Section Resources

 

Urinary Infections

Male Incontinence

Female Incontinence

Prostate Problems

Erectile Dysfunction

Urinary Bleeding

PSA Assessment

Kidney & Urinary Stones

Childhood Problems

Childhood Urologic Diseases

Urinary Incontinence in Children & Bedwetting

Childhood urologic diseases newport beach urology
Parents or guardians of children who experience bedwetting at night or accidents during the day should treat this problem with understanding and patience. This loss of urinary control is called urinary incontinence or just incontinence. Although it affects many young people, it usually disappears naturally over time, which suggests that incontinence, for some people, may be a normal part of growing up. Incontinence at the normal age of toilet training may cause great distress. Daytime or nighttime incontinence can be embarrassing. It is important to understand that many children experience occasional incontinence and that treatment is available for most children who have difficulty controlling their bladders.

 

How does the urinary system work?

Urination, or voiding, is a complex activity. The bladder is a balloon-like organ that lies in the lowest part of the abdomen. The bladder stores urine, then releases it through the urethra, the canal that carries urine to the outside of the body. Controlling this activity involves nerves, muscles, the spinal cord, and the brain.

The bladder is composed of two types of muscles: the detrusor, a muscular sac that stores urine and squeezes to empty; and the sphincter, a circular group of muscles at the bottom or neck of the bladder that automatically stay contracted to hold the urine in and automatically relax when the detrusor contracts to let the urine into the urethra. A third group of muscles below the bladder (pelvic floor muscles) can contract to keep urine back.

A baby’s bladder fills to a set point, then automatically contracts and empties. As the child gets older, the nervous system matures. The child’s brain begins to get messages from the filling bladder and begins to send messages to the bladder to keep it from automatically emptying until the child decides it is the time and place to void.

Incontinence happens less often after age 5: About 10 percent of 5-year-olds, 5 percent of 10-year-olds, and 1 percent of 18-year-olds experience episodes of incontinence. It is twice as common in boys as in girls.

Failures in this control mechanism result in incontinence. Reasons for this failure range from simple to complex.

What causes nighttime incontinence?

After age 5, wetting at night—often called bedwetting or sleepwetting—is more common than daytime wetting. Experts do not know what causes nighttime incontinence. Young people who experience nighttime wetting are usually physically and emotionally normal. Most cases probably result from a mix of factors including slower physical development, an overproduction of urine at night, a lack of ability to recognize bladder filling when asleep, and, infrequently, anxiety. For many, there is a strong family history of bedwetting, suggesting an inherited factor.

Slower Physical Development

Between the ages of 5 and 10, bedwetting may be the result of a small bladder capacity, long sleeping periods, and underdevelopment of the body’s alarms that signal a full or emptying bladder. This form of incontinence will fade away as the bladder grows and the natural alarms become operational.

Excessive Output of Urine During Sleep

Normally, the body produces a hormone that can slow the production of urine. This hormone is called antidiuretic hormone, or ADH. The body normally produces more ADH at night so that the need to urinate is lower. If the body doesn’t produce enough ADH at night, the production of urine may not be slowed down, leading to bladder overfilling. If a child does not sense the bladder filling and awaken to urinate, then wetting will occur.

Anxiety

Experts suggest that anxiety-causing events occurring in the lives of children ages 2 to 4 might lead to incontinence before the child achieves total bladder control. Anxiety experienced after age 4 might lead to wetting after the child has been dry for a period of 6 months or more. Such events include angry parents, unfamiliar social situations, and overwhelming family events such as the birth of a brother or sister.

Incontinence itself is an anxiety-causing event. Strong bladder contractions leading to leakage in the daytime can cause embarrassment and anxiety that lead to wetting at night.


Genetics

Certain inherited genes appear to contribute to incontinence. In 1995, Swedish researchers announced they had found a site on human chromosome 13 that is responsible, at least in part, for nighttime wetting. If both parents were bedwetters, a child has an 80 percent chance of also being a bedwetter. Experts believe that other, undetermined genes also may be involved in incontinence.

