Bed Wetting • Definitions • Natural History • Causes • Evaluation • Treatment
Bed Wetting Enuresis:- Persistence of inappropriate voiding beyond the age of anticipated bladder control Nocturnal Enuresis - 5 years Diurnal Enuresis ( Dribbling) – 3 years
Bed Wetting Nocturnal enuresis:- Involuntary passage of urine during sleep. - Primary NE:- No period of sustained dryness - Secondary NE:- recurrence of NE after 6 months or longer of dryness. Monosymptomatic nocturnal enuresis
Bed Wetting Diurnal enuresis:- involuntary leaking of urine during waking hours. - Incontinence. - Urgency. - Frequency Secondary to neurologic or urologic disorders - UTI - Spinal dysraphism - detrusor instability
Bed Wetting • NE with DE = Complicated Enuresis or Dysfunctional voiding. • NE with or without DE and bowel symptoms Dysfunctional elimination syndrome. Polysymptomatic nocturnal enuresis.
Bed Wetting - Causes • Maturational delay:- MSNE resolves spontaneously in almost all cases with 15%/Y. NE children have progressive maturation of bladder stability in conjunction with EEG findings that suggests increased CNS recognition of bladder fullness and the ability to suppress onset of bladder contraction.
Bed Wetting - Causes • Genetics:- Genetic tendency toward NE, Concordance among monozygotic twins – twice as in DZ twins. One parent –with NE – 50 % of offspring Two parents – 75% of offspring AD. Genetic Loci on Ch 12q & 22q11
Bed Wetting - Causes • Small bladder Capacity:- BC = Age + 2 (Ounce) BC during daytime was equal in NE and Controls. BC significantly smaller in NE during sleep. • Nocturnal polyuria and ADH:- in normal children urine output decreases during night due to increase in ADH secretion ( circadian pattern). In NE children Secretion of nocturnal ADH is decreased or have blunted response to ADH which results in increased urine output extending the bladder capacity.
Bed Wetting - Causes • Detrusor instability:- Urodynamic study during sleep showed increased rate of bladder contraction in association with enuresis. This was not associated in increase in pelvic floor activity as it should be to awake the child to void. • Sleep disorders:- NE are deep sleepers – parents – biased observation Sleep laboratory study- attempts at arousal were more often successful in the control group
Bed Wetting - Evaluation • History:- Presence of day time symptoms Period of dryness FH frequency and trend of NE Fluid intake diary voiding diary Stooling diary Medical history – OSA, DM, DI, SCD, UTI, CNS Social history – secondary NE. How NE is affecting the child and family Which intervention the family has tried.
Bed Wetting - Evaluation • Physical examination:- Normal in MSNE Wet underwear. Abdominal examination for fecal mass Perianal excoriation – Pinworms Poor growth or HTN Lower LSS abnormality Incomplete bladder emptying Dribbling, urinary stream Urologic abnormality
Bed Wetting - Evaluation • Urinalysis:- SG, Glucose, UTI. • Imaging:- U/S, MCUG, LSS – reserved for children with complicated enuresis
Bed Wetting - Treatment • Primary and secondary NE are treated the same. • Age to start treatment and maturity of the child. • Family history of NE or No. • NE is completely involuntary. Family should participate and the environment must be supportive. • Treatment course is prolonged with frequent relapses and may fail in the short term. • Treatment may involve one or a combination of more than one modality
Bed Wetting – Treatment Nonpharmacologic • Motivational therapy:- Once accepted responsibility, the child will be motivated by keeping a record of progress. Significant improvement - successful in 25% - relapse rate 5% First line therapy particularly in young children. for 3- 6 months.
Bed Wetting – Treatment Nonpharmacologic • Bladder retention training exercise:- For low bladder capacity. ( The child should hold his urine for successively longer intervals after first sensing the urge to void). The volume of voided urine should be recorded weekly on a diary to evaluate success. Success rate – 35%. Should be tried before the alarm and pharmacologic therapy.
Bed Wetting – Treatment Nonpharmacologic • Fluid management:- To record total fluid intake and be scheduled as the following:- 40% - morning 40% - afternoon 20% - evening ( after 5 pm) No fluid restriction:- as bladder training to increase bladder capacity, decrease need for fluid in the evening.
Bed Wetting – Treatment Nonpharmacologic • Enuresis alarms:- The most effective way Works through conditioning The child is in charge of the alarm Diary - Positive reinforcement for dry nights Used continuously to achieve 21–28 dry nights ---- 12-16 weeks. Reinitiated for relapses ( 2 wets/2 weeks) Rapid secondary response
Bed Wetting – Treatment Nonpharmacologic • Enuresis alarm:- During use – 75% dry for 2 weeks After use – 50% remained dry Less immediate response than DDAVP More effective in preventing relapse • Alarm clocks
Bed Wetting – Treatment pharmacologic • Desmopressin Acetate ( DDAVP):- Abnormal circadian rhythm Normal BC Given orally - late evening 0.2 mg up to 0.6 mg DilutionalHyponatremia A trial run of Desmopressin. Restrict fluid intake 1hr before to 8 hr after Course interrupted - electrolyte imbalance
Bed Wetting – Treatment pharmacologic • Tricyclic antidepressants:- Decrease time spent in REM sleep, Stimulates Vasopressin secretion and relax the detrusor muscle. Imipramine - 0.9-1.5 mg/kg at bedtime not to exceed 50 mg 6-12 yr, 75 mg 12 yr and older. Should be discontinued if no response after 4 weeks at the adequate dose.
Bed Wetting – Treatment pharmacologic Cardiac conduction disturbances, Myocardial depression, nervousness , personality changes, sleep disorders and increased suicidality.
Bed Wetting – Treatment pharmacologic • DDAVP & TCA Both have better short term cure rate but higher relapse rate. Rate of dryness after 12 months was 15%
Bed Wetting – Treatment pharmacologic • Indomethacin:- Removal of the inhibitory effect of Prostaglandins on Vasopressin and improves bladder function Rarely used Given as suppository, significantly increases no. of dry nights compared to Placebo
Bed Wetting – Treatment pharmacologic • Anticholinergics:- Oxybutynin Not effective in MSNE. • Atropine • Diclofenac Sodium • Furosemide • Acupuncture, Hypnosis and Psychotherapy: limited evidence to support their use in children
Bed Wetting – TreatmentAge related • Younger than 7 years:- Education and reassurance Motivational therapy • 7-12 years:- Enuresis alarm and intermittent DDAVP • Older than 12 years: Enuresis alarm and continuous DDAVP or TCAD