The more common preexisting condition for daytime incontinence, however, is constipation. A full sigmoid colon or rectal vault not only presses on the bladder, reducing its capacity, but also periodically stimulates the sacral nerves responsible for releasing urine. The child should be asked about large, hard infrequent stools, and even soiling, as this is often kept secret from the parents. The abdominal exam may not reveal this; a scan of the kidneys, ureters, and bladder may be needed. There is also a voiding dysfunction syndrome in some children under age 7 years with urinary incontinence, urinary tract infections, frequency, urgency, and constipation or encopresis in which there may be postvoid residual.
Even though the child appears to have a urine problem, treatment of constipation is the first line in care for every child with daytime incontinence and very often solves the wetting immediately. Don’t be shy in prescribing a capful of propylene glycol (Miralax), dissolved in any liquid for 15 minutes and consumed twice a day over a weekend, to clear out the retained stool. The usual maintenance of ½ capful of Miralax at night plus 5 minutes of toilet sitting using a timer in the morning and after dinner for 6 months is necessary, but not likely to be effective without a clean out first.
The next most common factor in daytime incontinence is ADHD (41%). Many aspects of having ADHD make this the case: A child with ADHD may be inattentive to the "need to go," has trouble shifting attention away from that video game, sits too briefly to defecate and gets constipated, may be taking stimulants that predispose to constipation, and is more likely to have comorbid learning disabilities or anxiety leading to stress. Optimizing management of ADHD, if present, should be part of the plan for managing incontinence.
Stress as a cause of daytime wetting is well known and even joked about by grown men when they say they were "scared s-less." But significant stress is not confined to the battlefield. A loud teacher, a new baby at home, school work that exceeds the child’s abilities, a bully at the bus stop, or having to give an oral presentation all can raise tension enough to reduce bladder capacity, increase bladder irritability, and result in daytime incontinence, particularly in children who are more sensitive as a result of having other coexisting stresses, low skills, a slow-to-warm-up temperament, or preexisting anxiety disorder.
In addition to working to alter any changeable stresses, you can teach the child relaxation techniques such as deep breathing, tightening then relaxing muscle groups, or imagining a peaceful safe place to go to in their mind. More severe stress such as from abuse (10%-15% of all children), domestic violence, marital discord (45%), or viewing violence (25%) can certainly cause incontinence and deserves to be addressed.
Parents may be angry and humiliated by the child’s wetting or embarrassed by what they have already tried to address it, including corporal punishment. The child, thinking that this is something she/he should be able to control, is often reluctant to even speak about it. Having private conversations with the child and the parents separately may be necessary to get a clear history and uncover the relevant factors. Trivial as "peeing your pants" sounds, solving daytime incontinence can be satisfying for the clinician and life changing for the child.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to IMNG Medical Media. E-mail her at pdnews@frontlinemedcom.com.