Incontinence training in children with cerebral palsy: A prospective controlled trial



      Urinary incontinence is the most frequently observed lower urinary tract symptom in children with cerebral palsy (CP). Being continent can positively influence quality of life of the child and the social environment.


      To investigate the effectiveness of incontinence training with urotherapy in children with CP.

      Study design

      A population-based case-control study was conducted including 21 children with CP and 24 typically developing children between 5 and 12 years old, both with daytime incontinence or combined daytime incontinence and enuresis.
      Children received treatment for one year with three-monthly examination by means of uroflowmetry, a structured questionnaire and bladder diaries. Children started with three months of standard urotherapy. After three, six and nine months of training, specific urotherapy interventions (pelvic floor muscle training with biofeedback, alarm treatment or neuromodulation) and/or pharmacotherapy could be added to the initial treatment. Therapy was individualized to probable underlying conditions.
      Effectiveness was controlled for spontaneous improvement due to maturation and analysed by means of longitudinal linear models, generalized estimating equations and multilevel cumulative odds models. Comparison with typically developing children was assessed by means of Kaplan–Meier survival analysis.


      Results suggest effectivity rate of incontinence training is lower and changes occur more slowly in time in children with CP compared to typically developing children (Figure).
      Within the group of children with CP, significant changes during one year of training were found for daytime incontinence (p < 0.001), frequency of daytime incontinence (p = 0.002), frequency of enuresis (p = 0.048), storage symptoms (p = 0.011), correct toilet posture (p = 0.034) and fecal incontinence (p = 0.026).


      Maximum voided volume and fluid intake at the start of training were significantly lower in children with CP and could explain a delayed effectiveness of urotherapy. Treatment of constipation demonstrated a positive effect on maximum voided volume and should be initiated together with standard urotherapy when constipation is still present after implementation of a correct fluid intake schedule. Future research with a larger sample size is recommended.


      Summary Figure
      Graphical AbstractPercentage of patients with 50 % improvement daytime incontinence. Legend: –Children with cerebral palsy; ····Typically developing children; + Lost to follow-up.


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        • Samijn B.
        • Van Laecke E.
        • Renson C.
        Lower urinary tract symptoms and urodynamic findings in children and adults with cerebral palsy: a systematic review.
        Neurourol Urodyn. 2016; 36: 541-549
        • Yildiz N.
        • Akkoc Y.
        • Ersoz M.
        Cross-sectional study of urinary problems in adults with cerebral palsy: awareness and impact on the quality of life.
        Neurol Sci: Off J Ital Neurol Soc Ital Soc Clin Neurophysiol. 2017; 38: 1193-1203
        • Young N.L.
        • McCormick A.M.
        • Gilbert T.
        Reasons for hospital admissions among youth and young adults with cerebral palsy.
        Arch Phys Med Rehabil. 2011; 92: 46-50
        • Mulders M.M.
        • Cobussen-Boekhorst H.
        • de Gier R.P.
        Urotherapy in children: quantitative measurements of daytime urinary incontinence before and after treatment according to the new definitions of the International Children's Continence Society.
        J Pediatr Urol. 2011; 7: 213-218
        • Austin P.F.
        • Bauer S.B.
        • Bower W.
        The standardization of terminology of lower urinary tract function in children and adolescents: update report from the standardization committee of the International Children’s Continence Society.
        Neurourol Urodyn. 2016; 35: 471-481
        • Nieuwhof-Leppink A.J.
        • Hussong J.
        • Chase J.
        Definitions, indications and practice of urotherapy in children and adolescents: - a standardization document of the International Children’s Continence Society (ICCS).
        J Pediatr Urol. 2021; 17: 172-181
        • Decter R.M.
        • Bauer S.B.
        • Khoshbin S.
        Urodynamic assessment of children with cerebral palsy.
        J Urol. 1987; 138: 1110-1112
        • Mayo M.E.
        Lower urinary tract dysfunction in cerebral palsy.
        J Urol. 1992; 147: 419-420
        • Murphy K.P.
        • Boutin S.A.
        • Ide K.R.
        Cerebral palsy, neurogenic bladder, and outcomes of lifetime care.
        Dev Med Child Neurol. 2012; 54: 945-950
        • Reid C.J.
        • Borzyskowski M.
        Lower urinary tract dysfunction in cerebral palsy.
        Arch Dis Child. 1993; 68: 739-742
        • Van Laecke E.
        • Raes A.
        • Vande Walle J.
        Adequate fluid intake, urinary incontinence, and physical and/or intellectual disability.
        J Urol. 2009; 182: 2079-2084
        • American Psychiatric Association
        Diagnostic and statistical manual of mental disorders.
        5th ed. 2013 (Washington, DC)
        • Chang S.J.
        • Van Laecke E.
        • Bauer S.B.
        Treatment of daytime urinary incontinence: a standardization document from the International Children's Continence Society.
        Neurourol Urodyn. 2017; 36: 43-50
        • Franco I.
        • Franco J.
        • Lee Y.S.
        Can a quantitative means be used to predict flow patterns: agreement between visual inspection vs. flow index derived flow patterns.
        J Pediatr Urol. 2016; 12: 218 e1-8
        • van Tilburg M.A.
        • Squires M.
        • Blois-Martin N.
        Test of the child/adolescent Rome III criteria: agreement with physician diagnosis and daily symptoms.
        Neurogastroenterol Motil. 2013; 25 (302-e246)
        • Cadnapaphornchai M.A.
        • Chantler C.
        Kidney disease in children.
        in: Schrier R.W. Disease of Kidney and urinary tract. 8th ed. Lippincott Williams & Wilkins, 2006: 2056-2087
        • Samijn B.
        • Van den Broeck C.
        • Deschepper E.
        Risk factors for daytime or combined incontinence in children with cerebral palsy.
        J Urol. 2017; 198: 937-943
        • Hassouna T.
        • Gleason J.M.
        • Lorenzo A.J.
        Botulinum toxin A's expanding role in the management of pediatric lower urinary tract dysfunction.
        Curr Urol Rep. 2014; 15: 426
        • Vande Velde S.
        • Van Renterghem K.
        • Van Winkel M.
        Constipation and fecal incontinence in children with cerebral palsy. Overview of literature and flowchart for a stepwise approach.
        Acta gastro-enterologica Belgica. 2018; 81: 415-418
        • Tabbers M.M.
        • DiLorenzo C.
        • Berger M.Y.
        Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN.
        J Pediatr Gastroenterol Nutr. 2014; 58: 258-274
        • Nock M.K.
        • Ferriter C.
        Parent management of attendance and adherence in child and adolescent therapy: a conceptual and empirical review.
        Clin Child Fam Psychol Rev. 2005; 8: 149-166
        • Panicker J.N.
        • Fowler C.J.
        • Kessler T.M.
        Lower urinary tract dysfunction in the neurological patient: clinical assessment and management.
        Lancet Neurol. 2015; 14: 720-732
        • Wright A.J.
        • Fletcher O.
        • Scrutton D.
        Bladder and bowel continence in bilateral cerebral palsy: a population study.
        J Pediatr Urol. 2016; 12: 383.e1-383.e8
        • Heinen F.
        • Desloovere K.
        • Schroeder A.S.
        The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy.
        Eur J Paediatr Neurol: EJPN: Off J Eur Paediatr Neurol Soc. 2010; 14: 45-66
        • Wager E.
        • Kleinert S.
        Responsible research publication: international standards for authors.
        Pril (Makedon Akad Nauk Umet Odd Med Nauki). 2014; 35: 29-33