for potential bladder irritants and foods that may increase constipation. A majority of kids who come to the VIP with daytime incontinence have some measure of constipation. About 70-to-80 percent of the time, the clinical history indicates the child is having daily bowel movements. An x-ray is also ordered to determine if there is significant stool and rectal dilation, both of which may cause the incontinence.
- If constipation is a factor, our team takes a standardized approach — one based on protocol developed with help from our Gastroenterology colleagues. If the approach is unsuccessful, we recommend the patient see a GI specialist.
- Additional testing: Through the investigative process, our Voiding Improvement team will order an ultrasound and uroflowmetry to determine if there are any structural or anatomical issues. The results of these tests determine which treatment options should be administered.
Once it has been determine that there are no structural or anatomical issues, what are the next steps?
Introduce a timed voiding schedule. The goal is to make sure the child urinates first thing in the morning — ideally every two-to-three hours during the daytime to promote regular bladder emptying, and routinely before going to bed. This schedule keeps the child’s bladder as empty as possible, eliminating the risk of incontinence. It also helps promote healthy toileting habits.
Voiding dysfunction. If the child isn’t experiencing positive change, we investigate voiding dysfunction — a condition where the bladder contracts during the voiding process. This can lead to incomplete emptying and some bladder irritability, which causes bladder over activity and consequently incontinence.
How do you treat voiding dysfunction?
Biofeedback training: Often children with voiding dysfunction are sent for biofeedback training provided by trained nurses and nurse practitioners in our Urodynamics laboratory. Biofeedback is an innovative and non-invasive approach to pelvic floor muscle retraining that involves an interactive software program, resembling a video game, that engages children to participate . (This is in addition to addressing toileting habits, diet and constipation.)
Utilizing this technology, we reteach children to relax their pelvic muscles when they are voiding. If you tell any patient, especially a child, to relax your pelvic muscles, they have no idea what you are talking about. With biofeedback training, the patient is connected to a computer and we monitor their ability to relax and contract their pelvic musculature while voiding.
The number of training sessions required varies by child. In general six to 12 sessions are spaced over a one-to-two week period. With consistency, children generally do exceptionally well with this approach.
Relaxation techniques and behavioral modification training: Age appropriate techniques such as deep breathing and guided imagery are often included in biofeedback visits. Interventions are tailored to each individual child and family. The goal is to help the child learn to relax while they are voiding. The condition is simple but it is a complex issue that needs to be pieced together and worked through.
Medication: When a child has an overactive bladder, the bladder will frequently become irritable, which may prompt the need for medication to remove the overactive contractions and relax the bladder. We don’t give medication right away, and typically reserve its use for kids whose clinical history supports an overactive bladder.
Sometimes kids get a combination of biofeedback training, overactive bladder medication, the time voiding schedule and the constipation clean out. Every child’s treatment is individualized.
What are the psychological effects, if any, for a child managing daytime wetting, and how does the Voiding Improvement Program address them?
The psychological effects of wetting can be quite profound. The more severe the incontinence, the more severe the psychological issues. Every child is unique and as you can imagine, soiling your underpants is very difficult for a children and families. Bullying and developing poor self-esteem has been associated with wetting and it’s a real issue. Our program has a dedicated clinical psychologist and social worker.
Children may also start wetting in response to social stresses, such as a divorce or a death in the family. Sexual abuse may potentially prompt incontinence. Our nurse practitioners conduct a very careful examination and our psychologist and social worker may play a prominent role in a child’s overall care.
What makes Boston Children’s Voiding Improvement Program unique?
A lot of what we do is demystifying the condition. Our dedicated nursing staff talk about how common the condition is and remind the child and family that this isn’t something a child chooses to do. That is why it is so important for us to spend so much time with these kids and families and not simply diagnose and quickly treat.
Our clinical psychologist and clinical social worker work with families to identify barriers to follow through with interventions, positive motivators and behavioral modification techniques are used to support children and families. Our team collaborates with all caregivers and includes school nurses and pediatricians as part of the treatment plan. This allows for consistency and coordination of follow though at home and in school, if needed. These interventions are done with the parents request, consent and partnering.
Learn more about Boston Children’s Voiding Improvement Program.
About our experts:
Carlos Estrada, Jr., MD, is the director of Voiding Improvement Program, director of the Spine Bifida Center, co-director of Neurourology and Urodynamics, and associate professor of Surgery (Urology) at Harvard Medical School.
Pamela Kelly, MS, RN, CPNP, is nursing director of the Voiding Improvement Program, nurse manager of Urodynamics and a clinician in Urology.