Obstructive Sleep Apnea

Nighttime incontinence may be one sign of another condition called obstructive sleep apnea, in which the child’s breathing is interrupted during sleep, often because of inflamed or enlarged tonsils or adenoids. Other symptoms of this condition include snoring, mouth breathing, frequent ear and sinus infections, sore throat, choking, and daytime drowsiness. In some cases, successful treatment of this breathing disorder may also resolve the associated nighttime incontinence.


Structural Problems

Finally, a small number of cases of incontinence are caused by physical problems in the urinary system in children. Rarely, a blocked bladder or urethra may cause the bladder to overfill and leak. Nerve damage associated with the birth defect spina bifida can cause incontinence. In these cases, the incontinence can appear as a constant dribbling of urine.

What causes daytime incontinence?

Daytime incontinence that is not associated with urinary infection or anatomic abnormalities is less common than nighttime incontinence and tends to disappear much earlier than the nighttime versions. One possible cause of daytime incontinence is an overactive bladder. Many children with daytime incontinence have abnormal elimination habits, the most common being infrequent voiding and constipation.

An Overactive Bladder

Muscles surrounding the urethra—the tube that takes urine away from the bladder—have the job of keeping the passage closed, preventing urine from passing out of the body. If the bladder contracts strongly and without warning, the muscles surrounding the urethra may not be able to keep urine from passing. This often happens as a consequence of urinary tract infection (UTI) and is more common in girls.

Infrequent Voiding

Infrequent voiding refers to a child’s voluntarily holding urine for prolonged intervals. For example, a child may not want to use the toilets at school or may not want to interrupt enjoyable activities, so he or she ignores the body’s signal of a full bladder. In these cases, the bladder can overfill and leak urine. In addition, these children often develop UTIs, leading to an irritable or overactive bladder.

Other Causes

Some of the same factors that contribute to nighttime incontinence may act together with infrequent voiding to produce daytime incontinence. These factors include:

  • small bladder capacity
  • structural problems
  • anxiety-causing events
  • pressure from a hard bowel movement (constipation)
  • drinks or foods that contain caffeine, which increases urine output and may also cause spasms of the bladder muscle, or other ingredients to which the child may have an allergic reaction, such as chocolate or artificial coloring
Sometimes overly strenuous toilet training may make the child unable to relax the sphincter and the pelvic floor to completely empty the bladder. Retaining urine, or incomplete emptying, sets the stage for UTIs.

What treats or cures incontinence?

Growth and Development

Most urinary incontinence fades away naturally. Here are examples of what can happen over time:

  • Bladder capacity increases.
  • Natural body alarms become activated.
  • An overactive bladder settles down.
  • Production of ADH becomes normal.
  • The child learns to respond to the body’s signal that it is time to void.
  • Stressful events or periods pass.

Many children overcome incontinence naturally—without treatment—as they grow older. The number of cases of incontinence goes down by 15 percent for each year after the age of 5.

Medications

Nighttime incontinence may be treated by increasing ADH levels. The hormone can be boosted by a synthetic version known as desmopressin, or DDAVP, which is available in pill form, nasal spray, or nose drops. Desmopressin is approved for use in children.

Another medication, called imipramine, is also used to treat sleepwetting. It acts on both the brain and the urinary bladder. Researchers estimate that these medications may help as many as 70 percent of patients achieve short-term success. Many patients, however, relapse once the medication is withdrawn.

If a young person experiences incontinence resulting from an overactive bladder, a doctor might prescribe a medicine that helps to calm the bladder muscle. This medicine controls muscle spasms and belongs to a class of medications called anticholinergics.

Bladder Training and Related Strategies

Bladder training consists of exercises for strengthening and coordinating muscles of the bladder and urethra, and may help the control of urination. These techniques teach the child to anticipate the need to urinate and prevent urination when away from a toilet. Techniques that may help nighttime incontinence include:

  • determining bladder capacity
  • drinking less fluid before sleeping
  • developing routines for waking up

Unfortunately, none of these techniques guarantees success.

