The primary care physician needs to have in place appropriate strategies for evaluation of urologic issues and recommendations to parents who broach these topics.
Primary care offices in the pediatric world are busy with numerous topics to cover during well-child visits. Development, prevention, and safety issues rank as high priority. By the time the primary care provider (PCP) asks if there are any other outstanding issues besides the required topics, the visit may already be winding to a close.
What does the busy PCP recommend when the parent brings up the topic of incontinence, urinary frequency, or nocturnal enuresis? If the child is of an age deemed likely to outgrow these issues, the PCP may say just that. Advice to not worry about the urinary issues because they will spontaneously resolve often will be offered. Yet is this advice ideal or just the best that can be offered in the time allotted?
The purpose of this article is to provide the pediatric PCP with the best knowledge available so that the child and family can be counseled adequately. What are appropriate strategies for evaluation and for recommendations to a parent who broaches these topics? What are the red flags that the pediatric PCP needs to recognize? What are the most important caveats during the evaluation and management of enuresis and incontinence?
Impact of urologic issues
Many pediatric PCPs have educated themselves on urologic issues or sought education from pediatric urology specialists. They may begin the evaluation of urinary issues, recommend treatment, and order diagnostic testing where appropriate. Perhaps one particular care provider in the office could develop an expertise in such issues and begin an educational program with the family. A nurse practitioner (NP) with such an interest would be a good choice for this role. This article provides evidence-based algorithms for diagnosing urologic complaints and is a starting point for the evaluation and management of common pediatric bladder and bowel issues (Figure 1,1-3 Figure 2,1,4,5 and Figure 31,6).
It is important to remember that while reviewing the medical history and conducting the physical exam, potential physical causes of enuresis should be ruled out. These varied etiologies are included in Table 1. Physical issues, however, are not the single concern here. The psychologic and emotional harm that can result from urinary tract dysfunction is imperative to consider. Bladder issues including bedwetting and incontinence are legitimate problems. Families may be told, “Don’t worry about it . . . your child will outgrow it in due time,” or “Return to see me if it persists until the age of 10 years” (or the age a particular care provider deems appropriate). Whereas these statements may be made with the best intentions, families report much frustration over the presence of urinary issues.
One study that involved direct interviews with parents showed that having a child with enuresis can be stressful as parents feel the need to protect their children from teasing. Parents feel that enuresis is socially stigmatizing and say that support from healthcare providers would help.7 Other studies have shown that children with enuresis suffer lowered self-esteem and, when treated, actually exhibit increases in the same.8,9 The wetting creates a physical, financial, and emotional burden on the parents as they must do extra laundry, buy incontinence briefs, and deal with a malodorous house. It has been shown that between 30% and 80% of parents punish their children and adolescents for wet nights.10-12 Punishments described include reprimanding, deprivation of sleep, and beating.12 In addition, punishments for bedwetting have been associated with childhood depression.13 Punishments have been inversely correlated with successful treatment of bedwetting.12
The International Children’s Continence Society (ICCS) is an organization that includes multiple disciplines and specialties that care for children with bladder and bowel dysfunction. This group recommends that pediatric PCPs, including pediatricians, nurse practitioners, and family physicians, develop early recognition and appropriate management skills of bladder and bowel dysfunction (BBD). These care providers can serve an important role in the initial evaluation and management of BBD and reduce the associated morbidity.14 Nocturnal enuresis, daytime incontinence, and functional constipation all impact the physical and emotional well-being of the child and family.
For this article, the ICCS terminology and definitions will be used. Monosymptomatic nocturnal enuresis is defined as night wetting without any lower urinary tract symptoms. By the age of 4 years, most children void 5 to 6 times a day.15 The definition of daytime urinary frequency is said to occur in children who void 8 or more times a day and the definition of daytime infrequency is those who void 3 or fewer times a day.16 Daytime urgency is defined as the sudden development of an overwhelming need to void.
