DOI: 10.1542/peds.111.1.136 2003;111;136-139 Pediatrics

Sven Mattsson and Gunilla Gladh Urethrovaginal Reflux—A Common Cause of Daytime Incontinence in Girls

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Urethrovaginal Reflux—A Common Cause of Daytime Incontinence inGirls

Sven Mattsson, MD, Med Dr, and Gunilla Gladh, RN, Med Dr

ABSTRACT. Objective. The objective of this studywas to estimate the frequency of urethrovaginal reflux asthe cause of daytime incontinence in school-age girls,and to study the characteristic symptoms and the effect ofsimple instructions intended to amend the problem.

Material and Methods. Girls with urethrovaginal re-flux were identified in a group of 169 girls, aged 7 to 15years, referred to a specialist clinic because of daytimeincontinence. They were evaluated by a noninvasivescreening protocol, including a careful history and neuro-urologic examination, bladder diaries, urine analysis,uroflows, and residual urine determined by ultrasound.Girls with urethrovaginal reflux were instructed by aurotherapist on how to achieve better toilet habits.

Results. Urethrovaginal reflux was found in 21(12.4%) of 169 girls as the sole (19) or contributing (2)cause of their daytime urinary incontinence. They all hada typical history of small leakage 5 to 10 minutes aftervoidings during the day, confirmed by a specific bladderdiary. All were neurologically healthy, and all but 2 hada normal bladder function. The latter 2 girls had residualurine and asymptomatic bacteriuria. At follow-up aftermedian 2 years, all girls were free from postmicturitionleakage, but the 2 with residual urine remained daytimeincontinent with cystometrically proven phasic detrusoroveractivity.

Conclusions. Urethrovaginal reflux is a commoncause of urinary incontinence in girls. The diagnosis iseasily obtained by an adequate history, completedwith a specific bladder diary. The problem is easilyresolved by proper voiding instructions. Pediatrics2003;111:136 –139; children, urinary incontinence, ure-throvaginal reflux, bladder diary.

Daytime incontinence of different causes oc-curs in 3.1% to 9.5% of school-age girls.1–3 Inmost cases, isolated day wetting is found to

be idiopathic, but incontinence may be a first symp-tom of a serious neurologic disorder. A correct diag-nosis can often be obtained by child-adapted nonin-vasive procedures; only in special cases may invasiveinvestigations be required.

Urethrovaginal reflux has been recognized as apossible cause of urinary leakage in girls.4 Retro-grade filling of the vagina is frequently found inassociation with voiding cystourethrography, even

when performed in an erect position.4,5 Such fillingin young girls is usually viewed as a normal finding.The condition has mainly been considered in relationto suspected bacterial contamination of urine sam-ples4–6 and as a possible risk for urinary tract infec-tion.7 To our knowledge, the role of urethrovaginalreflux as the cause of incontinence has not beenevaluated. The aims of the present study were toestimate the frequency of this condition in girls re-ferred for treatment of daytime incontinence, and tostudy its characteristic symptoms and the effect ofsimple instructions intended to amend the problem.

MATERIALS AND METHODSThe frequency of urethrovaginal reflux was estimated in a

consecutive sample of 169 girls, aged 7 to 15 years (median: 10years), referred to a specialized urotherapeutic clinic because ofdaytime urinary incontinence. All girls were of normal weight andheight, and apart from their incontinence, they were all healthywithout known neurologic problems. They were evaluated by anoninvasive screening protocol including a careful history, clinicalexamination with particular focus on neurourologic status, blad-der diary for 3 days, urine analysis, and 3 uroflowmetries fol-lowed by residual urine determination by ultrasound (Bladder-Scan 2500, Diagnostic Ultrasound Corporation, Redmond, WA).

All girls with a history of small urinary leakage shortly afterdaytime micturitions were further examined. The girls completedadditional bladder diaries at home with extra focus on urinaryleakage episodes 5 to 10 minutes after voidings (Fig 1). At thesecond visit, after confirmation of the diagnosis urethrovaginalreflux, they received instructions by a qualified urotherapist onhow to sit properly on the toilet to void with minimal reflux andhow to evacuate urine from the vagina (Table 1). The effect ofinstruction was evaluated by submitted bladder diaries and/or bytelephone contact by the urotherapist.

