Stress Incontinence in Children
Stress incontinence, or a leakage of urine with physical activity, is rare in children but can cause significant distress. It is defined as the involuntary loss of urine from the urethra during activities that increase intra-abdominal pressure, such as coughing, sneezing, laughing, or exercising. It is often a sign of an underlying bladder dysfunction or a structural abnormality of the lower urinary tract.
Causes of Stress Incontinence in Children
Stress incontinence, or involuntary urine leakage with increased abdominal pressure, is rare in children but can have a number of underlying causes. The primary issue is a weakness or dysfunction of the urethral sphincter, which is the muscle that controls the flow of urine.
Weak Pelvic Floor Muscles: The pelvic floor muscles, which support the bladder and urethra, may be weak or underdeveloped.
Bladder Neck Incompetence: This refers to the inability of the bladder neck and internal sphincter to properly close. It can be due to a congenital abnormality or a neurological condition that affects the nerves supplying the bladder.
Overactive Bladder (OAB): An overactive bladder can cause a sudden, involuntary contraction that can overwhelm a child’s ability to hold urine, especially during a physical activity that puts pressure on the bladder.
Increased Intra-abdominal Pressure: Any condition that consistently raises pressure in the abdomen, such as chronic coughing from conditions like asthma or severe constipation, can contribute to stress incontinence.
Clinical Assessment and Investigations
History
Symptoms: Ask about when the leakage occurs. Is it with a cough, a sneeze, or a laugh? What is the volume of the leakage?
Voiding Diary: A bladder diary for at least 48 hours is crucial to assess voiding patterns, fluid intake, and the relationship between physical activity and incontinence.
Associated Symptoms: Enquire about any other symptoms of bladder dysfunction, such as urgency or frequency, or a history of recurrent urinary tract infections.
Examination
General: A full abdominal examination and a neurological examination of the lower limbs and spine are necessary to rule out a spinal cord abnormality or a neurological cause.
Urine Leakage: Observe the child during a cough or a jump to see if there is any leakage.
Investigations
Urinalysis: A urinalysis is essential to rule out a urinary tract infection.
Uroflowmetry: This test measures the flow rate of urine and can help identify any issues with bladder emptying.
Ultrasound: A bladder ultrasound can be used to assess bladder capacity and post-void residual volume.
Urodynamic Studies: These are more specialised tests that measure bladder pressure and sphincter function. They are typically reserved for complex cases or when a structural abnormality is suspected.
Management of Stress Incontinence in Children
Management is a tailored approach based on the underlying cause and typically involves a combination of non-surgical and, in rare cases, surgical strategies.
1. Non-Surgical Management
Physiotherapy: Pelvic floor exercises are the cornerstone of management. A paediatric physiotherapist can teach the child how to identify and strengthen these muscles.
Timed Voiding: Encouraging the child to use the toilet at regular intervals (e.g., every 2-3 hours) can prevent the bladder from becoming too full and reduce the risk of leakage during physical activity.
Constipation Management: If constipation is a contributing factor, it should be treated with dietary changes, increased fluid intake, and, if necessary, laxatives.
Pharmacological: In cases where an overactive bladder is a contributing factor, medications that relax the bladder muscle, such as oxybutynin, may be used in combination with physiotherapy.
2. Surgical Management
Surgery is a last resort and is only considered for severe cases with a confirmed structural abnormality that has not responded to conservative management.
Surgical procedures aim to improve the function of the urethral sphincter or bladder neck. These are typically complex and are performed by a specialist paediatric urologist.