Incontinence Problem Psychological or Physical?

[jmasters]

My daughter is 7 years old and we've been battling daytime wetting for over a year.  Last summer she started wetting herself (although not at night) and it's continued ever since.  We've seen pediatric urologists, psychologists & biofeedback specialists. Behaviorly, we've tried rewards, vibrating watch reminders, charts, etc.  Hasn't helped. Physically, we've tried x-rays, ultrasounds & urine cultures. They're all normal.  We're scheduling a VCUG test next month. If this doesn't produce any results then I feel like giving up.  Does anyone have any ideas of other tests to try?  Any suggestions on behavior modifications? The psychologist wants us to try punishments but I'm not comfortable punishing her if there is any chance it's a physical problem.

[Dr Smitha Mathews]

Hi,
"Functional incontinence refers to cases of urinary incontinence in which no structural or neurologic abnormality can be identified. The underlying etiologic mechanisms are heterogeneous, and include disorders of both the storage and voiding phases of the bladder cycle. Optimal treatment of functional daytime wetting depends on an accurate determination of the underlying etiology. Therapeutic options include behavior modification, medication, and aggressive treatment of comorbid conditions such as urinary infection and constipation"
"One reason why daytime wetting is difficult to treat is that it can result from a wide spectrum of bladder storage and voiding disorders"

http://www.medscape.com/viewarticle/546017

"causes are quite varied and could include:

    * Incomplete emptying of the bladder
    * Irritable bladder
    * Constipation
    * Stress
    * Urinary tract infection
    * Urgency (not “making it” to the bathroom in time)
    * Anatomic abnormality
    * Poor toileting habits
    * Small bladder capacity
    * Medical conditions like overactive bladder disorder
    * Others"
"In most current programs, non-invasive treatments incorporate hydration, timed voiding, correction of constipation and in some cases, computer assisted pelvic floor retraining. These methods have been extremely successful in correcting daytime wetting"
en.wikipedia.org/wiki/Daytime_wetting

"Management

   1. Reassurance and avoid punishment. Often condition is only intermittent and self limited.
   2. Talk to child about going to toilet when they have the urge
   3. Treat infection
   4. If suspect vaginal reflux, instruct on proper positioning on the toilet to avoid problem
   5. Avoid circumstances leading to stress and associated enuresis.
   6. Treat constipation
   7. Certain drugs to relax detrussor muscle increased activity.
   8. Surgery to correct anatomical abnormalities.
   9. If there is labial adhesion, application of estrogen cream and improved hygiene may break the adhesions.
  10. Pelvic floor strengthening exercises may help if there is urge syndrome, stress, and giggle incontinence"
pedclerk.bsd.uchicago.edu/diurnalEnuresis.html

I agree that punishing the child would only add another dimension of complications to the existing picture.
Try to talk about the problem in a nonjudgemental manner with your child to identify what she faces.

Do keep us posted on your doubts and progress.
Regards