Introduction
International Children’s Continence Society (ICCS) defines urinary incontinence as involuntary wetting at an inappropriate time and place in a child aged five years or more.1 Daytime urinary incontinence is common in school-aged children affecting their psycho-social development. The overall prevalence in India is 7.61% with 14.29% of them experiencing daytime wetting and only 24.11% of the parents seeking medical consultation. Urinary incontinence has a multifactorial origin, hence treatment considering the child, family and environment as a whole is recommended. Physiotherapeutic treatment can be used in the management of urinary incontinence in children.
Case Report
An 8-year-old girl was referred for physiotherapy by the pediatrician with complaints of urinary incontinence and dribbling episodes occurring throughout the day as well as at night (5-6 pads per day), with no family history of the same. As reported by the parent, bedwetting and dribbling was first noticed at 2 years of age, but no treatment was taken for the same. As the problem persisted, they approached the pediatrician and was prescribed anti-inflammatory, antibacterial and antimuscarinic medications (TAB Dapsone 25 mg and TAB Tropan 5 mg) for 10 days. No improvement was noticed, and she was admitted to the pediatric ward for further investigations and was referred for physiotherapy management.
Table 1
Pre-treatment and post-treatment physiotherapy assessment
Table 2
Pre-treatment and post-treatment outcome measures assessment
Table 3
Voiding diary
|
Weeks of Physiotherapy management |
Frequency (times/day) |
|
Week 0-3 |
17 |
|
Week 3-6 |
15 |
|
Week 6-9 |
10 |
|
Week 9-12 |
8 |
|
Week 12-15 |
6 |
Table 4
Physiotherapy management
The investigations consisting of routine urine examination, complete blood count, peripheral smear, Chest X-ray, creatinine serum levels, activation platelet thromboplastin time, CT scan and USG of Kidney Ureter Bladder (KUB)showed normal findings. The X-ray and MRI of the lumbar spine showed loss of lumbar lordosis and sacralisation of L5 vertebrae. Cystogenitoscopy with Micturating cystourethrogram(MCU) found a wide urinary bladder neck and also leakage via the neck. The Cystoscopy performed in 2019 stated that the trigone was not seen and the urethra neck was wide open. The cystoscopy performed in 2021 reported that the capacity of the urinary bladder was small, along with a slightly hypospastic urethra and bifid vagina.
Physiotherapy Management
Physiotherapy management was done throughout 15 weeks, twice a day consisting of 3 supervised sessions per week and an unsupervised home exercise program for the other days. The initial management started with activation of the pelvic floor muscles using 2 – Pole IFT (Interferential Therapy) stimulation (2 electrodes bilaterally over lower end of Labio Majora, frequency 4 Hz, 10mins, comfortable intensity). Isometric activation of the muscles groups of the hip and the knee was initiated along with pelvic bridging and Kegel’s exercises. Later exercises for strengthening the abdominal capsule, stretching of the bilateral hamstring and iliopsoas muscles along with postural correction and gait training were added. We observed that with treatment progression, dribbling episodes were associated only with high impact jumping activities while playing hence, we incorporated knack manoeuvre in the program. The progression of these exercises was done every 3 weeks by increasing the repetitions and duration (Table 4). The same exercises were advised to the parent to be continued as home program with the same repetitions and hold time as that of the supervised sessions.
Discussion
In our case study, the 8-year-old girl came to us with a complaint of urinary incontinence. Our physiotherapy management was a combination of various treatment approaches over 15 weeks. In a study conducted by Sankarganesh et al. (2018) they stated that the stimulation of pudendal nerve using electrical currents would cause a direct motor response and widespread contraction of pelvic floor muscles2 hence, our treatment began with electrical stimulation using IFT which assisted in the initiation of contraction of the pelvic floor muscles. The abdominal capsule consists of the diaphragm, the abdominal muscles, the back extensors and the pelvic floor and weakness of any one of the components would lead to dysfunction in the other. Based on this concept and the results of previous studies our exercise protocol consisted of a combination of breathing exercises,3 abdominal muscle strengthening3 along with pelvic floor muscle strengthening using Kegel’s exercise4 to improve the strength of the abdominal capsule as a whole which showed a positive result in reducing the dribbling episodes. As we observed postural deviations during our assessment postural correction was started along with stretching and strengthening of lower limb muscles. The posture correction along with balance training cumulatively helped in adapting better gait patterns. As we progressed with our treatment we noticed that the dribbling episodes occurred only with high impact activities such as jumping and hence the incorporation of Knack maneuver in the treatment protocol helped in reducing the dribbling episodes even during high impact activities. Thus physiotherapy management including multiple components helped in dealing with the problem of urinary incontinence and improving the patients overall quality of life and negated the need for surgical intervention.
