Functional daytime incontinence: clinical and urodynamic assessment.

Assessment of children with daytime wetting starts with the distinction between 'enuresis diurna' and 'functional incontinence', incontinence being defined as any form of wetting caused by bladder/sphincter dysfunction. Standard history-taking does not allow for a sharp enough distinction: pertinent questions have to be asked about daytime wetting, night-time wetting, micturition, and about urge and reactions to urge. By using urodynamics to expose the pathophysiology behind the patterns of bladder/sphincter dysfunction, these questions were formulated and validated in a series of 156 children, referred with persistent daytime wetting to a programme for cognitive bladder training. With history-taking organized into a simple questionnaire, complemented by urodynamics, four patterns of bladder/sphincter dysfunction emerged: urge syndrome, staccato voiding, fractionated and incomplete voiding, and lazy bladder syndrome. A strong correlation was found between recurrent urinary tract infections and non-neuropathic bladder/sphincter dysfunction, implying that detection and treatment of bladder/sphincter dysfunction is essential in every child with recurrent urinary tract infections, especially in the presence of vesico-ureteral reflux.

Functional daytime incontinence: non-pharmacological treatment.

In children with 'functional incontinence', defined as any form of (daytime) wetting caused by non-neuropathic bladder/sphincter dysfunction, most signs and symptoms are rooted in habitual non-physiological responses to signals from bladder and urethra. These responses develop at toddler age, when children learn how to remain dry. Once they have become a habit, incomplete bladder emptying and recurrent urinary tract infections come into play, reiterating the non-physiological responses into fixed patterns of bladder/sphincter dysfunction with functional incontinence as the leading symptom. Non-pharmacological treatment of functional incontinence implies relearning and training the normal responses to signals from bladder and urethra: a cognitive process, with perception of the signals reinforced by biofeedback. This type of treatment is best combined with long-term chemoprophylaxis. Severe cases will benefit from anticholinergic drugs, as adjuvants to the training programme. Urodynamics play a crucial role in documenting the specific patterns of incontinence and in providing biofeedback. For a successful programme, psychological screening of the children is indispensable.