Online Health Chat with Halima Janjua, MD
November 13, 2012
Urinary problems are common in children of various ages. Urinary symptoms that children experience can include bedwetting, daytime urinary incontinence, urinary frequency, urinary urgency, and pain or burning on urination. These symptoms can be due to a variety of causes including urinary tract infections, calcium or crystals in the urine, or kidney stones. As parents it is important to know about your child’s urinary problems, as they may not be able to describe their symptoms, or may be too embarrassed to tell you about them. Whether your child is a toddler or an adolescent, Cleveland Clinic Children’s Hospital clinicians can answer your questions to help make urinary problems a thing of the past.
Bedwetting, also known as nighttime incontinence or nocturnal enuresis, is involuntary urination in children 5 years of age or older. Bedwetting is common, occurring in approximately 15 percent of 5-year-old children in the U.S. Although the problem goes away over time, many children continue to experience bedwetting. Another health condition, kidney stones, can affect children as well as adults. Kidney stones are small, hard rocks that are made within the kidneys. They normally begin as a small crystal-like material and gradually build up into larger, solid masses. Urine normally contains chemicals that inhibit the crystals from forming. However, when crystals combine together to form a kidney stone, they can stick to the lining of the kidney or settle in an area where urine cannot carry them out of the body. Modification in diet alone or with the help of medications can prevent more kidney stones to form.
The health of your child’s urinary system and kidneys are important to his or her overall health. Many therapies are available for daytime urinary incontinence, bedwetting, blood in urine, urinary tract infections and kidney stones, which can cure or lessen the severity of these conditions.
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On Cleveland Clinic
Cleveland Clinic Children’s Hospital’s Center for Pediatric Nephrology provides primary and consultative care and treatment to children and adolescents with all forms of kidney disease. In addition, our Transplant Center has extensive experience with pediatric kidney transplantation, offering living-related and cadaver renal transplantation services. Cleveland Clinic Children’s Hospital’s Center for Pediatric Nephrology also offers regularly scheduled subspecialty clinics for peritoneal dialysis, transplantation and consultation for pediatric patients with urinary tract infections, voiding difficulties, blood in urine, kidney stones as well as other interrelated urinary problems.
Cleveland Clinic Children’s Hospital’s consists of pediatric specialists who manage disorders of the kidney, bladder and genitalia in children. Our team includes urologists, nephrologists, fetal medicine specialists, endocrinologists, oncologists, radiologists, neurosurgeons, nurses and social workers. The team collaborates to offer inpatient evaluation, as well as medical or surgical intervention for acquired and congenital problems.
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About the Speakers
Halima Janjua, MD, is a board-certified pediatric nephrologist for Cleveland Clinic’s Center for Pediatric Nephrology. Dr. Janjua completed her fellowship in pediatric nephrology at Nationwide Children’s Hospital in Columbus, Oh, after completing her residency in pediatrics at Children’s Hospital of Michigan, in Detroit. Dr. Janjua graduated from medical school at King Edward Medical College in Lahore, Pakistan. She has been with Cleveland Clinic since 2011. Her specialties include pediatric kidney stones, pediatric urinary incontinence and pediatric urinary tract infection among others.
Let’s Chat About From Bedwetting to Kidney Stones: Urinary Problems in Children’
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Halima Janjua. We are thrilled to have her here today for this chat on ‘From Bedwetting to Kidney Stones: Urinary Problems in Children.’
Bedwetting Diagnosis and Causes
wellness2013: At what age should medical assistance be sought for bedwetting? What should be the first step—urologist or sleep specialist?
Dr_Janjua: After the age of five years old. It's not considered a problem if a child is less than five years old. A good place to start with is either the child's primary care physician or pediatric nephrologist or urologist. Sleep disorders can give a child bedwetting problems, but there are many other causes that should also be looked at.
chs: My daughter is eight years old and still has accidents at night. I feel like that’s not normal. I also noticed that she tends to have severe mood swings when she doesn’t eat. I’ve read diabetic issues can lead to urinary incontinence. Could that be the case? Are those things actually related?
Dr_Janjua: About 15 percent of five-year-olds wet the bed. This resolves by about 15 percent each year. Most of the time it is a primary problem, meaning there is no secondary cause. Children wet the bed just because their bladder is not mature enough. It runs in families. Usually, there is a first-degree relative that had the same problems when he or she was a child or adolescent. At times, bedwetting is secondary to another cause. One of them is diabetes. Usually, children with diabetes will get up at night to drink and urinate quite a bit throughout the day, too. If you suspect diabetes, you should have your child's fasting glucose get checked.
blades: Why is bedwetting more common in boys?
