MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

1. MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

2. Enuresis • Definitions • Aetiology • Anatomy and physiology • Impact • Assessment • Treatment options • Summary

3. DEFINITIONS IN ENURESIS

4. Definitions; ICCS THE INTERNATIONAL CHILDRENS CONTINENCE SOCIETY The journal of Urology July 2006 Volume 176. number 1. New definitions and standardised terminology in the field of the lower urinary tract

5. Continuous incontinence Intermittent incontinence Day-time incontinence Nocturnal incontinence, Enuresis URINARY INCONTINENCE

6. Definition ENURESISIntermittent incontinence whilst sleeping This is regardless of whether voiding is normal or not, what the suspected cause is, or the presence or absence of daytime wetting

7. PRIMARY ENURESIS; A child who has never been dry for more than six months • SECONDARY ENURESIS; A child who has previously been dry for more than six months

8. MONO-SYMPTOMATIC ENURESIS Enuresis in a child with no day time bladder symptoms, • NON MONO-SYMPTOMATIC ENURESIS Enuresis in a child with day time bladder symptoms,

9. Prevalence in school children Yeung et al. BJU Int 2006;97:1069–73 25 Male (n=7455) Female (n=9057) 20 All (n=16512) 15 Prevalence (%) 10 5 0 11 5 6 7 8 9 10 12 13 14 15 16 17 18 19 Age (years)

10. PREVALENCE ACCORDING TO AGE: At 5 years = 16.1% At 7 years = 10.1% At 9 years = 3.1% At 19 years = 2.2% SPONTANEOUS REMISSION RATE 15% PER YEAR

11. AETIOLOGY • GENETICS • EXPERIENCES • PSYCHOLOGICAL DISTURBANCE

12. AETIOLOGY OF ENURESIS

13. AETIOLOGY; FAMILY HISTORY • 15% risk where there is no parental history of enuresis • 40% if siblings also had PNE • 43% risk where only one parent had been enuretic as a child • 77% risk where both parentshad been enuretic as a child Bakwin. Am J Dis Child 1971;121;222–5; Jarvelin et al. Acta Paediatr Scand 1988;77:148–53

14. AETIOLOGY; • Formula feeding and low birth weight • UTI • Developmental delay • Emotional upset • Urinary tract abnormalities • Diabetes Mellitus • Recurrent UTI • Kidney disease • ADHD and other behavioural difficulties • Sleep Apnoea (Snoring)

15. HOW THE CHILD VIEWS ENURESIS 1998 Study youngsters aged 8–16 years rated bedwetting as the third most traumatic event following divorce and parental fighting. ALSPAC study 8580 9 year old children were asked to rate difficulty of life events Enuresis was rated fourth out of twenty one .

16. ALSPAC • The Avon Longitudinal Study of Parents and Children (ALSPAC) was formerly called the Avon Longitudinal Study of Pregnancy and Childhood. • ALSPAC is also known locally as Children of the 90s. • ALSPAC recruited more than 14,000 pregnant women with estimated dates of delivery between April 1991 and December 1992. These women, the children arising from the index pregnancy and the women's partners have been followed up since then and detailed data collected throughout childhood. • ALSPAC is a two-generational resource available to study the genetic and environmental determinants of development and health. • http://www.bristol.ac.uk/alspac

17. IMPACT OF ENURESIS

18. IMPACT These are potential effects and by no means universal Some children are not adversely affected and have no long term sequelae However some do….

19. IMPACT ON CHILD THE CHILD CAN • Feel ashamed • Fear bullying • Feel guilty this can lead to restriction in activities no sleepovers or with only certain family members No school trips

20. IMPACT ON CHILD • Impaired self image and self esteem • Impaired emotional state • Avoidance behaviour • Attention span, • Achievement • Performance IQ Children with non mono-symptomatic enuresis are more vulnerable to adverse psychological effects.

21. IMPACT ON PARENTS • Feel helpless • Worry about health of child • Upset about impact on child’s life • Upset about impact on their life • Significant financial cost • Last straw……

22. IMPACT ON FAMILY RELATIONSHIPS STRESS ON CHILD AND FAMILY CAN LEAD TO…. • PARENTAL INTOLERENCE where the child is seen as lazy and disinterested • CHILD ABUSE

23. EFFECTS OF TREATMENT • THERE ARE A RANGE OF EVIDENCE BASED TREATMENTS AVAILABLE • SIGNIFICANT IMPROVEMENT in psychological functioning follows treatment • ALL ASPECTS BENEFIT from treatment; attention, achievement, Social, emotional, avoidance behaviours, low self esteem

24. Treatment is for Everyone SPECIAL NEEDS For the majority of children with mild to moderate learning difficulties in the absence of any neurological difficulties there is no reason why they should not be toilet trained and even those with more severe problems have been found to respond to training (Louiselli, 1994)

25. ANATOMY AND PHYSIOLOGY IN ENURESIS

26. URINARY TRACT

27. KIDNEY; FUNCTION • BLOOD is brought to the kidneys through the renal arteries • KIDNEYS filter blood at a rate of a litre a minute (20% of blood circulating volume per minute.) • THE FILTRATE is then modified by the kidneys depending on the requirements of preservation or excretion of the body • URINE REGULATION a minimum urine production is an absolute necessity

