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Hot Topic. Enuresis. Definition. Uncontrolled/Involuntary passage of urine by day/night/both Children aged 5 or over In absence of physical disease DSMM defines nocturnal enuresis as wetting at least x2/wk in the above group. Day or night?. 85% nocturnal enuresis

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hot topic
Hot Topic
  • Enuresis
definition
Definition
  • Uncontrolled/Involuntary passage of urine by day/night/both
  • Children aged 5 or over
  • In absence of physical disease
  • DSMM defines nocturnal enuresis as wetting at least x2/wk in the above group
day or night
Day or night?
  • 85% nocturnal enuresis
  • Daytime enuresis more likely associated with pathology
  • Potentially large effect on family
  • Bullying, problems with schoolwork, social life
nocturnal enuresis
Nocturnal enuresis
  • Common - approx 15% of children experience it, rising to 75% if both parents had it.
  • Disorder of sleep arousal, a low nocturnal bladder capacity and nocturnal polyuria
  • History needs to distinguish b/w primary and secondary nocturnal enuresis.
  • Primary - bladder control has never been achieved
  • Secondary - lost after having had bladder control for at least 6 months
nocturnal enuresis5
Nocturnal enuresis
  • 15% of 5 year olds
  • 5% of 10 year olds
  • Teenagers 1-2% occasionally wet the bed
  • Yearly spontaneous remission rate is 15%
  • Usually can be considered a variation of the normal rate of maturation
  • Girls usually ahead of boys
  • 23% of nocturnal enuresis is associated with encopresis and daytime incontinence
contributing factors
Contributing factors
  • Genetics - 70% have +ve family history
  • Caffeine
  • Emotional stress
  • ADHD, premature delivery
  • Organic pathology
  • Disturbed sleep, mother young or smoker
organic causes
Organic causes
  • 1-2% have underlying physical cause
  • UTI
  • Chronic constipation
  • Bladder overactivity
  • Diabetes
  • Renal failure
  • Congenital anomalies eg ectopic ureter
  • Neurological disorders eg neural tube defect
  • Sleep apnoea
assessment history
Assessment - History
  • Age of child
  • Nocturnal or daytime or both?
  • Primary or secondary?
  • Other urinary symptoms? (UTI, bladder overactivity)
  • Hx of constipation/soiling?
  • Sx of diabetes or of sleep apnoea?
  • Family history?
  • Girls: early morning wetting? (ectopic ureter)
  • PMHx
assessment history9
Assessment - history
  • How many dry nights past wk/month?
  • Any potential causes of emotional distress
  • Fluid intake at bedtime
  • Diet - caffeine containing foods eg chocolate
  • Impact on family
  • Any strategies tried so far, ways parents respond to the wetting
examination
Examination
  • Abdo exam - distended bladder/mass/constipation
  • Inspect perineum/genitals
  • Spine
  • Check lower limb neurology
  • Growth chart
investigations
Investigations
  • Urine for glucose, protein, C&S in more or less all.
  • If daytime enuresis - consider USS abdo to exclude anatomical abnormalities/residual volume
management
Management
  • If indication of underlying cause manage/refer as appropriate Eg deal with constipation/UTI
  • Most children with enuresis are normal
  • <5 yrs no need to treat
  • <7 yrs and parents/child coping ok often no need to treat
  • >10 treat promptly
  • Advice
management advice
Management - advice
  • Primary enuresis - occurs because the volume of urine produced at night exceeds the bladder capacity and the sensation of a full bladder doesn’t wake the child
  • Not done out of defiance/contrariness
  • Try not to be angry with the child, stress aggravates the situation
  • Try to reinforce success
  • Give it time if child is young
simple advice for all
Simple advice for all
  • Empty bladder before bed
  • Avoid drinking after 1hr before bed
  • Otherwise don’t restrict fluids - encourage regular intake throughout the day but avoid any containing methylxanthines
  • Check access to bathroom at night
  • Waterproof covers for bed
  • Involve child in cleaning up mess but not as punishment
enuresis alarms
Enuresis alarms
  • Tx of choice for long-term Mx.
  • Children >7yrs. Needs to be a well-motivated child and family; Usually needed for 3-5 months. 30-50% of children relapse
  • Sensor in pad under child or attached to underwear
  • Alarms if gets wet - child has to get up to stop it. Parents must hear it too (eg baby monitor). Child to help with cleaning up.
  • Child learns to waken before alarm sounds or to sleep through night without passing urine
enuresis alarms16
Enuresis alarms
  • If dry for 14 nights in a row can stop alarm
  • Can be used together with drug treatment of needed
  • Treat relapses promptly
  • “Overlearning” - once dryness achieved encourage drinking at bedtime to “over-condition” bladder, stop once 14 dry nights.
  • Avoid if child shares a room, more than one child has enuresis at once, unmotivated parents.
star charts
Star charts
  • Alternative to enuresis alarm
  • Involves a wall calendar and star stickers
  • If dry in the morning child gets a sticker on the chart and praise as a reward
  • Child responds to rewards - reinforce success
  • As wetting less frequent can increase rewards value
  • If bed is wet - no punishment but stay calm and practical
desmopressin
Desmopressin
  • 2nd line treatment
  • In general practice use as short-term measure
  • School trips, sleepovers, holidays
  • Effective in 70% but high relapse rate once stop use
  • Can be used longer term but not initiated in primary care
  • May be useful adjunct to alarm treatment
desmopressin19
Desmopressin
  • Synthetic version of antidiuretic hormone
  • Reduces amount of urine produced - increased water resorption from distal tubules and collecting ducts
  • Taken at night as tablet or a melt
  • SEs - headache, nausea, congestion, nosebleeds, sore throat, cough, mild abdo cramps
  • Risk of water overload - need to counsel parents and child - limit fluid intake to 1 cup from 1hr before to 8hrs after taking tab
desmopressin20
Desmopressin
  • Preferably use in >7yr olds
  • Never use for daytime enuresis due to risk of fluid overload
  • Usual dose 200mcg tab/120mcg sublingual tab at bedtime
  • To determine dose and effectiveness trial of 2wks desmopressin. If not enough can try 2wks at double dose
  • Once effective dose established can prescribe it for intermittent use when needed eg school trip
secondary enuresis
Secondary enuresis
  • If wets after being dry for min 6 months
  • Look for underlying cause physical/emotional
  • Treat when able but consider referral for some causes or if can’t identify cause - enuresis clinic/paediatrics/child psychologist
daytime enuresis
Daytime enuresis
  • Rule out organic causes
  • Refer on to secondary care
  • MSU + dipstix
  • Usually USS
  • Star charts/bladder training/pelvic floor exercises
when to refer
When to refer
  • Most cases can be managed in primary care
  • Failed trials of alarm/star chart/desmopressin
  • If parents not coping
  • If suspicion of underlying cause
  • Older children
  • Daytime enuresis
  • Severe psychological distress
  • Secondary nocturnal enuresis if caused by emotional distress, cause not clearly identified or enduring/big impact
who can you involve
Who can you involve?
  • Health visitor if child is pre-school
  • School nurse
  • Local enuresis clinic
  • Voluntary groups eg ERIC for support and advice for parents
resources
Resources
  • ERIC - Education and Resources for Improving Childhood Continence www.eric.org.uk
  • Clinical Knowledge Summaries www.cks.nhs.uk
  • Tayside intranet - Bedwetting leaflet in Children’s hospital section wih local clinic details
  • Oxford Handbook of General Practice
  • DXS has selection of leaflets/evidence