RESULTSUrethrovaginal reflux was identified as the cause

of daytime urinary leakage in 21 (12.4%) of 169 girls.They all had a characteristic pattern of leakage inconnection with voidings. Typically, they were drywhen going to the toilet but frequently wet theirpanties within 5 to 10 minutes after the voiding. Thispattern was easily discovered by adequate questionsduring history taking and supported by the specificbladder diary, as shown in Fig 1 from a typical girlwith urinary leakages at 5 of 6 voidings during theday. Characteristically, the leakages were rathersmall but enough to wet the panties.

Although not necessary or specific for the diagno-sis,4,5 urethrovaginal reflux can frequently be ob-served in micturition cystourethrography (Fig 2).The illustrated investigation was performed to ex-clude ureteric reflux in a girl with repeated distalurinary tract infections. In practice, the diagnosis of

From the Division of Pediatrics, Department of Molecular and ClinicalMedicine, Faculty of Health Sciences, Linkoping, Sweden.Received for publication Mar 14, 2002; accepted July 30, 2002.Reprint requests to (S.M.) Division of Pediatrics, Department of Molecularand Clinical Medicine, Faculty of Health Sciences, SE-581 85 Linkoping,Sweden. E-mail: sven.mattsson@lio.sePEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad-emy of Pediatrics.

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urethrovaginal reflux is obtained by the finding thatthe girls can evacuate urine from the vagina aftervoidings. Furthermore, their incontinence problem isresolved by teaching them how to sit and void tominimize vaginal reflux and how to empty the va-gina (Table 1).

The girls with urethrovaginal reflux had the sameage distribution, 7 to 15 years, as the total group ofgirls with daytime incontinence. There was no obvi-ous deviation in the shape of their urethral meatus,external genitals, or hymenal ring compared with thenormal anatomy of girls in the same age group. Theirneurourologic findings were also normal. Voidingfrequency was 4 to 8 voidings per day (median: 5),which is within the normal range for healthy school-aged girls.8 All but 1 had normal urinary flows; theexceptional girl had several voidings with inter-rupted flow curves. She and another girl were theonly ones who voided with residual urine (�20 mL).Both girls also had asymptomatic bacteriuria, as dida third girl without signs of bladder dysfunction. Forthe remaining 18 girls, the urine analysis was nor-

mal. However, 6 had a previous history of 1 (2 girls)or more (4 girls) episodes of acute cystitis. Despitereferral because of daytime incontinence, 3 girls hadprimary nocturnal enuresis. This elaborate listshould not conceal that the majority of the girls withurinary leakage attributable to urethrovaginal refluxhad normal bladder function at the time of evalua-tion.

All girls with urethrovaginal reflux received athorough voiding instruction by a qualified uro-therapist, as outlined in Table 1. Their problem withpostmicturition urinary leakage immediately re-solved. At follow-up (median: 2 years), all girls but 2remained continent and all but 1 with recurrent acutecystitis became free from urinary tract infections. Forthese 19 girls (11.2%), the urethrovaginal reflux wasapparently the sole cause of their daytime urinaryleakage. The 2 girls, who at first visit had residualurine, remained incontinent with cystometricallyproven phasic detrusor overactivity. Both had lastingasymptomatic bacteriuria, and 1 had lasting residualurine. Clearly, the original leakage problem of thesegirls was attributable to a combination of urethro-vaginal reflux and urge incontinence. The third girlwith asymptomatic bacteriuria became dry despiteremaining bacteriuria. At follow-up, the 3 girls withnocturnal enuresis were all dry at night.

DISCUSSIONUrethrovaginal reflux is a surprisingly common

cause of urinary leakage in schoolgirls. It was themajor problem in �10% of the girls referred to aspecialized clinic for daytime incontinence. The di-

TABLE 1. Voiding Instructions for Girls With UrethrovaginalReflux

Sit steadily on the toilet brim, legs fully supported.Keep the legs well apart.Lean the trunk forward (as much as you can) making the pelvic

tilt forward and the urinary stream more vertical.Separate the labia before voiding.At end of voiding, use toilet paper to press and lift the

perineum forward/upward (from the base of the vagina andaway from the rectum) to empty urine from the vagina.

Fig 1. A typical bladder diary for a 9-year-old girl with daytime urinary leakage caused by urethrovaginal reflux.