28. URINE PRODUCTION KIDNEYS; regulate urine production to maintain disposal of waste products and maintain fluid balance in the face of….. • OSMOTIC PULL e.g. naturesis, acid base balance, fluid load etc • HYPOTHALAMUS/PITUITARY who maintain water regulation • ALDOSTERONE which maintains salt regulation • etc etc etc

29. NEPHRON STRUCTURE

30. CONCENTRATION OF URINE • SODIUM is actively reabsorbed in the proximal tubule and 70% of water in the filtrate is reabsorbed with it. • The remaining 30% of WATER is reabsorbed in the distal tubule and collecting ducts. • This reabsorbtion is dependent on ANTI DIURETIC HORMONE (ADH) also known as Vasopressin • Without ADH only dilute, hypo-osmolar urine is produced.

31. BLADDER; URINE STORAGE AND RELEASE

32. URINE STORAGE • BLADDER WALL; DETRUSOR MUSCLE; Relaxes during bladder filling and contacts during bladder emptying (autonomic control) • BLADDER; NECK INTERNAL SPHINCTER Contracts during bladder filling and relaxes during bladder emptying (autonomic control) • EXTERNAL SPHINCTER; PELVIC FLOOR Contracts to maintain bladder and bowel integrity (voluntary control)

33. BLADDER TRAINING Bladder awareness begins in infancy. Modification of bladder function over time leads to the brain taking control of bladder function usually by age 3 to 4 years. BLADDER-BRAIN-KIDNEYS Working in harmony For toilet training

34. DAY TIME CONTINENCE Successful toilet training requires… • Recognition of a full bladder or bowel • Appropriate access to toilet facilities • Ability to indicate need • Will to act upon need • The ability to “hold on” Generally 2 ½ to 3 ½ yrs

35. NIGHT TIME CONTINENCE DRY NIGHTS ARE ACHIEVED When a bladder doesn’t need to empty when you are asleep. Or if a bladder does need to empty and you can wake to void. Generally 5 years and above

36. Bladder-Brain Relationship

37. THREE SYSTEMS MODEL Nocturnal polyuria (Lack of ADH Release) Reduced nocturnal functional bladder capacity Nocturnal enuresis Impaired arousal response to bladder fullness from sleep

38. THREE SYSTEMS MODEL Nocturnal enuresis Impaired arousal response to bladder fullness from sleep

39. AROUSAL and SLEEP • Pontine Micturition centre; fills bladder to capacity overnight • Micturition Control centre; recognises bladder is full and defers • Arousal centre; wakes you up

40. AROUSAL and SLEEP • Children with Enuresis have the same number of stages and the same amount of the different depths of sleep as other children • Wetting can occur during all stages of sleep and not always during “deep” sleep yet many parents have reported their children to be a “deep sleepers” • Even though sleep may lighten and children may become restless there is not wakening to a full bladder Therefore AROUSAL is the problem

41. SLEEP • Several studies have now shown that patients with enuresis have elevated arousal thresholds • Elevated sleep threshold is associated with increased bladder activity • Sleep architecture becomes normal and sleep arousal thresholds return to normal post treatment

42. THREE SYSTEMS MODEL Nocturnal polyuria (Lack of ADH Release) Nocturnal enuresis

43. NOCTURNAL POLYURIA Where nocturnal urine production exceeds normal nocturnal bladder capacity. (defined by ICCS as 130% of Expected Bladder Capacity)

44. NOCTURNAL POLYURIA WATER REGULATION/FLUID BALANCE is controlled by The HYPOTHALAMUS and PITUITARY. The Hypothalamus monitors changes in extra cellular fluid volume, the sodium concentration and osmotic pressure of plasma. It then signals the post pituitary to release Vasopressin/Anti-Diuretic Hormone into the bloodstream.

45. NOCTURNAL POLYURIA • ADH/Vasopressin released when water conservation is required. It acts on the collecting ducts to reduce water loss from kidneys. • ADH/Vasopressin is suppressed when increased water loss is required from kidneys.

46. VASOPRESSIN AND URINE Vasopressin levels pg/ml Urinary excretion rate ml/hr Non enuretic child Non enuretic child Enuretic child Enuretic child 5.0 80 70 4.0 60 50 3.0 ml/hour pg/ml 40 2.0 30 20 1.0 10 0.0 0 Day Night Rittig S et al.Am J Physiol 1989;256:F664–71

47. THREE SYSTEMS MODEL Reduced nocturnal functional bladder capacity Nocturnal enuresis

48. REDUCED FUNCTIONAL NOCTURNAL BLADDER CAPACITY Generally associated with day-time symptoms/ low bladder capacity but not always Low bladder capacity; ICCS definition; where actual day time voided volumes are less than 70% of Expected Bladder Capacity (EBC=Age +1x30)

49. ASSESSMENT OF ENURESIS

50. HISTORY • Family Situation • Fluid intake • Voiding habits • Bowel habits • Sleep habit • Co-existing conditions • History of bedwetting inc. family history • Previous experiences • Daytime symptoms