1. Urethrovaginal Reflux—A Common Cause of Daytime Incontinence in Girls
Sven Mattsson and Gunilla Gladh
Pediatrics 2003;111;136-139
DOI: 10.1542/peds.111.1.136
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2. Urethrovaginal Reflux—A Common Cause of Daytime Incontinence in
Girls
Sven Mattsson, MD, Med Dr, and Gunilla Gladh, RN, Med Dr
ABSTRACT. Objective. The objective of this study when performed in an erect position.4,5 Such filling
was to estimate the frequency of urethrovaginal reflux as in young girls is usually viewed as a normal finding.
the cause of daytime incontinence in school-age girls, The condition has mainly been considered in relation
and to study the characteristic symptoms and the effect of to suspected bacterial contamination of urine sam-
simple instructions intended to amend the problem. ples4 – 6 and as a possible risk for urinary tract infec-
Material and Methods. Girls with urethrovaginal re-
flux were identified in a group of 169 girls, aged 7 to 15
tion.7 To our knowledge, the role of urethrovaginal
years, referred to a specialist clinic because of daytime reflux as the cause of incontinence has not been
incontinence. They were evaluated by a noninvasive evaluated. The aims of the present study were to
screening protocol, including a careful history and neuro- estimate the frequency of this condition in girls re-
urologic examination, bladder diaries, urine analysis, ferred for treatment of daytime incontinence, and to
uroflows, and residual urine determined by ultrasound. study its characteristic symptoms and the effect of
Girls with urethrovaginal reflux were instructed by a simple instructions intended to amend the problem.
urotherapist on how to achieve better toilet habits.
Results. Urethrovaginal reflux was found in 21
MATERIALS AND METHODS
(12.4%) of 169 girls as the sole (19) or contributing (2)
cause of their daytime urinary incontinence. They all had The frequency of urethrovaginal reflux was estimated in a
a typical history of small leakage 5 to 10 minutes after consecutive sample of 169 girls, aged 7 to 15 years (median: 10
years), referred to a specialized urotherapeutic clinic because of
voidings during the day, confirmed by a specific bladder daytime urinary incontinence. All girls were of normal weight and
diary. All were neurologically healthy, and all but 2 had height, and apart from their incontinence, they were all healthy
a normal bladder function. The latter 2 girls had residual without known neurologic problems. They were evaluated by a
urine and asymptomatic bacteriuria. At follow-up after noninvasive screening protocol including a careful history, clinical
median 2 years, all girls were free from postmicturition examination with particular focus on neurourologic status, blad-
leakage, but the 2 with residual urine remained daytime der diary for 3 days, urine analysis, and 3 uroflowmetries fol-
incontinent with cystometrically proven phasic detrusor lowed by residual urine determination by ultrasound (Bladder-
overactivity. Scan 2500, Diagnostic Ultrasound Corporation, Redmond, WA).
Conclusions. Urethrovaginal reflux is a common All girls with a history of small urinary leakage shortly after
daytime micturitions were further examined. The girls completed
cause of urinary incontinence in girls. The diagnosis is additional bladder diaries at home with extra focus on urinary
easily obtained by an adequate history, completed leakage episodes 5 to 10 minutes after voidings (Fig 1). At the
with a specific bladder diary. The problem is easily second visit, after confirmation of the diagnosis urethrovaginal
resolved by proper voiding instructions. Pediatrics reflux, they received instructions by a qualified urotherapist on
2003;111:136 –139; children, urinary incontinence, ure- how to sit properly on the toilet to void with minimal reflux and
throvaginal reflux, bladder diary. how to evacuate urine from the vagina (Table 1). The effect of
instruction was evaluated by submitted bladder diaries and/or by
telephone contact by the urotherapist.
