INCONTINENCE OF URINE IN CHILDREN. 
BY 
CHARLES W. TOWNSEND, M.D., 
BOSTON, MASS. 
[Reprinted from Archives of Pediatrics, December, 1887.] INCONTINENCE OF URINE IN CHILDREN. 
A study of the etiology of any disease or abnormal con- 
dition, its frequency and the circumstances under which it 
occurs, is always essential to the rational and successful treat- 
ment of that condition, while the treatment of a disease as a 
symptom without regard to its causation is generally as un- 
successful as it is irrational. The symptom of incontinence 
of urine, or enuresis, in children illustrates very perfectly this 
fact, for the physician who attempts to treat it in a routine 
way without investigating its cause generally regards it as a 
disease unaffected by the healing art, an idea which, as a 
natural consequence, prevails among the people. 
As shown by Goltz,* there is a reflex centre for micturition 
in the lumbar spinal cord. Impulses descending from the 
brain call this centre into action, and result in contraction of 
the muscles of the walls of the bladder and ejaculator urinse, 
and in relaxation of the sphincter, thus causing micturition. 
The sensation of a full bladder is, of course, the normal 
incentive to this reflex act. In the child, owing to the high 
state of tension of the nervous system, various peripheral 
irritations may send reflex impulses to this centre, which, 
proving too strong to be overcome by impulses from the brain, 
throw the centre into action, and involuntary micturition, or 
incontinence of urine, is the result. This would occur most 
naturally during sleep, when the centre for volition is least 
active, but if the irritation be strong enough, it may occur as 
* Pfliiger's Archiv, viii. p. 474. 2 
Incontinence of Urine in Children. 
well during the waking hours. Various reflex disturbances 
would therefore be among the causes of incontinence of urine; 
a second cause would be found in a relaxed or atonic state of 
the bladder, and a third in any malformation of the bladder or 
urethra. 
The following table of these three great causes, with their 
subdivisions, will, I think, be sufficiently clear after this 
physiological explanation: 
Causes of Incontinence of Urine. 
I. Reflex. 
1. Increased quantity of urine: 
(a) diabetes, (6) nephritis. 
2. Irritant quality of urine : 
(a) increased acidity, (6) uric acid crystals, (c) cal- 
cic oxalate crystals, (d) excess of phosphates. 
3. Vesical calculus. 
4. Hypersensitive state of external genitals from: 
(а) stricture of urethra. 
(б) phimosis. 
(c) balanitis or vulvitis. 
5. Anal irritation from : 
(а) pin-worms. 
(б) eczema. 
(c) fissure. 
6. Psychical. 
7. Increased irritability of bladder. 
II. Atony of sphincter vesicse. 
1. General debility. 
2. Spinal disease. 
3. Acute febrile disease. 
III. Malformations of bladder or urethra. Incontinence of Urine in Children . 
3 
Owing to the common idea that this disorder cannot be cured, 
statistics obtained from lists of diseases treated in out-patient 
departments give no idea of its prevalence. Thus, Adams* 
finds that out of nineteen thousand two hundred and sixty- 
one cases in children's out-patient departments of various hos- 
pitals, only fifty-five applied for treatment for incontinence. 
I found that in fifteen hundred cases of children's diseases 
treated in the medical out-patient department of the Boston 
Children's Hospital, twenty-five applied for treatment for this 
disorder. Morrisf states that in some boys' reformatories one 
boy in twenty wets his bed, and that incontinence is even more 
frequent than this among the colored. 
In order to get some idea of the prevalence of this disorder 
and its most frequent source, mothers of families as met in a 
dispensary district and at the out-patient department of the 
Boston Children's Hospital were asked the ages of all their 
children, their general health, the time at which incontinence 
ceased, or, if it continued or began again later in life, the par- 
ticulars of this habit were inquired into and the child ex- 
amined if possible. The families were therefore all among 
the lower and lower middle classes, and the results are rather 
surprising that twenty-one and a half per cent, of all cases were 
found to have or have had incontinence. As the mothers 
were generally ashamed of their children's habit in this regard, 
it is probable that some cases that existed may have been denied, 
and therefore that the figures are not exaggerations. 
The following is an analysis of my cases: Boys, 179; 
girls, 176 ; total number of children, 355. Of these, 77 were 
incontinent, 278 were not, or twenty-one and a half per cent, of 
* Journal Am. Med. Assoc., 1885, iv. 6. 
j- Med. and Surg. Reporter, 1881, xliv. 652. 4 
Incontinence of Urine in Children. 
all cases were incontinent; and of these, 42 were boys, 35 
were girls. The incontinence was diurnal and nocturnal in 28, 
diurnal only in 2, and nocturnal only in 47. 
The ages at which the physiological incontinence of infancy 
ceased were: 
Under 1 year in 45 
1 to 1J years " 129 
lj to 2 " " 45 
2 to 2| " " 44 
2J to 3 " " 15 
Total, 278 
Cases in which incontinence continued beyond the third year 
were classed among the abnormally incontinent. Incontinence 
was found rarely to cease before the ninth month; in three it 
was said to have stopped at six months, and in one at three 
months. It continues generally longer at night than day, 
and is apt to recur in slight acute diseases, especially colds. 