Dr_Janjua: Bedwetting is twice as common in boys as girls. No one knows why but it is thought to be related to bladder maturity.
Using Bedwetting Alarms
wad: My seven-year-old son continues to wet the bed nightly and we've tried just about everything over the last two or three years. He is an extremely deep sleeper. We've had some success with a urine monitor that senses wetness and sounds an alarm, but occasionally he will sleep through the high-pitched noise right by his ear until we come from down the hall to rouse him! We've also tried waking him up to urinate around the same time each night (when we go to bed) to try and retrain his body to not go into that deep sleep. We have done this for weeks at a time, but when we discontinue the practice he goes back to wetting. It is extremely frustrating for us and for him as well. Do you have any other recommendations to help him wake up dry?
Dr_Janjua: The treatment plan for bedwetting may involve many modalities, used in combination or one after another. Treatment can take up to many months. Your son may not be completely cured of the problem after treatment and may have relapses. Enuresis alarms may take many months to show improvement, but they are the most long-term solution for bedwetting as they make the child ‘learn’ to void when needed at night. You are doing the right thing to try enuresis, or bedwetting, alarms. This alarm might wake you up for weeks before it starts waking your child up, but eventually you will see the difference. It’s a family effort.
Other things that can help are as follows:
- Adjusting fluid intake—Total daily fluid intake should be focused more in the morning and early afternoon hours, so that the child can have limited fluid intake two to three hours before bedtime.
- Toileting habit—The child should void regularly during the day (every two to three hours) and just before going to bed.
- Reward system—You can have rewards like a sticker chart and other small rewards for dry nights.
sand: I have a seven-year-old granddaughter (she'll be eight in December) who still wets the bed. She's just begun getting physical therapy (PT) for help with this challenge. What are the chances PT will help? My daughter already tried a type of monitor that attaches to the underpants that goes off when moisture is detected, but my granddaughter sleeps right through it.
Dr_Janjua: Bedwetting alarms take time to work, but they are the most lasting form of therapy for bedwetting as they train the body to get up at the time of bedwetting. Eventually, your granddaughter will get up on her own when she gets wet and the alarm goes off. After that she will get up at the start of urination. It might take months to reach to the point when she would get up before she wets herself.
murphyj: Do you have any programs available for children with frequent bedwetting issues that can’t seem to be resolved?
Dr_Janjua: We have a bladder control clinic on Tuesdays and Wednesdays at Cleveland Clinic. It is run by physicians and nurse practitioners. We work intensely with children and their caregivers during those clinics to help set and achieve goals.
Medical Conditions Associated with Bedwetting—Constipation and Sleep Apnea
sunny: My son has a problem with wetting his bed at night and I think it’s a result of him being constipated a lot. Could that be the case? How do you suggest I try to combat his constipation issue? Do you think that might help reduce his bedwetting?
Dr_Janjua: Constipation is a well known cause for urinary problems in children. It can give daytime symptoms and/or nighttime bedwetting.
Other than increasing your son's fluid intake and increasing fruits and vegetables in his diet, you can try Miralax® which is an over-the-counter medication. You would have to give him Miralax® regularly, even after you think his constipation is relieved, to ensure he maintains a soft bowel movement everyday.
yellowstone: I’ve read that sleep apnea can cause accidental wetting, is that true?
Dr_Janjua: Yes. Sleep apnea can cause bedwetting.
HBS926: My five-year-old daughter has been potty trained since the age of two and a half years. She never has nighttime accidents, but has daytime accidents when she laughs (if her bladder is full). I have read about ‘giggle incontinence’, and was wondering if this could be her issue. She has been tested for urinary tract infection, and that was negative. She will say she does not have to go, but could then have an accident shortly after when she laughs.
Dr_Janjua: If your daughter has daytime incontinence other than when she laughs as well, it can be related to holding urine. When an action like giggling or coughing raises intra-abdominal pressure (inside the tummy), it can leak urine out of an overfilled bladder. 'Giggle incontinence' is a rare condition and can happen solely when someone giggles due to low tone of some of the muscles.
I recommend you have your daughter empty her bladder every two to three hours during the day to ensure she is not holding urine or overfilling her bladder. Also keep an eye on her urine leakage when she coughs, sneezes or strains.
Voiding: Urine and Stool Retention
ho_hum: My daughter does not like to use the restroom at school. As a result she frequently holds her fluids and stools throughout the school day. I think it’s not good and wondered what effects this could have on her system? Do you have any suggestions for getting her to use the restroom during the day?