D
aytime incontinence of different causes oc-
curs in 3.1% to 9.5% of school-age girls.1–3 In RESULTS
most cases, isolated day wetting is found to
be idiopathic, but incontinence may be a first symp- Urethrovaginal reflux was identified as the cause
tom of a serious neurologic disorder. A correct diag- of daytime urinary leakage in 21 (12.4%) of 169 girls.
nosis can often be obtained by child-adapted nonin- They all had a characteristic pattern of leakage in
vasive procedures; only in special cases may invasive connection with voidings. Typically, they were dry
investigations be required. when going to the toilet but frequently wet their
Urethrovaginal reflux has been recognized as a panties within 5 to 10 minutes after the voiding. This
possible cause of urinary leakage in girls.4 Retro- pattern was easily discovered by adequate questions
grade filling of the vagina is frequently found in during history taking and supported by the specific
association with voiding cystourethrography, even bladder diary, as shown in Fig 1 from a typical girl
with urinary leakages at 5 of 6 voidings during the
day. Characteristically, the leakages were rather
From the Division of Pediatrics, Department of Molecular and Clinical small but enough to wet the panties.
Medicine, Faculty of Health Sciences, Linkoping, Sweden.
¨ Although not necessary or specific for the diagno-
Received for publication Mar 14, 2002; accepted July 30, 2002. sis,4,5 urethrovaginal reflux can frequently be ob-
Reprint requests to (S.M.) Division of Pediatrics, Department of Molecular served in micturition cystourethrography (Fig 2).
and Clinical Medicine, Faculty of Health Sciences, SE-581 85 Linkoping,
¨
Sweden. E-mail: sven.mattsson@lio.se
The illustrated investigation was performed to ex-
PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad- clude ureteric reflux in a girl with repeated distal
emy of Pediatrics. urinary tract infections. In practice, the diagnosis of
136 PEDIATRICS Vol. 111 No. 1 January 2003
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3. Fig 1. A typical bladder diary for a 9-year-old girl with daytime urinary leakage caused by urethrovaginal reflux.
TABLE 1. Voiding Instructions for Girls With Urethrovaginal mal. However, 6 had a previous history of 1 (2 girls)
Reflux or more (4 girls) episodes of acute cystitis. Despite
Sit steadily on the toilet brim, legs fully supported. referral because of daytime incontinence, 3 girls had
Keep the legs well apart. primary nocturnal enuresis. This elaborate list
Lean the trunk forward (as much as you can) making the pelvic should not conceal that the majority of the girls with
tilt forward and the urinary stream more vertical. urinary leakage attributable to urethrovaginal reflux
Separate the labia before voiding.
At end of voiding, use toilet paper to press and lift the
had normal bladder function at the time of evalua-
perineum forward/upward (from the base of the vagina and tion.
away from the rectum) to empty urine from the vagina. All girls with urethrovaginal reflux received a
thorough voiding instruction by a qualified uro-
therapist, as outlined in Table 1. Their problem with
postmicturition urinary leakage immediately re-
urethrovaginal reflux is obtained by the finding that solved. At follow-up (median: 2 years), all girls but 2
the girls can evacuate urine from the vagina after remained continent and all but 1 with recurrent acute
voidings. Furthermore, their incontinence problem is cystitis became free from urinary tract infections. For
resolved by teaching them how to sit and void to these 19 girls (11.2%), the urethrovaginal reflux was
minimize vaginal reflux and how to empty the va- apparently the sole cause of their daytime urinary
gina (Table 1). leakage. The 2 girls, who at first visit had residual
The girls with urethrovaginal reflux had the same urine, remained incontinent with cystometrically
age distribution, 7 to 15 years, as the total group of proven phasic detrusor overactivity. Both had lasting
girls with daytime incontinence. There was no obvi- asymptomatic bacteriuria, and 1 had lasting residual
ous deviation in the shape of their urethral meatus, urine. Clearly, the original leakage problem of these
external genitals, or hymenal ring compared with the girls was attributable to a combination of urethro-
normal anatomy of girls in the same age group. Their vaginal reflux and urge incontinence. The third girl
neurourologic findings were also normal. Voiding with asymptomatic bacteriuria became dry despite
frequency was 4 to 8 voidings per day (median: 5), remaining bacteriuria. At follow-up, the 3 girls with
which is within the normal range for healthy school- nocturnal enuresis were all dry at night.