Techniques that may help daytime incontinence include:

  • urinating on a schedule—timed voiding—such as every 2 hours
  • avoiding caffeine or other foods or drinks that you suspect may contribute to your child’s incontinence
  • following suggestions for healthy urination, such as relaxing muscles and taking your time

Moisture Alarms

At night, moisture alarms can awaken a person when he or she begins to urinate. These devices include a water-sensitive pad worn in pajamas, a wire connecting to a battery-driven control, and an alarm that sounds when moisture is first detected. For the alarm to be effective, the child must awaken as soon as the alarm goes off, go to the bathroom, and change the bedding. Using alarms may require having another person sleep in the same room to awaken the bedwetter.

Points to Remember

  • Urinary incontinence in children is common.
  • Nighttime wetting occurs more commonly in boys.
  • Daytime wetting is more common in girls.
  • After age 5, incontinence disappears naturally at a rate of 15 percent of cases per year.
  • Treatments include waiting, dietary modification, moisture alarms, medications, and bladder training.

Urinary Tract Infections in Children

Urinary tract infections (UTIs) affect about 3 percent of children in the United States every year. Throughout childhood, the risk of a UTI is 2 percent for boys and 8 percent for girls. UTIs account for more than 1 million visits to pediatricians’ offices every year. The symptoms are not always obvious to parents, and younger children are usually unable to describe how they feel. Recognizing and treating urinary tract infections is important. Untreated UTIs can lead to serious kidney problems that could threaten the life of your child.

How does the urinary tract normally function?

The kidneys filter and remove waste and water from the blood to produce urine. They get rid of about 1-1/2 to 2 quarts of urine per day in an adult and less in a child, depending on the child's age. The urine travels from the kidneys down two narrow tubes called the ureters. The urine is then stored in a balloon-like organ called the bladder (see figure 1). In a child, the bladder can hold about 1 to 1-1/2 ounces of urine for each year of the child's age. So, the bladder of a 4-year-old child may hold about 4 to 6 ounces (less than 1 cup); an 8-year-old can hold 8 to 12 ounces. When the bladder empties, a muscle called the sphincter relaxes and urine flows out of the body through the urethra, a tube at the bottom of the bladder. The opening of the urethra is at the end of the penis in boys (see figure 2) and in front of the vagina in girls (see figure 3).

How does the urinary tract become infected?

Normal urine contains no bacteria (germs). Bacteria may, at times, get into the urinary tract and the urine from the skin around the rectum and genitals by traveling up the urethra into the bladder. When this happens, the bacteria can infect and inflame the bladder and cause swelling and pain in the lower abdomen and side. This bladder infection is called cystitis.

If the bacteria travel up through the ureters to the kidneys, a kidney infection can develop. The infection is usually accompanied by pain and fever. Kidney infections are much more serious than bladder infections.

In some children a urinary tract infection may be a sign of an abnormal urinary tract that may be prone to repeated problems. For this reason, when a child has a urinary infection, additional tests are often recommended. In other cases, children develop urinary tract infections because they are prone to such infections, just as other children are prone to getting coughs, colds, or ear infections. Or a child may happen to be infected by a type of bacteria with a special ability to cause urinary tract infections.

Children who frequently delay a trip to the bathroom are more likely to develop UTIs. Regular urination helps keep the urinary tract sterile by flushing away bacteria. Holding in urine allows bacteria to grow. Keeping the sphincter muscle tight for a long time also makes it more difficult to relax that muscle when it is time to urinate. As a result, the child’s bladder may not empty completely. This dysfunctional voiding can set the stage for a urinary infection.

What are the signs of urinary tract infection?

A urinary tract infection causes irritation of the lining of the bladder, urethra, ureters, and kidneys, just like the inside of the nose or the throat becomes irritated with a cold. If your child is an infant or only a few years old, the signs of a urinary tract infection may not be clear, since children that young cannot tell you exactly how they feel. Your child may have a high fever, be irritable, or not eat.

On the other hand, sometimes a child may have only a low-grade fever, experience nausea and vomiting, or just not seem healthy. The diaper urine may have an unusual smell. If your child has a high temperature and appears sick for more than a day without signs of a runny nose or other obvious cause for discomfort, he or she may need to be checked for a bladder infection.