In fourteen cases incontinence came on after the primary 
incontinence of infancy had ceased, and of these it began again 
in seven at the sixth year, in six before that age, and in one- 
a boy-at the age of fourteen and a half years. Of the sixty- 
three in whom incontinence continued from infancy, in 
eighteen it had ceased ; of these, in six it stopped at four 
years; in one, at five years; four, at seven to nine years; five, 
at eleven to thirteen years ; one at fourteen years, and one at 
sixteen years. The average age of the remaining forty-five in 
whom incontinence still continued was found to be seven and 
a half years. 
Of the list of families, six were found where two members 
were affected by this disorder, three, where three members 
were affected, and in one family four members were inconti- 
nent, the family in this case consisting of five members Incontinence of Urine in Children. 
5 
otherwise healthy, and no cause for the trouble other than an 
irritable bladder could be found. 
Where the incontinence occurred in the day, it was fre- 
quently said that if the child could go at once to the closet 
when the sudden desire to micturate came on the clothes 
would be saved. But in school, where this was impossible, 
and often elsewhere, the accident would occur. In some cases 
the mothers stated that drinking water the last thing at night 
was followed by bed-wetting. In many cases the mother 
would try to prevent the wetting by taking up the child once 
or twice in the night and compelling it to pass its water, but 
although this precaution was in some cases successful, in others 
it was not. 
The following is a list of the causes of incontinence in the 
seventy-seven cases: 
Long and adherent prepuce 
.. 8 
Small meatus 
.. 1 
Vulvitis 
.. 1 
Pin-worms, or pruritus ani 
.. 4 
Sloth and habit 
.. 6 
Epispadias 
.. 1 
Atonic condition, of which 4 were rachitic and 1 idiotic... 
.. 18 
No cause found 
,. 38 
77 
In a considerable number of these cases no examination was 
made, as the child was not seen, and these were put down 
among those in which no cause was found. The following list 
of chronic diseases in which incontinence did not occur is of 
interest: 
Pott's disease, 2; hip-disease, 3; scrofula, 8; rachitis, 3; 
chorea, 5; lateral curvature, 1; petit mal, 1; inguinal hernia 
operated on unsuccessfully, 2; pin-worms, 1; leucorrhcea, 1. 6 
Incontinence of Urine in Children. 
In one case incontinence occurred nightly till the fourteenth 
year, when menstruation came on; after that the incontinence 
ceased. 
Of the cases put down as due to sloth and habit, five were 
in dirty families, and had been cured by the use of the rod. 
In the other case the habit came on after a fall on the back, 
and was nearly cured by the mother threatening to whip the 
child every time she wet the bed. After this, from occurring 
nightly it occurred only once a week. But, on the other hand, 
a large proportion of the cases are scolded and whipped for 
what they cannot help, as is evident from the uselessness of 
this heroic treatment in the majority of cases. Parker* says 
that punishment tends to confirm the habit. 
The case of small meatus was treated by nicking and 
stretching the meatus, after which incontinence occurred only 
twice in several weeks. 
Of the eight cases of long and more or less adherent prepuce, 
in one circumcision was followed by marked improvement, 
but not a cure, of the incontinence. In a second case the long 
prepuce was removed, with improvement of the symptoms for 
a few days, but incontinence returned as badly as ever at the 
end of a fortnight. In another case-a well-developed boy 
of ten years-incontinence of urine, both diurnal and nocturnal, 
had continued since infancy, with also almost daily incontinence 
of faeces. The boy was much mortified, but protested his in- 
ability to prevent it. Whippings and scoldings had been of no 
avail. There was slight balanitis from constant maceration in 
wet underclothing, and, although the prepuce was of but moder- 
ate length, it could not be retracted owing to adhesions all around 
the corona. These were broken up with the finger-nail. 
* Obstet. Journ. Grt. Brit., 1880, p. 206. Incontinence of Urine in Children. 
7 
The boy was seen last four months after the operation; 
there had been no incontinence of faeces and no bed-wetting, 
and he had wet his clothes only once or twice a month, 
probably through carelessness. 
As to its frequency in circumcised Jews an inquiry would 
be interesting, but its occurrence among them would simply 
show that other causes than a long prepuce may be responsible 
for the trouble. Among seven Jew boys in my list, two had 
been incontinent, but were cured by whipping. The surround- 
ings were very filthy. 
It is a very easy matter to find a long prepuce as the cause 
of incontinence, or any other reflex symptom, in boys, simply 
from the fact that a long prepuce is the rule, and even adhe- 
sions occur in a large number of cases. The investigations of 
Roswell Park* on the condition of the prepuce in hospital 
and private practice in boys under nine years of age are of 
interest here, and are as follows : 
Number. 
Per Cent. 
I. 
Cases permitting easy and perfect retraction of 
prepuce 
30 
19.62 
II. 
Cases of slight or partial adhesions with little 
or no retained smegma . 
48 
31.37 
III. 
Cases of complete or nearly complete adhesions 
without stenosis but with retained smegma.. 
