Reasoning GP · Algorithm · 1-page summary
Daytime urinary incontinence in children
For: children with daytime wetting, urgency, frequency, dysfunctional voiding or bladder–bowel dysfunction in primary care. Not for: bedwetting alone (nocturnal enuresis), or detailed management of UTI or constipation (use those pages).
Core rule: exclude spinal, structural, diabetes and safeguarding causes first — examine the back, legs and stream — then treat constipation before any bladder medicine. Most daytime wetting is functional and treatable.
0Stop — act now — 999 or same-day emergency
- Polyuria, polydipsia or weight loss and drowsy, vomiting or breathless (suspected DKA) → 999
- New wetting with back pain or new neurological signs (leg weakness, gait or sensory change, saddle anaesthesia, abnormal reflexes, loss of anal tone), acute urinary retention, or fever suggesting spinal infection → Same-day emergency paediatrics; spinal imaging via that team
- Safeguarding concern (disclosure, injuries, genital symptoms, concerning context) → Immediate safeguarding / MASH. Do not lead the child or do an unnecessary genital examination; record their words verbatim.
1Triage by pattern
| Pattern | Think of → action |
|---|---|
| Primary | Never reliably dry: overactive bladder (commonest) or dysfunctional voiding. Assess when wetting beyond usual toilet training is persistent, troublesome or impairing — age 5 is not an absolute threshold. |
| Secondary | New after ≥6 months dry → investigate more urgently: UTI, constipation, stress, diabetes, safeguarding, new cord pathology. |
| Continuous dribble | Girl, wet from birth, normal voids = ectopic ureter → Prompt paediatric urology |
2Screen — one row is enough
- Polyuria, polydipsia, weight loss → capillary glucose + dipstick now; suspected type 1 diabetes → Same-day paediatric diabetes team; do not wait for HbA1c or lab tests
- Suspected obstructive uropathy (poor stream, palpable bladder, renal impairment) → Same-day
- Recurrent febrile UTI, haematuria, abnormal stream (valves, reflux) → Prompt paediatric urology / nephrology; ultrasound per NG224
- Dysuria, fever, flank pain, haematuria → urine test, sample before antibiotics; treat per NG224
- Hard stools, <3 per week, soiling, faecal mass → treat constipation first; often missed
3Assess
☐ Abdomen: bladder or faecal mass ☐ Lumbosacral spine (dimple, hair tuft, lipoma) and lower-limb tone, reflexes, sensation, gait ☐ Observe stream if possible ☐ Growth and BP where indicated ☐ Urine dipstick if indicated ☐ 2-day bladder and bowel diary. Not routine: abdominal X-ray, MCUG, pelvic examination, repeated MSU in typical functional wetting, ultrasound for poor response alone.
4Classify — only if the screen is negative
- Overactive bladder — urgency, >7 voids/day, holding manoeuvres, small voids → urotherapy, timed voiding, treat constipation.
- Dysfunctional voiding — straining, staccato stream, infrequent voids, recurrent UTI → refer for uroflowmetry + post-void residual; double voiding.
- Voiding postponement — ignores signals; infrequent large voids → timed voiding, school access plan, reward chart.
- Giggle incontinence — full emptying with laughter → education, urotherapy; refractory → specialist.
- Uncertain → diary and review; abnormal examination → Prompt paediatric urology.
5Treat today — doses: NICE/SPC, BNFC, local formulary
- Constipation: macrogol disimpaction then maintenance per CG99; review within 1 week; continue for weeks–months, wean gradually.
- Urotherapy: relaxed voiding every 2–3 hours awake, feet supported; adequate fluids spread through the day; less caffeine; non-punitive rewards.
- School letter: unrestricted toilet access, water bottle, spare clothes; healthcare plan where needed.
- Medicines: oxybutynin only after constipation is treated and with an experienced clinician. No desmopressin for isolated daytime wetting.
6Refer and follow up
- Review with the diary, bowels and school functioning; earlier if worse.
- No meaningful improvement despite adherence and effective constipation treatment → Routine paediatric continence service (or community paediatrics).
- Paediatric urology / nephrology: abnormal ultrasound, raised creatinine, hypertension or proteinuria, significant residual, dysfunctional voiding not responding.
- Shame, bullying or anxiety → school nurse, psychological or CAMHS support when clinically indicated.
7Never reassure by
- Calling it behavioural without examining the spine, leg neurology and stream.
- Absence of pain — it does not exclude UTI.
- "Normal" bowels by report — constipation is common and often missed.
- Secondary wetting as regression — look for UTI, diabetes, constipation, safeguarding, cord pathology.
- Waiting for age 5 when wetting is persistent, troublesome or impairing.
- Starting oxybutynin before constipation is treated — it worsens both.
8Safety-net — say it, then document it
999 “Call 999 if your child is very thirsty and weeing a lot and becomes drowsy, is vomiting or is breathing hard.” Same day “Get same-day emergency help if new back pain, leg weakness, a change in walking or numbness appears, or your child cannot pass urine.”
On oxybutynin: stop and seek advice for urinary retention, a swollen tummy, marked constipation, eye problems or confusion. Wetting can recur with stress — come back promptly.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Spine, lower-limb neurology, abdomen and stream examined
Urine and glucose tested where indicated
Constipation treated; diary, urotherapy and school letter arranged
Safety-net given; safeguarding considered; review booked
Summary of the full Reasoning GP daytime urinary incontinence in children algorithm, which holds the history, examination, doses and evidence. Sources: ICCS terminology; EAU paediatric urology guidelines; NICE NG224, CG99, CG111, NG18; ERIC. Clinical reference — follow local paediatric continence pathways and check doses in the current BNFC.