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Re: Pediatric stress incontinence

Posted By Steve on March 01, 1998 at 00:12:39:

In Reply to: Re: Pediatric stress incontinence posted by HFHS M.D.-MS on February 23, 1998 at 18:29:44:

My almost 8-year-old son has had a severe case of urinary stress incontinence for years now.  He never was completely toilet-trained.  He is almost always dry at night, and fairly dry when quiet during the day, but immediately starts leaking with any movement, even with a fairly empty bladder.  He never lets a full load go, just leaking.  He wears training pants to school, but can even soak through that by the afternoon, even after going to the bathroom 3 times at school.
We are presently trying a beeper on him.  If he's active, though, he can go through 4 underpants in an hour with this.  It seems like a long road this way.  A couple of years ago, a pediatric urologist performed a urinary function test (fill the bladder with a catheter, watch it empty).  It seemed normal, except for a somewhat undersized bladder.
What could be causing this?  Infection?  The urine doesn't show it, but the end of his foreskin is often red from irritation and occasionally swollen.  Neurological?  He says he doesn't feel anything when he's leaking and isn't aware of it.  Structural?  Would Kegals help him?  What would a cystoscopic examination reveal?  That's a possible next step.
Any enlightenment you could provide would be much appreciated.
Dear Steve
Thanks for your questions.
There are multiple reasons your son could be leaking and a carefully planned work-up will help determine what is best for him.
With urinary leakage in small amounts all the time, two causes come to mind:overflow urinary incontinence and stress urinary incontinence.  Overflow incontinence occurs is when the bladder is so full it spills over the top like a pale of water.  A few things go against overflow as the diagnosis in your childs case.  The bladder would always be distended and would not be able to really let go a large amount of urine at one time. The bladder would be damaged by being stretched over time. Stress urinary incontinence, where the nerves to the sphincter are damaged, is a diagnosis usually made in children with obvious abnormalities. Epispadius ( the urine tube located on top of the penis instead of the bottom), urethral trauma, neurological conditions like meningomyelocele (congenitally displaced  spinal cord ) are just a few. These congenital abnomalities may have only subtle differences from normal, however. These conditions all effect the nerves to the sphincter of the bladder and/or the local anatomy.
The way to document  stress incontinence is by a low leak point pressure. This can be measured during the bladder filling /emptying test you wrote about.( urodynamics)  The leak point pressure is the pressure in the bladder when urine leaks around the catheter on urodynamic exam. This documents a weak sphincter if the catheter is not to large.   If the leak point pressure  is low, you know the result  of the insult but not the cause of his stress incontinence. An MRI of the spine to look for possible structural neurologic causes may be quite helpful.
A good urodynamic exam needs to be sure the bladder has good compliance also. A slightly small bladder is okay if it has good compliance ( stretchability).  If it does not the bladder will not be able to store urine. A small thick irregular bladder seen on cystogram also is associated with a neurological abnormality.  In extreme cases, the bladder needs to made larger by reconstructive surgery.
Treatment options for the resultant stress urinary incontinence depends on the amount of leakage.  If it is small pseudophedrine ( yes, the cold medicine) can tighten the sphincter.  Trofranil can increase the sphincters tone and decrease the bladder tone to allow it to store more urine.
Keigel exercises are  not indicated for this problem in a child.
If leakage is a lot, the treatment options move to surgical.  Collagen can be injected into the lining of the urethra.  This results in temporary dryness in males but works better in females.   A fascial sling (strong tissue) can be wrapped around the bladder neck to increase the resistance.  An artificial sphincter can be implanted. This device has an inflatable cuff which slightly squeezes the urethra.  When it is time to void , an implanted bulb in the scrotum  is pumped  to decompress the cuff temporarily.              
  A cystoscopy probably would not add much information to the work-up, but may be necessary for completeness.
My overall impression is that your son would best be managed by a repeat and thorough reevaluation by a pediatric urologist The problems that were considered at the time of his initial evaluation change as a child grows and therefore the need for such a repeat. Both from an emotional and physical standpoint I recommend that you not postpone such an evaluation.
This information is provided for general medical information purposes only. Please consult  your physician for diagnostic and treatment options pertaining to your specific medical condition. Dr Gonzalez  at our institution has experience with pediatric urologic problems of this nature and I would highly recommend that you see him for your problem. If you would like to make an appointment], please call us at  (1-800-653-6568). We can also arrange local accommodations through this number if this is  your need. Please bring any x-rays (not just the reports) as well as any physiciansnotes and lab test results that you may be able to obtain. These will help us greatly.

Hope this information has helped.  
* Keyword: male stress urinary incontinence
Thanks much for your thoughtful comments.  We have started a second round with the pediatric urologist locally, but I wanted to get a clearer understanding of what the possible explanations and options were.  There is surprisingly nothing that I could find on the Internet relating to pediatric stress incontinence, as opposed to the more typical night time wetting.  We obviously want to take the most conservative approach possible, but we still, at some point, have to make some progress.  We will keep your recommendation of Dr. Gonzalez in mind, at least for a second opinion in the event that we can't make more progress locally or more serious procedures are recommended.
Thanks again.
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