How should I evaluate and manage urinary incontinence in a toddler?

Evaluation and Management of Urinary Incontinence in Toddlers

Begin with urotherapy as first-line treatment for all types of urinary incontinence in toddlers, while simultaneously addressing constipation if present, as this combination resolves symptoms in up to 89% of cases. 1, 2

Initial Clinical Assessment

Distinguish the pattern of incontinence to guide your diagnostic and therapeutic approach:

• Determine timing: Daytime-only wetting suggests functional causes like detrusor overactivity or dysfunctional voiding, while nighttime-only wetting (after age 5) indicates monosymptomatic enuresis 1, 2, 3
• Assess frequency and urgency: Sudden urges with inability to hold urine point toward detrusor overactivity, the most common functional cause in young children 4, 5
• Document associated symptoms: Ask specifically about dysuria, hematuria, straining to void, weak stream, or dribbling—these suggest voiding phase disorders or structural abnormalities 2, 6
• Evaluate bowel habits: Constipation coexists in the majority of cases and must be identified through questions about stool frequency, consistency, pain with defecation, and soiling 1, 7
• Obtain family history: 44% of children have incontinence when one parent was affected, rising to 77% when both parents were enuretic 1, 2

Physical Examination Priorities

Focus your examination on these specific findings:

• Abdominal palpation: Check for bladder distention (suggests incomplete emptying) and fecal impaction (palpable stool in left lower quadrant) 2, 6
• Spine examination: Look for sacral dimple, hair tuft, or skin discoloration suggesting occult spinal dysraphism 6
• Neurologic assessment: Test lower extremity reflexes, gait, and perineal sensation to exclude subtle spinal cord dysfunction 6
• Genital examination: Identify meatal stenosis, labial adhesions, or signs of local irritation 6

Mandatory Initial Testing

Urinalysis is the only obligatory laboratory test for initial evaluation:

• Dipstick screening has 95-98% negative predictive value for urinary tract infection when negative for leukocyte esterase and nitrites 2, 6
• Send urine culture only if urinalysis is abnormal or clinical suspicion remains high despite negative screening 2, 6
• Check for glycosuria to exclude diabetes mellitus, though unlikely without polydipsia/polyuria 6, 8

When to Order Imaging

Avoid routine imaging in straightforward cases:

• Renal ultrasound is indicated only for: recurrent documented UTIs, continuous day-and-night wetting, abnormal urinalysis suggesting structural disease, or palpable abdominal mass 2, 6
• Spinal MRI is required if sacral dimple or abnormal neurologic findings are present 6
• Uroflowmetry with EMG should be obtained (repeated 3 times in same setting) if dysfunctional voiding is suspected based on symptoms of straining, interrupted stream, or recurrent UTIs 1

First-Line Treatment: Urotherapy

Implement urotherapy immediately as it is effective for all incontinence types:

• Education component: Explain normal bladder function to child and parents in age-appropriate terms 1, 2
• Timed voiding schedule: Have child void every 2-3 hours during waking hours, even without urge 1, 2
• Proper voiding posture: Ensure feet are supported on floor or stool, knees apart, relaxed position to facilitate pelvic floor relaxation 1
• Adequate hydration: Maintain regular fluid intake throughout day (avoid excessive evening fluids for nighttime wetters), eliminate caffeine 1, 2
• Voiding diary: Keep 2-week record of fluid intake, voiding times, volumes, and wet episodes to monitor progress 1, 2

Aggressive Constipation Management

Treat constipation concurrently and aggressively, as this is the most common pitfall:

• Rectal disimpaction first if impaction is present on examination or suspected clinically 7
• Maintenance therapy with daily stool softeners to achieve soft, painless daily bowel movements 7
• Resolution of constipation alone leads to improvement in bladder emptying in 66% of children with elevated post-void residual, and resolves daytime wetting in 89% 1, 2

Escalation for Refractory Cases

If urotherapy and constipation management fail after 2-3 months:

• For detrusor overactivity with persistent urgency/frequency: Consider anticholinergic medication (oxybutynin or tolterodine) as adjunct to continued urotherapy 1, 5
• For dysfunctional voiding: Refer for biofeedback therapy using uroflowmetry with real-time visual feedback, which achieves 90-100% success rates 1
• For detrusor underactivity ("lazy bladder"): Implement timed double voiding and consider clean intermittent catheterization if large residuals persist 1, 5

Follow-Up Strategy

Schedule monthly appointments to maintain motivation and assess response:

• Continue treatment minimum 2-3 months before attempting to wean interventions 2
• Repeat uroflowmetry if dysfunctional voiding was diagnosed, to document normalization of flow pattern 1
• Monitor for UTI recurrence as marker of treatment success 1

Critical Pitfalls to Avoid

• Never punish the child for wet episodes—this worsens psychological impact and reduces treatment success 1, 2
• Do not overlook constipation—it is present in the majority of cases and must be treated first 1, 7
• Avoid extensive urologic workup (cystoscopy, urodynamics) in typical cases responding to conservative management 1
• Do not attribute symptoms to behavioral causes when red flags are present (abnormal neurologic exam, sacral findings, continuous wetting) 6
• Never start medication without first implementing urotherapy, as behavioral interventions alone succeed in most cases 1, 2