Incontinence nighttime

A 65-year-old man who had had primary insomnia for 20 years, was given olanzapine 2.5 mg/day at nighttime because of lack of response to various anxiolytics he developed fecal incontinence during the 20 days of olanzapine treatment in combination with two anxiolytic drugs. The frequency of incontinence varied from 1 to 3 times a day, and withdrawal of olanzapine resulted in complete recovery. 

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. 

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. 

---