Dysuria is defined as discomfort during urination.16 Holding maneuvers are visible postures or positioning of the body when a child is postponing urination, such as placing pressure on the perineum, the potty dance, or crossing the legs. Intermittent wetting during daytime (awake) hours is termed daytime incontinence (not enuresis). Any wetting during sleeping hours is called enuresis. This would include wetting during sleep at night or during daytime naps.
Dysfunctional elimination syndrome and dysfunctional voiding are terms no longer recommended. Instead, BBD is used as it is a term that describes lower urinary tract symptoms combined with fecal problems consisting of primarily constipation and encopresis.
Nocturnal enuresis and/or daytime incontinence
Many theories exist as to the etiology of nocturnal enuresis including genetics, small bladder capacity, detrusor overactivity, nocturnal polyuria, and sleep arousal thresholds. Figure 1 shows an algorithm for the evaluation of the child who presents with nocturnal enuresis.1-3 The history should include determining the presence of daytime wetting or other lower urinary tract symptoms.
The frequency of nocturnal enuresis and its effects on the family should be determined. Is the child developmentally appropriate? Were milestones such as gross motor skills and toilet training reached on target? Are there behavioral issues or family stressors that could affect the child’s and family’s ability to participate in working on the bedwetting? Of utmost importance is whether the child is bothered by the enuresis. If the child is motivated to work on the enuresis, it is time to assist the family. When the child is developmentally ready, and especially when the child’s life is negatively impacted by enuresis, the family needs help.
In the case of daytime and nighttime symptoms, the algorithm in Figure 2 should be followed.1,4,5 The history needs to elicit voiding habits in particular with children who exhibit daytime incontinence and/or urinary tract infections (UTI). Many of these children are found to have poor fluid intake and also may void infrequently. Both habits predispose to the development of incontinence and UTIs. Daytime incontinence may occur when the child has never been toilet trained or may have been trained for several months and then regressed.
Constipation and enuresis
Typically, the physical examination of the child with monosymptomatic nocturnal enuresis is normal. Certain findings could elicit an underlying medical cause. One finding is palpable stool in the abdomen, which suggests constipation. It is important to note, however, that many times copious amounts of stool are present in the bowel but not palpable.2 It is not safe to assume that a soft abdomen indicates the absence of bowel issues. Furthermore, the definition of constipation is not uniform in the medical literature, nor is it uniformly understood by physicians and lay people.17 Most pediatric PCPs would identify infrequent or large, hard, and painful stools as evidence that constipation is an issue. The presence of these symptoms would likely cause the care provider to initiate a bowel management program.
Most parents and many care providers think that a daily stool indicates that constipation does not exist. This could not be further from the truth. Oftentimes, multiple daily stools are an indication that the rectum has become stretched and does not empty completely. The rectum being in such close proximity to the bladder then places pressure on the bladder, never allowing it to fully expand or empty to completion. Furthermore, stool backed up in the transverse and descending colon continues to empty into the rectum, placing more pressure on the bladder.
The relationship between enuresis and constipation was initially described in 1986.18 O’Regan and colleagues measured rectal distention in 25 enuretic children to determine the presence of constipation. Twenty-two of the 25 patients with enuresis showed decreased perception of rectal distention, and the majority tolerated very large balloon insufflation in the rectum. Seventeen of these 22 patients were treated with an enema program and a regimen of increased fiber content in the diet. All 17 showed total or partial improvement of nocturnal enuresis within 6 weeks by managing the bowels alone. The remaining 5 patients did not undergo bowel management. Whereas rectal distention is probably not at the top of the list when identifying constipation, it is clear from this data that it has an important impact on treatment.
To add further clarification to the concept of rectal distention affecting bladder function, Hodges and Anthony undertook a retrospective study to review 30 consecutive patients who presented with nocturnal enuresis.17 The researchers used specific radiologic criteria to measure rectal distention and abnormal stool burden. Results showed that all 30 patients showed rectal distention and 80% had an abnormally high stool burden. Only 10% of those patients with an abnormally heavy stool burden by radiography had a history of being constipated. Aggressive bowel management alone cured about 80% of those with nocturnal enuresis within 3 months. The use of polyethylene glycol caused the nocturnal enuresis to resolve in 80% of children. For those children that continued with rectal distention at a month’s follow-up, stimulant laxatives and/or enemas were added.
