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Wetting, daytime incontinence, urine leakage, incontinence and children

More about wetting and 

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Causes: Daytime wetting (urinary incontinence)

Daytime wetting (urinary incontinence) has very different causes - depending on what form it is. In some forms, genetic causes predominate, in others there are acquired risks.

A very common form is urge incontinence, which is predominantly hereditary. The bladder cannot be filled, the children feel an urge to urinate and have to go to the toilet frequently. The amounts of urine are rather small. Other children put off going to the toilet so they can continue playing. At some point the urine can no longer be held and the bladder empties unintentionally. This is called urinary incontinence with delayed micturition. In other children there is a disorder of the sphincter, which does not open completely when emptying the bladder (detrusor-sphincter dyscoordination). 

In addition to these three common forms of urinary incontinence, there are also rare forms such as stress incontinence, laughing incontinence and underactive bladder. Stress incontinence can lead to involuntary leakage of urine as a result of coughing and sneezing. Tensing the abdominal muscles while playing or doing sports can also increase the pressure on the bladder to such an extent that it suddenly empties. With laughter incontinence, complete emptying of the bladder is only triggered by laughter.  With underactive bladder, affected children rarely feel the need to urinate because their bladder is very dilated. When you go to the toilet, you don't completely empty your bladder, so significant amounts of urine may remain in your bladder. 

Symptoms: daytime wetting (urinary incontinence)

If urine leaks unintentionally during the day, this is known as urinary incontinence. While 2-3% of 7-year-olds still wet during the day, less than 1% of young people are affected.   

Children with urge incontinence need to go to the toilet more often than other children. Girls are affected more often than boys. Even small amounts of urine cause their bladder to contract and trigger an urge to urinate. This mechanism is not sufficiently inhibited by the brain of those affected. Since the urge to urinate can suddenly become very urgent, children often develop holding maneuvers such as pressing their thighs together, restlessly stepping back and forth from one leg to the other or tensing the pelvic floor muscles. If they don't get to the toilet quickly enough or are tired, they will wet themselves. As a rule, however, the underpants only become slightly damp, and usually not really wet. The affected children suffer from urinary tract infections more often than other children. 

However, if children put off going to the toilet, they go to the toilet less often than 5 times a day or avoid going to the toilet in certain situations (urinary incontinence when micturition is delayed). Some children also oppose their parents' wishes and orders in this way. The bladder may then empty unintentionally. 

If there is a disorder of bladder emptying, the affected children have to press violently against the resistance of the sphincter (detrusor-sphincter dyscoordination). Occasionally the flow of urine is also interrupted. Instead of relaxing, the bladder sphincter contracts during urination. The bladder then does not empty completely, so that the affected children may often suffer from urinary tract infections.  These symptoms often occur in combination with constipation and encopresis.

Therapy: daytime wetting (urinary incontinence)

Children with urge incontinence who suddenly and urgently need to go to the toilet must first learn to forego the holding maneuvers they have developed. As part of behavioral therapy, you learn to recognize the urge symptoms and then go to the toilet immediately without tensing your pelvic floor. Micturitions without enuresis (e.g. with flags) and those with enuresis (e.g. with clouds) are recorded in a calendar. During training, it is important that the child can go to the toilet immediately, anytime and anywhere. Therefore, educators and teachers should be informed about the training and asked for benevolent support. Over time, the pants stay dry more and more often, and the time intervals between visits to the toilet become longer. For a third, these simple measures are sufficient. For others, treatment with oxybutinin, propiverine or other medications that calm the bladder is necessary. The plans should be continued.

If children delay emptying their bladder, it should first be explained to them that there is a connection between holding in urine and enuresis. The children are sent to the toilet at fixed times as part of a subsequent behavioral therapy program. For example, an alarm clock can remind you every two to three hours that you need to go to the toilet. The goal should be for the child to go to the toilet about seven times a day. For their cooperation, the children can be rewarded for every visit to the toilet (e.g. with small stickers). They receive the reward only for their cooperation and not for staying dry. Occasional accidents are also not punished by withdrawal of rewards. 

If children suffer from a bladder emptying disorder, they have to push before the urine begins to flow. The flow of urine is usually interrupted. In this case, bio-feedback training can help. On a special toilet, children can observe the flow of urine on a monitor and the usually unconscious tensing of the pelvic floor. Through the feedback, they learn to specifically relax the pelvic floor and thus the sphincter. For this training, expert supervision is essential. Children with stress incontinence need pelvic floor training, children who suffer from underactive bladder need intensive bladder training. Conditioning and medication help with laughter incontinence.

Control of the intestines

By the age of about four, most children are clean and able to control their bowel movements. 2-3% of 4-year-olds and 1% of 13-year-olds still defecate (encopresis). Encopresis may continue into adolescence and even young adulthood in some children. That's why early treatment is important. indispensable. Boys are affected three to four times more often than girls. Physical causes such as intestinal diseases (e.g. Hirschsprung's disease) must be ruled out. Two different forms can be distinguished: encopresis with and encopresis without constipation (constipation).

The affected children often also have other problems, such as attention problems, low frustration tolerance, hyperactivity, etc.depressionFear or poor coordination skills. Sometimes a child starts  after a stressful change in one's life, such as the birth of siblings, parents' separation or divorce, family problems or moving to a new home. 

