Urotherapy: A successful treatment for daytime urinary incontinence in children

Incontinence is a distressing and debilitating condition defined as the involuntary loss of faeces or urine in individuals aged over five years. Daytime urinary incontinence (daytime wetting) occurs in 7-10% of children with no underlying health condition. Lower urinary tract dysfunction is a broad term used to describe several conditions causative of daytime incontinence. As the name suggests, individuals with overactive bladders experience an urgent and unstoppable need to urinate. An overactive bladder causes unpleasant symptoms such as needing the toilet desperately and often, which leads to wetting. On the other hand, an underactive bladder prevents the sufferer from sensing the need to urinate. This leads to overfilling of the bladder and subsequent wetting. Dysfunctional voiding occurs most often in females. It is associated with contractions of the pelvic floor muscles or urethral sphincter during voiding, which results in bladder outflow obstruction. Failure to void the bladder fully can result in recurring urinary tract infections (UTI) and eventual incontinence. Other bladder problems associated with paediatric daytime incontinence include postponement of urination (usually due to other more interesting activities) and stress incontinence (involuntary urination due to coughing or laughing). Daytime urinary incontinence is often co-morbid with nocturnal enuresis (night-time wetting) and bowel problems such as constipation.

It is difficult to know the true prevalence of daytime wetting as many sufferers undergo no treatment and wait for the condition to improve, which it sometimes does with age. However, daytime incontinence is a psychologically distressing condition for children which can lead to emotional or social issues, with long term impacts on physiology if left untreated. It is therefore vitally important that awareness of daytime incontinence and possible treatment options are increased. Dr Anka Nieuwhof-Leppink of Wilhelmina Children’s Hospital in collaboration with Drs Aart Klijn, Rogier Schroeder and Renske Schappin have recently assessed the efficacy of urotherapy as a treatment for daytime incontinence. Over a series of published papers, the researchers have attempted to reveal which aspects of urotherapy are most useful. This important research has helped to increase the knowledge base for the most effective means for treating daytime incontinence.

“This important research has helped to increase the knowledge base for the most effective means for treating daytime incontinence.”

Risk factors & Diagnosis

Individuals are more likely to experience daytime incontinence if there is a family history. Multiple studies have found a strong heritable link particularly with nocturnal enuresis. This raises the age-old problem of nature versus nurture i.e. is it learnt or genetic? Daytime wetting is also more common in females and in individuals from low socioeconomic backgrounds and/or poor education. School is considered a risk factor due to restricted toilet times. Additionally, potentially embarrassing situations amongst peer groups may have an influence and also bad hygiene on school toilets. Some diseases such as childhood obesity and joint hypermobility are additionally considered to be a risk factor for daytime wetting. Children who have attention deficit hyperactive disorder (ADHD) are more likely to present with daytime incontinence and require more attentive treatment. Previously it was assumed that emotional/behavioural problems were causative of daytime wetting. This long-held belief is now being challenged and any associated behavioural problems in sufferers are more likely a response to incontinence.

Diagnosis begins with a consultation in which a detailed history of the wetting is recorded. The child will also undergo a psychological assessment and a physical examination. The medical professional will use uroflowmetry which essentially maps out the flow of urination. For example, a normal urination will follow a bell-shaped curve. Ultrasound can also be used for a detailed visualisation of the bladder and the amount of urine residual after voiding.

Urotherapy

Urotherapy is the first line of defence for treatment of daytime urinary incontinence. The technique is non-invasive and focuses on re-education and rehabilitation for bladder-bowel management. Standard urotherapy emphasises education of the family and simple lifestyle changes as treatment. Such lifestyle changes include how much liquid to drink throughout the day and how often the child should be urinating. Urotherapy also aims to teach the child the correct way to urinate i.e. posture and muscle contractions. Regular follow-ups alongside a diary are then used over a period of months as the child implements the treatment advice. Bowel management problems can result in lower urinary tract dysfunction. So, problems such as constipation are addressed at the start of the treatment plan as well as the presence of any UTI. The endpoint of urotherapy treatment is most often considered to be when both parents and child are sufficiently satisfied with the progress.

If standard urotherapy doesn’t work, then specific urotherapy is recommended. Specific urotherapy focuses on intensive training of the child about when, how and how often they should void their bladder. Specific urotherapy involves multi-disciplinary elements, like psychological support and behavioural modification, biofeedback by the use of a flow meter and/or physiotherapy. So what elements are important for the rehabilitation of daytime incontinence?