Because the history and physical exam of children who present with enuresis often does not identify the presence of constipation or fecal impaction, alternative sources of identification are recommended. Children and their parents often do not know that constipation exists. Initially when questioned, children may say they have soft, easy-to-pass stools. Children may not pay attention to their own bowel habits and may not possess the ability to discern whether their stools are hard or soft, large or small. They may have no comparison in their limited experience. Parents often deny that any difficulties with their child’s bowel movements have ever existed. Once toilet training has been accomplished, parents may rarely or never see another of their child’s bowel movements.
The Bristol stool scale is a visual chart of 7 types of stool that can be used to determine if constipation is present (Table 2).19 Types 1, 2, and 3 are constipated stools, whereas types 4 and 5 are stools with more desirable consistency. Children may say their stools are soft until they are shown the Bristol chart. When they point out types 1 or 2 as their usual stools, it is apparent this is not the case.
Another source for determining the diagnosis of functional constipation is the Rome classification, which is accepted by both pediatric and adult gastroenterologists. This system consists of 6 criteria, 5 of which are based on clinical history (Table 3).20 When clinical history does not identify a child who is constipated, a plain abdominal radiograph can be obtained. Many children who are determined to be constipated by abdominal radiograph and the Bristol stool chart will not meet Rome criteria. This could be considered a shortcoming of the Rome criteria as the majority of findings are obtained through history, which can be difficult for families to recall or identify. The 1 physical finding of a rectal fecal mass is not easily determined by current criteria. Perhaps a seventh measure, that of the presence of an abdominal fecal mass or masses on physical exam, could be a vital addition. The early diagnosis and treatment of a large stool load and/or mega-rectum will cause the enuresis cure to be easier, shorter, and less costly. Some red flags that may be found in the history or physical exam that might lead to a diagnosis of an organic cause of constipation are listed in Table 4.21
Abdominal radiographs and constipation
Primary care physicians may be hesitant to order a plain abdominal x-ray (AXR), particularly when obvious symptoms of functional constipation are not present. The sixth Rome criterion, that of fecal impaction, is made by rectal examination, radiography, or ultrasound (US). Rectal examination is not the norm in pediatric primary care. For children and adolescents, rectal examination can be frightening and potentially painful and may sour a good relationship between care provider and patient. Often, the main concern about ordering an abdominal film is the radiation exposure. To ease concern about this, it is helpful to realize that the radiation exposure from 1 AXR is equivalent to about 2 months’ worth of natural background radiation.22 Taking this into consideration makes the occasional abdominal film a highly justifiable tool.
Speaking from years of experience, this author has found that many parents will not even consider treating constipation in their child who shows no outward evidence. However, showing parents the computer image and pointing out the large colonic stool load, and in particular the recto-sigmoid, will likely convince the parents. Leech and colleagues also found that showing the abdominal film image to parents and children encourages compliance with treatment.23 The transabdominal US to measure rectal diameter is a useful method to diagnose fecal impaction, but it is not widely used. Its use has been described in Europe and Japan, and it has shown to be reliable when performed by an experienced clinician.24,25
It is extremely important to note that when an abdominal radiograph is obtained, the ordering provider must assess the image, not just read the radiologist’s report. Over time, the PCP will become familiar with images that constitute a small, moderate, or large stool load and to pay specific attention to the recto-sigmoid. Of note is the recognition that not all PCPs will have access to the actual radiographic images via their electronic medical records system. Perhaps, families may be more inclined to begin a bowel regimen without an AXR when suggested by their trusted PCP with whom a professional relationship has already been developed. When the pediatric specialist has been consulted, the recommendation for bowel management often occurs during the first visit.
