A 7-year-old boy was referred to the Child Guidance Clinic at the Department of Pediatrics, Medical College, Calicut for school refusal. The problem started six months prior to consultation when he started passing urine frequently, while sitting in the class. He also developed nocturnal enuresis. The classmates, because of the smell of urine, ridiculed the child and he refused to go to school. He had previously attained full bladder control both day and night. There was no history of polyuria, polydipsia or pain during micturition.

He was born of non-consanguineous parents and had 4 siblings. There was no past history of seizures and no family history of epilepsy or mental retardation. The ante natal, natal and postnatal history and developmental milestones were normal. Child had below average academic performance.

Physical examination was within normal limits. Mental status examination was un-remarkable except that he was sad because he was laughed at by his friends. Routine blood and urine examination results were within normal limits. Urine culture was sterile. Abdominal ultrasound examination was normal.

Possibility of an emotional disorder was thought of. The child and the parents were counselled regarding behavior therapy and he was started on Imipramine 1 mg/Kg single bedtime dose.

There was no relief of symptoms. During one of the follow up visits the child had an episode of vacant stare associated with incontinence. There were no twitching movements of the face or extremities and no loss of tone. Then the mother said that every time he passed urine he had the same facial expression, which she attributed to the child’s embarrassment.

The possibility of absence seizures was considered and the child was referred to the Department of Neurology. The EEG was abnormal and suggestive of atypical absence seizures. The child was put on sodium valproate and the symptoms remitted completely.

In a typical simple absence episode the patient abruptly loses consciousness, ongoing activity ceases without significant alteration in postural tone and the patient’s eyes stare vacantly straight ahead or roll upwards(1). Atypical (complex) absence seizures are characterized by absence attacks associated with motor components consisting of myoclonic movements of the face or extremities and occasionally loss of body tone(1,2). They are associated with atypical EEG spike and wave discharges at the rate of 2-2.5/sec.(2). Urinary incontinence can occur in association with complex absence seizures(1,3). Urinary incontinence was reported to be one of the features distinguishing epileptic and non-epileptic events in children with staring spells(4).

The other causes of daytime incontinence in a child are urinary tract infections, pediatric unstable bladder (uninhibited bladder, bladder spasms), detrusor sphincter dyssynergia, infrequent voiding, giggle incontinence and Hinman syndrome(2).

The case is reported to stress the importance of detailed history taking and also to emphasize that organic causes should be considered and ruled out in any child presenting with daytime incontinence.

P. Krishnakumar,
P. Rajeshchandran,
Department of Pediatrics,
Institute of Maternal and Child Health,
Medical College, Calicut, Kerala, India.
E-mail: [email protected]  

1. Lockman LA. Absence Seizures. In: Swaiman. KF. Ed. Pediatric Neurology. Principles & Practice. 2nd edn. Missouri: Mosby; 1994, p. 531-535.

2. Johnson MV. Seizures in childhood. In Behrman RE, Kliegman RM, Jenson HB. Eds. Nelson Textbook of Pediatrics, 17th edn. Philadelphia: Saunders 2004; p. 1993-2005.

3. So EL, King DW, Murvin AJ. Misdiagnosis of complex absence seizures. Arch Neurol 1984; 41: 640-641.

4. Rosenow F, Wyllie E, Kotagal P, Mascha E, Wolgamuth BR, Hamer H. Staring spells in children. Descriptive features distinguishing epileptic and non-epileptic events. J Pediatr 1998; 133: 660-663.