aged girls.8 All but 1 had normal urinary flows; the
exceptional girl had several voidings with inter-
rupted flow curves. She and another girl were the DISCUSSION
only ones who voided with residual urine ( 20 mL). Urethrovaginal reflux is a surprisingly common
Both girls also had asymptomatic bacteriuria, as did cause of urinary leakage in schoolgirls. It was the
a third girl without signs of bladder dysfunction. For major problem in 10% of the girls referred to a
the remaining 18 girls, the urine analysis was nor- specialized clinic for daytime incontinence. The di-
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4. Fig 2. Urethrovaginal reflux shown by micturition cystourethrography in an 8-year-old girl. A, Side view of the bladder filled with
contrast medium at the start of voiding. B, End of void picture with almost empty bladder and vagina filled with contrast medium.
agnosis is easily obtained by a careful history, com- hind the low barrier of the hymen. The vagina has
pleted with an adequate bladder diary. In affected also a more horizontal position before puberty,
girls, the anatomy of the urethral meatus and exter- which may contribute to the vaginal reflux.
nal genitals is apparently normal for the age. Most When the girl rises from the toilet, urine will start
affected girls also have a normal bladder function. to dribble and wet the panties. For some girls, the
The condition is very gratifying to handle, because it majority of leakage may occur when they start to
is rapidly amended by proper instructions about move. Others may squeeze out urine first when they
voiding position and how to evacuate the vagina increase the abdominal pressure by laughing or
from reflux urine. coughing. In most cases, the leakage is just a few
The mechanisms behind urethrovaginal reflux are milliliters, which is enough to leave a wet spot in the
not quite clear. Presumably, the problem arises from panties. The described course of events explains the
the specific anatomic situation in young girls, as the
typical history of girls with urethrovaginal reflux—
condition is not found in postpubertal girls or
women. In young girls, the urethral opening is close they are dry when going to the toilet but wet when
to the vagina and hymenal ring with the labia minora leaving.
and majora small and in close proximity. Even with- Urethrovaginal reflux is frequently found when
out anatomic adhesions, the labia may stick together performing voiding cystourethrography4 – 6 in girls.
and direct the urine backwards. Therefore, the urine Such findings are not diagnostic, because most girls
may pass through the vaginal opening and stay be- with radiologically demonstrated reflux have no
138 INCONTINENCE AND URETHROVAGINAL REFLUX
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5. symptom of urinary leakage. Either the vagina is not ACKNOWLEDGMENTS
filled during everyday voidings or empties sponta- ¨
The study was supported by grants from Ostergotlands Land-
¨
neously before the girl gets up from the toilet. What- sting and from the Research Fund of the University Hospital of
Linkoping.
¨
ever the case, this finding has caused some concern Urotherapists Monica Eldh and Monica Brannstrom and spe-
¨ ¨
regarding bacterial contamination of urine samples cialist nurse Kerstin Rydmyr provided voiding instructions to the
for culture.4 – 6 It can be expected that urethrovaginal girls. Assistant Professor Margareta Resjo kindly supplied the
¨
reflux in some girls may cause genital irritation, radiograph.
smarting, bad smell, and vaginal discharge. The con- REFERENCES
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CONFLICT OF INTEREST IN BIOTECHNOLOGY
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is hard to find scientists who are not potentially conflicted by their financial
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Full disclosure solves a lot of these issues, but when you think of the erosion of
the confidence the public may have in what scientists say, these conflicts, real or
perceived, become very important.“
Harold Shapiro, ex-president of Princeton University, quoted in The New York Times, July 2, 2002
Submitted by Student
ARTICLES 139
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6. Urethrovaginal Reflux—A Common Cause of Daytime Incontinence in Girls
Sven Mattsson and Gunilla Gladh
Pediatrics 2003;111;136-139
DOI: 10.1542/peds.111.1.136
Updated Information including high-resolution figures, can be found at:
& Services http://www.pediatrics.org/cgi/content/full/111/1/136
References This article cites 8 articles, 2 of which you can access for free at:
http://www.pediatrics.org/cgi/content/full/111/1/136#BIBL
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