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agnosis is easily obtained by a careful history, com-pleted with an adequate bladder diary. In affectedgirls, the anatomy of the urethral meatus and exter-nal genitals is apparently normal for the age. Mostaffected girls also have a normal bladder function.The condition is very gratifying to handle, because itis rapidly amended by proper instructions aboutvoiding position and how to evacuate the vaginafrom reflux urine.

The mechanisms behind urethrovaginal reflux arenot quite clear. Presumably, the problem arises fromthe specific anatomic situation in young girls, as thecondition is not found in postpubertal girls orwomen. In young girls, the urethral opening is closeto the vagina and hymenal ring with the labia minoraand majora small and in close proximity. Even with-out anatomic adhesions, the labia may stick togetherand direct the urine backwards. Therefore, the urinemay pass through the vaginal opening and stay be-

hind the low barrier of the hymen. The vagina hasalso a more horizontal position before puberty,which may contribute to the vaginal reflux.

When the girl rises from the toilet, urine will startto dribble and wet the panties. For some girls, themajority of leakage may occur when they start tomove. Others may squeeze out urine first when theyincrease the abdominal pressure by laughing orcoughing. In most cases, the leakage is just a fewmilliliters, which is enough to leave a wet spot in thepanties. The described course of events explains thetypical history of girls with urethrovaginal reflux—they are dry when going to the toilet but wet whenleaving.

Urethrovaginal reflux is frequently found whenperforming voiding cystourethrography4–6 in girls.Such findings are not diagnostic, because most girlswith radiologically demonstrated reflux have no

Fig 2. Urethrovaginal reflux shown by micturition cystourethrography in an 8-year-old girl. A, Side view of the bladder filled withcontrast medium at the start of voiding. B, End of void picture with almost empty bladder and vagina filled with contrast medium.

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symptom of urinary leakage. Either the vagina is notfilled during everyday voidings or empties sponta-neously before the girl gets up from the toilet. What-ever the case, this finding has caused some concernregarding bacterial contamination of urine samplesfor culture.4–6 It can be expected that urethrovaginalreflux in some girls may cause genital irritation,smarting, bad smell, and vaginal discharge. The con-dition may also contribute to lower urinary tractinfections.7 In agreement, a relatively high propor-tion of the girls with urethrovaginal reflux (43%) hada history of urinary tract infections. Most became freeof infections when their problem with urethrovagi-nal reflux resolved.

CONCLUSIONUrethrovaginal reflux is a surprisingly common

cause of daytime urinary leakage in girls. The con-dition is easily diagnosed by an adequate history andamended by instructions aimed at improving toilethabits. With no need for specialized urologic inves-tigations, the outpatient pediatrician can properlyhandle the condition.

ACKNOWLEDGMENTSThe study was supported by grants from Ostergotlands Land-

sting and from the Research Fund of the University Hospital ofLinkoping.

Urotherapists Monica Eldh and Monica Brannstrom and spe-cialist nurse Kerstin Rydmyr provided voiding instructions to thegirls. Assistant Professor Margareta Resjo kindly supplied theradiograph.

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habits and incontinence in 7-year-old Swedish school entrants. EurJ Pediatr. 1990;149:434–437

2. Mattsson S. Urinary incontinence and nocturia in healthy school chil-dren. Acta Paediatr. 1994;83:950–954

3. Bower WF, Moore KH, Shepherd RB, Adams RD. The epidemiology ofchildhood enuresis in Australia. Br J Urol. 1996;78:602–606

4. Kelalis PP, Burke EC, Stickler GB, Hartman GW. Urinary vaginal refluxin children. Pediatrics. 1973;51:941–943

5. Davis LA, Chunley WF. The frequency of vaginal reflux during mic-turition—its possible importance to the interpretation of urine cultures.Pediatrics. 1966;38:293–294

6. Tamburrini O, Palescandolo P, Bartomoleo-De Iuri A, Dolezalova H,Porta E. Urethro-vaginal reflux. Radiol Med (Torino). 1984;70:11–12

7. Linshaw MA. Controversies in childhood urinary tract infections. WorldJ Urol. 1999;17:383–395

8. Mattsson S. Voiding frequency, volumes and intervals in healthy schoolchildren. Scand J Urol Nephrol. 1994;28:1–11

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DOI: 10.1542/peds.111.1.136 2003;111;136-139 Pediatrics

Sven Mattsson and Gunilla Gladh Urethrovaginal Reflux—A Common Cause of Daytime Incontinence in Girls

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