An older child with bladder irritation may complain of pain in the abdomen and pelvic area. Your child may urinate often. If the kidney is infected, your child may complain of pain under the side of the rib cage, called the flank, or low back pain. Crying or complaining that it hurts to urinate and producing only a few drops of urine at a time are other signs of urinary tract infection. Your child may have difficulty controlling the urine and may leak urine into clothing or bedsheets. The urine may smell unusual or look cloudy or red.

How do you find out whether your child has a urinary tract infection?

Only by consulting a health care provider can you find out for certain whether your child has a urinary tract infection.

uti urinary tract infectionsSome of your child's urine will be collected and examined. The way urine is collected depends on your child’s age. If the child is not yet toilet trained, the health care provider may place a plastic collection bag over your child's genital area. It will be sealed to the skin with an adhesive strip. An older child may be asked to urinate into a container. The sample needs to come as directly into the container as possible to avoid picking up bacteria from the skin or rectal area. A doctor or nurse may need to pass a small tube into the urethra. Urine will drain directly from the bladder into a clean container through this tube, called a catheter. Sometimes the best way to get the urine is by placing a needle directly into the bladder through the skin of the lower abdomen. Getting urine through the tube or needle will ensure that the urine collected is pure.

Some of the urine will be examined under a microscope. If an infection is present, bacteria and sometimes pus will be found in the urine. If the bacteria from the sample are hard to see, the health care provider may place the sample in a tube or dish with a substance that encourages any bacteria present to grow. Once the germs have multiplied, they can then be identified and tested to see which medications will provide the most effective treatment. The process of growing bacteria in the laboratory is known as performing a culture and often takes a day or more to complete.

The reliability of the culture depends on how long the urine stands before the culture is started. If you collect your child's urine at home, refrigerate it as soon as it is collected and carry the container to the health care provider or lab in a plastic bag filled with ice.

How are urinary tract infections treated?

Urinary tract infections are treated with bacteria-fighting drugs called antibiotics. While a urine sample is being examined, the health care provider may begin treatment with a drug that treats the bacteria most likely to be causing the infection. Once culture results are known, the health care provider may decide to switch your child to another antibiotic.

The way the antibiotic is given and the number of days that it must be taken depend in part on the type of infection and how severe it is. When a child is sick or not able to drink fluids, the antibiotic may need to be put directly into the bloodstream through a vein in the arm or hand. Otherwise, the medicine (liquid or pills) may be given by mouth or by shots. The medicine is given for at least 3 to 5 days and possibly for as long as several weeks. The daily treatment schedule recommended depends on the specific drug prescribed: The schedule may call for a single dose each day or up to four doses each day. In some cases, your child will need to take the medicine until further tests are finished.

After a few doses of the antibiotic, your child may appear much better, but often several days may pass before all symptoms are gone. In any case, your child should take the medicine for as long as the doctor recommends. Do not stop medications because the symptoms have gone away. Infections may return, and germs can resist future treatment if the drug is stopped too soon.

Children should drink fluids when they wish. Make sure your child drinks what he or she needs, but do not force your child to drink large amounts of fluid. The health care provider needs to know if the child is not interested in drinking.

What tests may be needed after the infection is gone?

Once the infection has cleared, additional tests may be recommended to check for abnormalities in the urinary tract. Repeated infections in abnormal urinary tracts may cause kidney damage. The kinds of tests ordered will depend on your child and the type of urinary infection. Because no single test can tell everything about the urinary tract that might be important, more than one of the following tests may be needed:

