Incontinence daytime

Urinary incontinence (UI) is defined as the complaint of involuntary leakage of urine.1 It is often associated with other bothersome lower urinary tract symptoms such as urgency, increased daytime frequency, and nocturia. Despite its prevalence across the lifespan and in both sexes, it remains an underdetected and underreported health problem that can have significant negative consequences for the individual s quality of life. Patients with UI may be depressed due to a... 

Sodium oxybate (yhydroxybutyrate a potent sedative-hypnotic) improves excessive daytime sleepiness and decreases episodes of sleep paralysis, cataplexy, and hypnagogic hallucinations. It is taken at bedtime and repeated 2.5 to 4 hours later. Side effects include nausea, somnolence, confusion, dizziness, and incontinence. 

In 64 women mean age 53 years enrolled in a randomized, placebo-controlled, crossover study of desmopressin 40 micrograms by nasal spray for the treatment of severe daytime urinary incontinence, there were drug-related adverse events in 25 women taking desmopressin and 24 adverse drug reactions in 15 women taking placebo (35). The most common adverse event with desmopressin was headache (36%). Nausea occurred in 10%. 

Robinson D, Cardozo L, Akeson M, Hvistendahl G, Riis A, Norgaard JP. Antidiuresis a new concept in managing female daytime urinary incontinence. BJU Int 2004 93 996-1000. 

Tricyclic antidepressants. Imipramine, amitriptyline and nortriptyline are effective, especially for nocturnal but also for daytime incontinence. Their parasympathetic blocking (antimuscarinic) action is probably in part responsible but imipramine... 

An 11-year-old boy with ADHD was given methylphenidate and after the daily dosage had been titrated to 20 mg enuresis started to occur. After 2 months, the medication was withdrawn and the enuresis stopped immediately. About 1 month later, methylphenidate was restarted and the enuresis reoccurred when the dose reached 20 mg/day. It continued for about 3 months but immediately stopped when the medication was withdrawn. Another rechallenge after 2 months, followed by withdrawal of methylphenidate, replicated the response. Other causes of enuresis were excluded and the patient never had daytime urinary incontinence. 

The study by Mayo and Burns (1990) and the publication of Hoebeke et al. (1999) show that the number of cases with unstable bladder is around 60%. Passerini-Glazel et al. (1992) describe a rate of unstable bladder of 90% in children with nonneurogenic bladder-sphincter dysfunction. In 156 children with daytime incontinence, Van Gool (1992a) found unstable bladder in 53% and dysfunctional voiding in 59%. Weerasinghe and Malone (1993) reported unstable bladder in 54% and dysfunctional voiding in 3.5%. 

In about 70% of cases this dysfunction leads to (urge) incontinence, which is clinically manifested as wetting (mostly daytime, but nighttime as well). But even in severe cases the obligatory voluntary contraction of the striated urethral sphincter against the contracting detrusor can prevent leakage in up to 30% of cases. 

Worldwide constipation is a common problem in children. Estimated prevalence rates have varied from 4 to 37% (Yong et al. 1998 Van der wal et al. 2005 De Araujo Sant Anna and Calcado 1999 Zaslavsky et al. 1988, Maffei et al. 1997). Constipation may vary from mild and short-lived to severe and chronic and is sometimes associated with fecal and urinary incontinence, urinary tract infections and abdominal pain. The prevalence of fecal incontinence ranges in children from about 0.3% to 8% (Van der Wal et al. 2005 Bellman 1966 Howe and Walker 1992). In a study by Loening Baucke (2006), a prevalence rate of 22.6% for constipation, 4.4% for fecal incontinence and 10.5% for urinary incontinence in a US primary care clinic was found. In this study on 482 children the fecal incontinence was coupled with constipation in 95% of their children. From the 10.5% prevalence rate for urinary incontinence, 3.3% were found for daytime only, 1.8% for daytime with nighttime and 5.4% for nighttime urinary incontinence. And it was concluded that fecal and urinary incontinence was significantly more commonly observed in constipated than non-constipated children. 

Of greatest importance is the observation by Naseer and Steinhardt (1997) who, in their study on 538 patients with a history of daytime urinary incontinence, identified 51 children with VUR, UTI and dysfunctional voiding in whom new renal scars had developed while they were under care. They concluded that voiding dysfunction is a significant risk factor not only for UTI and VUR development and perpetuation, but also for the development of new renal scars when associated with infection and VUR. An association between urinary tract dysfunction and reflux nephropathy was also demonstrated by Nielsen (1984). 

Most cases of daytime and nighttime wetting are functional forms of urinary incontinence resulting from nonneurogenic bladder sphincter dysfunction, clinically manifested by frequency, urgency and urge incontinence. UTls, covered bac-teriuria, VUR, constipation, encopresis and structural abnormalities of the urinary tract are often associated. 

Distinction should be made between monosymptomatic enuresis nocturna and incontinence. Patients with persistent and severe monosymptomatic enuresis nocturna despite treatment should undergo kidney and bladder ultrasound and VCU as well, if there are positive ultrasound findings and/or a history of urinary tract infection. In wetting children (daytime with or without nighttime urinary incontinence) with urinary tract infection with/without urge, kidney and bladder ultrasound and a VCU have to be performed as well. Assessment of potential stool retention has to be part of the imaging studies. 

We do not perform VCU for monosymptomatic, primary nocturnal enuresis or initially in children with daytime and nighttime wetting in the absence of severe urge, urge incontinence or UTI. 

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