Editorials for Clinical Practice
CHADIS Co-Director and President, Dr. Barbara Howard is a regular contributor to the Behavioral Consult column of Pediatric News and an Assistant Professor of Pediatrics at The Johns Hopkins University School of Medicine.
Dr. Howard is a developmental-behavioral pediatrician trained by Dr. T. Berry Brazelton at Harvard University. She is a national speaker on child behavior problems and is a past president of the Society for Developmental and Behavioral Pediatrics. She was a contributing author for Bright Futures™, Diagnostic and Statistical Manual for Primary Care (DSM-PC) and Bright Futures in Practice: Mental Health and has served on national committees of the American Academy of Pediatrics.
Internet incontinence and other daytime disasters
Can you remember the name of that kid who wet his pants in your second-grade class? I can. Daytime wetting, now properly called daytime incontinence (wetting when awake), affects 2%-7% of children and really makes a mark, and not just on the sofa! Technically, according to DSM-IV, it is defined by two or more wetting episodes per week for 3 months in a child 5 years or older (mental age) that are not due to substances or another medical disorder.
School-aged children are painfully aware of those who are different, especially in a way that appears to be a developmental deficiency. Being called a "baby" is never a compliment to 6- to 12-year-olds. Wetting your pants is sure to be noticed and the child is certain to be labeled. But daytime wetting is not a simple matter of a developmental delay. It is most helpful to divide incontinence into problems of storage and of release. These categories also help you decide what assessments need to be done.
A child who can hold urine fine all night but wets during the day has a release problem, not a storage problem. A child with dyssynergy. The early or mid-pubescent girl who laughs until she wets has giggle micturition (and often also has attention-deficit/hyperactivity disorder [ADHD] underlying it that can be helped by stimulants, if indicated by other criteria). The girl who voids, wipes, stands up and discovers wet panties has vaginal reflux. Such girls often are overweight. They can resolve the incontinence by sitting backward on the toilet to spread the legs, relaxing, and then stand over the toilet before sitting down to wipe again (and ideally losing weight). Thus both history and observation of voiding can help sort out the cause. A bladder ultrasound to check bladder capacity and postvoid residual may be needed in a few cases, but history or a diary will usually suffice.renal disease, sickle cell disease, hyperthyroidism, diabetes mellitus or diabetes insipidus, or who uses diuretics and thus creates excess dilute urine will have trouble containing her urine both night and day. A child who has an erratic spray of urine or has to grunt and strain to void has a release problem that is either structural or more likely a learned
It is helpful to normalize wetting by saying, "This is really common but really embarrassing," and assuring them that you know how to help them control it. Asking, "How hard has this been for you?" and "Is this something you want to fix?" will help you assess their motivation. All the behavioral strategies for wetting require the child’s participation to be effective.
The new epidemic I am seeing in daytime wetting I now dub Internet incontinence! Most daytime activities are not so captivating for a child as to keep the child from the socially face-saving act of heading for the bathroom on time, but electronic games can clearly do that! Some children have this priority-setting problem when playing outside with friends, but there is usually a tree handy (for boys), so it does not come to clinical attention. Cases of video game addiction in Japanese teens have included starvation as well as "voiding in place" and even required a special new kind of hospital detox program!
"But how can I get him/her to go to the bathroom?" the parents moan. Without being sarcastic, you can problem solve this situation with the parent and child together: Suggest setting a timer to go off every hour to remind the child to go to the bathroom. If the pants are dry at that time plus the child goes willingly, then they may resume their activities. If the pants are wet or the child is uncooperative, there will be a consequence. No electronics for 1 hour is a logical one, but not being able to play outside with friends would be appropriate for the "playground pee-er."
This is a good occasion to discuss the number of electronics the child is engaged in and their effect on the child and family life. Rewards for being dry also are helpful. Once this is working, the interval between bathroom trips can be gradually increased to 2, then 3 hours.
Any child with new-onset daytime wetting should be checked for bacteriuria and more importantly stress. Twenty-five percent will have a urinary tract infection as the cause and antibiotics as the treatment – more girls than boys. Keep in mind that 20% of young children have a period of "toilet-training relapse" after age 6 years. These cases do not count in the estimate that 43% of those with daytime incontinence have a structural lesion. Lesions should be sought with a voiding cystourethrogram and ultrasound only if behavioral management is adhered to but ineffective. Spine films or magnetic resonance imaging are indicated only if there is an abnormal spine exam or motor or sensory exam of the lower extremities or anal sphincters as the nerves innervating the bladder sphincters enter the sacral cord in proximity to those.
Neurologic functional reasons for daytime incontinence include maturational delay of the sacral voiding reflex, low bladder sensory awareness, poor bladder compliance, and dyssynergy between detrusor contraction and sphincter relaxation, an acquired behavior.
The more common preexisting condition for daytime incontinence, however, is constipation. A full sigmoid colon or rectal vault not only presses on the bladder, reducing its capacity but also periodically stimulates the sacral nerves responsible for releasing urine. The child should be asked about large, hard infrequent stools, and even soiling, as this is often kept secret from the parents. The abdominal exam may not reveal this; a scan of the kidneys, ureters, and bladder may be needed. There is also avoiding dysfunction syndrome in some children under age 7 years with urinary incontinence, urinary tract infections, frequency, urgency, and constipation or encopresis in which there may be postvoid residual.
Even though the child appears to have a urine problem, treatment of constipation is the first line of care for every child with daytime incontinence and very often solves the wetting immediately. Don’t be shy in prescribing a capful of propylene glycol (Miralax), dissolved in any liquid for 15 minutes and consumed twice a day over a weekend, to clear out the retained stool. The usual maintenance of ½ capful of Miralax at night plus 5 minutes of toilet sitting using a timer in the morning and after dinner for 6 months is necessary, but not likely to be effective without a clean out first.
The next most common factor in daytime incontinence is ADHD (41%). Many aspects of having ADHD make this the case: A child with ADHD may be inattentive to the "need to go," has trouble shifting attention away from that video game, sits too briefly to defecate and gets constipated, may be taking stimulants that predispose to constipation, and is more likely to have comorbid learning disabilities or anxiety leading to stress. Optimizing management of ADHD, if present, should be part of the plan for managing incontinence.
Stress as a cause of daytime wetting is well known and even joked about by grown men when they say they were "scared s-less." But significant stress is not confined to the battlefield. A loud teacher, a new baby at home, school work that exceeds the child’s abilities, a bully at the bus stop, or having to give an oral presentation all can raise tension enough to reduce bladder capacity, increase bladder irritability, and result in daytime incontinence, particularly in children who are more sensitive as a result of having other coexisting stresses, low skills, a slow-to-warm-up temperament, or preexisting anxiety disorder.
In addition to working to alter any changeable stresses, you can teach the child relaxation techniques such as deep breathing, tightening then relaxing muscle groups, or imagining a peaceful safe place to go to in their mind. More severe stress such as from abuse (10%-15% of all children), domestic violence, marital discord (45%), or viewing violence (25%) can certainly cause incontinence and deserves to be addressed.
Parents may be angry and humiliated by the child’s wetting or embarrassed by what they have already tried to address it, including corporal punishment. The child, thinking that this is something she/he should be able to control, is often reluctant to even speak about it. Having private conversations with the child and the parents separately may be necessary to get a clear history and uncover the relevant factors. Trivial as "peeing your pants" sounds, solving daytime incontinence can be satisfying for the clinician and life-changing for the child.
Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at firstname.lastname@example.org.