Voiding Dysfunction, Urgency, Urinary Incontinence, and VUR

Families often confuse these two concepts. Urinary incontinence (or, at night, enuresis) is the involuntary leaking of urine out of the bladder into the underwear. Vesicoureteral reflux, on the other hand, is the backward flow of urine upward from the bladder into the kidney through the ureter (the urinary channel between the kidney and the bladder); it is not visible from the outside and does not cause wetness.

Overactive bladder is the involuntary contraction of the bladder muscle before it is fully filled. Its symptom is sudden, unpostponable urgency; the child voids frequently, sometimes doesn't make it in time, and leaks small amounts. This is the most common cause of daytime incontinence in children.

• Crossing the legs, squatting, sitting on the heel
• Suddenly freezing, bending forward, facial flushing
• Leaking small amounts right after the urge to go
• More than 8 voids a day, or constantly searching for a toilet

Dysfunctional voiding is the habitual contraction of the pelvic floor muscles and external urethral sphincter, which should relax during voiding. Urine comes out in a staccato pattern or with pauses; the child strains, voiding takes longer, and the bladder does not empty completely.

In a child with reflux who also has voiding dysfunction, the correct sequence is clear: bladder first, then reflux. Once the bladder is calmed with urotherapy, constipation treatment, and medication if needed, infections stop in some children and reflux regresses on its own; no intervention is needed.

• If incontinence begins together with fever, flank pain, or foul-smelling urine, get a urine culture the same day
• New-onset daytime incontinence in a child who was previously dry
• Continuous dribbling wetness (incontinence without interruption) — an anatomical cause is investigated
• A weak, thin, or strained urine stream (especially in boys)

• If reflux persists despite bladder improvement and febrile infections keep recurring, endoscopic injection or ureteral reimplantation (reconnecting the ureter to the bladder) is discussed; at this stage, the success of the procedure is markedly higher once performed on a bladder that has been corrected. In our practice, the follow-up of voiding dysfunction and the decision on reflux are carried out together by two pediatric urologists; bladder treatment is never decided in one place and the surgical decision in another.