Dr_Janjua: It’s a very frequent complaint from young girls. Holding stools can lead to chronic constipation and that, in turn, can lead to voiding problems and recurrent UTI'. Counseling your daughter about the need for defecation and urination throughout the day is the way to go.
trust_me: Is there any way to train children who are eight years old how to hold their urine? It's not always convenient to take my son to the bathroom constantly. Is it O.K., that is healthy, to do this?
Dr_Janjua: If your son is showing urgency to urinate, more than you see in your other children or his friends, it can be related to an underlying problem like high calcium excretion in urine or an overactive bladder. Such children are at times urinating every 15 minutes or feel the need to go, but nothing or very little urine comes out when they go. I recommend that he should be evaluated, if that is the case. If you don't think this is the case, I suggest that you don't try to make him hold urine, but to use the restroom when he needs to.
Urinary Tract Infection
654pjf: What are the potential effects of an untreated urinary tract infection (UTI)?
Dr_Janjua: An untreated UTI or frequent UTIs can cause scarring of the kidneys and lifelong damage to the kidneys. If your child is having frequent UTIs, the cause of these UTIs needs to be sorted out to prevent further episodes.
gellman: Why are urinary tract infections more common in girls than boys?
Dr_Janjua: The anatomy of girls' urinary tract and its close proximity to rectum puts girls at more risk for UTIs.
gabby: For a non-sexually active girl, could frequent UTIs be caused by improper use of feminine products? How are they preventable?
Dr_Janjua: There might be another cause of frequent UTIs in a non-sexually active girl, most frequently seen is chronic constipation. Urinary retention can also cause UTIs. There might be more than improper hygiene.
janny1: I think my daughter urinates frequently, but she complains that she feels like her bladder is never fully emptied. What could the different reasons for this? Is this a symptom of a UTI?
Dr_Janjua: It can be a symptom of a UTI. Other things that can cause this feeling include crystalluria—meaning excretion of crystals in the urine that most commonly is due to a higher level of calcium excretion in the urine. It can also be due to bladder dysfunction when the bladder is not contracting when it should or contracting more than it should, giving a feeling of an urge to void even when there is no urine. That constant urge to void can give the sensation of the bladder being full.
alive_and_well: My seven-year-old daughter had a very bad urinary tract infection. What damage to the kidney can an untreated urinary tract infection cause?
Dr_Janjua: Recurrent or untreated UTIs can cause scarring of kidney tissue. This can lead to a decrease in kidney function and/or high blood pressure.
rosy: Are the typical symptoms of a kidney stone in children different from those in adults?
Dr_Janjua: Children can have the same symptoms as adults when experiencing a kidney stone. Kidney stones sitting in the kidney do not cause pain. When the stone starts traveling down the ureter is when it produces pain. Children can have abdominal pain, blood in urine, pain or burning on urination, and urgency to void. The younger the children are, the more vague their symptoms get.
duck_feet: What causes kidney stones?
Dr_Janjua: Kidneys stones can be caused by any of the following:
- High urinary concentrations of calcium, oxalate, uric acid and cystine due to increased excretion from kidneys excretion.
- Low urine volume due to less fluid intake
- Low levels of inhibitors of stone formation in urine, like citrate
- Urinary tract infection
- Structural abnormality of urinary tract or kidneys
A cause can be identified in 75 percent to 85 percent of children with kidney stones. Sometimes a cause cannot be identified.
hard_spots: My son just battled kidney stones, and I wondered how we could combat him getting them again—especially in the near future since these just passed?
Dr_Janjua: He should be evaluated by a pediatric nephrologist for the risks specific to your son. Usually a 24-hour urine collection is done to evaluate for those risk factors. High urinary concentrations of calcium, oxalate, uric acid and cystine due to increased renal excretion, low urine volume due to less fluid intake, and low levels of inhibitors of stone formation in urine can lead to stone formation. It is a recurrent problem unless these risks are modified.
jarro: Is it possible to pinpoint the cause of kidney stones in a young child? My daughter's stones started at the age of eight years old, and are now becoming very frequent. We were told they were calcium stones?
Dr_Janjua: A cause can be identified in 75 percent to 85 percent of children with kidney stones. Most commonly stones are made up of calcium. There are changes in diet and medications that help prevent kidney stones, but restricting calcium from a child's diet is not recommended.
EJ933: Does diet have any effect on kidney stone formation in children?
Dr_Janjua: Modification in diet can prevent kidney stone formation.
Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Halima Janjua, MD is now over. Thank you Dr. Janjua for taking the time to answer our questions today about Urinary Problems in Children.
Dr_Janjua: Thank you for all the wonderful questions.
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