  • Kidney and bladder ultrasound. An ultrasound test examines the kidney and bladder using sound waves. This test shows shadows of the kidney and bladder that may point out certain abnormalities. However, this test cannot reveal all important urinary abnormalities. It also cannot measure how well a kidney works.
  • Voiding cystourethrogram (VCUG). This test examines the urethra and bladder while the bladder fills and empties. A liquid that can be seen on x rays is placed into the bladder through a catheter. The bladder is filled until the child urinates. This test can reveal abnormalities of the inside of the urethra and bladder. The test can also determine whether the flow of urine is normal when the bladder empties.
  • Intravenous pyelogram. This test examines the whole urinary tract. A liquid that can be seen on x rays is injected into a vein. The substance travels into the kidneys and bladder, revealing possible obstructions.
  • Nuclear scans. These tests use radioactive materials that are usually injected into a vein to show how well the kidneys work, the shape of the kidneys, and whether urine empties from the kidneys in a normal way. Each kind of nuclear scan gives different information about the kidneys and bladder. Nuclear scans expose a child to about the same amount of radiation as a conventional x ray. At times, it can even be less.
  • Computed tomography (CT) scans and magnetic resonance imaging (MRI). These tests provide 3-D images and cross-sections of the bladder and kidneys. With a typical CT scan or MRI machine, the child lies on a table that slides inside a tunnel where the images are taken. If the child’s infection is complicated or difficult to see in other image tests, a CT scan or MRI can provide clearer, more detailed images to help the doctor understand the problem.

What abnormalities lead to urinary problems?

Many children who get urinary tract infections have normal kidneys and bladders. But if a child has an abnormality, it should be detected as early as possible to protect the kidneys against damage. Abnormalities that could occur include the following:

  • Vesicoureteral reflux (VUR). Urine normally flows from the kidneys down the ureters to the bladder in one direction. With VUR, when the bladder fills, the urine may also flow backward from the bladder up the ureters to the kidneys. This abnormality is common in children with urinary infections.
  • Urinary obstruction. Blockages to urinary flow can occur in many places in the urinary tract. The ureter or urethra may be too narrow or a kidney stone at some point stops the urinary flow from leaving the body. Occasionally, the ureter may join the kidney or bladder at the wrong place and prevent urine from leaving the kidney in the normal way.
  • Dysfunctional voiding. Some children develop a habit of delaying a trip to the bathroom because they don’t want to leave their play. They may work so hard at keeping the sphincter muscle tight that they forget how to relax it at the right time. These children may be unable to empty the bladder completely. Some children may strain during urination, causing pressure in the bladder that sends urine flowing back up the ureters. Dysfunctional voiding can lead to vesicoureteral reflux, accidental leaking, and UTIs.

Do urinary tract infections have long-term effects?

Young children are at the greatest risk for kidney damage from urinary tract infections, especially if they have some unknown urinary tract abnormality. Such damage includes kidney scars, poor kidney growth, poor kidney function, high blood pressure, and other problems. For this reason it is important that children with urinary tract infections receive prompt treatment and careful evaluation.

How can urinary tract infections be prevented?

If your child has a normal urinary tract, you can help him or her avoid UTIs by encouraging regular trips to the bathroom. Make sure your child gets enough to drink if infrequent voiding is a problem. Teach your child proper cleaning techniques after using the bathroom to keep bacteria from entering the urinary tract.

Some abnormalities in the urinary tract correct themselves as the child grows, but some defects may require surgical correction. A common procedure to correct VUR is the reimplantation of the ureters. During this surgery, the doctor repositions the connection between the ureter and the bladder so that urine will not back up into the ureters and kidneys. In recent years, doctors have treated some cases of VUR by injecting collagen, or a similar substance, into the bladder wall, just below the opening where the ureter joins the bladder. This injection creates a kind of valve that keeps urine from flowing back into the ureter. The injection is delivered to the inside of the bladder through a catheter passed through the urethra, so there is no need for a surgical incision.

Points to Remember

  • Urinary tract infections affect about 3 percent of children in the United States every year.
  • A urinary tract infection in a young child may be a sign of an abnormality in the urinary tract that could lead to repeated problems.
  • Symptoms of a urinary infection range from slight burning with urination or unusual smelling urine to severe pain and high fever.
  • Untreated urinary infections can lead to serious kidney damage.
  • Talk to a doctor if you suspect your child has a urinary tract infection.

Circumcision

Circumcision is the removal of the foreskin, which is the skin that covers the tip of the penis. In the United States, it is often done before a new baby leaves the hospital. There are medical benefits and risks to circumcision. Possible benefits include a lower risk of urinary tract infections, penile cancer and sexually transmitted diseases. The risks include pain and a low risk of bleeding or infection. These risks are higher for older babies, boys and men.