36 
23.53 
IV. 
Cases where retraction was impossible and 
adhesions only could be felt by probe....... 
39 
25.48 
153 
100.00 
Adamsf regards circumcision as a reliable cure for incon- 
tinence, and states that he has known only one instance where 
the incontinence continued after the operation, and in that case 
* Chicago Med. Journ. and Exam., 1880, p. 561. 
f Archiv. of Pediat., April, 1887. 8 
Incontinence of Urine in Children. 
there was a possibility of stricture as the cause. D. B. Sim- 
mons* thinks that the adhesions and not the long prepuce are 
the cause of the trouble; of fourteen cases of incontinence twelve 
were cured by breaking up the adhesions, in one case without 
adhesions the removal of smegma sufficed, and in the remaining 
case, a young man just past puberty, relief was obtained by the 
passage of a steel sound. In one of the above cases there was 
also incontinence of faeces, which was cured as in my case. 
Klingensmuthj" gives three cases of cure by circumcision; 
others, however, have found no result from the operation in 
some cases, and in others there has been a return of the habit 
in a few weeks after a seeming cure. 
Farquharsonj; speaks of a case where the operation was tem- 
porarily curative, but nocturnal incontinence returned and 
defied all treatment. C. L. Dana§ gives two cases, both of 
whom had long, adherent, irritated prepuces, both had various 
nervous symptoms, the first only having incontinence. In this 
one circumcision was done without improvement. The second 
was not circumcised, but improved under various tonic treat- 
ment. Summing up, then, we may say that circumcision in 
some, but not in all, cases is followed by a relief from incon- 
tinence of urine, whether this cure be due to the impression on 
the nervous system of the pain and excitement of the operation, 
or whether it is the direct result of the removal of the point 
of irritation. Where circumcision is not curative, it is still 
possible that the long prepuce may have been the original cause, 
and that the symptom continues simply from habit. 
* Am. Obstet. Journ., 1880, xiii. p. 431. 
f Archiv. Pediat., 1884, i. p. 577. 
J Practitioner, 1879, xxiii. p. 7. 
§ Med. Pec., 1881, xx. p. 569. Incontinence of Urine in Children. 
9 
Where other reflex causes exist, such as abnormal quantity 
or quality of the urine or anal irritation (vide table), they 
should be treated. In the psychical class are to be included 
those cases where the child dreams of urinating, or has a 
nightmare and wets the bed. In some cases it appears to be 
similar to nocturnal pollutions of adults, by which it is super- 
seded. In girls, as we have already seen, the incontinence 
may cease on the establishment of the catamenia. A plausible 
explanation for these cases is that the incontinence of the 
child acts as an escape-valve for reflex irritation, which after 
puberty is relieved by menstruation in the female and noc- 
turnal pollutions in the male. These psychical cases are to be 
treated by avoidance of late suppers and of sleeping on the 
back, and by the use of bromides if necessary. The dorsal 
position, by favoring hyperseroia of the cord, makes the reflex 
centre for micturition in the lumbar region more ready to 
react to slight impulses. 
Under the head of "increased irritability of the bladder" 
would come all those cases where no other cause can be found, 
and is a convenient refuge for our ignorance. In these cases 
various drugs have been used, but belladonna given in full and 
increasing doses and the treatment continued for weeks or 
months is as a rule very satisfactory. The reason this drug 
is regarded with disfavor by some, it seems to me, is because its 
use is discontinued too soon and the trouble returns. For a 
child of five years five drops of the tincture of belladonna 
should be given at night, the dose being increased one drop 
every other night till physiological effects appear. Given by 
the rectum, with a small dose of morphia, as recommended 
by Dr. E. T. Williams,* I have also found very effectual. 
* Boston Med. and Surg. Journ., Sept. 16, 1887, p. 257. 10 
Incontinence of Urine in Children. 
Ergot is another drug highly recommended by some, and 
believed to act by contracting the blood-vessels in the lumbar 
cord. 
Goodhart* says that by long persistence of the habit the 
bladder becomes so contracted as to be incapable of holding 
the normal amount of urine, and in these cases he overcame 
the difficulty by distending the bladder by injecting water, the 
patient being chloroformed. 
Atony of the sphincter vesicae due to debility is probably 
not very common. Here nux vomica or its alkaloid, strychnia, 
and iron should be used. Some have had very good results 
from the use of electricity, one pole, the cathode, according to 
Althaus,f over the bladder, the anode over the lumbar region 
of the spine. Others place one pole in the membranous ure- 
thra or at the perineum. A tepid or cold sitz-bath at night, or 
cold douche or counter-irritation to the spine, are also to be 
recommended. 
Every mechanical device for preventing the escape of urine 
is as harmful as it is irrational, whether it be a simple string 
tied around the penis or the elaborate apparatus of a physician J 
in Australia for giving an electrical shock to the offending 
member as soon as the first drop of water is passed. 
* Diseases of Children, p. 451. 
f Brit. Med. Journ., 1883, i. p. 104. 
j Anderson, Austral. Med. Journ., 1884, n. s., vi. p. 99.