Significance of urinalysis and importance of urine culture
When BBD exists, or a UTI is suspected, it is necessary to review the results of a macroscopic and microscopic urinalysis. It is not sufficient to check the urine with a reagent test strip. Two significant substances to look for on the test strip when evaluating for UTIs are nitrites and leukocyte esterase. Nitrites are the reduced form of nitrates in the urine. Some bacteria that cause UTIs produce enzymes that reduce urinary nitrate to nitrite. For this reaction to occur, the urine must have been present in the bladder for a minimum of 4 hours. Children may not hold urine in their bladders for this long. In addition, not all bacteria that cause UTIs produce this reaction.
Furthermore, numerous other reasons for a false-negative test result exist (Table 5).26 A false-positive result may occur from urine that has been left sitting at room temperature or from highly pigmented urine. If the urine is red due to blood or orange due to nitrofurantoin or phenazopyridine, for example, a positive result is not valid. The leukocyte esterase reaction is based on the fact that neutrophils contain enzymes known as esterases. The esterases are detected by reagent strips that contain an appropriate substrate.27 False negatives can occur with a high urine specific gravity and in urines that contain glucose and protein. In this environment, white blood cells (WBCs) will crenate (become notched) and are not able to release esterase.
Also, the presence of certain chemicals and drugs in the urine can cause false negatives to occur.26 Because of these limitations with testing for nitrites and leukocyte esterase in the urine, it is necessary to always obtain a microscopic analysis of the urine. If the resources are not available in the PCP’s office, it is necessary to send the urine to a lab. Importantly, the nitrite and leukocyte esterase tests are screening measures and are not meant to take the place of a urine culture.27
The microscopic urinalysis result will report the presence of red blood cells (RBCs), WBCs, and bacteria, in addition to other cells and microorganisms. On average, normal urine contains up to 5 RBCs and 5 WBCs per high-power field. A properly collected normal midstream urine specimen will not contain bacteria. When the urine specimen contains large numbers of bacteria, particularly when accompanied by many WBCs, it is indicative of a urinary tract infection. The type of bacteria will not be identified on urinalysis, which necessitates the sending of a urine specimen for culture. Should the urine grow bacteria, the colony count will be reported. A clean catch midstream urine culture growing 50,000 or more colony forming units per milliliter of a single organism is indicative of a urinary tract infection. This along with a microscopic urinalysis that shows pyuria or bacteriuria confirms a UTI.1
1. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595-610.
2. Tu ND, Baskin LS, Arnhym AM. Nocturnal enuresis in children: etiology and evaluation. UpToDate. Available at: https://www.uptodate.com/contents/nocturnal-enuresis-in-children-etiology-and-evaluation. Updated November 15, 2017. Accessed March 14, 2018.
3. Tu ND, Baskin LS. Nocturnal enuresis in children: management. UpToDate. Available at: https://www.uptodate.com/contents/nocturnal-enuresis-in-children-management. Updated October 19, 2017. Accessed March 14, 2018
4. Allen HA, Austin JC, Boyt MA, Hawtrey CE, Cooper CS. Initial trial of timed voiding is warranted for all children with daytime incontinence. Urology. 2007;69(5):962-965.
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6. Shaikh N, Hoberman A. Urinary tract infections in infants and children older than one month: clinical features and diagnosis. UpToDate. Available at: https://www.uptodate.com/contents/urinary-tract-infections-in-infants-and-children-older-than-one-month-clinical-features-and-diagnosis?search=urinary-tract-infections-in-infants-and-children-older-than-one-month:clinical-features-and-diagnosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Updated October 5, 2017. Accessed March 14, 2018.
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12. Ferrera P, Di Giuseppe M, Fabrizio GC, et al. Enuresis and punishment: the adverse effects on child development and on treatment. Urol Int. 2016;97(4):410-415.
13. Al-Zaben FN, Sehlo MG. Punishment for bedwetting is associated with child depression and reduced quality of life. Child Abuse Negl. 2015;43:22-29.
14. Yang S, Chua ME, Bauer S, et al. Diagnosis and management of bladder bowel dysfunction in children with urinary tract infections: a position statement from the International Children’s Continence Society. Pediatr Nephrol. October 3, 2017. Epub ahead of print.
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