Urinary Incontinence in Childhood Cancer
Symptom Management, Palliative Care, or Supportive Care to relieve side-effects is an important part of cancer care and treatment and should always form part of the overall treatment plan.
Some cancers and cancer treatments may result in incontinence (the inability to control urination), which could be really embarrassing for your child, especially if it happens at school or in front of their friends.
Incontinence can occur in boys or girls, and may be short-term (temporary) or long-term (permanent). There are different types of incontinence, ranging from mild to severe.
- Stress Incontinence can cause a child to leak urine during activities such as coughing, laughing, sneezing, or exercising;
- Overflow Incontinence is when it takes an especially long time before one can urinate and then there is only a dribbling stream of urine;
- Urge Incontinence is experiencing urinary leakage when the bladder contracts unexpectedly;
- Continuous Incontinence is the loss of all ability to control urination.
Because incontinence can cause major discomfort or affect your child’s quality of life, it is important to talk with their health care team about how easiest to treat or manage this condition.
The urinary tract is the body’s drainage system for removing wastes and extra water. The urinary tract includes two kidneys, two ureters, a bladder, and a urethra. The kidneys are two bean-shaped organs, each about the size of a fist. They are located near the middle of the back, just below the rib cage, one on each side of the spine. Every day, the two kidneys process about 200 quarts of blood to produce about 1 to 2 quarts of urine, composed of wastes and extra water. Children produce less urine than adults. The amount produced depends on their age.
Urine forms in the kidneys then flows into the bladder (a hollow, balloon-like organ) from where it then flows down a tube called the urethra and out of the body. Sphincter muscles (which act like a valve that holds urine in or releases it) work in tandem with nerves that carry signals between them and the bladder to control urination.
To urinate, the brain signals the bladder muscles to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincters to relax. As the sphincters relax, urine exits the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs.
Some types of cancer and some cancer treatments can damage or change these nerves and muscles; they may also cause other changes to the body that lead to incontinence.
Cancers that may put your child at greater risk for incontinence include:
- Cancers in or near the Pelvic Region (the area of the body that holds the bladder and reproductive organs), such as rectal, urethra, colon, and bladder cancers, as well as gynaecological cancers (cancers that affect the female reproductive system), such as cervical cancer and uterine cancer;
- Brain or Spinal Cord Cancers, which could affect the nerves that assist in controlling the bladder and pelvic muscles;
- Lung or Oesophageal Cancer, which can cause chronic coughing that would place stress on the bladder
Cancer treatments that may put your child at greater risk for incontinence include:
- Radiation Therapy to the pelvic area, which can irritate the bladder;
- Chemotherapy, because it may cause nerve damage, vomiting (which strains the muscles that control urination), or loss of hormones;
- Surgery to the pelvic area, which can damage muscles or nerves that help control urination;
- Bone Marrow/Stem Cell Transplant with high dose chemotherapy which can cause vomiting and bladder inflammation;
- Hormone Therapies, which can dry out the urethra;
If your child is having bladder-control problems, their healthcare team will work with you and your child to find out why.
Evaluation methods include:
- Conducting a stress-test in which your child will be asked to cough as hard as possible with a full bladder;
- Cystogram (an x-ray of the bladder);
- Cystoscopy (a tiny camera is inserted into the bladder);
- Keeping a bladder journal for your child in which you keep track of when they urinate, how often, and how much;
- Ultrasound (a test that uses high-frequency sound waves to create a picture of your child’s bladder and other body parts that help control urination);
- Urine testing to look for signs of infection or other causes;
- Various techniques that measure pressure in the bladder and urine flow
Relieving side effects is an important part of total cancer care and treatment, which is why you should discuss any symptoms your child is experiencing, new symptoms and changes in symptoms with their Oncology Team so that they can work out a regimen of palliative or supportive care for them.
Incontinence is often treatable. How it is treated depends on what caused it, the type, how long it has occurred, and severity. A combination of treatments is often used, including:
- Behavioural Techniques such as bladder training, which will include your child learning to delay urination after they get the urge to go, thereby gradually lengthening the time between trips to the bathroom; this can also help to stretch the bladder so that it can hold more urine. Exercises to strengthen the bladder muscles to better control urination,scheduling toilet trips, fluid and diet management, and biofeedback (measuring devices that can help them gain control over the muscles that hold in urine)
- Catheterisation (a procedure in which a tube is inserted through the urethra and into the bladder to drain urine)
- Collagen Injections into the neck of your child’s bladder to reduce leaking
- Medical Devices such as a urethral insert (a plug inserted into the urethra) or a pessary (a stiff ring placed in a female’s vagina to help support bladder muscles)
- Medications or antidepressants. Medications such as synthetic hormones can be used to increase ADH levels. Desmopressin (DDAVP) is available in pill form, nasal spray, and nose drops and is approved for use in children. Although medications may help children achieve short-term success, relapse is common once the medication is withdrawn.
- Moisture Alarms that can wake children when they begin to urinate. These devices use a water-sensitive pad connected to an alarm that sounds when moisture is first detected. A small pad can clip to the pajamas, or a larger pad can be placed on the bed. For the alarm to be effective, children must awaken as soon as the alarm goes off, stop the urine stream, and go to the bathroom. Children using moisture alarms may need to have someone sleep in the same room to help wake them up.
- Oestrogen (a type of hormone) applied to the urethra or vaginal tissue (for female children)
- Physical Therapy, which includes kegel exercises (an exercise that strengthens muscles used to hold in urine) and electrical stimulation
- Surgery to insert an artificial urinary sphincter or create a “sling” around the neck of the bladder and urethra to keep it closed
If your child has incontinence, the following methods and tips may help them manage it:
- Limit the amount of fluids your child drinks
- Urinating before bedtime and before strenuous activity
- Wearing an absorbent pad inside their underwear
- Losing any extra weight, which could place pressure on the bladder and supporting muscles
- Sticking to a urination schedule
- Avoiding foods that can irritate the bladder such as dairy products, citrus fruits, sugar, chocolate, soda, tea, and vinegar
Getting support; Incontinence is common so you need to let your child know that they should not be embarrassed to talk about it with you, their healthcare team, counselor, or teacher.