Most children have accidents while learning to toilet-train, but the vast majority do so only rarely—and the problem usually goes away on its own. Yet, sometimes daytime urinary incontinence or bedwetting (called nocturnal enuresis) persists. And when that happens, it’s a good idea to get the problem checked out by a pediatric urologist.

“One third of children who wet will continue to have urinary incontinence (in varying degrees) for the rest of their lives,” says Israel Franco, MD, a Yale Medicine pediatric urologist and director of the Pediatric Bladder & Continence Program. That’s especially true for girls with a type of incontinence called overactive bladders.

Bedwetting and daytime incontinence can run in the family, too. Chances are greater that a child will have urinary incontinence if a parent had it, and even greater if both parents wet the bed or their pants during childhood.

Here’s how urination normally works for children and adults, too. The bladder, a small balloon-shaped organ receives and stores urine produced by the kidneys. The bladder muscles remain relaxed while the bladder fills with urine. Then when it’s convenient, the bladder contracts and empties through the urethra—where sphincters and pelvic floor muscles loosen to allow the urine pass and tighten afterwards to stop it.

But when children have urinary incontinence, they involuntary release urine even after being toiled-trained. It may occur during the day or night. Most children are potty-trained by age 5, and those who aren’t fully trained by then or who continue to have “accidents” may have an underlying medical condition or other issue that is causing the problem. If a child between the ages of 5 and 18 has two or more wetting episodes a month, he or she may benefit from treatment to gain bladder control.

Children may experience one or more of the several different kinds of incontinence, which include:

• Urge syndrome: Children who feel the need to urinate more frequently than normal are said to have an overactive bladder.
• Dysfunctional voiding: The sphincter muscle contracts when the bladder is trying to empty, so urine is retained, causing the child to go more frequently.
• Lazy or underactive bladder: The bladder muscle isn’t as strong as it is should be, so children end up visiting the bathroom more often.
• Neurogenic bladder: This is the diagnosis when bladder symptoms are associated with a neurological condition such as spina bifida or spinal cord injury.

Bedwetting issues are more prevalent in boys, especially when there’s a family history of nocturnal enuresis. Daytime incontinence occurs more frequently in girls.

• Daytime incontinence occurs in children ages 5 or older older. 
• Nighttime incontinence (nocturnal enuresis) is usually not diagnosed until age 7 because staying dry all night can take longer to achieve than staying dry during the day. A small percentage of children will continue to have problems into adulthood.

A number of issues can be involved in a child’s bedwetting and daytime accidents, including:

• Constipation: Because the nerves from rectum and the bladder are in close proximity to each other in the spine, there is a mixing of signals that can trigger bladder contractions and lead to urinary incontinence.
• Incomplete or early toilet training: Sometimes premature potty-training will lead children to push to urinate (urine should be released without being forced). When this happens, the pelvic floor muscles don’t relax and eventually the child can develop problems with urination.
• Bladder over-activity: The child’s bladder may involuntarily contract and release urine before it’s full.
• Deep sleeping: When a child doesn’t wake up from sleep to urinate, bedwetting can become a problem.
• Parental history: If you had this issue growing up, your children are more likely to as well.

• Recurrent urinary tract infections (UTIs): Wetting accidents can go hand-in-hand with bladder infections.
• Sexual abuse: Incontinence issues can develop after girls are sexually abused.
• Developmental issues: Children with developmental delays or who struggle with executive functioning for other reasons may have toileting issues.
• Other medical conditions. In some cases, children’s incontinence may be caused by another medical condition or diseases such as type 1 diabetes, attention deficit disorder, anxiety, depression, oppositional behavior, compulsive behaviors or cerebral palsy, for instance. Some children have a neurogenic bladder, mentioned above, which means there’s an underlying neurological condition (such as spina bifida) that interrupts the neurological signals from the bladder to the brain. 

Help is available, including:

• Transcutaneous Electrical Nerve Stimulation (TENS): This is a pain-free and non-invasive treatment. Following the doctor’s instructions, the child or parent places an inexpensive, handheld device on the sacral area of the lower back. The device sends an electrical signal through the nerves, located near the surface of the skin, to the brain. These electrical signals can interrupt reflexes that impede proper bladder function.
• Biofeedback: Special sensors are placed on the skin near the anus to measure the strength of the pelvic floor muscles. Using computerized graphics and sounds, biofeedback therapy can help children perform exercises to strengthen the muscles.
• Urotherapy: The child is taught to go to the bathroom using a schedule and to use proper voiding and bowel movement techniques. In up to 50 percent of the cases, urotherapy can solve incontinence without further intervention.
• Clinical trials: At Yale Medicine, we provide access to clinical trials so children with severe urinary urgency issues can try treatments that are not yet available to everyone. 
• Medications: We use medications as little as possible. But when needed, several classes of medications are utilized such as anticholinergics (oxybutynin and solifeneacin), alpha blockers (tamsulosi and terazosin), beta 3 agonists (mirabegron) and even medications that act on the central nervous system. Antibiotics should be used as a last resort to treat frequent urinary tract infections. “It is our goal to identify the cause of the recurrent infections and correct this problem instead of randomly prescribing antibiotics,” says Dr. Franco. A probiotic such as Lactobacillus GG is commonly recommended for recurrent infections. 
• Counseling: Our program team works directly with experts at Yale Medicine Child Study Center because cognitive and behavioral therapy can help some children to modify behavior in order to manage the incontinence. In some cases, cognitive behavioral therapy can be a better method to treat overactive bladder. Counseling can also help children cope with social embarrassment.
• Surgery: Sometimes an anatomical problem needs to be corrected surgically by a urologist.

Here are some tips to help your child stay dry through the night from Yale Medicine’s Pediatric Bladder & Continence Program:

• Eat dinner at least three hours before bedtime.
• Stop all fluids one hour before bed, no milk or ice cream from dinner on.
• Make sure your child urinates at least five times a day. If they don’t, make sure that they are drinking enough fluids during the day to do so.
• Find out if your child is constipated. Avoid hard stools or bowel movements more than two days apart. 
• Encourage your child to go to the bathroom right before bedtime.
• Record when accidents happen, and see a pediatric urologist for evaluation if problems persist.

“When I started out 25 years ago, no one was interested in kids wetting their pants,” reflects Dr. Franco. That’s why he built the first program in southwestern Connecticut for young patients with incontinence issues. His team is dedicated to the treatment and care of children who need help in gaining control of their bladders—and their lives.

At Yale Medicine, we take a holistic approach to solving incontinence issues in children, considering all the factors that could be causing them. Our treatments range from simple fixes such as solving constipation to more complex solutions such as surgically addressing anatomical problems. Currently, we’re conducting clinical trials for children who have difficult-to-solve cases of urinary incontinence.

No matter what the cause, at Yale Medicine Pediatric Urology, we are experts in diagnosing and treating urinary incontinence issues in children of all ages.