The researchers have assessed the various different aspects of urotherapy to discern the most important parts. Inpatient treatment programmes in children old enough (> 8 yrs) to be self-aware led to a 74% improvement in children where other treatment had failed. This highlights the need to conduct age-appropriate treatment to maximise results. New technical tools were investigated. The first involved a wireless ultrasonic sensor which informed the child when the bladder is full. This helps children who suffer from an underactive bladder as it reminds them when they should be urinating. The second is an app which promotes bladder training for individuals with bladder problems. It is important for them to gradually increase the bladder capacity volume over time. The researchers found both tools to be a positive in the treatment of daytime wetting.

“This important research has helped to increase the knowledge base for the most effective means for treating daytime incontinence.”

Biofeedback is an important component of specific urotherapy. It is the process of gaining greater awareness of pelvic floor muscle/sphincter action using external instruments that provide information about the action of these muscles with the goal of increasing awareness and voluntary control by the child. Visual or auditory feedback can be used, and this together with the assessment, coaching and encouragement of the therapist, aims to improve motor control. It involves showing the child when their bladder is empty e.g. using ultrasound or uroflowmetry. The researchers elucidated that pelvic muscle training alone didn’t seem to be useful to reach continence. The combination of all elements of specific urotherapy are paramount. On the contrary the therapist’s attention received by the child has showed to be a very important factor.

The team also investigated another new technical tool for children with refractory DUI: a portable ultrasound bladder sensor and bladder training app. This intensive inpatient bladder training programme focuses on relearning, concentration on, and awareness of the bladder. Interestingly, using methods like a game didn’t increase the child’s motivation to retrain their bladder. This could potentially be attributed to the fact that the children are already extremely motivated to attain continence and so do not require any further persuasion.

Other treatment options

In instances when urotherapy doesn’t prove useful, there are other treatment avenues. Pharmacological intervention can include laxatives for constipation, or drugs that relaxate the bladder muscle. However, drug treatments are limited and may cause side effects and are only useful when an overactive bladder is causing daytime incontinence. More invasive options include Botox injections into the bladder muscle, to prevent wetting or even surgery for girls. Nerve stimulation exists in various forms as a treatment but its efficacy is unclear.

Conclusion

Incontinence can be complex and the causes can be intertwined, making treatment plans challenging. Treatment for daytime urinary incontinence is multidisciplinary and requires expert knowledge. Dr Anka Nieuwhof-Leppink and colleagues advocate the need for further research to build the knowledge base for the evidence-based treatment and management of incontinence in children and adolescents.

References

• Nieuwhof-Leppink, A.J., Schroeder, R.P.J., vab de Putte, E.M., de Jong, T.P.V.M., Schappin, R. (2019) Daytime urinary incontinence in children and adolescents. Lancet Child Adolesc Health, [online], 3 (7), 492-501. Available at:
  https://doi.org/10.1016/S2352-4642(19)30113-0 [Accessed 21/09/2020] .
• Meijer, E.F.J., Nieuwhof-Leppink, A.J., Dekker-Vasse, E., de Joode-Smink, G.C.J. & de Jong, T.P.V.M. (2015) Central inhibition of refractory overactive bladder complaints, results of an inpatient training program. Journal of Pediatric Urology, 11 (21), 21.e1-21.e5.
• Nieuwhof-Leppink, A.J, van Geen, F.J., van de Putte, E.M. Schoenmakers, M.A.G.C., de Jong, T.P.V.M., Schappin, R. (2019) Pelvic floor rehabilitation in children with functional LUTD: does it improve outcome? Journal of Pediatric Urology, 15, 530.e1-530.e8
• van Leuteren P.G., Nieuwhof-Leppink, A.J. Dik.P (2019) SENS-U: clinical evaluation of a full bladder notification – a pilot study. Journal of Pediatric Urology, 15, 381.e1-381.e5.

Research Objectives
Dr Anka Nieuwhof-Leppink’s research is focused on behavioural problems and incontinence.

Collaborators

• Dr Aart Klijn
• Dr Rogier Schroeder
• Dr Renske Schappin

Bio
Anka Nieuwhof-Leppink, PhD,
is Paediatric Nurse and Psychologist, coordinator of the Urotherapy Department at Wilhelmina Children’s Hospital, (part of UMC Utrecht). She is Head of the Dutch education programme for Urotherapists. She is currently a board member of the International Children’s Continence Society, (ICCS) and member of the European Society for Paediatric Urology, (ESPU) research committee.

Contact
Dr Anka Nieuwhof-Leppink

E: [email protected]
W: www.i-c-c-s.org
W: https://www.hetwkz.nl/nl

Urotherapy A successful treatment for daytime urinary incontinence in children