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What causes urinary incontinence in a child?

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Posted on Mon, 30 Jun 2014
Question: What can be the differential diagnosis and causes for a 61/2 year old girl that is still not potty trained?
Details: 61/2 year old girl. Not potty trained. Intermittently goes to toilet on her own, but more often don't go and wets pants. Bowel movement is fully controlled. Admits to knowing when she needs to go, but I cannot be 100% sure of this. When she does go to the toilet to urinate it is normally within less than 1 hour that she will have to go again, or else wets her pants. Some days however it seems that she can go for longer, without wetting the pants or going to the toilet.
Pediatrician diagnosed constipation as cause and treatment follow but no resolution.
Treated with Imipramine 25mg daily in 2013 for 1 month, but with no improvement.
Treated with Oxybutinine - 5mg daily since March 2014, dose changed to 5mg bd since May 2014 with no improvement.
Any more information in this situation will be appreciated.
doctor
Answered by Dr. Deepak Kishore Kaltari (3 hours later)
Brief Answer:
Thorough evaluation required

Detailed Answer:
Hi
Welcome to Healthcare-Magic
Greetings of the day

Dear Ms,

Being a Pediatric Surgeon, I come across several such cases.
Lets analyze the symptoms:

Feeling of need to go within 1 hour of passing Urine, failure to do so result in spontaneously passing out urine: It suggest Urgency , with Urge Incontinence.
Urinary bladder is unlikely to get filled within 1 hour , so itt is not overflow incontinence.
Urgency could be due to mainy factors
1. Urinary tract infection
2. Constipation: Constipation could be associated spasm of muscle of pelvic floor-- This causes stimulation of Detrussor(muscle of Urinary bladder) to contract leading to frequent urge to pass urine and if there is delay causing incontinence.
3. Spontaneous Detrussor muscle over activity.

Oxybutinine is a anti-muscuranic drug which suppresses the contraction of detrussor muscle. Imipramine is a Tric-cyclic antidepressant which because of its anti-muscuranic activity is helpful in detrussor muscle over activity.

I would not recommend the use of it without appropriate Urodynamic Study(UDS).


Had she been my patient I would have managed her in the following way

1. Detailed examination Of Perineum:

a) Examination of genitals to look for two seperate opening for Urethra and Vagina ( this will rule out Urogenital sinus in which there is single opening)

b) To rule out fungal infection of the surrounding area

c) Examination of anal opeing followed by digital rectal examination: Anal fissure could be cause of constipation, visual inspection will rule out the possibility . Digital rectal examination will assess the severity of constipation

2. Investigations:

a. X ray of Lumbo-sacral spine: To rule out any spine abnormality
b . Urine Examination: To ru;e out urinary tract infection
c. Ultrasound abdomen

Having accessed the severity of constipation. It can be managed in following way

1. Ensuring consumption of good quantity of water:
Follow rule of 1: 1 glass of water 1 hour before every meal and 1 hour after every meal will ensure adequate intake of water.
Decreased consumption of water is one of the factor for constipation
2. Laxative like Lactulose
3. High fiber diet
4. Toilet training: Inculcate habit of passing urine every 2 hours. Also make her sit for potty at fixed times twice a day for 20 minutes each. Children usually do not spend sufficient time, this leads to incomplete evacuation of stools and further worsening constipation.
5. Retention Enema : This will help in evacuation of loaded colon and rectum ,therby decreased the pelvic muscle spasm

6. Hot seitz bath: To a tub of lukewarm water add handful of common table salt. Make the baby sit in it for 15-20 minutes. This will relax the muscle. This can be carried out before bathing the child

7. Double voiding at night: Habit of making her pass urine twice, let her pass urine and again make her pass urine after 5 minutes. This can be done daily before she goes to bed


This will require patience, but will definitely work. If there is no improvement in symptoms after 2 months, would suggest you to get revaulation with Ultrasound abdomen and Urodynamic Study which will document flow and pressure in urinary Bladder.

Discuss it with treating physician and I am quite sure things should work out fine.

Do get back to me for any further assistance, will be glad to assist you.