The American Academy of Pediatrics (AAP) does not recommend routine circumcision. Parents need to decide what is best for their sons, based on their religious, cultural and personal preferences.

How do I decide about circumcision?

Deciding whether to have your newborn son circumcised may be difficult. You will need to consider both the benefits and the risks of circumcision. Other factors, such as your culture, religion and personal preference, will also affect your decision.

What is circumcision?

During a circumcision, the prepuce or the foreskin, which is the skin that covers the tip of the penis, is removed. Circumcision is usually performed on the first or second day after birth. It becomes more complicated and riskier in infants older than 2 months and in boys and men. The procedure takes only about 5 to 10 minutes. A local anesthetic (numbing medicine) can be given to your baby to lessen the pain from the procedure.

Are there any benefits from circumcision?

Studies about the benefits of circumcision have provided conflicting results. Some studies show certain benefits, while other studies do not. The American Academy of Pediatrics (AAP) says the benefits of circumcision are not significant enough to recommend circumcision as a routine procedure and that circumcision is not medically necessary. The American Academy of Family Physicians believes parents should discuss with their son's doctor the potential benefits and the risks involved when making their decision.

A recent AAP report stated that circumcision does offer some benefit in preventing urinary tract infections in infants. Circumcision also offers some benefit in preventing penile cancer in adult men. However, this disease is very rare in all men, whether or not they have been circumcised. Circumcision may reduce the risk of sexually transmitted diseases. A man's sexual practices (e.g., if he uses condoms, if he has more than one partner, etc.) has more to do with STD prevention than whether or not he is circumcised.

Study results are mixed about whether circumcision may help reduce the risk of cervical cancer in female sex partners, and whether it helps prevent certain problems with the penis, such as infections and unwanted swelling. Some studies show that keeping the penis clean can help prevent these problems just as well as circumcision. Infections and unwanted swelling are not serious and can usually be easily treated if they do occur.

What are the risks of circumcision?

Like any surgical procedure, circumcision has some risks. However, the rate of problems after circumcision is low. Bleeding and infection in the circumcised area are the most common problems. Sometimes the skin of the newly exposed glans becomes irritated by the pressure of diapers and ammonia in the urine. The irritation is usually treated with petroleum ointment (Vaseline) put directly on the area. This problem will usually lessen after a few days.

How do I care for my baby's penis after a circumcision?

Gently clean the area with water every day and whenever the diaper area becomes soiled. Some swelling of the penis is normal after a circumcision. A clear crust will probably form over the area. It normally takes 7 to 10 days for the penis to heal after a circumcision.

After the circumcision, you may notice a small amount of blood on the baby's diaper. If the bloodstain is larger than the size of a quarter, call your doctor right away. In addition, you should call your doctor if a Plastibell device was used during the circumcision and the device doesn't fall off within 10 to 12 days. If there is a bandage on the penis instead of a Plastibell, the bandage should be changed each time you change your son's diaper. This will help prevent infection. Signs of infection also signal the need to call your doctor. These signs include a temperature of 100.4°F or higher, redness, swelling and/or a yellowish discharge.

When to call your doctor

  • If the wound does not stop bleeding.
  • If your son does not have a wet diaper within 6 to 8 hours after the circumcision.
  • If the redness and swelling around the tip of the penis do not go away or get worse after 3 to 5 days.
  • If there is a yellow discharge or coating around the tip of the penis after 7 days.
  • If the Plastibell device does not fall off within 10 to 12 days.

How do I care for my baby's penis if I choose not to have him circumcised?

Simply keeping the penis clean with soap and water helps reduce the risk of problems or infections.

In older boys and adult men, the foreskin slides back and forth over the penis, allowing the area underneath to be cleaned. The foreskin doesn't retract in boys for a few years. Don't try to force the foreskin to retract, because this can damage the penis and cause problems. When the foreskin is ready to retract, you can teach your son how to retract it himself and clean the skin underneath. He should wash his foreskin every day while bathing.