A third of children who defecate also wet themselves. This is often because feces press against the bladder and thus impair bladder function (constipation).

Ursachen: Einkoten (Enkopresis)

Auch das Einkoten kann genetisch bedingt sein, vor allem wenn sie zusätzlich eine Verstopfung (Obstipation) haben. Bei der Enkopresis mit Obstipation verweilt die Nahrung  länger als üblich im Darm und wird daher stärker eingedickt. Weil der Stuhl dabei trocken und hart wird, kann seine Ausscheidung dann sehr schmerzhaft sein. Häufig entspannt auch der äußere Schließmuskel nicht richtig. Bei anderen Betroffenen ist dagegen die Wahrnehmung für den Stuhldrang vermindert oder der Darm wird massiv ausgeweitet.

Untersuchungen haben ergeben, dass etwa ein Drittel der Kinder, die einkoten, auch einnässen. Dies wird damit erklärt, dass der Enddarm und die Blasenhinterwand eng beieinander liegen. Bei einer Ausdehnung des Rektums wird automatisch Druck auf die Blase ausgeübt. Manchmal können die Betroffenen die Blase dann nicht vollständig entleeren oder der Harn staut sich im Nierenbecken. Außerdem werden die Schließmuskeln von Darm und Blase, die beide Teil der Beckenbodenmuskulatur sind, immer gemeinsam angespannt oder entspannt.

Es gibt aber auch Kinder, die einkoten, obwohl sie nicht unter einer Obstipation leiden. Die Ursachen für diese Fälle sind bisher nicht im Detail bekannt. 

Bei 30-50% der Kinder, die einkoten, werden gleichzeitig bestehende psychische Auffälligkeiten festgestellt. Allerdings kann selten geklärt werden, ob das Einkoten eine Folge der psychischen Probleme ist oder ob die psychischen Störungen eine Folge des Einkotens sind. Aufmerksamkeitsprobleme, Hyperaktivität, Störungen des Sozialverhaltens oder emotionale Störungen werden häufig im Zusammenhang mit der Enkopresis beobachtet. 

Untersuchungen haben ergeben, dass Kinder, die frühzeitig konsequent zur Sauberkeit angehalten werden, zwar früher sauber sind, zwischen dem ersten und zweiten Lebensjahr aber häufig rückfällig werden. Ab dem fünften Lebensjahr hat die Sauberkeitserziehung dann keinen Einfluss auf das Einkoten mehr.

Disorder: defecating (encopresis)

Children who defecate often suffer from constipation. They rarely have bowel movements and often have hard, dry stools. Accordingly, bowel evacuation is painful for them, so they hold back the stool. Under certain circumstances, the e.g. T. palpable fecal stones in the  Intestinal also abdominal pain. Due to the prolonged intestinal transit time, it thickens and becomes increasingly harder. Finally, peristalsis, which normally moves the stool into the rectum by tensing and relaxing the muscles in the intestinal wall, also decreases. 40 percent of affected children also have little appetite. 

The symptoms often appear in infancy after acute, i.e. temporary, constipation. This can be triggered, for example, by painful tears in the mucous membrane in the rectum or by stressful life events. A group of toddlers refuse to do their business on the toilet for more than a month, they only defecate in their diapers. This is called toilet refusal syndrome. The result can be a severe expansion of the large intestine, in which the feces build up.

But there are also children who defecate even though they pass normal stools every day and have a good appetite. As a rule, they do not have any pain and their perception of the stretching stimuli in the rectum is not reduced. Fecal stones are also not palpable. The affected children are also less likely to wet themselves than those who also suffer from constipation.

Therapy: defecation (encopresis)

As a first step, the affected children should be accustomed to regular bowel movements. Natural bowel emptying reflexes after meals make this training easier. To do this, children should sit relaxed on the toilet for about 5 to 10 minutes after breakfast, lunch and dinner. They should be able to place their feet on a bench. So that they don't get bored, they can read, paint or play in the meantime. If the alarm goes off after 10 minutes, the child should leave the toilet. A calendar records when the children pass urine or feces. Any defecation should also be noted. For their cooperation, the children can receive a small reward after each planned visit to the toilet, regardless of whether they do their business or not. Accidents are not punished. These measures are usually sufficient, especially when defecating without constipation. 

Additional measures are necessary for children who suffer from constipation. Since a lot of feces may have accumulated in her intestines, it must first be removed. Therefore, if necessary, the pediatrician will prescribe a medication called polyethylene glycol. The dosage is determined by the treating doctor on a case-by-case basis. The active ingredient binds water in the intestines, softens the stool and ensures rapid emptying of the intestines. The child must also drink plenty of water. For some children, this medication is not enough to empty the bowels, so enemas must also be performed. 

Once the intestines have been emptied, it is important that no new feces accumulate in the intestines. Therefore, in the following months, the child must be consistently sent to the toilet after eating. In addition, the child should be treated with polyethylene glycol for a longer period of time (usually 6 months to 2 years). If the constipation is caused by the children not drinking enough, the daily drinking amount must also be increased. School children, for example, should drink one to two liters every day. A change in diet may also be necessary so that the children get enough fiber, fruit and vegetables.

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