Take Care

Best Regards
Dr Deepak Kishore
MBBS,MS,MCH
Consultant Ped Surgeon
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Deepak Kishore Kaltari (6 hours later)
Dear Dr XXXXXXX

Thank you for the insights. I think my next question is - what type of specialist would be best to see for this treatment? Currently we are seeing a Urologist, but according to the doctor there is not really a problem and he is not keen on doing the suggested investigative tests, although none of the treatments are helping, to be honest he seems to ignore this fact.

I would really like to take my daughter to the correct specialist who will look at it holistically.

Kind regards
XXXX
doctor
Answered by Dr. Deepak Kishore Kaltari (18 minutes later)
Brief Answer:
Consult Pediatric Surgeon

Detailed Answer:
Hi
Greetings,

Dear Ms,

I understand your problem. I would suggest you to consult either Pediatric Urologist or Pediatric Surgeon for further assessment and management.

Take Care
Wishing you and your family a very happy and healthy life.

Regards
Deepak
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Deepak Kishore Kaltari

General Surgeon

Practicing since :2002

Answered : 3194 Questions

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What causes urinary incontinence in a child?

Brief Answer: Thorough evaluation required Detailed Answer: Hi Welcome to Healthcare-Magic Greetings of the day Dear Ms, Being a Pediatric Surgeon, I come across several such cases. Lets analyze the symptoms: Feeling of need to go within 1 hour of passing Urine, failure to do so result in spontaneously passing out urine: It suggest Urgency , with Urge Incontinence. Urinary bladder is unlikely to get filled within 1 hour , so itt is not overflow incontinence. Urgency could be due to mainy factors 1. Urinary tract infection 2. Constipation: Constipation could be associated spasm of muscle of pelvic floor-- This causes stimulation of Detrussor(muscle of Urinary bladder) to contract leading to frequent urge to pass urine and if there is delay causing incontinence. 3. Spontaneous Detrussor muscle over activity. Oxybutinine is a anti-muscuranic drug which suppresses the contraction of detrussor muscle. Imipramine is a Tric-cyclic antidepressant which because of its anti-muscuranic activity is helpful in detrussor muscle over activity. I would not recommend the use of it without appropriate Urodynamic Study(UDS). Had she been my patient I would have managed her in the following way 1. Detailed examination Of Perineum: a) Examination of genitals to look for two seperate opening for Urethra and Vagina ( this will rule out Urogenital sinus in which there is single opening) b) To rule out fungal infection of the surrounding area c) Examination of anal opeing followed by digital rectal examination: Anal fissure could be cause of constipation, visual inspection will rule out the possibility . Digital rectal examination will assess the severity of constipation 2. Investigations: a. X ray of Lumbo-sacral spine: To rule out any spine abnormality b . Urine Examination: To ru;e out urinary tract infection c. Ultrasound abdomen Having accessed the severity of constipation. It can be managed in following way 1. Ensuring consumption of good quantity of water: Follow rule of 1: 1 glass of water 1 hour before every meal and 1 hour after every meal will ensure adequate intake of water. Decreased consumption of water is one of the factor for constipation 2. Laxative like Lactulose 3. High fiber diet 4. Toilet training: Inculcate habit of passing urine every 2 hours. Also make her sit for potty at fixed times twice a day for 20 minutes each. Children usually do not spend sufficient time, this leads to incomplete evacuation of stools and further worsening constipation. 5. Retention Enema : This will help in evacuation of loaded colon and rectum ,therby decreased the pelvic muscle spasm 6. Hot seitz bath: To a tub of lukewarm water add handful of common table salt. Make the baby sit in it for 15-20 minutes. This will relax the muscle. This can be carried out before bathing the child 7. Double voiding at night: Habit of making her pass urine twice, let her pass urine and again make her pass urine after 5 minutes. This can be done daily before she goes to bed This will require patience, but will definitely work. If there is no improvement in symptoms after 2 months, would suggest you to get revaulation with Ultrasound abdomen and Urodynamic Study which will document flow and pressure in urinary Bladder. Discuss it with treating physician and I am quite sure things should work out fine. Do get back to me for any further assistance, will be glad to assist you. Take Care Best Regards Dr Deepak Kishore MBBS,MS,MCH Consultant Ped Surgeon