Key points to remember
- daytime wetting occurs in about 3 and a half percent of healthy children
- 67 percent of these children will have bedwetting as well - see bedwetting
- it is important that all children with daytime wetting are seen by a doctor experienced with children's problems
- daytime wetting needs to be controlled before bedwetting can be sorted out
- the problem is more common in girls and late school entrants
- usually wetting is just a small patch through the layers of clothes rather than the full amount in the bladder
- children list wetting pants in class as the third most stressful event after losing a parent and going blind!
- lots of patience and support are needed to correct this problem but a positive approach is usually rewarded by success
- children don't want to wet their pants
- be supportive
- seek help early
What causes daytime wetting?
There are many causes of daytime wetting but dysfunctional voiding is the most common problem - 'voiding' means doing wee (passing urine).
Children with daytime wetting feel the urge at the last minute and may suddenly demonstrate holding postures or may 'curtsey' using their heel to stop the flow of wee (urine). When they get to the toilet the outlet valve may not relax fully and so stops the bladder from emptying fully. When they go back to their desk the outlet valve will relax and wee leaks out. This leftover wee also leads to infections so all children with urinary tract infections should be asked if there are problems with daytime wetting.
Some other causes of daytime wetting
- a twitchy or 'overactive' bladder which may lead to wet pants or urgency
- a weak outlet valve which may lead to wet pants when laughing, coughing or straining
- urinary tract infections
- constipation which can lead to wet pants as well as soiling
- structural abnormalities with the bladder or the tubes from the kidneys - suspicious symptoms include pain on doing wee, a poor urinary stream or continuous dribbling of wee
- problems with the nerves from the lower spinal cord; weakness in the legs may be associated
Daytime wetting is rarely due to disease or child abuse.
What can I do to help?
- be patient and understanding - reassure your child, especially if they are upset
- respond gently if your child is wet even if you feel angry; they do not want it to happen either
- give the child plenty of fluid during the day; children may try to drink less to reduce the amount of wee but the slow bladder filling makes it harder to feel the bladder filling up and makes the problem worse
- avoid drinks with caffeine such as tea, chocolate and fizzy drinks
- teach your child to relax and take time when doing wee; girls should learn to wee with their legs apart and smaller girls may find a footstool helpful
- provide spare underwear or a panty liner for school; the smell of wee may embarrass your child and lead to teasing
- punish your child for what they can't control
- use nappies or plastic pants if your child is over 4 or is embarrassed
When should I seek help?
It is important that all children with daytime wetting are seen by a doctor experienced with children's problems.
The doctor will take a detailed history of the problem and examine your child. A diary with the following information is very helpful:
- the time your child does wee
- the amount of wee they do
- how much fluid they drink
Your child may be referred to a paediatrician (child health specialist) or urologist (a doctor specially trained in conditions of the bladder and urinary system).
If a psychological problem is suspected, your child may be referred for help in this area.
What tests are needed?
Your child may have laboratory tests on blood and wee to rule out any medical conditions. 50 percent of girls who wet during the day will have occasional bacteria in their wee.
Ultrasound scans or x-rays may be required to check the bladder and kidneys.
Occasionally a child may need cystoscopy, where a tube is used to look for any abnormalities in the bladder outlet. This is done by a urologist (a doctor specially trained in conditions of the bladder and urinary system).
The urologist may also perform urodynamics to show the unstable bladder and incoordination between the bladder contraction and the expected relaxation of the outlet valve. This can lead to increased bladder pressure, which may cause reflux of urine up the tubes to the kidneys.
How is daytime wetting treated?
10 to 15 percent of children with daytime wetting become dry each year but it is very distressing and dysfunctional voiding can last for a long time. (Voiding means passing urine).
Daytime wetting can be brought under control with retraining, and occasionally suitable medication.
The best approach is to encourage the child to pass urine on a timed basis before they feel the urge. This allows the bladder to empty while the outlet valve is still relaxed. This needs to be individually tailored for the child and family, especially one who is going to school. The child should also try to relax and empty the bladder without straining. Sympathetic and energetic management putting the child in control, offering reminder alarms and sticker chart strategies are often helpful especially as the programme needs to be continued for at least six months.
After voiding urine children count to 20 and try to empty their bladders again. This reduces residual urine in the bladder.
Pelvic floor exercises
Pelvic floor exercises and teaching control with relaxation of sphincter muscles can be helpful, but exercises that encourage holding on to urine make things worse.
Treatment of constipation
Treatment of constipation is essential to reduce residual urine in the bladder and obstruction of the outflow.
Some medicines can be useful. Antibiotics control urinary tract infections and can reduce bladder instability. Antispasmodic drugs such as 'oxybutinin' do not result in long term benefits by themselves, but may help short term to help with bladder retraining.
In most cases, surgery has limited success and may sometimes make the problem worse.
This content has been produced by the Paediatric Society of New Zealand in collaboration with the Enuresis Guideline Team, KEEA (Kiwi and Enuresis Encopresis Association) NZ and NZCA (The New Zealand Continence Association).